European Journal of Case Reports in Internal Medicine 2021-01-25T12:03:15+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> Can an infection with SARS COV-2 cause or exacerbate rheumatoid arthritis? Description of a clinical case 2021-01-25T12:03:15+00:00 Caterina Naclerio Antonietta Cavallera Raffaele Di Sarno Salvatore Scarpato <p><strong>ABSTRACT</strong></p> <p>Infectious disease can activate the immune system favoring a highly inflammatory response.</p> <p>Rheumatoid Arthritis is a long term inflammatory disease characterized by an autoimmune trigger.</p> <p>What happens when SARS COV 2 infection occurs in a patient suffering from early stage of rheumatoid arthritis?</p> <p>In this clinical case we want to highlight that the infection by SARS COV 2 could esacerbate or precipitate a clinical picture of Rheumatoid Arthritis.</p> <p>This condition should make you reflect on the probable therapeutic implications.</p> Copyright (c) Coronavirus Disease 2019 and Cold Agglutinin Disease: case report with literature review 2021-01-24T23:40:48+00:00 Ruby Gupta Sukhmani Singh Nwabundo Anusim Sachin Gupta Sorab Gupta Marianne Huben George Howard Ishmael Jaiyesimi <p>The pandemic of coronavirus disease 2019 (COVID-19) has caused significant morbidity and mortality worldwide. While patients with COVID-19 most frequently present with pneumonia, respiratory failure and acute respiratory distress syndrome, increasing cases of immune-mediated disorders such as autoimmune thrombocytopenia, hemolytic anemia, and antiphospholipid syndrome have been reported. In this article we describe rare case of cold agglutinin disease (CAD) in a patient with COVID-19. This is a 77-year-old male with a history of glucose-6-phosphate dehydrogenase (G6PD) deficiency who presented with COVID-19 infection and acute respiratory failure. Initially he was started on intravenous steroids, antibiotics and hydroxychloroquine. Laboratory analysis revealed hemolytic anemia with positive direct anti-globulin test (DAT) and high titers of cold agglutinins. Later, hydroxychloroquine was stopped due to suspicion of hemolysis due to G6PD deficiency. Patient continued to have evidence of hemolysis despite discontinuing hydroxychloroquine. Unfortunately, patient’s respiratory failure progressed, and he died.&nbsp;In summary,CAD is a rare and poorly understood fatal disorder in patients with COVID-19. No definite treatment for CAD in COVID-19 patients has been approved so far. In this article, we have described this case in detail and reviewed literature on this topic to help clinicians manage this life-threatening manifestation of COVID-19.</p> Copyright (c) Giant rectal villous adenoma presenting with acute renal failure 2021-01-24T18:48:35+00:00 Ali Mohammed <p>Colorectal adenomatous polyps are relatively common as they are found in 25% of colonoscopy studies and 10% of sigmoidoscopy studies, some of them are sporadic while others are part of other syndromes.Severe electrolyte and fluid depletion secondary to a hypersecretory rectal neoplasm is a rare life-threatening condition, leading to severe dehydration and acute renal failure. We are presenting a case of a 75-year-old gentleman who suffered from a typical picture of McKittrick-Wheelock syndrome for ten months and unfortunately was only diagnosed with rectal villous adenoma when he presented with acute kidney injury.</p> <p>&nbsp;</p> <p>McKittrick-Wheelock syndrome should be on top of the differential diagnosis list, especially when dealing with elderly patients presenting with persistent watery diarrhoea.</p> <p>&nbsp;</p> <p><strong>KEY WORDS</strong></p> <p>Rectum, villous adenoma, acute renal failure, McKittrick-Wheelock syndrome.</p> <p>&nbsp;</p> <p><strong>INTRODUCTION</strong></p> <p>While the majority of colorectal polyps are asymptomatic, some can present with rectal bleeding, tenesmus, and diarrhea, which can lead to dehydration and mild electrolyte imbalance [1]. Severe electrolyte and fluid depletion secondary to a hypersecretory rectal neoplasm is well known as McKittrick-Wheelock syndrome, in which a villous adenoma is overwhelmingly the culprit [2].</p> <p>&nbsp;</p> <p>The syndrome was first described by Leland S. McKittrick and Frank C. Wheelock in 1954 when they reported a case of an 84-year-old woman who presented with weakness, syncope and oliguria which was found to be attributed to a large rectal villous adenoma [3]. A possible explanation for clinical findings associated with the syndrome is that the distal location of the tumour precludes reabsorption of the secreted fluid by the colonic mucosa also these tumours can daily release up to 4000 cc of clear, thin mucus containing up to 11 grams of sodium [4].</p> <p>&nbsp;</p> <p>Management of McKittrick-Wheelock syndrome include medical supportive measure followed by definitive endoscopic or surgical intervention to resect the villous adenoma</p> Copyright (c) A case report Spontaneous retroperitoneal hematoma diagnosed from fever 2021-01-23T16:41:34+00:00 Axelle Deconinck Philippe van de Borne Caroline Carpentier <p><strong><em>Background</em></strong> Spontaneous retroperitoneal hematoma has a large array of symptoms and clinical signs. Here we present a case where pyrexia of undermined origin turned into an abdominal pain and hypovolemic shock.</p> <p><strong><em>Case summary</em></strong> A 80-years old woman presented during her hospitalization a fever with no clinical focus. She developed several days later an abdominal pain and vomiting&nbsp;; An abdominal CT-scan showed a retroperitonal hematoma and she received an emergency treatment by embolization.</p> <p><strong><em>Conclusion</em></strong> Retroperitoneal hematoma is a complex pathology with an atypical and varied clinical presentation. It must be evoked not only in the presence of abdominal pain, especially in elderly patients at high risk.</p> Copyright (c) A rare cause of thrombotic microangiopathy 2021-01-23T12:45:27+00:00 Diana Mendes Oliveira Daniela Salazar Jorge Oliveira Jorge Almeida <p>Introduction: This case report describes 55-year-old diabetic men who presented to the emergency department (ER) with weight loss and icteric, without fever or abdominal pain. He was lethargic, with no other changes upon physical exam. Abdominal echography showed signs of chronic hepatopathy and splenomegaly; upper endoscopy showed already known oesophageal varices, without signs of recent bleeding. Laboratory findings showed Coombs negative haemolytic anaemia and thrombocytopenia, with low dosing of cyanocobalamin. The patient was monitored and started on vitamin B12 supplementation, without plasmapheresis. A posterior diagnosis of pernicious anemia was made. The patient improved and as discharged home.</p> <p>Aims: To describe a rare cause of thrombotic microangiopathy (TMA).</p> <p>Background: TMA can be primary or secondary; thrombotic thrombocytopenic purpura (TTP) is a primary form. Vitamin B12 deficiency can cause a syndrome named pseudo-TMA.</p> <p>Discussion: TMA is characterized for haemolytic anaemia, thrombocytopenia and end organ damage. TTP usually manifests also by neurological alterations and the treatment is plasmapheresis, with high mortality without it. Pseudo-TMA caused by vitamin B12 deficiency (commonly pernicious anaemia) usually happens in older patients, with higher levels of LDH and inappropriate reticulocytopenia. It does not respond to plasma exchange but to cyanocobalamin intramuscular supplementation. This case report intends to alert physicians to a very treatable cause of TMA that should not be overlooked upon diagnostic investigation.</p> Copyright (c) Systemic lupus erythematosus in a male patient with autoimmune hepatitis 2021-01-22T15:58:53+00:00 Soumaya Zaouga Soumaya Mrabet Raida Harbi Imen Akkari Elhem Ben Jazia <p>Overlap syndrome involving autoimmune hepatitis (AIH) and systemic lupus erythematosus (SLE) is a rare condition. The difference between the hepatic involvement of SLE and autoimmune hepatitis has not been clearly defined due to the presence of clinical and laboratory common features.<br>We report a 42-year-old male patient with autoimmune hepatitis who presented with intermittent fever, jaundice, and dyspnea. CT scan showed pleural and pericardial effusion, high titer of antinuclear antibodies and positive anti-DNA antibody were found. Our patient fulfilled both the international criteria of SLE and AIH. Clinical symptoms and laboratory findings improved with treatment by corticosteroids.</p> Copyright (c) multiple sclerosis, spasticity and nabiximols: an experience for use - a case report 2021-01-22T09:19:10+00:00 Giovanni Bosco Zimatore Vincenzo felica Claudio Zimatore <p>This clinical case concerns a 45-year-old woman with onset of multiple sclerosis at the age of 21 years, a long remission for 12 years and a subsequent resumption of disease activity partially contained by therapies. Not surprisingly, the increased burden of disability and impairment of quality of life is related not so much to the severity of the neurological damage as to the spasticity associated with the disease, which is responsible for the severe alterations in the posture control and trunk instability.</p> <p>A complex therapeutic strategy pathway started combining physical and pharmacological treatment, which reached a delicate balance with the introduction of nabiximols.</p> <p>&nbsp;</p> Copyright (c) An Unusual Cause of Proptosis: Orbital Metastasis of Paratesticular Leiomyosarcoma 2021-01-21T03:48:54+00:00 MUHAMMET OZER Kirti Juneja Mohammed Mahdi Namrata Jannareddy Neel Gandhi <p>Paratesticular leiomyosarcomas are uncommon malignant tumors that originate from smooth muscle. Paratesticular leiomyosarcoma shows aggressive tumor behavior due to a high incidence of local recurrence and distant metastasis. The orbit metastasis is also rare and associated with a poor prognosis. Clinical suspicion plays an essential role in the diagnosis of orbital leiomyosarcoma due to uncommon presentation. Comprehensive neuroimaging and histopathological work-up warranted for definitive diagnosis and management. To date, surgical resection remains the best curative treatment. However, leiomyosarcomas are usually friable and unencapsulated, which makes surgery challenging. Also, whether adjunctive chemotherapy will alter the long-term prognosis remains to be determined. Herein, we report the case of a young male who presented with proptosis and decreased vision, subsequently diagnosed with metastatic orbital leiomyosarcoma from a primary paratesticular tumor. We performed orbital enucleation with negative margins. The patient is currently under systemic, systemic pazopanib chemotherapy.</p> Copyright (c) Pseudotumoral lesion as a manifestation of autoimmune pancreatitis 2021-01-20T23:07:56+00:00 Catarina Parente Rúben Reis Daniela Rodrigues António Cardoso Joaquim Peixoto <p>Autoimmune pancreatitis (AIP) is a benign disease that can mimic pancreatic cancer by presenting as a mass in imaging studies and by provoking symptoms such as obstructive jaundice and dramatic weight-loss. The inflammatory infiltrates in pancreas can also produce endocrine dysfunction leading to diabetes.</p> <p>The authors report the case of a 68-year-old man that presented with unexplained weight loss and a poorly controlled diabetes despite progressive adjustment of therapy and later onset of obstructive jaundice that underwent pancreaticoduodenectomy with the pre-operative diagnosis of pancreatic malignant neoplasm which was posteriorly identified as type 1 autoimmune pancreatitis.</p> <p>The distinction of diagnoses may be difficult, so a high level of suspicion is necessary to avoid unnecessary surgery.</p> <p>Corticosteroid therapy can lead to resolution of symptoms and glycaemic control and it is the cornerstone of IgG4-related disease treatment. However, corticosteroid-sparing agents may be of interest to achieve clinical suppression.</p> Copyright (c) Congenital inferior vena cava agenesis with ulceration and deep vein thrombosis: a case report 2021-01-20T17:33:19+00:00 Melanie Menning <p>Objectives: This is one of few case reports of congenital inferior vena cava atresia (IVCA) with extensive bilateral lower extremity ulcers.</p> <p>Background: IVCA is a congenital anomaly characterized by poor venous return in the lower extremities with increased risk of deep vein thrombi (DVT) and, rarely, non-healing ulcers.</p> <p>Results: A 45-year-old woman with history significant for DVT presented with extensive bilateral lower extremity ulcers, and a CT scan revealed congenital inferior vena cava atresia. Edema management, DVT prevention, routine wound care, and skin grafts resolved the ulcers.</p> <p>Conclusion: When considering a differential diagnosis for multiple unprovoked DVTs and non-healing ulcers, congenital venous abnormalities should be included.</p> Copyright (c)