SummaryWe present the case of a 77-year-old woman who initially presented with pyrexia of unknown origin, anaemia and mild renal impairment. When her omeprazole was stopped she improved rapidly. When omeprazole was re-started she developed fever and acute renal failure, which again settled quickly on discontinuation of omeprazole. This case demonstrates how drugs can cause severe multisystem disorders that may appear to be infective or inflammatory.Keywords: omeprazole; acute renal failure; anaemia; pyrexia; adverse drug reaction A 77-year-old woman initially presented with a one-week history of malaise, nausea, rigors and sweats with weight loss of 2.5 kg. She had nonpleuritic left-sided lower back pain and nonproductive cough for two days. Oral cefuroxime (250 mg bid) had been started before admission without improvement. She had had malaria and possible pyelonephritis in Africa. She was taking omeprazole 20 mg daily, prescribed empirically for dyspepsia for two months. She had never smoked.On admission she was pyrexial at 38.5°C and tachypnoeic. No other abnormality was found on clinical examination. The initial full blood count was normal with haemoglobin 12.0 g/dl and white cell count 9.9 x 109/l (eosinophils 2.6%). Renal function was impaired with serum creatinine 202 jmol/l. Other biochemistry was normal. The erythrocyte sedimentation rate (ESR) was markedly raised at 96 mm/h. A midstream specimen of urine sent before commencing antibiotics was normal but a repeat specimen demonstrated sterile pyuria. Blood cultures were negative at seven days. A chest X-ray was normal.Investigations to identify the cause of the pyrexia, including further cultures of blood, urine and stool, specimens for acid-fast bacilli, serology for Legionella and other atypical infections, Mantoux-testing and autoantibody screen, were negative. Ultrasound examination of the abdomen and computed tomography of the chest and abdomen were normal on two occasions, one month apart, as was echocardiography. Lumbar spine X-rays and skeletal scintigraphy were normal. There was no improvement after seven days treatment with intravenous cefuroxime 750 mg eighthourly.

Laryngeal varices are rare and are usually associated with vocal cord trauma secondary to excessive use of voice. This report is the first documented case of laryngeal varices secondary to thyroid goitre. This is a report of an 83-year-old woman with a known retrosternal goitre chiefly with symptoms of globus. Retrosternal goitre was found to be compressing the pharyngeal venous plexus causing laryngeal venous structures bilaterally to be engorged along the aryepiglottic folds, arytenoids, posterior commissure and extending in to the postcricoid region. The presence of laryngeal varices carries a significant increased risk of haemorrhage. This case presents an atypical presentation of globus and the first reported case in the literature of laryngeal varices secondary to a thyroid goitre.

Introduction This study aimed to assess whether combination modality imaging (CT, and/or Technetium/Gallium) had any additional benefits over single modality imaging (CT) in the management of malignant otitis externa (MOE). Method A six-year retrospective case-controlled series was performed including 73 patients presenting with a potential diagnosis of MOE. Results CT imaging was undertaken in 69/73 patients, and of these the CT confirmed the diagnosis in 58% (40/69). Of the 42% (29/69) of CT negative patients, 25 underwent Technetium scanning, revealing 40% (10/25) to be negative. These patients were discharged on a short course of topical and oral therapy with no disease recurrence. Gallium scan results, performed at the end of treatment, were more inconsistent, with 47% (25/53) of imaging still positive despite extended intravenous/oral/topical therapy. However,40% (10/25) of these had their therapy stopped without any further disease relapse. Conclusions Combination modality imaging, with CT and Technetium, did infer additional benefit over single modality imaging using CT. However, this was not the case for Gallium scanning, used to determine treatment end, which seemed to be poorly representative of residual disease presence. This study was utilised to provide a management algorithm to guide future practice.