European Journal of Case Reports in Internal Medicine 2021-05-08T12:30:53+00:00 Editorial Office Open Journal Systems <p><strong>The&nbsp;<span class="HPblu">European Journal of Case Reports in Internal Medicine</span>&nbsp;</strong>is an official journal of the European Federation of Internal Medicine (EFIM), representing 35 national societies from&nbsp;<a href="">33 European countries</a>.&nbsp;<br><br>The journal’s mission is to promote the best medical practice and innovation in the field of acute and general medicine. It also provides a forum for internal medicine doctors where they can share new approaches with the aim of improving diagnostic and clinical skills in this field.&nbsp;<strong><br><span class="HPblu">EJCRIM&nbsp;</span></strong>welcomes high-quality case reports describing unusual or complex cases that an internist may encounter in everyday practice. The cases should either demonstrate the appropriateness of a diagnostic/therapeutic approach, describe a new procedure or maneuver, or show unusual manifestations of a disease or unexpected reactions. The Journal only accepts and publishes those case reports whose learning points provide new insight, contribute to advancing medical knowledge both in terms of diagnostics and therapeutic approaches. Case reports of medical errors, therefore, are also welcome as long as they provide innovative measures on how to prevent them in the current practice (Instructive Errors).&nbsp;<strong><br></strong>The Journal may also consider brief and reasoned reports on issues relevant to the practice of Internal Medicine, as well as Abstracts submitted to the scientific meetings of acknowledged medical societies.<br><br> <strong>EJCRIM</strong> is peer-reviewed with single-blind review and freely accessible to all.</p> Incidental Finding of Colonic amyloid polyp in A Young Patient Newly diagnosed with AL-Amyloidosis Initially Presented with Cardiac Manifestations: A Case Report 2021-05-08T12:30:53+00:00 Maab Elhaj Ashraf Ahmed Omar Ibrahim Ahmed Osman <p>Amyloidosis is a systemic illness due to the deposition of proteins resistant to proteolysis digestion. It is manifested by the primary causes of amyloidosis like hematological malignancy or chronic inflammatory process, and the organs where’s the proteins deposited. AL-Amyloidosis is secondary to monoclonal plasma cell expansion, where the light or heavy chains of the immunoglobulins deposited in specific organs like the heart, the kidneys, the gastrointestinal tract, or the nervous system. Cardiac manifestations are commonly heart failure and conduction defects causing variable arrhythmia and syncope. Gastrointestinal manifestations are variable, but common presentations are recurrent vomiting, hepatomegaly, and gastrointestinal bleeding. In this report, we present a case of amyloidosis presented with syncope that was missed to be due to amyloidosis and presented later with heart failure and an incidental recto-sigmoid amyloid polyp. Additionally, we review the relevant literature to raise awareness about this entity.</p> Copyright (c) An atypical manifestation of Mycobacterium tuberculosis infection. 2021-05-07T16:56:26+00:00 Iván Fernández Castro María Jesus Isorna Porto Ignacio Novo Veleiro Clara Casar Cocheteux Lucía Barrera López Ariadna Helena Andrade Piña María López Rodríguez Antonio Pose Reino <p>Aortitis is a strange manifestation of wide variety disease. In the past, it was rare to find this vascular inflammation isolated, as a guiding sign of the diagnostic process; but nowadays with the new imaging techniques this is changing.</p> <p><strong>Case presentation: </strong>We present a case of a 45-year-old male who in a thyroid ultrasound showed pathological lymphadenopathy. The complete imaging study demonstrated infrarenal aortitis and pathological lymphadenopathies in different locations. An exhaustive diagnostic process allowed us to reach the definitive diagnosis of tuberculous aortitis; an infrequent manifestation of extrapulmonary tuberculosis. The condition resolved after a 6-month course of antibiotics and a 6-week course of corticosteroids.</p> <p><strong>Conclusion: </strong>Tuberculous aortitis is an atypical manifestation of <em>Mycobacterium Tuberculosis</em> infection; the absence of typical symptoms and the difficulty to isolate in microorganisms make its diagnosis difficult. But clinical suspicion, new imaging tests and the combination of microbiological tests are the key to reach the diagnosis and start treatment of a serious disease that can lead to the appearance of aneurysms of the aorta and their dissection</p> Copyright (c) Post Covishield (AstraZeneca) Vaccination - Guillain Barre Syndrome (GBS): A Case report and Literature review. 2021-05-07T12:39:45+00:00 Yash Kripalani Vidyadhara Lakkappan Lipika Parulekar Anjum Shaikh Rakesh Singh PradeepKumar Vyas <p>As Covid-19 cases surge exponentially since March 2020, the hunt for a safe and effective vaccine becomes the need of the hour. With development of various vaccines and conclusion of clinical trials by December 2020 and their emergency administration in healthcare settings, numerous adverse effects have been noted despite being termed safe during the clinical trials. Development of Guillain-Barre syndrome (GBS) after the first dose of vaccination by covishield has not been reported as yet and is extremely rare. A case of GBS post covishield vaccination is presented here to highlight the possibility of developing this adverse condition which will be followed by a brief review of literature.</p> Copyright (c) Hypophysitis, a challenging diagnosis in medical clinical practice 2021-05-07T09:15:59+00:00 Patrick Hassler Oliver Keller Seyyid Baloğlu Xavier Jannot Emmanuel Andres Noel Lorenzo-Villalba Noel Lorenzo Villalba <p>&nbsp;</p> <p style="margin: 0cm 0cm 10pt; text-align: justify; -ms-text-justify: inter-ideograph;"><span lang="EN-US" style="line-height: 115%; font-family: 'Palatino Linotype','serif'; font-size: 9pt; mso-ansi-language: EN-US;">A 34 years old female patient initially admitted to the psychiatric department for postpartum depression was transferred to the emergency department owing to progressing worsening of general condition, drowsiness and hypoglycemia. The patient had two previous normal pregnancies with vaginal delivery as the last pregnancy two months ago.<span style="mso-spacerun: yes;">&nbsp; </span>The laboratory test showed evidence of antero-hypophysis deficiency with normal somatrotopic axis,<span style="mso-spacerun: yes;">&nbsp;&nbsp; </span>the ophthalmological exam showed bitemporal blindness, and the MRI was consistent with hypophysitis. Hormonal therapy replacement was started and surgical intervention initially not considered despite the presence of compressive symptoms. The patient clinical recovered and the MRI three months after showed a reduction in the lesion size. </span></p> <p>&nbsp;</p> Copyright (c) Staphylococcal Toxic Shock Syndrome with bacteremia due to a TSST1-producing Staphylococcus aureus in a healthy young boy. 2021-05-07T07:29:49+00:00 Anouk Goudsmit Samuel Markowicz Salah Eddine Lali Soraya Cherifi <p><strong>Keywords:</strong> Staphylococcal Toxic Shock Syndrome, Staphylococcus aureus, TSST-1, Intensive Care, Infectious disease</p> <p>&nbsp;</p> <ol> <li><strong><u>Introduction:</u></strong></li> </ol> <p>&nbsp;</p> <p>Toxic Shock Syndrome is a very rare complication of<em> Staphylococcus aureus</em> (SA), a common bacterial pathogen, in which production of several toxins act as superantigens generating an overwhelming immune response(1). This leads to a clinical picture of septic shock with multiple organ failure. The most common toxin implicated is TSS toxin-1 (TSST-1).</p> <p>&nbsp;</p> <ol start="2"> <li><strong><u>Case presentation:</u></strong></li> </ol> <p>&nbsp;</p> <p>A 15-year old boy was admitted to our Emergency Department with fever and confusion, appearing one day after having eaten meat in a fast food restaurant. He reported sweating, vomiting, myalgias and a cutaneous rash, whilst his mother noted that he was mildly confused. The patient had no medical history or treatment and had not traveled recently. On the initial physical examination his body temperature was 38.6°C, blood pressure 60/30 mmHg, heart rate 170 bpm, and oxygen saturation 98%. He had a diffuse cutaneous exanthema appearing mainly on the chest and upper limbs. The rest of the examination was normal, except for moderate abdominal tenderness and mild confusion. Blood tests showed elevated inflammatory markers with 21 000 WBC/mm³ (92% neutrophils) and a CRP of 250 mg/L, coagulopathy, and acute renal failure. The patient was transferred to the Intensive Care Unit where he was stabilized with intravenous fluids and vasopressors; empirical amoxicillin-clavulanate was initiated. Next day, both admission blood cultures were positive for staphylococci. Rapid identification by Maldi-TOF MS (Bruker® Germany) from a short culture of 5 hours showed <em>Staphylococcus aureus</em> and quick test of PBP2a (Alere®) was negative. Antibiotic therapy was changed to intravenous flucloxacilline. The patient was rapidly stabilized, with a rapid biological and clinical improvement. Complete antibiogram confirmed a multi-sensitive bacterial strain. Follow-up blood cultures remained negative, stool culture was negative, and a trans-esophageal echocardiography was normal. <em>&nbsp;</em>Intravenous antibiotics were maintained during 7 days and the patient was discharged with oral antibiotics for another week.&nbsp; In outpatient clinic hand and feet desquamation was observed 2 weeks after disease onset. Molecular analysis by real-time PCR assay of the <em>Staphylococcus aureus</em> strain confirmed the presence of the <em>tsst-1</em> gene and the absence of <em>eta </em>or <em>etb</em> toxins. Typing of the strain showed a <em>t2509 Staphylococcus aureus</em>.</p> <p>&nbsp;</p> <ol start="3"> <li><strong><u>Discussion:</u></strong></li> </ol> <p>&nbsp;</p> <p><em>Staphylococcus aureus </em>is a common bacteria which can cause a wide range of infections, from cutaneous infection to bacteremia (community-acquired or hospital-acquired) and shock. The rate of <em>Staphylococcus aureus</em> bacteremia (SAB) decreased significantly over time with a rate of 5/1000 in 2010(2). TSS is characterized by fever, rash, hypotension, multisystem involvement and cutaneous desquamation during the healing phase due to the ability of the toxin (TSST-1) produced by the bacteria to cross mucosal surfaces(3). Non-menstrual cases have occurred in males and females of all ages and races, whereas menstrual cases are seen predominately in White women. Our patient didn’t present any risk factor for TSS such as cutaneous lesions or surgical wound. Among non-menstrual cases, mortality in adults was estimated at 13-17%. Our patient ate meat in a fast food restaurant and presented four hours after with food intoxication syndrome (emesis and diarrhea). Interestingly, an <em>in vivo</em> study of Schlievert et al. proved that the ingestion of TSST-1 induces a clinical appearance of TSS(4). In this case, ingestion of a meal with a <em>Staphylococcus aureus</em> producer of TSST-1 can be highly suspected. Indeed, the <em>Staphylococcus aureus</em> strain found here, <em>t2509,</em> has been associated with epidemic food poisoning in St Petersburg in 2013. The TSST-1 has been isolated from SA strain with PCR. This toxin is specific for TSS but some SA strains may have the <em>tsst-1</em> gene without expression of the toxin. Accordingly, a Norwegian study showed that the toxin was found in 15.3% cases of <em>Staphylococcus aureus</em> bacteremia without TSS(5). In our patient, <em>Staphylococcus aureus</em> was found in blood cultures, which occurs only in 5% of the cases of TSS. Nevertheless, the positivity of blood culture isn’t associated with a higher mortality. Some studies have highlighted the presence of TSST-1 producing <em>S. aureus</em> on the hands of food handlers. A possibility is that, prior to degradation, TSST-1 was able to cross the gut mucosa into circulation and induced TSS. To our knowledge, this is the first Belgian case reported of bacteremia due to a TSS1-producing <em>S. aureus </em>causing a TSS acquired by ingesting contaminated food. The management of TSS is based on the recognition of the pattern, treatment of the shock and appropriate antibiotic therapy. An adjunct treatment by intravenous immunoglobulin showed positive effects in vitro but has not been validated in clinical trials(6).</p> <p><strong>&nbsp;</strong></p> <ol start="4"> <li><strong><u>Conclusion</u></strong><strong>:</strong></li> </ol> <p>&nbsp;</p> <p>In conclusion, we present a case of Staphylococcal Toxic Shock Syndrome in a 15-year old boy, associated with a TSST-1 producing <em>Staphylococcus aureus</em> bacteremia, appearing rapidly after ingestion of contaminated food, without any risk factor. Rapid clinical improvement was obtained with medical management and appropriate antibiotics.</p> Copyright (c) An unusual cause of fever in a patient with acute hepatitis 2021-05-06T21:16:21+00:00 Nuno Melo Sílvia Policarpo Manuela Dias Jorge Almeida <p>Drug fever is a cause of fever of unknown origin. It is considered an exclusion diagnosis and can lead to unnecessary investigation and prolonged hospitalization. Any drug can be responsible. Here, we present a case report of a female admitted due to acute hepatitis. Pantoprazole was started for stress ulcer prophylaxis when she was admitted to the ICU. Fever developed a few days later and an extensive diagnostic work-up was negative. Fever remitted after pantoprazole discontinuation and the diagnosis of drug fever was established.</p> Copyright (c) COVID-19 pneumonia complicated by seizure due to severe hyponatremia 2021-05-06T20:18:56+00:00 Mhd Baraa Habib Mohamad Khair Hamad Tarif Kalash Ashraf Ahmed Mouhand Mohamed <p>Coronavirus disease 2019 (COVID-19) is a widespread disease. Vaccines were rapidly developed to prevent and the infection and lessen its associated morbidity and mortality. COVID-19 induced hyponatremia and Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH) was reported with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Nonetheless, seizure as a prominent manifestation of hyponatremia due to SIADH induced by COVID-19 is rare. We present the case of a middle-aged gentleman with mild COVID-19 pneumonia post-vaccination. A seizure complicated his course due to SIADH-induced severe hyponatremia.</p> Copyright (c) A rare case of a second degree atroventricular block and Takotsubo syndrome 2021-05-06T15:40:02+00:00 Raquel Costa Joana Fontes Tiago Mendes Joana Faria Silva Bárbara Sousa <p><em>Background:</em> Takotsubo cardiomyopathy is characterized by a transient left systolic dysfunction that can mimic an acute myocardial infarction. The presence of atrioventricular (AV) block associated with Takotsubo is rare, but in recent years a few number of cases has been reported</p> <p><em>Methods:</em> We present the case of a 77-year-old woman presenting with a second degree atrioventricular block and Takotsubo syndome.</p> <p><em>Results:</em> The diagnosis of Takotsubo syndrome was based on the echocardiogram changes and in the absence of obstruction of the coronary arteries in coronary angiography</p> <p><em>Conclusions:</em> We describe a case of a patient that had a diagnosis of Takotsubo syndrome and AV conduction defect. &nbsp;These rarely occur simultaneous. When they do, this poses a dilemma regarding the implantation of the pacemaker.</p> Copyright (c) A rare case of hypophosphatemic osteomalacia in von Recklinghausen neurofibromatosis 2021-05-06T12:00:45+00:00 yasmine makhlouf Soumaya Boussaid Houda Ajlani Samia Jemmali Sonia Rekik Hela Sehli Mouhamed ELeuch <p><strong>Background</strong></p> <p>The neurofibromatoses type 1 (NF1), also known as the "von Recklingausen disease", is one of the most common hereditary autosomal disorders. Osteomalacia in neurofibromatosis type 1 is very rare tumor-induced osteomalacia, fibroblast growth factor 23 is usually incriminated.</p> <p><strong>Patients and methods</strong></p> <p>We report a case of a patient with a history of von Recklinghausen neurofibromatosis who presented with hypophosphatemic osteomalacia.</p> <p><strong>Results</strong></p> <p>The patient was treated with high dose of calcitriol and oral phosphate. The evolution was marked by clinical improvement.</p> <p><strong>Conclusion </strong></p> <p>Even though it is a rare entity, we must consider the diagnosis of hypophosphatemic osteomalacia in patients with neurofibromatoses, in order to adopt the appropriate treatment.</p> Copyright (c) The Meaning of SARS-CoV-2 antibodies in a patient with systemic reaction to the mRNA-1273 SARS-CoV-2 vaccine after previous natural immunization 2021-05-06T08:46:20+00:00 Lorraine Sazgary Andrea Meienberg Christoph T. Berger Michael Mayr <p>Objectives: There is limited experience regarding the meaning of SARS-CoV-2 antibodies after vaccination in patients with naturally acquired immunity.</p> <p>Methods: We describe the case of a patient who received the first dose of the mRNA-1273 SARS-CoV-2 vaccine 6 months after his recovery from moderately severe COVID-19.</p> <p>Results: Our patient had a positive nucleocapsid SARS-CoV-2 IgG/IgM titer with 78.7 multiple of cut-off indicating persistent humoral immune response 6 months after infection. After vaccination, he developed prolonged systemic symptoms (fever, fatigue, nausea, diarrhea, and myalgia) for a duration of 6 days.</p> <p>Conclusion: SARS-CoV-2 nucleocapsid antibodies provide information about naturally acquired immunity. For the assessment of immune response to vaccination, the measurement of the SARS-CoV-2 spike antibody titer before and after vaccination is essential. Patients with naturally acquired immunity might develop a prolonged systemic reaction to the first dose of the mRNA-1273 SARS-CoV-2 vaccine.</p> Copyright (c)