Trans-diaphragmatic intercostal hernia is a rare entity. Patient with multiple medical comorbidities, including obstructive sleep apnoea, presents with shortness of breath, leg oedema and a bulging swelling through the right chest wall. CT shows partial herniation of the right lung and liver through intercostal space and an echocardiogram reveals right heart failure. He was treated initially with continuous positive airway pressure with poor response and subsequently treated with adaptive servo ventilation with much better symptomatic relief and treatment tolerance.

A 45-year-old man with a raised body mass index presented with an acute history of right lower chest pain and increasing breathlessness. C reactive protein, D dimer and cardiac echocardiography were negative, with mild bibasal atelectasis the only positive reported finding from erect chest X-ray and CT pulmonary angiogram. He was discharged with antibiotics for a chest infection. He remained severely breathless and was referred to the sleep-related breathing disorders clinic. He described shoulder pain, daytime tiredness and sleeping upright due to a ââ'¬Ëœsuffocatingââ'¬â"¢ sensation. The video demonstrates the clinical findings. The CT topogram confirmed bilateral diaphragmatic paralysis. Spirometry demonstrated an 80% reduction in forced vital capacity in the supine position, when compared with erect. Consultation with a neurologist yielded the diagnosis of neuralgic amyotrophy, leading to bilateral diaphragmatic paralysis. The respiratory symptoms have been controlled with night-time non-invasive ventilation, allowing him to sleep supine.

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SummaryA 37-year-old female presented following a witnessed generalised tonic clonic seizure while washing her car. Witnesses reported the patient hit her head on the car bumper upon falling. She was investigated for a cause of a second seizure with blood tests, CT and MR brain which were normal. On day 3 of her admission she was still unable to walk since the seizure and a neurological examination was performed which revealed signs consistent with a cervical myelopathy. A cervical MRI scan revealed a disc prolapse with cord compression at C5/6. This was successfully operated and the patient made a good recovery. Given that many of our medical assessment units and emergency department frequently assess patient with seizures, there was an important lesson for us to be more aware of the consequences as well as the cause of seizures.

AbstractWe report a case of a woman with bilateral silicone breast implants who presented with recurrent high grade fever, joint and muscle aches. An extensive workup failed to indicate an infectious source of her illness, so based on her symptoms a clinical diagnosis of Adult Onset Still’s disease was made. However, subsequent investigations revealed raised IgA paraprotein levels in her serum which led to a bone marrow examination. Bone marrow examination was consistent with IgA Myeloma. Chemotherapy was commenced which led to a decrease in the paraprotein level. In addition, she was treated with non steroidal anti-inflammatory drugs and intraarticular steroid injections which provided marked symptomatic relief. The case indicates a possible association of Myeloma and Adult Onset Still’s Disease in a patient with bilateral silicone breast implant.