The calcium tablet in the bronchus, the ascites that was endometriosis, and four other surprises

An airway CT showed a bright object that turned out to be a calcium tablet. A patient with recurrent, massive bloody ascites had endometriosis rather than one of the usual explanations. In four other reports, a child's blood pressure crisis came from a diseased aorta, a clot-buster bled into a knee, an eye mass became a rare fibrous tumour, and congenital adrenal hyperplasia later collided with Addison's disease. All six cases were published online by BMJ Case Reports between August 4 and August 14, 2026. 1

Published online August 14, 2026 — Airway calcium pill aspiration syndrome. 2

A man in his early 70s developed acute cough and shortness of breath for two days after taking his usual nighttime medicines. The chest CT did not show an obviously recognisable tablet. It showed a hyperdense lesion inside the right bronchus intermedius, the airway that carries air toward the middle and lower parts of the right lung. 2

That finding left a deceptively broad question: was this a lesion in the airway, or a foreign body that had acquired the appearance of one? Bronchoscopy under general anaesthesia confirmed an object. The team used a cryoprobe through a rigid bronchoscope and removed it intact. It was a calcium tablet. 2

Pills create a particular diagnostic problem because their coating, solubility, and chemical ingredients can produce airway reactions unlike those caused by a solid food fragment. The report's useful detail is the sequence: respiratory symptoms after medication, a dense bronchial finding on CT, and a retrieval technique chosen for a suspected foreign body. The successful extraction resolved the immediate puzzle; the case is a reminder that a patient's medication list can contain the object seen on the scan.

Published online August 13, 2026 — Endometriosis presenting as recurrent massive haemorrhagic ascites. 3

Haemorrhagic ascites means that the fluid collecting in the abdomen contains a large amount of blood. The common explanations include cirrhosis, malignancy, and iatrogenic injury. This patient had recurrent, massive haemorrhagic ascites, but an extensive work-up for those familiar causes was negative. 3

The decisive step was laparoscopic tissue sampling. Pathology confirmed endometriosis, moving the case from a search for liver disease, cancer, or a procedure-related complication to a rarer pelvic explanation. 3

The diagnostic trap is the volume of blood. A large haemorrhagic effusion makes the dangerous common causes feel mandatory, while the unusual cause stays outside the first frame. This report ends at the biopsy that established the diagnosis rather than offering a dramatic recovery story. Its value is earlier in the pathway: when the usual causes have been investigated and the fluid keeps returning, the differential has to widen on evidence, not on how familiar the first list feels.

Published online August 6, 2026 — Paediatric midaortic syndrome associated with ascending aortic and renal aneurysm managed with complex multidisciplinary medical management and surgical repair. 4

A previously healthy girl in middle childhood arrived in hypertensive emergency, with a blood pressure above 200/100 mm Hg. Her upper and lower extremities also showed a marked pressure gradient. That combination pointed away from ordinary childhood hypertension and toward a problem in the aorta and its branches. 4

The report identified midaortic syndrome with ascending aortic dilation and renal-artery disease. The high pressure was renovascular: the circulation supplying the kidneys was part of the problem, so controlling the number on the cuff required more than adding medication. Hypertension remained refractory despite four drugs: amlodipine, metoprolol, losartan, and transdermal clonidine. 4

The repair was correspondingly large. Surgeons performed an aorto-aortic bypass and revascularised the superior mesenteric artery and both renal arteries by reimplantation. At 18 months, the child was normotensive on losartan alone, and both her symptoms and left-ventricular hypertrophy had resolved. 4

The clinical twist is visible before the final diagnosis: a blood-pressure reading that changes sharply with body location is an anatomical clue. In this case, the numbers did not merely measure severity. They mapped where the circulation was failing.

Published online August 10, 2026 — Spontaneous haemarthrosis after tenecteplase administration for acute ischaemic stroke. 5

A man in his 70s received tenecteplase, a genetically modified fibrinolytic drug, for acute ischaemic stroke. Four hours later, he developed sudden pain and swelling in his right knee. There had been no trauma and no coagulopathy to explain the joint findings. 5

Arthrocentesis confirmed haemarthrosis, bleeding into the joint, and relieved his symptoms. BMJ Case Reports describes the event as a rare extracranial bleeding complication of tenecteplase. 5

The timing made the drug the leading suspect, but the location made the diagnosis easy to miss. A painful swollen knee usually sends clinicians toward trauma, infection, crystal disease, or a chronic bleeding tendency. Here, the important clue was the new symptom arriving shortly after systemic fibrinolysis, with the usual alternatives absent.

Tenecteplase is given as a single bolus and is increasingly used in acute ischaemic stroke because of its fibrin specificity, according to the report. The case adds a joint to the list of places clinicians should inspect when a patient develops new bleeding symptoms after thrombolysis. 5

Published online August 4, 2026 — Solitary fibrous tumour of the conjunctiva: a rare presentation. 6

A man in his early 50s had a painless, slowly growing mass on the temporal bulbar conjunctiva of his right eye for four months. It was firm, well demarcated, and beneath the surface. Anterior-segment optical coherence tomography showed a compact, mildly reflective subepithelial lesion with back-shadowing. The initial clinical possibilities included benign reactive lymphoid hyperplasia and conjunctival lymphoma. 6

Excisional biopsy changed the category. Histopathology showed a stromal tumour made of spindle cells in short fascicles. Nuclear staining for STAT6 supported the diagnosis of a solitary fibrous tumour, a rare connective-tissue tumour in this location. 6

The treatment also depended on the second look. After excision, the patient received ruthenium-106 plaque radiotherapy at a dose of 50 Gy. At 18 months, there were no signs of recurrence. 6

This is a quieter diagnostic reversal than a foreign body or a blood-pressure crisis. The lesion looked like several more common entities until imaging, morphology, and immunohistochemistry were read together. A plausible first differential was still useful; it simply was not the final answer.

Published online August 14, 2026 — Congenital adrenal hyperplasia, ovarian adrenal rest tumours and Addison's disease: an exceptional clinical constellation. 7

A woman in her 20s had congenital adrenal hyperplasia, clinically diagnosed as 11β-hydroxylase deficiency. She also developed adrenal-rest tumours in both ovaries, autoimmune Addison's disease, and premature ovarian insufficiency. These are distinct adrenal and ovarian problems crowded into one clinical history. 7

The reproductive course made the case harder to compress into one expectation. Despite the congenital adrenal hyperplasia and bilateral ovarian tumours, she conceived spontaneously twice. Glucocorticoid therapy was followed by complete regression of the tumours. 7

Years later, the direction changed. She developed an Addisonian crisis, with autoimmune disease confirmed by positive 21-hydroxylase antibodies. Ovarian failure and mineralocorticoid deficiency followed. 7

The unusual feature is the collision of mechanisms over time: a congenital adrenal disorder, hormone-responsive ovarian lesions, and later autoimmune adrenal failure. The case resists the urge to make every finding part of one tidy syndrome. Sometimes the correct diagnosis is a stack of diagnoses, each explaining a different chapter.

Across these reports, the decisive clue was a mismatch. The object in the airway looked like a lesion. The abdominal blood had no usual cause. A child's blood pressure changed with the anatomy of the aorta. A swollen knee appeared after fibrinolysis. An eye mass required tissue and staining to identify it. A long endocrine history acquired a second adrenal disease years later.

That is the useful habit these cases leave behind: when a plausible label explains most of a patient but leaves one conspicuous finding outside the frame, treat the mismatch as data. The next scan, sample, stain, or targeted question should explain the leftover detail rather than force it back into the first diagnosis.