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> en-US <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previously unpublished material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> (Editorial Office) (Editorial Office) Tue, 11 Jan 2022 08:43:59 +0000 OJS 60 Is air an issue? A severe case of subcutaneous emphysema in an immunocompromised patient <p>The finding of abdominal crepitus on physical examination and confirmation of air in the subcutaneous tissue by imaging should be recognized early. This is imperative as the most common etiologies for subcutaneous emphysema are fatal if not treated acutely. We present the case of a 67-year-old female who developed subcutaneous emphysema as a result of the dehiscence of a previously closed gastrocutaneous fistula. Some of the risk factors for wound dehiscence in this patient include terminal cancer and use of immunosuppressive agents.&nbsp;</p> Eloy F. Ruiz, David O. Rahni Copyright (c) “Cheiro-oral-pedal syndrome in a patient with hereditary antithrombin III deficiency: a case report” <p>Cheiro-oral-pedal syndrome is an incomplete pure sensory disorder characterized by a sensory disturbance in the unilateral hand and foot and ipsilateral mouth region. This rare syndrome occurs due to a lesion in the thalamocortical projections or thalamus and brainstem as a consequence of ischemic or hemorrhagic stroke or cerebral vascular malformations. We report a case of a 55 years old woman diagnosed with type II hereditary antithrombin III deficiency with decreased antithrombin activity level of 53% and history of popliteal venous thromboembolism, who developed numbness around the right side corner of the mouth and in the right hand and foot. Objective sensory deficit was noticed in these areas without other relevant findings on neurologic examination. Cranioencephalic computed tomography did not reveal any changes. Brain magnetic ressonance imaging showed a lesion on the left thalamic-capsular region suggestive of an acute lacunar infarction. The patient maintained her sensory symptoms during hospitalization, started anticoagulation and did not develop other neurological deficits during follow-up. To conclude, we report this case to raise awareness to the cheiro-oral-pedal syndrome, which is a rare disorder that can be a manifestation of significant neurological conditions, as the lacunar infarction in this case. This is an underdiagnosed syndrome due to its difficulty to be recognized by the physician and identified by the patient, so it is important to be investigated in all neurological patients to prevent misdiagnosis of serious conditions. To finish, anticoagulation is essential in patients with high thrombotic risk, as in this case, to prevent ischemic events.</p> Maria Lume, Marisa Couto, Luís Lemos, José Carlos Martins Copyright (c) SWELLING FINGER – AN ATYPICAL PLACE FOR METASTATIC LESION <p>Acrometastasis are metastases located distal to de elbow and knee, are a rare observation. The most common primary cancer site is the lung, followed by the colo-rectal, breast and genito-urinary tract.</p> <p>We present a case of a 54-years-old woman with a history of 25 pack-year smoking history, chronic obstructive pulmonary disease and squamous cell carcinoma of the lung diagnosed at age 50. At physical examination in the distal phalanx of the fourth finger of the right hand, there was a hypervascularized swelling, purplish and painful. Distal amputation of the fourth finger was performed with pathological anatomy compatible with acrometastasis of primary squamous cell carcinoma of the lung.</p> <p>The clinicians should be aware of this type of metastasis because it is sometimes difficult to distinguish with tuberculous dactylitis and other osteomyelitis in patients with undiagnosed cancer. The presence of acrometastasis confers a poor prognosis.</p> Maria Lume, Marisa Couto, Luís Lemos, Ana Monteiro, José Carlos Martins Copyright (c) Invasive pulmonary aspergillosis after COVID-19 pneumonia <p>COVID-19 pneumonia emerged in China in late 2019 but quickly spread worldwide. The severe immunomodulation and depletion of lymphocytes caused by the virus and therapy lead to an increase in the incidence of superinfections. COVID-19-associated pulmonary aspergillosis (CAPA) is a new entity with increasing incidence and high associated mortality.</p> <p>We present a 68-year-old patient admitted to our ward after being cured of severe COVID-19 pneumonia. Due to a worsening of her clinical condition, a chest computed tomography was performed and a lung abscess was identified with the identification of Aspergillus niger. Despite therapy with voriconazole, the patient maintained an unfavourable evolution, culminating in her death.</p> Filipa David Copyright (c) MASKED POLYCYTHEMIA VERA IN A FERTILE-AGED WOMAN <p>Polycythemia Vera (PV) is a chronic proliferative disorder with clonal stem cell expansion of myeloid lineage leading to increased red blood cell (RBC) mass. Activating V617F mutation for Janus kinase 2 (JAK2) is present in 95-97% of cases, as well as other JAK2 pathway mutations, despite they are not exclusive for this condition. As the radionuclide assay for accessing RBC mass has low accessibility to clinicians, haemoglobin and haematocrit are used as surrogate markers in WHO diagnostic criteria for PV. These criteria were updated in 2016, with lower thresholds as a strategy to increase diagnostic sensitivity, mitigating the effect of plasma expansion and other concurrent factors that can occult the disease. We present the case of a fertile-aged woman with menometrorrhagia, whose induced iron depletion state worked as a limiting factor for major clonal expansion, delaying proper diagnosis. As this case points out, despite not meeting diagnostic criteria at presentation, masked PV (mPV) exhibited clinical, laboratory and imaging features of evolving disease. These symptoms and laboratory findings can be easily misinterpreted and not recognised as part of the disease course. For that, a higher level of suspicion must be held for fertile-aged women who present with significant iron depletion, besides normal haemoglobin, and haematocrit, in the presence of low erythropoietin levels or elevated RBC count.</p> Luis Reis de Almeida Copyright (c) PURULENT PERICARDITIS PRESENTING AS CARDIAC TAMPONADE <p>Purulent pericarditis (PP) is an uncommon, localized infection of the pericardial space that usually occurs in a compromised host. We report the case of a 70-year-old male that presented a PP, manifested as cardiac tamponade, and aortic valve endocarditis. The underlying mechanism was hematogenic spread of <em>Streptococcus agalactiae</em>, after bacterial translocation. There were several complications secondary to septic embolization and progression to constrictive pericarditis.</p> Ana P. Ferro, Leila Duarte, Daniela Carvalho, Gracieta Malangatana Copyright (c) Bacteroides fragilis bacteremia complicated by spondylodiscitis, spinal epidural abscess and sepsis <p>We describe a 63-year-old man, with a free past medical history, who presented with fever and altered level of consciousness. Significant thoracic spine pain was also reported during the last three months. He was finally diagnosed with vertebral spondylodiscitis, contiguous spinal epidural abscess and sepsis due to <em>Bacteroides fragilis </em>bacteremia. Clinical recovery was achieved after surgical decompressive therapy with abscess drainage combined with appropriate antibiotic therapy for twelve weeks. The primary focus of the infection was not clarified despite all the investigations that were performed.</p> Georgios Papaetis, Theodosis Petridis, Stylianos Karvounaris, Theodora Demetriou, Savvas Lykoudis Copyright (c) Acquired hepatocerebral degeneration - a rare neurological complication of liver cirrhosis <p>We reported a 64-years-old woman with medical history of hepatic cirrhosis caused by Hepatitis B and Hepatitis C virus, Child-Pugh Score 8 (Class B), with portal hypertension, ascites suppressed with diuretics, esophageal varices and hypertensive gastropathy, that presents with seven months history of subacute-onset hand tremor and postural imbalance. Neurological examination showed bilateral extreme nystagmus, rest and kinetic hand tremor, doubtful Romberg test and slightly enlarged base gait. Dosage of ammonia was normal. MRI showed homogenously increased T1 signal within the basal ganglia (nucleus pallidus), with normal T2-weighted, associated to manganese accumulation. The diagnose of Acquired hepatocerebral degeneration was made.</p> <p>Acquired hepatocerebral degeneration is a rare and debilitating neurological syndrome, characterized by movement disorders and cognitive impairment in cirrhosis or portosystemic shunts. Bilateral hyperintensity in the globus pallidus on T1-weighted sequences, with normal T2-weighted are the most common abnormal finding. It is a consequence of manganese deposition in nucleus ganglia. Medical treatments are not effective. Liver transplantation showed good outcomes.</p> Catarina Medeiros, David Ferreira, Daniela Brito, Rita Serras Jorge Copyright (c) Pseudoaneurysm of a bronchial artery: an unusual cause of chest pain. <p>We report a case of a bronchial artery pseudoaneurysm presenting as acute retrosternal pain. We want to discuss and to announce the extremely rare finding of a bronchial artery pseudoaneurysm. Bronchial artery aneurysms and pseudoaneurysms are uncommon however missing this diagnosis is associated with significant morbidity and mortality. When suspecting this pathology an urgent CT-angiography and a selective angiography (DSA) are crucial. Urgent treatment with transarterial embolization is preferred.</p> Pepijn Van Hove, Thomas Jardinet Copyright (c) Misdiagnosis due to false-positive detection of pneumococcal urinary antigen: a case report Kaori Notomi, Taku Harada, Takashi Watari, Juichi Hiroshige, Taro Shimizu Copyright (c)