European Journal of Case Reports in Internal Medicine 2020-09-17T18:48:07+00:00 Editorial Office Open Journal Systems <p><strong>The&nbsp;<span class="HPblu">European Journal of Case Reports in Internal Medicine</span>&nbsp;</strong>is an official journal of the European Federation of Internal Medicine (EFIM), representing 35 national societies from&nbsp;<a href="">33 European countries</a>.&nbsp;<br><br>The journal’s mission is to promote the best medical practice and innovation in the field of acute and general medicine. It also provides a forum for internal medicine doctors where they can share new approaches with the aim of improving diagnostic and clinical skills in this field.&nbsp;<strong><br><span class="HPblu">EJCRIM&nbsp;</span></strong>welcomes high-quality case reports describing unusual or complex cases that an internist may encounter in everyday practice. The cases should either demonstrate the appropriateness of a diagnostic/therapeutic approach, describe a new procedure or maneuver, or show unusual manifestations of a disease or unexpected reactions. The Journal only accepts and publishes those case reports whose learning points provide new insight, contribute to advancing medical knowledge both in terms of diagnostics and therapeutic approaches. Case reports of medical errors, therefore, are also welcome as long as they provide innovative measures on how to prevent them in the current practice (Instructive Errors).&nbsp;<strong><br></strong>The Journal may also consider brief and reasoned reports on issues relevant to the practice of Internal Medicine, as well as Abstracts submitted to the scientific meetings of acknowledged medical societies.<br><br> <strong>EJCRIM</strong> is peer-reviewed with single-blind review and freely accessible to all.</p> ENCEPHALOPATHY AFTER BENDAMUSTINE TREATMENT, A RARE SIDE EFFECT? 2020-09-17T18:48:07+00:00 Carolina Amado Gisela Ferreira Fernando Silva Mariana Silva Leal Margarida Cruz <p>Bendamustine is a chemotherapeutic drug associated with frequent hematologic and gastrointestinal adverse effects and, more rarely, neurological toxicity.</p> <p>We present a case of a 79-year-old man withFollicular Lymphoma, grade 2, Ann-Arbor stage IV-A, FLIPI 4, High Risk, with bulky disease and vital organ compression, treated with R-CHOP and then R- Bendamustine, who developed an encephalopathy roughly 2 months after the last cycle. After ruling out other possible etiologies, we assumed patient’s encephalopathy was due to a delayed bendamustine side effect, possibly aggravated by the concomitant administration of Rituximab.</p> <p>The authors intend to alert for this rare adverse effect, its difficult identification and the need to rule out other etiologies.</p> Copyright (c) Unusual location of a recurrent epidermoid cyst 2020-09-17T14:51:40+00:00 OUMNIYA ABOUHANINE AICHA MERZEM VIANNEY NDAYISHIMIYE HASNAA BELGADIR OMAR AMRISS NADIA MOUSSALI NAIMA EL BENNA <p><strong>Introduction</strong></p> <p>Epidermoid cysts of the temporal bone are rare benign lesions that grow slowly.</p> <p><strong>Patient and Methods</strong></p> <p>We report a case of a 69-year-old female patient followed up for a symptomatic intradiploic epidermoid cyst of the temporal scale and left mastoid region, operated on and recurrent.</p> <p><strong>Results</strong></p> <p>MRI noted a well-limited lesion in T1 hyposignal, T2 hypersignal, FLAIR and diffusion not enhanced by gadolinium, compressive, with bone lysis on CT.</p> <p><strong>Conclusion</strong></p> <p>The epidermoid cysts of the temporal bone are rare benign lesions whose diagnosis is presumed with a lesion of fluid signal except in FLAIR sequence.</p> Copyright (c) Subcutaneous abscess secondary to a totally implantable venous access port (TIVAPs) infection 2020-09-17T11:35:12+00:00 Sonia Morón Losada Cristina Macía-Rodríguez Ana Belén Sanjurjo Rivas Javier de la Fuente Aguado <p>A 64-year-old woman with an infiltrative left breast carcinoma presented with fever, pain, redness and swelling in her front right arm where a brachial venous access port is placed. A computerized tomography showed a subcutaneous abscess and the blood, port and subcutaneous abscess cultures were positive for <em>Staphylococcus aureus.</em> The patient was successfully treated with Cloxacilin for 14 days after the abscess was drained.</p> Copyright (c) Graves’ disease combined with acute myocarditis and thyrotoxic periodic paralysis:a case report and review of the literature 2020-09-16T00:37:18+00:00 Mengmei Li Weisheng Liu Ping Li Ruicai Shan Jun Teng <p>Graves’ disease is the most common reason for hyperthyroidism which manifest as multi-system changes.Among these clinical manifestations acute myocarditis and thyrotoxic periodic paralysis are very rare and patients who are combined with both two haven’t been reported yet.The etiology may attribute to autoimmunity.Physicians should check thyroid function when facing patients with hypokalemia and cardiac symptoms.</p> <p>We report a rare case of Graves’ disease combined with acute myocarditis and thyrotoxic periodic paralysis.The patient was a 25-year-old Chinese young male who was healthy previously.He was suddenly paralyzed when he woke up in the morning,then he felt palpitations and dyspnea.He was then sent to our emergency department by ambulance.Upon arrival,the electrocardiograph showed junctional tackycardia and ST depression in all leads,laboratory findings showed extreme hypokalemia and elevated troponin I,he was given potassium tablets and also intravenous potassium supplement, then metoprolol was given to control heart rate,after this coronary CTA was perfomed and there was no abnormal findings of the coronary artery,so acute myocarditis was diagnosed.Afterwards,he was admitted to our ED ward. We continued giving him potassium supplement and metoprolol,further testing showed Graves’ disease and continued elevated cardiac enzymes and BNP. We suggested the patient to accept cardiac MR(CMR) and endocardial myocardial biopsy(EMB),but the patient refused further examination.By consulting an endocrinologist,we then gave him methiamazole to treat hyperthyroidism,and trimetazidine,calcium dibutyryl adenosine cyclophosphate for myocarditis.After 6 days,the patient’s cardiac enzymes,BNP,potassium and electrocardiograph returned to normal. His symptoms were relieved and he was discharged from the hospital. During a 6-mouth follow up the patient continued taking metoprolol, trimetazidine and methiamazole. He was asymptomatic and checked his thyroid,liver,kidney function routinely to adjust his medicine. His hyperthyroid state was controlled.</p> <p>Acute myocarditis and thyrotoxic periodic paralysis are two rare manifestations of Graves’ disease.In our case,we almost missed the diagnosis of Graves’ disease,we first thought acute myocarditis was the primary cause of the patient’s clinical manifestations.So physicians should think of Graves’ disease when patients have unknown reason of hypokalemia and elevated cardiac enzymes.</p> <p>Learning points:</p> <p>?Graves’ disease combined with acute myocarditis is a rare manifestation,the etiology is considered to be due to an autoinmmune process. It is usually misdiagnosed as myocardial infarction.</p> <p>?Graves’ disease manifest as thyrotoxic periodic paralysis is usually seen in young males,it can be manifested as sudden paralysis and extreme hypokalemia.The etiology may attribute to high carbohydrate intake.The correction of hypokalemia and hyperthyroidism will relieve the symptoms.</p> <p>?The electrocardiograph of junctional tachycardia usually shows absence of P waves and heart rate is with 60-130 rates per minute,which is a manifestation of acute myocarditis.Graves’ disease can be diagnosed based on the thyroid function and thyroid static imaging.</p> <p>Key words: Graves’ diease,myocarditis,thyrotoxic periodic paralysis,junctional tachycardia.</p> Copyright (c) Association of Hashimoto’s Thyroiditis and Burkitt Lymphoma: a rare condition to think about 2020-09-15T21:16:27+00:00 Dea Degabriel Tanja Fusi-Schmidhauser <p>Primary thyroid lymphoma is a rare disease that accounts for only 1-5% of all thyroid cancers. In particular, primary Burkitt's lymphoma of the thyroid is very rare (1-2%) [1, 2]. &nbsp;The most common condition resulting in lymphoid migration is autoimmune thyroiditis (i.e., Hashimoto’s thyroiditis). The relationship between cancer and inflammation was first described by Rudolf Virchow in 1863; when he noted leukocytes in neoplastic tissue and suggested that this reflected the origin of cancer at sites of chronic inflammation.</p> <p>We present the case of a 72-year-old woman who was recently diagnosed with Hashimoto's thyroiditis and who developed a low-grade fever, fatigue and weight loss that prompted to perform a thyroid biopsy to rule out an underlying primary thyroid lymphoma. This case reports offers the opportunity to review the association between Hashimoto’s thyroiditis and primary thyroid lymphoma. Furthermore, it underlines the importance to consider the diagnosis of lymphoma when a thyroid mass is found in patients with an underlying Hashimoto’s disease, as the timely management is essential for survival of this rare thyroid condition.</p> <p><strong>Learning points </strong></p> <ul> <li>Assessing the relationship between Hashimoto’s thyroiditis and Burkitt lymphoma</li> <li>Addressing signs and symptoms of lymphoma in a patient with an underlying Hashimoto's thyroiditis</li> <li>Raising the awareness about the management of Burkitt lymphoma and the impact of delaying specific treatment on prognosis</li> </ul> <p><strong>Keywords </strong>Hashimoto's Thyroiditis, Burkitt Lymphoma, thyroid nodule biopsy</p> Copyright (c) Portal Vein Thrombosis Secondary To Occult Polycythemia Vera 2020-09-15T15:14:20+00:00 Antón F. R. Gameiro António Robalo Nunes Paula Guerra Estela Mateus Fátima Fernandes <p>Portal vein thrombosis (PVT) is an uncommon finding in non-cirrhotic patients. The underlying etiology is challenging, unfolding a large number of differential diagnosis. We present a PVT case in an anemic patient, with chronic iron and folic acid deficiency, masking an underlying Polycythemia vera (PV). Only an accurate review of the patient’s clinical history allowed the identification of a short period of laboratorial erythrocytosis, six months before the clinical onset, while the patient was on iron and folic acid supplementation. Subsequent investigation confirmed the presence of V617F JAK2 mutation. Myeloproliferative disorders are associated with systemic prothrombotic states. Polycythemia vera is distinguished clinically from the other myeloproliferative disorders by the presence of an increased red blood cell mass. This case emphasizes the importance of always considering myeloproliferative disorders in the etiological investigation of PVT, even in patients who apparently do not fulfill PV criteria.</p> Copyright (c) A delayed diagnosis of pulmonary thromboembolism which was related with too much focusing on the COVID-19 2020-09-15T12:34:23+00:00 Yukinori Harada Taro Shimizu <p>The pandemic of the coronavirus disease 2019 (COVID-19) has made it difficult situation for physicians to keep their usual diagnostic thinking process. We present the case of a 25-year-old man with adjustment disorder who developed dyspnea. He was concern about the COVID-19, but the test result was negative. After excluding the COVID-19, the physician concluded that his symptoms were related to his psychiatric conditions. However, the patient was diagnosed with pulmonary thromboembolism by another physician. To avoid missing diagnosis, physicians must consider zero-based thinking, regardless of COVID-19 concerns, without being distracted their attention from the patient's core problem.</p> Copyright (c) Persistent ketamine-induced cholangiopathy: An approach to management 2020-09-14T16:36:18+00:00 Tiwonge Nyirenda Ahmad Reza Shirazi-Nejad Ashraf Soliman Soliman <p>A 32-year-old man presented with profound jaundice, rigors and decreased appetite. Initial liver function tests (LFTs) were deranged in a cholestatic pattern with imaging demonstrating a dilated biliary system, with no filling defects. It has been observed that LFTs typically improve upon ketamine cessation, but this case demonstrated escalating hyperbilirubinaemia, despite ketamine cessation. Recurrent cholangitis and biliary duct stricturing were demonstrated on magnetic resonance cholangiopancreatography (MRCP). This prompted investigation of other biliary pathology and consideration for intervention.</p> Copyright (c) An Eminent Absent 2020-09-14T12:32:49+00:00 Giorgia Protti Fabrizio Elia Francesca Bosco Franco Aprà <p>Among thrombophilic risk factors for deep venous thrombosis (DVT), agenesia of the inferior vena cava (AIVC) is a very rare one, but it must be considered in specific settings. Here we present the case of an 18-year-old woman who was admitted to the Emergency Department with swelling and pain of her left leg. Clinical exam and ultrasonography detected extensive proximal DVT of the left leg. After an attempt of mechanical thrombectomy failed, an abdomen TC scan was obtained, which demonstrated bilateral thrombosis of the iliac-femoral axis in the context of congenital agenesia of inferior vena cava.</p> Copyright (c) Internal Herniation of the Caecum and Ascending Colon through the foramen of Winslow: A Case Report 2020-09-14T10:53:58+00:00 Omar Lasheen Aliasger Amin <p><strong><em>Introduction:</em></strong> An internal hernia occurs when part of the bowel protrudes through a mesenteric or a peritoneal orifice which could be either normally present or acquired. These hernias usually represent a challenge to diagnose. Of the natural anatomical orifices is the Foramen of Winslow through which the caecum and the ascending colon could herniate.</p> <p><strong><em>Case Report:</em></strong> An 85 year old gentleman presented to A+E with a one day history of abdominal pain. His pain had a sudden onset, an intermittent course and was mostly limited to the epigastric region. He was nauseated but not vomiting. He had opened his bowels a day before presenting to the hospital. CT scan of the abdomen and the pelvis revealed herniation of the caecal pole through the foramen of Winslow and into the lesser sac. The decision was made to take the patient to theater for laparotomy where it was revealed that the caecum and the part of the ascending colon has herniated through the foramen of Winslow. The content of the hernia was carefully reduced and it was all viable and right hemicolectomy was performed.</p> <p><strong><em>Conclusion:</em></strong> Unfortunately with the scarcity of similar cases, we currently have no consensus of management. How we deal with the hernia at laparotomy would be usually the choice of the surgeon depending on tissue viability and other operative findings.</p> Copyright (c)