European Journal of Case Reports in Internal Medicine 2022-01-18T19:33:13+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> MASKED POLYCYTHEMIA VERA IN A FERTILE-AGED WOMAN 2022-01-18T19:33:13+00:00 Luis Reis de Almeida <p>Polycythemia Vera (PV) is a chronic proliferative disorder with clonal stem cell expansion of myeloid lineage leading to increased red blood cell (RBC) mass. Activating V617F mutation for Janus kinase 2 (JAK2) is present in 95-97% of cases, as well as other JAK2 pathway mutations, despite they are not exclusive for this condition. As the radionuclide assay for accessing RBC mass has low accessibility to clinicians, haemoglobin and haematocrit are used as surrogate markers in WHO diagnostic criteria for PV. These criteria were updated in 2016, with lower thresholds as a strategy to increase diagnostic sensitivity, mitigating the effect of plasma expansion and other concurrent factors that can occult the disease. We present the case of a fertile-aged woman with menometrorrhagia, whose induced iron depletion state worked as a limiting factor for major clonal expansion, delaying proper diagnosis. As this case points out, despite not meeting diagnostic criteria at presentation, masked PV (mPV) exhibited clinical, laboratory and imaging features of evolving disease. These symptoms and laboratory findings can be easily misinterpreted and not recognised as part of the disease course. For that, a higher level of suspicion must be held for fertile-aged women who present with significant iron depletion, besides normal haemoglobin, and haematocrit, in the presence of low erythropoietin levels or elevated RBC count.</p> Copyright (c) PURULENT PERICARDITIS PRESENTING AS CARDIAC TAMPONADE 2022-01-18T13:36:27+00:00 Ana Ferro Leila Duarte Daniela Carvalho Gracieta Malangatana <p>Purulent pericarditis (PP) is an uncommon, localized infection of the pericardial space that usually occurs in a compromised host. We report the case of a 70-year-old male that presented a PP, manifested as cardiac tamponade, and aortic valve endocarditis. The underlying mechanism was hematogenic spread of <em>Streptococcus agalactiae</em>, after bacterial translocation. There were several complications secondary to septic embolization and progression to constrictive pericarditis.</p> Copyright (c) Bacteroides fragilis bacteremia complicated by spondylodiscitis, spinal epidural abscess and sepsis 2022-01-17T21:01:39+00:00 Georgios Papaetis Theodosis Petridis Stylianos Karvounaris Theodora Demetriou Savvas Lykoudis <p>We describe a 63-year-old man, with a free past medical history, who presented with fever and altered level of consciousness. Significant thoracic spine pain was also reported during the last three months. He was finally diagnosed with vertebral spondylodiscitis, contiguous spinal epidural abscess and sepsis due to <em>Bacteroides fragilis </em>bacteremia. Clinical recovery was achieved after surgical decompressive therapy with abscess drainage combined with appropriate antibiotic therapy for twelve weeks. The primary focus of the infection was not clarified despite all the investigations that were performed.</p> Copyright (c) Acquired hepatocerebral degeneration - a rare neurological complication of liver cirrhosis 2022-01-17T14:40:04+00:00 Catarina Medeiros David Ferreira Daniela Brito Rita Serras Jorge <p>We reported a 64-years-old woman with medical history of hepatic cirrhosis caused by Hepatitis B and Hepatitis C virus, Child-Pugh Score 8 (Class B), with portal hypertension, ascites suppressed with diuretics, esophageal varices and hypertensive gastropathy, that presents with seven months history of subacute-onset hand tremor and postural imbalance. Neurological examination showed bilateral extreme nystagmus, rest and kinetic hand tremor, doubtful Romberg test and slightly enlarged base gait. Dosage of ammonia was normal. MRI showed homogenously increased T1 signal within the basal ganglia (nucleus pallidus), with normal T2-weighted, associated to manganese accumulation. The diagnose of Acquired hepatocerebral degeneration was made.</p> <p>Acquired hepatocerebral degeneration is a rare and debilitating neurological syndrome, characterized by movement disorders and cognitive impairment in cirrhosis or portosystemic shunts. Bilateral hyperintensity in the globus pallidus on T1-weighted sequences, with normal T2-weighted are the most common abnormal finding. It is a consequence of manganese deposition in nucleus ganglia. Medical treatments are not effective. Liver transplantation showed good outcomes.</p> Copyright (c) Pseudoaneurysm of a bronchial artery: an unusual cause of chest pain. 2022-01-17T13:34:21+00:00 Pepijn Van Hove Thomas Jardinet <p>We report a case of a bronchial artery pseudoaneurysm presenting as acute retrosternal pain. We want to discuss and to announce the extremely rare finding of a bronchial artery pseudoaneurysm. Bronchial artery aneurysms and pseudoaneurysms are uncommon however missing this diagnosis is associated with significant morbidity and mortality. When suspecting this pathology an urgent CT-angiography and a selective angiography (DSA) are crucial. Urgent treatment with transarterial embolization is preferred.</p> Copyright (c) Misdiagnosis due to false-positive detection of pneumococcal urinary antigen: a case report 2022-01-17T11:06:35+00:00 Kaori Notomi Taku Harada Takashi Watari Juichi Hiroshige Taro Shimizu Copyright (c) Painless presentation of a deadly disease: Type A Aortic Dissection requiring Bentall Procedure 2022-01-17T10:42:38+00:00 Muhammad Atif Masood Noori Kalpesh Shah Hardik Fichadiya Mofe Adeosun Shruti Jesani Edmund Appiah-Kubi Hasham Saeed Sherif Elkattawy Meherwan Joshi <p>Aortic dissection (AD) is a relatively uncommon, though catastrophic disease which requires early and accurate diagnosis and treatment for patient survival. Aortic dissection can be difficult to diagnose due to the diverse presentation of symptoms. The varied presentation can lead to later diagnosis, resulting in a higher mortality rate. Here we present a case of Type A aortic dissection with a varied presentation of symptoms, highlighting the importance of early detection and the Bentall procedure for management of such cases. A 50-year-old male with no known past medical history presented with bilateral lower extremity swelling and fatigue for 2 weeks. The patient denied any chest pain or dyspnea. Vital signs showed blood pressure of 160/76 mmHg, pulse of 103 bpm, respiratory rate of 18, and temperature of 98 F. Lab findings indicated a BNP of 1901 PG/ML and Troponin of 0.5 NG/ML. An initial diagnosis of decompensated heart failure was made, and IV Lasix was started. Following this, an echocardiogram indicated an EF of 50-55% and an ascending dissection of the aorta. A CT angiogram of the chest and abdomen confirmed this diagnosis. This case presents an unusual symptomology of aortic dissection which lacked the typical presentation of chest pain. It is important to consider aortic dissection in a cardiac related case, and prompt imaging can help confirm the diagnosis. We explore the risks and benefits of the Bentall procedure for management as well as early detection of an aortic dissection.</p> Copyright (c) Central cyanosis and altered mental status in a young patient 2022-01-16T19:05:11+00:00 Deeba Ali Lingna Zhu Yilmaz Gorur Benoît Cardos Noel Lorenzo-Villalba jean Michel MOT <p>We report the case of a 29-year-old man admitted for dyspnea and altered consciousness following drugs consumption. The clinical picture is marked by a central cyanosis refractory to oxygen administration with high concentration mask. The arterial gases showed levels of methemoglobinemia higher than 30%. This was effectively treated by the administration of methylene blue. An early recognition of the intoxication and an effective treatment allowed a favorable evolution and avoid the occurrence of organ failures and eventually.</p> Copyright (c) An Interesting Case of Disappearing Hepatocellular Carcinoma 2022-01-16T08:38:21+00:00 Ankita Hingolikar Preet Shah Aabha Nagral <p>A 65 year old gentleman with hepatitis B related chronic liver disease was found to be having a hepatocellular carcinoma (HCC) on Computerized tomography (CT) scan. He was advised trans-arterial chemo-embolization (TACE) but it was delayed as he had to undergo spinal fixation surgery for severe backache. When he was followed up after 1 year, the HCC on the CT scan had completely disappeared.</p> <p>A possible explanation for the disappearance was thought to be due to spontaneous rupture of the tumor post spinal surgery as evidenced by clinical condition.</p> Copyright (c) Diabetes and the hidden foe 2022-01-15T16:48:52+00:00 André Santos Pinto Juliana Magalhães Rita dos Santos Marques Rita Fideles Wildemar Costa <p>There is a complex connection between diabetes mellitus and pancreatic carcinoma, whereby it has been a target of many studies. The new-onset diabetes may be a symptom caused by occult pancreatic cancer, but the most important question remains when to think about it. We present a case report of a 72 year old female with a new-onset diabetes mellitus, initially diagnosed with no associated complications. However, a few months later, glycemic index was uncontrolled despite optimized therapy. It led to further study and a pancreatic carcinoma was discovered. With this case we intend to raise awareness that new-onset diabetes could be a hint for a hidden disease, especially when glycemic index is difficult to control despite optimized therapy. For that reason, physicians must be aware of the intrinsic relationship between diabetes and pancreatic carcinoma.</p> Copyright (c)