bluuebunny/crossref_metadata_2025 huggingface dataset:
Factors of the Structural Dynamics of the Economy of Modern Russia
Authors: Basovskiy Leonid
Published: May 2021

The aim of the work was to study the dynamics of structural changes in the economy of modern Russia. Linear regression models used to assess trends in changing the contribution of industries to gross value added. The main factors of the sectorial structure of gross value added assessed by factor analysis based on a principal compo-nent model. The main factor in the dynamics of the sectorial structure is the factor of the development of sectors, which until recently were the least developed. It reflects the growth in the contribution of transport and communications, agriculture, real estate transactions, rent. The second most important factor reflects the cyclical redistribution of shares between industry - extractive and manufacturing and financial activities. The third factor reflects the cyclical redistribution of shares between household activities and most other sectors of the economy. The fourth main factor also reflects the cyclical redistribution of shares between industries. It assumed that the main factors of changes in the structure of the economy are associated with the transition processes taking place in the economy and reflecting the slow transition due to unfavorable institutional condi-tions to the dominance of the fifth post-industrial technological order.
The Construction Sector of the Oil and Gas Region in the Face of Declining Investment Activity
Authors: Lysenko I.
Published: May 2021

The article reviews the dynamics of statistical indicators of the development of the modern construction sector of the Tyumen region. The structure of the regional construction complex is described, indicating the key economic entities of the industry and the nomenclature of products of their own manufacture. The factors of the growth of construction in the region are identified based on the study of the dynamics of changes in prices and incomes in the Tyumen region in the analyzed period and the implemented support programs.
The Beard of Rameses VI
Authors: Czerkwiński Piotr
Published: May 2021

The beard first appeared in Egyptian iconography in the Early Dynastic period on the Narmer palette and remained a common feature thereafter. The pharaoh, as a god on earth, was a personification of perfection. Always crisp and clean-shaven, he represented both the Egyptian nation and divine power. His fake beard, which was attached with ribbons and was clearly visible on his images and reliefs, was one of the elements indicating his divine nature.Ordinary people also grew beards or moustaches. We can see stubble on the faces of men mostly engaged in physical work on a number of images on the walls of tombs. However, in these cases, the facial hair would not have indicated any godly qualities.Nevertheless, some depictions of the pharaoh are similar to those of simple men in that he also possesses stubble. This is most clearly seen on a number of ostracons from Deir el-Medina. However, if the pharaoh has stubble, its significance is quite different. Very few such unshaven images are known and published and only a small number of these are official depictions. The final such image that will be considered is the one found in KV 9 belonging to Pharaoh Rameses VI.
Polycephaly – Some Remarks on the Multi-Headed Nature of Late Egyptian Polymorphic Deities
Authors: First Grzegorz
Published: May 2021

One of the most intriguing motifs of Egyptian religious iconography is the representation of ‘pantheos’, a composite deity with additional animal heads and other animal attributes, as well as magical and religious symbols. This group is commonly described in Egyptology as pantheistic, although the new definition of ‘polymorphic’ has recently been proposed. This term does not lean towards any particular area of interpretation, but simply refers to a single visual aspect of the motif.The group of Late Egyptian, Ptolemaic and Roman objects with this type of representation consists of statuettes, magical stelae, amulets, illustrations on papyri and gems. The main feature of polymorphic deities is their additional animal elements, which are attached to the basic corpus. These elements are mostly heads, wings and other parts of the animal’s body, although polymorphic depictions also sometimes contain ithyphallic or androgynous elements. The most important element of polymorphic iconography and its interpretation is the multi-headed nature of the images. This suggests both that complicated thought processes created the composition of the depictions and that they had a close relationship to magic and religion. A polymorphic representation was not a simple visualisation of just one religious idea or god, but was testament to the diverse thinking behind popular and official beliefs in ancient Egypt in the second half of the 1st millennium BC and in later times. The debate on polymorphism centres either on the possible search for a personal, universal god with a solar, hidden aspect or focuses on the magical, practical dimension, which provided protection for the people from evil powers and dangers.
A Greek Fibula in the Collection of the Archaeological Museum in Wrocław
Authors: Kubala Agata
Published: May 2021

In the collection of the Archaeological Museum in Wrocław is a Greek fibula, which was donated by Wilhelm Grempler, a Wrocław doctor and researcher of antiquity well-known for his contribution to Silesian archaeology. It belongs to the ‘millwheel’ fibula group, which is characterised by the distinctive decoration of its bows. Fibulae of this type have been found in modern Bulgaria, Macedonia and northern and central Greece, although they seem not to have reached its south. Observable differences in the shapes of the decorative elements of these fibulae are of a regional nature and allow two varieties to be identified within the type: North Balkan and Greek. The best analogies for the Wrocław ‘millwheel’ fibula can be found in objects of the same type found at Halai in central Greece, which can be dated to the mid-5th century BC.
A Comprehensive Protocol to Mitigate Inappropriate Medication in the Elderly
Authors: Vera Vlahović-Palčevski
Published: May 2021

The percentage of elderly population is increasing and it is estimated that by 2050 30% of the population in developed countries will be over 65. Elderly often have multiple chronic diseases that require multiple medications.
A Case of Pulmonary Mycetoma Caused by Paecilomyces variotii
Authors: Diogo Paixão Marques  , Joana Carvalho  , Sara Rocha  , Raquel Domingos
Published: May 2021

Fungal infections caused by Paecilomyces species are rare. Although most cases of human infection occur in immunocompromised patients, this species is also being increasingly recognized as a pathogen in immunocompetent individuals. Paecilomyces variotii and P. lilacinus are the most common pathogens in humans. P. variotii infection usually manifests as peritonitis, pneumonia or endophthalmitis. We present the case of an 84-year-old immunocompromised patient with interstitial lung disease, who developed pulmonary mycetoma with isolation of P. variotii in bronchoalveolar lavage fluid culture. We found one similar case in the literature, but Paecilomyces species was not identified. Therefore, this is the first described case of pulmonary mycetoma caused by P. variotii.
Unusual Pneumonia Mimic
Authors: Joana Ricardo Pires  , Maria José Moreira  , Margarida Martins  , Clarinda Neves
Published: May 2021

Disease in atypical organ locations can mimic other pathologies, hampering the right diagnosis. Such conditions may even be emergencies, like appendicitis. Subhepatic appendix is a very rare entity which may be caused by caecum dehiscence failure. The authors present the case of a 55-year-old immunocompetent man admitted to the Emergency Department with sepsis and severe hypoxaemia. Chest x-ray showed right lower lobe infiltrate, and community-acquired pneumonia was diagnosed. The patient was started on broad-spectrum antibiotics, but he continued to deteriorate and after 3 days developed abdominal complaints. Exploratory laparoscopy revealed an abscess caused by perforated subhepatic appendicitis. Subhepatic appendicitis presents a diagnostic challenge and its clinical presentation may mimic that of other entities. This case highlights an atypical presentation, where the early development of inflammatory lung injury mimicked common pneumonia. Maintenance of a high index of suspicion and knowledge of these atypical locations is crucial.
Autoimmune Hepatitis and Systemic Sclerosis: a Rare Association
Authors: Elisabete Pereira Coelho  , Ana Rita Matos  , Sofia Caridade
Published: May 2021

A woman in her early 40s, with a history of excessive alcohol intake, presented with purpuric, ulcerative lesions on the lower limbs. On examination, hirsutism and generalized stiffening and thickening of the skin were noted. Laboratory investigations revealed hyperbilirubinemia, hypergammaglobulinemia and positive anti-smooth muscle antibodies. Histologic examination of the skin was compatible with scleroderma. Histologic examination of the liver was suggestive of autoimmune and alcoholic hepatitis.
Diagnostic and Management Errors in an Immunodeficient Patient with Pneumococcal Pneumonia with Bacteraemia due to Incorrect Assessment of the Patient’s Immune Status
Authors: Takahiro Ito  , Yukinori Harada  , Taro Shimizu
Published: May 2021

A 79-year-old woman presented with fever and pleural chest pain. Based on the assessment of mild community pneumonia in an immunocompetent patient, outpatient follow-up was planned. However, the patient was admitted several hours later with a diagnosis of pneumococcal pneumonia with bacteraemia. In addition, selective immunoglobulin M deficiency was detected. In this case, although a history of recurrent osteomyelitis was provided, the physicians overlooked the information suggesting immunodeficiency, which led to an incorrect diagnostic and management decision. Obtaining the past medical history is essential, but utilizing it is even more important to avoid clinical decision-making errors.
Orbital Plasmacytoma, An Uncommon Presentation of Advanced Multiple Myeloma
Authors: Andreia Margarida de Matos  , André Goulard  , André Ribeiro  , Ricardo Freitas  , Catarina Monteiro  , Paulo Martins
Published: May 2021

Introduction: Extramedullary plasmacytomas are present in 13% of multiple myeloma (MM) patients. Less than 5% of MM cases are non-secretory. The orbital location is uncommon and a minority of orbital tumours are plasmacytomas. Description: The patient was a 71-year-old man, with right proptosis, retro-ocular pain and epistaxis with visual acuity 2/10, limitation of upper eye movement and scattered ecchymosis. Blood tests revealed severe anaemia, coagulopathy, increased serum creatinine, LDH and C-RP without improvement after antimicrobial treatment. Peripheral immunophenotyping showed 9.4% of plasma cells with intracytoplasmic clonal κ chains. IgG and λ chains were decreased with normal plasma and urine immunofixation. Orbital CT: retro-orbital superomedial tumour with bone destruction. Histology of the tumour and bone biopsy was consistent with plasmacytoma. The patient was deceased in 2 weeks. Discussion: MM accounts for 10% of haematopoietic tumours; 7% of cases present with plasmacytomas at diagnosis. Orbital locations are rarely reported (frequently in the temporal region). Proptosis, ptosis and reduced visual acuity are common symptoms. However, orbital pain is less frequent. Most cases of MM demonstrate hypergammaglobulinaemia. Only 5% of MM cases are non-secretory. The uncommon location, topography, symptom peculiarities and absence of monoclonality led to the diagnostic challenge of this fatal case of MM.
She Has The Blues: An Unusual Case of Copper Sulphate Intoxication
Authors: Aurore Moussiegt  , Luis Ferreira  , Jérome Aboab  , Daniel Silva
Published: May 2021

Background: Copper is an essential trace element of the human body. However, it is related to many diseases. Copper intoxication is not common in Western countries, but needs to be rapidly recognised because of its high lethality. Case presentation: We report the case of a 40-year-old woman who presented to the emergency department after performing intrarectal administration of a blue powder sent from Cameroon by her family, in the belief that this would help her to get pregnant. Her evolution was complicated by multiorgan failure and the unusual circumstances. The diagnosis was suspected on the basis of the clinical presentation and the colour of the powder, and confirmed by blood dosage and toxicological analysis of the powder. She underwent symptomatic treatment, and the outcome was progressively favourable, apart from persistent chronic renal failure with dependence on dialysis. Conclusion: Copper intoxications are rare but severe. Laboratory diagnosis of the condition is not an issue; the difficulty is suspecting it and quickly initiating chelation treatment associated with symptomatic treatments.
Cardiopulmonary Resuscitation Induced Consciousness - A Case Report in an Elderly Patient
Authors: Joel Pinto  , Paulo Almeida  , Fani Ribeiro  , Rita Simões
Published: May 2021

Cardiopulmonary resuscitation-induced consciousness is a rarely described and often misunderstood phenomenon, although it can be encountered. High quality cardiopulmonary resuscitation (CPR) may lead a patient to recover consciousness while in cardiac arrest. The authors present the case of an 89-year-old male patient who received CPR after a cardiac arrest. Spontaneous movements during CPR were noted and prompted several CPR interruptions. These movements immediately stopped during chest compression pauses. Physical restraint was used in order to be able to continue with the CPR algorithm, but sedation may be the best approach. Guidelines on how to identify and manage these cases need to be developed.
A Mesothelial Inclusion Cyst Presenting in a 40-Year-Old Woman as Abdominal Pain and Bloating – A Rare Diagnosis
Authors: Sonia Canadas  , Rita Fernandes  , Hugo Almeida  , João Santiago Correia
Published: May 2021

Cystic mesotheliomas (also called mesothelial inclusion cysts) are rare benign neoplasms that occur more often in young women. Symptoms are usually non-specific, demanding a thorough work-up. We report a case of a 40-year-old female patient with 2 prior caesarean sections presenting with a 3-month history of abdominal pain. Laboratory tests revealed microcytic hypochromic anaemia and an elevated tumour marker CA-125. An investigation identified a large cystic abdominal mass, mostly in the left side of the abdomen. A laparotomy was performed with total resection of the lesion. Histological assessment resulted in a diagnosis of a mesothelial inclusion cyst. The patient had no recurrence after 3 years.
Urea Treatment of Syndrome of Inappropriate Antidiuretic Hormone Secretion Secondary to Amyotrophic Lateral Sclerosis
Authors: Francisco-Javier Mena-Martín  , Maria Gonzalez-Fernandez  , Marina Cazorla-Gonzalez  , Juan Carlos Martin-Escudero
Published: May 2021

Amyotrophic lateral sclerosis (ALS) rarely presents with hyponatraemia caused by syndrome of inappropriate antidiuretic hormone secretion (SIADH). We present a patient with hyponatraemia of multifactorial aetiology, in whom, after withdrawal of the drugs that contributed to this ionic alteration, SIADH secondary to ALS was confirmed. After initiating treatment with urea, sodium levels were normalized.
Turicella otitidis as an Unusual Agent Causing Palmoplantar Eczema: An Emerging Pathogen
Authors: Dimitra Koumaki  , Vasiliki Koumaki  , Sotirios Boumpoucheropoulos  , Alexander Katoulis  , Panagiotis Bitados  , Maria Stefanidou  , Konstantinos Krasagakis
Published: May 2021

Introduction: Turicella otitidis, described as a new species over 20 years ago, has been isolated mainly from the external ear canal and middle ear fluid. Here, we report the first case of palmoplantar eczema related to T. otitidis. Case presentation: Here, we report the first case of palmoplantar eczema in a 74-year-old female related to T. otitidis. Conclusions: The question as to whether T. otitidis is a potential pathogen in cases of dyshidrotic eczema is still open, but this could be better elucidated if corynebacteria were speciated more often.
The Dark Purple Side of Ceftriaxone: A Case Report on Leucocytoclastic Vasculitis
Authors: Elia Rigamonti  , Francesca Bedussi  , Jerome Blanc  , Pietro Gianella  , Gianluca Vanini
Published: May 2021

We present a case of an 85-year-old woman diagnosed with uncomplicated pyelonephritis, who was treated with intravenous ceftriaxone. Her chronic medications were phenprocoumon, diltiazem and bisoprolol. During the infectious phase, the patient presented tachycardia – despite high-dose beta-blocker treatment – and developed left acute heart failure, with acute renal failure (pre-renal origin). After introduction of furosemide diuretic therapy, clinical conditions improved and better control of the volemic status and heart rate was achieved. Several days after ceftriaxone and digoxin therapy initiation, worsening multiple non-blanching palpable purpuric lesions with bullae and papules, limited to the lower extremities, were noted. Skin biopsy was performed and a diagnosis of leucocytoclastic vasculitis, with associated panniculitis, was made. Ceftriaxone was discontinued and systemic corticosteroids were introduced, with a clear improvement in the cutaneous condition.
Intellectual Disability, Falls and Gait Disturbances: A Misdiagnosis
Authors: Noel Lorenzo Villalba  , Santiago Díaz Nicolas  , Maria Belen Alonso Ortiz  , Zaida Cordoba Sosa  , Saturnino Suárez Ortega  , Abrar-Ahmad Zulfiqar
Published: May 2021

We report the case of a 27-year-old man presenting with slowly progressive extrapyramidal dysfunction and learning disability considered to have a syndromic intellectual disability. The re-evaluation of the clinical features and the investigations performed led to the diagnosis of atypical pantothenate kinase-associated neurodegeneration (PKAN).
Pleural Listeriosis: A Rare Entity
Authors: Maria Inês Silva  , Isabel Ferreira  , Teresa Brandão  , Paulo Telles de Freitas
Published: May 2021

Listeria monocytogenes is a gram positive bacillus responsible for listeriosis. This infection manifests mainly as bacteremia and / or central nervous system (CNS) infection. Involvement of other sites is rare. Pleural listeriosis is an uncommon presentation of L. monocytogenes infection and there is little data to guide the management of these patients. First-line antibiotics used empirically to treat bacterial respiratory infections are ineffective in treating these L. monocytogenes infections, which contributes to the progression of the infection and a worse prognosis. We present a case report of a patient admitted to an intensive care unit with septic shock secondary to systemic listeriosis with L. monocytogenes isolation in pleural fluid culture and blood cultures. The evolution of the hospitalization and the clinical outcome are reported.
Type B Interrupted Aortic Arch with a Patent Ductus Arteriosus in an Adult Presenting with Secondary Polycythaemia
Authors: Jonan Chun Yin Lee  , Jeanie Betsy Chiang  , Boris Chun Kei Chow
Published: May 2021

Interrupted aortic arch (IAA) is an extremely rare congenital cyanotic heart disease characterized by complete disruption between the ascending and descending aorta. A patent ductus arteriosus (PDA) or other collateral pathways provide blood flow to the distal descending aorta. Mortality is extremely high at early infancy, particularly after the closure of ductus arteriosus. Survival and presentation in adulthood are extremely rare. Here we illustrate a rare case of type B interrupted aortic arch in an adult who presented with secondary polycythaemia. The blood supply to descending aorta and beyond is almost solely by a patent ductus arteriosus. The case demonstrates the value of multimodality imaging including CT and MRI for diagnosis and treatment planning in these patients.
Olmesartan-Induced Enteropathy: A Case of Recurrent Diarrhoea
Authors: Ana Rita Matos  , Elisabete Coelho  , Sofia Caridade
Published: May 2021

A 77-year-old man with arterial hypertension and dyslipidaemia, treated with olmesartan/hydrochlorothiazide and simvastatin, was admitted with a 3-week history of anorexia, nausea, vomiting, profuse diarrhoea and weight loss. He was dehydrated and blood tests showed acute kidney injury. The aetiological study was inconclusive. The patient had a favourable clinical evolution during hospitalization and was discharged. However, after about 10 days at home, he was re-admitted to hospital with the same clinical presentation. It was noticed that olmesartan had not been prescribed during the previous admission but had been restarted on an outpatient basis. Biopsy examination showed duodenal mucosa with villous atrophy and polymorphic inflammatory infiltrate. Antibody testing for coeliac disease was negative. Based on these facts, it was hypothesized that the patient had olmesartan-induced enteropathy, which was subsequently confirmed.
Inferior Vena Cava Syndrome: A Rare Complication
Authors: Teresa Gantes Padrão  , Miguel Casimiro  , Augusto Gaspar  , Anabela Raimundo
Published: May 2021

Inferior vena cava syndrome is rare and often difficult to diagnose because of its rarity and consequent low suspicion.  We describe the case of a 28-year-old female patient with a history of nephroblastoma of the right kidney, stage IV, with a favourable histology with epidural metastasis (D5-D9), diagnosed at 3 years of age. The patient underwent treatment with surgery, chemotherapy and radiotherapy. The patient suffered from sudden low back pain worsening over 2 weeks, with progressive inability to walk. The pain radiated to the front of the thighs. Concomitantly, oedema of the lower limbs with cephalocaudal progression was observed. At admission to our institution, the physical examination showed peripheral oedema, abdominal wall venous collaterals, an inability to walk due to low back pain in the supine position, with no neurological deficits. Lumbar MRI showed exuberant epidural venous congestion. The hypothesis of inferior vena cava thrombosis (IVCT) was considered and confirmed by angio-CT. IVCT is prevalent in patients with congenital anomalies of the inferior vena cava, occurring in approximately 60–80% of these cases, and most published series on inferior vena cava syndrome refer to thrombotic complications in this subgroup of patients. There are currently no guidelines defined or validated to guide the diagnosis and approach to IVCT. With this case, we would like to draw attention to a rare disease that should be suspected in all patients with inferior vena cava disease, whether resulting from congenital disease or after surgical procedures.
Elevated Adenosine Deaminase in Pleural Effusion - A Case of Non-Hodgkin Lymphoma Misdiagnosis
Authors: Tiago Seco  , Ana Margarida Cerqueira  , Ana Luís Ferreira  , Ana Costa  , Carlos Fernandes  , Jorge Cotter
Published: May 2021

Despite a recent decline, tuberculosis (TB) infection is still a frequent diagnosis in Portugal. Adenosine deaminase (ADA) measurement has become an important tool in the timely diagnosis of this infection. However, ADA elevation in bodily fluids is not pathognomonic of TB infection. We present the case of a 70-year-old woman, undergoing treatment for pleural TB, diagnosed based on elevated ADA levels in a pleural effusion. Due to worsening symptoms she was readmitted, and the previous diagnosis was reconsidered. Thoracocentesis was repeated and cytometry analysis of the fluid was performed, showing the presence of diffuse large B cell lymphoma (DLBCL). DLBCL is the most frequently occurring non-Hodgkin lymphoma (NHL). Pleural involvement is rare in the initial stages. ADA elevation >250 U/l should raise suspicion of malignancy, especially in association with markedly elevated LDH levels. The purpose of this case report is to highlight that in the absence of microbiologic or histologic confirmation, a presumptive TB diagnosis should not be lightly made, and alternative diagnoses should be systematically ruled out.
Primary Aortoesophageal Fistula: Is a High Level of Suspicion Enough?
Authors: Ana Sara Monteiro  , Rute Martins  , Catarina Martins da Cunha  , Jorge Moleiro  , Henrique Patrício
Published: May 2021

Aortoenteric fistula (AEF) is a rare condition with a high mortality rate. AEFs are classified according to their primary and secondary causes, the former being less frequent. Primary AEFs occur in a native aorta and their causes include aneurysms, foreign bodies, tumours, radiotherapy and infection. The classic triad of aortoesophageal fistulas, a subtype of AEFs, are mid-thoracic pain and sentinel haemorrhage, followed by massive bleeding after a symptom-free interval. We present the case of a 41-year-old male patient who presented in the emergency room after successive episodes of abundant haematemesis. He was hypovolemic, hypothermic and acidotic at presentation. His medical history included an emergency room visit the week before with chest pain but no relevant anomalies on work-up, active intravenous drug use and chronic hepatitis. Esophagogastroduodenoscopy (EGD) showed a bulging ulcerated lesion suspicious for aortoesophageal fistula, confirmed by computed tomography (CT) angiography, which revealed a saccular aortic aneurysm with a bleeding aortoesophageal fistula. The patient underwent urgent thoracic endovascular aortic repair. The sentinel chest pain, leucocytosis and CT findings hinted at the presence of a mycotic aneurysm, despite the negative blood cultures. It was most likely caused by a septic embolus due to the patient’s risk factors. While a high level of suspicion for aortoesophageal fistula is needed to prompt a fast diagnosis, EGD and CT findings were crucial to establish it and allow a life-saving intervention. We conclude that chest pain cannot be disregarded in a patient aged 41 years with multiple comorbidities, despite normal work-up, to prevent a fatal outcome.
From Wellens To Kounis Syndrome: An Unlucky Patient
Authors: Ossama Maadarani  , Zouheir Bitar  , Sania Shoeb  , Jadan Alsaddah
Published: May 2021

Wellens syndrome (WS) is identified by ECG changes in the precordial leads after resolution of angina chest pain. WS indicates critical stenosis of the proximal left anterior descending (LAD) artery. On the other hand, Kounis syndrome (KS) is an allergic reaction to various substances resulting in acute coronary syndrome. Contrast media can trigger the allergic reaction associated with KS. We describe a patient with WS who developed an allergic reaction to contrast media after percutaneous coronary intervention and experienced recurren myocardial infarction on re-exposure.
COVID-19 and Pulmonary Embolism: Not a Coincidence
Authors: Adriana Tamburello  , Giovanni Bruno  , Marco Marando
Published: May 2021

In December 2019, a novel coronavirus called SARS-CoV-2 was reported to be responsible for a cluster of acute atypical respiratory pneumonia cases in Wuhan, in Hubei province, China. The disease caused by this virus is called COVID-19 (coronavirus disease 2019). The virus is transmitted between humans and the outbreak was declared a pandemic by the World Health Organization (WHO) on 11 March 2020. Coagulopathy is a common abnormality in patients with COVID‐19 due to inflammation, hypoxia, immobilisation, endothelial damage and diffuse intravascular coagulation. However, the data on this topic are still limited. Here we report the case of a man presenting with pneumonia complicated by bilateral pulmonary embolism.
Effectiveness of Tocilizumab in a COVID-19 Patient with Cytokine Release Syndrome
Authors: Sadettin Uslu
Published: May 2021

Cytokine release syndrome (CRS) is a systemic inflammatory response that can be triggered by many factors such as infections. CRS in patients with coronavirus disease 2019 (COVID-19) is life-threatening and can occur very rapidly after COVID-19 diagnosis. Tocilizumab (TCZ), an interleukin‐6 (IL-6) inhibitor, may ameliorate the CRS associated with severe COVID‐19 and thus improve clinical outcomes. We present a case of life-threatening CRS caused by COVID-19 infection successfully treated with TCZ.
Spontaneous Breast Haematoma after Heparin Anticoagulation
Authors: Imran Yaseen Gani  , Rajan Kapoor  , Muhammad Irfan Saeed
Published: May 2021

Heparin is commonly used in clinical practice for the prevention and treatment of various thrombotic conditions. Its use can be associated with bleeding which can range from minor to life threatening. Non-traumatic causes of breast haematoma are very rare. We report a case of spontaneous bleeding into the breast in a female patient who was anticoagulated with heparin.
A Peculiar Case of Priapism: The Hypercoagulable State in Patients with Severe COVID-19 Infection
Authors: Germain Lam  , Rowan Mccarthy  , Rana Haider
Published: May 2021

It is increasingly recognised that patients with severe COVID-19 infection have a significant risk of thromboembolic events. We describe a patient who rapidly deteriorated due to severe infection with COVID-19, and developed priapism in the last days of his life. We believe development of priapism may be associated with a prothrombotic state secondary to COVID-19 infection. This case report supports the widely reported increased incidence of thrombosis in patients with severe COVID-19 infection.
Subungual Squamous Cell Carcinoma in a Patient with Psoriasis
Authors: Sherif Monib  , Kevin Seebah
Published: May 2021

Subungual squamous cell carcinoma (SCC) is a rare malignant tumour with an indolent course and unknown aetiology. It is usually misdiagnosed as a benign lesion, resulting in delayed treatment. Although psoriasis is not a precancerous skin condition, the treatment modalities cyclosporine and psoralen with ultraviolet A (PUVA) might increase the risk of developing cutaneous SCC, although a relationship has not been confirmed. We describe a patient with psoriasis who had been treated with cyclosporine and PUVA 6 years previously. He developed back SCC 2 years later, a subungual skin lesion after another 2 years and presented to us 1 year later, when nail elevation and biopsy revealed SCC.
Cutaneous Vasculitis During Secukinumab Treatment
Authors: Camila da Silva Cendon Duran  , Mittermayer Barreto Santiago
Published: May 2021

Secukinumab is an inhibitor of interleukin IL-17A, and is mainly used in the treatment of psoriasis, psoriatic arthritis and ankylosing spondylitis. Although rarely, this drug may induce paradoxical reactions, such as cutaneous vasculitis. Worldwide, only four previous cases of vasculitis induced by secukinumab have been reported. We herein report the first case described in Brazil of cutaneous vasculitis due to secukinumab in a patient with peripheral spondyloarthritis who demonstrated good resolution after withdrawal of the drug and initiation of etanercept. Clinicians should be aware of this rare but potentially serious adverse effect of secukinumab.
Masquerading Hypervascular Exophytic Liver Nodule
Authors: Kevin Kim-Jun Teh  , Albert Su-Chong Low  , Jason Pik-Eu Chang  , Chee-Kiat Tan
Published: May 2021

Patients with liver cirrhosis are at increased risk of developing hepatocellular carcinoma (HCC) and are placed on routine surveillance for HCC. Diagnosis algorithms are in place to guide clinicians in the evaluation of liver lesions detected during surveillance. Radiological assessments are critical with diagnostic criteria based on identification of typical hallmarks of HCCs on multiphasic computed tomography (CT) and dynamic contrast-enhanced magnetic resonance imaging (MRI). We report a patient with a hypervascular exophytic lesion indeterminate for HCC on CT imaging. While the detection of an exophytic arterially-enhancing lesion in an at-risk patient on CT imaging may prompt clinicians to treat the lesion as HCC without further evaluation, the patient underwent contrast-enhanced MRI with the lesion being eventually diagnosed as an exophytic haemangioma. Thus, no further action was necessary and the patient was continued on routine HCC surveillance.
Multi-Focal Splenic Tumour in a Belgian Patient and a Brief Review of the Literature on Littoral Cell Angioma
Authors: Maaike Ramael  , Patrick Schoeters  , Karl De Pooter  , Frederik Van Sonhoven  , Hilde Van Steelandt  , Jacqueline Swaegers  , Wim Develter  , Marc Ramael
Published: May 2021

We describe the case of a 66-year-old woman with littoral cell angioma (LCA) confirmed by histopathology and immunohistochemistry, to our knowledge the first case in Belgium. LCA is an extremely rare primary vascular tumour of the splenic red pulp, probably originating from littoral cells. If a splenic mass and nodules are incidentally identified on imaging and the patient has no associated signs or symptoms, LCA should be suspected. Histopathology and adjacent techniques are mandatory for definitive diagnosis. Splenectomy followed by adequate follow-up is necessary to exclude underlying pathology.
Spontaneous Periodic Hypothermia in the Elderly: A Rare or Under-Recognised Syndrome
Authors: Hassene Attout  , Sofia Amichi  , Youcef Belkheir
Published: May 2021

Spontaneous periodic hypothermia is a rare syndrome presenting with recurrent, centrally mediated hypothermia without an identifiable systemic cause or brain lesion. The case of an 88-year-old woman with recurrent hypothermia is reported. Despite intensive investigation, no other manifestations of hypothalamic or autonomic dysfunction were found. No corpus callosum lesion was seen on MRI. The patient was successfully treated with clomipramine chlorhydrate.
Propofol-Induced Hepatitis
Authors: Hanna Raisi  , Thomas Longerich  , Bernardo Moreira Assuncao  , Sebastian Mueller  , Peter Schirmacher  , Helmut-Karl Seitz
Published: May 2021

Objectives:To present a rare case of propofol-induced hepatitis. Materials and methods: A 59-year old man was referred to our department because of suspicion of toxic hepatitis after propofol anaesthesia for endoscopic colonoscopy.  Results: The patient had jaundice, increased transaminases demonstrating liver necrosis, and liver stiffness of 18 kPa. Liver biopsy revealed bridging necrosis and initial post-collapse fibrosis. Following therapy with steroids and N-acetyl cysteine, the patient was discharged on the seventh day after admission in good general condition. Conclusion: Although propofol is considered safe, it can cause acute hepatitis, the seventh published case of which is reported here. Importantly, treatment with N-acetyl cysteine, a radical scavenger, but especially with steroids resulted in hepatic improvement.
Tracheobronchopathia Osteochondroplastica: Two Different Facets of a Rare Entity
Authors: Margarida Barata  , Ricardo Gomes  , Ana Catarina Moreira  , Jorge Soares
Published: May 2021

Tracheobronchopathia osteochondroplastica (TBPO) is an uncommon benign disease, characterized by osseous or metaplastic cartilaginous nodules in the submucosa of the tracheobronchial tree. TBPO is easy to misdiagnose due to its non-specific clinical manifestation. We describe two cases of TBPO. The first patient was a 57-year-old woman with nocturnal dry cough and wheezing, in whom bronchoscopy revealed small diffuse mucosal irregularities involving the airway until the segmental bronchi. The other patient was a 69-year-old man with progressive worsening dyspnoea and productive cough presenting with severe stenosis of the trachea. Histological examination of both cases was consistent with TBPO. These cases highlight distinct forms of presentation of this rare entity.
Relapsing Haemothorax as an Unusual Presentation of Primary Angiosarcoma of the Spleen
Authors: Alba Bergas  , Francesc Escrihuela-Vidal  , Davinia Fernández Calvo  , Olga Capdevila Pons  , Xavier Corbella
Published: May 2021

Spontaneous haemothorax (SH) is a rare subcategory of haemothorax that involves the accumulation of blood within the pleural space in the absence of trauma. SH especially occurs in middle-aged or elderly patients, but data are usually limited to case reports and case series. Coagulopathy, aneurysm or aortic dissection, Rendu-Osler-Weber syndrome and malignancy have to be considered among the causes of SH. Aim: We describe a case of primary angiosarcoma of the spleen presenting as relapsing haemothorax. Results: An 81-year-old woman was referred to our hospital because of a 2-month history of relapsing haemothorax after the performance of urgent splenectomy due to active bleeding from large spleen cysts. No evidence of neoplasm was seen after pathological examination of the spleen. On admission, left haemothorax and 2 new cystic masses in the thoracic wall were documented, both in close relation to the scars of previous surgery and chest tubes. After excision of 1 mass, histological examination revealed angiosarcoma, and a final diagnosis of primary angiosarcoma of the spleen with postsurgical metastatic dissemination to the thorax and pleura was made. Conclusion: Primary angiosarcoma should be included in the differential diagnosis of haemorrhagic spleen cysts. Clinical diagnosis and management usually requires splenectomy, but it should be carefully planned in order to avoid local metastatic dissemination or haematogenous spread of the tumour.
Keep an Eye Out for Crohn’s Disease: Orbital Myositis as the Initial Sign before Gastrointestinal Manifestations
Authors: Gilles Jadd Hoilat  , Abinash Subedi  , Mohamad Fekredeen Ayas  , Nuri Ozden
Published: May 2021

Extraintestinal manifestations of Crohn's disease sometimes occur and can present prior to intestinal symptoms. Ocular manifestations of Crohn's disease are considered rare, with orbital myositis an even rarer manifestation with only a handful of cases reported in the literature. We present the case of a young woman who was diagnosed with orbital myositis, which was initially attributed to pseudotumor cerebri after an extensive negative work-up. Months later, the patient presented with haematochezia, and was subsequently diagnosed with Crohn's disease.
Delayed Diagnosis of Pulmonary Thromboembolism Due to Overfocus on COVID-19
Authors: Yukinori Harada  , Taro Shimizu
Published: May 2021

The coronavirus disease 2019 (COVID-19) pandemic has made it difficult for physicians to follow their usual diagnostic processes. We present the case of a 25-year-old man with adjustment disorder who developed dyspnoea. He was concerned about COVID-19, but his test result was negative. After excluding COVID-19, the physician concluded that his symptoms were related to his psychiatric condition. However, the patient was diagnosed with pulmonary thromboembolism by another physician. To avoid missing a diagnosis, physicians must practice zero-based thinking, regardless of COVID-19 concerns, and not be distracted from the patient's core problems.
Radiotherapy-Associated Paraneoplastic Pemphigus and Its Complications in a Patient with Nasopharyngeal Carcinoma
Authors: Ali Hamza Khair  , Aimen Asim Dar  , Abu Baker Sheikh  , Aamir Iftikhar Malik
Published: May 2021

Paraneoplastic pemphigus arising in association with non-haematological cancers is extremely rare, and there are no reported cases of a patient developing this in the setting of nasopharyngeal carcinoma and only 2 reported cases of patients developing this in response to radiotherapy. Here, we present the case of a patient who developed radiotherapy-associated paraneoplastic pemphigus in the setting of nasopharyngeal carcinoma and who then developed multiple complications.
Hard-To-Treat Idiopathic Refractory Autoimmune Haemolytic Anaemia with Reticulocytopenia
Authors: Marcelo Aveiro  , Gisela Ferreira  , Carla Matias  , Ana Oliveira  , Tatiana Rodrigues
Published: May 2021

Autoimmune haemolytic anaemia (AIHA) is an uncommon condition characterized by increased destruction of erythrocytes associated with reticulocytosis in the great majority of cases. We present the case of a 68-year-old woman with jaundice and malaise. Investigation revealed AIHA with reticulocytopenia. The patient failed to respond to prednisolone or to rituximab. Azathioprine and epoetin beta were subsequently started, the prednisolone dose was increased, and the patient began to respond after 1 month. In AIHA, reticulocytopenia is a very rare presentation and a sign of great severity and poor outcome. The scarcity of therapeutic options in refractory cases poses a major challenge for physicians.
The Utility of Delta-9-Tetrahydrocannibinol Therapy in a Multiple Sclerosis Patient with a Neoplastic Brain Lesion
Authors: Fuiani Aurora
Published: May 2021

Multiple sclerosis (MS) can sometimes cause uncommon pseudotumoural lesions that produce atypical symptoms, such as motor epileptic seizures which are often pharmacoresistant. In these cases, accurate diagnosis is essential for correct therapy, even if unconventional. We present the case of a brain tumour in a 40-year-old relapsing-remitting MS patient who presented with pharmacoresistant seizures which eventually responded to nabiximols. After various therapeutic approaches, delta-9-tetrahydrocannabinol therapy was introduced with good results. Spasticity improved, pain decreased and we observed a reduction in the number of daily seizures. It is possible that delta-9-tetrahydrocannabinol can enhance the efficacy of anti-epilepsy therapy.
COVID-19 in a Patient Newly Diagnosed with AIDS: Asymptomatic Disease
Authors: Manuel Serrano Martins  , Fabiana Pimentel  , Wildemar Costa  , Claudia Fernandes
Published: May 2021

The COVID-19 pandemic has imposed new challenges to scientific community. It’s behaviour and outcomes in people living with HIV is not yet well studied. We report a case of a 34-year-old-male with a newly diagnosed HIV infection stage 4 and asymptomatic SARS-CoV-2 infection. Although immunocompromised patients are classified as a high risk group for developing severe COVID-19, HIV related immunosuppression may have a protective role.
Metamizole-Induced Type I Kounis Syndrome
Authors: Catarina Lameiras  , Ana Corte-Real  , Ana Órfão  , Marta Mendes Lopes  , Maria do Céu Dória
Published: May 2021

Kounis syndrome (KS) is defined as acute coronary syndrome (ACS) triggered by mast cell and platelet activation in the setting of allergic or anaphylactic insults. KS is a unique and complex cause of ACS and many cases may be missed due to its highly variable clinical manifestations. In this report, we present a case of KS type I triggered by metamizole in the absence of a previous history of allergy to this drug. Following the administration of metamizole, the patient developed generalized acute urticaria, chest pain and diaphoresis. Electrocardiography (ECG) showed ST-segment elevation suggestive of myocardial infarction complicated by ventricular tachycardia. No coronary disease was observed on coronary angiography. The cardiac manifestations of KS may be life-threatening, and so it is important to appropriately recognize and treat this condition.
Beware of Drug Interactions Treating Iatrogenic Mycobacterium bovis Endocarditis from Intravesical BCG Instillation
Authors: Francesca Curri  , Andrea Da Porto  , Viviana Casarsa  , Daria Albini  , Giorgio Minen  , Leonardo Alberto Sechi
Published: May 2021

We report a case of mechanical mitral valve endocarditis associated with miliary disseminated bacillus Calmette-Guerin (BCG) infection following intravesical instillations for minimally invasive bladder cancer in a 65-year-old man. The diagnosis was established by echocardiographic evidence of vegetation on the prosthetic mitral valve, miliary lesions in the lungs and evidence of bloodstream infection sustained by Mycobacterium. We successfully treated the patient with the classical regimen of quadruple antituberculous therapy.
Use of Brentuximab Vedotin in a Non-HIV Patient with Primary Effusion Lymphoma
Authors: Joana Ferra  , Filipa Mousinho  , Francisca Miranda  , Sandra André  , Celina Afonso  , Fernando Nogueira
Published: May 2021

Primary effusion lymphoma is a rare and aggressive large B-cell lymphoma presenting as malignant effusion with poor prognosis. Although it is more prevalent among HIV patients, it has also been described in non-HIV immunocompromised individuals. Given its rarity, there are no large randomized trials regarding the best therapeutic option. The choice of therapy is based on retrospective studies, case reports and preclinical data. We present the case of a non-HIV patient with relapsed disease after treatment with CHOP who was then successfully treated with brentuximab vedotin, achieving complete remission.
Efficacy of Rituximab on Rheumatoid Leptomeningitis as the First Symptom of Rheumatoid Arthritis
Authors: Mickaël Chouk  , Alexandre Halb  , Christine Mekhail  , Amélie Godot  , Frank Verhoeven  , Clément Prati  , Daniel Wendling
Published: May 2021

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized mainly by arthritis, with the possible occurrence of extra-articular manifestations. We report the case of a patient who developed leptomeningitis as the first sign of RA, one year before the diagnosis of RA. Methylprednisolone 1000 mg was given intravenously. Because of the onset of seizures and cognitive impairment, rituximab was started. After three cycles of rituximab (1000 mg on day 0 and 1000 mg on day 15, every 6 months), neurological clinical examination, MRI and electroencephalogram findings were significantly improved.
Hypercalcaemia: An Extremely Rare Presentation of Hepatosplenic T-Cell Lymphoma
Authors: Sara Almeida Ramalho  , Francisca Abecasis  , Letícia Santos  , Vanessa Leite  , Diogo Gonçalves  , Inês Pintassilgo  , Ana Luisa Broa
Published: May 2021

Hypercalcaemia is a frequent finding in malignancies including lymphomas. However, there are no reports of hypercalcaemia in hepatosplenic T-cell lymphoma (HSTCL). HSTCL is a rare and aggressive neoplasm which is usually difficult to diagnose. We present a case of HSTCL in which hypercalcaemia was the initial presentation.
Coronavirus Disease 2019 and Cold Agglutinin Syndrome: An Interesting Case
Authors: Ruby Gupta  , Sukhmani Singh  , Nwabundo Anusim  , Sachin Gupta  , Sorab Gupta  , Marianne Huben  , George Howard  , Ishmael Jaiyesimi
Published: May 2021

The coronavirus disease 2019 (COVID-19) pandemic has caused significant morbidity and mortality worldwide. While patients with COVID-19 most frequently present with pneumonia, respiratory failure and acute respiratory distress syndrome, increasing cases of immune-mediated disorders such as autoimmune thrombocytopenia, haemolytic anaemia and antiphospholipid syndrome have been reported. In this article we describe a rare case of cold agglutinin syndrome (CAS) in a patient with COVID-19. The patient was a 77-year-old man with a history of glucose-6-phosphate dehydrogenase (G6PD) deficiency who presented with COVID-19 infection and acute respiratory failure. Initially he was started on intravenous steroids, antibiotics and hydroxychloroquine. Laboratory analysis revealed haemolytic anaemia with a positive direct anti-globulin test (DAT) and high titres of cold agglutinins. Hydroxychloroquine was stopped due to suspicion of haemolysis due to G6PD deficiency but the haemolysis persisted. Unfortunately, the respiratory failure progressed and the patient died. In summary, this article describes a rare case of CAS associated with COVID-19. CAS is a heterogenous group of cold autoimmune haemolytic anaemias occurring secondary to infections or malignancies. No definite treatment for CAS in COVID-19 patients has been approved so far.
Prostate Cancer and Reactive Haemophagocytic Lymphohistiocytosis
Authors: Laura Dumont  , Adriano Salaroli  , Lissandra Dal Lago  , Thierry Gil  , Thierry Pepersack
Published: May 2021

We report the case of a 76-year-old man presenting with reactive haemophagocytic lymphohistiocytosis (rHLH) in the setting of disseminated prostate cancer. This often fatal syndrome must be diagnosed early in order to maximize survival. Treatment should be initiated whenever the clinical diagnosis is suspected, even if the HLH-2004 criteria are not met. The HScore is a useful diagnostic tool for rHLH. In case of neurological symptoms, an extensive assessment must be performed. The goal of this case report is to raise awareness of this rare syndrome among oncologists.