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previously unpublished material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, 26 Nov 2019 15:50:10 +0000 OJS 60 When the Heart Triggers the Esophagus: Esophageal Spasm after Electrical Cardioversion <p><em>Introduction:</em>“Esophageal spasm” is a generic term widely used to attribute unexplained non-cardiac chest pain and/or dysphagia to an esophageal motility disorder. <br> <em>Patient and methods:</em> The authors present the case of an 86-year-old male patient with complete dysphagia after an elective electrical cardioversion for atrial fibrillation. An upper endoscopy performed shortly after the onset of the clinical picture documented disordered esophageal contractions. The patient became asymptomatic within 12 hours of the administration of a spasmolytic therapy. <br> <em>Results:</em> To the best of our knowledge, this is the first report of esophageal spasm after an electrical cardioversion. <br> <em>Discussion:</em> The temporal correlation supports the explanation of a cause-effect relationship between the clinical presentation and the preceding procedure, thus providing elements for clinicians to recognize and treat this particular condition.</p> Riccardo Manfredo Campaner, Marco Enzo Tau, Francesca Ortelli, Maria Luisa De Perna, Tanja Fusi-Schmidhauser ##submission.copyrightStatement## Wed, 11 Dec 2019 09:11:50 +0000 Benzylthiouracil-induced ANCA-associated Vasculitis: A Case Report and Literature Review <p>Iatrogenic antineutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV) is not exceptional. Many cases of small vessel vasculitis induced by anti-thyroid drugs (ATD), mainly propylthiouracil (PTU), have been reported. We present a case of AAV related to another ATD: benzylthiouracil (BTU) and review the literature. An 84-year-old man with a 4-year history of multinodular goitre with hyperthyroidism was treated with BTU. He presented an acute syndrome with weakness, fever, epigastric pain and abdominal distension. Lactate and lipase tests were normal. An abdominal scan showed a thrombosis of the splenic artery with splenic infarction. We excluded a hypothesis of associated embolic aetiology: atrial fibrillation, atrial myxoma, intraventricular thrombus or artery aneurysm. Exploration of a possible prothrombotic state (complete blood count, haemostasis tests, activated protein C resistance, factor V Leiden, protein C, S, antithrombin III) gave normal results. Tests for antinuclear antibodies (ANA) and antiphospholipid antibodies (APL) were negative. However, testing for p-ANCA, with antimyeloperoxidase (MPO) specificity, was positive: 120.6 CU (N&lt;20.0). We did not find other systemic manifestations, except a non-specific kidney failure. BTU was discontinued without steroids or immune-modulating drugs. Subsequently, symptoms disappeared progressively and titres of ANCA fell until normalization, 4 months later. Many patients treated with BTU present a high prevalence of ANCA, mainly, but not exclusively, directed against MPO. Vasculitis, however, remains an uncommon complication. The mechanism of this anomaly remains to be elucidated. Some studies suggest the possibility of an autoimmune reaction initiated by drug bioactivation mediated by neutrophil-derived MPO. The present observation is particular because the involved drug was BTU and clinical expression was unusual.</p> Fatima Bensiradj, Mathilde Hignard, Rand Nakkash, Alice Proux, Nathalie Massy, Nadir Kadri, Jean Doucet, Isabelle Landrin ##submission.copyrightStatement## Tue, 10 Dec 2019 08:09:54 +0000 Acute Heart Failure in a Healthy Young Patient after Severe Carbon Monoxide Poisoning <p><em>Introduction:</em> Carbon monoxide (CO) poisoning may cause severe cellular hypoxia.<br> <em>Materials and methods</em>: A 28-year-old male presented reduced levels of consciousness and dyspnoea after CO exposure. Clinical examination revealed tachypnoea, bilateral rales, dilated jugular veins and confusion. Troponin I, lactate and carboxyhaemoglobin levels were increased. Thoracic X-ray depicted pulmonary oedema and an echocardiogram, severe heart failure (HF; EF&lt;25%). He was intubated due to clinical deterioration.<br> <em>Results:</em> He remained intubated for 5 days with excellent improvement of left ventricular function (EF&gt;55%). He was discharged 1 week later with full recovery. <br> <em>Discussion:</em> Acute HF is a rare serious complication of CO poisoning, even in healthy young individuals.</p> Christos E Lampropoulos, Evagelia Sklavou, Charalampos Anastogiannis, Vasiliki Papanikolaou, Dimitris Tsilivarakis, Vasilis Vasiliou, Ioanna Papaioannou ##submission.copyrightStatement## Mon, 09 Dec 2019 09:12:24 +0000 Inferior Vena Cava Agenesis and Deep Vein Thrombosis: A Pharmacological Alternative to Vitamin K Antagonists <p>Inferior vena cava (IVC) agenesis is a rare congenital abnormality affecting the infrarenal segment, the suprarenal or the whole of the IVC. It has an estimated prevalence of up to 1% in the general population that can rise to 8.7% when abnormalities of the left renal vein are considered. Most IVC malformations are asymptomatic but may be associated with nonspecific symptoms or present as deep vein thrombosis (DVT). Up to 5% of young individuals under 30 years of age with unprovoked DVT are found to have this condition. Regarding the treatment of IVC agenesis-associated DVT, there are no standard guidelines. Treatment is directed towards preventing thrombosis or its recurrence. Low molecular weight heparin and oral anticoagulation medication, in particular vitamin K antagonists (VKAs) are the mainstay of therapy. Given the high risk of DVT recurrence in these patients, oral anticoagulation therapy is suggested to be pursued indefinitely. As far as we know, this is the first case reporting the use of a direct factor Xa inhibitor in IVC agenesis-associated DVT. Given VKA monitoring limitations, the use of a direct Xa inhibitor could be an alternative in young individuals with anatomical defects without thrombophilia, but further studies will be needed to confirm its efficacy and safety.</p> Inês Esteves Cruz, Pedro Ferreira, Raquel Silva, Francisco Silva, Isabel Madruga ##submission.copyrightStatement## Fri, 06 Dec 2019 08:55:52 +0000 When Zoster Virus Hides a Primary Brain Lymphoma <p><em>Aim:</em> To describe an unusual presentation of a primary lymphoma of the central nervous system in a patient who, four months prior to admission, was diagnosed with herpes zoster ophthalmicus (HZO). <br> <em>Case description:</em> A 68-year-old man, with a history of HZO, was admitted to the emergency department with nausea and vomiting that had persisted over the previous two weeks. Neurological evaluation showed right ptosis, divergent strabismus and anisocoria. Blood tests showed high c-reactive protein, while serology was negative for human immunodeficiency virus. A brain CT scan revealed three round lesions, slightly hyperdense, periventricular in the occipital and frontal regions, which biopsy revealed to be a diffuse large B-cell lymphoma. The patient started chemotherapy but progression to death was inevitable.<br> <em>Conclusion:</em> The authors describe an unusual presentation of primary lymphoma of the central nervous system and urge physicians to be aware of this presentation in order to avoid misdiagnosis.</p> Rafael Ferreira Nascimento, João Miguel Freitas, Maria da Luz Brazão ##submission.copyrightStatement## Thu, 05 Dec 2019 08:24:33 +0000 Two Dabigatran Fast Reversals in a 4-month Period – a Case Report <p><em>Introduction:</em> Idarucizumab is available for immediate reversal of dabigatran-induced anticoagulation in life-threatening bleeding or urgent surgery in patients with non-valvular atrial fibrillation (nvAF).<br> <em>Case description:</em> We report a case of an 85-year-old female treated with dabigatran for nvAF, submitted to two fast reversal procedures with idarucizumab in a 4-month period. In the first emergency episode, the patient was admitted due to a fall-related cerebral haemorrhage and subdural haematoma. There was a fast reversal of the effects of dabigatran after idarucizumab administration, which allowed stoppage of the bleeding and a decrease in intracranial pressure, with full patient recovery. Four months later, the patient revisited the hospital complaining of diffuse abdominal pain while on the same antithrombotic therapy. Physical examination showed signs of peritoneal irritation and the use of idarucizumab to reverse the effects of dabigatran was decided upon to secure normal bleeding conditions before surgery.<br> <em>Discussion:</em> Idarucizumab is an efficient, safe and feasible option for dabigatran-treated nvAF patients, when urgent anticoagulant effect reversal is needed.</p> Vítor Fagundes, Mari Mesquita ##submission.copyrightStatement## Wed, 04 Dec 2019 09:08:53 +0000 Cervical Lymphadenopathy in a Nonagenarian Woman: What to Think? <p>Tuberculosis remains a worldwide public health problem. Cervical tuberculous lymphadenitis (TBL) or scrofula is the most common form of extrapulmonary tuberculosis, affecting the cervical lymph nodes. We report the case of a 93-year-old woman presenting with cervical adenopathies with 3 months duration. Fine needle aspiration (FNA) biopsy yielded a noncaseous granulomatous process, but was negative for Mycobacterium tuberculosis (MT). As the adenopathies had grown, an excisional biopsy was performed. An extensive study of infectious aetiologies was performed, including for MT, with a negative outcome. Owing to the persistence of cervical lymphadenitis with caseous granulomas, a diagnosis of TBL was strongly suspected and presumptive treatment was initiated. Afterwards, diagnostic confirmation was obtained by isolation of MT in the lymph node culture. The patient presented a favourable clinical outcome. This case highlights that a high index of suspicion is essential for the diagnosis of TBL, especially in the elderly, and emphasizes the importance of pursuing diagnostic confirmation, in which FNA and excisional biopsy plays a key role.</p> Vanessa Meireles Chaves, Fernando Nogueira, Gilberto Pires da Rosa, Sofia Tavares, Inês Ferreira, Ana Oliveira Monteiro, Ester Ferreira ##submission.copyrightStatement## Tue, 03 Dec 2019 08:34:17 +0000 Moyamoya Syndrome after Radiation Therapy: a Clinical Report <p>Moyamoya syndrome (MMS) is a rare, chronic and progressive vasculopathy with a characteristic angiographic pattern and well-recognized predisposing conditions, such as cranial therapeutic radiation. We report the case of a 36-year-old Caucasian female with a history of craniopharyngioma treated with whole-brain radiotherapy 20 years previously. She was admitted to the emergency department with disorientation and imperceptible speech lasting for 1 hour. Upon examination, she had slight motor aphasia, without sensory or motor deficits. However, the neurological deficits worsened on standing position. The computed tomography (CT) angiogram and transcranial Doppler ultrasonography revealed occlusion of the distal portion of the left internal carotid artery (ICA). Mechanical thrombectomy was attempted without success. Head CT was repeated, revealing left periventricular acute ischaemic stroke. The cerebral angiography showed total occlusion of the left ICA with an exuberant network of transdural collateral vessels, confirming MMS. The patient completed a functional rehabilitation program with progressive improvement of deficits and maintained a multidisciplinary follow-up. MMS is a serious late complication from cranial radiation therapy and a well-described risk factor for ischaemic stroke in younger patients. Therefore, early detection and prompt treatment are mandatory, as the consequences can be disastrous, such as cognitive and neurologic decline due to repeated strokes.</p> Paulo Almeida, Ana Rocha, Gonçalo Alves, Tiago Parreira, Maria Silva, António Cerejo, Pedro Abreu, Ana Monteiro ##submission.copyrightStatement## Mon, 02 Dec 2019 09:31:50 +0000 Haemoglobin A1C Levels Constantly Below Lower Reference Limit in a Diabetic Patient With Microcytic Anaemia <p><em>Introduction:</em> Haemoglobin A<sub>1C</sub> (A1C), as a parameter of long-term glycaemic control, has been adopted to guide diabetic therapy all over the world. However, falsely high or low A<sub>1C</sub> could be troublesome in daily practice. <br> <em>Case description:</em> A 75-year-old male diabetic patient affected by a reasonably inferred life-long history of microcytic anaemia was found to have abnormally low A<sub>1C</sub> values in the previous 5 months. Subsequent laboratory assessment with brilliant cresyl blue staining and haemoglobin electrophoresis detected haemoglobin H disease as the underlying cause of both the microcytic anaemia and the disturbed A<sub>1C</sub> measurement. <br> <em>Discussion:</em> Enhanced erythrocyte destruction such as in haemoglobin H disease could explain a falsely decreased A<sub>1C</sub> level very well. Upon facing a questionable A<sub>1C</sub> value, physicians dealing with diabetes should consider the possibility of undiscovered underlying causes rather than too tightly glycaemic control.</p> Frank Sheng Fan, Chih-Hao Chen, Hui-Chun Yang ##submission.copyrightStatement## Fri, 29 Nov 2019 09:35:20 +0000 Cardiac Amyloidosis Associated with Apolipoprotein A-IV Deposition Diagnosed by Mass Spectrometry-Based Proteomic Analysis <p>Amyloidosis is a group of disorders characterised by the accumulation of extracellular deposits of insoluble protein aggregates. Clinical management depends on the accurate identification of the amyloid precursor and underlying cause. We describe a rare case of apolipoprotein A-IV cardiac amyloidosis, the diagnosis of which required mass spectrometry-based proteomic analysis.</p> Elisabete Martins, Joana Urbano, Sérgio Leite, Adriana Pinto, Raquel Garcia, Rui Bergantim, Pedro Rodrigues Pereira, Paulo Pinho Costa, Hugo Osório, Isabel Tavares ##submission.copyrightStatement## Wed, 27 Nov 2019 08:48:06 +0000