Anyone who has ever submitted a case report to a journal will know how hard it can be to get this published. This journal regularly receives 2-3 times as many as we could ever include, so there is often a tough task in selecting those which the editorial team feel will most interest our readers. A rather unusual quandary recently arose when two cases of VGKC encephalitis arrived in the same week, submitted independently from different parts of the UK. The referees felt that both had merits, so I was very grateful when the authors agreed to co-operate to combine the cases into a single submission, highlighting the varied presentation of a rare, but increasingly recognised condition. Both might have remained undiagnosed, had the appropriate antibody test not been requested. An awareness of this unusual, but treatable form of encephalitis will hopefully ensure that it enters the differential diagnosis for patients whose non-specific neurological presentation remains undiagnosed after the standard investigations have been completed.
Vigilence for the unusual is also the theme of the case report from Declan O’Kane; here the diagnosis of aorto-oesophageal fistula (AOF) following ablation therapy for AF was not considered until after the patient suffered a stroke, apparently precipitated by trans-oesophageal echo (TOE). The authors stress the potential for delayed presentation of this condition, and the need to ensure that it can be eliminated from the differential before oesophageal instrumentation is carried out. The fact that AOF is a more common complication of ablation therapy than endocarditis requires that CT images are carefully reviewed, and repeated if necessary, before proceeding to TOE when patients present with unexplained and persistent pyrexia following this procedure.
The team from Delft in Holland describe their case as ‘remarkable’, highlighting the importance of perseverance in the management of patients whose cardiac arrest results from massive pulmonary embolism. The patient made a full recovery after 90 minutes of cardiopulmonary resuscitation, which was conducted alongside simultaneous intra-pulmonary thrombolysis in a district general hospital setting. The patient’s age and prior good health undoubtedly contributed to this good outcome, although enormous credit must be afforded to the skills and teamwork described in the report. She should certainly consider herself lucky, on many different levels.