Journal of the Royal College of Physicians of Edinburgh

In some patients undiagnosed diabetes may present with metabolic complications of diabetes as their initial presentation. Suboptimal glycaemic control in diagnosed and undiagnosed diabetes can cause hypertriglyceridaemia which can cause pancreatitis. In patients presenting with pancreatitis where common causes of pancreatitis are excluded hypertriglyceridaemia should be considered as a cause and hence their lipid profile should be evaluated. If hypertriglyceridaemia is confirmed, then such a patient should be screened for diabetes. We present three cases presenting to hospital with pancreatitis secondary to hypertriglyceridaemia. Hypertriglyceridaemia in all three were secondary to undiagnosed and uncontrolled type 2 diabetes. Early treatment of hypertriglyceridaemia can prevent morbidity and mortality. Diagnosing type 2 diabetes in this context can result in optimisation of glycaemic control, and hence improve hypertriglyceridaemia and reduce the risk of recurrent attacks of pancreatitis.

Sinusitis is a common condition, but only very rarely accompanied by isolated cranial nerve palsies. We describe a case of a 64-year-old male with a two-day history of left-sided ptosis associated with one week of nasal congestion and frontal sinus pain. Examination revealed ptosis with left pupil mydriasis. Uncontrasted computed tomography and angiography of the head demonstrated neither intracranial vascular abnormalities nor acute lesions; however, it did show mucosal thickening in the left frontal sinus, ethmoid air cells and left maxillary sinus, indicating potential obstruction of the left ostiomeatal complex. The sinusitis was treated with intranasal steroids, xylomethazoline and nasal douching. The patient reported resolution of all symptoms, including left ptosis, within one week of therapy. This rare case of sinusitis causing ptosis is presented due to its infrequent nature, such that awareness of the differential diagnosis of cranial nerve palsy and complications of sinusitis may be improved.

Eradication therapy in Plasmodium vivax in variants of glucose-6-phosphate dehydrogenase (G6PD) deficiency individuals remains a clinical challenge. We present a case of primaquine-induced methaemoglobinaemia and haemolytic anaemia in a patient with falsely normal qualitative G6PD result during initial presentation, which was complicated with clinical sequelae of thrombosis. Further investigations showed moderate degree of G6PD deficiency. Our patient responded well to vitamin C and a modified weekly regimen of primaquine with no evidence of malaria relapse.

A 73-year-old man presented with lower back pain and bilateral palmar lesions. Urine culture grew Streptococcus agalactiae and C-reactive protein was raised. He was treated with antibiotics for urinary tract infection with suspected pyelonephritis. An echocardiogram ordered to look for infective endocarditis was suggestive of a left atrial myxoma. He subsequently developed an acute right common iliac artery embolus, which resolved with conservative management. He underwent a successful open-heart left atrial mass and appendage resection, with histopathology confirming atrial myxoma. Skin biopsies of the lesions ten weeks post onset showed granuloma annulare of the palms.

We report a 49-year-old Southeast Asian woman diagnosed with metastatic primary right atrial angiosarcoma (PCA) and the difficulties encountered in this diagnosis and its subsequent management. Diagnosis of PCA is often delayed due to non-specific clinical presentation of patients. These tumours often present once metastatic spread has occurred, restricting treatment options and leading to very poor prognosis. Patients undergo a multidisciplinary team (MDT) approach involving chemotherapy, radiotherapy and, if eligible, surgery, but evidence-based treatment guidelines have yet to be established due to the rarity of the tumour.

Dermatological manifestations of COVID-19 are rare, with fever, dry cough, breathlessness, loss of taste and myalgia constituting most of the symptoms spectrum. However, these rare skin manifestations may be the only presentation of COVID-19 as in our presented patient. It is therefore prudent to be aware of such presentation in asymptomatic COVID-19 patients, as this is important for early diagnosis and hence taking appropriate preventive measures.

COVID-19 has had a significant impact on internal medicine training in the UK. Many unprecedented changes have been made to prioritise the care of affected patients. The medical workforce was re-shaped, training programmes were disrupted, Membership of the Royal College of Physicians (MRCP) examinations were cancelled and their format changed on re-commencement, teaching programmes were suspended and delivery methods amended, out of programme (OOP) opportunities deferred, non-COVID related research halted, trainee progression impacted and trainee mental health and wellbeing suffered. Despite this, the pandemic has undoubtedly created a plethora of unique learning opportunities for trainees that could make them better doctors and healthcare leaders in the future.

Geriatric medicine in Britain was born in the setting of a former poor law workhouse in London. Its early pioneers developed models of geriatric services and instigated research into the diseases pertinent to older people. Government initiatives championed the establishment of geriatric units but denied geriatric medicine the status of a clinical medical specialty. Despite an unfavourable image within the medical profession, medical services for older people flourished under the National Health Service to become one of the largest groups of medical specialties. The development of the specialty is traced from its origins in the care of chronically sick patients through to its greater involvement in the medical care of a wider spectrum of older people.

During the 1980s and 1990s, Edinburgh and the Lothians suffered significantly high rates of HIV infections, considered to be the result of a high proportion of intravenous drug users sharing injecting equipment. This young, sexually active cohort had the potential to pose a threat to the wider population via heterosexual spread, and hence measures were required to prevent, where possible, a second wave of the epidemic. A coalition of health professionals, local authority groups and voluntary organisations consequently acted by producing a series of health promotional campaigns, such as the ‘Take Care’ campaign, in order to promote healthy and safe sexual practice and to educate the community about the risks of HIV and AIDS. Many of the strategies utilised by Lothian public bodies were pioneering, using distinctive imagery and novel marketing techniques. Despite aiming these campaigns at the broader community however, campaigns spearheaded by health providers and local government often excluded certain high-risk populations, such as drug users and gay men, and subsequently these demographic groups had to turn to other services (in voluntary, nongovernmental sectors) for health education and promotion.

Rhabdomyolysis is a clinical syndrome characterised by the destruction of skeletal muscle with subsequent leakage of intracellular muscle contents into the systemic circulation. It is commonly caused by trauma, strenuous physical activities, medications, illicit drug use, toxins, infections and electrolyte abnormalities. It can manifest as myalgia, muscle weakness, or myoglobinuria with or without acute kidney injury. Severe hypokalaemia leading to rhabdomyolysis is a rare initial presentation of primary aldosteronism, with limited case reports in existing medical literature. Here, we report a case of primary hyperaldosteronism presenting with rhabdomyolysis due to profound hypokalaemia.