European Journal of Case Reports in Internal Medicine <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> en-US <h3>Copyright and Disclosures</h3> <p>Every author must sign a copyright transfer agreement and disclose any financial or professional interest in any company, product, or service mentioned in an article. This authorization includes all submitted text including illustrations, tables, and other related materials.<br> If this submission contains any <strong>material that has been previously published</strong>, this authorization <strong>must also be accompanied</strong> by all necessary Permission to Reproduce Published Material" forms completed by the current copyright owner. If this submission contains any <strong>previously unpublished material</strong> for which the person(s) signing this form <strong>does not own copyright</strong>, an additional "Authorization to Publish" form is required from each corresponding copyright owner.</p> <h3>Copyright Transfer Declaration</h3> <p>(this may be included as a word document with your manuscript submission)<br> I confirm that I am the current copyright owner of the material described above and hereby transfer and assign to the European Journal of Case Reports in Internal Medicine (EJCRIM) all copyrights in and to the material for publication throughout the world, in all forms and media, in English and in any other language(s). Such transfer includes publication in this and all future editions of the publication named above and in any other publications (including slide collections and any other nonprint media) of EJCRIM and gives EJCRIM the sole authority to grant rights for use of the material by others.<br> I waive EJCRIM from any liabilities connected to the incorrect copyright statement.<br>The copyright agreement form can be downloaded <a style="font-weight: bold;" href="/documents/EJCRIM_Copyright_auth.pdf">HERE</a> or requested to the editorial office <a style="font-weight: bold;" href=""></a></p> (Editorial Office) (Editorial Office) Mon, 28 Oct 2019 13:39:42 +0000 OJS 60 A Case of Fluorine-18 Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Imaging of Eosinophilic Granulomatosis With Polyangiitis Combined With Non-tuberculous Mycobacterium <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> Juhyung Kim, Man-Hoon Han, Sang Jin Lee ##submission.copyrightStatement## Fri, 22 Nov 2019 08:57:09 +0000 Pituitary Apoplexy Following Systemic Anticoagulation <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> Ana Rita Mairos dos Santos, Carlos Tavares Bello, Alice Sousa, João Sequeira Duarte, Luís Barreto Campos ##submission.copyrightStatement## Wed, 20 Nov 2019 09:18:25 +0000 The Reversed Halo Sign: Not Such a Specific Sign of Organising Pneumonia <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> Inês Carrilho Oliveira, Joana Carvalho, Rita Rosa, Catarina Barata ##submission.copyrightStatement## Mon, 18 Nov 2019 11:11:20 +0000 Spindle Coma in the Intensive Care Unit: Different Aetiologies – Different Outcomes <p>Spindle coma is an electroclinical entity that has been used to describe an EEG pattern of “sleep-like” activity in comatose patients. Although it has been associated with favourable prognosis, its aetiology is one of the key factors for patient outcome. The authors present three cases of spindle coma with different aetiologies (amitriptyline overdose, pontine myelinolysis and hypoxic-ischaemic encephalopathy) that culminated in different outcomes.</p> Ana Catarina Emidio, Rita Faria, Patricia Patricio, Nuno Canas, António Messias, Carlos Meneses-Oliveira ##submission.copyrightStatement## Fri, 15 Nov 2019 08:30:18 +0000 Diagnostic Pitfalls in a Man with Systemic Lupus Erythematous <p>Systemic lupus erythematosus (SLE) is a chronic multi-systemic immune-mediated disease with confusing symptoms and delayed diagnosis. We report the case of a 32-year-old man with a persistent Venereal Disease Research Laboratory (VDRL)-positive reaction treated for syphilis 5 years previously, who was admitted for rash, weight loss, pancytopenia, inflammatory syndrome, and an important spontaneous prolongation of activated partial thromboplastin time (aPTT). Antiphospholipid antibodies were identified in the patient and he was diagnosed with SLE. The unrecognized false positive VDRL reaction and the delayed diagnosis of SLE were harmful as the patient had developed renal and cardiac complications by the time of diagnosis.</p> Andrei Cristian Dan Gheorghe, Andreea Simona Hodorogea, Cristina Elena Georgescu, Ana Ciobanu, Ioan Tiberiu Nanea, Gabriela Silvia Gheorghe ##submission.copyrightStatement## Wed, 13 Nov 2019 08:56:52 +0000 Efficacy of Rituximab in Refractory Inflammatory Myopathy Associated With Coexistence of Behçet's Disease and Antiphospholipid Syndrome <p>A 43-year-old Caucasian male initiated myalgias and loss of muscle strength in the upper and lower limbs, but especially at the shoulder and pelvic girdle. Creatinine phosphokinase was elevated seven-fold above the normal reference value and aldolase was slightly elevated. He had a previous diagnosis of Behçet's disease, antiphospholipid syndrome and hypertriglyceridaemia. At this time, he was on azathioprine 150 mg daily, colchicine 1 mg daily, warfarin and fenofibrate 200 mg daily. Fenofibrate was stopped and creatinine phosphokinase re-evaluated 2 months later, but it was higher, with persistent myalgias. By this time, prednisolone was restarted and the azathioprine dose reduced until it was discontinued. Nevertheless, 2 months after stopping azathioprine, the patient remained symptomatic and creatinine phosphokinase was persistently elevated. At this point, the authors requested myositis antibody testing to exclude overlap with a third autoimmune disorder, and Ro52 antibody was positive. Electromyography was normal. Magnetic resonance imaging of lower limb muscles was compatible with polymyositis. Muscular biopsy of the medial gastrocnemius revealed inflammatory myopathy. The authors proposed treatment with rituximab and after 3 months, the patient had clinically and analytically improved, with reduction of creatinine phosphokinase, without adverse reactions. As we can see in this case, rituximab could be a secure treatment for patients with idiopathic inflammatory myopathy without improvement on glucocorticoids plus another immunosuppressive agent. This patient has a rare overlap syndrome, since this is the first case of an association between inflammatory myopathy, Behçet's disease and antiphospholipid syndrome described in the literature.</p> Verónica Guiomar, Diana Oliveira, Cristina Correia, Edite Pereira ##submission.copyrightStatement## Mon, 11 Nov 2019 10:17:13 +0000 Non-small-cell Carcinoma Localised within the Pulmonary Artery Misdiagnosed as Pulmonary Thromboembolism <p>In this case report we describe a 69-year-old male ex-smoker with non-small-cell carcinoma localised within the pulmonary artery, misdiagnosed as pulmonary thromboembolism. This case indicates that non-small-cell carcinoma can be localised within the pulmonary artery. Furthermore, it emphasises the importance of performing a positron emission tomography scan and diagnostic intraluminal biopsy in unexplained lesions in the pulmonary artery to reach the proper diagnosis at the early stages of the disease. The patient is currently undergoing concurrent chemotherapy and radiation therapy.</p> Zeyad Albadri, Omar Khattab ##submission.copyrightStatement## Fri, 08 Nov 2019 14:17:00 +0000 Pulmonary Arteriovenous Malformation can be Associated with Embolic Stroke of Undetermined Source (ESUS) <p>Pulmonary arteriovenous malformations (PAVMs) are rare vascular anomalies. Alternative designations are pulmonary arteriovenous fistulae or aneurysms. Although mostly asymptomatic, PAVMs can cause respiratory symptoms due to right-to-left shunt. The central nervous system is a potential target for complications, including stroke, as a result of paradoxical embolism. In this report, the authors describe an unusual case of cerebral emboli caused by paradoxical embolism through a PAVM, presenting with a broad pathology including orthodeoxia, central cyanosis and digital clubbing, which should be kept in mind since misdiagnosis may cause severe morbidity in young adults.</p> Mariana Barros Cruz, Nuno Palma, Joao Rocha, Ricardo Meireles ##submission.copyrightStatement## Wed, 06 Nov 2019 08:50:30 +0000 Aortic Dissection with Haemothorax Mimicking a Stroke <p>Aortic dissection is a life-threatening clinical emergency and a challenging diagnosis. Depending on its initial location, it may present with several symptoms with the most common being chest pain. We describe the case of a 62-year-old man admitted to the Emergency Department with acute neurological deficits and triaged for the stroke protocol. After unexpected findings on physical examination, other diagnostic hypotheses were evaluated, culminating in the diagnosis of aortic dissection with haemothorax mimicking a stroke.</p> Joana Ricardo Pires, Mariana Teixeira, Margarida Ferreira, Clarinda Neves ##submission.copyrightStatement## Mon, 04 Nov 2019 08:11:16 +0000 Consider Nitrofurantoin as a Cause of Lung Injury <p>Nitrofurantoin-induced diffuse lung toxicity is well documented in the literature but is often misdiagnosed. We describe an 82-year-old female medicated with nitrofurantoin for the previous 2 years who was admitted for dyspnoea, dry cough and fatigue for 4 months. She was febrile and tachypnoeic and she presented with bilateral basal crackles, hypoxaemic respiratory failure and slightly elevated C-reactive protein levels. A chest radiograph showed bilateral air-space consolidation and interstitial infiltrates and the high-resolution computed tomography scan was evocative of a perilobular pattern of organising pneumonia (OP). Due to the clinical–radiological context, she was diagnosed with a presumable nitrofurantoin-induced OP. She was started on prednisolone 60 mg daily with a progressive improvement. It is important that clinicians are aware of the spectrum of side effects associated with nitrofurantoin so as to monitor patients.</p> Paulo Almeida, Eduarda Seixas, Beatriz Pinheiro, Pedro Ferreira, Ana Araújo ##submission.copyrightStatement## Wed, 30 Oct 2019 08:35:54 +0000