2022: Vol 9 No 4

Cholecystogastric fistulas are a rare but life-threatening complication of cholelithiasis. This medical condition has been explained in detail in several cases in the medical literature. However, there is still conflicting debate on how well to effectively manage patients with such a complex medical condition. We present a 70-year-old Caucasian female with complaints of intermittent dull non-radiating abdominal pain. Her pain started abruptly after breakfast. Patient took some acetaminophen which alleviated her symptom. Several days later, pains return but at this time it was associated with constipation. Patient’s primary care physician (PCP) suspected peptic ulcer disease, which was quickly ruled out following negative result of Helicobacter pylori breath test. The PCP advised patient to visit the emergency department for further investigations to rule out/in possible gallstone ileus causing intestinal obstruction, or Bouveret’s syndrome.

A young man was treated in hospital for sepsis, disseminated intravascular coagulation and multi-organ failure. He was a regular intranasal cocaine user up to 1 day prior to symptom onset. Clinical examination revealed extensive retiform purpura affecting both his lower limbs. Skin biopsy revealed widespread thrombosis in the small- and medium-sized vessels of the mid dermis and the subcutaneous fat with surrounding leucocytoclasis. There was also extensive ischaemic necrosis of the upper reticular and papillary dermis and focal ischaemic necrosis of the epidermis. These findings were in keeping with a thrombotic vasculopathy with associated cutaneous ischaemic necrosis, likely associated with levamisole-adulterated cocaine (LAC). An autoimmune screen showed extremely raised levels of anti-B2-glycoprotein IgM, IgG and anti-cardiolipin IgG antibodies, usually seen in antiphospholipid syndrome (APS). The literature describes how APS could be secondary to various underlying conditions, including LAC, and that levamisole toxicity may mimic APS and hence be missed.

Infective endocarditis is a condition associated with high morbidity and mortality, usually with univalvular involvement. We describe the case of a 76-year-old woman with triple-valve endocarditis due to Streptococcus gallolyticus complicated by perivalvular suppurative lesions, acute heart failure and acute kidney injury. Unfortunately, the patient died despite antibiotic therapy and emergent surgery. This case highlights uncommon triple-valve involvement in the absence of risk factors, posing a diagnostic and therapeutic challenge.

Background: Chyluria is usually associated with parasitic disease caused by Wuchereria bancrofti and is rare in non-endemic regions. The management of chyluria varies according to the severity of the condition. This report describes a case of mild chyluria and successful treatment using sclerotherapy.

Case description: A 44-year-old man presented with a first episode of painless milky urine. The diagnosis of chyluria was established following retrograde pyelography showing a fistula between the right pelviocalyces and the retroperitoneal lymphatic systems. The patient had not travelled to any endemic regions. Sclerotherapy using povidone-iodine was carried out resulting in closure of the fistula.

Conclusion: Sclerotherapy using povidone-iodine as the sclerosing agent was effective and safe for the management of a patient with mild chyluria. However, the best treatment for chyluria should be tailored to the patient’s condition.

Patients with severe iron deficiency, malabsorption or intolerance to oral iron are frequently treated with intravenous iron replacement. We report the case of a 42-year-old woman with non-erosive oligoarticular arthritis with antiparietal cell antibodies and iron deficiency anemia secondary to menorrhagia and unresponsive to oral iron preparations. She was treated with an intravenous infusion of ferric gluconate. After the first infusion of 125 mg (in 250 mL saline), she developed transient pain in her knee and wrist joints. When the dose was subsequently halved, the patient showed no adverse symptoms in the next four infusions and had normalized hemoglobin levels and iron indices. However, after a subsequent 125 mg ferric gluconate infusion she developed severe leg pain, muscular and joint stiffness, and functional impairment of her hands, right foot, and ankle. Laboratory tests showed a progressive increase in creatine kinase, transaminase, and C-reactive protein that normalized several days after the infusion. Although rhabdomyolysis is not reported among endovenous iron-induced adverse events, our findings suggest that intravenous iron infusions might have increased free iron generation promoting oxidative joint and muscular injury, which would explain the joint pain and stiffness, and rhabdomyolysis. Greater attention should be paid to the more frequent cases of myalgia occurring after iron infusion, which may underlie a rhabdomyolytic event requiring clinical observation.

A 57-year-old man presented to the outpatient clinic with tremor, palpitations, weight loss and fatigue 1 week after receiving the first dose of the Oxford-AstraZeneca SARS-CoV-2 vaccine (ChAdOx1 nCoV-19). Laboratory studies showed a suppressed TSH with elevated total and free T4. Thyroid peroxidase and thyroglobulin antibodies were elevated but thyrotropin receptor autoantibodies were indeterminate. Thyroid scintigraphy with technetium Tc-99m pertechnetate revealed increased diffuse, symmetric uptake. The patient was treated with thiamazole 15 mg three times a day and propranolol with resolution of his symptoms and normalization of his thyroid function tests until discontinuation of the antithyroid drug 6 months after symptom onset.

Inhalants are common drugs of abuse. Hydrocarbons, the active ingredient in most inhalants, exert depressant effects on the central nervous system, causing a ‘high’. In the heart, hydrocarbon toxicity can predispose patients to arrhythmias and heart failure through increased sympathetic susceptibility. We present the case of a 28-year-old female who developed dilated cardiomyopathy in the setting of chronic inhalant abuse.

Bradycardia, renal failure, atrioventricular (AV) nodal blockade, shock, and hyperkalemia (BRASH) syndrome is a relatively new clinical entity. It is often underrecognized, underdiagnosed, and confused with other causes of bradycardia. Treatment of BRASH syndrome differs from the standard bradycardia algorithm in advanced cardiac life support (ACLS), and the cornerstone management remains treating the hyperkalemia, improving renal function by treating the underlying cause, withholding AV nodal blocking agents, and considering dialysis in refractory cases, as any single factor could precipitate the vicious cycle. Here we describe two cases of BRASH syndrome with different clinical presentations that were treated with conservative management: one case in a 77-year-old Japanese woman and the other in an 86-year-old man.

Colorectal cancer (CRC) is the third most common cancer and the fourth most common cause of cancer-related death in the USA. Primary signet ring cell carcinoma (SRCC) of the colon and rectum is extremely rare with a reported incidence of less than 1%. Here we present the case of a 41-year-old man who presented with abdominal pain, severe microcytic anaemia and a negative faecal occult blood test (FOBT). A CT scan of the abdomen revealed thickening of the terminal ileum and proximal right colon with extensive lymphadenopathy and a fistula tract extending from the terminal ileum to the right buttock. Endoscopic features like cobblestoning of the ileocolic junction along with elevated blood and stool inflammatory markers raised suspicion of Crohn’s disease (CD). However, histopathological study surprisingly revealed primary colorectal signet cell carcinoma (PCRSCC) with no evidence of CD. Cases of simultaneous PCRSCC and CD have been reported, but no clear association has been established. Our case is unique in that it presented with classic clinical features of CD, but PCRSCC without any histological evidence of underlying CD was found on histology.

Introduction: Strokes are common but can be caused by a rare illness. Moyamoya disease (MMD) justifies a family assessment because of its hereditary nature and the availability of new therapies.

Case description: A 42-year-old man was admitted because of convulsions with sensorimotor deficit due to a massive cerebral haemorrhage caused by MMD. The fact that the patient died suggested his children should be screened.

Discussion: MMD is rare and its consequences disastrous. Many cases in both children and adults have been described. Investigations should be carried out when the diagnosis is suspected, and, if confirmed, the family should be screened given the genetic nature of some forms of the disease. Effective and increasingly personalized therapeutic solutions are available.

Conclusions: A minority of strokes are caused by rare diseases including MMD. Our current knowledge of this pathology and the treatments available justify a family assessment when the clinical or family context requires it.

Diverticulitis and ulcerative colitis (UC) are two separate colonic pathologies with different underlying mechanisms. Diverticulosis involves herniation of mucosal and submucosal tissue through muscular tissue in response to increased intraluminal pressure. In contrast, it is believed that the muscular tone in patients with UC is reduced due to chronic inflammatory changes. Thus, it has been reported that there may be an inverse relationship between the presence of diverticulosis in patients with UC, in that UC may possibly be protective against developing diverticular disease. Consequently, the co-presence of both pathologies is uncommon. Here we present a case in which a woman with a history of UC and recurrent diverticulitis after elective partial colectomy was admitted for recurrent acute diverticulitis. It is quite challenging to diagnose diverticulitis in ulcerative colitis patients given the usually similar presentation with abdominal pain, diarrhoea and hematochezia. A level of high suspicion is required for diagnosis.

Stevens-Johnson syndrome (SJS) is a severe dermatological disease classically characterized by erythematous target lesions and mucosal involvement. Fuchs syndrome is an incomplete presentation of SJS which has oral, conjunctival and genital manifestations but no skin lesions. To the best of our knowledge, our case of Fuchs syndrome in an 80-year-old man is the first such case related to herpes simplex virus (HSV)-1 infection to be described. Our patient quickly recovered following IVIG therapy, although specific treatment is still a topic of discussion. Research is required on this poorly understood dermatological disease to determine optimum therapy.

Spontaneous renal haemorrhage is a rare but severe condition known as Wunderlich syndrome (WS). The classic presentation includes sudden-onset flank pain, a palpable flank mass and hypovolaemic shock (Lenk’s triad). WS can be due to neoplasms, vascular diseases, cystic rupture, coagulopathies and infections. A contrast-enhanced CT scan of the abdomen is mandatory for diagnosis. Surgery is reserved for haemodynamically unstable patients and those with neoplastic disease. We describe a case of WS in an anticoagulated patient with chronic atrial fibrillation, diabetes mellitus type 2 and hypertension, who developed acute renal failure and severe anaemia, that completely resolved with conservative treatment and discontinuation of anticoagulation therapy.