Vol 6 No 5
  • Mohammad Mahdi Adib Sereshki, Simin Almasi, Behdad Behnam, Farbod Semnani

    The presence of different autoimmune disorders in the same individual is called multiple autoimmune syndrome (MAS). One of these co-occurring conditions is autoimmune haemolytic anaemia (AIHA), which is characterized by the production of autoantibodies against red blood cells due to immune system malfunction and which results in severe tissue oxygenation disturbance. AIHA is not uncommon but occurs rarely in MAS; if it does, MAS is then classified as MAS type III. Herein, we describe a case of MAS type III including AIHA which was successfully treated with hydrocortisone with gradual resolution of symptoms.

  • Sherif Monib

    In addition to the most likely diagnoses for umbilical signs in adults (umbilical hernia, metastatic tumour, endometriosis, congenital abnormalities such as umbilical-urachal sinus and gallstones retained or spilled at the umbilicus), the differential diagnosis should also include epidermoid cyst arising from the skin of the umbilicus.We describe the case of a young man who presented with a persistent umbilical discharge which was initially thought to be umbilical-urachal sinus, but later found to be a sebaceous cyst.

  • Neeraja Swaminathan, Akanksha Agrawal, Pradhum Ram

    The presence of air in the mediastinal cavity (i.e., pneumomediastinum) is an uncommon condition. It is usually precipitated by an event such as penetrating trauma, barotrauma or increased intrathoracic pressure caused by severe vomiting or coughing. We present the case of a 32-year-old man who developed pneumomediastinum as a result of heavy weightlifting.

  • Napohn Chongprasertpon, Ronan Cusack, John Joseph Coughlan, Wing Tung Chung, Chun Ho Leung, Thomas John Kiernan

    We describe a case of Streptococcus lutetiensis infective endocarditis occurring in a patient following colonic polypectomy. The patient had multiple risk factors for infective endocarditis including pre-existing mitral valve prolapse and regurgitation.
    Transoesophageal echocardiography revealed a friable mass on the posterior mitral valve leaflet, confirming the diagnosis. The patient was treated with intravenous antibiotics, successfully underwent mitral valve surgery and was discharged home for outpatient follow-up.
    This report details an uncommon case presentation, highlights areas for improvement in clinical practice, and summarises the current knowledge available in the literature regarding Streptococcus bovis infective endocarditis.

  • Sara Nguyen, Martine Grosber, Jan Gutermuth

    Introduction: Some cutaneous manifestations can be the first presentation of an underlying malignancy. These so-called paraneoplastic syndromes can sometimes be very subtle or strongly resemble other benign cutaneous diseases.
    Aims: In this report, we want to emphasize the need for further investigation of eczema-like cutaneous presentations which develop at a later age and are recalcitrant to therapy. Exclusion of an underlying malignancy needs to be considered.
    Patients and Methods: A 53-year-old man with thickening of the skin, more pronounced on the hands, feet and face, was diagnosed with classic nodular sclerosing Hodgkin disease based on cutaneous presentation.
    Results: After two rounds of chemotherapy (adriamycin, bleomycin, vinblastine and dacarbazine), the cutaneous symptoms had disappeared. After six rounds of chemotherapy and 14 months of follow-up, the patient is still in remission without recurrence of the cutaneous symptoms.
    Conclusions: Cutaneous symptoms recalcitrant to adequate treatment should raise suspicion and prompt further investigation to exclude an underlying malignancy. A multidisciplinary approach with the dermatology department can accelerate diagnosis and improve the patient’s prognosis.

  • Magdalena Grzesiek, Christina Ellmann, Tilmann Ditting

    Electrical accidents are not reported very frequently, and may occur undetected as the signs are often manifold and not very specific. We report the case of a 43-year-old woman admitted to hospital due to a fall of unclear cause, with loss of consciousness, partial amnesia, paresis of both legs and crush syndrome. Only by thorough and repeated history-taking, and a careful physical examination that revealed burns typical of electrical current injuries, was the case resolved. With this case presentation, we would like to make the reader aware of electrocution as a possible cause of bruises and unconsciousness of unclear origin.

  • Sofia Gomes Brazao, Diana Silva, Joana Duarte, José Bernardes, Manuel Teixeira Verissimo, Armando Carvalho

    Introduction:Superior vena cava (SVC) syndrome is caused by obstruction of the superior vena cava due to vascular compression by a mass or intrinsic obstruction. The authors describe SVC syndrome caused by an isolated metastatic mediastinal mass from a resected primary colon carcinoma.
    Case Report: An 81-year-old woman was referred to the hospital with swelling of the neck and upper left limb, dysphonia and dysphagia, associated with an involuntary weight loss of 16 kg. Mediastinal metastasis of colon adenocarcinoma was found, causing the SVC syndrome. The mass was unresectable and the patient was referred to palliative radiotherapy.
    Discussion: Only 12 cases of mediastinal metastasis from colorectal cancer have been reported in the English literature.
    Conclusion: As a rare manifestation of colorectal cancer, the presented case highlights the need for clinicians to be aware of rare metastases at the time of diagnosis.

  • Nuno Zarcos Palma, Mariana da Cruz, Vítor Fagundes, Lindora Pires

    Botulism is rare neuroparalytic disease caused by botulinum toxin, one of the most toxic substances known. Foodborne botulism is caused by consumption of foods contaminated with botulinum toxin. The clinical manifestations are flaccid, symmetrical, descending paralysis affecting cranial and peripheral nerves. The only specific treatment is botulinum antitoxin. We report the case of a 37-year-old man with gastrointestinal manifestations and posterior cranial nerve palsy who was diagnosed with botulism infection. Clinicians should be aware of rare causes of infection and determine the aetiology of symptoms.

  • Sofia Gomes Brazao, Regina Costa, Miguel Nico Albano, Nelson Jesus, Armando Carvalho

    Introduction: Chest wall masses are caused by various entities and have diverse aetiologies. A careful history and physical examination are crucial to establish the correct diagnosis.
    Case report: A 77-year-old man presented with depressive mood, anorexia (weight loss of 20 kg) and a 1-month history of a non-painful breast lump with well-defined contours, which was about 6 cm in diameter. There was no history of trauma. Computed tomography of the thorax revealed a collection of liquid in the left anterior thoracic wall, associated with discontinuity of the 4th left costal cartilage, and upper left lobe cavitation, suggesting pulmonary tuberculosis. The patient was started on quadruple therapy with anti-tuberculosis drugs and discharged after a negative smear.
    Conclusion: In this case, the indolent onset of unspecific symptoms made it difficult to reach a diagnosis of pulmonary tuberculosis, which was confirmed by positive culture and imaging. A breast lump in an elderly patient with unspecific clinical manifestations is an unusual presentation of pulmonary tuberculosis. It is important to be aware of rib invasion and exclude tuberculosis in a patient with a chest wall mass. As tuberculosis is treatable, early diagnosis is vital as diagnostic delay can lead to contagion.

  • Guillermo Ropero-Luis, Francisco Páez-Codeso, Ricardo Gómez-Huelgas

    A 67-year-old man with a history of seropositive rheumatoid arthritis (RA) was admitted to the Internal Medicine ward for bilateral pleural effusion. Two years before this episode, coinciding with an exacerbation of the RA, he was incidentally diagnosed with asymptomatic left pleural effusion compatible with rheumatoid exudate, which was resolved with a tube thoracostomy. Three weeks before admission, the patient developed asthenia, orthopnoea and progressive dyspnoea. A chest x-ray revealed bilateral pleural effusion occupying the lower third of the left hemithorax and a smaller portion of the right hemithorax along with marked elevation of N-terminal fragment of pro-brain natriuretic peptide levels. The patient was admitted with a diagnosis of left-sided heart failure. Transthoracic echocardiography and cardiac catheterization confirmed the existence of ischaemic cardiomyopathy. After 2 days of diuretic treatment, the right pleural effusion resolved, but the left effusion persisted. A needle thoracentesis was performed, draining 800 ml of milky fluid compatible with rheumatoid pseudochylothorax.

  • Dor Cohen, Gila Shpitalni, Yulia Lifshitz, Sapir Anani, Ana Eyal, Gad Segal

    Introduction: The differential diagnosis of stroke in a comparatively young adult should always include cardiovascular aetiologies as well as central nervous system infection.
    Case Presentation: A 56-year-old man, with no significant medical history, presented with headache, nausea and vomiting, and right hemiparesis. Routine stroke investigation was initiated, while CNS infection was also sought. Diagnoses of HIV infection, neurosyphilis, HCV and HBV were established. Targeted therapy resulted in prompt clinical improvement.
    Conclusion: This case highlights the importance of considering CNS infection as a cause of neurological deficits in parallel with other investigations in cases of stroke in a comparatively young adult.

  • Alice Pirovano, Erica Matino, Erika Zecca, Martina Costanzo, Alessandro Croce, Monica Leutner, Raffaele Romito, Mario Pirisi

    Serous effusions complicating the course of lymphomas occur commonly in the pleural space but seldom in the peritoneum, where they most often present as chylous ascites with diagnostic cytology. Almost invariably, in these rare cases, the serum to ascites albumin gradient is low. We describe a 28-year-old woman with anasarca, ascites and a serum to ascites albumin gradient of 1.1 g/dl, consistent with portal hypertension. No tumour cells were detected in the ascitic fluid. However, a CT scan of the chest and abdomen disclosed liver and spleen enlargement and multiple enlarged retroperitoneal lymph nodes, suspicious for a lymphoproliferative disorder. Bone marrow aspiration and biopsy were not diagnostic, so a decision was made to proceed with a splenectomy despite the onset of low-grade disseminated intravascular coagulation.
    Surgery was uneventful. Diffuse large B cell lymphoma was diagnosed. A liver biopsy taken at the time of surgery demonstrated that the liver parenchyma was massively infiltrated by reactive T lymphocytes surrounding rare large CD20+ tumour cells. This infiltrate had likely led to increased portal pressure attended by ascites formation, which resolved completely after chemotherapy. The case emphasizes the rewards of pursuing a diagnosis supported by a high prior probability even in the presence of apparently discordant laboratory findings, as well as the importance of performing a diagnostic splenectomy in case of splenomegaly with unexplained focal lesions.