2020: Vol 7 No 11
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Objective: To describe a patient who developed euglycaemic diabetic ketoacidosis (DKA) in the setting of SGLT2 inhibitor use precipitated by COVID-19.
Patient and methods: A 52-year-old male with type II diabetes on empagliflozin and no history of DKA presented with symptoms of COVID-19 as well as laboratory findings consistent with euglycaemic DKA. His hospital course was complicated by recurrent episodes of euglycaemic DKA as well as hyperglycaemic DKA.
Conclusion: SGLT2 inhibitors should be held as early as possible in COVID-19 cases due to the risk of euglycaemic DKA. These patients should also have more intense glucose monitoring.
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Diagnostic errors are a serious problem in healthcare. The diagnostic process is highly susceptible to cognitive bias and the current COVID-19 pandemic may cause normally accurate healthcare workers to make incorrect decisions. We report a case of aseptic meningitis that required five healthcare visits before it was correctly diagnosed. This case highlights the risk of anchoring bias and the importance of carefully assessing diagnostic processes during the COVID-19 pandemic.
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The coronavirus disease 2019 (COVID-19) pandemic has made it difficult for physicians to follow their usual diagnostic processes. We present the case of a 25-year-old man with adjustment disorder who developed dyspnoea. He was concerned about COVID-19, but his test result was negative. After excluding COVID-19, the physician concluded that his symptoms were related to his psychiatric condition. However, the patient was diagnosed with pulmonary thromboembolism by another physician. To avoid missing a diagnosis, physicians must practice zero-based thinking, regardless of COVID-19 concerns, and not be distracted from the patient's core problems.
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We describe the case of a patient hospitalized for the second time in a month due to delayed worsening of lung lesions in COVID-19 infection without bacterial superinfection. He was treated with hydroxychloroquine, IV dexamethasone and ruxolitinib with rapid improvement of respiratory failure; 1 month after the second discharge, maintaining low-dose oral prednisone, lung consolidations were significantly reduced on control CT.
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Nocardia is a genus of aerobic, non-motile and non-spore-forming filamentous branching bacteria with fragmentation into bacillary or coccoid forms. Infections caused by Nocardia often occur in immunocompromised hosts and are potentially life-threatening. Nocardia beijingensis has rarely been reported to cause infection in immunocompetent hosts. We present a case of disseminated infection due to Nocardia beijingensis in a patient with no known medical comorbidities, who presented with new-onset seizure. Another interesting finding in our case is that our patient did not have any pulmonary symptoms despite chest CT showing the pulmonary system as the likely primary site of infection. As per our literature review, this is the seventh reported case of infection due to Nocardia beijingensis in an immunocompetent host.
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Myeloid sarcoma (MS) is a very rare malignant tumour composed of myeloblasts. It most commonly involves soft tissue, bone, periosteum and lymph nodes, but unusual presentation sites have also been reported. Typically, MS evolves concurrently with active leukaemia or following remission, when it is known as secondary MS. But rarely MS can occur de novo without evidence of concomitant haematological disease. Herein, we report an unusual case of central nervous system-MS in a patient without evidence of concomitant haematological disease. In this case, progressive thoracic and lumbar pain with paraplegia ultimately led to the diagnosis of acute myeloid leukaemia. We also conducted a PubMed search for case reports, case series and reviews of past literature regarding central nervous system-MS and report our findings.
Rare Presentation of Toxoplasma Pneumonitis in the Absence of Neurological Symptoms in an AIDS Patient and Use of Next-Generation Sequencing for DiagnosisViews: 760 HTML: 91 PDF: 469
Toxoplasma gondii is a known cause of encephalitis in human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) patients. Toxoplasma pneumonitis is a manifestation of extracerebral toxoplasmosis and can be clinically indistinguishable from other opportunistic infections including Pneumocystis jirovecii pneumonia (PJP) and miliary tuberculosis. In this case report, Toxoplasma pneumonitis and disseminated toxoplasmosis was diagnosed using next-generation sequencing (NGS) and polymerase chain reaction (PCR) assessment. NGS can detect microbial cell-free DNA (cfDNA) circulating in the plasma of over 1,000 pathogens. This case is a rare presentation of Toxoplasma pneumonitis in the absence of neurological symptoms and we discuss the use of NGS of microbial cfDNA and PCR tests that may be utilized for the timely diagnosis of such challenging cases.
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Background: Although many studies have demonstrated the effectiveness of transcranial direct current stimulation (tDCS) in improving speech recovery in post-stroke aphasia, as far as we know patients affected by thalamic aphasia have never been investigated.
Patient and method: A 65-year-old man with severe non-fluent aphasia due to a left thalamic haemorrhagic stroke underwent intensive daily speech therapy combined with tDCS.
Results: The patient showed progressive improvement with almost complete recovery of his speech disorder, behavioural disinhibition and apathy.
Conclusions: Our findings suggest that tDCS with concurrent speech therapy can be useful in patients with subcortical stroke lesions.
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Background: Reversible cerebral vasoconstriction syndrome (RCVS) is defined as a clinical and radiological syndrome that comprises a group of disorders characterized by sudden-onset severe headache and segmental vasoconstriction of the cerebral arteries with resolution within 3 months.
Case presentation: A 51-year-old female patient with a 2-week history of sudden-onset severe headache, visual disturbances and cerebellum; no relevant imaging findings, except for an infundibular dilation at the origin of the posterior communicating artery, and so, angiography was performed. When symptoms persisted, a new imaging study was carried out with findings of RCVS as the cause of the symptoms from the beginning.
Conclusions: Findings of RCVS can be obtained in various vasculopathies of the nervous system and vasculitis, being misdiagnosed, and so, clinical suspicion is essential; if vasoconstriction is not demonstrated on the initial image and other diagnoses have been excluded, the patient should be managed as having possible or probable RCVS.
Multi-Focal Splenic Tumour in a Belgian Patient and a Brief Review of the Literature on Littoral Cell AngiomaViews: 797 HTML: 126 PDF: 348
We describe the case of a 66-year-old woman with littoral cell angioma (LCA) confirmed by histopathology and immunohistochemistry, to our knowledge the first case in Belgium. LCA is an extremely rare primary vascular tumour of the splenic red pulp, probably originating from littoral cells. If a splenic mass and nodules are incidentally identified on imaging and the patient has no associated signs or symptoms, LCA should be suspected. Histopathology and adjacent techniques are mandatory for definitive diagnosis. Splenectomy followed by adequate follow-up is necessary to exclude underlying pathology.
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Tracheobronchopathia osteochondroplastica (TBPO) is an uncommon benign disease, characterized by osseous or metaplastic cartilaginous nodules in the submucosa of the tracheobronchial tree. TBPO is easy to misdiagnose due to its non-specific clinical manifestation. We describe two cases of TBPO. The first patient was a 57-year-old woman with nocturnal dry cough and wheezing, in whom bronchoscopy revealed small diffuse mucosal irregularities involving the airway until the segmental bronchi. The other patient was a 69-year-old man with progressive worsening dyspnoea and productive cough presenting with severe stenosis of the trachea. Histological examination of both cases was consistent with TBPO. These cases highlight distinct forms of presentation of this rare entity.
A Rare Association of Antiphospholipid Antibody Syndrome, Systemic Lupus Erythematosus and Aortic Dissection: A Striking Presentation with Multi-Organ Failure?Views: 975 HTML: 112 PDF: 429
Systemic lupus erythematosus is a chronic autoimmune disease with a wide variety of clinical presentations induced by different immunocomplexes and autoantibodies. Antiphospholipid antibody syndrome (APLAS) is a life-threatening clinical condition characterized by venous and arterial thromboses or pregnancy morbidity in the presence of persistent moderate/high levels of antiphospholipid antibodies. Aortic dissection is rarely associated with APLAS and always requires prompt diagnosis and early treatment. We report a rare case with a striking presentation. The patient developed multi-organ failure due to lethal aortic dissection and the obstruction of abdominal and thoracic branch vessels.
Infectious Mononucleosis Resulting in Acute Necrotizing Mediastinitis: A Case Report and Literature ReviewViews: 794 HTML: 304 PDF: 380
The serological prevalence of Epstein-Barr virus (EBV) among young adults exceeds 90% worldwide. Even though EBV primary infection is usually benign, severe complications can occur in adolescents and young adults and so the disease must be promptly diagnosed. The development of an oropharyngeal abscess leading to a descending necrotizing mediastinitis (DNM) is exceptional and potentially lethal, so early diagnosis with a CT scan, appropriate antibiotics and surgery are essential.
The authors present a case where DNM was associated with reactive hemophagocytic syndrome as a result of infectious mononucleosis, as well as a review of similar cases in the English literature.
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Parental iron replacement is given to patients with severe iron deficiency or intolerance to oral iron. Hypophosphataemia has been reported to occur as a complication of parental iron replacement, and is postulated to be related to the carbohydrate moieties used in the parenteral preparations. Hypophosphataemia is under-diagnosed as symptoms such as fatigue, muscle weakness and poor effort tolerance mimic anaemia. Severe hypophosphataemia (<0.32 mmol/l) can result in significant complications such as confusion, rhabdomyolysis and arrhythmias. We report a patient with recurrent admissions for non-specific symptoms attributed to iron deficiency anaemia who received multiple doses of parenteral ferric carboxymaltose (FCM). He was found to have severe hypophosphataemia, with further evaluation showing increased renal phosphate wasting and elevated serum levels of fibroblast-growth-factor 23 (FGF23). FCM was stopped and he was given high-dose oral iron supplementation, with no further episodes of hypophosphataemia.
Defining the Cause of Postpartum Myocardial Infarction – Another Use for Optical Coherence TomographyViews: 810 HTML: 57 PDF: 433
Chest pain in a young postpartum female can have many causes; however, when associated with ST elevation on ECG, spontaneous coronary artery dissection (SCAD) should be high on the list. Coronary angiography remains the first step in delineating the coronary lesion in suspected cases of SCAD and optical coherence tomography (OCT) can be crucial when the angiographic appearance remains uncertain. We present a case of a young postpartum female with ST elevation myocardial infarction (STEMI). Coronary angiography revealed a dilated part of the middle segment of the left anterior descending (LAD) artery while intramural haematoma (IMH) of the coronary artery wall was found on OCT, which confirmed the clinically suspected diagnosis of SCAD.
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Significant leucocytosis in the setting of an underlying malignancy may be attributed to several causes and is not uncommon; however, extreme leucocytosis (>50×109 cells/l) and hypereosinophilia is less common and may represent a paraneoplastic syndrome. The underlying mechanism is thought to be bone marrow stimulation by tumour-produced cytokines, most notably interleukin-5 (IL-5) and granulocyte-macrophage colony-stimulating factor (GM-CSF). This paraneoplastic syndrome is likely reflective of extensive disease and dissemination, and options for treatment are limited but include tumour resection, corticosteroids and hydroxyurea. In this report, we discuss an unusual case of known stage III lung adenocarcinoma presenting with an ischaemic stroke and extreme leucocytosis and hypereosinophilia.
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A 61-year-old woman with a history of primary aldosteronism caused by unilateral hyperplasia of the adrenal gland presented with a 2-week history of redness and severe pain in the right thumb and thenar regions. She had initially visited a dermatologist and was diagnosed with cellulitis and treated with cefditoren pivoxil for 5 days, but there was no improvement. The pain worsened and was accompanied by a burning sensation. The dermatologist prescribed famciclovir for 5 days owing to suspicion of herpes zoster. The patient was then referred to our department because her symptoms persisted. Physical examination showed no abnormalities other than the redness in the right thumb and thenar regions and spontaneous moderate pain present throughout the right thumb. Investigations revealed normal blood chemistry and coagulation factor levels, except for elevated haemoglobin (18.2 g/dl). Further investigations revealed an erythropoietin level of 2.3 IU/ml and Janus kinase 2 mutation. Hence, we diagnosed the patient with erythromelalgia caused by polycythemia vera. In this report, we discuss the treatment of polycythemia causing erythromelalgia, and the aetiology of primary aldosteronism and polycythemia vera.
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Haemoptysis is a frequently occurring but sometimes life-threatening condition. Congenital cardiovascular abnormalities are rare causes of haemoptysis. We report a case of a 33-year-old man without any past medical history complaining of haemoptysis with no other associated clinical manifestations. A contrast-enhanced chest computed tomography scan revealed aortic coarctation with dilation of the internal mammary, intercostal and bronchial arteries. He underwent stent placement after balloon angioplasty with favourable outcomes.
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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.
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Pheochromocytoma, papillary thyroid carcinoma and hyperparathyroidism have rarely been reported together. Whether this association is coincidental or results from an unknown genetic predisposition is difficult to ascertain.
We present the case of a patient who was diagnosed with pheochromocytoma, bilateral papillary thyroid carcinoma and parathyroid hyperplasia with primary hyperparathyroidism. A genetic mutation was hypothesized as the connection between these lesions. Previously described mutations were explored.
Anaplastic Large Cell Lymphoma Presenting as Haemophagocytic Lymphohistiocytosis with Underlying Coxiella burnetii and Bartonella henselae SeropositivityViews: 681 HTML: 311 PDF: 321
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.
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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.
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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.
Recurring Asystole and Paradoxical Air Embolization in a Patient with a Patent Foramen Ovale Treated with Home Parenteral NutritionViews: 603 HTML: 54 PDF: 278
Home parenteral nutrition is a therapeutic option for chronic intestinal failure. A tunnelled central venous catheter is commonly used for self-application of nutrition and hydration over a long period of time; that is, months or years. Air embolization within the venous circulation can be caused by inconsistent self-handling of the catheter in combination with air bubbles in the infusion set. Paradoxical air embolization within the brain and coronary arteries together with catheter perforation is a rare medical and technical complication. The authors report the case of a 63-year-old woman with type 3 chronic intestinal failure treated with home parenteral nutrition. During the first year of treatment and use of the catheter a fatal complication occurred. The patient experienced recurring asystolic episodes and strokes with monoplegia during flushing of the catheter. Although 2 resuscitations were successful, the third was not, and the patient died. The cause of these life-threatening complications was an unknown patent foramen ovale, with paradoxical air embolization within the coronary and brain arteries. The authors discuss the clinical consequences of arterial and venous air embolization, the differences between these and the therapeutic algorithm with a link to practice.
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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.