Objective: Spontaneous pneumoperitoneum is a rare condition. It presents a challenge to the surgeon as the clinical presentation and radiological findings mimic perforated viscus resulting in unnecessary surgical intervention. The aim of this article is to describe a case of a spontaneous pneumoperitoneum in an elderly patient who underwent diagnostic. Methods: A 77-year-old female with multiple comorbidities presented to the emergency department with productive cough, shortness of breath, vomiting and abdominal pain. On examination she had tenderness in epigastric region. Chest X-ray and CT showed free air and fluid in peritoneal cavity. Results: The patient underwent diagnostic laparoscopy that did not reveal any gastrointestinal perforation Conclusion: Spontaneous pneumoperitoneum is frequently mistaken for perforated viscus. If the patient presents with features of peritonitis, diagnostic laparoscopy has a vital role as it prevents unnecessary midline laparotomy.

Acute confusional state is a challenging condition especially when present in young patients. I am presenting a challenging case of acute confusion in young patient which was not diagnosed in timely manner. Thirty three years old pleasant lady was initially admitted with fits and managed with sodium valproate. There were no past medical problems. No cause was found and she was discharged with outpatient neurologist follow up. One week later she was re-admitted with confusion, bizarre behaviour and personality change. Her confusion got worse and her personality was changed to that extent that her family and other ward members including nursing staff felt about demonic possession. This presentation was considered secondary to sodium valproate which was changed to phenytoin. Afterwards she went through extensive investigations including CT head, MRI head and spine, lumbar puncture, septic and autoimmune screen. Her pregnancy test was negative. LP results confirmed leucocytosis and EEG showed diff use abnormality. MRI head and MRV were normal. CSF culture did not grow any organism. She was treated with 14 days course of IV acyclovir for encephalitis which did not help and her condition deteriorated further and she was transferred to ITU. Neurologist subsequent review advised for VGKC, NMDA, GAD and paraneoplastic antibodies. NMDA receptor antibodies result later came back positive. She had a CT TAP and TV ultrasound which ruled out any ovarian malignancy. She was treated with immunoglobins and IV steroids and her condition improved slightly however later she aspirated during fi tting and was intubated and transferred to tertiary hospital where she received plasma exchange and got almost full recovery.