• José Pedro Fonseca, Telma Pereiro, Diana Pinho dos Santos, José Miguel Correia, Joana Capelo, Adelino Carragoso

    Objectives: To report a case of mechanical aortic prosthesis Brucella endocarditis successfully treated with antibiotics alone.

    Materials and methods: We describe a clinical case and present a review of the literature.

    Results: A 60-year-old female farmer with a mechanical aortic prosthetic valve presented with low back pain and fever. She was diagnosed with prosthetic valve Brucella mellitensis endocarditis and was cured with antibiotic therapy alone. Few cases of successfully treated prosthetic valve Brucella endocarditis without surgery have been reported.

    Conclusion: Prosthetic valve Brucella endocarditis usually requires surgical valve replacement. However, selected patients may be successfully treated with antibiotic therapy alone.

  • Muhammad Fahad Arshad, Nasir Javed, Syed Monawer Karim, Ehtasham Ahmad, Noor Ul Ain Abid

    Atraumatic splenic rupture is a rare but potentially life-threatening event. It mostly happens when the spleen is already diseased; however, sometimes it can be drug induced in a previously normal spleen. Although anticoagulation has been attributed to spontaneous splenic rupture quite frequently, the role of dual antiplatelet therapy is underestimated. We report a case of an 80-year-old woman who developed spontaneous splenic rupture 4 weeks after starting dual antiplatelet therapy.

  • Joana Silva Marques, Nuno Monteiro, Ana Nunes, João Machado, João Olivério, Ana Sofia Martins, Antonio Correia

    Background: Hyperkinetic disorders such as hemichorea can be caused by cerebrovascular, infectious or inflammatory diseases or by metabolic conditions such as hyperglycaemia. Hyperglycaemic hemichorea is a rare movement disorder which is frequently misdiagnosed. It is characterized by involuntary, continuous, non-patterned movements on one side of the body, basal ganglia lesions seen on head CT or MRI, and clinical improvement after blood glucose normalization. We describe the case of a female patient with uncontrolled diabetes who presented with hemichorea.

    Case presentation: We report the case of a 69-year-old woman with type 2 diabetes who presented with abnormal movements of the right upper limb. She had no neurological signs other than hemichorea. Her blood glucose level was 349 mg/dl and her glycosylated haemoglobin level (HbA1c) was 10.5%. Head CT and MRI showed no changes in the basal ganglia or ischaemic lesions. The patient was started on insulin and haloperidol with clinical improvement.

    Conclusion: Larger case series are needed to establish better understanding of the physiopathological mechanisms and diagnostic criteria of hyperglycaemic hemichorea. The most important diagnostic criterion is clinical improvement after glycaemic control.

  • Jiten Desai, Zalak Desai, Jay Shah, Ofek Hai, Andrea Mignatti, Roman Zeltser, Amgad Makaryus

    A 56-year-old woman presented with gradually worsening shortness of breath associated with dull left leg pain over 5 days. She denied any recent travel, recent surgeries or immobilization.
    CT pulmonary angiography and CT venography revealed multiple bilateral pulmonary emboli and extensive left pelvic and left lower extremity deep vein thromboses. Contrast-enhanced CT showed that the right common iliac artery crossed the left common iliac vein and compressed it externally, indicative of May–Thurner syndrome. Catheter-directed thrombolysis of the left lower extremity was performed and heparin infusion was started. The patient also underwent left iliac vein balloon angioplasty with stenting and infra-renal inferior vena cava filter placement via the jugular approach to prevent further embolization.

  • Fabio Andreozzi, Giovanni Cominetti, Rafik Karmali, Prochore Kamgang

    A 56-year-old woman presented with cognitive impairment, confusion and slowed speech, muscle cramps and peripheral paraesthesia preceded by vomiting. Blood tests revealed severe hypokalaemia, hyponatremia, hypomagnesemia and hypocalcaemia. Following a diagnosis of Takotsubo cardiomyopathy based on ultrasonography, the patient was treated with electrolyte supplementation and recovered within 48h. When heart failure is suspected, electrolyte abnormalities should be carefully ruled out as they can affect cardiac function.

  • Patrícia Afonso Mendes, Diana Marques Ferreira, Helena Temido, Rui Pina, Armando Carvalho

    The association between mesenteric panniculitis and Sjögren's syndrome, although rare, is starting to be recognized. Usually, mesenteric panniculitis is symptomatic, presenting with either general or gastrointestinal symptoms. Sjögren's syndrome is an autoimmune disease that typically affects secretory glands, but may have serious systemic involvement. We report the case of a 77-year-old patient in whom accidental discovery of asymptomatic mesenteric panniculitis on computed tomography led to the diagnosis of Sjögren's syndrome with several systemic manifestations.

  • Sara Ferreira, Arsénio Barbosa, Filipa Gomes, Jorge Almeida, Jorge Santos Almeida, Mário Amorim, José Paulo Araújo

    Tricuspid stenosis is an uncommon valvular abnormality commonly associated with other valvular lesions. Ebstein's anomaly is a rare congenital heart malformation characterized primarily by abnormalities of the tricuspid valve and right ventricle. Endomyocardial fibrosis is a restrictive cardiomyopathy observed in tropical and subtropical regions. It may cause right ventricular distortion with apparent apical displacement of the tricuspid valve, mimicking Ebstein’s anomaly. Eosinophilia is the most commonly cited aetiological link in endomyocardial fibrosis. Here we report the case of 42-year-old male patient who presented with heart failure and severe tricuspid stenosis where a diagnosis of hypereosinophilic syndrome was also established. This case represented a diagnostic challenge in the search for the definitive cause of the tricuspid stenosis.

  • Marta de Sousa, André Casado, Alexandre Buinhas Marques, Francisco Pereira Machado, Isabel Esperança

    Takotsubo syndrome (TS) is an acute and reversible clinical syndrome characterized by transient hypokinesis of the left ventricular (LV) apex. Variant forms of LV dysfunction have been reported, including inverted Takotsubo syndrome (ITS), which represents only 5% of cases and has previously been linked to excessive use of inhaled adrenergic beta-2 agonists. The authors describe the case of a 60-year-old female patient who was diagnosed with ITS after the excessive use of inhaled adrenergic beta-2 agonists. This case highlights an uncommon variant of this syndrome that may not be obvious and must be suspected in this particular context.

  • Tiago Manuel Mendes

    Objectives: To describe a case of a stroke mimic caused by iatrogenic ataxia due to acetazolamide.

    Case description: An 86-year-old man with a history of gout and glaucoma, presented to the emergency department with progressive confusion, dizziness, disequilibrium and slurred speech, 3 days after he had started acetazolamide following ocular surgery. Physical examination showed he was hypertensive and had dysarthria; it was not possible to observe his gait due to pain in the right foot presumed to be due to a gout crisis. A stroke was thought to be the cause of these neurological deficits so a head CT scan was performed but did not show any alterations. During a stay in the stroke unit the neurological deficits remained unchanged and so, after review of the history, neurological side effects due to acetazolamide were suspected and the drug was suspended. A head MRI was performed to rule out stroke and the patient gradually improved. In the meanwhile, the patient was observed by an ophthalmologist and repeat surgery was proposed because of increased intraocular pressure.

    Conclusions: Neurological deficits with a normal head CT scan in the emergency department pose many difficulties and require extensive knowledge of brain vascular anatomy and the differential diagnoses for stroke.

  • Prisca Theunissen, Mike Kliffen, Ad Dees

    We describe a 58-year-old woman presenting with headache and an elevated erythrocyte sedimentation rate (ESR), who was diagnosed with and successfully treated for giant-cell arteritis (GCA). Seven months after the end of treatment, ovarian GCA was incidentally found after ovariectomy for a simple cyst. GCA of extracranial vessels like the ovarian arteries is rare. Nevertheless, we stress that extracranial GCA should be considered in patients older than 50 years with an elevated ESR, even if a temporal artery biopsy is negative or specific symptoms are absent. Moreover, we discuss the importance of imaging techniques when GCA of the extracranial large vessels is suspected.

  • Zsófia Vesza, Pedro Marques da Silva

    3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are generally safe and well-tolerated drugs that are extensively used for the primary and secondary prevention of atherosclerotic cardiovascular events. Muscle and liver adverse reactions are the best recognized, while cutaneous side effects are exceedingly rare. We present the case of a 65-year-old woman with severe hypercholesterolemia, who developed generalized erythematous cutaneous lesions with pruritus, resembling lichen planus, months after starting treatment with simvastatin. The symptoms disappeared on withdrawal of simvastatin and reappeared within 3 months upon rechallenge with rosuvastatin. In addition to describing a rare adverse effect of statins, the authors also discuss the nutraceutical approach to the management of a statin-intolerant patient.

  • Ahmed Khedher, Khaoula Meddeb, Nesrine Sma, Abdelbaki Azouzi, Nesrine Fraj, Mohamed Boussarsar

    Introduction: Pulmonary interstitial emphysema is a rare finding defined as abnormal air collection inside the lung interstitial tissues. Described more frequently in ventilated new-borns, pulmonary interstitial emphysema is an uncommon barotrauma-related complication in adults. Management and clinical sequelae are poorly described.

    Patient: We describe the case of a 64-year-old man who presented with huge pulmonary interstitial emphysema together with simultaneous pulmonary barotrauma in status asthmaticus requiring invasive ventilation.

    Discussion: There are no guidelines for the management of such complications and their possible sequelae but conservative treatment seems to be effective. The treatment of our patient is described.

  • Abdul-Wahab Al-Allaf, Yousef Yahia

    Kikuchi-Fujimoto disease (KFD) or Kikuchi histiocytic necrotizing lymphadenitis, is an extremely rare, benign and self-limiting disease which can be confused with lymphoma and sometime with infections such as tuberculosis. It has also been infrequently reported in association with autoimmune diseases. KFD shares sex and age predisposition as well as histological features with systemic lupus erythematosus. The co-existence of KFD with primary Sjögren’s syndrome has only been rarely reported. Here we describe the case of a 33-year-old woman who was diagnosed with KFD and also found to have primary Sjögren’s syndrome.

  • Davide Donelli, Lorenzo Morini, Chiara Trenti, Rosaria Santi, Dimitriy Arioli, Emanuele Alberto Negri

    Diabetic ketoacidosis (DKA) can quite frequently present in association with acute pancreatitis (AP) caused by transient severe hypertriglyceridemia (HTG). Here we report the case of a patient presenting with DKA, severe HTG and AP who received urgent plasma exchange for HTG control, and who reached adequate serum triglyceride levels only after appropriate DKA management. The treatment of patients presenting with DKA and coexistent AP associated with severe HTG should focus first on appropriate DKA management. Plasma exchange as a treatment for severe HTG in patients with DKA and AP should be evaluated carefully.

  • Ahmed Khedher, Nesrine Sma, Dorsaf Slama, Nesrine Fraj, Wissem Hachfi, Mohamed Boussarsar

    Introduction: Cerebral vasculitis is an uncommon life-threatening complication of community-acquired bacterial meningitis.

    Patient and methods: We report the case of a 64-year-old woman with pneumococcal meningitis who developed parainfectious vasculitis causing ischaemic brain damage. Cerebral magnetic resonance imaging (MRI) confirmed the diagnosis. Clinical and radiological recovery after delayed addition of corticosteroid was achieved.

    Discussion: This report shows that the onset of neurological deficits following pneumococcal meningitis can be caused by cerebral vasculitis. Underdosing with antibiotics and delayed adjunctive dexamethasone seem to favour this complication. There are no guidelines for treatment but high doses of steroids led to resolution in this case.

  • Andrea Farina, Giorgio Bassanelli, Alfredo Bianchi, Guido Coppola, Stefano Savonitto

    We describe the case of a patient with malignant vasodepressive cough syncope. We demonstrated a vaso-vagal mechanism related to left vagal neuritis, by means of laryngoscopy and laryngeal electromyography. The condition resolved with steroid therapy.

  • João Afonso Rodrigues, Pedro Brogueira, Sara Rodrigues; Margarida Cardoso; Tiago Pack

    Introduction: Haemoptysis is a common symptom which can sometimes mimic gastrointestinal bleeding.

    Case description: We describe the case of a 31-year-old man who presented to the emergency department after an episode of sudden nausea and presumed massive haematemesis. The situation was interpreted as gastrointestinal bleeding but clinical evolution and greater attention to the anamnesis resulted in a diagnosis of pulmonary tuberculosis and the provision of appropriate care.

    Discussion: This report emphasizes the difficulty of differentiating between haemoptysis and haematemesis and the importance of a careful anamnesis and attention to all clinical circumstances for an accurate diagnosis.

  • Sapir Anani, Gad Segal

    Introduction: The combination of acute/sub-acute neurological and metabolic derangements should always raise the suspicion of toxicity, either endogenous or exogenous. The adverse effects of psychiatric medications are especially difficult to determine since the psychiatric background of patients is often inaccessible.

    Clinical Presentation: A 66-year-old man presented to the emergency department with dysarthria and uncontrolled tremor, rapidly deteriorating into a complex of severe neurological and metabolic derangements. Only after repeated attempts to take a thorough history was lithium toxicity identified.

    Conclusion: Thorough, comprehensive history taking, including chronic medications and their substitutes, is essential and lifesaving when potentially lethal medications are involved.

  • Izzat Khanjar, Ibrahim Abdulmomen, Yousef Yahia, Abdul-Wahab Al-Allaf

    Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiological entity with many causes. The primary abnormality is cerebral vasogenic oedema. Here we describe the management of five patients with PRES syndrome who presented to our hospital.

  • Steeve Neves Rosado, Vera Silveira, Ana Isabel Reis, André Gordinho, Carla Noronha

    Primary Sjögren’s syndrome (SS) is a chronic, systemic autoimmune disease, most commonly presenting with sicca symptoms—xerostomia and xerophthalmia. Up to one-half of affected individuals also develop extra-glandular involvement. Early diagnosis is important to prevent further complications. This paper describes an atypical case of SS in a 21-year-old woman who presented first with neuropsychiatric symptoms and fever. She was diagnosed and treated for a presumed psychotic episode. However, because she remained febrile, a thorough investigation resulted in the challenging diagnosis of SS.

  • Ricardo Jorge Gonçalves Fernandes, Márcia Leite, Joana Cochicho, Rafaela Veríssimo, Agripino Oliveira

    Chylous ascites is rare and results in accumulation of lymph in the abdominal cavity, due to several mechanisms. The ascitic liquid is milky because of the high concentration of triglycerides (>200 mg/dl). The higher incidence compared to the past is explained by increased survival of patients with cancer and more aggressive surgery. We describe the case of an 87-year-old man admitted to the geriatric ward due to general oedema, chylous ascites and loss of weight, explained by mantle cell lymphoma.

  • Matteo Traversa, Andrea Collini, Paola Villois, Fabrizio Elia, Andrea Verhovez, Franco Aprà

    Background: Hydrochlorothiazide (HCTZ) is one of the most popular drugs for the treatment of hypertension and heart failure. Most of its side effects are harmless and predictable, but some studies report a few life-threatening reactions to this drug, one of the most dangerous being acute pulmonary oedema.
    Case Report: A 73-year-old woman was admitted to the Emergency Department with acute respiratory failure due to pulmonary oedema. Her past medical history included long-lasting hypertension with permanent atrial fibrillation and mitral stenosis. Her blood pressure control had been suboptimal, so her cardiologist had changed amlodipine to combination therapy with ramipril and HCTZ. However, 20 min after taking the new drug, the patient experienced fever, vomiting and diarrhoea immediately followed by acute onset of dyspnoea.
    Conclusion: Since HCTZ is one of the most popular drugs for hypertension treatment and millions of patients take it every day, it is important to keep in mind both the common adverse reactions as well as the dangerous, although rare, ones.

  • Imen Gargouri, Benzarti Wafa Hergli, Sana Aissa, Samia Kanoun-Belajouza, Abdelaziz Hayouni, Abdelhamid Garrouche, Ahmed Abdelghani, Mohamed Benzarti

    Gingival metastasis of lung cancer is uncommon. We report the case of an 82-year-old male smoker admitted to the pulmonology department with right pleural effusion. A chest computed tomography (CT) scan showed an invasive right hilar tumour, adherent to the superior vena cava, pulmonary artery, main right bronchus, mediastinal pleura and pericardium with lymphangitic carcinomatosis of the right lung. Pleural biopsy revealed pleural metastasis of pulmonary adenocarcinoma, its primary lung origin being confirmed by immunohistochemistry. One month later, the patient developed an ulcerated polypoid gingival mass. Biopsy of this lesion showed a poorly differentiated carcinoma compatible with metastasis from the lung adenocarcinoma. The patient underwent irradiation of the gingival mass at a dose of 30 Gray, but his condition worsened rapidly and he was not fit for chemotherapy. He received palliative treatment and died 2 months after diagnosis of his metastatic lung cancer.

  • Maria Margherita Rando, Giuseppe De Matteis, Marco Gessi, Matteo Bartoli, Marco Galli, Giovanni Gambassi

    Tuberculosis (TB) is an infectious disease caused by the Mycobacterium tuberculosis complex (MTBC). Pulmonary TB is the most common form of presentation, but extrapulmonary tuberculosis (EPTB) contributes significantly to morbidity and mortality. Rarely, patients with EPTB develop a form of ankle or foot arthritis. The diagnosis of TB arthritis is often overlooked because of the insidious onset and the non-specific clinical symptoms. Prognosis is generally poor; early diagnosis and delivery of the most appropriate treatment is critical to avoid functional disability.

  • Diego Martínez, Maria Teresa Belmonte, Piotr Kosny, Maria Rosario Gómez, Diego Hellín

    We describe the incidental finding of an aneurysm of the left branch of the portal vein in a patient without liver pathology. The diagnosis was confirmed by Doppler ultrasound.


  • Toni El Murr, Ricardo El Nouwar

    Primary hepatic lymphoma (PHL) is a rare variant of non-Hodgkin's lymphoma. Diffuse hepatic involvement is uncommon and therefore presentation as progressive hepatitis or acute fulminant hepatic failure is rare. Acute onset of signs and symptoms can mimic a variety of infectious and inflammatory disorders, thus delaying the diagnosis. A high index of suspicion and liver biopsy early in the course of liver dysfunction may establish the diagnosis and allow rapid initiation of chemotherapy to prevent a fatal outcome. In this report, we describe a rare case of fulminant primary hepatic diffuse large B-cell lymphoma in a 55-year-old woman who died 2 weeks after admission, before the initiation of chemotherapy.