• Lorenzo Morini, Davide Donelli, Rosaria Santi, Chiara Trenti, Giuseppe Battaglino, Francesco Iannuzzella, Emanuele Alberto Negri

    Background: Milk-alkali syndrome is a life-threatening condition defined by the triad of hypercalcaemia, metabolic alkalosis and acute renal failure, and is associated with consumption of calcium and absorbable alkali.
    Methods: We report the case of a patient admitted to a step-down unit of a large hospital in Italy.
    Results: The patient was a 59-year-old woman with hypoparathyroidism and mild chronic kidney insufficiency, treated for a preceding episode of hypocalcaemia with high doses of calcitriol and calcium carbonate, who was also taking hydrochlorothiazide and unreported herbal anthranoid laxatives. The patient was admitted to hospital with severe hypercalcaemia, severe metabolic alkalosis and acute renal insufficiency. The patient was successfully treated with urgent dialysis, loop diuretics and calcitonin administration.
    Conclusions: This case underlines the need for caution when treating patients with impaired calcium metabolism regulation, and suggests that herbal anthranoid laxatives might act as triggers for milk-alkali syndrome..

  • Luigi Petramala, Federica Olmati, Antonio Concistrè, Vincenza Saraceno, Gino Iannucci, Antonio Ciardi, Giorgio De Toma, Claudio Letizia

    Introduction: Pheochromocytoma (PHEO) is a rare catecholamine-producing tumour arising from chromaffin cells in the sympatho-adrenal system, and can present as asymptomatic adrenal incidentaloma (AI).
    Patient: We describe the case of a 61-year-old woman with a right adrenal mass incidentally discovered, who was biochemically characterized with subclinical hypercortisolism (SH). The patient was scheduled for adrenalectomy because of increasing seizure of the right adrenal gland with a haemorrhagic and focal pseudocystic appearance macroscopically, incidental histological and immunohistochemical PHEO, and micronodular cortico-adrenal hyperplasia.
    Discussion: This report describes a rare case of incidental non-functioning PHEO coexisting with corticomedullary hyperplasia and SH.

  • Matthieu Barras, Marc Uhlmann

    Bleomycin lung toxicity is well established and can manifest as bleomycin-induced pneumonitis, but pneumomediastinum and pneumothorax are very rare complications. We report the case of a 73-year-old woman, recently treated with bleomycin for Hodgkin’s disease, who was admitted for bleomycin-induced pneumonitis. Two weeks later she had a pneumomediastinum with extensive subcutaneous emphysema and small bilateral pneumothoraces. Three months after that she was readmitted for dyspnoea. The CT scan showed complete regression of the pneumomediastinum but extensive bilateral ground-glass infiltrates. The patient died from respiratory failure 2 weeks later.

  • Inês Almeida Costa, Margarida Alvelos, Paulo Bettencourt

    Hypocalcaemia is known for its neuromuscular symptoms, which are rapidly alleviated by intravenous supplementation. Calcium is also essential for both cardiac cell excitability and contraction. We present a case of acute heart failure due to hypocalcaemia in a young male with a complex medical history.

  • Laura Virginia Gonzalez, Andrew Whitehead

    Platypnoea-orthodexia syndrome is a rare cause of dyspnoea when hypoxaemia is induced by the upright position and relieved by recumbency. We report two cases in which platypnoea-orthodexia syndrome was present and caused by two different mechanisms: intracardiac shunt and intrapulmonary shunt.

  • Mikkel Brabrand, Jan Dahlin, Marianne Fløjstrup, Stine Thorhauge Zwisler, Jens Michelsen, Louise Gramstrup Nielsen, Jens Ahm Sørensen

    Objective: Necrotizing fasciitis is a difficult diagnosis with a very high mortality. However, thermal imaging has the potential to identify increasing skin temperature and rapid progression.
    Materials and methods: We used repeat photographs taken with a thermal camera to visualize changes in skin temperature over time.
    Results: An unstable male patient presented at the emergency department. Thermal imaging showed increased skin temperature of his left foot with a rapid increase and progression in extent within 1 hour. Necrotizing fasciitis was suspected and later confirmed.
    Conclusions: We believe thermal imaging could be an important adjunct for the diagnosis of suspected necrotizing fasciitis.

  • Joana Sá Couto, Luis Pontes dos Santos, Joana Carlos Alves, Raquel López, Cristina Maldonaldo

    Although crystalluria is a frequent finding in the routine examination of urine, amoxicillin crystalluria is a rare event whose incidence remains unknown. Crystalluria caused by amoxicillin is very uncommon and may be asymptomatic or have severe renal implications. The authors describe the case of an 87-year-old female patient who presented with massive amoxicillin crystalluria due to poor hydration, low urinary pH and high intravenous amoxicillin dosage.

  • Rosalie Koot, Marcel van Borren, Hans de Boer

    Liraglutide, a glucagon-like peptide-1 (GLP-1) analog, is increasingly used in obese patients with type 2 diabetes mellitus (T2DM) in doses of up to 3.0 mg/day because of its attractive pharmacological profile. It is currently not known how to proceed with this medication during fasting for surgery. Discontinuation is likely to result in hyperglycaemia, while continuation might lead to hypoglycaemia, but, in view of its mode of action, continuation of GLP-1 analogs is likely to be safe. However, as evidence-based guidelines on GLP-1 management during perioperative fasting are not available, the safety of either policy needs to be confirmed on an individual basis. We therefore decided to perform a preoperative assessment of the glucose response to fasting during continuation of GLP-1 before giving a recommendation in individual cases. So far, 12 severely obese T2DM patients scheduled for bariatric surgery have been evaluated preoperatively by measuring glucose and insulin levels during a 32-hour fast with continuation of liraglutide. Hypoglycaemia was not observed. This suggests that liraglutide in doses of up to 3.0 mg can be safely continued during surgery without risking hypoglycaemia.

  • Patrícia Afonso Mendes, Tatiana Cunha Pereira, Rui Pina, Rui Marques Santos

    Chlorpyrifos is an organophosphate compound recognized as causing acute toxicity. However, organophosphate-induced delayed polyneuropathy (OPIDP), although rare, has also been described. We describe an unusual presentation of OPIDP with flaccid quadriplegia progressing to a locked-in-like syndrome, 30 days after a 60-year-old man voluntarily ingested chlorpyrifos. In the absence of specific treatment, the patient only recovered partial motor responses and the ability to communicate. The authors present this report in order to highlight a form of OPIDP which can hinder diagnosis due to its atypia and the delay in the onset of symptoms from initial contact with the toxicant.

  • Abdalla Khalil, Mohammed Bafaraj, Badr Badr, Majduldeen Azzo, Ahmed Sabry

    Introduction: Missing a leaking abdominal aortic aneurysm (AAA) is common in medical practice because few at-risk patients have a history of AAA and many have an unusual presentation.
    Background: AAA is less common among Asians than white Caucasians of the same age. Our patient had no significant risk factors apart from age and sex and had an unusual presentation.
    Patient and Methods: A 67-year-old Asian man presented to the emergency room (ER) with a 1-day history of nausea, vomiting, diarrhoea, fever and abdominal pain. He was febrile, dehydrated. and had marked tenderness at the right iliac fossa. Laboratory findings suggested bacterial gastroenteritis but this did not explain the localized tenderness at the right iliac fossa.
    Result and Discussion: A CT scan of the abdomen revealed an AAA arising above the origins of the renal arteries, an intramural thrombus, a retroperitoneal haematoma and a leak extending to the right iliac fossa. The patient was transferred to another hospital and underwent exploratory laparotomy, surgical repair of the aneurysm, and aortobi-iliac grafting with removal of the thrombus. The patient was discharged in good shape 3 weeks after surgery. Without the CT scan of the abdomen, the AAA could have been missed and the patient treated for severe gastroenteritis.

  • Abuajela Sreh, Shailesh Nakeshree, Senthil-Kumar Krishnasamy, Nuri Alfasi

    This case demonstrates the therapeutic challenges encountered when managing an acute pulmonary embolism in a cancer patient with thrombocytopenia. A 64-year-old man with a history of lung cancer receiving chemotherapy was admitted to Walsall Manor Hospital with haemodynamic instability consistent with a pulmonary embolism, proven on computed tomographic pulmonary angiogram. His platelet count was noted to be 35×109/l (chemotherapy-induced thrombocytopenia). After discussions, he was deemed not suitable for thrombolysis based on risk versus benefits. The patient was initially transfused one adult dose of platelets and treated with half the therapeutic dose of low molecular weight heparin (LMWH). The same management plan was followed until the platelet count exceeded 50×10sup>9/l, after which the patient was established on the full therapeutic dose of LMWH. Clinically, the patient improved and was discharged. Three months after discharge, follow-up revealed sustained clinical improvement while the patient continued to be on the full therapeutic dose of LMWH with a stable platelet count.

  • Laurentiu Broscaru, Claudiu Dobre, Frederik Rösick, Arnela Halilovic, Dietrich Gulba

    A 46-years old woman presented with acute onset of nausea, vomiting and prostration in the ER. She appeared ill and was poorly responsive to verbal stimuli. The physical examination showed a systolic blood pressure of 60 mmHg and a pulse of 40 bpm. ECG was notable for slight ST-elevations in the inferior leads. Right ventricular myocardial infarction with cardiogenic shock and bradycardia was suspected. Supportive therapy with catecholamines was initiated and a emergency coronary angiography was arranged. However, lab results showed normal troponin levels and a subsequent echocardiogram showed the absence of abnormal wall motions. By thorough history taking with the spouse it turned out that the patient had consumed a Turkish honey approximately an hour before the beginning of the symptoms. The patient made a full recovery within 24 hours with only supportive therapy. In retrospect the clinical presentation was highly indicative of poisoning with Grayanotoxins from a plant, Rhododendron, which is found as contaminant in some sorts of honey in the Black Sea area. A pollen analysis confirmed the presence of Rhododendron in a honey sample.  Historically this poisoning is mentioned over the millennia as mad honey disease. The ST-elevations in the ECG were a sign of early repolarization, a non-pathological finding.  

  • João Rua, Ricardo Marques, Rafael Silva, Bráulio Gomes, Jorge Fortuna

    An 84-year-old woman had five episodes of pneumonia in 4 months. Despite extensive comorbidities and advanced age, her health status was good and the recurrence seemed unjustified. Exhaustive background investigation revealed 14 episodes of right-sided pneumonias during the 3 previous years and an inconclusive investigation with CT of the thorax and bronchofibroscopy, despite some fibrotic and atelectasic alterations in the right middle lobe. A new right-sided x-ray showed a wedge-shaped density extending anteriorly and inferiorly from the hilum, and CT of the thorax revealed aggravated middle lobe abnormalities with thickening of the bronchial wall and segment atelectasis, without any visible airway obstruction. After extensive work-up had excluded other causes of recurrent pneumonia and immunodeficiency, a non-obstructive middle lobe syndrome (MLS) was deemed responsible for the repeated episodes of pneumonia. MLS is characterised by chronic hypoventilation and atelectasis of the middle lobe, facilitating secretion accumulation, chronic inflammation and repeated infection. After treatment with bronchodilators and immunostimulants was initiated, the patient experienced no recurrences for several months.

  • André Rodrigues, Diana Neves, Inês Maury, Dora Sargento, Aida Pereira

    Cysticercosis is triggered by infection with the larval form of the tapeworm Taenia solium. The usual sites for the development of cyscticerci are the central nervous system (neurocysticercosis – NCC), subcutaneous tissue, skeletal muscle, heart muscle, and the eye. Ocular cysticercosis is caused by the growth of the larvae within ocular tissues. The extraocular muscles form is the most common type of orbital cysticercosis. We report a case of a patient admitted with seizures secondary to NCC, who developed ocular symptoms after starting combined treatment with albendazole, praziquantel and dexamethasone. The investigation revealed a cystic lesion in the lateral rectus muscle.

  • Shuwei Zheng, Cheng Chuan Lee

    We describe a patient with a Salmonella enteritidis mycotic aneurysm. A 91-year-old man presented with recurrent episodes of S. enteritidis bacteraemia 2 months apart. During the second presentation, he underwent magnetic resonance imaging of the left lower limb that revealed rupture of the popliteal artery with a popliteal fossa collection. This was aspirated and cultures grew S. enteritidis. He underwent endovascular stenting and received a prolonged course of antibiotics. Popliteal artery mycotic aneurysm should be considered as a differential in patients presenting with unilateral painful leg swelling and bacteraemia from microorganisms with a propensity for endovascular infections.

  • Pietro Benedetto Faré, Ileana Allio, Rita Monotti, Fabrizio Foieni

    A young woman presented with right upper quadrant abdominal pain exacerbated by movement and breathing. Extensive evaluation revealed no gallstones or any other specific cause. Urine polymerase chain reaction results for Chlamydia trachomatis were positive, so the clinical diagnosis of Fitz-Hugh-Curtis syndrome was confirmed. This type of localized peritonitis is thought to be a complication of an ascending genital infection leading to pelvic inflammatory disease. The diagnosis is established on clinical grounds after excluding alternative, more common conditions. Proper antibiotic treatment usually leads to recovery and prevents long-term complications.

  • Javier Moreno Díaz, David De las Cuevas León, Ana Martinez González, Rebeca Rubio Escuin

    We present the case of a 70-year-old male patient with fever of unknown origin after a long period of convalescence from a previous admission to a chronic care hospital. During the admission, multiple combinations of antibiotic and antifungal treatments were prescribed, but with persistent fever and, eventually, neutropenia (200 lymphocytes, 0 neutrophils). Given the suspicion of infection at bone marrow level, a biopsy was performed as was serology of Leishmania, both diagnostic determinations.
    Treatment with amphotericin B liposomal resulted in a good outcome.