European Journal of Case Reports in Internal Medicine 2020-02-21T08:13:10+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> Complexities of Diagnosing and Treating a Mesenteric Cyst in a Chronic Myeloid Leukaemia Patient 2020-02-21T08:13:10+00:00 Carlos Fernando Dias Rodrigues Gisela Ferreira Eduardo Oliveira Marta S. Oliveira Sara Pinto João Fonseca <p>Mesenteric cysts are a rare nosologic entity, the diagnosis of which is complex due to their nonspecific presentation. They may emerge from any part of the mesentery and grow to any size, thus conditioning a wide range of clinical manifestations that renders them easily mistaken for different gastrointestinal pathologies. Diagnosis encompasses a mixture of clinical suspicion, imaging techniques and sometimes surgery, and curative treatment is based on complete surgical resection of the cyst. We hereby present a case of a mesenteric cyst that developed on the anterior abdominal wall of a 59-year-old man awaiting allogeneic bone marrow transplantation after being diagnosed with chronic myeloid leukaemia. He was admitted to the emergency room with complaints of an increased abdominal perimeter and increased weight, not associated with alterations to his dietary or physical exercise habits. Suspecting ascites in the context of leukaemic progression, the patient was admitted to the medical ward; however, subsequent study identified a mesenteric cyst as the most probable diagnosis and the patient was proposed to undergo surgery. He underwent laparotomic cyst excision without complications and the histological evaluation of the surgical specimen confirmed the diagnosis.</p> 2020-02-21T08:09:22+00:00 ##submission.copyrightStatement## Tuberculosis as a Cause of Rapid Salivary Gland Swelling in the Elderly – A Case Report 2020-02-21T08:13:10+00:00 Noel Lorenzo Villalba Maria Belen Alonso Ortiz Zaida Cordoba Sosa Saturnino Suárez Ortega Abrar-Ahmad Zulfiqar <p>A 77-year-old man was admitted to the internal medicine department for a 5-day history of progressive preauricular swelling. Two lines of antibiotic treatment failed to achieve any improvement. Fine needle aspiration cytology was conducted and smear staining with the Ziehl-Neelsen stain as well as a PCR test were positive for <em>Mycobacterium tuberculosis</em>. These results were confirmed with culture of the sample. A diagnosis of tuberculosis parotitis was made and anti-tuberculous drugs were initiated.</p> 2020-02-20T10:04:23+00:00 ##submission.copyrightStatement## Not All ENT Granulomas Are Wegener’s – Keep Tuberculosis in Mind 2020-02-21T08:13:10+00:00 Bárbara Pedro Marta Meleiro António Marinho <p><em>Mycobacterium tuberculosis</em> affects the middle ear in rare cases and is a challenging diagnosis. In this case, we present a 57-year-old patient diagnosed with anti-neutrophil cytoplasmic antibody (ANCA)-negative granulomatosis with polyangiitis (GPA) following a biopsy result of nasal granulomas, who was immediately started on immunosuppressive treatment. Years later, she developed progressive hypoacusis. Magnetic resonance imaging (MRI) revealed an extensive mass in the tympanic cavity extending to the mastoid. A biopsy of the mass was positive for <em>Mycobacterium tuberculosis</em>. Immunosuppressants were weaned and the patient was started on anti-tuberculous therapy with resolution of the complaints and findings. Tuberculous infections are difficult to diagnose and frequently mimic other illnesses, but in our case, we believe that an indolent tuberculous process was present from the beginning and evolved under immunosuppressive therapy.</p> 2020-02-19T08:42:55+00:00 ##submission.copyrightStatement## Salmonella infection as a trigger for Polyarteritis Nodosa 2020-02-21T08:13:10+00:00 Pedro Neves Tavares Patricia Alves Rita Lizardo Grácio Paula Gonçalves Costa Carla Falcão Catarina Duarte Santos Filipa Amado <p>Polyarteritis nodosa is a systemic necrotizing vasculitis that typically affects medium-sized muscular arteries, with occasional involvement of small muscular arteries. Most cases of polyarteritis nodosa are idiopathic but multiple infectious agents have been associated with this disease. We present a clinical case of a 72-year-old male with fever, diarrhoea and haemodynamic instability, diagnosed with a bacterial infection caused by <em>Salmonella</em> Typhi. One week after clinical resolution of the infection, the patient developed purpuric lesions with ulcers, pustules and necrotic areas accompanied by testicular pain and weight loss of 5 kg over the previous 15 days. A skin biopsy was performed and it revealed typical histologic signs of polyarteritis nodosa. The aetiologic association between bacteria of the genus <em>Salmonella</em> and polyarteritis nodosa has been previously described in the scientific literature but seldom meeting classification criteria and with histologic confirmation.</p> 2020-02-18T08:31:38+00:00 ##submission.copyrightStatement## Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia: A Clinical Case 2020-02-17T09:35:08+00:00 Adelaide Pereira Alves Ana Barroso Margarida Dias <p>Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is a rare pulmonary condition characterized by diffuse proliferation of neuroendocrine cells in the epithelium of the bronchial wall. DIPNECH may be easily missed in daily clinical practice and diagnosis is often delayed, which may impair prognosis since this condition is considered a pre-invasive lesion for lung carcinoid tumours. We report a clinical case of DIPNECH in order to discuss the diagnostic and therapeutic approach for this entity, the management of which is not yet well established in the literature.</p> 2020-02-17T09:15:48+00:00 ##submission.copyrightStatement## Diabetic Myonecrosis: An Uncommon Complication of a Common Condition 2020-02-17T09:35:08+00:00 Michael Harrison Storandt Chandra Thondapi Abhishek Matta <p><em>Introduction:</em> Diabetic myonecrosis is an uncommon complication of diabetes mellitus, most often occurring in patients with poorly controlled, insulin-dependent diabetes. Its etiology is poorly understood, with many suggesting microvascular occlusion to be a key factor resulting in necrosis of skeletal muscle.<br> <em>Case presentation:</em> A 28-year-old male with a history of poorly controlled type I diabetes mellitus and end-stage renal disease requiring dialysis presented to the emergency department with severe pain of the lower extremities bilaterally. <br> <em>Results:</em> Work-up included an x-ray, which demonstrated no acute fractures but extensive vascular calcification of the lower extremities, and Doppler ultrasonography, which showed no DVT. MRI demonstrated severe muscular edema with patchy, geographic areas of sparing, which, in conjunction with the patient’s clinical presentation, allowed for a diagnosis of diabetic myonecrosis. He underwent conservative treatment, consisting of rest and pain management, leading to resolution of symptoms.<br> <em>Discussion:</em> Diabetic myonecrosis, although uncommon, can be easily diagnosed with a high degree of clinical suspicion. It typically presents in a patient with poorly controlled diabetes, and will commonly involve the proximal muscles of the lower extremity unilaterally, but may present bilaterally and involve the distal muscles, as demonstrated in this case. Diagnosis is made via MRI, and it is treated conservatively with pain management and rest. Most cases resolve with conservative management but recurrence is common.</p> 2020-02-14T08:17:12+00:00 ##submission.copyrightStatement## Intellectual Disability, Falls and Gait Disturbances: A Misdiagnosis 2020-02-13T09:33:43+00:00 Noel Lorenzo Villalba Santiago Díaz Nicolas Maria Belen Alonso Ortiz Zaida Cordoba Sosa Saturnino Suárez Ortega Abrar-Ahmad Zulfiqar <p>We report the case of a 27-year-old man presenting with slowly progressive extrapyramidal dysfunction and learning disability considered to have a syndromic intellectual disability. The re-evaluation of the clinical features and the investigations performed led to the diagnosis of atypical pantothenate kinase-associated neurodegeneration (PKAN).</p> 2020-02-13T08:28:23+00:00 ##submission.copyrightStatement## Persistent Facial Oedema and Erythema in a Woman, An Uncommon Manifestation of Chronic Cutaneous Lupus Erythematosus 2020-02-13T09:33:43+00:00 Mónica García-Arpa María Rodríguez-Vázquez David Bellido-Pastrana Natalia Villasanti-Rivas Marcos Carmona-Rodríguez <p>Manifestations of chronic cutaneous lupus erythematosus are variable. Periorbital and facial swelling occurs in dermatomyositis and systemic lupus, but it has been rarely reported as a manifestation of exclusively cutaneous lupus. A 48-year-old woman presented with a 16-year history of asymptomatic, bilateral swelling and erythema of her face with marked worsening after sun exposure. No systemic symptoms were associated. A complete evaluation did not reveal other findings. Cutaneous biopsy showed features of lupus erythematosus. She was treated with photoprotection, topical tacrolimus, hydroxychloroquine and azathioprine with a partial response. Facial swelling with erythema represents quite an unusual manifestation of chronic cutaneous lupus erythematosus. Dermatomyositis, systemic lupus and Morbihan disease are the main differential diagnoses.</p> 2020-02-12T08:34:15+00:00 ##submission.copyrightStatement## Fever During Anti-integrin Therapy: New Immunodeficiency 2020-02-13T09:33:43+00:00 Eleonora Bonfanti Christian Bracco Paolo Biancheri Andrea Falcetta Marco Badinella Martini Remo Melchio <p><em>Background:</em> The causes of inflammatory bowel disease (IBD) have not yet been clearly elucidated, but it is known that genetic susceptibility, altered gut microbiota and environmental factors are all involved, and that a combination of these factors causes an inappropriate immune response, resulting in impaired intestinal barrier function. With regard to the treatment of IBD, the use of conventional immunosuppressive drugs has been complemented by more specific therapeutic agents, including biological drugs. Systemic immune suppression is a risk factor for cytomegalovirus (CMV) infection, which is associated with considerable morbidity and mortality in immunocompromised hosts.<br> <em>Case Report:</em> A 33-year-old male patient was admitted to our medical unit complaining of a 10-day history of fever, fatigue and headache. He had been suffering from ulcerative colitis and primary sclerosing cholangitis for five years and was currently being treated with azathioprine and vedolizumab. In the past he had already taken infliximab, adalimumab and golimumab without any clinical response. After the exclusion of systemic infectious diseases, his serology was consistent with a primary CMV infection. This was successfully treated with intravenous ganciclovir therapy.<br> <em>Conclusion:</em> Vedolizumab is an anti-integrin biological agent approved for IBD treatment. Its gut-selective mechanism of action would appear to increase its safety profile, however data on this are still limited. Moreover, it should always be remembered that IBD patients have an increased risk of CMV infection, both primary and reactivation, because of their concurrent immunosuppression.</p> 2020-02-11T09:51:31+00:00 ##submission.copyrightStatement## Turicella otitidis as an Unusual Agent Causing Palmoplantar Eczema: An Emerging Pathogen 2020-02-10T13:11:24+00:00 Dimitra Koumaki Vasiliki Koumaki Sotirios Boumpoucheropoulos Alexander Katoulis Panagiotis Bitados Maria Stefanidou Konstantinos Krasagakis <p><em>Introduction:</em> <em>Turicella otitidis</em>, described as a new species over 20 years ago, has been isolated mainly from the external ear canal and middle ear fluid. Here, we report the first case of palmoplantar eczema related to <em>T. otitidis</em>.<br> <em>Case presentation:</em> Here, we report the first case of palmoplantar eczema in a 74-year-old female related to <em>T. otitidis</em>.<br> <em>Conclusions:</em> The question as to whether <em>T. otitidis</em> is a potential pathogen in cases of dyshidrotic eczema is still open, but this could be better elucidated if corynebacteria were speciated more often.</p> 2020-02-10T10:08:09+00:00 ##submission.copyrightStatement##