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previously unpublished material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> Gitelman Syndrome Diagnosed in a Woman in the Second Trimester of Pregnancy <p>Gitelman syndrome is a rare renal tubule disease characterized by hypokalaemia, metabolic alkalosis, hypomagnesaemia, hypocalciuria and normal blood pressure. It shows autosomal recessive inheritance and is usually not diagnosed until late childhood or adulthood. We report the case of 34-year-old woman who at 21 weeks of pregnancy was admitted to the gynaecology department for abdominal pain, muscle cramps and weakness. Routine blood tests showed hypokalaemia (2.32 mEq/l), hypomagnesaemia (1.18 mEq/l), compensated metabolic alkalosis (pH 7.439, bicarbonate 26.1 mmol/l), increased urinary magnesium excretion (140.25 mg/day, normal range 73–122 mg/day) and reduced urinary calcium excretion (49.25 mg/day, normal range 100–250 mg/day). In light of these findings, the patient was diagnosed with Gitelman syndrome and optimum potassium and magnesium levels were maintained with oral supplements.</p> Sila Çetik Nursel Calik Basaran Lale Ozisik Serife Gul Oz Mustafa Arici ##submission.copyrightStatement## 2019-04-24 2019-04-24 10.12890/2019_001100 Secondary Parkinsonism Due to a Large Anterior Cranial Fossa Meningioma <p>Secondary Parkinson’s disease or subacute Parkinson’s may occur after stroke, drug overdose carbon monoxide or manganese toxicity, and rarely owing to a brain tumor. Loss of dopaminergic neurons in the substansia negra pars compacta (SNc), or presence of the proteinaceous inclusions called Lewy bodies are thought to be the cause of Parkinson’s disease. Notwithstanding, in the past few decades, many case reports have been published describing Parkinson’s symptoms following either stroke, ischemia, toxicity, brain hemorrhage or rarely neoplasm.</p> Wissam Al-Janabi Iram Zaman Anza Memon ##submission.copyrightStatement## 2019-04-19 2019-04-19 10.12890/2019_001055 The Perfect Storm: A Case of Non-Uremic Calciphylaxis <p>Calciphylaxis is a severe condition associated with chronic kidney disease. We describe a rare case of non-uremic calciphylaxis in a 79-year-old woman with prosthetic aortic and mitral valves, chronic kidney disease and anaemia, who presented with painful skin lesions on her left leg. She was taking warfarin, calcium and iron supplements, and had been recently diagnosed with oligoarthritis and started on prednisolone, all factors associated with calciphylaxis. Despite treatment, the lesions rapidly progressed to large ulceration and sepsis, and pain management was challenging. Calciphylaxis was confirmed following a second skin biopsy but the patient died from septic shock and multi-organ failure. This case highlights the challenges associated with the diagnosis and treatment of calciphylaxis despite a high level of suspicion.</p> Manuel Martins Barbosa Elsa Araújo Marta Matos Pereira Tiago Mendes ##submission.copyrightStatement## 2019-04-17 2019-04-17 10.12890/2019_001078 A Rare Case of Adult Acute Disseminated Encephalomyelitis Associated with Primary Epstein-Barr Virus Infection <p>We report a rare case of acute disseminated encephalomyelitis (ADEM) secondary to a primary Epstein-Barr (EBV) infection, in a 22-year-old male. Symptomatic infectious mononucleosis and ADEM are both quite uncommon conditions in this age group.</p> Deeba Ali Benoît Cardos Yilmaz Gorur Noel Lorenzo Villalba Nathalie Janssen Carmen Bartha Philippe Desfontaines Joseph Weerts Pascal Fajardo ##submission.copyrightStatement## 2019-04-15 2019-04-15 10.12890/2019_001094 Olmesartan-Associated Enteropathy: An Unexpected Cause of Chronic Diarrhoea <p>Olmesartan-associated enteropathy is a rare cause of severe enteropathy that should be considered in the differential diagnosis of patients with unexplained chronic diarrhoea. It may be difficult to recognise because of its clinical and histologic similarities to other clinical entities. The authors present the case of a 72-year-old woman with a 6-month clinical history of non-bloody diarrhoea and weight loss. Discontinuation of olmesartan resulted in clinical and histologic recovery, and therefore, physicians need to be aware of olmesartan-associated enteropathy in order to avoid unnecessary testing. Although rare, it is considered an emerging and underdiagnosed enteropathy.</p> Mónica Martins Teixeira Sara Macedo Ana Sofia Martins Tânia Batista António Novais Maria Costa Eugénia Maria Cancela ##submission.copyrightStatement## 2019-04-12 2019-04-12 10.12890/2019_001093 When Do Ring-Enhancing Brain Lesions Need to Be Biopsied, and Should They Be Treated Empirically First? <p>Other than acute cerebrovascular accidents, multiple ring-enhancing lesions are among the most common lesions encountered in neuroimaging. We herein describe the case of a 63-year-old diabetic man presenting with altered mental status, hyperglycaemia and community-acquired pneumonia who was found to have two ring-enhancing lesions involving the left frontal lobe and left basal ganglia. The lesions were biopsied to reveal positive fungal cultures and toxoplasma cysts. RPR titres returned reactive for non-treponemal antibodies and a suppressed CD4 count was found without evidence of HIV infection.</p> Nadia Khosrodad Justin Khine Jeffrey Maclean Fnu Abhishek ##submission.copyrightStatement## 2019-04-10 2019-04-10 10.12890/2019_001068 An Unusual Presentation of Metastatic Breast Carcinoma <p>Cutaneous metastasis from a carcinoma is a relatively uncommon phenomenon. Prompt diagnosis is crucial, as it will have future implications, particularly regarding prognosis and treatment. Skin metastases can be suspected and recognized earlier through physical examination than metastases in other organs or systems. However, they can be a diagnostic challenge due to the variable clinical presentation. This case highlights the importance of having a high index of suspicion for cutaneous metastases, especially in patients with a previous history of cancer.</p> Maria Mendonça-Sanches Inês Rolim José Cabeçadas Margarida Rafael ##submission.copyrightStatement## 2019-04-08 2019-04-08 10.12890/2019_001089 Cardiac Angiosarcoma: From Cardiac Tamponade to Ischaemic Stroke – A Diagnostic Challenge <p>Cardiac angiosarcoma (CA) is the most common primary malignant heart tumour. Its atypical symptoms and rapidly progressive nature contribute to delayed diagnosis and poor outcome. We report the case of a 52-year-old woman admitted with a large pericardial effusion. An extensive study of the aetiology of the pericardial effusion was inconclusive. Two months later the patient returned with ischaemic stroke. An echocardiogram revealed a probable right atrium contained rupture. The patient was submitted to surgical correction but died 9 days later. Histology revealed an angiosarcoma. This case exemplifies the atypical presentation of CA and highlights the importance of a multimodal diagnostic work-up in patients with idiopathic pericardial effusion.</p> Vanessa Meireles Chaves Catarina Pereira Marta Andrade Pedro von Hafe Jorge Almeida ##submission.copyrightStatement## 2019-04-03 2019-04-03 10.12890/2019_001079 Systemic Amyloidosis with Renal Failure: A Challenging Diagnosis of SAPHO Syndrome <p>Synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome is a rare, unrecognized and chronic inflammatory disorder characterized by distinct cutaneous and osteoarticular manifestations. Renal complications are uncommon. We describe the unusual case of a patient with severe refractory and chronic hidradenitis suppurativa (HS) that progressed to chronic renal failure due to secondary amyloidosis, presenting with mandibular pain and renal failure. The challenging diagnosis of SAPHO syndrome was made. The purpose of this case report is to emphasize the need for vigilance, timely recognition and multidisciplinary treatment. The fundamental management of AA amyloidosis and SAPHO syndrome requires an individualized approach with control of the underlying inflammatory disease.</p> Cristina Pires Correia António Martins Jorge Oliveira Sérgio Andrade Jorge Almeida ##submission.copyrightStatement## 2019-03-27 2019-03-27 10.12890/2019_001087 Intra-Alveolar Haemorrhage Complicating IgA Vasculitis: A Case Report, Literature Review and Discussion of Treatment <p><em>Introduction:</em> Immunoglobulin A vasculitis (IgAV) is a small-vessel vasculitis with IgA-dominant immune deposits. IgAV frequently involves the skin, gastrointestinal tract, joints and kidneys. In contrast to other types of small-vessel vasculitis, IgAV is rarely complicated by intra-alveolar haemorrhage (IAH).<br> <em>Methods/Results:</em> We describe a patient with relapsing bladder cancer who presented with IAH during the course of IgAV successfully treated with corticosteroids alone.<br> <em>Conclusion:</em> This case report reminds us that IgAV can manifest with IAH. There are no robust data to support the systematic use of cyclophosphamide or plasma exchange as first-line therapy for IgAV with IAH.</p> Benjamin Savoye Gwenola Maigne Evangeline Pillebout Gaetane Planchard Maxime Faisant Achille Aouba Alexandra Audemard ##submission.copyrightStatement## 2019-03-25 2019-03-25 10.12890/2019_001083