The most common cause of bilateral symmetrical polyarthritis in the small joints is rheumatoid arthritis. However, if seronegative arthritis is involved, it could be the case that other underlying causes need to be diagnosed. This is particularly important for those coming from or living in developing countries where infectious causes should always be considered. The case of a young Nepali woman is presented in this article. She was referred as a case of seronegative rheumatoid arthritis for DMARDs therapy but this was not the case due to her origin from Nepal and seronegativity for RF, Anti-ccp, and ANA as well as faint macular skin lesions over her face and upper extremities, which the patients are not aware of. Consequently, skin biopsy was carried out which subsequently confirmed that the infectious cause of her polyarthritis was leprosy.

May–Thurner syndrome (MTS) usually presents as acute or chronic deep vein thrombosis (DVT) in patients. A 49-year-old woman presented with left lower limb DVT, which was followed by a diagnosis of MTS on a background of polycystic ovary syndrome (PCOS) and hypothyroidism. MTS is more common among women in the second to fourth decades of life. An endovascular approach is the preferred first-line treatment for MTS.

Objectives: To demonstrate difficulties in diagnosing and treating Addison’s disease caused by tuberculosis.
Materials and methods: We present a clinical case and review of the literature.
Results: A 62-year-old man presented with gastrointestinal symptoms, weight loss and enlarged adrenal glands. After 2 months of diagnostic tests, a working diagnosis of Addison’s disease due to extrapulmonary tuberculosis was made. Treatment was challenging due to interaction between rifampicin and steroids.
Conclusion: Our case illustrates that in non-endemic countries, extrapulmonary tuberculosis still needs to be considered as a possible cause of Addison’s disease.

Introduction: Isolated right pulmonary artery agenesis in an adult patient is an extremely rare condition that requires a high level of suspicion to make the diagnosis.
Case Description: A 32-year-old woman presented to the emergency room with a 4-month history of recurrent respiratory infections. Chest radiography and computerized tomography (CT) revealed alveolar opacities on the medium and inferior right lobes. Fibreoptic bronchoscopy with bronchial aspirate was negative on both cytological and microbiological analysis. Due to the persistent of the imaging findings after a full course of a wide-spectrum antibiotic, an angio-CT was performed, revealing a complete stop at the level of the right pulmonary artery. Angiography confirmed the diagnosis of right pulmonary artery agenesis.
Discussion: Currently, the patient has no exertional dyspnoea, screening for pulmonary hypertension has so far been negative and no further respiratory infections have occurred. It is important to call attention to a major congenital malformation that may remain asymptomatic until adulthood.

Purpose: Solid organ re-transplantation in the context of allograft failure is a challenging clinical and ethical problem. Ideally, solid organ re-transplantation after initial allograft failure should be performed in all recipients, but this is often not clinically or logistically feasible.
Methods: This report details what we believe is the first combined heart–kidney transplant in a recipient of a previous sequential heart and kidney transplant. Results: Eight years after a combined heart and kidney transplant after initially receiving a sequential heart and kidney transplant, a 31-year-old man is doing extremely well, with no rejection episodes or significant complications after transplantation.
Summary: This case confirms that combined heart and kidney transplantation is a viable option for tackling the complex issue of graft failure in recipients of previous cardiac and renal grafts.

Sarcoidosis is a systemic disorder that most commonly affects the lungs. Bone involvement is rare, and spinal involvement is even more rare. The presence of focal lesions of the vertebrae is highly suspicious of advanced malignancy. However, malignant metastatic spread to the spine involves the vertebral cortex rather than the bone marrow itself, a distinction that is often missed and therefore misleading. We describe here a middle-aged woman with multiple focal oedematous lesions of the bone marrow suspected of being advanced malignancy but finally diagnosed as a rare case of spinal sarcoidosis.

Objective: To report a case of successful long-term conservative management of a patient with aortic graft infection due to multiple infectious agents.
Materials and methods: We describe the clinical case and present a review of relevant literature.
Results: An 82-year-old man presented with recurrent Escherichia coli bacteraemia. He was diagnosed with an endovascular aortic graft infection. As the patient declined surgery, conservative treatment with daily antibiotic therapy was instituted. We report good clinical results after almost 2 years of treatment and follow-up.
Conclusions: The preferred treatment of aortic graft infections is surgical. Conservative management is usually offered to poor surgical candidates and is associated with an unfavourable outcome. However, we report that selected patients may be successfully treated using prolonged antibiotic therapy.

Background: Bilateral third cranial nerve palsy has only been reported in a handful of conditions including some with inflammatory, tumoural and vascular causes. An urgent imaging study is mandatory to rule out vascular aetiology, mainly aneurysmal subarachnoid haemorrhage (aSAH).
Case presentation: A 28-year-old Hispanic woman presented to the emergency department with a 21-day history of a sudden-onset and severe headache that on three occasions was accompanied by transient loss of awareness, the last episode occurring a week previously. The simple CT image showed minimal bleeding at the level of the perimesencephalic cisterns, with evidence of SAH. An angioCT revealed a 5×6 mm bilobed saccular aneurysm of the right posterior communicating artery and a 2×2 mm saccular aneurysm in the posterior left communicating artery.
Conclusions: A mirror aneurysm is found in 2–25% of aSAH cases. To date there is no consensus about the optimal management of patients with these findings.

Heyde’s syndrome describes an association between aortic stenosis and a predisposition to bleeding from intestinal angiodysplasia resulting from acquired von Willebrand disease.
We present the case of an 82-year-old woman with recurrent intestinal bleeding, severe anaemia and secondary myocardial infarction. Investigation identified ileal angiectasia as the source of haemorrhage. As echocardiography revealed severe aortic stenosis the patient underwent surgical valve replacement. At her 3-month follow-up, the patient reported no new bleeding episodes and her functional status had improved.
This case highlights Heyde’s syndrome, an entity probably underdiagnosed despite the high prevalence of aortic stenosis and intestinal angiodysplasia in elderly patients.

Immunoglobulin G4-related disease (IgG4-RD) is a systemic immune-mediated fibroinflammatory condition characterized by tumefactive lesions that can affect multiple organs. Serum IgG4 levels may be elevated. Early recognition is sometimes difficult but is important to avoid irreversible organ damage. We describe the case of a 28-year-old male patient who presented with a 2-year history of recurrent low-grade fever, night sweats and non-specific manifestations. We eventually diagnosed IgG4-related aortitis by PET-CT scan. The patient was successfully treated with prednisolone and mycophenolate mofetil with complete clinical and radiological resolution.

This case report describes an unusual form of gout, called miliarial gout, in association with carpal tunnel syndrome in a 54-year-old woman. Miliarial gout was first described in 2007 and is a very rare presentation of chronic tophaceous gout. The latter condition can cause carpal tunnel syndrome, but this association has not previously been described in association with miliarial gout. In addition, the authors discuss the use of the parsimony principle in internal medicine whereby a single cause is first sought for different symptoms presenting at the same time.