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previously unpublished material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, 28 Jan 2020 08:21:11 +0000 OJS 60 Diabetic Myonecrosis: An Uncommon Complication of a Common Condition <p><em>Introduction:</em> Diabetic myonecrosis is an uncommon complication of diabetes mellitus, most often occurring in patients with poorly controlled, insulin-dependent diabetes. Its etiology is poorly understood, with many suggesting microvascular occlusion to be a key factor resulting in necrosis of skeletal muscle.<br> <em>Case presentation:</em> A 28-year-old male with a history of poorly controlled type I diabetes mellitus and end-stage renal disease requiring dialysis presented to the emergency department with severe pain of the lower extremities bilaterally. <br> <em>Results:</em> Work-up included an x-ray, which demonstrated no acute fractures but extensive vascular calcification of the lower extremities, and Doppler ultrasonography, which showed no DVT. MRI demonstrated severe muscular edema with patchy, geographic areas of sparing, which, in conjunction with the patient’s clinical presentation, allowed for a diagnosis of diabetic myonecrosis. He underwent conservative treatment, consisting of rest and pain management, leading to resolution of symptoms.<br> <em>Discussion:</em> Diabetic myonecrosis, although uncommon, can be easily diagnosed with a high degree of clinical suspicion. It typically presents in a patient with poorly controlled diabetes, and will commonly involve the proximal muscles of the lower extremity unilaterally, but may present bilaterally and involve the distal muscles, as demonstrated in this case. Diagnosis is made via MRI, and it is treated conservatively with pain management and rest. Most cases resolve with conservative management but recurrence is common.</p> Michael Harrison Storandt, Chandra Thondapi, Abhishek Matta ##submission.copyrightStatement## Fri, 14 Feb 2020 08:17:12 +0000 Intellectual Disability, Falls and Gait Disturbances: A Misdiagnosis <p>We report the case of a 27-year-old man presenting with slowly progressive extrapyramidal dysfunction and learning disability considered to have a syndromic intellectual disability. The re-evaluation of the clinical features and the investigations performed led to the diagnosis of atypical pantothenate kinase-associated neurodegeneration (PKAN).</p> Noel Lorenzo Villalba, Santiago Díaz Nicolas, Maria Belen Alonso Ortiz, Zaida Cordoba Sosa, Saturnino Suárez Ortega, Abrar-Ahmad Zulfiqar ##submission.copyrightStatement## Thu, 13 Feb 2020 08:28:23 +0000 Persistent Facial Oedema and Erythema in a Woman, An Uncommon Manifestation of Chronic Cutaneous Lupus Erythematosus <p>Manifestations of chronic cutaneous lupus erythematosus are variable. Periorbital and facial swelling occurs in dermatomyositis and systemic lupus, but it has been rarely reported as a manifestation of exclusively cutaneous lupus. A 48-year-old woman presented with a 16-year history of asymptomatic, bilateral swelling and erythema of her face with marked worsening after sun exposure. No systemic symptoms were associated. A complete evaluation did not reveal other findings. Cutaneous biopsy showed features of lupus erythematosus. She was treated with photoprotection, topical tacrolimus, hydroxychloroquine and azathioprine with a partial response. Facial swelling with erythema represents quite an unusual manifestation of chronic cutaneous lupus erythematosus. Dermatomyositis, systemic lupus and Morbihan disease are the main differential diagnoses.</p> Mónica García-Arpa, María Rodríguez-Vázquez, David Bellido-Pastrana, Natalia Villasanti-Rivas, Marcos Carmona-Rodríguez ##submission.copyrightStatement## Wed, 12 Feb 2020 08:34:15 +0000 Fever During Anti-integrin Therapy: New Immunodeficiency <p><em>Background:</em> The causes of inflammatory bowel disease (IBD) have not yet been clearly elucidated, but it is known that genetic susceptibility, altered gut microbiota and environmental factors are all involved, and that a combination of these factors causes an inappropriate immune response, resulting in impaired intestinal barrier function. With regard to the treatment of IBD, the use of conventional immunosuppressive drugs has been complemented by more specific therapeutic agents, including biological drugs. Systemic immune suppression is a risk factor for cytomegalovirus (CMV) infection, which is associated with considerable morbidity and mortality in immunocompromised hosts.<br> <em>Case Report:</em> A 33-year-old male patient was admitted to our medical unit complaining of a 10-day history of fever, fatigue and headache. He had been suffering from ulcerative colitis and primary sclerosing cholangitis for five years and was currently being treated with azathioprine and vedolizumab. In the past he had already taken infliximab, adalimumab and golimumab without any clinical response. After the exclusion of systemic infectious diseases, his serology was consistent with a primary CMV infection. This was successfully treated with intravenous ganciclovir therapy.<br> <em>Conclusion:</em> Vedolizumab is an anti-integrin biological agent approved for IBD treatment. Its gut-selective mechanism of action would appear to increase its safety profile, however data on this are still limited. Moreover, it should always be remembered that IBD patients have an increased risk of CMV infection, both primary and reactivation, because of their concurrent immunosuppression.</p> Eleonora Bonfanti, Christian Bracco, Paolo Biancheri, Andrea Falcetta, Marco Badinella Martini, Remo Melchio ##submission.copyrightStatement## Tue, 11 Feb 2020 09:51:31 +0000 Turicella otitidis as an Unusual Agent Causing Palmoplantar Eczema: An Emerging Pathogen <p><em>Introduction:</em> <em>Turicella otitidis</em>, described as a new species over 20 years ago, has been isolated mainly from the external ear canal and middle ear fluid. Here, we report the first case of palmoplantar eczema related to <em>T. otitidis</em>.<br> <em>Case presentation:</em> Here, we report the first case of palmoplantar eczema in a 74-year-old female related to <em>T. otitidis</em>.<br> <em>Conclusions:</em> The question as to whether <em>T. otitidis</em> is a potential pathogen in cases of dyshidrotic eczema is still open, but this could be better elucidated if corynebacteria were speciated more often.</p> Dimitra Koumaki, Vasiliki Koumaki, Sotirios Boumpoucheropoulos, Alexander Katoulis, Panagiotis Bitados, Maria Stefanidou, Konstantinos Krasagakis ##submission.copyrightStatement## Mon, 10 Feb 2020 10:08:09 +0000 Sweet’s Syndrome Induced by Aromatase Inhibitor in the Treatment of Early Breast Cancer <p><em>Background:</em> Breast cancer is the most commonly diagnosed cancer in women, mainly at an early stage, allowing treatment with curative intent. Aromatase inhibitors are widely used in the adjuvant treatment of oestrogen receptor-positive breast cancer, mainly in postmenopausal women. The most frequent adverse events associated with these therapies are musculoskeletal symptoms and an increased risk of bone fractures. Cutaneous adverse events have been rarely described. Sweet’s syndrome can present as an idiopathic disorder in addition to being malignancy-associated or drug-induced. <br> <em>Case presentation:</em> We report the case of a 69-year old woman, diagnosed with early stage breast cancer, who underwent breast-conserving surgery, followed by adjuvant radio and endocrine treatment with letrozole 2.5 mg daily, for a foreseeable duration of 5 years. Three months after starting letrozole, she presented with sudden fever and exuberant and painful erythematous skin papules and plaques on her upper body. After a full work-up and exclusion of other potential causes, a skin biopsy confirmed the presence of dermal oedema and a diffuse neutrophilic infiltrate, suggesting Sweet’s syndrome. After discontinuation of letrozole and treatment with corticosteroids, the patient fully recovered. She resumed adjuvant treatment with tamoxifen, without symptom recurrence.<br> <em>Conclusions:</em> Sweet’s syndrome is a rare condition and an association with aromatase inhibitors has not been previously reported. Although its occurrence has already been observed in the onset of malignancies such as breast cancer, aromatase inhibitors must be added to the list of potential causes of drug-induced Sweet’s syndrome.</p> Debora Cardoso, Andreia Coelho, Leonor Fernandes, Leonor Vasconcelos Matos, Isabel Serrano, Helena Miranda, Ana Martins ##submission.copyrightStatement## Fri, 07 Feb 2020 10:26:31 +0000 Viscous Leptomeningeal Pseudotumoural Masses and Multiple Cranial Neuropathy – Severe Presentation of Neurosarcoidosis <p>We present a case of a 56-year-old man with a history of episcleritis (left) and cluster headache (left) who had a penetrating trauma of the left eye leading to amaurosis 1 month previously. Since then, he developed multiple cranial neuropathy of the right side (V, VII, VIII, IX, X, XI and XII cranial pairs). Magnetic resonance imaging (MRI) revealed an infiltrative lesion of the base of the skull which extended to the retropharyngeal and jugular space, which progressed to multiple leptomeningeal masses extending to the clivus, despite aggressive immunosuppression. Rebiopsy of 1 meningeal mass supported the diagnosis of neurosarcoidosis. The patient finally responded to high-dose prolonged infliximab therapy, with complete remission.</p> Rita Ribeiro Dias, Inês Henriques Ferreira, Raquel Faria ##submission.copyrightStatement## Thu, 06 Feb 2020 08:50:03 +0000 Portal Vein Thrombosis in a Patient with Type 1 Diabetes Presenting as Acute Pyelonephritis <p><em>Background:</em> Few cases have been reported with respect to portal vein thrombosis in non-cirrhotic patients. Asymptomatic or non-specific symptoms of portal vein thrombosis may lead to misdiagnosis or may delay the diagnosis until complications develop. We report a case of portal vein thrombosis in a patient with type 1 diabetes presenting as acute pyelonephritis. <br> <em>Case description:</em> An 18-year-old female with type 1 diabetes on an insulin pump presented with epigastric abdominal pain for 3 days associated with nausea and vomiting. She was a conscious, alert, young female who appeared to be in pain. Vital signs were stable with a random blood sugar (RBS) level of 179 mg/dl. Abdominal examination revealed a soft and lax abdomen with tenderness in the epigastric area and right renal angle, as well as no sign of rigidity or rebound tenderness. No signs of ascites, splenomegaly or hepatomegaly were noted. Investigations showed a WBC count of 10.2, neutrophils at 65%, urine microsopy analysis revealed WBCs between 30–50 per high power field, with culture showing &gt;105 CFU/ml. All parameters of a thrombophilic screen were within normal values. Computed tomography (CT) revealed reduced enhancement of the right kidney, likely indicating acute pyelonephritis, and left portal vein oedema with complete occlusion. Local factors and prothrombotic disorders were ruled out. The patient was managed with ciprofloxacin, enoxaparin and warfarin. Follow-up imaging revealed complete resolution of thrombosis. <br> <em>Conclusions:</em>Portal vein thrombosis is an uncommon condition in the absence of liver disease. Few case reports exhibit sepsis and portal vein thrombosis. Sepsis can create a predisposed environment for hypercoagulability. To our knowledge, this is the first case report of pyelonephritis with portal vein thrombosis.</p> Zahra Abdulwahed AL Saeed, Fatimah Mohammed Alabdrabalnabi, AlAnoud AlAnazi, Waleed Ibrahim Albaker, Osma Abdullah Al-Sultan ##submission.copyrightStatement## Wed, 05 Feb 2020 09:49:34 +0000 Reactive Arthritis – A Rare Complication of Intravesical BCG Instillation <p>Reactive arthritis (ReA) with the classic triad of arthritis, conjunctivitis and urethritis, previously termed Reiter’s syndrome, is a systemic illness, usually induced by genitourinary or gastrointestinal infections. However, it can be a rare complication of intravesical Bacillus Calmette-Guérin instillation (iBCG), a therapy prepared from attenuated strains of <em>Mycobacterium bovis</em>, a common and effective treatment for carcinoma in situ of the bladder (CisB). We report a case of a patient with CisB who developed ReA after iBCG. The symptoms resolved completely with corticosteroids. iBCG was stopped with no recurrence of carcinoma within 2 years.</p> Marta Freixa, Sara Úria, Glória Nunes da Silva ##submission.copyrightStatement## Tue, 04 Feb 2020 07:58:15 +0000 Recurrent Klebsiella pneumoniae Infection Causing Transcatheter Aortic Valve Implantation (TAVI)-Related Endocarditis <p>The authors report the case of an 86-year-old woman presenting with recurrent <em>Klebsiella pneumoniae</em> bacteraemia. She had severe aortic stenosis submitted to a recent transcatheter aortic valve implantation (TAVI). Initially, <em>Klebsiella pneumoniae</em> bacteraemia from a urinary source was diagnosed . Following another 4 episodes of bacteraemia with the same agent, the source was ultimately found to be a periprosthetic abscess. Considering the patient’s unsuitability for surgery, a decision was made for life-long antimicrobial therapy. This approach has been successful in preventing recurrences or complications. Endocarditis is one of the most severe complications seen following TAVI, often carrying a poor prognosis. Even though Klebsiella spp. are common pathogens for healthcare-associated infections among the elderly, they are seldom the causative agent for endocarditis. Being the first reported case of TAVI-related Klebsiella endocarditis, it was successfully managed using a medical approach.</p> Valentina Tosatto, Cristiano Cruz, Teresa Ferreira, Torcato Moreira Marques, Matteo Boattini, André Almeida, Rita Barata Moura ##submission.copyrightStatement## Mon, 03 Feb 2020 08:35:54 +0000