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BMJ Case Reports from UHNM staff

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 BMJ Case Reports is available to UHNM staff both to view full-text and to submit your own case reports. There have been 2 recent case reports submitted by UHNM staff:

Penetrating head trauma unbeknown to the patient

David Bristow and Shayda Karimi
Abstract
Penetrating head trauma often leads to significant morbidity or mortality. A man presented to our tertiary centre with concerns of a nail in his brain after work colleagues reviewed closed-circuit television footage which appeared to show a pneumatic nail gun discharging against his head during an incident at work 4 days earlier. Remarkably, the patient reported no symptoms and no clinical signs apart from a small scabbed area on his scalp. A CT scan of his head was performed which showed a 4 cm nail lodged within the parietal lobe of his brain. The patient subsequently underwent a craniotomy with removal of the nail along with antimicrobial cover with antibiotics and tetanus prophylaxis. The patient made a full recovery and was discharged 3 days later. This interesting case highlights both the insensate nature of the brain parenchyma and the critical importance of broad-spectrum antimicrobial cover to prevent cerebral infection following penetrating head trauma.

Acute retinal necrosis refractory to treatment

Ian R. Reekie, Jekaterina Sidhom and Randhir Chavan
Abstract
A female patient in her 60s presented with a right eye hypertensive uveitis and subsequently developed vitritis and retinitis. An anterior chamber tap was PCR positive for herpes simplex virus. Despite oral valaciclovir 2 g three times a day and an initial intravitreal foscarnet 2.4 mg/0.1 mL injection her condition worsened, with more extensive retinal necrosis and retinal haemorrhages. A repeat anterior chamber tap was performed and PCR testing confirmed viral strains resistant to aciclovir. The patient was therefore treated with repeated intravitreal injections of foscarnet along with intravenous foscarnet which stabilised her clinical condition for a time, though unfortunately her retina later detached. Acute retinal necrosis is an uncommon but visually devastating infectious uveitis; in situations where initial antiviral treatments are not stabilising or improving the clinical picture it is important to consider the rare possibility of antiviral resistance. Intravenous foscarnet carries the risks of unpleasant and potentially dangerous side effects, about which patients must be counselled.

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