MRI imaging of vein of Galen malformations at Steve Biko Academic Hospital: A mini case series

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Conned by Conn’s Syndrome

Conn’s Syndrome is a rare entity amongst hypertensive patients and imaging of the aldosterone producing adenoma (APA) can prove challenging but is none the less very important for surgical planning and cure. We present two patients with MRI confirmation of APA with negative and equivocal computed tomography (CT) scans

Global Challenges for Cancer Imaging

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Lifethreatening Listeria meningitis: Need for revision of South African acute bacterial meningitis treatment guidelines

Background. The recent listeriosis outbreak in South Africa (SA) received widespread attention in the media. More than 1 000 laboratory-confirmed cases of listeriosis occurred during an 18-month period, with a case fatality rate of 28%. Acute bacterial meningitis due to listeriosis was extremely rare at Steve Biko Academic Hospital in Pretoria until 2017/18, when we saw two very sick adults with this condition during the listeriosis outbreak.Objectives. To describe the presentation, treatment and outcome of these patients to raise awareness of this potentially fatal but treatable infection that does not respond to empirical third-generation cephalosporins.Case reports. Case 1: A 60-year-old man collapsed at home after being discharged from hospital for treatment of Listeria meningitis. On readmission he had neck stiffness and a depressed level of consciousness with right-sided hemiparesis. A computed tomography (CT) scan of the brain showed possible subarachnoid haemorrhage, but on CT angio- and venograms, extensive thrombosis of the superior sagittal, right transverse and bilateral sigmoid sinuses extending into the right internal jugular vein was noted. Patient 2: A 55-year-old HIV-positive hypertensive man on highly active antiretroviral therapy and antihypertensives visited the emergency department complaining of a new-onset headache. He was discharged on pain medication, but was readmitted the next day with a depressed level of consciousness, neck stiffness, low-grade fever and generalised tonic-clonic convulsions. A lumbar puncture revealed active cerebrospinal fluid that was culture-positive for L. monocytogenes. The patients received ampicillin and gentamicin for 3 weeks; the cerebral venous thrombosis was treated with unfractionated heparin. In both cases, the course of the disease was complicated. The first patient remained confused and suffered from psychotic episodes for 5 weeks. He was finally discharged after 6 weeks in hospital and continued to improve to the extent that he was able to return to work. The second patient needed intubation and ventilation and was treated in the intensive care unit. He improved over the next week and was finally discharged home with no residual neurological sequelae.Conclusions. Our two cases demonstrate that the listeriosis outbreak should change the way we view bacterial meningitis in SA: according to the National Institute for Communicable Diseases, empirical treatment for meningitis should include ampicillin and gentamicin in all adult patients with features of meningitis. There may be a need for an updated meningitis treatment guideline in SA

Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): an unmasked randomised controlled trial.

BACKGROUND: Studies evaluating titration of antihypertensive medication using self-monitoring give contradictory findings and the precise place of telemonitoring over self-monitoring alone is unclear. The TASMINH4 trial aimed to assess the efficacy of self-monitored blood pressure, with or without telemonitoring, for antihypertensive titration in primary care, compared with usual care. METHODS: This study was a parallel randomised controlled trial done in 142 general practices in the UK, and included hypertensive patients older than 35 years, with blood pressure higher than 140/90 mm Hg, who were willing to self-monitor their blood pressure. Patients were randomly assigned (1:1:1) to self-monitoring blood pressure (self-montoring group), to self-monitoring blood pressure with telemonitoring (telemonitoring group), or to usual care (clinic blood pressure; usual care group). Randomisation was by a secure web-based system. Neither participants nor investigators were masked to group assignment. The primary outcome was clinic measured systolic blood pressure at 12 months from randomisation. Primary analysis was of available cases. The trial is registered with ISRCTN, number ISRCTN 83571366. FINDINGS: 1182 participants were randomly assigned to the self-monitoring group (n=395), the telemonitoring group (n=393), or the usual care group (n=394), of whom 1003 (85%) were included in the primary analysis. After 12 months, systolic blood pressure was lower in both intervention groups compared with usual care (self-monitoring, 137·0 [SD 16·7] mm Hg and telemonitoring, 136·0 [16·1] mm Hg vs usual care, 140·4 [16·5]; adjusted mean differences vs usual care: self-monitoring alone, -3·5 mm Hg [95% CI -5·8 to -1·2]; telemonitoring, -4·7 mm Hg [-7·0 to -2·4]). No difference between the self-monitoring and telemonitoring groups was recorded (adjusted mean difference -1·2 mm Hg [95% CI -3·5 to 1·2]). Results were similar in sensitivity analyses including multiple imputation. Adverse events were similar between all three groups. INTERPRETATION: Self-monitoring, with or without telemonitoring, when used by general practitioners to titrate antihypertensive medication in individuals with poorly controlled blood pressure, leads to significantly lower blood pressure than titration guided by clinic readings. With most general practitioners and many patients using self-monitoring, it could become the cornerstone of hypertension management in primary care. FUNDING: National Institute for Health Research via Programme Grant for Applied Health Research (RP-PG-1209-10051), Professorship to RJM (NIHR-RP-R2-12-015), Oxford Collaboration for Leadership in Applied Health Research and Care, and Omron Healthcare UK

Unusual mammography findings of patients with ductal carcinoma in situ (DCIS) of the breast.

Abstract The early detection of carcinoma is the highlight of mammography. We present two patients with pathological diagnosis of DCIS with unusual mammographic findings for which one needs to have a higher index of suspicion. The first patient presented with multifocal disease requiring biopsy of all visible lesions and the second patient (twenty four years old) presented with segmental distribution of calcifications, which may have been missed had a single-view baseline mammogram not been done

Histo-pathological correlation of BI-RADS 4 lesions on mammography with emphasis on microcalcification patterns.

A retrospective study of 20 patients with Breast Imaging Reporting and Data System (BI-RADS) 4 lesions was undertaken. These patients were classified as BI-RADS 4 lesions due to presence of a mass (clinical or on mammography), architectural distortion and microcalcifications (MC). In some patients, the pattern of MC was benign but there were other features that were suspicious of malignancy. A comparison was made with the histological diagnosis in order to compare the radiological appearance of benign and malignant microcalcification patterns with the final histology. The study design included retrospective analysis of patients with MC on digital mammography who underwent biopsy. An analysis of the histology was then undertaken. Other factors in the history and physical examination were also considered. Results showed that although the study was not statistically significant due to limited study population, interesting trends are determined in assessing calcification patterns using the Breast Imaging Reporting and Data System (BI-RADS) classification system, since some lesions that were thought to have benign calcification patterns were actually malignant and vice versa. Further study in this field is required

Duodenal obstruction due to a preduodenal portal vein

An infant presented with clinical signs and symptoms suggestive of a pyloric stenosis. On abdominal ultrasound, pyloric stenosis was excluded, and other causes for proximal duodenal obstruction, such as a duodenal web or annular pancreas, were suspected. At surgery, the cause was found to be due to an anterior portal vein or preduodenal portal vein, compressing the duodenum. There were no associated findings such as midgut malrotation, duodenal web and congenital anomalies. The treatment was a diamond-shaped duodeno-duodenostomy anterior to the portal vein. The patient improved after surgery

Extramedullary haematopoeisis causing spinal cord compression

Extramedullary haematopoeisis (EMH) is a rare cause of spinal cord compression. However, in a patient with a haematological disorder and in particular thalassaemia, EMH with paraspinal masses should be considered and imaging planned appropriately