European Journal of Case Reports in Internal Medicine <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> SMC media s.r.l. - Via Giovenale 7, Milan - Italy en-US European Journal of Case Reports in Internal Medicine 2284-2594 <h3>Copyright and Disclosures</h3> <p>Every author must sign a copyright transfer agreement and disclose any financial or professional interest in any company, product, or service mentioned in an article. This authorization includes all submitted text including illustrations, tables, and other related materials.<br> If this submission contains any <strong>material that has been previously published</strong>, this authorization <strong>must also be accompanied</strong> by all necessary Permission to Reproduce Published Material" forms completed by the current copyright owner. If this submission contains any <strong>previously unpublished material</strong> for which the person(s) signing this form <strong>does not own copyright</strong>, an additional "Authorization to Publish" form is required from each corresponding copyright owner.</p> <h3>Copyright Transfer Declaration</h3> <p>(this may be included as a word document with your manuscript submission)<br> I confirm that I am the current copyright owner of the material described above and hereby transfer and assign to the European Journal of Case Reports in Internal Medicine (EJCRIM) all copyrights in and to the material for publication throughout the world, in all forms and media, in English and in any other language(s). Such transfer includes publication in this and all future editions of the publication named above and in any other publications (including slide collections and any other nonprint media) of EJCRIM and gives EJCRIM the sole authority to grant rights for use of the material by others.<br> I waive EJCRIM from any liabilities connected to the incorrect copyright statement.<br>The copyright agreement form can be downloaded <a style="font-weight: bold;" href="/documents/EJCRIM_Copyright_auth.pdf">HERE</a> or requested to the editorial office <a style="font-weight: bold;" href=""></a></p> Encephalitis: a rare complication of mediterranean spotted fever <p>Introduction: Mediterranean spotted fever (MSF) is an emerging zoonosis caused by <em>Rickettsia connori</em>. Its clinical spectrum may range from a mild febrile illness to a potentially life-threatening condition. The MSF typically presents with a triad of fever, generalized cutaneous rash and inoculation eschar. Although many other manifestations may be present, central nervous system involvement is highly rare.</p> <p>Case report: We report the clinical case of a 63-year-old male patient with MSF complicated by acute encephalitis and multi-organic failure.</p> <p>Discussion: There are few cases described in the literature of adults with encephalitis related to <em>Rickettsia connori</em> infection and those who have survived present important neurological sequelae. We describe a case of a patient with no risk factors for severe disease who developed multi-organic failure and experienced full recovery.</p> Jorge Miguel Bastos Mendes João Madaleno João Filipe Gomes Tatiana Gonçalves Bernardo Canhão Teresa Fraga Adélia Simão Copyright (c) Acute myocarditis in a patient with exertional heat illness - a rare association <p><strong>Introduction:</strong></p> <p>Exertional heat illness (EHI) is common in hot weather among young athletes, outdoor manual workers, and military personnel. EHI can involve multiple organs of the body, including the muscles, kidneys, and brain; however, myocardium involvement is infrequent.</p> <p>&nbsp;</p> <p><strong>Materials and methods:</strong></p> <p>We present a case of a 26-year-old male construction worker, working outdoors in the hot arid environment. He presented with acute kidney injury and rhabdomyolysis and was diagnosed with EHI. During hospital stay, he developed a complete heart block and cardiac MRI showed features of myocarditis. Work up to identify other etiologies of myocarditis was normal. This case highlights the effects of EHI on the myocardium.</p> <p>&nbsp;</p> <p><strong>Conclusion:</strong></p> <p>&nbsp;It is important to keep in mind the various effects of EHI on the myocardium. Myocarditis due to EHI is rare, and conduction defects resulting from it might persist necessitating specialist intervention</p> ADEEL AHMAD KHAN Aamir Shahzad Muhammad Awais Arif Zohaib Yousaf Copyright (c) Recurrent Stroke events secondary to a late presentation of Mitochondrial Encephalomyopathy with Lactic Acidosis and Stroke-like symptoms (MELAS) syndrome. A case report. <p>Mitochondrial Encephalomyopathy with Lactic Acidosis and Stroke-like symptoms (MELAS) is a rare mitochondrial disorder. Typically, MELAS patients present before the age of 40 with 75% of patients are diagnosed before the age of 20. (1,2,3) We present a case of a 56-year-old lady presenting with recurrent ischaemic strokes and seizures associated territorial low attenuation areas on brain imaging. Together with a raised serum lactate, genetic analysis was carried out that confirmed the presence of the most common mutation associated with MEALS syndrome which is m.3243A&gt;G mutation. This case raises the importance of considering a diagnosis of inherited mitochondrial disorder when faced with recurrent atypical stroke-like episodes, when neuroimaging is inconsistent with ischemic infarction, even in adults or elderly individuals.</p> Ihab Jameel Abuajela Sreh Partha Das Copyright (c) ECG in hypokalemia <p><img src=""><img src=""><img src=""></p> Georgios Koilias Copyright (c) Two sites - one major problem <p>The authors present the case of a 36-year-old woman with disseminated tuberculosis evidenced by pulmonary nodules and urogenital involvement. Diagnosis was confirmed through positive culture for <em>Mycobaterium tuberculosis</em>in urine and bronchial secretions. After&nbsp; 3&nbsp; months&nbsp; of&nbsp; multidrug treatment there was&nbsp; clinical and radiologic improvement.</p> <p>This case highlights that an uncommon case of an immunocompetent patient with disseminated.</p> <p>A delay in the diagnosis of pulmonary tuberculosis can result in serious public health problems with disease spread.</p> Carina Rolo Silvestre André Nunes Ricardo Cordeiro João Eusébio Teresa Falcão António Domingos Copyright (c) Uterine leiomyoma as a cause small bowel obstruction! <p>Small bowel obstruction (SBO) account for a good number of acute surgical admissions; recent developments in both imaging modalities and minimally invasive techniques have lead to better identification of the cause as well as the selection of patients requiring surgical intervention. It is still essential that rare cases are identified and presented to achieve better outcomes.</p> <p>&nbsp;</p> <p>Mechanical causes of small bowel obstruction are not uncommon; we are presenting a rare cause of mechanical bowel obstruction caused by a huge uterine fibroid in a 45 years old lady.</p> Sherif Monib Priyanka Chadha Gary Cross Jamal Zuberi Copyright (c) Persisting SARS-CoV-2 infection in an immunosuppressed medical resident. A case report. <p>&nbsp;</p> <p>Little is known about the behavior of SARS-CoV-2 infection in special populations such as immunosuppressed patients. A 27-year-old medical resident that received Rituximab for anti-NMDA receptor encephalitis, presented to the emergency department with cough and respiratory distress due to SARS-CoV-2 infection. Pulmonary function deteriorated so endotracheal intubation and mechanical ventilation support were necessary. Her symptoms simulated secondary bacterial infection but, SARS-CoV-2 RNA detection by PCR in bronchoalveolar lavage and clinical evolution confirmed otherwise. She was treated as a persistent coronavirus infection due to immunosuppressive agents.</p> Marco Antonio Baez-Garcia José J. Zaragoza Monica Grecia Cadena-Loces Copyright (c) Modified BLUE Protocol Ultrasonography can diagnose thrombotic manifestations of COVID-19 with Normal lung Ultrasound <p>Acute Dyspnoea is one of the most distressing complains for the patients and challenging diagnosis for the physicians. In many cases Physical examination and chest x ray alone not helpful in diagnosis. Lung ultrasonography is becoming a standard tool in critical care medicine. Blue Protocol of ultrasound lung is very beneficial, easy to be applied and help to save time that can be consumed in doing sophisticated investigations like Computerized tomography examination of the chest. Anterior lung sliding is checked first . Its presence exclude pneumothorax. The B profile (Anterior bilateral B-lines associated with lung sliding) suggests pulmonary oedema.</p> <p>The A profile (Anterior bilateral A-lines associated with lung sliding) prompts a search for venous thrombosis. The presence of lung A profile plus Venous thrombosis, Make pulmonary Embolism as a cause of acute dyspnoea on the top of the diagnosis list.</p> <p>Extending the Blue protocol of lung ultrasound by adding Focused cardiac ultrasound (FECHO) can confirm diagnosis of pulmonary embolism in this situation especially in the presence of acute right ventricular strain pattern, pulmonary hypertension and positive McConnell’s sign.</p> <p>&nbsp;In the current Coronavirus disease 2019 (COVID-19) pandemic, A lot of atypical presentations especially thrombotic manifestations is there. We present a case of acute dyspnoea with history of fever diagnosed by Blue protocol ultrasonography plus FOCUS as a case of lower limb thrombosis and acute pulmonary Embolism with no ultrasonographic evidence of lung parenchymal affection.</p> <p>With the help of modified BLUE protocol, we diagnose DVT and massive pulmonary Embolism as manifestation of COVID-19, which was confirmed later with positive nasopharyngeal swab.</p> tamer mohamed Zaalouk Copyright (c) PLEUROPARENCHYMAL FIBROELASTOSIS SECONDARY TO CROHN’S DISEASE – A NEW ETIOLOGY? <p>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.&nbsp;It can be idiopathic or associated with some forms of autoimmune disease.</p> <p>The authors present the case of a 78-year-old woman with previous diagnosis of Crohn’s disease. She presented a protracted respiratory infection (albeit with no significant history of previous infections), andunderwent a high-resolution chest computerized tomography that eventually showed alterations compatible with PPFE. After excluding other possible underlying causes, a possible link to CD was considered. The follow-up at 12 months showed clinical and radiological stability and also stable lung function under treatment with hydroxychloroquine and prednisolone.</p> <p>This is the first report of PPFE in the context of Crohn’s disease. Further studies will be important to further investigate this pathological association and its prognostic implication<strong>.</strong></p> Carolina Amado Pedro Gonçalo Ferreira Copyright (c) Inflammatory bowel disease storm: case report <p>Inflammatory bowel disease (IBD) with it is two variants ulcerative colitis and Crohn’s disease are recognized causes of gastrointestinal diseases affecting around 2.2 million of European population and 1.5 million Americans.</p> <p>The incidence of IBD in Saudi Arabia is 6.72 cases per 100,000 persons.</p> <p>Thromboembolism (TE) is known to be one of the extraintestinal complication of IBD affecting around 0.7 to 7.7 % of the patients 4 and usually it occurs as long-term sequel in association with disease activity.</p> <p>A rare form known as “thrombotic storm could be the initial presentation of the patients.</p> Abdulrahman Nasiri Mohammed Alkathami Copyright (c)