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Accurate and timely assessment of suspected acute aortic syndrome is crucial in this life-threatening condition. Imaging with CT plays a central role in the diagnosis to allow expedited management. Diagnosis can be made using locally available expertise with optimized scanning parameters, making full use of recent advances in CT technology. Each imaging centre must optimize their protocols to allow accurate diagnosis, to optimize radiation dose and in particular to reduce the risk of false-positive diagnosis that may simulate disease. This document outlines the principles for the acquisition of motion-free imaging of the aorta in this context., published_or_final_version

High resolution computed tomography (HRCT) is an effective technique for demonstrating the lung parenchyma in detail and overcomes many of the inadequacies of chest radiography in the diagnosis of diffuse lung disease. This article reviews the role of HRCT in the management of patients with chronic infiltrative lung disease, occupational lung disease, airways disease and acute and sub-acute lung disease.

An increase in the prevalence of gallstones has been reported from the Middle East and the Republic of Yemen. Changing dietary habits and obesity are thought to be responsible but other local factors may contribute such as chewing the leaves of the khat plant (Catha edulis Forsk.) which is a widespread social custom in Yemen. We have studied the effects of khat chewing on gallbladder motility in a group of 10 healthy volunteers. All subjects underwent ultrasound measurements of gallbladder volume after chewing khat leaves or lettuce, which was used as the control. Results were compared after chewing for up to 2h in the fasting state and in response to a fatty meal. There was no significant change in gallbladder volume after chewing khat compared with lettuce in the fasting state (P=0.7) or in gallbladder emptying after a fatty meal (P=0.4) and we conclude that khat chewing has no clinically significant effect on gallbladder motility.

In patients with transposition of the great arteries, the identification of coronary anatomy is fundamental to optimal surgical outcome. A number of classifications describing the coronary vessels' origin and course in transposition of the great arteries have been published. However, all are limited to operative or pathological case series. They are often alphanumeric classifications that do not lend themselves to clinical practice; they do not consider certain important anatomical variations that may increase surgical morbidity and mortality, nor do they fully delineate coronary anatomy or define the relationship to adjacent structures seen with cardiovascular computed tomography. Using cardiovascular computed tomography for illustrative purposes, we propose and validate a universal sequential descriptive classification and an associated alphanumeric classification that may be used for all coronary anomalies with or without associated congenital heart disease.

In order to characterize the appearances of bronchiolitis obliterans on high-resolution CT (HRCT) and to relate the extent of HRCT abnormalities to pulmonary function tests, the HRCT scans of 18 patients with bronchiolitis obliterans were examined by two independent observers. The underlying causes for the development of bronchiolitis obliterans were penicillamine therapy (n = 5), previous infection (n = 4), graft-vs-host disease (n = 3), and miscellaneous causes (n = 6). Abnormal HRCT findings were present in all cases. The commonest HRCT abnormalities consisted of patchy areas of decreased parenchymal attenuation (n = 15), subsegmental (n = 12) and segmental (n = 6) bronchial dilatation and centrilobular branching structures (n = 5). There was no significant correlation between the extent of abnormalities and the static lung volumes or the impairment in gas transfer (all P values0.05). The only significant correlation was between the number of segments with subsegmental bronchial dilatation and the forced expiratory volume in one second (Wilcoxon r = 0.61, P0.01). We conclude that the great majority of patients with bronchiolitis obliterans have HRCT abnormalities. However, there is poor correlation between the extent of abnormalities on HRCT and functional impairment.

High-resolution computed tomography (HRCT) may show parenchymal abnormalities in patients with normal or questionable findings on the chest radiograph; and because it provides an accurate assessment of the pattern and distribution of lung disease, it also improves the accuracy of the differential diagnosis. HRCT may be able to distinguish areas of potentially reversible disease from irreversible fibrosis and be a helpful guide to the optimal type and site of lung biopsy. This review summarizes the current indications for HRCT of the chest in the assessment of patients with acute lung disease, chronic infiltrative lung disease, pneumoconiosis, bronchiectasis, and emphysema.

A joint initiative by the British Thoracic Society and the Society for Cardiothoracic Surgery in Great Britain and Ireland was undertaken to update the 2001 guidelines for the selection and assessment of patients with lung cancer who can potentially be managed by radical treatment.

Whilst parenchymal changes in pulmonary sequestrations are well described, there are comparatively little data on associated vascular changes and their extent. The aim of this study was to retrospectively review morphological changes within sequestrations, concentrating on vascular changes and associations with clinical parameters.Twenty-seven resected cases of sequestrations (intralobar n = 20, extralobar n = 7) showed a male predominance (n = 16) and an age range of 2 months-60 years (average 13 years). Plexogenic vascular changes (medial hypertrophy and intimal fibrosis) were seen in 15 of 27 cases, as well as plexiform lesions in seven cases. Patients with plexogenic changes had a higher mean age compared with those lacking vascular changes (19 versus 6 years) and were more commonly female. Respiratory tract infections were associated solely with intralobar sequestrations. No other associations between presenting symptoms and histopathological parameters were identified. Adjacent lung showed lesser plexogenic changes in six of 22 intralobar cases. There were features of type 2 congenital cystic adenomatoid lesions in 63% of cases. Dissection of the supplying systemic artery (n = 1), intralesional aspergilloma (n = 1) and coexistent lymphangiomatosis (n = 1) were also identified.Hypertensive vascular changes are not uncommon in both intrapulmonary and extrapulmonary sequestrations, although their relative severity seems unrelated to presenting symptoms.

A prospective study was performed comparing computed and conventional radiography for the detection and visibility of cardiovascular devices in intensive care unit patients. Computed images were obtained using a commercially available 2K x 2K, 12-bit storage phosphor plate system. Image sets from 50 patients were assessed independently by three observers. A significant difference between the types of image was found for the detection of mediastinal drainage tubes and prosthetic valves. Computed images allowed greater confidence in the identification of courses and tips of lines. This advantage was most marked with edge- enhanced computed images. Consistent high-quality portable chest radiographs are difficult to obtain. Computed radiography employing reusable photostimulable phosphor plates has several advantages: the wide dynamic range of these imaging plates ensures that retakes due to incorrect exposure are rarely necessary. In addition, a reduction in radiation dose to the patient, whilst obtaining high-quality images, can be achieved (Cohen et al, 1989). Digital aquisition of the image enables post-processing such as contrast manipulation and edge enhancement. A theo- retical disadvantage of computed radiographic systems is their reduced spatial resolution. Conventional screen/ film combinations have a resolution of greater than 10 line pairs/mm whilst computed systems achieve at best 5 line pairs/mm in adult chest radiography. In most centres, portable chest radiography is most frequently requested on the intensive care unit and in this context the evaluation of drains, catheters and other cardiovascular devices is of prime importance. These devices also lend themselves to detection studies as their presence or absence can be verified with certainty. We undertook a prospective study to compare objectively the performance of a computed radiographic system, the first of its kind in clinical operation in the UK, with conventional film/screen radiography in this setting. The degree to which post-processing of the digital image improved the detection of cardiovascular devices was also investigated.

BACKGROUND: This study was designed to measure inter-observer variation between thoracic radiologists in the diagnosis of diffuse parenchymal lung disease (DPLD) using high resolution computed tomography (HRCT) and to identify areas of difficulty where expertise, in the form of national panels, would be of particular value. METHODS: HRCT images of 131 patients with DPLD (from a tertiary referral hospital (n = 66) and regional teaching centres (n = 65)) were reviewed by 11 thoracic radiologists. Inter-observer variation for the first choice diagnosis was quantified using the unadjusted kappa coefficient of agreement. Observers stated differential diagnoses and assigned a percentage likelihood to each. A weighted kappa was calculated for the likelihood of each of the six most frequently diagnosed disease entities. RESULTS: Observer agreement on the first choice diagnosis was moderate for the entire cohort (kappa = 0.48) and was higher for cases from regional centres (kappa = 0.60) than for cases from the tertiary referral centre (kappa = 0.34). 62% of cases from regional teaching centres were diagnosed with high confidence and good observer agreement (kappa = 0.77). Non-specific interstitial pneumonia (NSIP) was in the differential diagnosis in most disagreements (55%). Weighted kappa values quantifying the likelihood of specific diseases were moderate to good (mean 0.57, range 0.49-0.70). CONCLUSION: There is good agreement between thoracic radiologists for the HRCT diagnosis of DPLD encountered in regional teaching centres. However, cases diagnosed with low confidence, particularly where NSIP is considered as a differential diagnosis, may benefit from the expertise of a reference panel.

PURPOSE: To assess the ability of a semi-quantitative latex agglutination D-dimer test Accuclot™ with bedside measurements of arterial oxygen saturation, respiratory and cardiac rates to exclude pulmonary embolism (PE) on computed tomographic pulmonary angiography (CTPA). MATERIALS AND METHODS: All patients referred to our CT unit for investigation of suspected acute pulmonary embolism were enrolled. Pulse oximetery, respiratory rate, heart rate and blood sampling for D-dimer testing were carried out just before CT. A high resolution CT (HRCT) of the chest was followed by a CT pulmonary angiogram (CTPA). The images were independently interpreted at a workstation with cine-paging and 2D reformation facilities by three consultant radiologists blinded to the clinical and laboratory data. If positive, the level of the most proximal embolus was recorded. Discordant imaging results were re-read collectively and consensus achieved. RESULTS: A total of 101 patients were enrolled. The CTPA was positive for PE in 28/101 (28%). The D-dimer was positive in 65/101 (65%). Twenty-six patients had a positive CT and positive D-dimer, two a positive CT but negative D-dimer, 39 a negative CT and positive D-dimer, and 34 a negative CT and negative D-dimer. The negative predictive value of the Accuclot™ D-dimer test for excluding a pulmonary embolus on spiral CT was 0.94. Combining the D-dimer result with pulse oximetry (normal Sa O 2 ⩾ 90%) improved the negative predictive value to 0.97. CONCLUSION: A negative Accuclot™ D-dimer assay proved highly predictive for a negative CT pulmonary angiogram in suspected acute pulmonary embolus. If this D-dimer assay were included in the diagnostic algorithm of these patients a negative D-dimer would have unnecessary CTPA rendered in 36% of patients. Burkill, G. J. C.et al. (2002). Clinical Radiology57, 41–46.

Transthoracic ultrasound (US) of the chest is useful in the evaluation of a wide range of peripheral parenchymal, pleural, and chest wall diseases. Furthermore, it is increasingly used to guide interventional procedures of the chest and pleural space. The technique lends itself to bedside use in the intensive care unit, where suboptimal radiography may mask or mimic clinically significant abnormalities. The authors discuss the uses, techniques and applications of US of the chest. The sonographic appearances of pleural diseases (pleural effusion, pneumothorax, pleural mass, and mesothelioma), parenchymal diseases (pneumonia, neoplasms, heart failure, infarct, and rounded atelectasis), chest wall abnormalities (chest wall tumor and rib fracture), and diaphragmatic paralysis are discussed. The use of US in guiding biopsy, thoracocentesis, and other interventional procedures of the lung, pleural space, and mediastinum are also reviewed.

The aim of this study was to describe the imaging features of pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma. The chest radiographs (n = 18) and CT scans (n = 17) of 24 patients (18 men and 6 women) aged 27–78 years (mean = 56 years), with a known diagnosis of pulmonary MALT lymphoma, were retrospectively reviewed by two radiologists and the imaging findings are described. Six of the 24 patients had a history of an autoimmune disorder and 1 patient had acquired immune deficiency syndrome. Multiple pulmonary lesions were identified in 19 of 24 patients (79 %) and solitary lesions in 4 of 24 patients (17 %). Diffuse pulmonary infiltration was present in 1 patient. Lesions included masses or mass-like areas of consolidation (n = 21) and pulmonary nodules (n = 18). Associated findings were air bronchograms, airway dilatation, a positive angiogram sign and a halo of ground-glass shadowing at lesion margins. Peribronchovascular thickening was also observed, as were hilar or mediastinal lymph node enlargement and pleural effusions or thickening. Although rare, the diagnosis of pulmonary MALT lymphoma should be considered in patients with the imaging features described, particularly when in association with an indolent clinical course or a history of autoimmune disease.

Bronchioloalveolar cell carcinoma has a wide spectrum of pathologic and radiologic appearances. Some of the radiologic features are characteristic enough to suggest the underlying pathologic changes. This article illustrates the various manifestations of bronchioloalveolar cell carcinoma on high-resolution CT (1.5-mm collimation reconstructed with a high-spatial-frequency algorithm). Correlations between the CT and pathologic findings are included.

AIM: To evaluate the use of ultrasound-guided percutaneous injection of thrombin for treatment of femoral artery pseudoaneurysms. METHOD: Nine patients with a confirmed femoral false aneurysm were included in the study. 0.5–1ml of a 2000U/ml solution of activated bovine thrombin was injected under ultrasound visualization into the neck of the aneurysm to induce thrombosis. The parent artery and adjacent major vessels were checked during and after the procedure to exclude propagation of thrombus. A check ultrasound examination was undertaken on the following day. RESULTS: Eight patients were successfully treated by a single injection. One patient required a second injection due to recurrence of their pseudoaneurysm 4 days after the initial treatment. The procedure was well tolerated in all cases and no complications were encountered. CONCLUSION: This small series provides further evidence that ultrasound-guided thrombin injection is a promising new method for the treatment of femoral false aneurysms.Hughes, M. J. et al . (2000). Clinical Radiology 55 , 749–751.

AIMS: To document the presence and extent of air trapping on high resolution computed tomography (HRCT) in patients with pulmonary sarcoidosis and correlate HRCT features with pulmonary function tests. METHODS: Twenty-one patients with pulmonary sarcoidosis underwent HRCT and pulmonary function assessment at presentation. Inspiratory and expiratory HRCT were assessed for the presence and extent of air trapping, ground-glass opacification, nodularity, septal thickening, bronchiectasis and parenchymal distortion. HRCT features were correlated with pulmonary function tests. RESULTS: Air trapping on expiratory HRCT was present in 20/21 (95%) patients. The extent of air trapping correlated with percentage predicted residual volume (RV)/total lung capacity (TLC) (r = 0.499; P < 0.05) and percentage predicted maximal mid-expiratory flow rate between 25 and 75% of the vital capacity (r = -0.54; P < 0,05). Ground-glass opacification was present in four of 21 (19%), nodularity in 18/21 (86%), septal thickening in 18/21 (86%), traction bronchiectasis in 14/21 (67%) and distortion in 12/21 (57%) of patients; there were no significant relationships between these CT features and pulmonary function results. CONCLUSION: Air trapping is a common feature in sarcoidosis and correlates with evidence of small airways disease on pulmonary function testing. (C) 2000 The Royal College of Radiologists.

AIM: To determine current clinical practice in the radiological diagnosis of acute pulmonary embolism and assess the use of spiral volumetric computed tomography. METHOD: A survey of 327 acute hospitals including cardiothoracic and orthopaedic tertiary referral centres was undertaken to assess current utilization of lung scintigraphy, spiral computed tomography and pulmonary angiography in the investigation of suspected pulmonary embolism. Responses were received from 215327 (66%) centres. RESULTS: Lung scintigraphy was provided by 208 hospitals (144 on-site and 64 off-site). Spiral CT services were provided by 111 (52%) hospitals (on- or off-site), 142 (66%) units had access to angiography facilities. Sixty-three centres out of 215 (29%) offered both on-site lung scintigraphy and spiral CT while only 41215 (19%) hospitals were able to undertake all three tests on-site. On average, 501 perfusion (Q) or ventilation-perfusion (V/Q) scintigrams were performed per hospital per year with 26 spiral CT studies and just 4.6 pulmonary angiograms. CONCLUSION: These data suggest that lung scintigraphy is frequently the only imaging test in patients other than chest radiography, despite the large number of indeterminate results reported in most series.

Individual features of small airways disease depicted at computed tomography (CT) were correlated with functional indexes in patients with obliterative bronchiolitis.Fifteen patients (all women) who fulfilled the strict criteria for diagnosis of obliterative bronchiolitis underwent thin-section CT at full inspiration and at end expiration. The CT scans were scored by two observers for extent of decreased attenuation of the lung parenchyma; end-expiration CT signs of air trapping; and bronchial dilation, wall thickening, and mucous plugging. The functional importance of each CT sign was evaluated.Areas of decreased attenuation were present in all patients (median score at end expiration, 61%; range, 21%-83%). Bronchial wall thickening was identified in 13 of the 15 patients. Correlations of the extent of decreased attenuation and measures of air-flow obstruction were strongest between decreased attenuation at end expiration and air flow at low lung volumes (r(s) = -.70, P.005). This relationship remained intact after correction for the severity of bronchial wall thickening.In patients with obliterative bronchiolitis, the extent of decreased attenuation at CT was most strongly related to depression of pulmonary function tests of the small airways. Decreased attenuation is the cardinal sign for further quantitative studies of obliterative bronchiolitis.

To correlate the pattern and extent of abnormalities on thin-section computed tomographic (CT) scans with pulmonary function test results in subacute and chronic hypersensitivity pneumonitis.Thin-section scans (1-3 mm collimation) obtained in 22 patients were assessed for pattern of abnormality and extent of disease. CT scores were correlated with functional parameters by using Spearman rank correlation and forward stepwise regression analysis.The most common CT patterns were decreased attenuation and mosaic perfusion (n = 19), ground-glass opacification (n = 18), small nodules (n = 12), and a reticular pattern (n = 8). Areas of decreased attenuation correlated with severity of air trapping indicated by residual volume (r = .58, P.01), whereas ground-glass opacification and reticulation correlated independently with restrictive lung function.Areas of decreased attenuation and mosaic perfusion are an important ancillary CT finding in hypersensitivity pneumonitis, and obstructive functional abnormalities indicate that this phenomenon is caused by bronchiolitis.

The purpose of this study was to compare the sensitivities and diagnostic accuracies of chest radiography and CT in the assessment of diseases of the trachea and main bronchi in regard to detection, evaluation of focal vs diffuse disease, separation of benign from malignant disease, and accuracy of diagnosis.The chest radiographs and CT scans of 35 patients with proved diseases of the trachea and main bronchi and five control subjects were randomly assessed by two independent observers in a blind study. The diagnoses included 25 malignant and 10 benign conditions. The malignant lesions included 24 primary tumors and one metastatic melanoma. The benign lesions included two benign tumors, two tracheal stenoses, one focal amyloidosis, one tracheomalacia, and four miscellaneous diffuse abnormalities. The observers were asked to determine if an abnormality was present, to classify it as focal or diffuse and as benign or malignant, and to list the three most likely diagnoses. Sensitivities were compared by using the McNemar test.The sensitivity of both observers in detecting disease on the chest radiograph was 66%. The sensitivity on the CT scan was 97% for the first observer and 91% for the second observer (p.01). Both observers were able to correctly classify the detected abnormalities as either focal or diffuse in 91% of cases on the chest radiographs and 97% of cases on the CT scans. The abnormalities were correctly classified as either benign or malignant in 78% of cases by both observers on the chest radiographs and in 85% and 78% of cases on the CT scans by the first observer and the second observer, respectively. The correct diagnosis was included in the list of the three most likely diagnoses in 61% of cases by both observers after reviewing the radiographs and in 56% of cases by one observer and 63% of cases by the other observer after reviewing the CT scans.CT is superior to chest radiography in allowing detection of abnormalities of the major airways. Both CT and chest radiography are accurate for differentiating focal from diffuse disease, but neither technique is accurate for distinguishing benign from malignant disease or for establishing a specific diagnosis.

To compare the abilities of computed tomography (CT) and radiography in detection and diagnosis of acute pulmonary complications in immunocompromised non-AIDS patients, the CT scans and radiographs of 45 immunocompromised non-AIDS patients with proven pulmonary disease and 20 normal controls were independently assessed by two observers, without knowledge of clinical or pathologic data. The observers listed the three most likely diagnoses and their degree of confidence in the first-choice diagnosis on a three-point scale. The sensitivity and specificity in detecting pulmonary complications was 100% and 98% for CT, compared to 98% and 93%, respectively, for chest radiography. In the immunocompromised patients, the first-choice diagnosis was correct in 44% of CT and 30% of radiograph readings (P0.01). The correct diagnosis was among the top three diagnoses in 70% of CT scans and 53% of radiograph readings (P0.01). Confidence level one (definite) was reached in 33% of CT scans and 10% of chest radiographs (P0.001). Diseases with a dominant nodular pattern had a higher occurrence of correct first-choice diagnosis (62% vs 34%, P0.02) and level one confidence ratings (53% vs 13%, P0.001) than diseases with ground-glass opacity, consolidation or irregular linear opacities. We conclude that chest radiographs and CT scans have comparable sensitivity in detecting acute pulmonary complications in immunocompromised non-AIDS patients. CT is superior to chest radiography in the differential diagnosis of acute pulmonary complications in these patients.

The purpose of the study was to determine if the distribution of pulmonary opacities on CT scans could be used to predict the outcome of bronchoscopic biopsy procedures in immunocompromised non-AIDS patients with acute pulmonary complications.Thirty-three consecutive immunocompromised patients without AIDS who had acute pulmonary complications and who had had CT, bronchoscopic biopsy procedures, and proved diagnoses were included in the study. The distribution and dominant pattern of pulmonary opacities on CT were assessed independently by two observers. The pathologic diagnoses were invasive aspergillosis (eight), Candida pneumonia (six), bronchiolitis obliterans with or without organizing pneumonia (six), drug-induced lung disease (four), Pneumocystis carinii pneumonia (four), cytomegalovirus pneumonia (three), pulmonary hemorrhage (one), and recurrent lymphoma (one).The results of bronchoscopic techniques established a specific diagnosis in 17 patients (52%). In the remaining 16 patients, results of bronchoscopic biopsy could not be used to establish a specific diagnosis; open lung biopsy (15 patients) or transthoracic needle biopsy (one patient) were required for diagnosis. The results of bronchoscopic procedures were diagnostic more often in patients in whom pulmonary opacities involved the central third of the lung than in patients in whom the central third was spared (70% vs 23%, p = .02). Results were diagnostic more often in cases in which the causes of acute pulmonary complications were infectious than in cases in which the causes were noninfectious (71% vs 17%, p.005).We conclude that the presence or absence of central disease as shown by CT can be used to suggest whether results of bronchoscopic procedures in immunocompromised non-AIDS patients will be diagnostic.

The authors describe the computed tomographic (CT) appearances in three patients with pulmonary talcosis resulting from chronic intravenous drug abuse. There was widespread ground-glass attenuation in one case and an appearance similar to that of progressive massive fibrosis in two cases. In the latter cases, there were confluent perihilar masses with areas of high attenuation. While the CT appearances may be suggestive of pulmonary talcosis, tissue sampling is required for definitive diagnosis.

In order to determine the potential clinical utility of high-resolution CT (HRCT) in the assessment of drug-induced lung disease, we reviewed the chest radiographs and HRCT scans of 23 patients and five normal controls. The radiographs and HRCT scans were reviewed separately in random order by two independent observers who were not aware of the relative numbers of patients and controls. Abnormal findings were detected in the affected patients in 17/23 radiographs compared to 23/23 HRCT scans. The patients included five cases of bleomycin toxicity, five cases of nitrofurantoin toxicity, two cases each of penicillamine, busulphan, BCNU and amiodarone toxicity, and one case each of cyclophosphamide, procainamide, mitomycin and methotrexate toxicity. The HRCT appearances could be grouped into four categories according to their dominant pattern and distribution of disease. These include fibrosis with or without consolidation ( n = 12), ground-glass opacities ( n = 7), widespread bilateral consolidation ( n = 2), and bronchial wall thickening with areas of decreased attenuation ( n = 2). The results of this study indicate that HRCT is more sensitive than the radiograph in the detection of drug-induced lung disease. The appearances demonstrated by HRCT reflect the pathological mechanisms of drug-induced lung disease

To evaluate the manifestations of chronic hypersensitivity pneumonitis at radiography and high-resolution computed tomography (HRCT), findings in 16 patients with this disease were reviewed. To ensure objectivity, 50 patients with other chronic infiltrative lung diseases (fibrosing alveolitis [n = 29], sarcoidosis [n = 16], and miscellaneous conditions [n = 5]) were included. All patients had chronic disease with evidence of fibrosis at HRCT, as indicated by irregular linear areas and architectural distortion. Radiographs and HRCT scans were reviewed separately, in random order, and without knowledge of diagnosis. On radiographs and HRCT scans, the fibrosis in cases of hypersensitivity pneumonitis was situated predominantly in the middle lung zones or showed no zonal predominance. Lung apices and bases were relatively spared in all cases. The distribution of fibrosis in the transverse plane was random in seven cases, subpleural in six, and peri-bronchovascular in three. The distribution of fibrosis can allow distinction of chronic hypersensitivity pneumonitis from other causes of fibrosis in many cases.

Calcium channel blocker (CCB) therapy has an established role in the treatment of hypertension, but in a small proportion of patients, the side effect profile of these drugs may limit their use. The commonest clinical adverse effects include ankle swelling, flushing, headache, palpitations and constipation. We describe an unusual case where ankle swelling was associated with bilateral achilles tendonitis.