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previously unpublished material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> Late-Onset Rash from Irbesartan: An Immunological Reaction <p>Cutaneous delayed reactions to antihypertensive drugs have been described in a limited number of case reports but the mechanisms remain mostly unknown. We report the case of a 60-year-old female patient with a 3-week history of an itchy erythematous maculopapular eruption. Although the patient was polymedicated, irbesartan was the most likely culprit. Patch tests and a lymphocyte transformation test to irbesartan were both positive, which was useful for diagnosis and suggested an immunological reaction. No new lesions appeared after irbesartan was stopped or after the introduction of candesartan. Despite its similar chemical structure, candesartan may be tried in patients allergic to irbesartan.</p> Bárbara Kong Cardoso Marta Martins Sofia Martins Farinha Regina Viseu Elza Tomaz Filipe Inácio ##submission.copyrightStatement## 2019-06-19 2019-06-19 10.12890/2019_001128 Methamphetamine-Induced Lung Injury <p>Methamphetamine is a substance of abuse that is most commonly smoked. Both regular and non-regular use can cause toxic injury to the lung parenchyma, the signs and symptoms of which are non-specific. Clinical scenarios include non-cardiac pulmonary oedema, acute respiratory distress syndrome, alveolar haemorrhage, pneumonia and pneumoconiosis. As radiological imaging is often non-specific, a positive history of methamphetamine use is the only way to reach a definite diagnosis. The use of methamphetamine is now increasing in Europe, so it is important as physicians to be aware of this differential diagnosis in patients in respiratory distress with risk factors for illicit drug use.</p> Eilis McCarthy Erik McClain ##submission.copyrightStatement## 2019-06-17 2019-06-17 10.12890/2019_001067 Acute Parotitis: A Rare Complication of Fine Needle Aspiration in Warthin Tumour <p>Salivary gland tumours are a group of neoplasms with considerable heterogeneity regarding their histology and biological behaviour. Warthin tumour (WT) is the second most common benign parotid tumour. Options for tissue diagnosis include fine needle aspiration (FNA) and ultrasound-guided core needle biopsy. Complications related to FNA are rare. We present the case of a 49-year-old man admitted with parotitis after FNA and discuss management and an alternative investigative approach when WT is strongly suspected.</p> Margarida Viana Coelho Domingos Sousa Sergio Antunes da Silva Rui Marques Osorio Rita Martins Fernandes Ana Isabel Rodrigues ##submission.copyrightStatement## 2019-06-14 2019-06-14 10.12890/2019_001147 Bilateral Internuclear Ophthalmoplegia in a Young Woman with Vertebral Artery Dissection <p><em>Background:</em> Internuclear ophthalmoplegia (INO) is an eye movement disorder caused by a lesion in the medial longitudinal fasciculus (MLF) located in the midbrain. Adduction paralysis of both eyes and bilateral abduction nystagmus are the main features of INO<sup>[1]</sup>.<br> <em>Case presentation:</em> A 29-year-old Hispanic woman was admitted to the emergency department complaining of an intense holocranial headache lasting 9 days, associated with nausea and vomiting. She was discharged home with resolution of the headache but persistence of symptoms. However, she subsequently developed horizontal diplopia and gait abnormalities. She was readmitted to hospital because of anomalous eye movements and conjugate gaze palsy, manifested as bilateral INO. Magnetic resonance angiography (MRA) findings were consistent with dissection of the left V4 vertebral artery with multiple brain infarcts in the superior cerebellar artery territory, comprising both MLF tracts. <br> <em>Conclusions:</em> In young adults, bilateral INO is normally caused by demyelinating disease. In other patients, common causes include trauma, infections and autoimmune diseases with neurological symptoms. Vascular disease is implicated in over a third of cases.</p> Omar Cárdenas Enrique Gomez Mariana Marcín Adib Jorge de Sarachaga Verónica Sánchez Juan Manuel Calleja ##submission.copyrightStatement## 2019-06-12 2019-06-12 10.12890/2019_001105 Acquired von Willebrand Syndrome and Chronic Anaemia: A Different Diagnostic Approach <p>Heyde’s syndrome is a form of acquired von Willebrand syndrome that consists of bleeding from intestinal angiodysplasia in the presence of aortic stenosis (AS). An association with obstructive hypertrophic cardiomyopathy, rather than AS, by a similar mechanism has also been described. We report the case of a 78-year-old woman with chronic anaemia and hypertrophic obstructive cardiomyopathy in whom intestinal angiodysplasia with active bleeding was identified by an unconventional method. In this case, the authors describe a different approach to reach the correct diagnosis.</p> Nuno Zarcos Palma Mariana da Cruz Gisela Evaristo Vasconcelos Vitor Fagundes Lindora Pires Mari Mesquita ##submission.copyrightStatement## 2019-06-10 2019-06-10 10.12890/2019_001137 Leydig Cell Hyperplasia Mimicking a Testicular Tumour in a Patient with Klinefelter Syndrome <p><em>Background:</em> Klinefelter syndrome (KS) is the most common sex-chromosomal disorder in males. Frequently under-recognized, it occurs in 1 in 500–600 male births. It is caused by the inheritance of at least one additional X chromosome from either parent. Patients often have uncommon or atypical malignancies. <br> <em>Patient:</em> We describe the case of a 35-year-old man with 47XXY KS and previous cryptorchidism, presenting with a painful testicular mass. Histology confirmed Leydig cell hyperplasia. <br> <em>Discussion:</em> Cryptorchidism is an established risk factor for testicular tumours and occurs six times more commonly in KS than in the general population. Despite this, large epidemiological studies have shown a reduced burden of testicular cancer in these patients. The presentation of a hypoechoic lesion on ultrasound will prompt consideration of testicular tumours, however orchalgia represents an atypical presentation. In patients with KS, Leydig cell hyperplasia is a much more common entity and should be considered early in the differential diagnosis.</p> Christine Newman Stephen Connolly Owen MacEneaney Conor O'Keane Siobhan E McQuaid ##submission.copyrightStatement## 2019-06-07 2019-06-07 10.12890/2019_001129 Eruptive Junctional Nevi Appearing During Langerhans Cell Histiocytosis Treatment <p>Langerhans cell histiocytosis (LCH) is a multisystemic disorder that results from the clonal proliferation of immunophenotypically and functionally immature Langerhans cells (LC). The detection of the V600E mutation in the BRAF oncogene in LCH biopsy specimens supports previous evidence that LCH is a neoplastic disorder. This mutation is present in other cutaneous lesions including malignant melanoma and benign nevi. Single case reports of a correlation between LCH and the appearance of eruptive nevi limited to the inguinal folds after chemotherapy have previously been described in the literature. This suggested that LCH could be an additional cause of eruptive melanocytic nevi, with a specific distribution mimicking that of LCH cutaneous lesions. We present the case of a 6-year-old boy, previously treated with chemotherapy for Langerhans cell histiocytosis, with disseminated junctional nevi. Although this co-occurrence may be coincidental, the skin involvement is distinct from other previously reported clinical cases. It would be interesting to evaluate whether the BRAF mutation described in LCH cells might in fact support a genetic background for the development of nevi in these patients.</p> Maria Mendonça-Sanches Ines Rolim Joaninha Costa-Rosa Gabriela Caldas Cecilia Moura ##submission.copyrightStatement## 2019-06-05 2019-06-05 10.12890/2019_001088 Secondary Fahr’s Disease: A Consequence of Post-Thyroidectomy Hypoparathyroidism <p><em>Objective:</em>The objective of this case report is to emphasize the importance of considering uncommon conditions like Fahr’s disease in the differential diagnosis of seizures and cognitive impairment, especially in patients with a history of thyroidectomy. <br> <em>Materials and Methods:</em>&nbsp;A 56-year-old woman who had undergone subtotal thyroidectomy 25 years previously presented with movement disorder and cognitive impairment secondary to hypoparathyroidism. A CT scan of the brain showed pathognomonic bilateral calcification in the basal ganglia, thalamus and cerebellar nuclei. <br> <em>Result:</em> The patient was diagnosed with Fahr’s disease caused by post-thyroidectomy hypoparathyroidism and successfully managed with oral calcium, carbidopa/levodopa and haloperidol. <br> <em>Conclusion</em>: We recommend the routine use of CT scanning in the long-term follow-up of post-thyroidectomy patients.</p> Najia Mahmood Jahanzaib Hamid Faramarz Khan Muhammad Khurram Mubashar Alam ##submission.copyrightStatement## 2019-06-04 2019-06-04 10.12890/2019_001109 A Paraneoplastic Syndrome to Remember: A Case of Disseminated Intravascular Coagulation in Lung Cancer <p>Disseminated intravascular coagulation (DIC) is an acquired syndrome characterized by the widespread activation of coagulation. It can present as an acute life-threatening emergency or as a chronic process. Mortality is highly dependent on the reversibility of the aetiology and degree of coagulation impairment, so treatment of the underlying cause is vital. The authors present the case of a 57-year-old man whose inaugural presentation of lung cancer was chronic DIC, characterized by three thrombotic events, followed by acute DIC, culminating in death. Metastatic lung cancer was diagnosed only after death.</p> Rita de Sousa Gameiro Rodolfo Gomes Vanda Jorge Bárbara Sousa Picado Fernando Martos Gonçalves José Lomelino Araújo ##submission.copyrightStatement## 2019-06-03 2019-06-03 10.12890/2019_001134 Lenalidomide: An Alternative Treatment for Refractory Behçet’s Disease and Relapsing Polychondritis <p><em>Introduction:</em>Behçet’s disease (BD) is a chronic systemic condition characterized by recurrent oral and genital ulcers, neurological and vascular manifestations, ocular and skin lesions, and a positive pathergy test. Mouth and genital ulcers with inflamed cartilage (MAGIC) syndrome is rare and consists of features of BD together with relapsing polychondritis. The treatment of this syndrome is similar that of BD and depends on disease expression and symptoms. <br> <em>Case Report:</em> We report the case of a 50-year-old man diagnosed with BD with relapsing polychondritis (MAGIC syndrome) which had evolved over approximately 35 years, with exuberant and frequent oral and genital ulcers. Various treatments were unsuccessful and had adverse effects. Lenalidomide was initiated at a dose of 5 mg per day with remission of oral and genital ulcers and no haematological or adverse effects. <br> <em>Conclusion</em>: BD is a complex disorder with a variety of presentations. Its treatment can be challenging but sometimes off-label drugs, like lenalidomide, can be effective.</p> Sofia Gomes Brazao Jorge Crespo Armando Carvalho ##submission.copyrightStatement## 2019-05-31 2019-05-31 10.12890/2019_001117