Picture Quiz – Answers

A progressive and severe rash

Picture Quiz - Answers, Volume 20, Issue 4, Pages 249 – 308 (2021)

A 73-year-old female patient with epilepsy presented to hospital with a progressive, diffuse macular rash over the trunk and limbs with associated mucosal blistering and discharge. Ocular symptoms initially predominated and she was treated for presumed bacterial conjunctivitis by her General Practitioner the previous day. On the acute medical unit supportive management was initiated for suspected adverse drug reaction (ADR) to a recent lamotrigine dose increase. Skin biopsy confirmed a diagnosis of toxic epidermal necrolysis. We present this case to highlight the importance of medication history taking and raise awareness of indolent presentations of life-threatening ADRs. Caution should be applied following dose changes to anti-epileptics, even if previously stable.

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An unusual suspect for heart failure

Picture Quiz - Answers, Volume 19, Issue 1, Pages 1 - 60 (2020)

Constrictive pericarditis though an uncommon diagnosis is a potentially reversible form of heart failure (with surgical pericardiectomy) and hence is imperative to diagnose. Diagnosis is dependent on a high index of clinical suspicion and further testing with appropriate cardiac investigations including cardiac imaging with invasive cardiac catheterisation as the gold standard.

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MR-Brain Causing Confusion

Picture Quiz - Answers, Volume 18, Issue 4, Pages 205 – 264 (2019)

This is a T2 weighted image (T2WI). In T2WI compartments filled with fluid appear brighter (as is the case of the CSF in the lateral ventricles). On the contrary, tissues with a high fat content appear as dark. This T2WI demonstrates layering of debris (figure 2- marked red star) in the occipital horn of the lateral ventricles. In this particular patient, the complete MRI report additionally demonstrated that the debris did not show a high T1 signal, demonstrated diffusion restriction, and a high FLAIR sequence. There was also restricting material observed in the fourth ventricle and the sylvian fissures bilaterally. There were no parenchymal changes or pathological contrast enhancements within the brain tissue. Whilst this appearance could represent blood, the appearance of the debrinous material itself was more in keeping with infective/pus material within the ventricles suggestive of ventriculitis.

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The Source of the Problem

Picture Quiz - Answers, Volume 18, Issue 1, Pages 1 – 60 (2019)

The portable chest x-ray (Figure 1) shows a widened cardiac silhouette. An endotracheal tube is in situ, indicating the patient is now intubated.

The ECG (Figure 2) shows sinus rhythm with widespread mixed convex and concave ST elevation, most notable in V4, V5 and the lateral leads. There is a suggestion of PR depression in the inferior leads.

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Abnormal cardiac conduction in a septic patient: incidental finding or cause for concern?

Picture Quiz - Answers, Volume 17, Issue 2, Pages 57 – 116 (2018)

The initial ECG (figure 1A) demonstrates a regularly irregular rhythm at approximately 80bpm. There is a profound first-degree atrioventricular(AV) block with a PR interval of over 400ms. There is monomorphic ventricular ectopy in a right bundle branch pattern. The baseline QRS complexes are narrow.

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An Acute Severe Headache

Picture Quiz - Answers, Volume 15, Issue 2, Pages 49 - 108 (2016)

Discussion

Severe headaches are a frequent presentation to the Emergency Department, accounting for around 1% of presentations. Of these, 13-16% will have a sinister underlying pathology but accurate diagnosis of headaches on the medical take remain difficult for non-specialists. A retrospective study from the UK found that, of those presenting to Emergency Department with sudden onset severe headaches, only 60% were given a specific headache diagnosis, with one third of these given their diagnoses despite an inadequate history.

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