European Journal of Case Reports in Internal Medicine https://www.ejcrim.com/index.php/EJCRIM <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="http://www.efim.org/about/member-countries">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="mailto:ejcrim@smc-media.eu">ejcrim@smc-media.eu</a></p> A Case of Aortic Dissection in Familial Mediterranean Fever https://www.ejcrim.com/index.php/EJCRIM/article/view/2177 <p>Familial Mediterranean fever (FMF) is an ethnicity-specific autoinflammatory disease prevalent in the Mediterranean region. It has various presentations including amyloidosis, small- and medium-vessel vasculitis, and pericarditis. Different mutations in the Mediterranean fever (MEFV) gene can cause this disorder and it is inherited as an autosomal recessive pattern. A 23-year-old man of Iranian descent came to the emergency department with three hours of chest pain. History revealed a fever syndrome since childhood and laparotomy after a false diagnosis of an acute abdomen. The physical exam was unremarkable and the electrocardiogram was normal. A diagnosis of Stanford type A aortic dissection was make on computed tomography of the chest and abdomen.&nbsp;Although a disease of small to medium vessels, we present here a case of Stanford type A aortic dissection in an acute attack of FMF requiring aortic repair.<strong>&nbsp;</strong>To the best of our knowledge, this is the first case reported of such a complication.</p> Jahanzeb Malik Asmara Malik Muhammad Javaid Hamid Sharif Khan Muhammad Mohsin Muhammad Shoaib Copyright (c) Immune thrombocytopenia in Helicobacter pylori infection and Sjögren’s syndrome with low complement component 4 https://www.ejcrim.com/index.php/EJCRIM/article/view/2200 <p>&nbsp;</p> <p style="margin: 0mm 0mm 0pt; line-height: 200%;"><span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt;">Immune thrombocytopenia is an acquired thrombocytopenia caused by antiplatelet autoantibodies. Immune thrombocytopenia</span><span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt; mso-fareast-font-family: TimesLTStd-Roman; mso-font-kerning: 0pt;"> may occur in association with underlying diseases such as infection, malignancy, and autoimmune disease. However, most cases are classified as idiopathic immune thrombocytopenia and lack an identifiable cause.</span><span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt;"> W</span><span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt; mso-fareast-font-family: '?? ?????'; mso-font-kerning: 0pt;">e herein described a case of </span><span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt; mso-fareast-font-family: TimesLTStd-Roman; mso-font-kerning: 0pt;">immune thrombocytopenia in a patient with <em>Helicobacter pylori </em>infection and Sj</span><span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt;">&ouml;</span><span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt; mso-fareast-font-family: TimesLTStd-Roman; mso-font-kerning: 0pt;">gren&rsquo;s syndrome with low complement component 4</span><span lang="EN-US"><span style="font-family: Century;">.</span></span> <span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt;">Physicians should consider </span><span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt; mso-fareast-font-family: TimesLTStd-Roman; mso-font-kerning: 0pt;">Sj</span><span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt;">&ouml;</span><span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt; mso-fareast-font-family: TimesLTStd-Roman; mso-font-kerning: 0pt;">gren&rsquo;s syndrome</span><span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt;"> as an underlying disease of</span> <span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt;">Immune thrombocytopenia,</span><span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt; mso-fareast-font-family: TimesLTStd-Roman; mso-font-kerning: 0pt;"> particularly in patients with low complement levels and/or non-responders to <em>H. pylori</em> eradication therapy.</span></p> <p>&nbsp;</p> Jun Takaoka Tomomi Oka Kyoka Fujita Satoshi Kurahashi Naohiro Toda Toshiyuki Komiya Masaaki Fujita Copyright (c) the management of spasticity and related symptoms in a young adult with multiple sclerosis: a case report. https://www.ejcrim.com/index.php/EJCRIM/article/view/2198 <p>Spasticity is one of the main symptoms associated with multiple sclerosis, affecting nearly two-thirds of patients in their lifetime. Its impact on patient functioning and quality of life is significant. Unfortunately, spasticity continues to often be under-treated and its management of symptoms still remains an unmet need. We present a case of a 41-year-old man with a history of multiple sclerosis. He started complaining of spasticity in late 2019, and symptoms rapidly worsened without clinical relapse or radiological activity. The early introduction of nabiximols improved several clinical aspects and ameliorated the patient’s quality of life.</p> Valeria Barcella Copyright (c) Infective Endocarditis in a patient with Pacemaker and Prosthetic Valves https://www.ejcrim.com/index.php/EJCRIM/article/view/2197 <p>Infective endocarditis remains a serious disease, with a challenging diagnosis that relies on a high degree of clinical suspicion, especially if prosthetic heart valves or cardiac implantable devices are present. Herein, it’s described a case of a 60 year-old patient, with aortic and mitral mechanical valves and pacemaker, who was admitted twice with fever and no obvious source of infection. Repeated imaging tests, namely echocardiograms and positron emission tomography-scan, and multiple blood cultures remained negative. Nevertheless, the diagnosis of infective endocarditis was possible, according to the modified Duke criteria, by the recurrence of fever with antibiotics withdrawal, the appearance of embolic phenomenon and growth of an uncommon microorganism in blood cultures: <em>Pseudomonas aeruginosa</em>. Antibiotic therapy was changed, according to microorganism sensitivity, to amikacin and ceftazidime and, after 2 weeks, the pacemaker was removed. Thereafter, the patient remained afebrile and clinically stable after three years of follow-up.</p> Ana Ferreira Clara Gomes João Enes Ester Ferreira Jorge Almeida Copyright (c) Mesalazine-induced hypersensitivity pneumonitis https://www.ejcrim.com/index.php/EJCRIM/article/view/2194 <p>A 57-year-old woman with Crohn's disease (ulcerative proctitis) treated with mesalazine (5-ASA) developed worsening respiratory distress and cough. The lack of response to antibiotics and the results of bronchoalveolar lavage, led to the diagnosis of mesalazine-related hypersensitivity pneumonitis, an infrequent entity.Symptoms improved after discontinuation of mesalazine and corticosteroid therapy. The authors discuss the diagnosis and managment of this rare condition</p> Ana Pereira Cristina Marques Teresa Boncoraglio Joana Esteves Marinha Silva Joana Braga Márcia Ribeiro Copyright (c) Mycobacterial Spindle Cell Pseudotumor of the lymph nodes https://www.ejcrim.com/index.php/EJCRIM/article/view/2195 <p>Mycobacterial spindle cell pseudotumor&nbsp;(MSP) is characterized by benign proliferation of spindle-shaped histiocytes containing acid-fast mycobacterium. It is usually seen in immunocompromised patients. Limited literature is available regarding MSP.&nbsp;We report a case of 36-year-old African American male with past medical history of HIV (diagnosed in 2005), noncompliance who presented with generalized weakness, fever and dizziness on ambulation and was found to have generalized lymphadenopathy and underwent biopsy of the lymph nodes which was consistent with MSP.</p> Balraj Singh Parminder Kaur Nicole Majachani Michael Maroules Copyright (c) Immune thrombocytopenia in Helicobacter pylori infection and Sjögren’s syndrome with low complement component 4 https://www.ejcrim.com/index.php/EJCRIM/article/view/2193 <p>&nbsp;</p> <p style="margin: 0mm 0mm 0pt; line-height: 200%;"><span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt;">Immune thrombocytopenia is an acquired thrombocytopenia caused by antiplatelet autoantibodies. Immune thrombocytopenia</span><span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt; mso-fareast-font-family: TimesLTStd-Roman; mso-font-kerning: 0pt;"> may occur in association with underlying diseases such as infection, malignancy, and autoimmune disease. However, most cases are classified as idiopathic immune thrombocytopenia and lack an identifiable cause.</span><span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt;"> W</span><span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt; mso-fareast-font-family: '?? ?????'; mso-font-kerning: 0pt;">e herein described a case of </span><span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt; mso-fareast-font-family: TimesLTStd-Roman; mso-font-kerning: 0pt;">immune thrombocytopenia in a patient with <em>Helicobacter pylori </em>infection and Sj</span><span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt;">&ouml;</span><span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt; mso-fareast-font-family: TimesLTStd-Roman; mso-font-kerning: 0pt;">gren&rsquo;s syndrome with low complement component 4</span><span lang="EN-US"><span style="font-family: Century;">.</span></span> <span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt;">Physicians should consider </span><span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt; mso-fareast-font-family: TimesLTStd-Roman; mso-font-kerning: 0pt;">Sj</span><span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt;">&ouml;</span><span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt; mso-fareast-font-family: TimesLTStd-Roman; mso-font-kerning: 0pt;">gren&rsquo;s syndrome</span><span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt;"> as an underlying disease of</span> <span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt;">Immune thrombocytopenia,</span><span lang="EN-US" style="line-height: 200%; font-family: 'Arial','sans-serif'; font-size: 12pt; mso-fareast-font-family: TimesLTStd-Roman; mso-font-kerning: 0pt;"> particularly in patients with low complement levels and/or non-responders to <em>H. pylori</em> eradication therapy.</span></p> <p>&nbsp;</p> Jun Takeoka Tomomi Oka Kyoka Fujita Satoshi Kurahashi Naohiro Toda Toshiyuki Komiya Masaaki Fujita Copyright (c) COVID-19 and Adenovirus Multi lobar pneumonia on CT scan in a patient with repeatedly normal Chest X-Rays despite severe hypoxia and the need for non-invasive ventilation https://www.ejcrim.com/index.php/EJCRIM/article/view/2192 <p>We report a 34-year-old lady, who is otherwise fit and well. She presented with typical COVID-19 symptoms requiring supplemental oxygen, with normal CXR and COVID-19 Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) swab on admission. She deteriorated after 24 hours with severe hypoxia requiring up to 60% Oxygen. Repeated CXR remains normal, followed by Computed Tomography Pulmonary Angiogram (CTPA) that ruled out pulmonary embolism, however; it did confirm multi-lobar pneumonia consistent with COVID-19. Patient was admitted to ICU for non-invasive ventilation and ongoing care. Extended respiratory screening confirmed positive COVID-19 antibodies and positive Adenovirus swabs. Patient also developed COVID-19 related hepatocellular injury and myocarditis, in the absence of other causes. These has been treated by multidisciplinary team and patient achieved full recovery after three weeks. To the best of our knowledge, this is the first published case to highlight a normal CXR in severely sick COVID-19 patient requiring ICU admission.</p> Abuajela Sreh Hala Musleh Vani Shankaran Salim Meghjee Copyright (c) A case report of Idiopathic hemophagocytic lymphohistiocytosis in an immunocompetent adult https://www.ejcrim.com/index.php/EJCRIM/article/view/2191 <p><strong>Hemophagocytic lymphohistiocytosis</strong><strong>(HLH) is </strong><strong>a life-threatening syndrome that involves excessive immune activation, and poses a&nbsp;</strong><strong>diagnostic dilemma. The authors present the case of a 49-year-old female with constitutional symptoms, fever and abdominal pain, followed by a sepsis-like evolution. An extensive study revealed hyperferritinemia, polyserositis and generalized lymphadenopathy. HLH was considered and immunosuppressive treatment was started, with clinical improvement. Familiar form of HLH was excluded, and the patient was therefore not eligible for hematopoietic stem cell transplantation (HSCT). The authors report this remarkable case, due to the </strong><strong>absence&nbsp;</strong><strong>of specific clinical and laboratory findings, and also due to lack of a consistent trigger.</strong></p> Tiago Rabadão Leonor Naia Filipa Ferreira Mariana Teixeira Marcelo Aveiro Margarida Eulálio Fernando Silva Copyright (c) IgG4 related-disease: a rare presentation with secondary hypereosinophilic syndrome and eosinophilic ascites https://www.ejcrim.com/index.php/EJCRIM/article/view/2189 <p>IgG4 related-disease (IgG4-RD) is a multisystemic immune-mediated fibroinflammatory disease, with a strong predilection for salivary and lacrimal glands, pancreas, biliary tree, lungs, kidneys, aorta, and retroperitoneum. In the case of pancreatic involvement, it manifests as autoimmune pancreatitis. Patients with IgG4-RD usually have mild to moderate eosinophilia in the peripheral blood, however, they may present a secondary hypereosinophilic syndrome (HES). Although there are cases described with severe eosinophilia (&gt; 5000/µL), the 2019 American College of Rheumatology /European League Against Rheumatism classification criteria for IgG4-RD considers peripheral eosinophilia above 3000/µL as an exclusion criterion, although stating that assessment for the presence of exclusion criteria should be individualized depending on a patient's clinical scenario.</p> <p>Here, we describe the clinical case of a 30-year-old woman who presented with chronic diarrhea and abdominal pain. The diagnostic workup revealed eosinophilic ascites, severe peripheral blood eosinophilia (&gt; 5000/µL), IgG4 elevation (&gt; 2X upper normal limit), and also diffuse swelling in the body and pancreatic tail (C.T. scan). There was a prompt response to corticosteroid therapy with clinical resolution and continued remission under therapy.</p> <p>The patient was diagnosed with IgG4-RD with secondary HES, explaining the gastrointestinal tract and peritoneum damage in the form of entero-colitis and ascites. Exclusion of alternative diagnosis was made.</p> Luísa Serpa Pinto Nuno Jorge Lamas Ana Campar Álvaro Ferreira Ana Rita Cruz Copyright (c)