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previously unpublished material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> Emphysematous Pancreatitis: A Rare Complication <p>We describe a case of emphysematous pancreatitis, a rare and serious complication of acute pancreatitis, which has a high mortality rate.</p> Diego Martínez Maria Teresa Belmonte Piotr Kośny Mihaela Alina Ghitulescu Ignacio Florencio Jose Aparicio ##submission.copyrightStatement## 2018-10-18 2018-10-18 10.12890/2018_000955 Non-traumatic Hematomyelia: A Rare Finding in Clinical Practice <p>Non-traumatic haematomyelia is a rare finding of acute onset, which in most cases is the result of arteriovenous malformations (AVM), tumours, coagulation disorders or autoimmune conditions, but may also be secondary to treatment with anticoagulants and radiotherapy. We present the case of a 58-year-old woman with sudden onset cervical pain, followed by asymmetric diminution of strength in the upper limbs with reduced pain sensitivity. The diagnosis of AVM at the C7 and D1 levels was made following cervico-dorsal magnetic resonance imaging and angiography. Treatment was embolization with immediate isolation of the AVM.</p> Eva Claro Alexandra Dias Geetha Girithari Ana Massano Maria Aurora Duarte ##submission.copyrightStatement## 2018-10-16 2018-10-16 10.12890/2018_000961 Caffeine Toxicity Following Ingestion of an Exercise Supplement by a Patient with Type 1 Diabetes <p>We report the case of a patient with type 1 diabetes who developed acute severe diabetic ketoacidosis following ingestion of an energy supplement containing caffeine. Some 95% of the US adult population consume caffeine, and the general perception is that there are no negative consequences for health. The upper limit of safe consumption is less than 400 mg per day. However, acute ingestion of high doses of caffeine may cause significant metabolic changes that can be fatal. Here the patient consumed a toxic dose of caffeine causing unpleasant and puzzling symptoms, vomiting and, following omission of his long-acting basal insulin, severe diabetic ketoacidosis. As the sports nutrition market continues to expand, providers and manufacturers have a responsibility to give clear and accurate dosing instructions as well as side effect profiles for their products, particularly for diabetic patients.</p> Ehab Hamed ##submission.copyrightStatement## 2018-10-11 2018-10-11 10.12890/2018_000957 Not So Incidental: Pheochromocytoma in an Adult with Unrepaired Cyanotic Heart Disease <p>Pheochromocytoma, a rare neuroendocrine tumour, is often encountered in the general internal medicine clinic as an adrenal incidentaloma. Even rarer is its presence in adult cyanotic heart disease, although there are a few documented reports of this association in various paediatric populations, with chronic hypoxia being the likely driving force. Here we present the case of a 38-year-old adult with unrepaired complex cyanotic congenital heart disease with biochemically proven pheochromocytoma presenting as an adrenal incidentaloma to a general internal medicine clinic.</p> Nikesh Adunuri Marko Mrkobrada ##submission.copyrightStatement## 2018-10-09 2018-10-09 10.12890/2018_000959 A Challenging Diagnosis of Leg Ulcer <p>Ischaemic ulcers of the lower limb can have several aethiopathological mechanisms. For instance, the uncommon Martorell hypertensive leg ulcer is an infrequent complication of long-term uncontrolled arterial hypertension and is largely ignored and underdiagnosed. The typical ulcer is on the lower leg, is extremely painful and presents in female patients over 60 years of age with cardiovascular risk factors, mainly severe arterial hypertension. The diagnosis is histological, with obliteration of the arterioles by arteriolosclerosis. In these cases, antihypertensive medication is the standard treatment. We describe the case of an African-American female patient with long-term hypertension who presented with a very painful leg ulcer. The diagnosis was complicated by the coexistence of more common causes of ulcer. Despite analgesic medicines, pain relief was only obtained with control of hypertension. A definite diagnosis was made following biopsy.<br> In describing this diagnosis of an ischaemic leg ulcer, we highlight the need to consider the skin as a target organ of arterial hypertension.</p> Maria João Serpa Susana Franco Diana Repolho Isabel Araújo Sofia Mateus António Martins Baptista José Lomelino Araújo ##submission.copyrightStatement## 2018-10-04 2018-10-04 10.12890/2018_000952 Spontaneous Spinal Intradural Haematoma in an Anticoagulated Woman <p>A 57-year-old woman, with a history of deep venous thrombosis and medicated with warfarin, presented at the hospital with acute back pain with paraplegia, headache, high blood pressure and vomiting. Imaging of the spine showed an acute intradural extramedullary haemorrhage with blood clot formation. The patient underwent surgery and received intensive post-surgical physiotherapy but remains paraplegic. Non-traumatic spinal intradural extramedullary haematoma (SIEH) is a rare neurological emergency that can result in spinal cord compression. Physicians should always consider this clinical entity as a differential diagnosis, especially in a patient presenting with acute back pain on anticoagulant therapy.</p> Geetha Girithari Ines Coelho dos Santos Tiago Alves Eva Claro Marcia Kirzner Ana Massano ##submission.copyrightStatement## 2018-10-02 2018-10-02 10.12890/2018_000951 Metabolic Acidosis Due To Pyroglutamic Acid <p>Metabolic acidosis is a common clinical disturbance due to increased plasma acidity caused by a primary decrease in serum HCO3- concentration. It is classified as normal or high anion gap metabolic acidosis. High anion gap metabolic acidosis can result from either a decrease in unmeasured cations (K<sup>+</sup>, Ca2<sup>+</sup>, Mg2<sup>+</sup>) or an increase in unmeasured anions (PO<sub>4</sub><sup>3-</sup>, albumin). However, other anions such as lactic acid or keto acids may cause this acid-base disorder. It can also result from renal failure and intoxication (salicylate, methanol, ethylene glycol), or more rarely, from massive rhabdomyolysis and pyroglutamic (5-oxoproline) acidemia. Acidemia due to pyroglutamic acid should be considered when no other aetiology is found. High anion gap metabolic acidosis is diagnosed in children with inherited defects in enzymes of the γ-glutamyl cycle. In adults, this disorder from pyroglutamic acid has been described in association with chronic acetaminophen misuse. We report a case of pyroglutamic acidosis in a woman with acute misuse of acetaminophen concurrent with chronic use. .</p> Maria João Raposo Linhares Serpa Luís Falcão Susana Franco Diana Repolho Nuno Ribeiro Ferreira ##submission.copyrightStatement## 2018-09-27 2018-09-27 10.12890/2018_000949 Systemic Sarcoidosis Associated with Exposure to Borrelia burgdorferi in a 21-Year-Old Man <p><em>Objective:</em> Here we describe a rare case of systemic sarcoidosis in a healthy young man with neuroborreliosis as a putative trigger.<br> <em>Case:</em> A 21-year-old forestry worker was diagnosed with systemic sarcoidosis involving his lungs, kidneys and skin. Additional diagnostics revealed signs indicative of a recent infection with <em>Borrelia burgdorferi</em>. The patient was treated successfully with prednisolone and antibiotics.<br> <em>Conclusion:</em> Sarcoidosis is a multisystem granulomatous disorder of unknown aetiology. This case suggests that an infection with <em>B. burgdorferi</em>, the causal agent of Lyme disease, could act as a trigger for sarcoidosis.</p> Lars van Dee Mylene Stehouwer Thomas van Bemmel ##submission.copyrightStatement## 2018-09-24 2018-09-24 10.12890/2018_000942 Boerhaave Syndrome in an Elderly Man <p>Boerhaave syndrome is rare, has an non-specific clinical presentation and most commonly develops after persistent vomiting. Septic shock dominates the clinical picture as a result of extensive infection of the mediastinum and pleural and abdominal cavities. The current management of Boerhaave syndrome includes conservative, endoscopic and surgical treatments. The authors present the case of a 94-year-old man admitted to hospital with community-acquired pneumonia with mild respiratory insufficiency complicated by oesophageal perforation after an episode of vomiting and the development of a large left pleural effusion. An endoscopic approach with the placement of an oesophageal prosthesis was chosen given the advanced age of the patient. The hospital stay was complicated by pleural effusion infection requiring broad-spectrum antibiotics and prosthesis substitution. The patient was discharged after 60 days of hospitalization, without the need for oxygen supplementation, and scoring 80% on the Karnofsky Performance Status Scale. The increase in average life expectancy requires a case-by-case approach, where the benefits of invasive manoeuvres and likelihood of discharge are weighed against an acceptable quality of life, aiming to prevent futile medical treatment.</p> Maria João Rodrigues Ferreira Pinto Pedro Rodrigues Leonor Almeida Alexandra Leitão Luís Flores André Gomes Gonçalo Rocha Fernando Friões ##submission.copyrightStatement## 2018-09-20 2018-09-20 10.12890/2018_000944 Acute Anaemia: A Challenging Diagnosis <p>Acute anaemia is characterized by a reduction in the number of red blood cells, haemoglobin levels or haematocrit. By far the most common aetiology is haemorrhage, but in its absence other less frequent causes should be considered.<br> The authors present the case of a 42-year-old man with a diagnosis of glucose-6-phosphate deficiency and progressing gastric signet ring cell carcinoma, who was admitted to the internal medicine department for symptomatic back pain control. During his hospitalization, the patient developed acute anaemia with schistocytes on peripheral blood smear with no concurrent hyperbilirubinaemia or decreased haptoglobin. Bone metastatic disease was documented. The case was revised with the transfusion medicine department and malignancy-associated microangiopathic haemolytic anaemia (Ma-MAHA) was suggested. The patient was transferred to the oncology department and later discharged, dying at home shortly afterwards.</p> Rui Costa Catarina Araújo Faria Catarina Sofia Nunes Filipa Ferreira Rui Cunha Inês Egídio Sousa Inês Ferreira ##submission.copyrightStatement## 2018-09-18 2018-09-18 10.12890/2018_000956