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Clinical Review Interactive case report

A 66 year old woman with a rash: case outcomeCommentary: Patient's perspectiveCommentary: Vascular surgeonCommentary: DermatologyCommentary: View from primary careCommentary: Learning from interactive case reports

BMJ 2003; 326 doi: (Published 12 April 2003) Cite this as: BMJ 2003;326:804

A 66 year old woman with a rash: case outcome

  1. J Bligh, professor (,
  2. R Farrow, director of problem based learning
  1. Peninsula Medical School Tamar Science Park, Plymouth PL6 8BX
  2. Peninsula Medical School, Tamar Science Park, Plymouth PL6 8BX
  3. Nuffield Department of Surgery, John Radcliffe Hospital, Oxford OX3 9DU
  4. Department of Dermatology, Royal Free Hospital, London NW3 2QG
  5. General Practice and Primary Care Research Unit, Institute of Public Health, Cambridge CB2 2SR
  6. Division of Public Health and Primary Health Care, University of Oxford, Oxford OX3 7LF
  1. Correspondence to: J Bligh

    Three weeks ago (BMJ 2003;326:588) we published the case of Ruth, who presented to her general practitioner with a rash after feeling unwell for some time. She had dermatomyositis diagnosed and, during investigation for possible underlying causes, was found to have an aneurysm of the splenic artery (BMJ 2003;326:640). Ruth's case was discussed at a multidisciplinary meeting and a decision was made to treat her aneurysm with a covered stent placed under fluoroscopic guidance by a radiologist. A theatre space was booked for the same time as the procedure in case of complications. She had a repeat angiogram and a wire was passed across the aneurysm.

    Surgery and follow up

    Two covered stents were placed across the neck of the aneurysm and a repeat contrast injection showed that there was no communication between the splenic artery and the aneurysm sac (figure). Ultrasonography the next day showed the aneurysm filled with thrombus with no flow on colour Doppler. The following day contrast enhanced computed tomography showed no evidence of a leak. Follow up computed tomography continued to show no leak and no flow in the aneurysm sac. Ruth was given pneumococcal and haemophilus influenza vaccines as a prophylactic measure in case of future hyposplenism caused by migration or occlusion of the stent.

    Embedded Image

    Angiogram after placement of the splenic artery stent showing good flow through the stent but no leakage of contrast into the aneurysm sac

    As it was envisaged that Ruth would be taking steroids long term, she was referred for bone densitometry (dual x ray absorptiometry), which showed no evidence of osteoporosis. Ruth was reassured but advised that it would be sensible to increase her calcium intake to 1500 mg a day. She found this difficult to achieve and so was started on an oral calcium and vitamin D supplement. She was also advised …

    Correspondence to: N Kapur

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