A high index of suspicion helps diagnose ocular tuberculosis in areas of low prevalence of the disease. It forms part of the differential diagnosis of any chronic or recurrent uveitis, especially in an at-risk patient. Antitubercular treatment seems highly effective.

Background:Haemoptysis is a common clinical symptom. A small proportion of patients present with haemoptysis and normal chest radiograph. The investigation strategy for this group of patients is unclear. The aim of this study is to see whether further investigations for this group of patients are justified.Methods:A retrospective analysis was conducted of consecutive patients presenting with haemoptysis and normal chest radiograph over a period of 56 months irrespective of their smoking status. These patients were investigated by CT of the thorax and fibreoptic bronchoscopy.Results:275 episodes of haemoptysis with normal chest radiograph were investigated further in 270 patients (60% males). The median age was 60 years. Twenty-six patients were diagnosed to have respiratory tract malignancies (larynx, 1; trachea, 1; lung, 22; carcinoid, 1; and leiomyoma, 1). Eight (31%) of the 26 patients with respiratory tract malignancy had radical treatment. Fibreoptic bronchoscopy was diagnostic of cancer in 14 (54%) of the 26 patients with malignancy. CT of the thorax was suggestive of cancer in 24 (96%) of the 25 patients with malignancy.Conclusion:It is concluded that further investigation of haemoptysis in smokers is justified regardless of the amount or frequency of haemoptysis based on a 9.6% rate of malignancy in this consecutive series. It is recommended that these patients are investigated with CT of the thorax followed by fibreoptic bronchoscopy.

Case presentationA 19-year-old male university student with a background history of eczema and asthma presented with a day history of fl u-like symptoms, acute breathlessness, unproductive cough, chest tightness radiating to his neck and vomiting. His asthma was well controlled and he had one previous exacerbation as a child requiring a brief overnight hospital admission. He was compliant with his inhalers and was a nonsmoker. On examination, he was tall, thin built, alert, oriented and talking in full sentences. Respiratory examination showed polyphonic wheeze and crepitations at the lower sternal area. Baseline peak expiratory fl ow rate was 550 l/min (predicted 600 l/min). Blood tests showed leucocytosis with predominant neutrophilia and normal electrolytes. ECG showed normal sinus rhythm and arterial blood gases on room air showed hypoxic respiratory failure (pH, 7.38; pCO 2 , 4.5 kpa; pO 2 , 6.5 kpa; base excess, 4.1 mmol/l; lactate, 2.7 mmol/l; and, HCO 3 , 24 mmol/l). Chest X-ray ( Figure 1) showed air in the mediastinum with normal lungs and no evidence of pneumothorax. He tested negative for fl u.He was treated conservatively with high-flow oxygen, nebulisers, antibiotics and antiemetics. Although his hypoxia and wheeze improved, he developed progressive neck swelling and clinical examination showed worsening surgical emphysema. He underwent a CT thorax with concurrent 1.5% oral contrast administration pre-scan ( Figure 2). This showed no extra luminal contrast extravasation (no evidence of oesophageal perforation), but a large volume pneumomediastinum with air tracking through the neck fascial planes and subcutaneous emphysema in the left chest wall. There was further evidence of air in the posterior neck, thoracic soft tissues and epidural space.He was treated with conservative measures and had 5 days of intravenous antibiotics for a presumed mediastinitis with complete recovery. A follow-up chest X-ray performed after 6 weeks showed complete resolution (Figure 3). DiscussionSpontaneous pneumomediastinum (SPM) is a rare entity and is characterised by air leak into the mediastinum, not secondary to any underlying disease. 1 This process is selflimiting and was fi rst described in 1819 by Laennec and in 1939 was further characterised by Hamman. 2 It is common in tall and thin males, and presents between the second to forth decade with an average age of 25 years. 3 There are a paucity of data regarding the annual incidence of this condition; however, in a retrospective study it has been reported to be approximately 1 in 30,000 attendances to the emergency department. 4 Secondary pneumomediastinum may occur following barotrauma, mechanical ventilation, illicit drug withdrawal symptoms, tracheobronchial injury, cardiothoracic interventions, frequent retching, vomiting, oesophageal rupture, acute respiratory distress syndrome, weight lifting, parturition and straining against a closed glottis (valsalva manoeuvres). 5-8 A total of 25% of patients presenting with SPM have a combination of asthma and episodes o...

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