Laparoscopic cholecystectomy is a common surgical procedure, with potential for significant morbidity. The incidence of bile duct injuries has increased with the advent of laparoscopy, occurring in up to 1% of cases. Risk of injury increases with aberrant anatomy, acute inflammation and fibrosis. Preventative strategies include obtaining the critical view of safety, using a fundus-first approach and performing a subtotal cholecystectomy in the difficult gallbladder. Although controversy exists for routine cholangiography, its use is helpful in situations of obscure anatomy. We describe the case of a chronically inflamed and unusually small 1.5 cm gallbladder with an obliterated cystic duct. The critical view of safety was not able to be achieved and intraoperative cholangiography enabled identification of aberrant anatomy, with a dilated common duct mistaken as the gallbladder infundibulum. This case highlights the need to be vigilant to structural variation and the utility of selective cholangiography to clarify anatomy.

We describe a haemodialysis patient who presented with an exacerbation of previously undiagnosed chronic focal myositis during a hospital admission for missed dialysis and chronic foot osteomyelitis. The association of focal myositis with haemodialysis has been reported once previously, but we report the third case in our experience and argue that it is probably more common than previously appreciated. We consider a focused differential diagnosis for a diabetic dialysis patient with leg pain and discuss important features of this rare condition.

A 56-year-old man died following a fall resulting in complete submersion into a deep pit containing insulation material, expanded perlite. The most striking finding at autopsy was of impacted, moist pale yellow perlite that extended from the epiglottis into the main bronchi resulting in complete obstruction of the larger and smaller airways with cast formation. Perlite inhalation differs from inhalation of inert materials such as sand and wheat due to its hygroscopic properties and ability to expand forming an occlusive cast. Subsequent analyses of perlite from the worksite and within the airways indicated that hydration of perlite and adsorption of organic molecules into the perlite glass flakes had formed an interlocking, three-dimensional structure that was likely responsible for triggering a coagulation-flocculation process causing strong cohesion between the aggregates of glass flakes. This unique mechanism was likely responsible for the formation of the plug of perlite that obstructed the upper airway.

While bronchiectasis not related to cystic fibrosis remains a significant cause of chronic respiratory disease in low to middle income countries, it has a lower profile in Australia. Nonetheless, there is increasing recognition that people living in Australia can present for the first time with noncystic fibrosis bronchiectasis at all stages of life. In addition, clinicians are often faced with the conundrum of minor changes consistent with bronchiectasis incidentally reported on computed tomography scan. This article aims to provide advice regarding when to suspect bronchiectasis, how to proceed with confirming or refuting a diagnosis, and the principles of management to minimise disease progression and manage the acute exacerbations, symptoms and associated disability and impaired quality of life. Delay in the diagnosis, investigation and management of bronchiectasis in both children and adults is common, and this delay has been shown to be associated with more rapid progression of disease. General practitioners have a key role in suspecting and accurately diagnosing and assessing bronchiectasis, discussing potential cases with specialist respiratory colleagues early and leading a multidisciplinary team to help patients with bronchiectasis manage their disease and minimise disability and premature death.

Diagnosis of pulmonary mass lesions can be challenging with several possible differentials. A 41-year-old Caucasian woman presented with intermittent non-specific chest pain on a background of 30 pack years of smoking history. A CT scan of the chest confirmed an opacity in the right lower lobe suspicious for primary pulmonary malignancy and PET scan showed moderate FDG avidity of the lesion. Conventional flexible bronchoscopy did not demonstrate an endobronchial lesion, Using Endobrochial Ultrasound (EBUS) Guide sheath technique, the lesion was localized in the posterior segment of the right lower lobe. Brushings, biopsies and washings were taken through the guide sheath, along with transbronchial cryobiopsy. Culture of bronchial brushings from the lesion on Ashdown's agar medium showed Burkholderia pseudomallei, confirming melioidosis. Treatment was with intravenous ceftazidime for 4 weeks, followed by oral sulphamethoxazole/trimethoprim for 3 months. During the follow up visits, the patient demonstrated significant improvement both clinically and radiologically.

An unusual case of a traumatic dorsal transscaphoid perilunate dislocation occurring through an isolated scaphoid non-union is presented. This set of circumstances has not, to the authors' knowledge, been described previously.

We report the first case of envenomation by the billygoat plum stinging caterpillar, Thosea penthima Turner (Limacodidae). The sting, on the forearm, caused immediate burning pain and local wheal formation. Pain radiated up the arm and there was severe "crushing" chest pain lasting four hours. The local pain persisted for 10 hours and required opiate analgesia.

Lethal jellyfish envenoming is a very rare event. Two illustrative cases of fatalities following envenomation from the multi-tentacled box jellyfish, Chironex fleckeri, are reported that involved a six-year-old boy and a three-year-old girl, both of whom had been playing in shallow beach waters in remote Northern Territory communities (Australia). A recommended approach to autopsy in suspected cases is described, which should include examination of the clothing and skin surfaces for the fine tentacles of Chironex fleckeri. In addition, the combined length and maximum width of tentacle marks should be measured/calculated and collection of unfixed tentacles with adhesive tape onto a glass slide should be undertaken to check for nematocysts. Such rare cases show that children are at higher risk of a lethal outcome, particularly if they are resident in remote coastal tropical communities.

This communication reports invasive amoebic colitis and late onset amoebic liver abscess in three members of a group of 12 Australian travellers to Timor-Leste (TL). This is the first report of Entamoeba histolytica infection from TL. Clinicians in Australia need to consider amoebiasis in the differential diagnosis in travellers returning with colitis, abdominal pain and fever. Presentation with amoebic liver abscess months after exposure is rare but should be suspected in symptomatic individuals with a relevant history of travel.

We describe the first case of possible pulmonary chromoblastomycosis in the absence of any identified cutaneous lesions in a relatively immunosuppressed man. The causative organism was Cladophialophora arxii, which is a rare pathogen that has only been described as causing human disease two times previously.

A man with a long history of depression had recently borrowed a rifle. His body was found on its back in bed in his caravan. A rifle lay over the body with the muzzle pointing towards the head. A suicide note was found at the scene. Autopsy revealed entry via the nose with the track passing through the base of the skull to the right parietal region where the main bullet fragments were located beneath the scalp. The history, scene and autopsy findings were consistent with the gunshot wound being suicidal. We can find only one mention of a suicidal gunshot wound with nasal entry in the English-language literature, although a personal communication informed us of a similar case in the Republic of Ireland within the past two years. We report this case because of its unusual nature.

Endemic histoplasmosis occurs uncommonly in Australia and has not previously been reported in the tropical Northern Territory, nor in Aboriginal Australian patients. We report one suspected and one confirmed case of severe disseminated histoplasmosis in Aboriginal Australians from the Northern Territory. Underlying illness included chronic cardiac disease and Type 1 diabetes mellitus, respectively, and neither patient was infected with HIV. The clinical presentations resembled malignancy. Diagnosis of histoplasmosis was made on the basis of bowel histology in Case 1, demonstrating characteristic yeasts, and lymph node histology and culture in Case 2. Histoplasmosis should be considered in relevant clinical situations, even in HIV-negative patients who have not left Australia.

Hyponatraemia-induced rhabdomyolysis is a rare, but reported phenomenon, particularly in patients with chronic schizophrenia on depot antipsychotics prone to psychogenic polydipsia. To the best of our knowledge, there are no reported cases of hyponatraemia-induced rhabdomyolysis complicated by oligo-anuric acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT). The initiation of CRRT is complicated in severe hyponatraemia, predominantly due to the need to avoid rapid changes in tonicity associated with rapid changes in sodium. We report a case of severe hyponatraemia (104 mmol/L) complicated by oligo-anuric rhabdomyolysis-induced AKI and our management of the renal prescription.