2022: Vol 9 No 11

Autoimmune encephalitis (AIE) is an inflammatory brain condition with multiple aetiologies but is mainly associated with paraneoplastic syndromes. Several antibodies described in AIE are being investigated in relation to different cancers, including antibodies against Contactin-associated protein-like 2 (Caspr2), which have been associated with thymoma but very rarely with lung cancer. The authors present the case of a 72-year-old man with cardiovascular risk factors, who presented with a 3-week history of left hemichorea following a first unprovoked seizure the week before, with no other signs or symptoms. The patient was submitted to extensive aetiological investigation, testing positive for anti-Caspr2 antibodies in the cerebrospinal fluid. AIE was diagnosed after other possible causes had been excluded. A PET scan showed signs of abnormal metabolism, with a lung biopsy confirming lung adenocarcinoma. This case highlights a very rare association and the importance of a thorough aetiological investigation for neurological complaints.

Extraintestinal strongyloidiasis is rare in patients without immunosuppression. We describe the first case of chylous ascites as a result of strongyloidiasis. Alcohol cessation, diuretic therapy and repeated paracentesis did not lead to improvement of refractory chylous ascites with positive nucleic acid amplification test indicative of Strongyloides stercoralis infection. Only after therapy with ivermectin, could diuretics be withdrawn.

Although direct proof of S. stercoralis was not possible by microscopy, successfully treated strongyloidiasis was confirmed in this patient by the positive and negative nucleic acid amplification tests from ascites before and after treatment together with the clinical improvement only after antiparasitic therapy.

Vitamin B12 deficiency is a common finding in medical practice. It is easily treated with supplementation and typically has a favourable prognosis. In rare circumstances, it can hide a severe disease that should be promptly addressed. We report the case of an acute myeloid leukaemia presenting as an initially predictable B12 deficiency in a vegetarian patient with chronic gastritis. The supplementation rapidly corrected the deficit and the accompanying cytopenias. However, in the following month the cell counts fell once again, leading to the suspicion that other aetiology could be lying beneath the surface. Maintaining a normal peripheral blood smear, the bone marrow biopsy showed myeloblasts and extensive fibrosis compatible with the diagnosis of acute myeloid leukaemia. The neoplasm justified the vitamin deficit by excessive cellular turnover, a vicious cycle only uncovered after supplementation and that ultimately led to the patient’s death.

Takotsubo syndrome (TTS) is usually caused by physical or emotional negative stressors. Sometimes positive emotions trigger a rare form of Takotsubo syndrome, called the “happy heart” syndrome. We discuss the management of a 52-year-old female with happy heart syndrome, the differences between these stress cardiomyopathies and the relationship with hyperthyroidism.

Very often in clinical practice, an inflamed pelvic appendix shows left lower quadrant abdominal pain as the primary painful area. The clinicians are anchored to the most prominent symptom, thereby taking an unnecessary detour in reaching an accurate diagnosis.
A 40-year-old man presented to our emergency department with persistent lower left abdominal pain with a fever of 38 oC from a day earlier. He had a good appetite and repeatedly complained of severe constipation at the time of his visit. Physical examination revealed tenderness in the lower left abdomen without a peritoneal sign. Abdominal ultrasound and non-contrast-enhanced computed tomography revealed a left hydroureter. The next day, a radiologist pointed out the possibility of appendicitis. An urgent laparoscopic appendectomy was performed. 
The intriguing point of this case is the diagnostic delay because of three anchoring biases. First, the typical right lower abdominal pain of appendicitis was shielded by the intense left lower abdominal pain. Moreover, the presence of a left hydroureter distracted the physicians from the actual location of the pain. Furthermore, the presence of constipation anchored the physicians to constipation as the cause of abdominal pain.
In overcoming these biases, specific diagnostic strategies to avoid biases should be implemented.

Pulmonary arterial hypertension (PAH) is an increasingly recognised clinical entity that is associated with connective tissue disease (CTD) in up to one quarter of all diagnoses. Sjögren’s syndrome (SS) is a chronic autoimmune disease characterised by ocular and oral dryness resulting from lacrimal and salivary gland dysfunction. Additionally, SS may involve virtually any organ system and, as a result, the disease is characterised by pleomorphic clinical manifestations. However, SS-PAH reports are scarce, and the area remains insufficiently studied. We present a case of a 75-year-old female with a new diagnosis of PAH and SS.

A 71-year-old female presented with 5 days of diarrhoea and asthenia. Past medical history of rheumatoid arthritis, arterial hypertension, hypertrophic cardiomyopathy and chronic gastritis was treated with leflunomide, deflazacort, esomeprazole, carvedilol and spironolactone. At admission, the patient’s physical examination showed signs of dehydration. Lab results revealed leucocytosis, increased C-reactive protein, hypomagnesaemia, hypocalcaemia and hypokalaemia. A presumption of acute infectious diarrhoea causing hypomagnesaemia with hypocalcaemia and hypokalaemia was made. She was started on ciprofloxacin, IV hydration and electrolyte supplementation with an adequate response. However, magnesium levels fell repeatedly. After excluding other causes for hypomagnesaemia, chronic use of proton pump inhibitors (PPIs) was considered a plausible cause therefore PPI was discontinued, with normalisation of magnesium levels.

Hypomagnesaemia is a common disturbance, mainly caused by diarrhoea, gastrointestinal malabsorption, medications, alcoholism and volume expansion. Clinical manifestations include neuromuscular symptoms, cardiovascular manifestations, hypokalaemia and changes in calcium metabolism. PPI-related hypomagnesaemia has been described in later years particularly in chronic use cases, with a medium prevalence of 27%, but further studies remain necessary to clarify its pathophysiologic mechanism. Since PPIs are widely used, it is essential to be aware of hypomagnesaemia as a possible side effect, particularly in refractory cases and after excluding other common causes.

Ofatumumab is a monoclonal antibody used in the treatment of recurrent and progressive chronic lymphocytic leukaemia (CLL) and was recently approved for the treatment of multiple sclerosis.

We describe the case of a 68-year-old man who presented with complaints of irregular pulse readings while undergoing ofatumumab treatment for recurrent CLL. Electrocardiograms (ECGs) demonstrated premature ventricular contractions (PVCs) which eventually caused cardiomyopathy and failed to resolve despite ablative therapy. Ofatumumab-induced PVCs are confirmed in this case by the existence of documented PVCs on ECGs and the disappearance of these PVCs after the completion of ofatumumab treatment.

To the best of our knowledge, there have been no previously reported cases of PVCs associated with ofatumumab in the literature. 

A 28-year-old pregnant woman presented with swelling of the left foot after she was bitten by a Japanese pit viper. At first the swelling was mild to moderate but then spread up to the left knee the following day. The patient’s condition improved with antivenom treatment. No complication occurred in either the mother or the fetus. Although adverse reaction is a concern, antivenom should be considered as an option even in pregnant women if the benefits outweigh the risks.

Malignant melanoma with metastasis to the stomach is rare and seldom diagnosed before death. The most common gastrointestinal (GI) metastatic site is the small intestine, followed by the colon, rectum and stomach. We present the case of a 55-year-old woman with a history of melanoma who presented with melena and syncope, and was found to have metastatic gastric melanoma.

Suboptimal nutrition can lead to deficiencies in micronutrients such as ascorbic acid (vitamin C), which can present with catastrophic neurological sequalae. Deficiencies of vitamin C, vitamin B3 (niacin) and zinc levels contribute to reduced bone density. Vitamin C associated vertebral fractures although rare in adults, are still treatable if diagnosed early with a thorough clinical and nutritional history and early supplementation.  Radiological clues suggestive of scurvy induced vertebral fractures can be diagnosed on plain X-ray and MRI spine imaging.

Purpura fulminans (PF) is a dermatological manifestation of a life-threatening condition characterized by disseminated intravascular coagulation and endovascular thrombosis. The idiopathic/infectious form is the most common and usually associated with infection by Neisseria meningitidis or Streptococcus pneumoniae. We describe a case of Morganella morganii-induced bacteriaemia complicated with PF in an individual who had undergone a recent urinary tract infection intervention. The patient presented with purpuric skin lesions, fever and hypotension but had no alterations in coagulation parameters or disseminated intravascular coagulation. Aggressive early resuscitation, intravenous antibiotics and wound care were essential to a favourable response.

Introduction: Meningitis-related acute hydrocephalus is rare, challenging to diagnose, and has a high mortality rate. 

Case description: Here we describe the case of a 76-year-old patient diagnosed with bacterial meningitis who developed acute hydrocephalus and subsequently died. 

Discussion: Although meningitis-related acute hydrocephalus is usually non-occlusive, occlusive hydrocephalus may also occur. Moreover, worsening hydrocephalus despite cerebrospinal fluid drainage should prompt a diagnosis of obstructive hydrocephalus. In such conditions, potential management strategies include ventriculoperitoneal shunt and endoscopic third ventriculostomy.

Conclusion: In patients with meningitis-related hydrocephalus, worsening despite appropriate antibiotic administration, treatment may be complicated by ventriculitis and obstructive hydrocephalus, which can be fatal. If intracranial pressure is not medically controlled, bilateral decompression craniectomy should be considered as a potential management strategy.

Introduction: Amyloidosis is a rare illness characterized by the deposition in organs of amyloid, which can be detected by histological staining. Amyloidosis restricted to the lower respiratory tract is unusual.

Results: We reported the case of a 68-year-old woman with no history of chronic disease who presented with dyspnoea on exertion, cough and fatigue. The physical examination was unremarkable. A CT scan showed a cystic mass with a thickened wall in the apical segment of the left lower lobe. A biopsy of the mass was performed, and histological and immunohistochemical study confirmed the diagnosis of AL amyloidosis. The patient’s clinical and radiological symptoms spontaneously improved without treatment after 3 years.

Conclusion: Amyloid-related cystic lung disease is a rare presentation of amyloidosis in the thorax. More case reports are required to determine if such masses can resolve without treatment and whether amyloid-associated cystic lung disease actually exists.