2023: Vol 10 No 4

Introduction: High altitude illness is a complication of rapid ascent above 2,500 m elevation. Ventilatory, circulatory and haematological adjustments, known as acclimatization, occur to maintain adequate delivery of oxygen. Although (non-)pharmaceutical strategies that modulate ventilation and circulation have long been accepted, the haematological approach has not.

Case description: This report describes the application of a comprehensive strategy, including prior pre-acclimatization using an erythropoiesis-stimulating agent (ESA), in two healthy subjects ascending from sea level to 6,268 m. Following ESA administration 30 days prior to ascent, the subjects had a cumulative haemoglobin rise of 7.1% and 11.9%, respectively. Both subjects experienced minimal symptoms during four incremental ascents to the final altitude and no adverse events occurred.

Discussion: This report has limited external validity, lacking both a sample size and controls, but can serve as practical exploration of the concept. Administration of an ESA may be a safe and useful pre-acclimatization strategy but cannot be recommended based on current evidence. More comprehensive research is needed.

Intrathoracic kidney is a very rare finding, representing less than 5% of all renal ectopias. Because of the location of the liver, thoracic kidney on the right side is much less common than thoracic kidney on the left side. Although an increasing number of case reports are being published in the literature, few describe the impact of the ectopia on kidney function. We report the case of a woman with intrathoracic right kidney and chronic kidney disease that was initially misdiagnosed as pneumonia because of its presentation on chest x-ray. We highlight the need to including this condition in the differential diagnosis as the literature rarely links it to changes in kidney function.

Sweet's syndrome or acute febrile neutrophilic dermatosis is characterized by an acute inflammatory skin eruption of oedematous and erythematous papules, plaques or nodules, accompanied by fever, and leucocytosis with possible extracutaneous involvement. Aetiologies include infections, inflammatory bowel disease, pregnancy or malignancy, or the syndrome may be drug-induced by many classes of medications or very rarely, radiocontrast exposure. Herein, the authors report a case of radiocontrast-induced bullous Sweet's syndrome and contrast-induced acute kidney injury in a woman in her 60s with a complex medical history.

Introduction: Groove pancreatitis is a rare form of chronic pancreatitis. Its radiological diagnosis is challenging and it can be difficult to distinguish from pancreaticoduodenal malignancy.

Case description: A 64-year-old woman was admitted to our internal medicine ward after she contracted severe COVID-19 pneumonia requiring mechanical ventilation. She presented with right upper abdominal pain, and a CT scan showed pancreaticoduodenal inflammatory tissue; malignancy was ruled out.

Conclusion: Diagnosing groove pancreatitis is challenging and malignancy must be quickly excluded. No cases of COVID-19-associated groove pancreatitis have been previously described.

Introduction: The Fontan procedure is used to treat congenital heart defects and has improved long-term survival. Long-term complications include liver disease due to congestive hepatopathy. Fontan-related cirrhosis can manifest with ascites, gastrointestinal bleeding and encephalopathy.

Case description: A 43-year-old man with history of Fontan surgery was admitted with COVID-19 pneumonia. There was rapid clinical and neurological deterioration, with coma and shock. CT imaging showed thrombosis of the Fontan conduit. The patient was successfully subjected to recanalization of the Fontan circulation, with progressive improvement of coma.

Discussion: Fontan-associated liver disease is a major complication following the Fontan procedure. Clinicians must be aware of this pathology during patient follow-up.

An otogenic origin is identified in over half of cases pertaining to brain abscess.  They are typically associated with either mastoiditis, cholesteatoma or otitis media and carry a risk of mortality in the region of twenty per cent.  We describe the case of a 71-year-old gentleman presenting with acute confusion and unilateral neurology in the absence of systemic signs of sepsis or associated laboratory biomarkers who was diagnosed with a particularly large spherical temporal lobe brain abscess of 5cm diameter on neuroimaging.  This abscess was treated successfully with craniotomy, evacuation and a prolonged course of anti-microbials enabling him to return to his pre-morbid level of functioning.  His prolonged course of anti-microbials was complicated by a candidaemia and colonisation of an indwelling central venous catheter that was treated successfully with antifungals.

Introduction: Inflammatory myofibroblastic tumours are rare neoplasms which most commonly affect children and young adults. With an intermediate malignant potential, they are typically detected in the abdomen, lung, mediastinum, head and neck, gastrointestinal tract, and genitourinary tract.

Case description: We describe the case of a 33-year-old postpartum woman incidentally diagnosed with a pulmonary inflammatory myofibroblastic tumour following complaints of poorly controlled hypertension a week after caesarean section. She was ALK-negative and received an ALK inhibitor with complete resolution of the lesion. A ROS1–TFG fusion confirmed the diagnosis of an inflammatory myofibroblastic tumour after CT-guided fine needle aspiration.

Discussion: This case highlights an uncommon presentation posing a diagnostic and therapeutic challenge and the potential treatment option of crizotinib.

Chest pain and dyspnoea are among the most common complaints seen in the emergency room and each symptom calls for a broad differential diagnosis. Large hiatal hernias are infrequent, but they can lead to atypical symptoms mimicking different cardiovascular, pulmonary and neoplastic diseases. We present two cases of older patients with an apparent left atrial mass on transthoracic echocardiography, which was subsequently identified as hiatal hernia by other imaging modalities. A multidisciplinary team with multimodality imaging is necessary for diagnostic work-up of chest pain and dyspnoea of non-cardiac origin and especially for a suspected mass compressing the heart, causing chest discomfort.

The alkaloid derivatives of Mitragyna speciosa, commonly known as kratom, pose a threat to society due to its potential for abuse, adverse reactions and tendency to be used as self-medication for opioid withdrawal, pain and mood disorders. A number of deaths have been reported along with complications such as respiratory depression, cardiopulmonary arrest, torsade de pointes and seizures. Its various effects and potential are yet to be fully studied. We describe the case of a healthy young male who presented with progressive respiratory failure requiring mechanical ventilation. Imaging revealed multifocal lung infiltrates while extensive infectious and cardiac work-up was negative. Based on the clinical course, a diagnosis of acute respiratory distress syndrome (ARDS) caused by kratom was made. The patient showed gradual clinical improvement and was weaned off supplemental oxygen. This case highlights yet another adverse reaction to kratom and the growing threat posed by its use.

Unstable angina, characteristic of coronary artery disease, is caused by in-situ clot formation complicating ruptured atheromatous plaque. Abdominal angina, however, usually reflects chronic mesenteric ischaemia, caused by multi-vessel stable plaques involving mesenteric arteries. Herein, we describe a patient with new-onset abdominal pain caused by a ruptured atheromatous plaque at the superior mesenteric root. The diagnosis was based on an evident reversible epigastric bruit and high-degree eccentric stenosis caused by a non-calcified atheroma. Symptoms and bruit resolved within 3 weeks on aspirin and statins with regression of the stenotic lesion. Although the condition is likely common, this is the first clear-cut report compatible with 'unstable' abdominal angina, resolved by conservative treatment.