European Journal of Case Reports in Internal Medicine 2017-11-14T11:59:59+00:00 Editorial Office Open Journal Systems <p>The <strong>European Journal of Case Reports in Internal Medicine</strong> is an official journal of the European Federation of Internal Medicine (EFIM). The journal wants to promote the practice of internal medicine in Europe. Its aim is to provide a forum to internal medicine doctors.<br> <strong>EJCRIM</strong> welcomes papers describing unusual or complex cases and case series that an internist may encounter in everyday practice. Case series are also welcomed as long as they demonstrate the appropiateness of a therapeutical approach or unusual manifestation of a disease.<br> The journal would also consider brief reasoned reports of issues relevant to the practice of Internal Medicine, as well as Abstracts submitted to scientific meetings of European societies of Internal Medicine.<br> <strong>EJCRIM</strong> utilizes the CNR-SOLAR system to permanently archive the journal for purposes of preservation, reservation and research and it is also indexed on Google Scholar and DOAJ. We encourage the use of Kudos to maximize the article's visibility.<br> <strong>EJCRIM</strong> is peer-reviewed with single-blind review and freely accessible to all.</p> Therapeutic Challenges in the Management of Acute Pulmonary Embolism in a Cancer Patient with Chemotherapy-induced Thrombocytopenia 2017-11-14T11:59:59+00:00 Abuajela Sreh Shailesh Nakeshree Senthil-Kumar Krishnasamy Nuri Alfasi <p>This case demonstrates the therapeutic challenges encountered when managing an acute pulmonary embolism in a cancer patient with thrombocytopenia. A 64-year-old man with a history of lung cancer receiving chemotherapy was admitted to Walsall Manor Hospital with haemodynamic instability consistent with a pulmonary embolism, proven on computed tomographic pulmonary angiogram. His platelet count was noted to be 35×10<sup>9</sup>/l (chemotherapy-induced thrombocytopenia). After discussions, he was deemed not suitable for thrombolysis based on risk versus benefits. The patient was initially transfused one adult dose of platelets and treated with half the therapeutic dose of low molecular weight heparin (LMWH). The same management plan was followed until the platelet count exceeded 50×10sup&gt;9/l, after which the patient was established on the full therapeutic dose of LMWH. Clinically, the patient improved and was discharged. Three months after discharge, follow-up revealed sustained clinical improvement while the patient continued to be on the full therapeutic dose of LMWH with a stable platelet count.</p> 2017-11-14T11:44:39+00:00 ##submission.copyrightStatement## An Abdominal Aortic Aneurysm, Intramural Thrombus and Moderate Leak in an Asian Man Presenting with Acute Gastroenteritis 2017-11-10T08:28:06+00:00 Abdalla Khalil Mohammed Bafaraj Badr Badr Majduldeen Azzo Ahmed Sabry <p><em>Introduction:</em> Missing a leaking abdominal aortic aneurysm (AAA) is common in medical practice because few at-risk patients have a history of AAA and many have an unusual presentation.<br> <em>Background:</em> AAA is less common among Asians than white Caucasians of the same age. Our patient had no significant risk factors apart from age and sex and had an unusual presentation. <br> <em>Patient and Methods:</em> A 67-year-old Asian man presented to the emergency room (ER) with a 1-day history of nausea, vomiting, diarrhoea, fever and abdominal pain. He was febrile, dehydrated. and had marked tenderness at the right iliac fossa. Laboratory findings suggested bacterial gastroenteritis but this did not explain the localized tenderness at the right iliac fossa.<br> <em>Result and Discussion:</em> A CT scan of the abdomen revealed an AAA arising above the origins of the renal arteries, an intramural thrombus, a retroperitoneal haematoma and a leak extending to the right iliac fossa. The patient was transferred to another hospital and underwent exploratory laparotomy, surgical repair of the aneurysm, and aortobi-iliac grafting with removal of the thrombus. The patient was discharged in good shape 3 weeks after surgery. Without the CT scan of the abdomen, the AAA could have been missed and the patient treated for severe gastroenteritis.</p> 2017-11-09T14:55:11+00:00 ##submission.copyrightStatement## Tuberculous Tonsillitis in a Patient Treated with an Anti-TNF Ag 2017-11-10T08:28:29+00:00 Sara Ferreira Paula Vaz-Marques <p>Tuberculosis remains a concern in patients receiving anti-TNF therapy as these individuals have a higher incidence of extrapulmonary and disseminated tuberculosis. Tuberculous tonsillitis is an unusual presentation of extrapulmonary tuberculosis, which is diagnosed mostly in immunodeficient patients. We report the case of a 33-year-old woman, diagnosed with Behçet’s syndrome, immunosuppressed with adalimumab, cyclosporine and prednisolone. She had odynophagia for 2 weeks, fever and a hypertrophied, ulcerated left tonsil. A tonsil biopsy revealed a granulomatous inflammatory process. Ziehl-Neelsen staining was positive for acid-fast bacilli. The chest x-ray revealed a milliary pattern. Gastric juice was positive for <em>Mycobacterium tuberculosis</em> complex DNA. A diagnosis of tonsillar and pulmonary tuberculosis was established. This case report highlights the low threshold for a tuberculosis diagnosis in unusual locations in patients treated with anti-TNF therapy. </p> 2017-10-30T15:57:25+00:00 ##submission.copyrightStatement## Raynaud's of the Tongue 2017-11-10T08:28:29+00:00 Martin Edward Perry Shazmeen Surtee Zainab Nawaz <p>We describe a 40-year-old lady who presents with a painful white tongue on exposure to the cold. The differential diagnosis and investigations are outlined with a discussion about this unusual presentation of a common problem.</p> 2017-10-30T15:57:25+00:00 ##submission.copyrightStatement## Spondylodiscitis with Epidural and Psoas Muscle Abscesses as Complications After Transrectal Ultrasound-guided Prostate Biopsy: Report of a Rare Case 2017-11-10T08:28:29+00:00 Chiao-Ching Li Chiao-Zhu Li Sheng-Tang Wu Tai-Lung Cha Shou-Hung Tang <p>A 71-year-old man presented with spondylodiscitis with epidural and psoas muscle abscesses following transrectal ultrasound (TRUS)-guided prostate biopsy. These rare complications were detected by computed tomography of the abdomen and magnetic resonance imaging of the lumbar spine. The patient was successfully treated with antibiotics and underwent neurosurgery. Awareness of presentations such as backache and weakness of the lower limbs after prostate biopsy is important as these symptoms are usually mistaken for bone or muscle problems and often not recognized as being related to infection.</p> 2017-10-30T15:57:25+00:00 ##submission.copyrightStatement## Goodpasture’s Syndrome with Negative Anti-glomerular Basement Membrane Antibodies 2017-11-10T08:28:29+00:00 Tjitske Berends-De Vries Susan Boerma Joan Doornabal Bert Dikkeschei Coen Stegeman Thiemo Veneman <p>A young male patient with rapidly progressive and life-threatening pulmonary haemorrhage due to anti-glomerular basement membrane (anti-GBM) antibody disease without renal involvement repeatedly tested negative for serum anti-GBM antibodies. Although rare, anti-GBM antibody disease should be considered in the differential diagnosis in patients with life-threatening pulmonary haemorrhage due to isolated diffuse alveolar haemorrhage. Enzyme-linked-immunosorbent assay (ELISA) testing for anti-GBM antibodies in anti-GBM antibody disease can give false-negative results. A negative serum anti-GBM antibody test is therefore insufficient to exclude the diagnosis. Thus, a kidney or lung biopsy should be considered in any case with a high clinical suspicion but negative anti-GBM antibody test to confirm or rule out the diagnosis.</p> 2017-10-30T15:57:24+00:00 ##submission.copyrightStatement## ANCA-negative Granulomatosis with Polyangiitis: A Difficult Diagnosis 2017-11-10T08:28:29+00:00 Eilis McCarthy Muneeb Mustafa Mike Watts <p>Granulomatosis with polyangitiis (GPA) is a systemic small and medium vessel vasculitis, commonly associated with anti-neutrophil cytoplasmic antibodies (ANCAs). Presenting signs and symptoms in GPA are varied and patients may present with constitutional, non-specific symptoms, which can delay the diagnosis. Tissue biopsy of the site of active disease can confirm the diagnosis of GPA, in which necrotising granulomatous inflammation is seen. However, surrogate markers may be used for diagnosis without a tissue biopsy. They include upper and lower airway symptoms, signs of glomerulonephritis and a positive ANCA. However, approximately 10–20% of patients with GPA are ANCA negative, allowing for the diagnosis to be overlooked, particularly in those patients with non-specific findings. The reason for the absence of ANCAs is unclear.</p> 2017-10-30T15:57:24+00:00 ##submission.copyrightStatement## Misleading Serum Procalcitonin Elevation in Heatstroke 2017-11-10T08:28:29+00:00 Marco Enzo Tau Melissa Cocca <p>A healthy 44-year-old man, with a typical presentation of exertional heatstroke, presented with an increase in serum procalcitonin (PCT) levels. Suspecting a coexisting infection, the emergency physician started empirical antibiotic treatment and obtained samples for culture. The antibiotic treatment was stopped immediately after ward admission due to lack of signs of infection. The patient recovered completely after several days of rehydrating therapy and cultures remained negative for bacterial growth. PCT elevation is typically found with heatstroke, but this association is rarely found in daily practice due to the futility of PCT testing in this situation. Increased serum PCT levels in the context of heatstroke must not lead to an unsupported alternative diagnosis and useless investigations, tests and treatment.</p> 2017-10-30T15:57:24+00:00 ##submission.copyrightStatement## Chlorpyrifos-Induced Delayed Neurotoxicity with A Rare Presentation of Flaccid Quadriplegia: A Diagnostic Challenge 2017-11-10T08:28:29+00:00 Patrícia Afonso Mendes Tatiana Cunha Pereira Rui Pina Rui Marques Santos <p>Chlorpyrifos is an organophosphate compound recognized as causing acute toxicity. However, organophosphate-induced delayed polyneuropathy (OPIDP), although rare, has also been described. We describe an unusual presentation of OPIDP with flaccid quadriplegia progressing to a locked-in-like syndrome, 30 days after a 60-year-old man voluntarily ingested chlorpyrifos. In the absence of specific treatment, the patient only recovered partial motor responses and the ability to communicate. The authors present this report in order to highlight a form of OPIDP which can hinder diagnosis due to its atypia and the delay in the onset of symptoms from initial contact with the toxicant.</p> 2017-10-30T11:09:22+00:00 ##submission.copyrightStatement## Continuation of Liraglutide during Fasting is not Associated with Hypoglycaemia 2017-11-10T08:28:29+00:00 Rosalie Koot Marcel van Borren Hans de Boer <p>Liraglutide, a glucagon-like peptide-1 (GLP-1) analog, is increasingly used in obese patients with type 2 diabetes mellitus (T2DM) in doses of up to 3.0 mg/day because of its attractive pharmacological profile. It is currently not known how to proceed with this medication during fasting for surgery. Discontinuation is likely to result in hyperglycaemia, while continuation might lead to hypoglycaemia, but, in view of its mode of action, continuation of GLP-1 analogs is likely to be safe. However, as evidence-based guidelines on GLP-1 management during perioperative fasting are not available, the safety of either policy needs to be confirmed on an individual basis. We therefore decided to perform a preoperative assessment of the glucose response to fasting during continuation of GLP-1 before giving a recommendation in individual cases. So far, 12 severely obese T2DM patients scheduled for bariatric surgery have been evaluated preoperatively by measuring glucose and insulin levels during a 32-hour fast with continuation of liraglutide. Hypoglycaemia was not observed. This suggests that liraglutide in doses of up to 3.0 mg can be safely continued during surgery without risking hypoglycaemia.</p> 2017-10-26T07:36:28+00:00 ##submission.copyrightStatement##