https://ejcrim.com/index.php/EJCRIM/issue/feed European Journal of Case Reports in Internal Medicine 2019-12-05T08:24:34+00:00 Editorial Office ejcrim@smc-media.eu 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="http://www.efim.org/about/member-countries">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> https://ejcrim.com/index.php/EJCRIM/article/view/1341 When Zoster Virus Hides a Primary Brain Lymphoma 2019-12-05T08:24:34+00:00 Rafael Ferreira Nascimento rafaelnascimento@campus.ul.pt João Miguel Freitas joaomigueldefreitas@gmail.com Maria da Luz Brazão mlbrazao@hotmail.com <p><em>Aim:</em> To describe an unusual presentation of a primary lymphoma of the central nervous system in a patient who, four months prior to admission, was diagnosed with herpes zoster ophthalmicus (HZO). <br> <em>Case description:</em> A 68-year-old man, with a history of HZO, was admitted to the emergency department with nausea and vomiting that had persisted over the previous two weeks. Neurological evaluation showed right ptosis, divergent strabismus and anisocoria. Blood tests showed high c-reactive protein, while serology was negative for human immunodeficiency virus. A brain CT scan revealed three round lesions, slightly hyperdense, periventricular in the occipital and frontal regions, which biopsy revealed to be a diffuse large B-cell lymphoma. The patient started chemotherapy but progression to death was inevitable.<br> <em>Conclusion:</em> The authors describe an unusual presentation of primary lymphoma of the central nervous system and urge physicians to be aware of this presentation in order to avoid misdiagnosis.</p> 2019-12-05T08:24:33+00:00 ##submission.copyrightStatement## https://ejcrim.com/index.php/EJCRIM/article/view/1311 Two Dabigatran Fast Reversals in a 4-month Period – a Case Report 2019-12-04T09:24:01+00:00 Vítor Fagundes vitorfagundes@hotmail.com Mari Mesquita mari.mesquita@chts.min-saude.pt <p><em>Introduction:</em> Idarucizumab is available for immediate reversal of dabigatran-induced anticoagulation in life-threatening bleeding or urgent surgery in patients with non-valvular atrial fibrillation (nvAF).<br> <em>Case description:</em> We report a case of an 85-year-old female treated with dabigatran for nvAF, submitted to two fast reversal procedures with idarucizumab in a 4-month period. In the first emergency episode, the patient was admitted due to a fall-related cerebral haemorrhage and subdural haematoma. There was a fast reversal of the effects of dabigatran after idarucizumab administration, which allowed stoppage of the bleeding and a decrease in intracranial pressure, with full patient recovery. Four months later, the patient revisited the hospital complaining of diffuse abdominal pain while on the same antithrombotic therapy. Physical examination showed signs of peritoneal irritation and the use of idarucizumab to reverse the effects of dabigatran was decided upon to secure normal bleeding conditions before surgery.<br> <em>Discussion:</em> Idarucizumab is an efficient, safe and feasible option for dabigatran-treated nvAF patients, when urgent anticoagulant effect reversal is needed.</p> 2019-12-04T09:08:53+00:00 ##submission.copyrightStatement## https://ejcrim.com/index.php/EJCRIM/article/view/1336 Cervical Lymphadenopathy in a Nonagenarian Woman: What to Think? 2019-12-04T09:24:01+00:00 Vanessa Meireles Chaves vanessameirelesc@gmail.com Fernando Nogueira fernandomnogueira@hotmail.com Gilberto Pires da Rosa gilbertopiresrosa@gmail.com Sofia Tavares sft.tavares@gmail.com Inês Ferreira inessalomebf@gmail.com Ana Oliveira Monteiro ana.galrao@hotmail.com Ester Ferreira esterferreira28@gmail.com <p>Tuberculosis remains a worldwide public health problem. Cervical tuberculous lymphadenitis (TBL) or scrofula is the most common form of extrapulmonary tuberculosis, affecting the cervical lymph nodes. We report the case of a 93-year-old woman presenting with cervical adenopathies with 3 months duration. Fine needle aspiration (FNA) biopsy yielded a noncaseous granulomatous process, but was negative for Mycobacterium tuberculosis (MT). As the adenopathies had grown, an excisional biopsy was performed. An extensive study of infectious aetiologies was performed, including for MT, with a negative outcome. Owing to the persistence of cervical lymphadenitis with caseous granulomas, a diagnosis of TBL was strongly suspected and presumptive treatment was initiated. Afterwards, diagnostic confirmation was obtained by isolation of MT in the lymph node culture. The patient presented a favourable clinical outcome. This case highlights that a high index of suspicion is essential for the diagnosis of TBL, especially in the elderly, and emphasizes the importance of pursuing diagnostic confirmation, in which FNA and excisional biopsy plays a key role.</p> 2019-12-03T08:34:17+00:00 ##submission.copyrightStatement## https://ejcrim.com/index.php/EJCRIM/article/view/1337 Moyamoya Syndrome after Radiation Therapy: a Clinical Report 2019-12-04T09:24:01+00:00 Paulo Almeida pauloricardo.salmeida@gmail.com Ana Rocha ana_rocha99@hotmail.com Gonçalo Alves goncalocalves@hotmail.com Tiago Parreira tiagoparreira@hotmail.com Maria Silva silva_marialuis@yahoo.com António Cerejo a.cerejo@sapo.pt Pedro Abreu pmabreu@netcabo.pt Ana Monteiro ana.mg.monteiro@gmail.com <p>Moyamoya syndrome (MMS) is a rare, chronic and progressive vasculopathy with a characteristic angiographic pattern and well-recognized predisposing conditions, such as cranial therapeutic radiation. We report the case of a 36-year-old Caucasian female with a history of craniopharyngioma treated with whole-brain radiotherapy 20 years previously. She was admitted to the emergency department with disorientation and imperceptible speech lasting for 1 hour. Upon examination, she had slight motor aphasia, without sensory or motor deficits. However, the neurological deficits worsened on standing position. The computed tomography (CT) angiogram and transcranial Doppler ultrasonography revealed occlusion of the distal portion of the left internal carotid artery (ICA). Mechanical thrombectomy was attempted without success. Head CT was repeated, revealing left periventricular acute ischaemic stroke. The cerebral angiography showed total occlusion of the left ICA with an exuberant network of transdural collateral vessels, confirming MMS. The patient completed a functional rehabilitation program with progressive improvement of deficits and maintained a multidisciplinary follow-up. MMS is a serious late complication from cranial radiation therapy and a well-described risk factor for ischaemic stroke in younger patients. Therefore, early detection and prompt treatment are mandatory, as the consequences can be disastrous, such as cognitive and neurologic decline due to repeated strokes.</p> 2019-12-02T09:31:50+00:00 ##submission.copyrightStatement## https://ejcrim.com/index.php/EJCRIM/article/view/1338 Haemoglobin A1C Levels Constantly Below Lower Reference Limit in a Diabetic Patient With Microcytic Anaemia 2019-12-04T09:24:01+00:00 Frank Sheng Fan fantast.fan@msa.hinet.net Chih-Hao Chen drchen.cv@gmail.com Hui-Chun Yang yang324557@gmail.com <p><em>Introduction:</em> Haemoglobin A<sub>1C</sub> (A1C), as a parameter of long-term glycaemic control, has been adopted to guide diabetic therapy all over the world. However, falsely high or low A<sub>1C</sub> could be troublesome in daily practice. <br> <em>Case description:</em> A 75-year-old male diabetic patient affected by a reasonably inferred life-long history of microcytic anaemia was found to have abnormally low A<sub>1C</sub> values in the previous 5 months. Subsequent laboratory assessment with brilliant cresyl blue staining and haemoglobin electrophoresis detected haemoglobin H disease as the underlying cause of both the microcytic anaemia and the disturbed A<sub>1C</sub> measurement. <br> <em>Discussion:</em> Enhanced erythrocyte destruction such as in haemoglobin H disease could explain a falsely decreased A<sub>1C</sub> level very well. Upon facing a questionable A<sub>1C</sub> value, physicians dealing with diabetes should consider the possibility of undiscovered underlying causes rather than too tightly glycaemic control.</p> 2019-11-29T09:35:20+00:00 ##submission.copyrightStatement## https://ejcrim.com/index.php/EJCRIM/article/view/1237 Cardiac Amyloidosis Associated with Apolipoprotein A-IV Deposition Diagnosed by Mass Spectrometry-Based Proteomic Analysis 2019-12-04T09:24:01+00:00 Elisabete Martins elisabetemartins09@gmail.com Joana Urbano joanaurb@gmail.com Sérgio Leite sergiolmml@gmail.com Adriana Pinto adriana.aslpinto@gmail.com Raquel Garcia raquel.motagarcia@gmail.com Rui Bergantim rui.bergantim@gmail.com Pedro Rodrigues Pereira pe_r_pereira@hotmail.com Paulo Pinho Costa paulo.costa@insa.min-saude.pt Hugo Osório hosorio@i3s.up.pt Isabel Tavares isabeltavaressalome@gmail.com <p>Amyloidosis is a group of disorders characterised by the accumulation of extracellular deposits of insoluble protein aggregates. Clinical management depends on the accurate identification of the amyloid precursor and underlying cause. We describe a rare case of apolipoprotein A-IV cardiac amyloidosis, the diagnosis of which required mass spectrometry-based proteomic analysis.</p> 2019-11-27T08:48:06+00:00 ##submission.copyrightStatement## https://ejcrim.com/index.php/EJCRIM/article/view/1224 Catastrophic Gastrointestinal Bleeding: Always Consider Meckel’s Diverticulum 2019-11-26T15:51:21+00:00 Filipa Pedro filipa_sofia25@hotmail.com Joana Romano joanaromanoc@gmail.com Marta Rebelo marta.crebelo@gmail.com Rogério Matias rmatias@chlo.min-saude.pt Eduarda Carmo eduardagcarmo@gmail.com <p>Meckel’s diverticulum, a congenital malformation of the gastrointestinal tract, is asymptomatic in the majority of patients but can be associated with some complications. Gastrointestinal bleeding is one such complication and is more common in children than in adults. Despite the variety of examinations available, diagnosis can be difficult, especially in older patients, because the sensitivity of examinations decreases with patient age. Here we present the case of a young man with gastrointestinal bleeding in whom a diagnosis of Meckel’s diverticulum was made intra-operatively.</p> 2019-11-25T08:48:50+00:00 ##submission.copyrightStatement## https://ejcrim.com/index.php/EJCRIM/article/view/1299 A Case of Fluorine-18 Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Imaging of Eosinophilic Granulomatosis With Polyangiitis Combined With Non-tuberculous Mycobacterium 2019-11-22T16:13:17+00:00 Juhyung Kim dnakim1@gmail.com Man-Hoon Han one-many@hanmail.net Sang Jin Lee dream1331@naver.com <p>Fluorine-18-fluorodeoxyglucose positron emission tomography/ computed tomography (18FDG-PET/CT) has been used to diagnose vasculitis, tuberculosis and malignancy. Because PET/CT scan show hotspots during an activation of clinically suspected lesions, it is widely used for diagnosis. However, there are rare cases of PET/CT images for vasculitis combined with tuberculosis. Here we report a case of an eosinophilic granulomatosis with polyangiitis in a patient with disseminated non-tuberculosis mycobacterial infection in multiple sites mimicking metastatic malignacy and describe the associated PET/CT scan findings before and after treatment.</p> 2019-11-22T08:57:09+00:00 ##submission.copyrightStatement## https://ejcrim.com/index.php/EJCRIM/article/view/1254 Pituitary Apoplexy Following Systemic Anticoagulation 2019-11-22T09:07:16+00:00 Ana Rita Mairos dos Santos ritamaysantos@gmail.com Carlos Tavares Bello bello.carlos04@googlemail.com Alice Sousa ma_cevolo@hotmail.com João Sequeira Duarte sequeira.duarte@netcabo.pt Luís Barreto Campos luisbarretocampos@gmail.com <p>Pituitary apoplexy is a rare medico-surgical emergency that stems from an acute expansion of a pituitary adenoma from infarction or haemorrhage and where the treatment strategy is still controversial. Clinical presentation is highly variable and a high index of suspicion is needed to make the diagnosis. Furthermore, in less than half of cases, a precipitating event is identified. We report a case of a 74-year-old female who, after introduction of anticoagulation for pulmonary thromboembolism, presented with pituitary apoplexy heralded by acute adrenal insufficiency, headaches, visual symptoms and hypogonadotropic hypogonadism. Timely initiation of corticosteroids was crucial, and after stabilisation, a conservative treatment strategy was favoured with good long-term prognosis. Long-term follow-up of pituitary function also revealed new growth hormone deficiency.</p> 2019-11-20T09:18:25+00:00 ##submission.copyrightStatement## https://ejcrim.com/index.php/EJCRIM/article/view/1326 The Reversed Halo Sign: Not Such a Specific Sign of Organising Pneumonia 2019-11-26T15:51:21+00:00 Inês Carrilho Oliveira ines.l.f.c.oliveira@gmail.com Joana Carvalho joana.svc@hotmail.com Rita Rosa rita_csrosa@hotmail.com Catarina Barata catarinabarata22@gmail.com <p>The reversed halo sign is defined as a focal rounded area of ground-glass opacity surrounded by a more or less complete ring of consolidation. It is a relatively rare sign and initially considered a specific sign of organising pneumonia. We report the case of a 55-year-old female who was being followed-up in a pulmonology consultation due to a 6 mm nodule which required vigilance. On a re-evaluation chest CT scan, besides a stable 6 mm nodule, a 36 mm mass with the reversed halo sign was diagnosed. The presence of the reversed halo sign misled the multidisciplinary team into the diagnosis of organising pneumonia and initiation of corticotherapy was suggested. However, after further investigation, a final diagnosis of pulmonary tuberculosis was made. Even though this sign is relatively rare, and still considered an important clue to the diagnosis of organising pneumonia in immunocompetent patients, other causes must be excluded before starting treatment.</p> 2019-11-18T00:00:00+00:00 ##submission.copyrightStatement##