Takahashi, Toshiaki

A man in his 80s presented with 3 weeks of lower back pain, generalised weakness, poor appetite and intermittent melena, without genitourinary symptoms or recent trauma. CT showed an old L1 compression fracture and new sclerotic lesions in the L3 and L4 vertebrae, as well as mildly enlarged abdominal lymph nodes. 3 days later, he returned to the emergency department with worsening symptoms, including new left hemiparesis. A head CT revealed a right subdural haematoma (SDH) with a midline shift. Despite treatment for disseminated intravascular coagulation, the patient’s condition deteriorated, leading to a suspicion of spontaneous intracranial hypotension. An autopsy revealed disseminated metastatic adenocarcinoma with dura and leptomeningeal metastases, ultimately causing spontaneous SDH and subsequent transtentorial herniation. This case highlights the impact of anchoring bias in clinical decision-making and the importance of early recognition of underlying malignancy as the aetiology of spontaneous SDH in patients presenting with signs and symptoms of metastatic cancer.

An 18-year-old previously healthy Filipino male presented with abdominal pain, vomiting, dyspnoea and fever. Initial investigations revealed severe hepatosplenomegaly, pancytopaenia, elevated liver enzymes, coagulopathy and extremely high ferritin levels. Bone marrow biopsy confirmed an abnormal CD8+ T-cell population with haemophagocytosis. Extensive workup was performed, and he was ultimately diagnosed with haemophagocytic lymphohistiocytosis (HLH) secondary to Epstein-Barr virus-positive T-cell lymphoma of childhood (EBV-TCL), a rare and aggressive malignancy. Despite the initiation of modified dexamethasone, methotrexate, ifosfamide, L-asparaginase and etoposide (SMILE) chemotherapy along with high-dose glucocorticoids, the patient did not respond to the treatment and expired. This case underscores the critical importance of early recognition and prompt intervention in EBV-TCL-associated HLH which is a unique condition and a rare entity. The diagnosis of this entity can be particularly challenging, given its rapid progression and high mortality rate. Therefore, timely diagnosis and the initiation of appropriate therapy are essential for improving patient outcomes. General medicine providers play a key role in identifying warning signs to avoid delays in treatment initiation.