Case Report ABSTRACTS

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Utilisation of PET CT for the diagnosis of atypical large vessels vasculitis Mahjubeen Akhtar Lancashire Teaching Hospitals Tahir Nazir Arvind Ponnusamy Case Report Giant cell arteritis (GCA) is a large vessel vasculitis that predominantly affects medium sized vessels such as arteries found in the head and neck. The prevalence is highest in females aged 70 years and it typically presents with symptoms of temporal arteritis. We present a case of atypical large vessel vasculitis with resulted diagnostic difficulties. A 70 year old Asian male who was admitted onto the rapid assessment unit with a 2 week history of lethargy, productive cough and fever, weight loss and poor appetite. Examination was unremarkable. A septic screen was inconclusive; however with a high C reactive protein (CRP) of 212, patient was treated for an infection of unknown source with intravenous (IV) antibiotics. The patient however, remained symptomatic in addition to the raised CRP, and erythrocyte sedimentation rate ( ESR) of 120 . Further investigations including an immunology screen, cANCA, C3/C4 level, echocardiogram, bone marrow examination, colonoscopy, and computed tomography (CT) were performed which were negative of any pathology. A possibility of tuberculosis (TB) was raised in view of his ethnicity and symptoms. A decision was being made to start him on anti-TB medication. PET CT was done to rule out occult malignancy which showed extensive underlying vasculitis involving ascending aorta, descending aorta, iliac, femoral, subclavian and carotid arteries. Patient was managed with a 3 day course of IV methylprednisolone followed by 60mg prednisolone to which he responded well with improvement of symptoms. Conclusion: This case demonstrates the atypical features of GCA with involvement of almost all large vessels and how these create challenges in prompt diagnosis of the disease. Furthermore, it signifies the role PET CT imaging has in diagnosing GCA where temporal arteritis isn’t the initial presenting problem. Acute physicians should be aware of the use of PET CT in diagnosing occult vasculitis.
Vertebral Artery Dissection - not as uncommon as we think? Yang Min Ng North Bristol NHS Trust Ben Grimshaw Case Report We present two cases of vertebral artery dissection (VAD) – along with neck vessel and cerebral imaging. Both cases presented in an atypical fashion. Vertebral artery dissection is thought to be a rare cause of ischaemic stroke. Observational studies have demonstrated that the classical features of minor cervical trauma, neck pain and headache were not found in many patients with proven VAD 1 . The true incidence of VAD may be higher due to the paucity of reliably associated clinical signs. A high index of suspicion is essential, particularly in young patients presenting with atypical neurological symptoms. CASE 1 - A 33 year old man presented to ED with a short history of frontal headache, unsteadiness, clumsiness, and falls. Neurological examination was normal with no cerebellar signs. An initial plain CT brain scan was reported as normal. The patient was discharged with a diagnosis of atypical migraine. However, a subsequent neuroradiology review revealed a small right superior cerebellar infarct. The patient was recalled to ED the next morning and CT angiogram confirmed a right vertebral artery dissection (VAD). CASE 2 - A 47 year old lady presented with loss of consciousness lasting 30 seconds during a pre-match hockey warm up. Afterwards she suffered from confusion and amnesia which lasted 12 hours. Initial CT brain scan and lumbar puncture was normal, but subsequent MRI revealed multiple embolic infarcts in the occipital lobes. CT angiogram confirmed a left VAD. References Debette S, Grond-Ginsbach C, Bodenant M, et.al. Differential features of carotid and vertebral artery dissections: the CADISP study. Neurology 2011;77(12):1174-81.
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