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SPOT DIAGNOSIS
Can you work out this diagnosis ?
SARA is a 33-year-old office manager who is fitted in urgently for review of sudden right-sided visual disturbance . This came on during a squats and burpees superset in a gym class that morning . She reports the vision in her right eye initially appeared “ pixelated ”, after which she developed a “ black hole ” in the centre of her vision . She has a history of migraine with aura , but these features are not her typical aura , nor has there been any migraine progression . She has no other medical history of note . On examination , vital signs are normal , pupils are equal and reactive , and visual acuity is counting fingers on the right and 6 / 5 on the left , uncorrected . Fundal findings on the right are pictured .
Reproduced from Ng J K Y , et al . Sudden loss of vision at the gym ; BMJ 2021
In most cases , abdominal CT cannot differentiate between gall bladder anomalies or clearly define their relationship to the biliary tree . 3
MRCP is the best imaging modality to accurately distinguish a duplicated gall bladder from other possible differential diagnoses and to confirm the specific type of duplication . 5 , 6 It is recommended to adequately visualise the cystic duct and define surrounding anatomical structures preoperatively in order to minimise the complexity and potential complications of cholecystectomy — if indicated . 7
Collectively , previous literature highlights the importance of recognising a duplicated gall bladder preoperatively to prevent potential surgical complications or repeated surgery . 3
MRCP is non-invasive , does not require anaesthesia or a surgically trained operator and has a 95 % accuracy in diagnosis of cystic duct variants . 8 However , it is an expensive investigation for both the patient and the healthcare system .
Duplicated gall bladders carry the same risk of associated pathology as normal single gall bladders , most commonly cholelithiasis . 6 , 9 Generally , surgery is recommended only for symptomatic patients , consistent with typical biliary disease . 6
The ideal surgical approach may differ in the presence of a duplicated gall bladder — specifically , laparoscopic surgery is recommended for a type 1 duplicated gall bladder . However , open surgery is recommended for a type 2 duplicated gall bladder as there is potentially an increased risk of damage to the common bile duct and right hepatic artery . 10
It is strongly recommended to remove both gall bladders during primary cholecystectomy in a symptomatic patient . 6 , 13 This is because , left in situ , anatomical variations of the gall bladder are associated with an increased risk of postoperative complications and subsequent surgery , as inspection and palpation of the gall bladder fossa is not possible . 11 , 12 Previous reports have demonstrated there is an increased risk of disease in the accessory gall bladder and subsequent surgery if only one of the two gall bladders is surgically removed . 6
Prophylactic cholecystectomy of a duplicated gall bladder is not recommended for an asymptomatic patient without gall bladder pathology because there is no significant increased risk for subsequent disease . 4 , 6 References on request from kate . kelso @ adg . com . au
Surgery is recommended only for symptomatic patients , consistent with typical biliary disease .
Have an interesting clinical case ?
Email the editor-in-chief at jo . hartley @ adg . com . au . We pay $ 400 for each case and photos are encouraged .
Medical Must-See
Testicle pops out of scrotum after COVID-19
Sophie Attwood WITH COVID-19 ’ s ever-expanding sequelae , new side effects are always coming out of left field .
Take this coronavirus complication in Urology Case Reports , where pruritic ulcers joined forces to create a hole large enough for a patient ’ s testicle to spill out of his scrotum .
The 72-year-old , who had type 2 diabetes , initially presented to dermatologists in the US complaining of a sixmonth history of pruritic scrotal ulcers .
These sores had developed after COVID-19 infection , coalescing into two larger lesions on the left hemiscrotum .
A punch biopsy revealed neutrophilic dermal inflammation ; dermatologists diagnosed the patient with pyoderma gangrenosum and prescribed prednisone .
However , before he had a chance to start the corticosteroid , the two scrotal ulcers combined yet again to form one large open wound , resulting in prolapse of the left testicle .
At this point , the protruding testis was still covered by
Reprinted from Urology Case Reports ,
Mashtura Hasan et al . Loose scrotal wound edge approximation in the setting of pyoderma gangrenosum after COVID-19 infection , 2022 , with permission from Elsevier tissue . It wasn ’ t until the patient was hospitalised for an exacerbation of congestive heart failure that the contents began to erode through the ulcer — ballooning out of the scrotal sac .
The patient was referred to a urology clinic , where the testis was pushed back inside the scrotum and the wound was loosely sutured to promote healing . Urol Case Rep 2022 ; 1 Feb .
What is the most likely diagnosis ? a Valsalva retinopathy b Acute migrainous infarction c Hypertensive retinopathy d Retinal detachment
Have an interesting spot diagnosis ?
Email a clinical / radiological image to the editor-in-chief at jo . hartley @ adg . com . au .
ANSWER The answer is a . The fundal image demonstrates a pre-retinal haemorrhage overlying the macula , with a visible fluid level resulting in the boat shape . The retinal vasculature and fundus appear otherwise unremarkable . 3
In the absence of risk factors for vascular retinopathy and with the history of onset during exertion , Valsalva retinopathy is the most likely cause .
Valsalva retinopathy typically occurs in patients who are otherwise well in the setting of a rapid rise in venous pressure following an increased intrathoracic or intra-abdominal pressure . This is usually due to a Valsalva-type manoeuvre , such as during cough , vomiting or a physical strain . 1 Cases have been reported to be associated with vigorous exercise , sexual activity , vomiting in pregnancy , labour , balloon blowing , breath holding and habitual ear popping . 2
The diagnosis is usually clear , based on historical features and fundoscopic findings . The typical presentation is with sudden , painless central loss of vision with preservation of peripheral vision and a fundoscopic finding of haemorrhage into the pre-retinal space . 3
In this case , the described pixelated effect was most likely the result of transient retinal stimulation during the acute haemorrhage . 3
Differential diagnoses for pre-retinal haemorrhage include proliferative diabetic retinopathy with neovascularisation , trauma , haemorrhagic posterior vitreous detachment and wet age-related macular degeneration . Blood dyscrasias and ruptured retinal aneurysm are less common causes . 3
In addition to ophthalmology review , relevant investigations to exclude underlying medical causes warrant consideration , including FBC , blood glucose and inflammatory markers .
Valsalva retinopathy is typically managed conservatively , with avoidance of triggers and observation until spontaneous resolution ( usually weeks to months ). Laser hyaloidotomy — to allow the blood to clear the visual axis — or surgical removal of the haemorrhage with a vitrectomy can be considered in select cases . 3 On recovery , patients with exercise-related presentations can be counselled to avoid breath holding during strenuous activity . 4
In this instance , no predisposing medical causes were identified . Sara recovered normal visual acuity with spontaneous resolution of the pre-retinal haemorrhage within two months . 3
Dr Kate Kelso is a GP and medical editor at Australian Doctor . References on request from kate . kelso @ adg . com . au