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.

Clinicians must be aware of atypical presentations of common conditions. Appendiceal perforation with peritonitis and sepsis presenting with cholestatic jaundice is an important example, given the prevalence of the condition and the mortality associated with delayed diagnosis. The authors describe a case seen at their hospital.

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.

Reported here is a case of cerebral Mycobacterium avium complex infection that occurred in an HIV-infected patient, who had been treated for disseminated infection and had discontinued clarithromycin and ethambutol following a significant rise in his CD4+ T-cell count after starting highly active antiretroviral therapy. He responded well to excision of the lesion and reinstitution of multidrug therapy. Caution should be exercised when considering ceasing maintenance therapy for disseminated Mycobacterium avium complex infection in HIV-infected patients who demonstrate an apparently good immunologic response to highly active antiretroviral therapy, as this response may not necessarily restore protective immunity against all opportunistic pathogens.

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.

Donovanosis (Granuloma inguinale) is an infectious disease, the effects of which are usually confined to the genital region. Various extragenital manifestations of the disease have been described. This report describes a case where the condition represented in the oral cavity some time after the apparently successful treatment of the genital lesion. Members of both the medical and dental profession serving the northern parts of Australia and adjacent tropical regions should be aware of the possibility of encountering this disease. Delay in its diagnosis may result in extensive tissue destruction and a potentially fatal outcome. Intensive antibiotic therapy followed by long-term follow-up is usually curative.

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.

Melioidosis is an infectious disease endemic in tropical northern Australia and Southeast Asia, and, if treated late or inappropriately, is usually fatal. We report a rare case of pleuro-pulmonary melioidosis with septicemia in a renal transplant recipient to highlight the potential risk of acquiring this infection in at-risk patients living in, or visiting, regions that are endemic for melioidosis, and to convey the importance of its early diagnosis and specific treatment.

A case is reported of a worker in an aluminium plant who was found lying in a shallow pool of concentrated caustic solution, which had been heated to approximately 95 degrees C. He had been employed to operate a pump draining a sump. A pressurised ruptured airline lay nearby, this being the likely precipitating cause of an alkaline spray. The spray led to the deceased running towards the nearest safety shower, at the base of which he was subsequently found. This is a relatively uncommon form of death, resulting from contact with a hot concentrated alkali solution. Subsequent experimentation indicated that the deceased had been in contact with the fluid for a period of approximately 13 min.

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.