bluuebunny/crossref_metadata_2025 huggingface dataset:
Two Cases of Cardiac Implantable Electronic Device Placement via Persistent Left Superior Vena Cava
Authors: Syed Haseeb Raza Naqvi  , Ishfaq Ahmed  , Pir Sheeraz Ali  , Jehan Zab  , Han Naung Tun
Published: May 2021

Persistent left superior vena cava (PLSVC) is the most common variation of anomalous venous return to the heart and present in 0.1–0.5% of the general population. The left anterior cardinal veins typically obliterate during early cardiac development but failure of involution results in PLSVC. It is an asymptomatic congenital anomaly, usually discovered while performing interventions through the left subclavian vein or during cardiovascular imaging. PLSVC can be associated with cardiac arrhythmias and congenital heart disease. We present two cases of PLSVC: first, a 68-year-old male who presented with complete heart block, for which a temporary pacemaker was initially inserted followed by a permanent pacemaker; second, a 53-year-old female with a history of hypertension and ischemic cardiomyopathy with a left ventricular ejection fraction of 25%, and a survivor of sudden cardiac death, who underwent an implantable cardioverter-defibrillator (ICD) for secondary prevention. Both cases of PLSVC were detected incidentally during the transvenous approach to the heart. PLSVC was suspected by the unusually left medial position of the lead, while cineflouroscopy showed the venous trajectory toward the coronary sinus and drainage into the right atrium. It is technically difficult to cross the wire through the tricuspid valve when coming from the PLSVC and coronary sinus without making a loop in the right atrium, which is known as a wide loop technique. PLSVC is an uncommon anomalous anatomical variant and should be recognized appropriately by specialists who frequently carry out procedures through the left subclavian vein, such as implantation of permanent pacemaker, ICD and cardiac resynchronization therapy. It should also be recognized that wide loop formation of the right ventricular lead in the right atrium is helpful to cross the tricuspid valve and to affix the lead in the right ventricle.
Cervical Lymphadenopathy in Two Young Women The Same Rare Diagnosis with Different Presentations
Authors: Sonia Canadas  , Rita Fernandes  , Mónica Santos  , Ana Vera-Cruz  , Ana Teresa Moreira
Published: May 2021

Kikuchi-Fujimoto disease (KFD) is a rare, benign and usually self-limiting disorder that more often affects young women, which is characterized by cervical lymphadenopathy and fever. Clinical presentation may be indistinguishable from other diseases, and its inclusion in the differential diagnosis of lymphoproliferative, infective and autoimmune diseases is essential. An association with systemic lupus erythematosus is acknowledged. We present 2 different cases of 2 young women with KFD; the first case highlights the classic diagnostic features of this rare entity, and the second, the findings when KFD occurs in association with systemic lupus erythematosus.
Ogilvie’s Syndrome Presented as Angina: A Case Report
Authors: Zakariya Abdulazeez  , Uyen Tran
Published: May 2021

Ogilvie’s syndrome is a non-mechanical, acute pseudo-obstruction of the colon, causing massive colonic dilation. Medical or surgical conditions can predispose patients to Ogilvie’s syndrome; however, the pathogenesis and clinical findings are still not well understood. Here, we present a case of a 48-year-old male patient who presented to the Emergency Department with intermittent self-resolved left-sided lower chest pain on a background of ischaemic heart disease and positive risk factors for acute coronary syndrome. Troponin testing was negative and an electrocardiogram showed no acute changes. Chest radiography showed a dilated bowel under the left hemidiaphragm and a computed tomography (CT) scan of the abdomen-pelvis confirmed the diagnosis of Ogilvie’s syndrome. The patient was treated conservatively with a short period of nil by mouth and intravenous fluids.
A Rare Cause of Dyspnoea: Right-sided Bochdalek Hernia in an Adult
Authors: David Rocha Paiva  , Daniela Casanova  , Helio Martins  , Margarida Cerqueira  , Mariana Formigo  , Olinda Miranda  , Jorge Cotter
Published: May 2021

Right-sided Bochdalek hernia (BH) is very rarely diagnosed in adults. It commonly presents with gastrointestinal symptoms (pain, abdominal distension and vomiting). Breathlessness, recurrent chest infections and other pulmonary sequelae can also be present. We report the case of a 92-year-old man with a 3-day history of dyspnoea, fever and thoracic pain and multiple episodes of vomiting. An x-ray was performed, and the diagnosis of a large BH hernia was confirmed by computed tomography of the thorax. The condition may be fatal in cases where the small bowel undergoes necrosis or perforation. An emergent laparotomy was performed, but the patient did not improve clinically and died immediately after the procedure.
Cladosporium herbarum Hot-Tub Lung Hypersensitivity Pneumonitis in a Greenhouse Worker
Authors: João Pedro Abreu  , Joana Esteves  , Maria Teresa Boncoraglio  , Francisca M Pereira  , Carla Costa  , Carlos Oliveira
Published: May 2021

Hypersensitivity pneumonitis is understood to be a delayed allergic reaction to the repeated exposure of a usually innocent inhaled agent, causing inflammatory damage to the pulmonary parenchyma, alveoli and terminal bronchioles. With ongoing exposure, it can cause respiratory compromise and pulmonary fibrosis. Recognizing the heterogeneity of the causative agents and the low incidence of the disease, we considered it important to report the case of a greenhouse worker who developed aCladosporium sp. related hot-tub lung hypersensitivity pneumonitis. We believe it to be the first reported case of a greenhouse occupational hypersensitivity pneumonitis due to Cladosporium sp.
Acetaminophen Use Concomitant with Long-Lasting Flucloxacillin Therapy: A Dangerous Combination
Authors: Luuk René van den Bersselaar  , Judith Maria Dimphena van den Brule  , Johannes Gerardus van der Hoeven
Published: May 2021

Acetaminophen and flucloxacillin both interfere with the γ-glutamyl cycle. Long-lasting concomitant use of flucloxacillin and acetaminophen can lead to 5-oxoproline accumulation and severe high anion gap metabolic acidosis. Females and patients with sepsis, impaired kidney and/or liver function, malnutrition, advanced age, congenital 5-oxoprolinase deficiency and supratherapeutic acetaminophen and flucloxacillin dosage are associated with increased risk. Therefore, a critical attitude towards the prescription of acetaminophen concomitant with flucloxacillin in these patients is needed. We present the case of a 79-year-old woman with severe 5-oxoprolinaemia after long-lasting treatment with flucloxacillin and acetaminophen, explaining the toxicological mechanism and risk factors, and we make recommendations for acetaminophen use in patients with long-lasting flucloxacillin treatment.
Giant Lactating Adenoma – Size of a Shot Put Ball
Authors: Sherif Monib  , Mohamed Elkorety
Published: May 2021

Lactating adenomas are benign breast tumours which normally present in the peripartum period. Aetiology, pathogenesis, best diagnostic modality and management are not yet clear in the literature. We present a case of a 32-year-old pregnant patient who was re-referred to us with a progressively increasing left breast lesion, pre-existing prior to pregnancy, which was found to be a huge lactating adenoma.
Idiopathic CD4+ T-cell Lymphocytopenia: Report of a Case 11 Years after Diagnosis
Authors: Noel Lorenzo Villalba  , Abrar-Ahmad Zulfiqar  , Yasmine Maouche  , Zaida Cordoba Sosa  , Maria Belen Alonso Ortiz  , Emmanuel Andres
Published: May 2021

We report the case of a 23-year-old woman evaluated for asthenia and lymphocytopenia. Clinical examination was unremarkable but laboratory tests showed the presence of CD4 lymphocytopenia. Secondary causes of CD4 lymphocytopenia were ruled out and a previous diagnosis of idiopathic CD4+ T-cell lymphocytopenia was retained. CD4 lymphocytopenia has persisted for 11 years now but the patient has been clinically asymptomatic.
A Fatal Case of Ciprofloxacin-induced Fulminant Hepatitis
Authors: Alice V Bevan  , Duncan J Napier  , Alexandra Di Mambro
Published: May 2021

Fatal hepatotoxicity associated with ciprofloxacin is extremely rare. This is the second fully investigated case of fulminant hepatotoxicity due to ciprofloxacin in a male patient previously ciprofloxacin tolerant. The patient’s medical history included stable Waldenstrom’s macroglobulinaemia, inguinal hernia repair, prostate cancer (radiotherapy in 2006) and idiopathic Parkinson’s disease. Extensive investigation for progressive liver failure confirmed drug-induced liver injury.
Sudden Development of Subcutaneous Nodules Shortly after Radioiodine Treatment for Thyroid Cancer Caused by Self-Limiting Sarcoidosis
Authors: Wael Zaher  , Sammy Place  , Yannick Gombeir
Published: May 2021

Case presentation: A 50-year-old female presented with an onset of multiple subcutaneous nodules on her 4 limbs. These nodules appeared concomitantly with the initiation of radioactive iodine therapy for papillary thyroid cancer. These nodules were not obvious on inspection of the skin, but easily felt on palpation. The biopsy of the subcutaneous nodules revealed hypodermic non-caseating granulomas consistent with sarcoidosis. The patient underwent an 18F-fluorodeoxyglucose positron emission tomography (PET) scan study that revealed, besides the subcutaneous nodules, multiple hypermetabolic mediastinal lymphadenopathies and cervical adenopathies. Biopsy of the mediastinal lymphadenopathy showed neither granulomas nor neoplastic cells. Cervical biopsy revealed neoplastic cells of thyroid origin. Laboratory tests were normal. Bronchoalveolar lavage showed a normal CD4/CD8 T-cell ratio. A diagnosis of cutaneous sarcoidosis was established, as well as a recurrence of the cancerous disease. The subcutaneous nodules regressed spontaneously in the absence of any treatment. Discussion and conclusion: Sarcoidosis is a multisystemic disease of unknown origin. This case illustrates an uncommon occurrence of sarcoidosis, triggered by radioactive iodine therapy. Radioiodine may lead to immunological changes, especially affecting the Th1/Th2 ratio, which may promote the emergence of sarcoidosis in genetically predisposed patients. There is still much to discover to fully understand the pathogenesis of sarcoidosis.
Massive Right Heart Thrombus Causing Complete Cardiac Obstruction Relieved by Thrombolysis: A Case Report
Authors: Christopher Wong  , John Yiannikas
Published: May 2021

Background: Right heart thrombus (RHT) is a medical condition associated with acute pulmonary embolism and congestive cardiac failure. Rapid recognition is essential for instituting early treatment and preventing adverse outcomes. Case summary: A 55-year-old male presented with symptoms of congestive cardiac failure complicated by cardiac arrest. Initial transthoracic echocardiography (TTE) demonstrated moderate impairment of both ventricles and a moderately dilated right ventricle (RV). After initial improvement with heart failure treatment, the patient subsequently had a second cardiac arrest. Bedside TTE revealed complete RV obstruction by thrombus, and intravenous thrombolysis was immediately instituted, with complete dissolution of the thrombus and haemodynamic recovery 15 minutes after treatment. Unfortunately, the patient suffered significant hypoxic brain injury and did not survive. Discussion: RHT can manifest acutely in a dramatic fashion with cardiac arrest. Bedside TTE is key to making a rapid diagnosis in this setting to allow early administration of thrombolytic therapy.
Testicular Adrenal Rest Tumour (TART) or Testicular Malignancy: A Clinical Dilemma
Authors: Moni Roy  , Ashish Kumar Roy  , Tulika Chatterjee  , Saurabh Bansal
Published: May 2021

Testicular adrenal rest tumour (TART) is a known entity in patients with congenital adrenal hyperplasia. An adult patient presenting with testicular enlargement raises a concern for malignancy and this creates a diagnostic dilemma between non-malignant conditions such as TART versus testicular malignancy. We describe a case where the patient underwent orchiectomy due to clinical concern for malignancy but, retrospectively, this outcome could have been prevented by medical treatment. This case emphasises the need to learn from errors. There is a need to increase awareness of the condition among medical professionals to reduce the chances of unnecessary surgical intervention.
Pneumocephalus Associated with Aggressive Pneumococcal Meningitis
Authors: Isabel I Taveira  , Hipólito Nzwalo  , José Sousa e Costa  , Pedro Moreira
Published: May 2021

A 44-year-old woman presented with headache and delirium. Brain tomography indicated pneumocephalus, while blood and cerebrospinal fluid cultures revealed Streptococcus pneumoniae. Despite antibiotic treatment and admission to the intensive care unit, the patient died 3 days later. Pneumocephalus in association with meningitis is very rare and may be caused by gas produced by microorganisms.
Acquired Haemophilia A in Association with Influenza A and Urinary Tract Infection
Authors: Felipe Peña-Muñoz  , Ernesto Parras  , Olga Compan  , Nora Gutierrez  , Celestino Martin  , Jose Ramon Gonzalez-Porras  , Jose Maria Bastida
Published: May 2021

Acquired haemophilia A (AHA) is a rare autoimmune disorder caused by an autoantibody against any circulating coagulation factor, especially factor VIII (FVIII). The lack of awareness of this condition suggests that diagnosis is a challenge and usually delayed, which leads to suboptimal treatment. Consequently, early diagnosis is mandatory to prevent potentially life-threatening bleeding complications. We present the case of an 85-year-old woman admitted to hospital with symptoms of respiratory infection who 12 hours later developed haematuria which required transfusion. Laboratory assays showed an isolated prolonged aPTT, a moderately reduced FVIII and a high inhibitor titre. Influenza A and Escherichia coli were also identified. Antivirals, antibiotics, immunosuppressive drugs and haemostatic agents were started. Two weeks later, the inhibitor was not detected, and bleeding and symptoms of infection had resolved. Immunosuppressive drugs were stopped on day 45 and there has been no recurrence since then. To date, no FVIII inhibitors have been reported in concomitant infection with influenza A and urinary E. coli. The identification of conditions potentially associated with AHA is essential to achieve complete remission.
Variegate Porphyria Triggered by Acute Hepatitis A Infection
Authors: Daniel Micallef  , Charlton Agius  , Charles Mallia-Azzopardi  , Gerald Buhagiar  , Lawrence Scerri
Published: May 2021

Background: Variegate porphyria (VP) is a rare disorder of haem biosynthesis. We report a novel association with hepatitis A infection. Patient and methods: A 31-year-old man was diagnosed with acute hepatitis A infection. During recovery, he presented with abdominal pain and a photoaggravated blistering skin eruption. Results: Urine porphyrin precursors were markedly raised with high coproporphyrin III isomer levels. Faecal protoporphyrin levels were markedly increased and a maximum plasma fluorescence emission at 629 nm was noted.  Discussion: Acute hepatitis A infection, and the associated metabolic stress exerted on the haem biosynthetic pathway, induced overt presentation of latent VP.
When the Treatment is the Cause: Disseminated Bacille Calmette–Guérin Infection
Authors: Ana Teresa Marques Afonso  , Montserrat Rodríguez Framil  , Joaquín Sánchez Leira  , Néstor Vázquez Agra  , Federico García-Rodeja Arias
Published: May 2021

Bacille Calmette–Guérin (BCG) administration for superficial bladder cancer is a well-tolerated and very effective therapy. However, unpredictable systemic complications may occur on rare occasions. We present the case of a patient who attended for consultation because of fever, asthenia and weight loss following BCG immunotherapy. The clinical response to treatment and computed tomography scanning were key to diagnosis.
Acute Pericarditis and Cardiac Tamponade in a Patient with COVID-19: A Therapeutic Challenge
Authors: Talal Asif  , Kameel Kassab  , Fady Iskander  , Tareq Alyousef
Published: May 2021

We report a case of acute viral pericarditis and cardiac tamponade in a patient with COVID-19 to highlight the associated treatment challenges, especially given the uncertainty associated with the safety of standard treatment. We also discuss complications associated with delayed diagnosis in patients who potentially may need mechanical ventilation.
Long-term Positivity to SARS-CoV-2: A Clinical Case of COVID-19 with Persistent Evidence of Infection
Authors: Damiano D'Ardes  , Andrea Boccatonda  , Ilaria Rossi  , Michela Pontolillo  , Giulio Cocco  , Cosima Schiavone  , Francesca Santilli  , Maria Teresa Guagnano  , Marco Bucci  , Francesco Cipollone
Published: May 2021

In December 2019, an outbreak of a new coronavirus (SARS-CoV-2) was reported in Hubei province in China. The disease has since spread worldwide and the World Health Organization declared it a pandemic on 11 March 2020. We describe the case of a 65-year-old woman who clinically recovered from COVID-19 but showed persistent infection with SARS-CoV-2 for 51 days.
Stress Cardiomyopathy in COVID-19 Disease
Authors: Maria Cristina Pasqualetto  , Eleonora Secco  , Manuele Nizzetto  , Moreno Scevola  , Lorella Altafini  , Alberto Cester  , Fausto Rigo
Published: May 2021

Patients affected by COVID-19 pneumonia may develop stress cardiomyopathy, also known as Takotsubo syndrome (TTS), at different stages during the disease and with different degrees of left ventricular dysfunction. We describe three cases of TTS in COVID-19-positive patients with different clinical presentations and outcomes. One of them died, while in the other two coronary angiography confirmed the diagnosis but was postponed until after pneumonia resolution because of the risk of virus spread.
D-dimer and C-reactive Protein Blood Levels Over Time Used to Predict Pulmonary Embolism in Two COVID-19 Patients
Authors: Yael Becher  , Leonid Goldman  , Nadav Schacham  , Irina Gringauz  , Dan Justo
Published: May 2021

The diagnosis of pulmonary embolism is challenging in symptomatic COVID-19 patients since shortness of breath, chest pain, tachycardia, tachypnoea, fever, oxygen desaturation and high D-dimer blood levels might be features of both diseases. We present two COVID-19 patients in whom pulmonary embolism was suspected (and diagnosed) due to a discrepancy between an increase in D-dimer blood levels and a decrease in C-reactive protein blood levels over time. We believe that an opposite change in the blood levels of both biomarkers over time may be used as a novel method to predict pulmonary embolism in COVID-19 patients.
A Case of Alveolar Haemorrhage Induced by Iodinated Contrast Medium Use
Authors: Motoi Ugajin  , Nobuo Ishiguro  , Hisanori Kani  , Hideo Hattori
Published: May 2021

An 81-year-old man complaining of exertional dyspnoea underwent coronary angiography using an iodinated contrast medium. After angiography, the patient required systemic corticosteroid therapy because of respiratory failure due to alveolar haemorrhage. Percutaneous coronary intervention was performed 29 days after angiography using the same contrast medium. After the intervention, the patient required intubated mechanical ventilation and renal replacement therapy. Bronchoalveolar lavage was bloody with many haemosiderin-filled macrophages. Systemic corticosteroid therapy again improved his clinical condition. Iodinated contrast media may cause alveolar haemorrhage and re-exposure to contrast media may induce a more severe adverse reaction.
Simultaneous VZV and HSV-1 Reactivation after Minor Head Injury
Authors: Romina Häfelfinger  , Anne-Valérie Burgener  , Michael Osthoff  , Eliska Potlukova
Published: May 2021

An 81-year-old patient presented to the emergency department with a dark lesion on his forehead and swelling of his left eye, 3 days after a minor forehead injury and skin laceration. He also showed singular papules on his chin, upper chest, upper arms and back, later evolving into vesicles. Polymerase-chain reaction testing of vesicle content was positive for VZV and HSV-1, confirming a diagnosis of disseminated cutaneous herpes virus infection and concomitant HSV-1 reactivation. Antiviral and antibiotic treatment was initiated for 1 week with an immediate response. This case report highlights the association of head trauma and subsequent reactivation of VZV in patients at risk. Simultaneous reactivation of HSV-1 and VZV is rare in immunocompetent patients.
Emphysematous Gastritis in the Setting of Chronic Abdominal Pain
Authors: Aws Alameri  , Alsadiq Al Hillan  , Abdulrahman S. Museedi  , Ahmed Oglah  , Mohammed Alkhero  , Sadie Trammell Velásquez
Published: May 2021

Emphysematous gastritis is a rare but fatal variant of gastritis. It is caused by gastric wall invasion by gas-forming organisms. It follows disruption of gastric mucosal integrity by a variety of factors, most commonly caustic ingestion and alcohol abuse. Patients typically present with abdominal symptoms with features of septic shock. Emphysematous gastritis carries a high mortality rate warranting early intervention with supportive measures and broad-spectrum antibiotics. It is essential to consider this rare entity in the differential diagnosis of a patient presenting with abdominal pain as timely intervention is crucial for survival.
Immune Thrombocytopenic Purpura in Patients with COVID-19
Authors: Sabine Revuz  , Nathalie Vernier  , Leilah Saadi  , Julien Campagne  , Sophie Poussing  , François Maurier
Published: May 2021

We described three COVID-19-infected patients with profound immune thrombocytopenia causing haemorrhagic mucocutaneous complications. We conclude that an immune mechanism was responsible as common causes were excluded. Since corticoids were considered harmful in the circumstances, the patients were successfully treated with intravenous immunoglobulins without later relapse.
Intrathoracic Acute Cholecystitis
Authors: Giovana Ennis  , Gabriela Venade  , Joana Silva Marques  , Paulo Batista  , Ana Abreu Nunes  , Júlio Constantino  , Luis Costa Matos
Published: May 2021

The authors present the case of a 51-year-old woman with no history of surgical or traumatic injury or accident, who presented with right hypochondrium and epigastric discomfort, malaise, nausea, loss of appetite and episodes of dark urine and greenish stools. Initial laboratory work-up revealed elevated inflammatory markers including leucocytosis with left shift and C-reactive protein, and a slight elevation of gamma-glutamyltransferase and alkaline phosphatase, with no other significant alterations. Computed tomography (CT) showed intrathoracic acute cholecystitis with a large diaphragmatic hernia. A literature search revealed only one other case of acute cholecystitis complicated by intrathoracic gallbladder due to a non-traumatic diaphragmatic hernia. Symptoms are uncharacteristic and the absence of pain or fever, explained by the altered location of the gallbladder, makes the diagnosis a challenge.
Erythematous Papular Rash: A Dermatological Feature of COVID-19
Authors: Catarina Sousa Gonçalves  , Nuno Alexandre de Sousa Reis Carreira  , Dúlio Teixeira Passos  , Ana Luísa Barbosa  , Ana Maria Baltazar  , Alexandra Wahnon  , Ana Mafalda Abrantes  , Pedro Miguel Garrido  , Teresa Ferreira  , Marisa Teixeira Silva  , Lourdes Alvoeiro
Published: May 2021

COVID-19 is the clinical expression of the highly contagious severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral infection. Most patients have mild symptoms, but a significant proportion have severe or critical disease, which can include cardiac injury, sepsis, acute kidney failure and respiratory failure. It is also worth highlighting the increasing number of reported COVID-19 cases with dermatological disease/manifestations. The cutaneous clinical spectrum is wide and includes maculopapular, urticarial, varicelliform and petechial rashes, pseudo perniosis, livedo reticularis, and pityriasis rosea-like, violaceous and pustular lesions. Until the physiological mechanism is fully understood, it is important to describe these manifestations, which could help identify a typical pattern. This report describes a cutaneous manifestation in a COVID-19 patient.
Unusually Rapid Development of Pulmonary Hypertension and Right Ventricular Failure after COVID-19 Pneumonia
Authors: Christel van Dongen  , Marlou Janssen  , Robrecht van der Horst  , Dave van Kraaij  , Ralph Peeters  , Leon van den Toorn  , Remy Mostard
Published: May 2021

COVID-19 is a novel viral disease caused by SARS-CoV-2. The mid- and long-term outcomes have not yet been determined. COVID-19 infection is increasingly being associated with systemic and multi-organ involvement, encompassing cytokine release syndrome and thromboembolic, vascular and cardiac events. The patient described experienced unusually rapid development of pulmonary hypertension (PH) and right ventricular failure after recent severe COVID-19 pneumonia with cytokine release syndrome, which initially was successfully treated with methylprednisolone and tocilizumab. The development of pulmonary hypertension and right ventricular failure – in the absence of emboli on multiple CT angiograms – was most likely caused by progressive pulmonary parenchymal abnormalities combined with microvascular damage of the pulmonary arteries (group III and IV pulmonary hypertension, respectively). To the best of our knowledge, these complications have not previously been described and therefore awareness of PH as a complication of COVID-19 is warranted.
Long lasting thrombocytopenia after transient treatment pancytopenia induced by short term concomitant radiotherapy and temozolomide
Authors: Aleksandar Stepanović  , Marina Nikitović  , Andrija Bogdanović  , Danica Grujičić
Published: May 2021

We describe long-lasting and incompletely resolved thrombocytopenia after transient profound pancytopenia in a 62-year-old female patient with glioblastoma after short-term radiotherapy with temozolomide. Pancytopenia was present for more than 4 weeks and thrombocytopenia for more than 6 months, without platelet recovery to normal levels.
Lung Ultrasound (LUS) in COVID-19 Pneumonia: Usefulness in Two Atypical Cases
Authors: Vincenza Giugno  , Giulia Di Marzio  , Andrea Domanico  , Esterita Accogli
Published: May 2021

Lung ultrasoundClinical experience and scientific articles have shown that patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can be paucisymptomatic or asymptomatic at the time of diagnosis. In this paper, we will discuss two paucisymptomatic patients with blood tests suggestive for SARS-CoV-2 infection but with repeated negative nasopharyngeal swabs and without typical features of COVID-19 pneumonia on chest high-resolution computed tomography. In these cases, lung ultrasound helped to raise clinical suspicion of COVID-19 pneumonia and facilitate diagnosis.
A Rare Case of Haemoptysis Revealing Aortic Coarctation in an Adult
Authors: Ahmed Ben Saad  , Asma Achour  , Asma Migaou  , Saousen Cheikh Mhamed  , Nesrine Fahem  , Naceur Rouatbi  , Samah Joobeur
Published: May 2021

Haemoptysis is a frequently occurring but sometimes life-threatening condition. Congenital cardiovascular abnormalities are rare causes of haemoptysis. We report a case of a 33-year-old man without any past medical history complaining of haemoptysis with no other associated clinical manifestations. A contrast-enhanced chest computed tomography scan revealed aortic coarctation with dilation of the internal mammary, intercostal and bronchial arteries. He underwent stent placement after balloon angioplasty with favourable outcomes.
Transient Type 1 Brugada Pattern without Ongoing Fever during COVID-19 Pneumonia
Authors: Maria Cristina Pasqualetto  , Andrea Corrado  , Eleonora Secco  , Fabio Graceffa  , Fausto Rigo
Published: May 2021

Patients with COVID-19 pneumonia can develop heart problems and may also may be susceptible to proarrhythmia, virus-related issues such as fever, stress, electrolyte disturbance and adverse effects from the use of antiviral drugs. We report a transient Brugada-like ECG pattern without ongoing fever in a 57-year-old man, admitted with a diagnosis of COVID-19 pneumonia, who did not have syncope or a family history of sudden cardiac death.
Minimal Change Disease and Phenylketonuria in an Adult Patient: The Two Sides of Protein Homeostasis
Authors: Cristina Pires Correia  , Inês Neves  , Paulo Chaves  , Teresa Cardoso  , Roberto Silva  , Jorge Almeida
Published: May 2021

Phenylketonuria (PKU), the most common inborn error of amino acid metabolism, has been associated with an increased risk of renal impairment, the reason for which is not fully understood. We report the case of a 33-year-old female patient diagnosed with PKU in adulthood after suspicion of the disease in her daughter. The diagnostic approach revealed proteinuria, and minimal change disease (MCD) was identified. Therapeutic measures and follow-up are discussed. The possible link between these two disorders is interesting. Attenuated developmental delay of untreated PKU could be explained by the decreased accumulation of phenylalanine secondary to proteinuria. On the other hand, MCD may be a possible, although as yet unreported, pathophysiological mechanism explaining the renal repercussions that have been found in adult PKU patients, who should be screened for proteinuria.
Asymptomatic Hyperinsulinaemic Hypoglycaemia
Authors: Ana Ferreira  , Mariana Serino Barbosa  , Rita Coelho  , Patrícia Lourenço
Published: May 2021

Hypoglycaemia is rare in apparently well patients without drug-treated diabetes mellitus and warrants evaluation and management when Whipple’s triad is present. Even in the absence of Whipple’s triad, when repeatedly low values of plasma glucose are documented, the presence of endogenous hyperinsulinism should be investigated. The authors describe a case of endogenous hypoglycaemic hyperinsulinism, its diagnosis and treatment and the challenges of determining its aetiology.
SARS-CoV-2 Infection with Associated Rhabdomyolysis and Probable Myocarditis
Authors: Franco Murillo  , Gastón Ramos  , Jose Luis Del Pozo  , Luis Manuel Valdez  , Jorge Zagaceta
Published: May 2021

We describe a patient with SARS-CoV-2 and severe pneumonia who required mechanical ventilation and developed associated rhabdomyolysis with probable myocardial involvement as evidenced by cardiac enzyme abnormalities and echocardiographic findings. Repeat testing should be done in cases highly suspicious for SARS-CoV-2 as initial molecular tests may be negative, as in our case.
The Clot Thickens: Diagnosing Acute Pulmonary Embolism as a Trigger for Chronic Obstructive Pulmonary Disease Exacerbation in the Setting of Anticoagulation Failure
Authors: Sameh Saleh  , Ishak Mansi
Published: May 2021

Chronic obstructive pulmonary disease (COPD) exacerbations are most commonly triggered by infections, but up to 25% of those that require hospitalization are thought to be triggered by acute pulmonary embolism. We present the case of a 71-year-old patient with a history of unprovoked pulmonary embolisms on anticoagulation therapy hospitalized for a COPD exacerbation. The exacerbation was triggered by an acute pulmonary embolism, representing anticoagulation failure.
Morel-Lavallee Syndrome: A Rare Tumefactive Lesion
Authors: Mohamed Labied  , Siham Salam  , Salma Jabri  , Dalal Laoudiyi  , Kamilia Chbani  , Lahcen Ouzidane
Published: May 2021

First described by the French surgeon Maurice Morel-Lavallee in 1853, Morel-Lavallee syndrome (MLS) is a serolymphatic effusion resulting from tangential injury to richly vascularized tissues. The imaging characteristics may be variable over time due to lesion progression and the eventual organization of a fibrous capsule. We report a case of extensive MLS in the lower leg of a 12-year-old child. We discuss the ultrasound and magnetic resonance imaging findings and describe the differential diagnoses.
Cutaneous Angiosarcoma in an Unusual Location and Without Predisposing Factors
Authors: Ana Oliveira Monteiro  , Inês Branco Ferreira  , Artur César  , Alberto Mota  , Jorge Pinheiro  , José Manuel Lopes  , M Teresa Cardoso
Published: May 2021

Cutaneous angiosarcoma is a rare, highly malignant tumour of vascular endothelial origin. It usually arises in the skin and superficial soft tissue, mostly on the head and neck. It presents as a variety of lesions, and so is considered a great mimicker, leading to a delay in diagnosis and evidencing the importance of biopsy with immunohistochemistry confirmation. There are few reports of extremity involvement in patients with pre-existing chronic lymphoedema, or exposure to radiation therapy. We report the case of an 82-year-old woman with lower limb extensive cutaneous involvement, distant metastatic disease, and poor therapy response. Its rare location without predisposing factors highlights the need to raise awareness about this disease
Bariatric Surgery can Lower the Efficacy of DOACs
Authors: Zouheir Ibrahim Bitar  , Ossama Sajeh Maadarani  , Mohamed Jaber Mohsen  , Nawal Usamah Alkazemi
Published: May 2021

A 39-year-old woman who was taking the contraceptive pill was admitted with right leg deep venous thrombosis (DVT). She was started on apixaban tablets, but after 8 days developed proximal progression of the DVT and pulmonary embolism. Her medical history later showed a history of sleeve gastrectomy. The patient responded to a vitamin K antagonist after heparin. The failure of the antithrombotic drug shed light on the efficacy and changed pharmacodynamics of direct oral anticoagulants (DOACs) after bariatric surgery in the absence of commercially available blood monitoring tests.
An Eminent Absence: Agenesis of Inferior Vena Cava Underlying Bilateral Iliac Vein Thrombosis
Authors: Giorgia Protti  , Fabrizio Elia  , Francesca Bosco  , Franco Aprà
Published: May 2021

Among thrombophilic risk factors for deep venous thrombosis (DVT), agenesis of the inferior vena cava (AIVC) is very rare, but it must be considered in specific settings. Here, we present the case of an 18-year-old woman who was admitted to the Emergency Department with swelling and pain of her left leg. Clinical examination and ultrasonography detected extensive proximal DVT of the left leg. After attempted mechanical thrombectomy failed, an abdominal CT scan was obtained, which demonstrated bilateral thrombosis of the iliac-femoral axis in the context of congenital AIVC.
A Patient with Severe Malaria and COVID-19: How Do You Tell the Difference between These Infections?
Authors: Maria João Correia  , Luciana Frade  , Renato Guerreiro  , Inês Araujo  , Teresa Baptista  , Cândida Fonseca  , Kamal Mansinho
Published: May 2021

Coronavirus infection, known as COVID-19, is characterized by clinical, epidemiological and biological features similar to those of malaria. In each case, fever, myalgia, fatigue, headaches and gastrointestinal symptoms may be present. Both diseases can also induce a cytokine storm and pro-coagulant states. An appropriate epidemiological approach and differential diagnosis are very important so that the right clinical intervention can be selected. Malaria remains a serious global public health issue, especially in endemic countries. Elimination campaigns are helping to control the disease, but in many countries these programs are now at risk of failure due to logistic and economic problems caused by COVID-19. The authors describe the case of a patient with co-infection with malaria and COVID-19, reminding us that during this coronavirus pandemic it is critical to consider other diagnoses, particularly in people traveling between countries.
Encephalopathy after Bendamustine Treatment: A Rare Side Effect?
Authors: Carolina Amado  , Gisela Ferreira  , Fernando Silva  , Mariana Silva Leal  , Margarida Cruz
Published: May 2021

Bendamustine is a chemotherapeutic drug associated with frequent haematological and gastrointestinal adverse effects and, more rarely, neurological toxicity. We present the case of a 79-year-old man with follicular lymphoma, grade 2, Ann-Arbor stage IV-A, FLIPI 4, high risk, with bulky disease and vital organ compression, treated with R-CHOP and then rituximab-bendamustine, who developed encephalopathy approximately 2 months after the last cycle. After ruling out other possible aetiologies, we assumed the patient’s encephalopathy was due to a delayed bendamustine side effect, possibly aggravated by the concomitant administration of rituximab. The authors hope to alert clinicians to this rare adverse effect, its difficult identification and the need to rule out other aetiologies.
Pleuroparenchymal Fibroelastosis Associated with Crohn’s Disease: A New Aetiology?
Authors: Carolina Amado  , Pedro Gonçalo Ferreira
Published: May 2021

Pleuroparenchymal fibroelastosis (PPFE) is a relatively rare interstitial lung disease (ILD) consisting of elastofibrosis involving the subpleural parenchyma and visceral pleura with an upper lobe predominance. It can be idiopathic or associated with some forms of autoimmune disease. The authors describe the case of a 78-year-old woman with a previous diagnosis of Crohn’s disease (CD). She presented with a protracted respiratory infection (with no significant history of previous infections), and underwent high-resolution chest computerized tomography that eventually showed alterations compatible with PPFE. After exclusion of other possible underlying causes, a possible link to CD was considered. Follow-up investigation at 12 months showed clinical and radiological stability and also stable lung function under treatment with hydroxychloroquine and prednisolone. This is the first report of PPFE in the context of CD. Future studies will be important to further investigate this pathological association and its prognostic implications.
Self-Expandable Transcatheter Aortic Valve Frame Infolding: An Increasingly Recognized Complication
Authors: Gurpreet Singh  , Vien Le  , Robert Wiechmann  , Steven Schreiter
Published: May 2021

Transcatheter aortic valve replacement (TAVR) with either a balloon-expandable or a self-expandable transcatheter heart valve (THV) is an approved therapy for patients with symptomatic severe aortic stenosis and high or intermediate surgical risk. Here we present a case of severe valve frame infolding of a CoreValve Evolut PRO® self-expandable THV (Medtronic Inc.), which was restored to optimal geometry with balloon post-dilation.
First Test of an Automated Detection Platform to Identify Risk of Decompensation in Elderly Patients
Authors: Abrar-Ahmad Zulfiqar  , Orianne Vaudelle  , Mohamed Hajjam  , Dominique Letourneau  , Jawad Hajjam  , Sylvie Ervé  , Anna Karen Garate Escamilla  , Amir Hajjam  , Emmanuel Andrès
Published: May 2021

Introduction: We tested the MyPrediTM e-platform which is dedicated to the automated, intelligent detection of situations posing a risk of decompensation in geriatric patients. Objective: The goal was to validate the technological choices, to consolidate the system and to test the robustness of the MyPrediTM e-platform through daily use. Results: The telemedicine solution took 3,552 measurements for a hospitalized patient during her stay, with an average of 237 measurements per day, and issued 32 alerts, with an average of 2 alerts per day. The main risk was heart failure which generated the most alerts (n=13). The platform had 100% sensitivity for all geriatric risks, and had very satisfactory positive and negative predictive values. Conclusion: The present experiment validates the technological choices, the tools and the solutions developed.
Generalized Lichen Planus-like Eruption Related to Trimebutine
Authors: Dimitra Koumaki  , Vasiliki Koumaki  , Alexander Katoulis  , Sotirios Boumpoucheropoulos  , George Evangelou  , Maria Stefanidou  , Konstantinos Krasagakis
Published: May 2021

Trimebutine is a spasmolytic agent with antimuscarinic effects that is used for the treatment of irritable bowel syndrome (IBS) and lower gastrointestinal tract motility disorders. Lichenoid drug eruptions (LDE) to trimebutine maleate have not been previously reported. Here we present the case of a 50-year-old male patient who developed an extensive lichenoid eruption on his upper and lower extremities and trunk 4 weeks after starting treatment with trimebutine maleate 300 mg once daily for IBS. Two months after discontinuation of the drug and administration of topical treatment with emollients and corticosteroids, the LDE cleared completely with no recurrence. The diagnosis of LDE due to trimebutine was made, based upon the clinical features resembling lichen planus, the histological findings of interface dermatitis, the evidence of a temporal relationship between drug intake and the development of skin lesions, and resolution upon discontinuation of the drug. To the best of the authors’ knowledge, LDE following trimebutine maleate intake has not been previously reported. Management of trimebutine-induced LDE includes withdrawal of the causative agent and treatment with potent topical corticosteroids.
Critical Care COVID-19 Patient with a Picture of Thrombotic Thrombocytopenic Purpura
Authors: Rehab AL-Ansari  , Mohanad Bakkar  , Leena Abdalla  , Khaled Sewify
Published: May 2021

Background: Thrombotic thrombocytopenic purpura (TTP) is an uncommon haematological disease which can occur at any age and may present with COVID-19. This case describes a COVID-19 complication associated with a presentation resembling TTP. Case description: A 51-year-old man who had received a kidney transplant and was on immunosuppressant medication, was admitted to a critical care unit with severe COVID-19 pneumonia/acute respiratory distress syndrome (ARDS) which required intubation, mechanical ventilation and inotropic support. The course was complicated by the classic pentad of thrombocytopenia, intravascular haemolysis, acute kidney injury, neurological symptoms and fever, which prompted the diagnosis of probable TTP. After five sessions of therapeutic plasma exchange, the patient’s general status improved, he was weaned off mechanical ventilation and his renal panel and haemolytic markers normalized. Conclusion: TTP is a life-threatening condition which requires urgent management with therapeutic plasma exchange. This case highlights some possible complications of COVID-19 generally and in immunocompromised patients specifically. The potential role of plasma exchange in COVID-19 patients without a positive diagnosis of TTP (the so-called ‘TTP resembling presentation’) is an area of further research.
A Case of Fatal Intestinal Infarct Preceded by Recurrent Ischaemic Colitis due to the Enterotoxic Effect of Sodium Polystyrene Sulfonate
Authors: Renato De Vecchis  , Andrea Paccone
Published: May 2021

Case description: A 64-year-old patient with chronic renal failure and persistent hyperkalaemia not corrected by dialysis, was prescribed sodium polystyrene sulfonate (SPS) at a low dose (30 g/day for 2 days a week during the long interdialytic interval). After 3 months of therapy, the patient developed intense abdominal pain with non-specific colitis identified with a colonoscopy. In addition, the biopsy specimens showed rhomboid SPS crystals in the intestinal mucosa. Fourteen months after discontinuing therapy, the patient again presented with colitis and persistent biopsy finding of SPS crystals. The patient died a few months later due to intestinal infarction.  Discussion and conclusion: SPS is a cation exchange resin used to treat hyperkalaemia resistant to dialysis, but may cause inflammation and ischaemia of the colon. In our patient, a short 3-month course of low-dose SPS therapy (without sorbitol, which is used to counter iatrogenic constipation caused by SPS) induced relapsing colitis, which was followed by massive intestinal infarction a few months later. In light of frequent reports of its enterotoxic effects, SPS should be replaced with the new potassium chelators (patiromer and sodium zirconium cyclosilicate).
Persistent Left Superior Vena Cava: A Finding After Central Venous Catheterization
Authors: Francisco Lopes Morgado  , Bárbara Saraiva  , Celestina Blanco Torres  , João Correia
Published: May 2021

Introduction: Persistence of the left superior vena cava (LSVC) is a rare anatomical variant in the general population with an estimated incidence of 0.3-0.5% in healthy individuals. Its diagnosis can be made incidentally after imaging control of central venous catheter (CVC) or other types of devices placements. Patient and Methods: We present the case of a patient with an acute disease which required central venous catheterization for the administration of intravenous chemotherapy. Results: Central venous catheterization proved difficult and after imaging control it revealed an unusual position of the catheter tip. Additional study to verify catheter tip position was performed and computed tomography (CT-scan) revealed the presence of a persistent left superior vena cava. The patient was then submitted to the planned treatment without any record of complications associated with CVC. Conclusion: Although uncommon the persistence of the LSVC can have an important impact in clinical practice, particularly when more invasive procedures are required. Its recognition is relevant in order to minimize the potential complications inherent to these procedures.
Neurofibromatosis Type 1 with Highly Active Relapsing-Remitting Multiple Sclerosis (RRMS)
Authors: Silvia Ciotti  , Antonella Cometa  , Claudia De Carlo  , Giancarlo Martini  , Andrea Marona  , Laura Filippetti  , Diego Carducci  , Silvano Baratta  , Mauro Zampolini  , Francesco Corea
Published: May 2021

Neurofibromatosis type 1 (NF1) is an autosomal dominant neurocutaneous disease which confers an increased risk of malignant tumour development. Relapsing remitting multiple sclerosis (RRMS) is an inflammatory demyelinating disease of the central nervous system. The coexistence of multiple sclerosis and NF1 is rare but has been reported. Here, we describe the case of a 31-year-old man with NF1 and subacute walking problems with proximal pain in the lower limbs who was successfully treated with natalizumab.
Mesalazine-induced Hypersensitivity Pneumonitis
Authors: Ana Pereira  , Cristina Marques  , Teresa Boncoraglio  , Joana Esteves  , Marinha Silva  , Joana Braga  , Márcia Ribeiro
Published: May 2021

A 57-year-old woman with Crohn's disease (ulcerative proctitis) treated with mesalazine (5-ASA) developed worsening respiratory distress and cough. The lack of response to antibiotics and the results of bronchoalveolar lavage led to the diagnosis of mesalazine-related hypersensitivity pneumonitis, an infrequent entity. Symptoms improved after discontinuation of mesalazine and the administration of corticosteroid therapy. The authors discuss the diagnosis and management of this rare condition.
Severe Obstructive Sleep Apnoea Leading to Raised Intracranial Pressure Hydrocephalus in a Patient with Aqueduct Stenosis
Authors: Hilary McLoughlin  , Gearoid Coughlin  , Iftikhar Nadeem  , Emma Burke
Published: May 2021

We present the case of a patient with severe obstructive sleep apnoea (OSA) and hypoventilation syndrome who had hydrocephalus and acquired aqueduct stenosis. A link between these conditions in our patient is postulated. We discuss the mechanisms through which this might have occurred and the potential problems which might arise in applying non-invasive ventilation to a patient with hydrocephalus.