bluuebunny/crossref_metadata_2025 huggingface dataset:
Interstitial Lung Disease in a Patient Treated with Denosumab
Authors: Ana Campo Ruiz  , Miguel F Carrascosa  , Sergio Tapia Concha  , Anibal Hernández Gil  , Juan García Rivero
Published: May 2021

Denosumab is an antiresorptive agent widely used for treating osteoporosis. Atypical femur fractures, osteonecrosis of the jaw and hypocalcaemia are well-known possible adverse effects of this drug. We present, to our knowledge, the first case report in the English literature of clinically significant interstitial lung disease likely related to denosumab.
Gastric Cancer Presenting as Isolated Ascites: A Diagnostic Challenge
Authors: Ines Duarte  , Cristina Outerelo
Published: May 2021

Malignant ascites is a rare first manifestation of gastric carcinoma and is usually associated with symptoms which include early satiety, abdominal pain and deteriorating clinical state. The authors describe the case of a male patient presenting with malignant ascites of rapid onset which was the sole presentation of gastric cancer, highlighting the importance of upper gastric endoscopy even in the absence of gastrointestinal symptoms.
Catastrophic Gastrointestinal Bleeding: Always Consider Meckel’s Diverticulum
Authors: Filipa Pedro  , Joana Romano  , Marta Rebelo  , Rogério Matias  , Eduarda Carmo
Published: May 2021

Meckel’s diverticulum, a congenital malformation of the gastrointestinal tract, is asymptomatic in the majority of patients but can be associated with some complications. Gastrointestinal bleeding is one such complication and is more common in children than in adults. Despite the variety of examinations available, diagnosis can be difficult, especially in older patients, because the sensitivity of examinations decreases with patient age. Here we present the case of a young man with gastrointestinal bleeding in whom a diagnosis of Meckel’s diverticulum was made intra-operatively.
When Zoster Virus Hides a Primary Brain Lymphoma
Authors: Rafael Ferreira Nascimento  , João Miguel Freitas  , Maria da Luz Brazão
Published: May 2021

Aim: To describe an unusual presentation of a primary lymphoma of the central nervous system in a patient who, four months prior to admission, was diagnosed with herpes zoster ophthalmicus (HZO). Case description: A 68-year-old man, with a history of HZO, was admitted to the emergency department with nausea and vomiting that had persisted over the previous two weeks. Neurological evaluation showed right ptosis, divergent strabismus and anisocoria. Blood tests showed high c-reactive protein, while serology was negative for human immunodeficiency virus. A brain CT scan revealed three round lesions, slightly hyperdense, periventricular in the occipital and frontal regions, which biopsy revealed to be a diffuse large B-cell lymphoma. The patient started chemotherapy but progression to death was inevitable. Conclusion: The authors describe an unusual presentation of primary lymphoma of the central nervous system and urge physicians to be aware of this presentation in order to avoid misdiagnosis.
Water-pipe Smoking as a Risk Factor for Transmitting Mycobacterium tuberculosis
Authors: Anna Ursula Marchetti  , Oliver Louis Boss  , Carla Michelle Schenker  , Kaspar Kälin
Published: May 2021

A 20-year-old Swiss male presented at the emergency department with acute onset of febrile temperatures and hemoptysis and a 3-month history of productive cough. An X-ray and CT scan of the chest, sputum samples for acid-fast bacilli, polymerase chain reaction(PCR), and cultures for Mycobacteria revealed pulmonary infection with Mycobacterium tuberculosis. None of the classical risk factors for tuberculosis were present, but the patient reported regularly smoking a water pipe. Water-pipe smoking poses a serious risk of M. tuberculosis transmission.
When the Heart Triggers the Esophagus: Esophageal Spasm after Electrical Cardioversion
Authors: Riccardo Manfredo Campaner  , Marco Enzo Tau  , Francesca Ortelli  , Maria Luisa De Perna  , Tanja Fusi-Schmidhauser
Published: May 2021

Introduction:“Esophageal spasm” is a generic term widely used to attribute unexplained non-cardiac chest pain and/or dysphagia to an esophageal motility disorder. Patient and methods: The authors present the case of an 86-year-old male patient with complete dysphagia after an elective electrical cardioversion for atrial fibrillation. An upper endoscopy performed shortly after the onset of the clinical picture documented disordered esophageal contractions. The patient became asymptomatic within 12 hours of the administration of a spasmolytic therapy. Results: To the best of our knowledge, this is the first report of esophageal spasm after an electrical cardioversion. Discussion: The temporal correlation supports the explanation of a cause-effect relationship between the clinical presentation and the preceding procedure, thus providing elements for clinicians to recognize and treat this particular condition.
Purpura Fulminans: a Rare but Fierce Presentation of Pneumococcal Sepsis
Authors: Adeel Nasrullah  , Anam Javed  , Usman Tariq  , Meilin Young  , Zunera Moeen  , Marvin Balaan
Published: May 2021

Infectious purpura fulminans (PF) is a rare presentation of disseminated intravascular coagulopathy (DIC) due to diffuse intravascular thrombosis and haemorrhagic infarction of the skin. PF can present in infancy/childhood or adulthood and usually presents as ecchymotic skin lesions, fever and hypotension. It is most commonly a consequence of sepsis related to Neisseria meningitidis, Streptococcus pneumoniae or Haemophilus influenzae. Despite aggressive management of sepsis with intravenous fluids, antibiotics, and conventional and nonconventional therapies, the condition still carries a mortality rate of 43%[1]. Streptococcus pneumoniae mostly presents with community-acquired pneumonia. We present a case of PF secondary to DIC related to Pneumococcal sepsis in an otherwise healthy and immunocompetent patient.
Behçet’s Disease and Tuberculosis: A Complex Relationship
Authors: Sara Mendonça Freitas  , Joana Silva Marques  , Ana Grilo  , Rodolfo Gomes  , Fernando Martos Gonçalves
Published: May 2021

Behçet’s disease (BD) is a systemic vasculitis characterized by recurrent orogenital ulceration and several systemic manifestations (such as gastrointestinal involvement, vascular disease or arthritis). The pathogenesis is still unknown but the trigger role of certain pathogens such as Mycobacterium tuberculosis is well documented. Furthermore, patients with BD are more susceptible to tuberculosis due to immunity defects. Here, we describe the case of a 70-year-old woman with a history of recurrent oral aphthae and inflammatory arthritis presenting with extensive thrombosis of left upper limb major veins, a positive HLA B51 genotype and colon ulceration; hence, BD diagnosis was made after excluding other causes. Simultaneously, the patient had cutaneous abscesses not associated with immunosuppressive therapy with continuous development, and after recurrent negative tuberculosis work-up, M. tuberculosis was isolated in an abscess culture.
A First Sign Not to be Missed: Cutaneous Metastasis from Breast Cancer
Authors: Elsa Carina Alves Araújo  , Manuel Barbosa  , Raquel Costa  , Bárbara Sousa  , Vítor Costa
Published: May 2021

Cutaneous metastasis has a frequency of 1 to 10% among all metastatic cancer forms and breast cancer accounts for 30% of all cases. We report the case of a 73-year-old woman who presented with 4 skin lesions distributed across the upper trunk and abdomen; these had developed over a period of 12 months. Over the previous 6 months she had also developed anorexia, asthenia and weight loss. Upon investigation, a nodular mass was found in the left breast. Skin and breast mass biopsy were performed. Histology confirmed the diagnosis: infiltrating lobular breast cancer with cutaneous metastasis. The patient underwent hormonal treatment, mastectomy and radiotherapy. In rare cases, cutaneous metastasis appears as the first clinical manifestation of breast cancer. It is therefore crucial for patients and health professionals alike to be aware of new skin lesions. Cutaneous metastasis is a diagnostic sign of cancer that, it must be emphasised, is not restricted exclusively to later forms of the disease.
Scrofula Caused by Multidrug-Resistant Tuberculosis
Authors: Bárbara Pedro  , Liliana Alves  , Rita Magano  , Tomás Nunes  , Nuno Marques
Published: May 2021

Tuberculosis (TB) is one of the top 10 causes of death worldwide. Multidrug-resistant tuberculosis (MDR-TB) occurs when at the minimum there is resistance to isoniazid and rifampin. Prevention of new infections of Mycobacterium tuberculosis and progression to TB disease is critical to reduce the burden and mortality of this disease. We present the case of a 73-year-old human immunodeficiency virus (HIV)-negative female who presented with cervical lymphadenopathy and who was diagnosed with MDR-TB.
Reversible Pulmonary Hypertension Secondary to Scurvy in a Patient with a Psychiatric Disorder: a Case Report and Literature Review
Authors: Carolina Cavalcanti Gonçalves Ferreira  , Deborah de Sá Pereira Belfort  , Paulo Miranda Cavalcante Neto  , Pedro Alves da Cruz Gouveia
Published: May 2021

Pulmonary hypertension (PH) can be related to several diseases, such as connective tissue disorders and pulmonary embolism, or to drugs; it may also be idiopathic. Few cases have been reported demonstrating an association between ascorbic acid deficiency and reversible PH. We report the case of a patient who arrived at the emergency department with dyspnoea, tachycardia and lower limb perifollicular haemorrhage. Examinations, including a transthoracic echocardiogram, revealed enlarged right chambers and an estimated pulmonary artery systolic pressure of 61 mmHg. Further evaluation revealed poor food intake due to paranoid personality disorder, leading to ascorbic acid deficiency and manifestations of scurvy.
Ozone Therapy for Oral Palatal Ulcer in a Leukaemic Patient
Authors: Giacomo Oldoini  , Giulia Ricci Frabattista  , Maria Saragoni  , Saverio Cosola  , Enrica Giammarinaro  , Anna Maria Genovesi  , Simone Marconcini
Published: May 2021

Chemotherapy usually causes complications affecting several tissues such as oral mucosa. In this case report, a soft palate oral ulcer caused by chemotherapy was treated by ozone gas. This kind of treatment is known for its antimicrobial, regenerative and analgesic proprieties. The results show a complete resolution of the lesion within 2 weeks of treatment. Ozone therapy demonstrates greater effectiveness with respect to this kind of oral lesion compared to traditional therapy. Considering this evidence, ozone therapy should be considered as a useful tool for the adjuvant therapy of oral complications in oncologic patients.
Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia: A Clinical Case
Authors: Adelaide Pereira Alves  , Ana Barroso  , Margarida Dias
Published: May 2021

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is a rare pulmonary condition characterized by diffuse proliferation of neuroendocrine cells in the epithelium of the bronchial wall. DIPNECH may be easily missed in daily clinical practice and diagnosis is often delayed, which may impair prognosis since this condition is considered a pre-invasive lesion for lung carcinoid tumours. We report a clinical case of DIPNECH in order to discuss the diagnostic and therapeutic approach for this entity, the management of which is not yet well established in the literature.
Reactive Arthritis – A Rare Complication of Intravesical BCG Instillation
Authors: Marta Freixa  , Sara Úria  , Glória Nunes da Silva
Published: May 2021

Reactive arthritis (ReA) with the classic triad of arthritis, conjunctivitis and urethritis, previously termed Reiter’s syndrome, is a systemic illness, usually induced by genitourinary or gastrointestinal infections. However, it can be a rare complication of intravesical Bacillus Calmette-Guérin instillation (iBCG), a therapy prepared from attenuated strains of Mycobacterium bovis, a common and effective treatment for carcinoma in situ of the bladder (CisB). We report a case of a patient with CisB who developed ReA after iBCG. The symptoms resolved completely with corticosteroids. iBCG was stopped with no recurrence of carcinoma within 2 years.
Kikuchi-Fujimoto Syndrome: A Rare Entity to Consider
Authors: Diogo Raposo André  , Filipa Vicente  , Jessica Chaves  , Mónica Caldeira  , Fernando Jacinto  , António José Chaves  , Maria Luz Brazão
Published: May 2021

Introduction: Kikuchi-Fujimoto disease (KFD) is a rare, benign, necrotizing lymphadenitis of unknown aetiology with good prognosis. It is characterized by cervical lymphadenopathy, nocturnal diaphoresis and fever. Surgical excision of the adenopathy, histopathological study and immunophenotyping are crucial for diagnosis. Patients and methods: This paper describes five patients with three different histological subtypes of KFD, including an atypical presentation masquerading as pyelonephritis and two other cases where physicians mistakenly started chemotherapy. In one other case cytomegalovirus was identified as the responsible aetiological agent, while in the remaining patient, KFD evolved into an autoimmune condition. Discussion: KFD, although rare, may mimic infectious, autoimmune and neoplastic diseases. It also poses a risk for the subsequent development of an autoimmune disorder.
An Improbable Case of Ascites
Authors: Virginia Visconti  , Andre Fernandes  , Ismenia Oliveira
Published: May 2021

Prostate cancer is the most frequent malignancy seen in males, with about 15% of cases showing metastatic disease at diagnosis, most commonly in bones (vertebrae, ribs, long bones). However, peritoneal metastasis with malignant ascites is extremely rare and may be overlooked by physicians. We report the case of a 77-year-old man presenting with symptoms of abdominal distension, nausea and weight loss. Abdominal ultrasound and computerised tomography confirmed ascites, peritoneal carcinomatosis and an enlarged prostate. Serum and ascitic prostatic-specific antigen were both elevated. Prostate biopsy identified a prostate adenocarcinoma, while biopsy of a peritoneal implant identified a prostate cancer metastasis, which responded well to hormonal therapy.
Tuberculosis as a Cause of Rapid Salivary Gland Swelling in the Elderly – A Case Report
Authors: Noel Lorenzo Villalba  , Maria Belen Alonso Ortiz  , Zaida Cordoba Sosa  , Saturnino Suárez Ortega  , Abrar-Ahmad Zulfiqar
Published: May 2021

A 77-year-old man was admitted to the internal medicine department for a 5-day history of progressive preauricular swelling. Two lines of antibiotic treatment failed to achieve any improvement. Fine needle aspiration cytology was conducted and smear staining with the Ziehl-Neelsen stain as well as a PCR test were positive for Mycobacterium tuberculosis. These results were confirmed with culture of the sample. A diagnosis of tuberculosis parotitis was made and anti-tuberculous drugs were initiated.
Disseminated Strongyloides stercoralis Infection Associated with Endogenous Hypercortisolism – A Case Report
Authors: Susana Lemos Cabral  , Nuno Deveza  , João Pedro Baptista  , Paulo Martins
Published: May 2021

Patients with Strongyloides stercoralis infections are usually asymptomatic but massive hyperinfection may occur in patients with diseases associated with abnormal cell-mediated immunity or receiving immunosuppressive therapy. The authors present the clinical case of a 49-year-old man with a history of diarrhoea and cramping abdominal pain, generalized oedema, petechial rash, melanoderma, cough and dyspnoea. He presented hypokalaemia and arterial hypertension and was admitted with the diagnostic hypothesis of Cushing’s syndrome or adrenocorticotropic hormone ectopic production. The patient developed respiratory failure associated with bilateral lung opacities and was admitted to the Intensive Care Unit. The abdominal computed tomography scan revealed liver and duodenal masses. The duodenal biopsy showed the presence of Strongyloides stercoralis and the liver biopsy showed the presence of small cell neuroendocrine carcinoma. The patient died 50 days after hospital admission. The high level of endogenous cortisol observed in this patient may have facilitated the progression to severe fatal infection.
Fulminant Emphysematous Hepatitis – A Rare Cause of Septic Shock
Authors: Gonçalo Miranda  , Ana Catarina Dionísio  , Constança Azevedo  , Eduardo Carvalho  , Miguel Semião  , Vítor Branco  , Miguel Castelo-Branco
Published: May 2021

Emphysematous hepatitis is a rare entity characterized by the replacement of hepatic parenchyma by gas, leading to acute liver failure. Often it occurs in patients with diabetes mellitus, liver disease or a recent history of abdominal surgery. We present a case of emphysematous hepatitis in a 74-year-old man with no recognizable risk factors. Despite the early broad-spectrum antimicrobial therapy and supportive care, the condition progressed to a fatal outcome, as seen in other case reports. Early recognition of this condition and rapid and aggressive management may improve patient outcomes.
Amoxicillin-induced Aseptic Meningitis
Authors: Débora Sousa  , Pedro Raimundo
Published: May 2021

Amoxicillin is a semi synthetic beta-lactam antibiotic that belongs to the penicillin family. It is the most prescribed antibiotic in the world. It has few side effects, even though hypersensitivity reactions may occur, with potential life-threatening effects. The authors present the case of a 63 years-old male admitted in the emergency department with a two-week history of fever and occipital headache. The symptoms began after he started antibiotic prophylaxis with amoxicillin for a dental procedure. Cerebrospinal fluid analysis was suggestive of aseptic meningitis and the patient improved quickly after discontinuation of the drug. The patient’s previous medical history highlighted a similar episode after he had started taking amoxicillin as part of a scheme for the treatment of a Helicobacter pylori infection. Aseptic meningitis is an extremely rare adverse reaction of amoxicillin, with only 16 cases reported in literature.
Myxoedema Coma Masquerading as Acute Stroke
Authors: Christopher Butter  , Nazia Rashid  , Rumaisa Banatwalla  , Thomas FitzGerald
Published: May 2021

This report describes the management of a patient with myxoedema coma masquerading as an acute stroke (with or without ‘cold sepsis’). Myxoedema coma is an endocrine emergency occurring when physiological adaptations to untreated hypothyroidism are overwhelmed by an acute precipitant. Even promptly treated, it has an associated mortality of up to 50%.
Kikuchi–Fujimoto Disease: Review of 11 Cases Diagnosed Over 10 Years at a Tertiary Care Hospital in Doha, Qatar
Authors: Ahmed A Mohamad  , Muhammed Zahid  , Adeel Ahmad Khan  , Belal Alani  , Mustafa Khalil  , Abazar Saeed  , Abdel-Naser Elzouki
Published: May 2021

Introduction: Kikuchi-Fujimoto (KF) disease is a rare and self-limiting disorder of unknown aetiology characterized by cervical lymphadenopathy (CLN) and fever. The pathophysiology remains unclear and may be triggered by an infectious agent leading to a self-limiting autoimmune process. There are no confirmatory laboratory tests and lymph node biopsy is required to differentiate KF disease from other serious conditions. Materials and methods: We report 11 cases of KF disease diagnosed at Hamad General Hospital, Qatar, between 2006 to 2016. The diagnosis is based on clinical presentation, investigations and histopathological examination of lymph nodes. Results: All patients had painful neck swelling (average duration of 2.9 weeks) and 10 had fever (average duration of 3.2 weeks). Five patients developed mild leucopenia which resolved completely. HIV and tuberculosis (TB) screening including sputum for AFB, a PPD skin test and chest x-ray was done for all patients and came back negative. Autoimmune screening was done for all patients and excluded any rheumatological disease. Ultrasound and CT of the neck confirmed cervical lymphadenopathy. Except for hepatomegaly in one patient, CT scans of the chest and abdomen were negative for any lymphadenopathy or organomegaly (performed in seven patients). Diagnosis was confirmed on lymph node excision biopsy. Histopathological examination showed findings consistent with the diagnosis of histiocytic necrotizing lymphadenitis (KF disease). Conclusion: KF disease should be kept in mind for patients presenting with fever and CLN. Lymphoma, TB and autoimmune diseases like systemic lupus erythematosus should be excluded in such patients.
Lisinopril-Induced Liver Injury: An Unusual Presentation and Literature Review
Authors: Ammar Al-Rifaie  , Mir Azam Khan  , Amjad Ali  , Asha Kumari Dube  , Dermot Gleeson  , Barbara Hoeroldt
Published: May 2021

Lisinopril is an angiotensin converting enzyme inhibitor (ACE-I) that has been on market for more than 25 years. ACE-I are usually well tolerated and rarely have serious or life-threatening side effects. We describe an unusual presentation of fulminant hepatic cholestasis probably secondary to lisinopril. To our knowledge, this is the second case report which shows lisinopril-induced liver injury though a cholestatic mechanism. The patient was a 59-year-old woman with type 2 diabetes, a high body mass index and hypertension, who presented with a 5-week history of jaundice and itching. She had been started on lisinopril for diabetic nephropathy 8 weeks before admission. Other causes for cholestasis had been excluded through non-invasive immunology and virology screening, an ultrasound of the liver, magnetic resonance cholangiopancreatography and a liver biopsy. The biopsy was consistent with drug-induced liver injury. Lisinopril was stopped 2 weeks before admission. The patient’s hospital stay was complicated by contrast nephropathy and influenza A which were both treated appropriately. Unfortunately, the liver cholestasis did not completely resolve following withdrawal of lisinopril and the patient died after 4 months. A literature search yielded only six other reported cases of lisinopril-induced liver injury. Five cases described hepatocellular damage and one showed cholestatic injury.
Suppression of CMV Infection with Letermovir in a Kidney Transplant Patient
Authors: Uta Köpf  , Hans Ulrich Klehr  , Anna-Maria Eis-Huebinger  , Souhaib Aldabbagh  , Christian Strassburg  , Dominik Boes  , Philipp Lutz
Published: May 2021

Infection with cytomegalovirus (CMV) with resistance to ganciclovir (GCV) is a therapeutic challenge in kidney transplant patients, because standard treatment options are nephrotoxic. We report the case of a kidney transplant recipient with GCV-resistant CMV disease, in whom letermovir, a novel inhibitor of CMV packaging, was administered off-label and prevented a relapse of disease once the CMV load was decreased by cidofovir. Furthermore, we observed significant drug interactions between letermovir and tacrolimus.
Erdheim-Chester Disease: A Rare Clinical Entity
Authors: Margarida Oliveira  , Sofia Monteiro  , Joana dos Santos  , Ana Catarina Silva  , Rute Morais Ferreira
Published: May 2021

Pericardial effusion represents a diagnostic challenge. Erdheim-Chester disease (ECD), though a rare cause, should be considered in the differential diagnosis. An 88-year-old woman was admitted to the hospital due to retrosternal pain, dyspnoea and constitutional symptoms. Hypoxaemic respiratory failure and increased inflammatory markers were documented. A chest x-ray revealed an increased cardiothoracic ratio. An echocardiogram showed a moderate-volume pericardial effusion, without signs of cardiac tamponade. A thoraco-abdomino-pelvic CT scan found a bilateral perirenal soft tissue halo. Perirenal mass biopsy showed diffuse infiltration by foamy histiocytes (CD68+), without IgG4, compatible with ECD. The correlation of anamnesis, radiology and histology is crucial for the diagnosis of ECD.
ST Elevation Myocardial Infarction as Presenting Feature of C-ANCA Vasculitis: A Case of a Diagnostic Dilemma
Authors: Abdulrahman S Museedi  , Mouhamed Nashawi  , Abdullah Ghali  , Ali Hussein  , James Saca
Published: May 2021

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS). Although uncommon, it should be included in the differential diagnosis for middle-aged patients without elevated atherosclerotic vascular disease risk or a family history of cardiovascular disease. SCAD is associated with postpartum women; however, reports noting its association with autoimmune disease and vasculopathy in other populations have recently gained prominence. We report a case of a 41-year-old male who was found to have SCAD after presenting with ST segment elevation myocardial infarction in the context of episodic vision loss, and who later underwent work-up for C-ANCA vasculitis and was successfully treated with corticosteroids.
Intermittent Pacemaker Malfunction Caused by Continuous Compression of the Lead by the Clavicle (Subclavian Crush Syndrome)
Authors: Ardian Rizal  , Evit Ruspiono  , Dinarsari Hayuning Putri
Published: May 2021

Subclavian vein access is still one of the most favoured access options for cardiac implantable electronic device (CIED) implantation. For the physician, the technique is reasonably familiar and easy to carry out. However, this has several potential complications. In this case, we present a late complication of subclavian access. The patient presented with intermittent loss of pacemaker output, which caused him to experience several syncopal events. In the acute setting, we changed the lead polarity and achieved a good outcome. Further management of this situation consisted of removal and replacement of the damaged lead.
Arterial Mesenteric Thrombosis as a Complication of SARS-CoV-2 Infection
Authors: Lia a Beccara  , Carlotta Pacioni  , Sara Ponton  , Simone Francavilla  , Antonio Cuzzoli
Published: May 2021

A 52-year-old patient with SARS-CoV-2 was diagnosed with interstitial pneumonia and treated with darunavir/ritonavir, hydroxychloroquine, azithromycin and low molecular weight heparin (LMWH). After LMWH cessation, he developed superior mesenteric arterial thrombosis. An abdominal CT scan showed arterial thrombosis of vessels efferent of the superior mesenteric artery with bowel distension. COVID-19 may predispose to venous and arterial thromboembolism. Anticoagulation prophylaxis should be considered in hospitalized patients with COVID-19, and potential thromboembolism investigated in each symptomatic patient affected by SARS-CoV-2.
Fungal Peptic Ulcer Disease in an Immunocompetent Patient
Authors: Ridwaan Albeiruti  , Fahad Chaudhary  , Hiren Vallabh  , Troy Krupica  , Justin Kupec
Published: May 2021

The lifetime prevalence of peptic ulcer disease (PUD) is 5–10%. While PUD in immunocompetent patients is most commonly associated with Helicobacter pylori infection or the use of non-steroidal anti-inflammatory drugs (NSAIDs), other common causes of PUD must also be considered in the differential diagnosis. We describe a case of endoscopic and histological resolution of PUD related to Candida infection in a healthy, immunocompetent woman.
Contrast-Induced Rhabdomyolysis Occurring after ERCP in a Patient with Pancreatic Cancer: A Case Report
Authors: Natassja Moriarty  , Jonathan Moriarty  , John Keating
Published: May 2021

Objective: We present a patient with pancreatic cancer who developed weakness, acute renal failure and significantly raised creatine kinase levels post-ERCP and who was assessed as having contrast-induced rhabdomyolysis. Results: The patient underwent haemofiltration and ultimately succumbed to his condition. Conclusion: Rhabdomyolysis is a potentially life-threatening condition which occurs because of damage to skeletal muscle, with release of myoglobin and electrolytes into the circulation. The mortality rate is 59% in severe cases, despite appropriate treatment.
Acalculous Acute Pancreatitis in a COVID-19 Patient
Authors: Pedro Antunes Meireles  , Filipe Bessa  , Pedro Gaspar  , Inês Parreira  , Virgílio Dias Silva  , Catarina Mota  , Lourdes Alvoeiro
Published: May 2021

Coronavirus disease 2019 (COVID-19) is a multisystemic condition caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with manifestations ranging from mild upper respiratory symptoms to cytokine storm causing acute respiratory distress syndrome. Pancreatic exocrine tissue and endocrine islets both express angiotensin-converting enzyme 2 (ACE2), the proven receptor for SARS-CoV-2 cell internalization. An increase in pancreatic enzymes has been increasingly recognized in patients with COVID-19, but little is known about the real prevalence of acute pancreatitis in this population. We report a case of acute acalculous pancreatitis in a COVID-19 patient.
Pulmonary MALToma Synchronous with Metastatic Prostate Adenocarcinoma: A Diagnostic Challenge
Authors: Aaron Braddy  , Rahul Janardan Mogal  , Anthony John Maddox  , Andrew Bryan Timothy Barlow
Published: May 2021

Objectives: We describe the novel case of a patient presenting with pulmonary mucosa-associated lymphoid tissue lymphoma (pMALToma) synchronous with metastatic prostate adenocarcinoma. Materials and methods: We report the clinical, laboratory, radiological and histological findings of the above patient. Results: While the patient’s metastatic prostate adenocarcinoma responded well to chemo-radio-hormonal therapy, a persistent area of lung consolidation was noted and further investigated, leading to the diagnosis of concurrent pMALToma. Conclusion: It is important to pursue further investigation when there appears to be persistent change or altered disease response in malignancy if there is evidence for disease response elsewhere, as there may be two synchronous primary cancers.
Inflammatory Myofibroblastic Tumour
Authors: Pedro Pimentel Duarte  , Rafaela Sousa  , Mariana Chaves  , Natacha Amaral  , César Lourenço
Published: May 2021

Inflammatory myofibroblastic tumour (IMT) is a rare mesenchymal tumour. It is usually benign but may behave as a malignant tumour with multiple recurrences and metastases. We present the case of a young woman with weight loss associated with diffuse abdominal pain, who was shown to have a large pancreatic mass. Investigation revealed fusocellular mesenchymal neoplasia, compatible with the diagnosis of IMT. As the mass was unresectable, glucocorticoid therapy was initiated with an excellent response and regression of the tumour.
High-Titre ANA Positivity in NAFLD: An Uncommon Presentation of a Common Disease
Authors: Asis Mitra  , Saswati Ray
Published: May 2021

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease and has emerged as a serious public health challenge. About 20% of NAFLD patients may have low titres (<1:320) of antinuclear antibodies (ANA). However, we describe a patient with NAFLD whose ANA titre was high (>1:320) on presentation. After 3 months of diet, exercise and vitamin E supplementation,the patient was symptomatically better but her ANA titre had increased (>1:640). Her liver biopsy showed features of NAFLD with minimal fibrosis. High-titre ANA (>1:320) positivity is rare. Our patient showed a progressive rise in ANA titre from >1:320 to >1:640 within 3 months even though she was improving and histology showed minimal fibrosis.
COVID-19 Presenting as Acute Limb Ischaemia
Authors: Parminder Kaur  , Sahitya Posimreddy  , Balraj Singh  , Firas Qaqa  , Habib A Habib  , Michael Maroules  , Fayez Shamoon
Published: May 2021

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic that developed in late 2019 and early 2020 has caused thousands of deaths and has had an enormous impact on our health systems and economies. Coronavirus disease 2019 (COVID-19) complications include disseminated coagulation and thrombosis, but, to the best of our knowledge, the literature to date on these manifestations has been limited. Herein, we report an unusual presentation in a 43-year-old man with a medical history of diabetes and hypertension who presented with dyspnoea and acute pain in his right leg and was found to have acute limb ischaemia and diabetic ketoacidosis. Our case adds to the literature regarding arterial thrombosis in COVID-19.
Fatal Ischaemic Stroke During COVID-19 and Acute Lung Injury
Authors: Iris Duroi  , Frederik Van Durme  , Tony Bruyns  , Sofie Louage  , Alex Heyse
Published: May 2021

Severe COVID-19 may predispose to both venous and arterial thrombosis. We describe a patient with acute ischaemic stroke while suffering from COVID-19 and respiratory failure, necessitating mechanical ventilation. Deep sedation may delay diagnosis.
Long-Term GeneXpert Positivity after Treatment for Pulmonary Tuberculosis
Authors: Luisa Costantini  , Marco Marando  , Pietro Gianella
Published: May 2021

Tuberculosis (TB) is a cause of ill health and death worldwide. Since 2010, the diagnostic process has strongly relied on GeneXpert assays on biological specimens. Xpert MTB/RIF is an automated nucleic acid amplification test (NAAT) for Mycobacterium tuberculosis and rifampicin resistance, endorsed by the World Health Organization and the US Food and Drug Administration. Xpert is used in many countries as the initial diagnostic test for tuberculosis. Nevertheless, the reliability of GeneXpert positive tests in patients with a history of TB is largely unknown, due to possible false-positive results (i.e., GeneXpert-positive but culture-negative patients). We present a case report of a patient with a history of pulmonary TB, who was GeneXpert positive but culture negative on bronchoalveolar lavage 22 months after completion of appropriate antitubercular therapy.
Cryptogenic Pyogenic Liver Abscess Due to Fusobacterium nucleatum in an Immunocompetent Patient
Authors: Neeraja Swaminathan  , Francisco Aguilar
Published: May 2021

In this case, a 76-year-old female presented with 3–4 days of fever with no other localizing signs. Notably, she had had an untreated Fusobacterium bacteraemia approximately 8 weeks prior to admission. She underwent abdominal imaging which demonstrated a liver abscess and had percutaneous drainage of the same. Blood and pus cultures both grew Fusobacterium nucleatum, which is an unusual organism to be associated with a liver abscess, especially in an immunocompetent host with no risk factors for this condition. Interestingly, this patient did not have any history of dental work, instrumentation, liver function test (LFT) abnormalities and no extrahepatic source for the abscess. This case highlights the importance of having a high index of clinical suspicion for an occult source of infection and emphasizes the importance of following up on cultures even after discharge of a patient, since anaerobic infections such as those caused by Fusobacterium can have a largely indolent course.
Thyroid Storm Associated with Testicular Choriocarcinoma
Authors: Julio César Martínez  , Ernesto Alfonso Ovalle-Zavala
Published: May 2021

Thyroid storm is a rare, life-threatening condition that can be caused by various pathologies including serious conditions associated with human chorionic gonadotropin (hCG)-producing tumours. We present the case of a 17-year-old male patient with a 1-month history of dyspnoea and a 3-day history of palpitations and fever. General examination revealed a left testicular mass. Blood tests revealed β-hCG >225,000 mIU/ml, thyroid-stimulating hormone (TSH) 0.02 IU/ml, and thyroxine (T4) 19.07 µg/dl. He was admitted with thyroid storm. Treatment with antithyroid drugs and chemotherapy was started, but the patient died on the third day of admission. This case highlights a rare occurrence of thyroid storm linked to testicular choriocarcinoma, and provides a necessary reminder that, in some instances, hCG at very high levels can exert a thyrotropic effect due to its molecular structure, which is similar to that of TSH.
Diffuse Dermal Angiomatosis Manifestation of Underlying Severe Peripheral Vascular Disease
Authors: Abu Baker Sheikh  , Nismat Javed  , Karl Stoltze
Published: May 2021

Diffuse dermal angiomatosis is a benign vascular disorder suspected in patients with cardiovascular risk factors. We report the case of a 62-year-old woman with a non-healing hip wound but no significant cardiovascular risk factors, who was found to have diffuse dermal angiomatosis on biopsy leading to the diagnosis of severe peripheral vascular disease. Her wound healed after revascularization.
COVID-19 in a Patient with Chronic Lymphocytic Leukaemia with Pseudohypoxemia
Authors: Orivaldo Alves Barbosa  , Talita Guimarães Andrade  , Maria Danielly de Almeida Sousa  , José Walter Correia
Published: May 2021

Infection with SARS-CoV-2 causes critical disease in approximately 5% of affected patients, particularly the elderly, hypertensive, obese and immunocompromised. Patients with haematological cancer, including chronic lymphocytic leukaemia (CLL), are particularly at risk of complications. Very rarely, patients with extreme leukocytosis may develop spurious hypoxemia, or pseudohypoxemia, which confuses the diagnosis of complications and can lead to intervention errors. We report the case of a patient with CLL, severe infection with SARS-CoV-2 and pseudohypoxemia.
Acute Soft Head Syndrome (Subgaleal Haematoma) with Periorbital Oedema as a Rare Presentation in Sickle Cell Disease
Authors: Rehab Yusuf AL-Ansari  , Maan Al Harbi  , Nawaf Al-Jubair  , Leena Abdalla
Published: May 2021

Background: Sickle cell disease is a genetic condition frequently found in Africa and the Arabian Peninsula. Uncommon complications include subgaleal haematoma (soft head syndrome) and periorbital oedema. Case presentation: A 17-year-old male patient presented with body aches and progressive right parieto-temporal and frontal head swelling. Physical examination revealed puffiness of the right eye that progressed rapidly to reddish periorbital oedema sparing the extraocular muscle and pupil response to light. CT and MRI of the brain suggested multiple subgaleal haematomas (soft head syndrome) and right periorbital oedema. Conclusion:Subgaleal haematoma (soft head syndrome) and periorbital oedema are uncommon complications of sickle cell disease. Management is conservative rather than surgical.
Cutaneous Complications Secondary to Haemostasis Abnormalities in COVID-19 Infection
Authors: Noel Lorenzo-Villalba  , Yasmine Maouche  , Aneska Syrovatkova  , Felix Pham  , Jean-Baptiste Chahbazian  , Pierre Pertoldi  , Emmanuel Andrès  , Abrar-Ahmad Zulfiqar
Published: May 2021

We describe the case of a patient hospitalized for acute decompensated heart failure in a standard medical ward. During hospitalization, he was diagnosed with COVID-19 and transferred to a special unit. The clinical course was marked by worsening of the respiratory disease, the development of right parotiditis and thrombosis of the left internal jugular vein. Therapeutic anticoagulation was initiated and 2 days later, the minimal dermatoporosis lesions previously present in the upper extremities evolved to haemorrhagic bullae with intra-bullae blood clots and dissecting haematomas. Surgical management of the dissecting haematomas was difficult in the context of haemostasis abnormalities. The patient died 29 days after hospital admission.
Transcranial Direct Current Stimulation in the Treatment of Subacute Post-Stroke Thalamic Aphasia
Authors: William Campanella  , Riccardo Pedrini  , Lucilla Vestito  , Lucio Marinelli  , Carlo Trompetto  , Laura Mori
Published: May 2021

Background: Although many studies have demonstrated the effectiveness of transcranial direct current stimulation (tDCS) in improving speech recovery in post-stroke aphasia, as far as we know patients affected by thalamic aphasia have never been investigated. Patient and method: A 65-year-old man with severe non-fluent aphasia due to a left thalamic haemorrhagic stroke underwent intensive daily speech therapy combined with tDCS.  Results: The patient showed progressive improvement with almost complete recovery of his speech disorder, behavioural disinhibition and apathy.  Conclusions: Our findings suggest that tDCS with concurrent speech therapy can be useful in patients with subcortical stroke lesions.
Non-Bacterial Thrombotic Endocarditis: A Presentation of COVID-19
Authors: Dilan Balata  , Johan Mellergård  , David Ekqvist  , Jacek Baranowski  , Isidro Albert Garcia  , Marina Volosyraki  , Mats Broqvist
Published: May 2021

The SARS-CoV-2 virus is a newly emergent pathogen first identified in Wuhan, China, and responsible for the COVID-19 global pandemic. In this case report we describe a manifestation of non-bacterial thrombotic endocarditis with continuous peripheral embolization in a COVID-19-positive patient. The patient responded well to high-dose LMWH treatment with cessation of the embolic process.
Multiple Endocrine Neoplasia or Accidental Association?
Authors: Georgiana Cristina Taujan  , Felicia Baleanu  , Linda Spinato  , Ruth Duttmann  , Rafik Karmali  , Laura Iconaru
Published: May 2021

Pheochromocytoma, papillary thyroid carcinoma and hyperparathyroidism have rarely been reported together. Whether this association is coincidental or results from an unknown genetic predisposition is difficult to ascertain. We present the case of a patient who was diagnosed with pheochromocytoma, bilateral papillary thyroid carcinoma and parathyroid hyperplasia with primary hyperparathyroidism. A genetic mutation was hypothesized as the connection between these lesions. Previously described mutations were explored.
Left-Sided Implantation of a Defibrillator Lead in Persistent Left Superior Vena Cava
Authors: Evelien De Roo  , Frederik Van Durme  , Laurent Vanneste  , Becker Alzand  , Alex Heyse
Published: May 2021

Persistent left superior vena cava (PLSVC) is a congenital venous abnormality, characterized by an enlarged coronary sinus, in most cases without haemodynamic consequences. We report the case of a patient with systolic heart failure undergoing implantation of a defibrillator lead through a PLSVC which was diagnosed at the moment of implantation.
Osler-Weber-Rendu Syndrome with Severe Hepatic Manifestations: A Rare Clinical Case
Authors: Maria Inês Silva  , Clara Matos  , Fabio Correia  , Sofia Carola  , Maria João Gomes  , Teresa Branco
Published: May 2021

Rendu-Osler-Weber syndrome is a rare inherited syndrome with autosomal dominant transmission characterized by systemic arteriovenous malformations (AVMs) with multi-organ involvement. Its incidence is 1–2/100,000 and it is predominant in females (the male/female ratio varies from 1:2 to 1:4.5).Clinical manifestations and complications are related to recurrent bleeding and, in some cases, the development of end-organ failure. Management is mostly supportive care and it is essential to promote control of the disease as much as possible and screen eventual complications. We describe the case of a 67-year-old male patient with Rendu-Osler-Weber syndrome admitted to the emergency department with decompensated heart failure due to acute anaemia because of severe epistaxis. During hospitalization, the patient progressed to acute-on-chronic liver failure with hepatic encephalopathy and an abdominal computed tomography scan showed multiple hepatic AVMs considered to be the cause of the chronic liver disease.
COVID-19 in a Patient with Accidental Drug-Induced Neutropenia
Authors: Pascal B Meyre  , Milos Radosavac  , Lukas Baumann  , Rein Jan Piso  , Matthias Hoffmann
Published: May 2021

Background: Coronavirus disease 2019 (COVID-19) presents with a wide range of illness severity, from asymptomatic disease to severe acute respiratory distress syndrome (ARDS). Immunosuppression is considered a risk factor for severe COVID-19, but there are only few reports on disease progression in immunocompromised patients.  Case Summary: We report the case of a 50-year-old patient with acute COVID-19 pneumonia, who had iatrogenic, clinically relevant bone marrow suppression due to accidental overdose with hydroxyurea, and decreased lung capacity due to a left-sided pneumonectomy 6 months earlier. Symptomatic treatment with oxygen supplementation and pulmonary physical therapy was initiated, and hydroxyurea was discontinued. Over 14 days, the patient’s blood counts slowly recovered, and his clinical condition gradually improved, such that supplemental oxygen was no longer necessary and he could be discharged.  Discussion: A gradual increase in neutrophil and lymphocyte counts may be preferable to dampen a potentially detrimental immunological response triggered by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Whether patients with severe COVID-19 benefit from immunosuppressive therapy should be further evaluated.
Anaplastic Large Cell Lymphoma Presenting as Haemophagocytic Lymphohistiocytosis with Underlying Coxiella burnetii and Bartonella henselae Seropositivity
Authors: Mohammad Ammad Ud Din  , Syed Ather Hussain  , Bassil Said  , Aneeqa Zafar
Published: May 2021

A 44-year-old woman with no significant medical history presented with a 3-week history of high-grade fevers, fatigue and shortness of breath. Laboratory investigation was significant for lymphopenia and thrombocytopenia which progressively worsened during her hospital stay, along with new-onset anaemia, and elevated ferritin, transaminase and triglycerides. A computerized tomography (CT) scan of the abdomen revealed retroperitoneal lymphadenopathy. A bone marrow biopsy confirmed the diagnosis of haemophagocytic lymphohistiocytosis (HLH). Extensive infectious work-up revealed high IgG titres for Bartonella henselae and Coxiella burnetii. Interestingly, the left supraclavicular node was negative for both microbes by polymerase chain reaction (PCR), but the biopsy revealed anaplastic large T-cell lymphoma.
Genetic Warfarin-Resistance Resulting in Surgery to Change a Prosthetic Valve
Authors: Jahanzeb Malik  , Uzma Ishaq  , Nismat Javed  , Mirza Adnan Baig  , Muhammad Javaid
Published: May 2021

Warfarin is a readily available anticoagulant used worldwide in a variety of clinical scenarios. Patients who need more than 15 mg/day are considered to be warfarin resistant. Numerous genes have been implicated in warfarin pharmacogenetics, with genes encoding CYP2C9 and VKORC1 shown to be the most important determinants of drug dosage requirements. A 27-year-old woman was admitted as she had a sub-therapeutic international normalized ratio (INR) after prosthetic mitral valve replacement. Even after a warfarin dose of 50 mg/day, her INR was not in the therapeutic range, so the heart team decided to replace her metallic valve with a bioprosthetic valve, thus alleviating the need for anticoagulation.
Severe Symptomatic Hypophosphataemia as a Complication of Parenteral Iron Replacement
Authors: Kevin Kim-Jun Teh  , Matthew Bingfeng Chuah  , Shu-Wen Tay  , Amanda Yuan-Ling Lim  , Joan Joo-Ching Koo
Published: May 2021

Parental iron replacement is given to patients with severe iron deficiency or intolerance to oral iron. Hypophosphataemia has been reported to occur as a complication of parental iron replacement, and is postulated to be related to the carbohydrate moieties used in the parenteral preparations. Hypophosphataemia is under-diagnosed as symptoms such as fatigue, muscle weakness and poor effort tolerance mimic anaemia. Severe hypophosphataemia (<0.32 mmol/l) can result in significant complications such as confusion, rhabdomyolysis and arrhythmias. We report a patient with recurrent admissions for non-specific symptoms attributed to iron deficiency anaemia who received multiple doses of parenteral ferric carboxymaltose (FCM). He was found to have severe hypophosphataemia, with further evaluation showing increased renal phosphate wasting and elevated serum levels of fibroblast-growth-factor 23 (FGF23). FCM was stopped and he was given high-dose oral iron supplementation, with no further episodes of hypophosphataemia.