• Shaul Yaari, Elchanan Juravel, Murad Daana, Samuel Noam Heyman

    Stab-like localized chest pain, aggravated by breathing, is compatible with pleuritic pain or with aching related to chest wall abnormalities. Local tenderness inflicted by palpation helps to differentiate pleuritic from musculoskeletal chest pain and serves as a principal accessory manoeuvre in the algorithm of chest pain evaluation.
    Herein, we report the case of a 27-year-old patient with pulmonary thromboembolism and right lower lobe consolidation/atelectasis. The patient presented with right-sided chest pain, radiating to the shoulder, related to pleural irritation, yet associated with confounding intense chest wall tenderness and guarding, also involving the costovertebral angle. We propose that spinal reflex-related chest wall tenderness was involved, similar to peritoneal signs evoked by irritation of the parietal peritoneum.
    This case report illustrates that localized chest wall tenderness and guarding, triggered by palpation, may not serve as unequivocal indicators of musculoskeletal pain, and could be unrecognized features of pleuritic chest pain also.

  • Tulika Chatterjee, Johnathon Stephens, Moni Roy

    Segmental arterial mediolysis (SAM) is a non-inflammatory, non-atherosclerotic vasculopathy mostly involving the abdominal arteries. SAM was recently recognized as a more prevalent aetiology of abdominal pain than initially thought by healthcare providers. It is still a commonly missed diagnosis in patients with recurrent emergency room (ER) visits for abdominal pain. Most published case reports in the past have highlighted catastrophic sequelae such as intra-abdominal haemorrhage requiring surgical intervention. We report a case of SAM where the diagnosis was initially missed. After diagnosis, conservative medical management was offered which led to clinical improvement.

  • Kevin Kim-Jun Teh, Albert Su-Chong Low, Jason Pik-Eu Chang, Chee-Kiat Tan

    Patients with liver cirrhosis are at increased risk of developing hepatocellular carcinoma (HCC) and are placed on routine surveillance for HCC. Diagnosis algorithms are in place to guide clinicians in the evaluation of liver lesions detected during surveillance. Radiological assessments are critical with diagnostic criteria based on identification of typical hallmarks of HCCs on multiphasic computed tomography (CT) and dynamic contrast-enhanced magnetic resonance imaging (MRI). We report a patient with a hypervascular exophytic lesion indeterminate for HCC on CT imaging. While the detection of an exophytic arterially-enhancing lesion in an at-risk patient on CT imaging may prompt clinicians to treat the lesion as HCC without further evaluation, the patient underwent contrast-enhanced MRI with the lesion being eventually diagnosed as an exophytic haemangioma. Thus, no further action was necessary and the patient was continued on routine HCC surveillance.

  • Evelien De Roo, Frederik Van Durme, Laurent Vanneste, Becker Alzand, Alex Heyse

    Persistent left superior vena cava (PLSVC) is a congenital venous abnormality, characterized by an enlarged coronary sinus, in most cases without haemodynamic consequences. We report the case of a patient with systolic heart failure undergoing implantation of a defibrillator lead through a PLSVC which was diagnosed at the moment of implantation.

  • Cristina Pires Correia, Inês Neves, Paulo Chaves, Teresa Cardoso, Roberto Silva, Jorge Almeida

    Phenylketonuria (PKU), the most common inborn error of amino acid metabolism, has been associated with an increased risk of renal impairment, the reason for which is not fully understood. We report the case of a 33-year-old female patient diagnosed with PKU in adulthood after suspicion of the disease in her daughter. The diagnostic approach revealed proteinuria, and minimal change disease (MCD) was identified. Therapeutic measures and follow-up are discussed. The possible link between these two disorders is interesting. Attenuated developmental delay of untreated PKU could be explained by the decreased accumulation of phenylalanine secondary to proteinuria. On the other hand, MCD may be a possible, although as yet unreported, pathophysiological mechanism explaining the renal repercussions that have been found in adult PKU patients, who should be screened for proteinuria.

  • Marta Mejias Trueba, Marta Alonso Moreno, Noemi Garrido Puñal, Maria Soriano Martinez

    Tumor necrosis factor (TNF) receptor-associated periodic syndrome (TRAPS) is a rare hereditary systemic autoinflammatory disease (SAID). Treatment is based on corticosteroids, but often requires the addition of a biologic drug (anti-TNF agent, IL-1 receptor antagonist, etc) to achieve symptom control. The addition of the second drug is not clearly defined and must take into account the characteristics and preferences of the patient. We describe a patient with TRAPS and an allergic reaction to anakinra which was difficult to manage clinically while alternative treatment was being identified.

  • Ana Ferreira, Mariana Serino Barbosa, Rita Coelho, Patrícia Lourenço

    Hypoglycaemia is rare in apparently well patients without drug-treated diabetes mellitus and warrants evaluation and management when Whipple’s triad is present. Even in the absence of Whipple’s triad, when repeatedly low values of plasma glucose are documented, the presence of endogenous hyperinsulinism should be investigated. The authors describe a case of endogenous hypoglycaemic hyperinsulinism, its diagnosis and treatment and the challenges of determining its aetiology.

  • Mohammad Ammad Ud Din, Syed Ather Hussain, Bassil Said, Aneeqa Zafar

    A 44-year-old woman with no significant medical history presented with a 3-week history of high-grade fevers, fatigue and shortness of breath. Laboratory investigation was significant for lymphopenia and thrombocytopenia which progressively worsened during her hospital stay, along with new-onset anaemia, and elevated ferritin, transaminase and triglycerides. A computerized tomography (CT) scan of the abdomen revealed retroperitoneal lymphadenopathy. A bone marrow biopsy confirmed the diagnosis of haemophagocytic lymphohistiocytosis (HLH). Extensive infectious work-up revealed high IgG titres for Bartonella henselae and Coxiella burnetii. Interestingly, the left supraclavicular node was negative for both microbes by polymerase chain reaction (PCR), but the biopsy revealed anaplastic large T-cell lymphoma.

  • Jahanzeb Malik, Uzma Ishaq, Nismat Javed, Mirza Adnan Baig, Muhammad Javaid

    Warfarin is a readily available anticoagulant used worldwide in a variety of clinical scenarios. Patients who need more than 15 mg/day are considered to be warfarin resistant. Numerous genes have been implicated in warfarin pharmacogenetics, with genes encoding CYP2C9 and VKORC1 shown to be the most important determinants of drug dosage requirements. A 27-year-old woman was admitted as she had a sub-therapeutic international normalized ratio (INR) after prosthetic mitral valve replacement. Even after a warfarin dose of 50 mg/day, her INR was not in the therapeutic range, so the heart team decided to replace her metallic valve with a bioprosthetic valve, thus alleviating the need for anticoagulation.

  • Maria Inês Silva, Clara Matos, Fabio Correia, Sofia Carola, Maria João Gomes, Teresa Branco

    Rendu-Osler-Weber syndrome is a rare inherited syndrome with autosomal dominant transmission characterized by systemic arteriovenous malformations (AVMs) with multi-organ involvement. Its incidence is 1–2/100,000 and it is predominant in females (the male/female ratio varies from 1:2 to 1:4.5).Clinical manifestations and complications are related to recurrent bleeding and, in some cases, the development of end-organ failure. Management is mostly supportive care and it is essential to promote control of the disease as much as possible and screen eventual complications.

    We describe the case of a 67-year-old male patient with Rendu-Osler-Weber syndrome admitted to the emergency department with decompensated heart failure due to acute anaemia because of severe epistaxis. During hospitalization, the patient progressed to acute-on-chronic liver failure with hepatic encephalopathy and an abdominal computed tomography scan showed multiple hepatic AVMs considered to be the cause of the chronic liver disease.

  • Rehab Yusuf AL-Ansari, Maan Al Harbi, Nawaf Al-Jubair, Leena Abdalla

    Background: Sickle cell disease is a genetic condition frequently found in Africa and the Arabian Peninsula. Uncommon complications include subgaleal haematoma (soft head syndrome) and periorbital oedema.
    Case presentation: A 17-year-old male patient presented with body aches and progressive right parieto-temporal and frontal head swelling. Physical examination revealed puffiness of the right eye that progressed rapidly to reddish periorbital oedema sparing the extraocular muscle and pupil response to light. CT and MRI of the brain suggested multiple subgaleal haematomas (soft head syndrome) and right periorbital oedema.
    Conclusion:Subgaleal haematoma (soft head syndrome) and periorbital oedema are uncommon complications of sickle cell disease. Management is conservative rather than surgical.

  • Camila da Silva Cendon Duran, Mittermayer Barreto Santiago

    Secukinumab is an inhibitor of interleukin IL-17A, and is mainly used in the treatment of psoriasis, psoriatic arthritis and ankylosing spondylitis. Although rarely, this drug may induce paradoxical reactions, such as cutaneous vasculitis. Worldwide, only four previous cases of vasculitis induced by secukinumab have been reported. We herein report the first case described in Brazil of cutaneous vasculitis due to secukinumab in a patient with peripheral spondyloarthritis who demonstrated good resolution after withdrawal of the drug and initiation of etanercept. Clinicians should be aware of this rare but potentially serious adverse effect of secukinumab.

  • Ana Teresa Marques Afonso, Montserrat Rodríguez Framil, Joaquín Sánchez Leira, Néstor Vázquez Agra, Federico García-Rodeja Arias

    Bacille Calmette–Guérin (BCG) administration for superficial bladder cancer is a well-tolerated and very effective therapy. However, unpredictable systemic complications may occur on rare occasions. We present the case of a patient who attended for consultation because of fever, asthenia and weight loss following BCG immunotherapy. The clinical response to treatment and computed tomography scanning were key to diagnosis.

  • Felipe Peña-Muñoz, Ernesto Parras, Olga Compan, Nora Gutierrez, Celestino Martin, Jose Ramon Gonzalez-Porras, Jose Maria Bastida

    Acquired haemophilia A (AHA) is a rare autoimmune disorder caused by an autoantibody against any circulating coagulation factor, especially factor VIII (FVIII). The lack of awareness of this condition suggests that diagnosis is a challenge and usually delayed, which leads to suboptimal treatment. Consequently, early diagnosis is mandatory to prevent potentially life-threatening bleeding complications. We present the case of an 85-year-old woman admitted to hospital with symptoms of respiratory infection who 12 hours later developed haematuria which required transfusion. Laboratory assays showed an isolated prolonged aPTT, a moderately reduced FVIII and a high inhibitor titre. Influenza A and Escherichia coli were also identified. Antivirals, antibiotics, immunosuppressive drugs and haemostatic agents were started. Two weeks later, the inhibitor was not detected, and bleeding and symptoms of infection had resolved. Immunosuppressive drugs were stopped on day 45 and there has been no recurrence since then. To date, no FVIII inhibitors have been reported in concomitant infection with influenza A and urinary E. coli. The identification of conditions potentially associated with AHA is essential to achieve complete remission.

  • Ossama Maadarani, Zouheir Bitar, Sania Shoeb, Jadan Alsaddah

    Wellens syndrome (WS) is identified by ECG changes in the precordial leads after resolution of angina chest pain. WS indicates critical stenosis of the proximal left anterior descending (LAD) artery. On the other hand, Kounis syndrome (KS) is an allergic reaction to various substances resulting in acute coronary syndrome. Contrast media can trigger the allergic reaction associated with KS. We describe a patient with WS who developed an allergic reaction to contrast media after percutaneous coronary intervention and experienced recurren myocardial infarction on re-exposure.

  • Asis Mitra, Saswati Ray

    Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease and has emerged as a serious public health challenge. About 20% of NAFLD patients may have low titres (<1:320) of antinuclear antibodies (ANA). However, we describe a patient with NAFLD whose ANA titre was high (>1:320) on presentation. After 3 months of diet, exercise and vitamin E supplementation,the patient was symptomatically better but her ANA titre had increased (>1:640). Her liver biopsy showed features of NAFLD with minimal fibrosis. High-titre ANA (>1:320) positivity is rare. Our patient showed a progressive rise in ANA titre from >1:320 to >1:640 within 3 months even though she was improving and histology showed minimal fibrosis.

  • Abu Baker Sheikh, Abhilash Perisetti, Nismat Javed, Rahul Shekhar

    Eribulin is an antineoplastic agent used in advanced breast cancer refractory to anthracycline and taxane treatment regimens. A wide variety of side effects with unclear mechanisms have been noted, but encephalopathy has not been widely reported. Here we describe the case of a middle-aged woman treated with eribulin for advanced breast cancer who subsequently developed central nervous system drug-induced toxicity but improved promptly with steroid administration.

  • Rodrigo Maia Alves, Cristina Gamboa

    Cardiac lipomas are rare benign primary neoplasms of the heart, usually found incidentally, that can become symptomatic depending on their size and location. We report the case of a 61-year-old man presenting with chest pain and elevated troponin and a normal EKG and D-dimers. A transthoracic echocardiogram revealed an intracardiac mass attached to the interventricular septum protruding to the left ventricle, later confirmed to be a lipomatous mass consistent with a cardiac lipoma on cardiac magnetic resonance imaging. Due to the mass characteristics and favourable evolution, it was decided not to excise the tumour, and the patient remains asymptomatic after a 4-year follow-up period.

  • Imran Yaseen Gani, Rajan Kapoor, Muhammad Irfan Saeed

    Heparin is commonly used in clinical practice for the prevention and treatment of various thrombotic conditions. Its use can be associated with bleeding which can range from minor to life threatening. Non-traumatic causes of breast haematoma are very rare. We report a case of spontaneous bleeding into the breast in a female patient who was anticoagulated with heparin.

  • Alice V Bevan, Duncan J Napier, Alexandra Di Mambro

    Fatal hepatotoxicity associated with ciprofloxacin is extremely rare. This is the second fully investigated case of fulminant hepatotoxicity due to ciprofloxacin in a male patient previously ciprofloxacin tolerant. The patient’s medical history included stable Waldenstrom’s macroglobulinaemia, inguinal hernia repair, prostate cancer (radiotherapy in 2006) and idiopathic Parkinson’s disease. Extensive investigation for progressive liver failure confirmed drug-induced liver injury.

  • Yuto Nakakubo, Kazuyo Yamamoto, Masaaki Fujita

    Acquired haemophilia is a bleeding disorder caused by antibodies against coagulation factors. Some cases are associated with autoimmune diseases. However, no cases of acquired haemophilia with eosinophilic fasciitis have been previously reported. Herein we describe the case of a patient with eosinophilic fasciitis associated with acquired haemophilia.

  • Pedro Pimentel Duarte, Rafaela Sousa, Mariana Chaves, Natacha Amaral, César Lourenço

    Inflammatory myofibroblastic tumour (IMT) is a rare mesenchymal tumour. It is usually benign but may behave as a malignant tumour with multiple recurrences and metastases. We present the case of a young woman with weight loss associated with diffuse abdominal pain, who was shown to have a large pancreatic mass. Investigation revealed fusocellular mesenchymal neoplasia, compatible with the diagnosis of IMT. As the mass was unresectable, glucocorticoid therapy was initiated with an excellent response and regression of the tumour.

  • Motoi Ugajin, Nobuo Ishiguro, Hisanori Kani, Hideo Hattori

    An 81-year-old man complaining of exertional dyspnoea underwent coronary angiography using an iodinated contrast medium. After angiography, the patient required systemic corticosteroid therapy because of respiratory failure due to alveolar haemorrhage. Percutaneous coronary intervention was performed 29 days after angiography using the same contrast medium. After the intervention, the patient required intubated mechanical ventilation and renal replacement therapy. Bronchoalveolar lavage was bloody with many haemosiderin-filled macrophages. Systemic corticosteroid therapy again improved his clinical condition. Iodinated contrast media may cause alveolar haemorrhage and re-exposure to contrast media may induce a more severe adverse reaction.

  • Maria Joao Gomes, Ana João, Inês Bargiela

    Body packing was first described in 1973 and refers to the intracorporeal concealment of illegal drugs, which are swallowed or placed in anatomical cavities and/or body orifices. The body packer can be asymptomatic or can have signs of systemic drug toxicity (neurological, cardiac, abdominal, renal and cutaneous) due to rupture of the packet(s) or symptoms of gastrointestinal obstruction or perforation. The diagnosis is established based on a suggestive history, findings on physical examination and laboratory findings and/or imaging. The vast majority of patients are asymptomatic and are treated conservatively. However, complex situations may require surgical intervention. We present a case of a 50-year-old man who was admitted in the emergency department with a generalized tonic-clonic seizure and vomiting with plastic film, which raised the suspicion of foreign body ingestion, confirmed by imaging and laboratory tests. He underwent exploratory laparotomy to remove the packages.

  • Aws Alameri, Alsadiq Al Hillan, Abdulrahman S. Museedi, Ahmed Oglah, Mohammed Alkhero, Sadie Trammell Velásquez

    Emphysematous gastritis is a rare but fatal variant of gastritis. It is caused by gastric wall invasion by gas-forming organisms. It follows disruption of gastric mucosal integrity by a variety of factors, most commonly caustic ingestion and alcohol abuse. Patients typically present with abdominal symptoms with features of septic shock. Emphysematous gastritis carries a high mortality rate warranting early intervention with supportive measures and broad-spectrum antibiotics. It is essential to consider this rare entity in the differential diagnosis of a patient presenting with abdominal pain as timely intervention is crucial for survival.

  • Giovana Ennis, Gabriela Venade, Joana Silva Marques, Paulo Batista, Ana Abreu Nunes, Júlio Constantino, Luis Costa Matos

    The authors present the case of a 51-year-old woman with no history of surgical or traumatic injury or accident, who presented with right hypochondrium and epigastric discomfort, malaise, nausea, loss of appetite and episodes of dark urine and greenish stools. Initial laboratory work-up revealed elevated inflammatory markers including leucocytosis with left shift and C-reactive protein, and a slight elevation of gamma-glutamyltransferase and alkaline phosphatase, with no other significant alterations. Computed tomography (CT) showed intrathoracic acute cholecystitis with a large diaphragmatic hernia.
    A literature search revealed only one other case of acute cholecystitis complicated by intrathoracic gallbladder due to a non-traumatic diaphragmatic hernia. Symptoms are uncharacteristic and the absence of pain or fever, explained by the altered location of the gallbladder, makes the diagnosis a challenge.

  • Ekaterini Tavernaraki, Sofia Athanasiou, Pavlos Ampatzis

    Uterine leiomyomas are very common gynaecological benign tumours. Spontaneous torsion of a uterine subserosal leiomyoma is a rare cause of acute lower abdominal pain and should be treated immediately with surgery. We report a case of an enlarged subserosal leiomyoma that was first detected by computed tomography (CT) and further confirmed by laparoscopic surgery to be a subserosal leiomyoma with torsion.

  • Natassja Moriarty, Nadeem Attar

    Objective: We present a case of a 22-year-old bodybuilder diagnosed with myocarditis secondary to clenbuterol use.
    Results: The patient was primarily managed conservatively by the discontinuation of clenbuterol and the temporary use of dual anti-platelets, beta-blockers and nitrates.
    Conclusion: Clenbuterol is a long-acting beta-2 agonist primarily used in veterinary medicine. In recent years, it has been illegally marketed as a weight loss supplement because of its anabolic properties and is popular among fitness enthusiasts. It is our aim to use this case to underscore the adverse effects of this drug with hopes that tighter regulations will be instituted to stem its illegal distribution.

  • Joaquín Escobar-Sevilla, Antonio Bustos Merlo, Juan Diego Mediavilla Garcia, Carmen Garcia Martínez

    Reactivation of human parvovirus B19 is exceptional and characteristic of immunosuppression, with anaemia being the predominant manifestation although pancytopenia and thrombotic microangiopathy may also occur. We describe a patient with a history of diffuse large B-cell lymphoma with pure erythrocyte aplasia due to reactivation of parvovirus B19, who was treated with corticosteroids and immunoglobulins.

  • Abu Baker Sheikh, Nismat Javed, Karl Stoltze

    Diffuse dermal angiomatosis is a benign vascular disorder suspected in patients with cardiovascular risk factors. We report the case of a 62-year-old woman with a non-healing hip wound but no significant cardiovascular risk factors, who was found to have diffuse dermal angiomatosis on biopsy leading to the diagnosis of severe peripheral vascular disease. Her wound healed after revascularization.

  • Napohn Chongprasertpon, Santhosh David

    We describe a case of coronary artery embolism leading to an out-of-hospital cardiac arrest (OHCA) in which the diagnosis was achieved with utilisation of cardiac magnetic resonance imaging. The patient was otherwise well prior to this episode. Emergency diagnostic coronary angiography revealed patent arteries with TIMI 3 flow. Subsequent cardiac magnetic resonance imaging demonstrated myocardial infarction and focal microvascular obstruction in the infarcted territory. This report describes an uncommon case presentation, highlights areas for improvement in diagnostic criteria, and briefly discusses the currently available data regarding coronary artery embolism.

  • Margarida Oliveira, Sofia Monteiro, Joana dos Santos, Ana Catarina Silva, Rute Morais Ferreira

    Pericardial effusion represents a diagnostic challenge. Erdheim-Chester disease (ECD), though a rare cause, should be considered in the differential diagnosis. An 88-year-old woman was admitted to the hospital due to retrosternal pain, dyspnoea and constitutional symptoms. Hypoxaemic respiratory failure and increased inflammatory markers were documented. A chest x-ray revealed an increased cardiothoracic ratio. An echocardiogram showed a moderate-volume pericardial effusion, without signs of cardiac tamponade. A thoraco-abdomino-pelvic CT scan found a bilateral perirenal soft tissue halo. Perirenal mass biopsy showed diffuse infiltration by foamy histiocytes (CD68+), without IgG4, compatible with ECD. The correlation of anamnesis, radiology and histology is crucial for the diagnosis of ECD.

  • Dimitrios Anyfantakis, Fani Katsanikaki, Serafim Kastanakis

    Spontaneous, non-traumatic intra-cerebral haemorrhage is the second most common type of stroke and is associated with significant morbidity and mortality. It is defined as the presence of blood within the cerebral parenchyma without prior injury or surgery. The purpose of this work is to describe an atypical presentation of spontaneous intra-cerebral haemorrhage in a healthy young adult. A literature review was also carried out.

  • Julio César Martínez, Ernesto Alfonso Ovalle-Zavala

    Thyroid storm is a rare, life-threatening condition that can be caused by various pathologies including serious conditions associated with human chorionic gonadotropin (hCG)-producing tumours.
    We present the case of a 17-year-old male patient with a 1-month history of dyspnoea and a 3-day history of palpitations and fever. General examination revealed a left testicular mass. Blood tests revealed ?-hCG >225,000 mIU/ml, thyroid-stimulating hormone (TSH) 0.02 IU/ml, and thyroxine (T4) 19.07 µg/dl. He was admitted with thyroid storm. Treatment with antithyroid drugs and chemotherapy was started, but the patient died on the third day of admission.
    This case highlights a rare occurrence of thyroid storm linked to testicular choriocarcinoma, and provides a necessary reminder that, in some instances, hCG at very high levels can exert a thyrotropic effect due to its molecular structure, which is similar to that of TSH.

  • Luisa Costantini, Marco Marando, Pietro Gianella

    Tuberculosis (TB) is a cause of ill health and death worldwide. Since 2010, the diagnostic process has strongly relied on GeneXpert assays on biological specimens. Xpert MTB/RIF is an automated nucleic acid amplification test (NAAT) for Mycobacterium tuberculosis and rifampicin resistance, endorsed by the World Health Organization and the US Food and Drug Administration. Xpert is used in many countries as the initial diagnostic test for tuberculosis. Nevertheless, the reliability of GeneXpert positive tests in patients with a history of TB is largely unknown, due to possible false-positive results (i.e., GeneXpert-positive but culture-negative patients). We present a case report of a patient with a history of pulmonary TB, who was GeneXpert positive but culture negative on bronchoalveolar lavage 22 months after completion of appropriate antitubercular therapy.

  • Aleksandar Stepanović, Marina Nikitović, Andrija Bogdanović, Danica Grujičić

    We describe long-lasting and incompletely resolved thrombocytopenia after transient profound pancytopenia in a 62-year-old female patient with glioblastoma after short-term radiotherapy with temozolomide. Pancytopenia was present for more than 4 weeks and thrombocytopenia for more than 6 months, without platelet recovery to normal levels.

  • Anouk Le Goueff, Nicolas Mavroudakis, Benjamin Mine, Olivier De Witte, Gauthier Remiche

    Spinal dural arteriovenous fistulas (SDAVFs) are often misdiagnosed as their symptoms are non-specific, leading to treatment delay and a poor outcome.
    We describe the case of a 53-year-old man with a history of progressive paraparesis that worsened abruptly after an epidural corticosteroid injection. We highlight here the need for high diagnostic suspicion for an SDAVF in patients deteriorating after an epidural injection and an indication of repeated spine imaging in such cases.
    Finally, this is the first reported case of an SDAVF in a HIV-positive patient and it emphasizes the need for a broad differential diagnosis.

  • Neeraja Swaminathan, Francisco Aguilar

    In this case, a 76-year-old female presented with 3–4 days of fever with no other localizing signs. Notably, she had had an untreated Fusobacterium bacteraemia approximately 8 weeks prior to admission. She underwent abdominal imaging which demonstrated a liver abscess and had percutaneous drainage of the same. Blood and pus cultures both grew Fusobacterium nucleatum, which is an unusual organism to be associated with a liver abscess, especially in an immunocompetent host with no risk factors for this condition. Interestingly, this patient did not have any history of dental work, instrumentation, liver function test (LFT) abnormalities and no extrahepatic source for the abscess. This case highlights the importance of having a high index of clinical suspicion for an occult source of infection and emphasizes the importance of following up on cultures even after discharge of a patient, since anaerobic infections such as those caused by Fusobacterium can have a largely indolent course.

  • Diana Pinho dos Santos, Marlene Delgado, Adelino Carragoso

    The authors present a case of phantom tumour of the lung. This is a type of pleural effusion where fluids accumulate in the interlobar fissures, typically in the transverse fissure. Its prompt recognition avoids additional, unnecessary or expensive examination and treatment mistakes.

  • Sherif Monib, Kevin Seebah

    Subungual squamous cell carcinoma (SCC) is a rare malignant tumour with an indolent course and unknown aetiology. It is usually misdiagnosed as a benign lesion, resulting in delayed treatment. Although psoriasis is not a precancerous skin condition, the treatment modalities cyclosporine and psoralen with ultraviolet A (PUVA) might increase the risk of developing cutaneous SCC, although a relationship has not been confirmed.
    We describe a patient with psoriasis who had been treated with cyclosporine and PUVA 6 years previously. He developed back SCC 2 years later, a subungual skin lesion after another 2 years and presented to us 1 year later, when nail elevation and biopsy revealed SCC.

  • Hui Boon Tay, Stanley Angkodjojo, Zhi En Amos Tay, Puay Hoon Tan, Yan Denise Tan

    New-onset systemic lupus erythematosus (SLE) is uncommon in elderly patients. We report the case of a 71-year-old woman who was diagnosed with SLE based on clinical manifestations of fever, alopecia, bicytopenia, hepatomegaly, lymphadenopathy, glomerulonephritis, positive antinuclear antibody (ANA) and anti-double stranded DNA (anti-dsDNA) antibody. Renal biopsy was consistent with lupus nephritis and excision biopsy of a right inguinal lymph node was initially reported as having features of reactive hyperplasia. However, a more careful review of the lymph node biopsy subsequently confirmed a concurrent angioimmunoblastic T-cell lymphoma. This case illustrates the importance of investigating secondary causes and possible alternative diagnoses in patients who present with atypical features of connective tissue disease, and the challenges in diagnosing a rare form of lymphoma.

  • Moni Roy, Ashish Kumar Roy, Jan Nalinee Upalakalin, Sharjeel Ahmad

    Disseminated histoplasmosis is most commonly caused by Histoplasma capsulatum and is a known opportunistic infection in immunocompromised patients. The clinical presentation of histoplasmosis varies from asymptomatic to a progressive disseminated form. Pulmonary and CNS involvement is common in disseminated histoplasmosis. Rarely, disseminated disease can present as vulvar lesion in the absence of pulmonary symptoms, causing a delay in diagnosis. As per our PubMed literature search, there have only been two reported cases where vulvar lesion was the only presenting symptom of disseminated disease. In our patient, a histopathological diagnosis was made with staining showing budding yeast forms of histoplasma.

  • Subash Ghimire, Kriti Suwal, Tsujung Yang, Hafiz Khan, Matthew Lincoln

    Introduction: Recurrent deliberate sharp foreign body ingestion is associated with frequent hospitalizations and a high risk of complications, including perforation and peritonitis. These patients require urgent care. In addition, removal of foreign bodies can be challenging.
    Case Description:We describe the case of a patient with borderline personality disorder who was admitted multiple times with sharps ingestion and presented challenges with her care.
    Conclusion: Our case highlights the cause of recurrent sharps ingestion and provides recommendations on the retrieval of sharp foreign bodies and prevention.

  • Brian Cheung, Abhijit Shivkumar, Ahmed Ahmed

    Background: Non-bacterial thrombotic endocarditis (NBTE) is a paraneoplastic phenomenon with sterile vegetations. It is associated with adenocarcinoma and can shower emboli, which can be the presenting symptom.
    Case Presentation: A 44-year-old woman with adenocarcinoma of the lung presented with chest pain, left hand weakness, and ataxia due to repeated embolic showering from NBTE to the central nervous system (CNS) and spleen.
    Conclusion: NBTE is a rare condition that should be on the differential diagnosis in patients with culture-negative endocarditis and a history of adenocarcinoma.

  • Christian Neumann, Rene Kaiser, Judith Bauer

    Toxic shock syndrome (TSS) is a rare inflammatory response syndrome associated with an infection by toxigenic strains of Staphylococcus aureus or group A ?-haemolytic Streptococcus. We report a rare case of menstrual TSS associated with usage of a menstrual cup. The diagnosis was established through case definition criteria and supported by vaginal cultural growth of Staphylococcus aureus with evidence of TSS toxin 1 (TSST-1). The patient received prophylactic intravaginal clindamycin in an individual approach to reduce the risk of recurrence. No relapse was reported in the 12 months following discharge.