Nidhi Bhatt

Mesothelioma and anti-Ma paraneoplastic syndrome; heterogeneity in immunogenic tumours increases

We present a patient with opsoclonus and diffuse cerebellar signs who had an anti-Ma2 antibody-associated paraneoplastic syndrome secondary to a sarcomatoid mesothelioma. This case highlights the importance of early tumour detection, instigation of therapeutic measures, and the heterogeneity of underlying malignancies in neurological paraneoplastic syndromes.

Imaging bronchogenic adenocarcinoma: emerging concepts.

Advances in our understanding of lung adenocarcinoma have led to the recently revised classification of lung adenocarcinoma. This replaces the term bronchoalveolar carcinoma and introduces the concept of preinvasive, minimally invasive, and frankly invasive lesions to the classification. Although more work is required to validate these concepts, it is likely that they will be incorporated into the next World Health Organization and TNM classifications. We illustrate the likely radiographic appearance of lesions in the new classification, highlight salient features to watch for on follow-up, and offer guidance on their management.

Pulmonary Langerhans Cell Histiocytosis in pre-existing chronic myelomonocytic leukaemia: a rare association.

Learning points for clinicians The association of PLCH in a patient with established CMML is rare. Both conditions are associated with disordered cellular proliferation of monocyte progenitor cell derivatives and chromosome 7 aberrations. The association between LCH and CMML will require further study. Cladribine offers a treatment option for single system PLCH in ex-smokers. A 72-year-old lady with a 58 pack year smoking history presented with a 2 week history of dyspnoea, lethargy, night sweats and abdominal pain. Past medical history was significant for rheumatoid arthritis, chronic myelomonocytic leukaemia (CMML), diabetes mellitus and previous breast cancer. She was not on any immunosuppression or pneumotoxic drugs. Examination revealed oxygen saturations of 96% on air and signs of her previous breast surgery but was otherwise non-contributory. Blood tests were notable for an elevated white cell count of 21 × 109/l (neutrophils 12.5 × 109/l, lymphocytes 4.2 …

Reversible cerebellar signs due to sarcoid-related severe hypercalcaemia

### Learning Points for Clinicians 1. Severe and symptomatic hypercalcaemia can occur in sarcoidosis but remains uncommon, <5% of cases (malignancy should remain top of the list in unexplained cases). If rehydration and steroids are unsuccessful, other options are ketoconazole and chloroquine in this context. 2. It is imperative to know the serum calcium level (amongst other electrolytes) in patients with abnormal mentation and neurological signs before undertaking cross-sectional neuroimaging. In this particular case, the computed tomography (CT) brain scan could have been avoided. 3. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) should be favoured as a diagnostic tool (especially if neck ultrasound core biopsy is not an option), avoiding the need for more invasive procedures requiring general anaesthesia, such as mediastinoscopy. A 58-year-old Caucasian man presented on the acute medical take with a week-long history of impaired cognition, abnormal gait and constitutional symptoms (weight loss and anorexia). Past medical history was significant for insulin controlled type 2 diabetes mellitus. There were …

Leprous ganglionitis and myelitis

A 27-year-old Brazilian woman presented with a 7-month history of progressive pain, tingling, numbness, and weakness of the left upper limb, and paroxysmal dysesthesia affecting the left foot. On examination, there were erythematous, anesthetic patches of skin overlying the metacarpophalangeal joints and on the palmar surfaces of the hands (figure e-1 at Neurology.org/nn). There was congenital, bilateral campylodactyly and new flexion deformity of the fingers of the left hand with an incomplete range of passive extension. The intrinsic muscles of the left hand were wasted, particularly the thenar eminence and the dorsal interossei. Fasciculations were not observed. There was marked tenderness in the antecubital fossa and at the wrist, and the left superficial radial nerve was palpable. There was severe weakness of intrinsic finger movements, wrist flexion, and extension. Left upper limb reflexes were brisk and painful to percuss but tone, power, and reflexes including plantar responses were otherwise normal. Sensation to pinprick was reduced throughout the left hand with loss of temperature, vibration, and proprioceptive sensation distal to the wrist.

Lesson of the month 1: A cough that doesn't fit the mould

Aspergillus disease has a wide spectrum of manifestations within the lungs; however invasive Aspergillus is most commonly associated with immunocompromise or pre-existing respiratory disease. Here we present a case of Aspergillus tracheobronchitis causing right middle lobe collapse, masquerading as late-onset asthma in a patient with no pre-existing risk factors following massive inhalation of Aspergillus spores from working with compost. This case highlights the importance of having a high index of suspicion for Aspergillus-related disease even in those with no traditional risk factors.

Isolated colorectal mediastinal metastasis

A 52-year-old man was referred for endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) having been found to have isolated asymptomatic right paratracheal adenopathy. He had previously had a sigmoid colectomy in 2008 for Dukes B carcinoma (pathological staging pT3 N0). One year later, he was found to have a lesion in the right lobe of the liver, which was successfully downsized with chemotherapy and resected. Subsequent serial follow-up computed tomography scans identified an enlarging isolated right 20 mm paratracheal …

A node or not a node; that is the question?

A 40-year-old woman was referred to the respiratory assessment clinic with a history of sudden onset, right-sided, posterior chest pain. The pain was noted to be exacerbated by respiratory excursion. She had a history of well-controlled asthma and seronegative arthritis for which she was being treated with methotrexate and depomedrone. No specific abnormal examination findings were found, vital signs were normal and a d-dimer was noted to be negative. A chest radiograph (CXR) suggested abnormal soft tissue in the right paratracheal area. Computed tomography (CT) pulmonary angiogram showed no evidence of pulmonary …