• Joana Cordeiro e Cunha, Ana Lima Silva, Renato Maia Nogueira, Diana Silva Fernandes, Tatiana Salazar, Maria Vilela, Jorge Salomão

    Non-polio enteroviruses are ubiquitous viruses responsible for a wide spectrum of disease in people of all ages, although infection and illness disproportionately affect infants and young children. Hand-foot-mouth disease (HFMD) is an enteroviral clinical syndrome most frequently caused by coxsackievirus-A16 and enterovirus-A71. Since 2008, a novel coxsackievirus-A6 genotype has been associated with more severe HFMD in both children and adults, presenting with a unique constellation of findings, and whose prevalence has been increasing over the last few years. In this case report, an atypical clinical picture of confirmed enterovirus HFMD is described in an immunocompetent adult, with exuberant clinical findings, clinically consistent with coxsackievirus-A6 infection. This case report highlights the importance of awareness of the clinical presentation of this increasingly common infection in adults.

  • Susana Lemos Cabral, Nuno Deveza, João Pedro Baptista, Paulo Martins

    Patients with Strongyloides stercoralis infections are usually asymptomatic but massive hyperinfection may occur in patients with diseases associated with abnormal cell-mediated immunity or receiving immunosuppressive therapy.
    The authors present the clinical case of a 49-year-old man with a history of diarrhoea and cramping abdominal pain, generalized oedema, petechial rash, melanoderma, cough and dyspnoea. He presented hypokalaemia and arterial hypertension and was admitted with the diagnostic hypothesis of Cushing’s syndrome or adrenocorticotropic hormone ectopic production. The patient developed respiratory failure associated with bilateral lung opacities and was admitted to the Intensive Care Unit. The abdominal computed tomography scan revealed liver and duodenal masses. The duodenal biopsy showed the presence of Strongyloides stercoralis and the liver biopsy showed the presence of small cell neuroendocrine carcinoma. The patient died 50 days after hospital admission. The high level of endogenous cortisol observed in this patient may have facilitated the progression to severe fatal infection.

  • Ammar Al-Rifaie, Mir Azam Khan, Amjad Ali, Asha Kumari Dube, Dermot Gleeson, Barbara Hoeroldt

    Lisinopril is an angiotensin converting enzyme inhibitor (ACE-I) that has been on market for more than 25 years. ACE-I are usually well tolerated and rarely have serious or life-threatening side effects. We describe an unusual presentation of fulminant hepatic cholestasis probably secondary to lisinopril. To our knowledge, this is the second case report which shows lisinopril-induced liver injury though a cholestatic mechanism. The patient was a 59-year-old woman with type 2 diabetes, a high body mass index and hypertension, who presented with a 5-week history of jaundice and itching. She had been started on lisinopril for diabetic nephropathy 8 weeks before admission. Other causes for cholestasis had been excluded through non-invasive immunology and virology screening, an ultrasound of the liver, magnetic resonance cholangiopancreatography and a liver biopsy. The biopsy was consistent with drug-induced liver injury. Lisinopril was stopped 2 weeks before admission. The patient’s hospital stay was complicated by contrast nephropathy and influenza A which were both treated appropriately. Unfortunately, the liver cholestasis did not completely resolve following withdrawal of lisinopril and the patient died after 4 months. A literature search yielded only six other reported cases of lisinopril-induced liver injury. Five cases described hepatocellular damage and one showed cholestatic injury.

  • Sclinda Lea Janssen, Thomas Scholbach, Susan Jeno, Holte Laurie, Mandy Meyer, Colin Combs, PhD

    We present a 53-year-old female patient with median arcuate ligament syndrome (MALS), also known as Dunbar syndrome or celiac artery compression syndrome, related to lumbar lordosis and hip dysplasia. She utilized interprofessional management strategies, which were beneficial in reducing lumbar lordosis and MALS-related symptoms. This finding is important because there are no other reports in the literature describing interprofessional strategies to manage symptoms for patients who are waiting for surgery or are not candidates for surgery.

  • David Rocha Paiva, Daniela Casanova, Helio Martins, Margarida Cerqueira, Mariana Formigo, Olinda Miranda, Jorge Cotter

    Right-sided Bochdalek hernia (BH) is very rarely diagnosed in adults. It commonly presents with gastrointestinal symptoms (pain, abdominal distension and vomiting). Breathlessness, recurrent chest infections and other pulmonary sequelae can also be present. We report the case of a 92-year-old man with a 3-day history of dyspnoea, fever and thoracic pain and multiple episodes of vomiting. An x-ray was performed, and the diagnosis of a large BH hernia was confirmed by computed tomography of the thorax. The condition may be fatal in cases where the small bowel undergoes necrosis or perforation. An emergent laparotomy was performed, but the patient did not improve clinically and died immediately after the procedure.

  • Uta Köpf, Hans Ulrich Klehr, Anna-Maria Eis-Huebinger, Souhaib Aldabbagh, Christian Strassburg, Dominik Boes, Philipp Lutz

    Infection with cytomegalovirus (CMV) with resistance to ganciclovir (GCV) is a therapeutic challenge in kidney transplant patients, because standard treatment options are nephrotoxic. We report the case of a kidney transplant recipient with GCV-resistant CMV disease, in whom letermovir, a novel inhibitor of CMV packaging, was administered off-label and prevented a relapse of disease once the CMV load was decreased by cidofovir. Furthermore, we observed significant drug interactions between letermovir and tacrolimus.

  • Eduardo Soriano-Navarro, Vanessa Cano-Nigenda, Fernanda Menéndez-Manjarrez, Esmirna Farington-Terrero, Juan José Méndez-Gallardo, Alejandro García-Irigoyen, Antonio Arauz

    Introduction: Despite the extremely favourable prognosis of patients with cerebral venous thrombosis (CVT), death occurs in 10–15% of patients. In severe cases of malignant CVT with supratentorial haemorrhagic lesions, cerebral oedema and brain herniation, decompressive surgery may be the only life-saving treatment.
    Patient and methods: We present the case of a puerperal young woman with progressive headache, seizures and decreased alertness. Thrombosis of the entire superior sagittal sinus with bifrontal venous infarcts and midline shift was confirmed by magnetic resonance imaging with venography sequencing. Despite medical treatment with anticoagulation, progressive neurological deterioration was observed, so bilateral, frontal decompressive craniectomy was performed.
    Results: At the 6-month follow-up, we observed partial functional recovery with a modified Rankin score of 3.
    Discussion: Bilateral decompressive craniectomy may be a life-saving therapeutic option when medical therapy fails and there are clinical and radiological features of progression in both cerebral hemispheres.

  • Christopher Butter, Nazia Rashid, Rumaisa Banatwalla, Thomas FitzGerald

    This report describes the management of a patient with myxoedema coma masquerading as an acute stroke (with or without ‘cold sepsis’). Myxoedema coma is an endocrine emergency occurring when physiological adaptations to untreated hypothyroidism are overwhelmed by an acute precipitant. Even promptly treated, it has an associated mortality of up to 50%.

  • Luuk René van den Bersselaar, Judith Maria Dimphena van den Brule, Johannes Gerardus van der Hoeven

    Acetaminophen and flucloxacillin both interfere with the γ-glutamyl cycle. Long-lasting concomitant use of flucloxacillin and acetaminophen can lead to 5-oxoproline accumulation and severe high anion gap metabolic acidosis. Females and patients with sepsis, impaired kidney and/or liver function, malnutrition, advanced age, congenital 5-oxoprolinase deficiency and supratherapeutic acetaminophen and flucloxacillin dosage are associated with increased risk. Therefore, a critical attitude towards the prescription of acetaminophen concomitant with flucloxacillin in these patients is needed.
    We present the case of a 79-year-old woman with severe 5-oxoprolinaemia after long-lasting treatment with flucloxacillin and acetaminophen, explaining the toxicological mechanism and risk factors, and we make recommendations for acetaminophen use in patients with long-lasting flucloxacillin treatment.

  • Lucía Barrera López, Cristina Macía-Rodríguez, Lucía Ferreiro-Fernández, José Antonio Díaz-Peromingo

    A 40-year-old man presented to the emergency room and was evaluated in the internal medicine department for unexplained weight loss, asthenia, anorexia and night sweats over the previous 2 months. After a loculated pleural effusion was identified on thoracic computed tomography, purulent fluid was drained from the lung and Fusobacterium nucleatum was isolated. The patient was successfully treated for 27 days with amoxicillin-clavulanic acid. This was an atypical presentation of a common micro-organism implicated in lung infections.

  • Diogo Raposo André, Filipa Vicente, Jessica Chaves, Mónica Caldeira, Fernando Jacinto, António José Chaves, Maria Luz Brazão

    Introduction: Kikuchi-Fujimoto disease (KFD) is a rare, benign, necrotizing lymphadenitis of unknown aetiology with good prognosis. It is characterized by cervical lymphadenopathy, nocturnal diaphoresis and fever. Surgical excision of the adenopathy, histopathological study and immunophenotyping are crucial for diagnosis.
    Patients and methods: This paper describes five patients with three different histological subtypes of KFD, including an atypical presentation masquerading as pyelonephritis and two other cases where physicians mistakenly started chemotherapy. In one other case cytomegalovirus was identified as the responsible aetiological agent, while in the remaining patient, KFD evolved into an autoimmune condition.
    Discussion: KFD, although rare, may mimic infectious, autoimmune and neoplastic diseases. It also poses a risk for the subsequent development of an autoimmune disorder.

  • Isabel I Taveira, Hipólito Nzwalo, José Sousa e Costa, Pedro Moreira

    A 44-year-old woman presented with headache and delirium. Brain tomography indicated pneumocephalus, while blood and cerebrospinal fluid cultures revealed Streptococcus pneumoniae. Despite antibiotic treatment and admission to the intensive care unit, the patient died 3 days later. Pneumocephalus in association with meningitis is very rare and may be caused by gas produced by microorganisms.

  • Maria Inês Silva, Isabel Ferreira, Teresa Brandão, Paulo Telles de Freitas

    Listeria monocytogenes is a gram positive bacillus responsible for listeriosis. This infection manifests mainly as bacteremia and / or central nervous system (CNS) infection. Involvement of other sites is rare. Pleural listeriosis is an uncommon presentation of L. monocytogenes infection and there is little data to guide the management of these patients. First-line antibiotics used empirically to treat bacterial respiratory infections are ineffective in treating these L. monocytogenes infections, which contributes to the progression of the infection and a worse prognosis.
    We present a case report of a patient admitted to an intensive care unit with septic shock secondary to systemic listeriosis with L. monocytogenes isolation in pleural fluid culture and blood cultures. The evolution of the hospitalization and the clinical outcome are reported.

  • Guiomar Pinheiro, Ana Margarida Alves, Isabel Neves, Teresa Sequeira

    Pulmonary hypoplasia or agenesis is a rare congenital disorder that results in lung underdevelopment. This disease is usually found in children but rarely encountered in adults. We describe the case of an 84-year-old woman diagnosed with a unilateral pulmonary hypoplasia presenting simultaneously with left pulmonary artery hypoplasia. Due to this condition, the patient had a lifelong history of pulmonary infections that resulted in several bronchiectases in the affected lung. Moreover, the pulmonary artery hypoplasia led to the development of pulmonary hypertension and collateral circulation causing hemoptysis, giving rise to the patient attending the emergency department. Although we were able to medically manage the hemoptysis, it can be fatal and require surgical intervention. Hence, an early diagnosis is essential so that appropriate follow-up and prompt prevention and treatment of complications, such as pulmonary infections, hemoptysis and pulmonary hypertension, are achieved.

  • Tara Burleigh, Khandalavala Birgit

    Objectives: This is the first case report of iatrogenic Takotsubo syndrome (TS) due to a combination of lisdexamfetamine and phentermine.
    Background: TS is characterized by transient acute ballooning of the left ventricular wall. Typically, it occurs in extremely stressed post-menopausal women, however a few iatrogenic causes have been described recently.
    Results: A 55-year old woman prescribed lisdexamfetamine and phentermine, presented with acute substernal chest pain. Acute coronary syndrome was excluded. The echocardiogram was diagnostic of TS, and she recovered spontaneously, with supportive care.
    Conclusion: Caution with the use of sympathomimetic medications in post-menopausal women appears warranted.

  • Miguel Angel Zamora-López, Iris Camelia Farias-Navarro, Erick Joel Rendon-Ramirez

    Introduction: Twenty-five per cent of tuberculosis patients have pleural tuberculosis, which is the third most common form of presentation. Most cases present as an exudative pleural effusion with just few cases reported as chylothorax in the literature. All pleural effusions from confirmed cases, including tuberculous chylothorax, had exudate features.
    Aim: To describe a patient with Mycobacterium tuberculosis affecting the lungs and pleura, which laboratory testing demonstrated had features of transudate chylothorax.
    Patient and methods: A 70-year-old man presented with constitutional symptoms, progressive exertional dyspnoea and right pleural effusion with fibrocavitary changes on chest imaging. Thoracentesis and pleural fluid analysis revealed chylous fluid with transudate features, high triglycerides, low cholesterol content and mononuclear cell predominance. Acid-fast sputum stains and pleural fluid were negative for Mycobacterium tuberculosis as was an adenosine deaminase test for pleural effusion. Tomography-directed lung biopsy sampling of a lung nodule revealed a chronic granulomatous inflammatory process associated with the presence of acid-fast bacilli.
    Discussion: Tuberculosis-associated chylothorax is an uncommon presentation of the disease. A recent review found only 37 cases of confirmed tuberculous chylothorax had been reported in the literature. All cases had exudate characteristics. The diagnosis of pleural tuberculosis was made through culture or testing of sputum, pleural fluid or biopsy samples in 72.2% of cases, with the rest identified by histopathology.

  • Ali Mir, Marzieh Lashkari, Fatemeh Jafari, Behnam Molavi

    In the present report, we describe our experience with a 44-year-old male with abnormal retroperitoneal primitive neuroectodermal tumours (PNETs) in our hospital, who was operated on with a spindle cell neoplasm diagnosis.

  • Tiago Seco, Ana Margarida Cerqueira, Ana Luís Ferreira, Ana Costa, Carlos Fernandes, Jorge Cotter

    Despite a recent decline, tuberculosis (TB) infection is still a frequent diagnosis in Portugal. Adenosine deaminase (ADA) measurement has become an important tool in the timely diagnosis of this infection. However, ADA elevation in bodily fluids is not pathognomonic of TB infection.
    We present the case of a 70-year-old woman, undergoing treatment for pleural TB, diagnosed based on elevated ADA levels in a pleural effusion. Due to worsening symptoms she was readmitted, and the previous diagnosis was reconsidered. Thoracocentesis was repeated and cytometry analysis of the fluid was performed, showing the presence of diffuse large B cell lymphoma (DLBCL).
    DLBCL is the most frequently occurring non-Hodgkin lymphoma (NHL). Pleural involvement is rare in the initial stages. ADA elevation >250 U/l should raise suspicion of malignancy, especially in association with markedly elevated LDH levels. The purpose of this case report is to highlight that in the absence of microbiologic or histologic confirmation, a presumptive TB diagnosis should not be lightly made, and alternative diagnoses should be systematically ruled out.

  • Stephanie de Montjoye, Benoit Boland, Jacqueline Van Raemdonck, Frederic Houssiau

    While functional decline is a common syndrome in geriatric medicine, the diagnosis of the underlying disease can be complex. We present a case of very late-onset systemic lupus erythematosus with fever, arthritis, lymphadenopathy, sicca syndrome, pleurisy, renal impairment and reversible functional and cognitive impairments. Prompt improvement was observed on prednisolone and hydroxychloroquine.

  • Moni Roy, Ashish Kumar Roy, Tulika Chatterjee, Saurabh Bansal

    Testicular adrenal rest tumour (TART) is a known entity in patients with congenital adrenal hyperplasia. An adult patient presenting with testicular enlargement raises a concern for malignancy and this creates a diagnostic dilemma between non-malignant conditions such as TART versus testicular malignancy. We describe a case where the patient underwent orchiectomy due to clinical concern for malignancy but, retrospectively, this outcome could have been prevented by medical treatment. This case emphasises the need to learn from errors. There is a need to increase awareness of the condition among medical professionals to reduce the chances of unnecessary surgical intervention.

  • Wael Zaher, Sammy Place, Yannick Gombeir

    Case presentation: A 50-year-old female presented with an onset of multiple subcutaneous nodules on her 4 limbs. These nodules appeared concomitantly with the initiation of radioactive iodine therapy for papillary thyroid cancer. These nodules were not obvious on inspection of the skin, but easily felt on palpation.
    The biopsy of the subcutaneous nodules revealed hypodermic non-caseating granulomas consistent with sarcoidosis. The patient underwent an 18F-fluorodeoxyglucose positron emission tomography (PET) scan study that revealed, besides the subcutaneous nodules, multiple hypermetabolic mediastinal lymphadenopathies and cervical adenopathies. Biopsy of the mediastinal lymphadenopathy showed neither granulomas nor neoplastic cells. Cervical biopsy revealed neoplastic cells of thyroid origin. Laboratory tests were normal. Bronchoalveolar lavage showed a normal CD4/CD8 T-cell ratio.
    A diagnosis of cutaneous sarcoidosis was established, as well as a recurrence of the cancerous disease. The subcutaneous nodules regressed spontaneously in the absence of any treatment.
    Discussion and conclusion: Sarcoidosis is a multisystemic disease of unknown origin. This case illustrates an uncommon occurrence of sarcoidosis, triggered by radioactive iodine therapy. Radioiodine may lead to immunological changes, especially affecting the Th1/Th2 ratio, which may promote the emergence of sarcoidosis in genetically predisposed patients. There is still much to discover to fully understand the pathogenesis of sarcoidosis.

  • Ahmad Reza Shirazi-Nejad, John M Hebden

    A 26-year-old woman presented with a 3-month history of worsening episodic abdominal pain, which was associated with frequent passage of watery stools, nausea and dyspepsia. Her peripheral eosinophil count was markedly elevated. This responded well to a reducing regimen of corticosteroids. Her symptoms completely resolved with a corresponding fall in eosinophil count. The patient was diagnosed with eosinophilic gastroenteritis. We have not considered steroid-sparing agents at this point, but should she have future exacerbations then this will be considered.

  • Christopher Wong, John Yiannikas

    Background: Right heart thrombus (RHT) is a medical condition associated with acute pulmonary embolism and congestive cardiac failure. Rapid recognition is essential for instituting early treatment and preventing adverse outcomes.
    Case summary: A 55-year-old male presented with symptoms of congestive cardiac failure complicated by cardiac arrest. Initial transthoracic echocardiography (TTE) demonstrated moderate impairment of both ventricles and a moderately dilated right ventricle (RV). After initial improvement with heart failure treatment, the patient subsequently had a second cardiac arrest. Bedside TTE revealed complete RV obstruction by thrombus, and intravenous thrombolysis was immediately instituted, with complete dissolution of the thrombus and haemodynamic recovery 15 minutes after treatment. Unfortunately, the patient suffered significant hypoxic brain injury and did not survive.
    Discussion: RHT can manifest acutely in a dramatic fashion with cardiac arrest. Bedside TTE is key to making a rapid diagnosis in this setting to allow early administration of thrombolytic therapy.

  • Ana Sara Monteiro, Rute Martins, Catarina Martins da Cunha, Jorge Moleiro, Henrique Patrício

    Aortoenteric fistula (AEF) is a rare condition with a high mortality rate. AEFs are classified according to their primary and secondary causes, the former being less frequent. Primary AEFs occur in a native aorta and their causes include aneurysms, foreign bodies, tumours, radiotherapy and infection. The classic triad of aortoesophageal fistulas, a subtype of AEFs, are mid-thoracic pain and sentinel haemorrhage, followed by massive bleeding after a symptom-free interval.
    We present the case of a 41-year-old male patient who presented in the emergency room after successive episodes of abundant haematemesis. He was hypovolemic, hypothermic and acidotic at presentation. His medical history included an emergency room visit the week before with chest pain but no relevant anomalies on work-up, active intravenous drug use and chronic hepatitis.
    Esophagogastroduodenoscopy (EGD) showed a bulging ulcerated lesion suspicious for aortoesophageal fistula, confirmed by computed tomography (CT) angiography, which revealed a saccular aortic aneurysm with a bleeding aortoesophageal fistula. The patient underwent urgent thoracic endovascular aortic repair.
    The sentinel chest pain, leucocytosis and CT findings hinted at the presence of a mycotic aneurysm, despite the negative blood cultures. It was most likely caused by a septic embolus due to the patient’s risk factors. While a high level of suspicion for aortoesophageal fistula is needed to prompt a fast diagnosis, EGD and CT findings were crucial to establish it and allow a life-saving intervention. We conclude that chest pain cannot be disregarded in a patient aged 41 years with multiple comorbidities, despite normal work-up, to prevent a fatal outcome.

  • Ana Rita Matos, Elisabete Coelho, Sofia Caridade

    A 77-year-old man with arterial hypertension and dyslipidaemia, treated with olmesartan/hydrochlorothiazide and simvastatin, was admitted with a 3-week history of anorexia, nausea, vomiting, profuse diarrhoea and weight loss. He was dehydrated and blood tests showed acute kidney injury. The aetiological study was inconclusive. The patient had a favourable clinical evolution during hospitalization and was discharged. However, after about 10 days at home, he was re-admitted to hospital with the same clinical presentation. It was noticed that olmesartan had not been prescribed during the previous admission but had been restarted on an outpatient basis. Biopsy examination showed duodenal mucosa with villous atrophy and polymorphic inflammatory infiltrate. Antibody testing for coeliac disease was negative. Based on these facts, it was hypothesized that the patient had olmesartan-induced enteropathy, which was subsequently confirmed.

  • Zakariya Abdulazeez, Uyen Tran

    Ogilvie’s syndrome is a non-mechanical, acute pseudo-obstruction of the colon, causing massive colonic dilation. Medical or surgical conditions can predispose patients to Ogilvie’s syndrome; however, the pathogenesis and clinical findings are still not well understood. Here, we present a case of a 48-year-old male patient who presented to the Emergency Department with intermittent self-resolved left-sided lower chest pain on a background of ischaemic heart disease and positive risk factors for acute coronary syndrome. Troponin testing was negative and an electrocardiogram showed no acute changes. Chest radiography showed a dilated bowel under the left hemidiaphragm and a computed tomography (CT) scan of the abdomen-pelvis confirmed the diagnosis of Ogilvie’s syndrome. The patient was treated conservatively with a short period of nil by mouth and intravenous fluids.

  • Hassene Attout

    Acquired haemophilia (AHA) is a rare autoimmune disorder caused by circulating autoantibodies that inhibit the activity of factor VIII (FVIII). Acquired inhibitors against FVIII are rarely seen, with a reported incidence of approximately 1 case per million/year. Clinical conditions and contexts associated with AHA include autoimmune diseases, lymphoproliferative malignancies, drug treatment, pregnancy and infections. An association with urticarial vasculitis is even more rare. Here, we report a case of a 59-year-old woman presenting with cutaneous and muscle haematomas secondary to AHA in association with urticarial vasculitis, who was successfully treated with factor eight inhibitor bypassing activity (FEIBA) and prednisolone.

  • Samuel Deokjong Yoo, John K Lusiba, Robert Lukande, Kyungmin Shin

    Background: Coccidioidomycosis is an endemic disease in the Americas. No cases have been reported in Africa.
    Patient: A 23-year-old HIV seronegative Ugandan man was referred to Mulago National Referral Hospital in Kampala, Uganda with a 10-month history of haemoptysis and difficulty breathing, and a 6-month history of localized swellings on the extremities. He had associated weight loss and drenching sweats, but no fevers. He had taken anti-tuberculosis medicine for 2 months with no improvement. He had never travelled out of Uganda. On physical examination, he had cystic swellings and ulcerated lesions on the extremities. He had tachypnoea, crackles in the chest and mild hepatomegaly. Bronchoscopic examination showed two masses occluding the right main bronchus. Bronchoscopic biopsy showed findings consistent with coccidioidomycosis. The patient improved with antifungal treatment and was discharged.
    Conclusion: We report the first case of disseminated coccidioidomycosis with pulmonary and cutaneous manifestations in Africa.

  • Ridwaan Albeiruti, Fahad Chaudhary, Hiren Vallabh, Troy Krupica, Justin Kupec

    The lifetime prevalence of peptic ulcer disease (PUD) is 5–10%. While PUD in immunocompetent patients is most commonly associated with Helicobacter pylori infection or the use of non-steroidal anti-inflammatory drugs (NSAIDs), other common causes of PUD must also be considered in the differential diagnosis. We describe a case of endoscopic and histological resolution of PUD related to Candida infection in a healthy, immunocompetent woman.

  • Charalampos I Kalogeropoulos, Konstantinos Papathanasiou, Ismini Tsagkaraki, Georgios Giannopoulos, Aristotelis Bamias, Eleni Boutati

    Pityriasis rubra pilaris (PRP) is a rare chronic inflammatory papulosquamous dermatosis affecting both adults and children. Six subtypes of PRP have been described. Recently, the management of PRP with biologic immunosuppressive agents regularly used in psoriasis has been supported by several case reports and series. Ustekinumab is an anti-IL12/23 IgG1 kappa human monoclonal antibody. It has been approved for the treatment of Crohn’s disease, plaque psoriasis, psoriatic arthritis and ulcerative colitis. It has also been reported to be effective as an off-label treatment for PRP. Current data are equivocal regarding infectious disease risk with ustekinumab administration. We describe a case of meningococcal and HSV-2 infection of the central nervous system in a patient being treated with ustekinumab for PRP.

  • João Dantas, Isabela S de Oliveira, Emanuela P Fonseca, Mittermayer Barreto Santiago

    Objectives: We describe a case of systemic sclerosis (SS) with acro-osteolysis associated with cutaneous mucinosis, usually characterized by mucin deposition in the skin. The main differential diagnosis was multicentric reticulohistiocytosis due to the presentation of papulonodular skin lesions.
    Materials and methods: A physical examination, imaging studies and laboratory tests were performed.
    Results: Distal bone resorption was evident on plain radiographs, and skin biopsy confirmed mucinosis. The SS diagnosis was based on the clinical features, high levels of antinucleolar antibodies and typical nailfold capillaroscopy findings.
    Conclusion: To the best of our knowledge, this is the first description of cutaneous mucinosis accompanying SS with acro-osteolysis.

  • Abdulrahman S Museedi, Mouhamed Nashawi, Abdullah Ghali, Ali Hussein, James Saca

    Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS). Although uncommon, it should be included in the differential diagnosis for middle-aged patients without elevated atherosclerotic vascular disease risk or a family history of cardiovascular disease. SCAD is associated with postpartum women; however, reports noting its association with autoimmune disease and vasculopathy in other populations have recently gained prominence. We report a case of a 41-year-old male who was found to have SCAD after presenting with ST segment elevation myocardial infarction in the context of episodic vision loss, and who later underwent work-up for C-ANCA vasculitis and was successfully treated with corticosteroids.

  • Ardian Rizal, Evit Ruspiono, Dinarsari Hayuning Putri

    Subclavian vein access is still one of the most favoured access options for cardiac implantable electronic device (CIED) implantation. For the physician, the technique is reasonably familiar and easy to carry out. However, this has several potential complications. In this case, we present a late complication of subclavian access. The patient presented with intermittent loss of pacemaker output, which caused him to experience several syncopal events. In the acute setting, we changed the lead polarity and achieved a good outcome. Further management of this situation consisted of removal and replacement of the damaged lead.

  • Beatrice Khater, Vicky Kassouf, Georges Haddad, Roula Hourany

    Obstructive sleep apnoea (OSA) is a common condition usually treated with continuous positive airway pressure (CPAP). No reports have linked it to an acute subdural haematoma. A 54-year-old white man who had hypertension well controlled with an angiotensin II receptor blocker, presented with a 2-week history of occipital headache with no other focal neurological symptoms. The headache began 12 days after he had started using CPAP for OSA. A brain MRI performed 2 weeks later showed bilateral subdural haematomas which were chronic on the left and sub-acute/acute on the right. Since the patient was clinically stable with no focal neurological deficits, he received prednisone for 3 weeks and was followed up with consecutive CT scans demonstrating gradual regression of the haematomas. This is the first report showing that subdural haematomas could be linked to CPAP use.

  • Natassja Moriarty, Jonathan Moriarty, John Keating

    Objective: We present a patient with pancreatic cancer who developed weakness, acute renal failure and significantly raised creatine kinase levels post-ERCP and who was assessed as having contrast-induced rhabdomyolysis.
    Results: The patient underwent haemofiltration and ultimately succumbed to his condition.
    Conclusion: Rhabdomyolysis is a potentially life-threatening condition which occurs because of damage to skeletal muscle, with release of myoglobin and electrolytes into the circulation. The mortality rate is 59% in severe cases, despite appropriate treatment.

  • Aaron Braddy, Rahul Janardan Mogal, Anthony John Maddox, Andrew Bryan Timothy Barlow

    Objectives: We describe the novel case of a patient presenting with pulmonary mucosa-associated lymphoid tissue lymphoma (pMALToma) synchronous with metastatic prostate adenocarcinoma.
    Materials and methods: We report the clinical, laboratory, radiological and histological findings of the above patient.
    Results: While the patient’s metastatic prostate adenocarcinoma responded well to chemo-radio-hormonal therapy, a persistent area of lung consolidation was noted and further investigated, leading to the diagnosis of concurrent pMALToma.
    Conclusion: It is important to pursue further investigation when there appears to be persistent change or altered disease response in malignancy if there is evidence for disease response elsewhere, as there may be two synchronous primary cancers.

  • Erika Poggiali, Andrea Vercelli, Teresa Iannicelli; Valentina Tinelli; Laura Celoni, Andrea Magnacavallo

    We describe the case of a male patient admitted to our emergency department during the Italian COVID-19 epidemic, for progressive worsening dyspnoea. A diagnosis of pneumothorax and diffuse interstitial lung involvement was promptly made by lung ultrasound and confirmed by an HRCT scan. A chest CT scan also showed diffuse emphysema, as observed in chronic obstructive pulmonary disease (COPD), and small consolidations in the lower lobes, suggestive for COVID-19 pneumonia. A chest tube was immediately inserted in the emergency room with complete resolution of the dyspnoea. A nasopharyngeal swab for 2019-nCoV was positive. Unfortunately, the patient died from COVID-19-related acute respiratory distress syndrome after 48 days of hospitalization.

  • 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.

  • Mariana Santos Leite Pessoa, Carla Franco Costa Lima, Ana Carla Farias Pimentel, José Carlos Godeiro Costa Júnior, Jorge Luis Bezerra Holanda

    The literature suggests that COVID-19 provokes arterial and venous thrombotic events, although the mechanism is still unknown. In this study, we describe patients with confirmed coronavirus infection associated with multisystemic infarction, focusing on splenic infarction. More data are required to elucidate how COVID-19 and thrombotic disease interact and so that preventive and early diagnosis strategies can be developed.

  • 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.

  • Andrea Boccatonda, Eugenia Ianniello, Damiano D'Ardes, Giulio Cocco, Fabrizio Giostra, Claudio Borghi, Prof, Cosima Schiavone, Prof

    Thromboembolic disease is strongly associated with, or even an integral part of, COVID-19 pneumonia. Indeed, endothelial/microvascular damage to pulmonary capillaries seems to be the main trigger of the pneumonia. Here we report a case of pulmonary embolism in a COVID-19 patient with an atypical clinical presentation. Blood gas analysis and lung ultrasound allowed the correct diagnosis to be reached.

  • 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.