Endgames Picture Quiz

Increasing confusion in a man after a fall—just a head injury?

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d4806 (Published 11 August 2011) Cite this as: BMJ 2011;343:d4806
  1. K Birdi, specialty trainee in radiology1,
  2. J Weir-McCall, specialty trainee in radiology1,
  3. R Grace, consultant haematologist1,
  4. D C Howlett, consultant radiologist1
  1. 1Eastbourne District General Hospital, Kings Drive, Eastbourne BN21 2UD, UK
  1. Correspondence to: kbirdi{at}doctors.org.uk

A 79 year old man presented with his carer to the accident and emergency department with a recent history of generalised weakness, tiredness, and weight loss. According to his carer, the patient had been having generalised aches and pains and had become increasingly irritable and confused after a head injury during a recent fall.

On examination, his Glasgow coma scale score was 13 and he was mildly disoriented in time and place. Soft tissue swelling was noted over his forehead, which was consistent with his fall. His neurological, cardiovascular, and respiratory examinations were unremarkable. Blood tests showed a haemoglobin concentration of 98 g/L (reference range 130-180), mean cell volume 87 fl (82-100), urea 10.9 mmol/L (2.5-7.5), creatinine 172 μmol/L (46-92), calcium 3.32 mmol/L (2.1-2.55), total protein 120 g/L (63-82), albumin 22 g/L (35-50), white cell count 3.9×109/L (4-11), neutrophil count 2.4×109/L (2-7.5), and erythrocyte sedimentation rate 98 mm in the first hour (<10).

In view of his altered consciousness level and history of head injury, he was referred for a cranial computed tomography, which showed age related involutional change and no acute intracranial haemorrhage. However, lucent areas were identified in the skull vault and a lateral skull radiograph was performed for further evaluation (fig 1).

Fig 1 Lateral skull radiograph

Questions

  • 1 What are the radiographic findings?

  • 2 Given the patient’s history, blood results, and radiographic findings, what is the most likely diagnosis?

  • 3 What further investigations would you request and why?

  • 4 What is the management of this condition?

Answers

1 What are the radiographic findings?

Short answer

The skull radiograph shows the typical appearance of a “pepper pot” skull, characterised by numerous well defined “punched out” lytic lesions.

Long answer

Multiple well defined osteolytic lesions of varying sizes throughout the skull vault giving it a “pepper pot” appearance (fig 2).1

Fig …

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