Vol 6 No 7

A masquerade syndrome is an ophthalmological entity where a neoplasm mimics an inflammatory condition. Ocular melanoma (chiefly uveal) may present with symptoms suggestive of intraocular inflammation such as endogenous endophthalmitis. Ocular melanoma is most commonly found in middle-aged and older caucasian patients. One-third of all uveal melanoma cases present asymptomatically. Early diagnosis facilitates treatment before ocular melanoma reaches metastatic stage IV. Current therapy options for stage IV patients are palliative care and clinical trial participation.eed for clinicians to be aware of rare metastases at the time of diagnosis.

Neurological and psychiatric diseases often present with overlapping features. Patients are sometimes seen by internal medicine, neurology and psychiatry clinicians and time can be important for determining whether a condition is organic or not. The authors present the case of a 31-year-old woman admitted to the emergency department with altered mental status and incomprehensible speech. She had a previous history of anxiety and smoking and was under therapy with benzodiazepines and combined hormonal contraceptives. After an acute neurological disorder was ruled out, the patient was transferred to the psychiatry department, where she was re-evaluated after 12 hours of observation and benzodiazepine washout. As speech impairment and confusion were still present, she was transferred to the Stroke Unit. A bilateral thalamic lesion containing a small focal haemorrhage and a moderate grade right-to-left shunt were identified. A patent foramen ovale was confirmed leading to the final diagnosis of acute ischaemic infarction secondary to a paradoxical embolism. Medical therapy was preferred over percutaneous closure. Risk factors were removed (smoking and hormonal contraceptives), and after the patient recovered completely acetylsalicylic acid 100 mg daily was initiated.

Denosumab is an antiresorptive agent widely used for treating osteoporosis. Atypical femur fractures, osteonecrosis of the jaw and hypocalcaemia are well-known possible adverse effects of this drug. We present, to our knowledge, the first case report in the English literature of clinically significant interstitial lung disease likely related to denosumab.

Malignant ascites is a rare first manifestation of gastric carcinoma and is usually associated with symptoms which include early satiety, abdominal pain and deteriorating clinical state. The authors describe the case of a male patient presenting with malignant ascites of rapid onset which was the sole presentation of gastric cancer, highlighting the importance of upper gastric endoscopy even in the absence of gastrointestinal symptoms.

Spontaneous rupture of a liver metastasis is a life-threatening complication of metastatic liver disease. Although metastatic liver lesions are much more common than primary tumours, spontaneous rupture of a liver metastasis is rare. Therapeutic decisions must take into account the extent of metastatic liver disease and the patient’s performance status. Transarterial embolization may be considered in cases of ongoing haemorrhage despite initial conservative measures. We describe a case of haemoperitoneum due to spontaneous rupture of a liver metastasis in a 72-year-old patient with carcinoma of unknown origin who responded well to conservative management.

Olmesartan's sprue-like enteropathy was first described in 2012 and typically presents with diarrhoea, weight loss, nausea, vomiting, low albumin and histological evidence of intestinal villous atrophy. Coeliac disease is one of the main differential diagnoses and should be excluded. We present the clinical case of a 63-year-old man treated with olmesartan for 10 years who presented with a 2-month history of diarrhoea and was diagnosed with olmesartan´s enteropathy. This case highlights the need for clinical suspicion of this new entity in order to reduce the associated morbidity and unnecessary costly investigations.

Background: The occurrence of a high-risk pulmonary embolism (PE) within 48 hours of a complicated pericardiocentesis to remove a haemorrhagic pericardial effusion, is an uncommon clinical challenge.
Case summary: The authors report the case of a 75-year-old woman who presented with signs of imminent cardiac tamponade due to recurring idiopathic pericardial effusion. The patient underwent pericardiocentesis that was complicated by the loss of 1.5 litres of blood. Within 48 hours, the patient had collapsed with clear signs of obstructive shock. This was a life-threating situation so alteplase was administered after cardiac tamponade and hypertensive pneumothorax had been excluded. CT chest angiography later confirmed bilateral PE. The patient achieved haemodynamic stability less than an hour after receiving the alteplase. However, due to the high risk of bleeding, the medical team suspended the thrombolysis protocol and switched to unfractionated heparin within the hour. The cause of the PE was not identified despite extensive study, but after 1 year of follow-up the patient remained asymptomatic.
Discussion: Despite the presence of a contraindication, the use of thrombolytic therapy in obstructive shock after exclusion of hypertensive pneumothorax can be life-saving, and low-dose thrombolytic therapy may be a valid option in such cases.

Immune thrombocytopenic purpura (ITP) is an autoimmune disorder that causes isolated thrombocytopenia. Many viruses have been identified as triggering the autoimmune process, including HIV, MCV, EBV, parvovirus, rubella and measles. However, ITP in association with coronavirus infection has not previously been reported. We describe the case of a healthy man who presented with severe ITP complicated by intracranial haemorrhage following upper respiratory tract infection. An infection screen revealed coronavirus infection.

Systemic capillary leak syndrome is a rare, underdiagnosed and life-threatening disease characterized by periodic episodes of hypovolaemic shock due to leakage of plasma from the intravascular to the extravascular space. It is associated with haemoconcentration, hypoalbuminaemia and generalized oedema.
We report the case of a patient with a history of emergent extensive small and large bowel resection and several episodes of hypovolaemic shock with acute renal injury, who presented with abdominal pain, headache and generalized oedema. Severe systemic capillary leak syndrome was diagnosed after a complex diagnostic approach. This case report describes the acute and prophylactic treatment administered to the patient and the 4-year follow-up. We highlight the importance of timely recognition and prompt treatment, as well as the need for new investigations to prevent the serious and unusual complications seen in this case.

Ogilvie’s syndrome or acute colonic pseudo-obstruction is characterized by massive colon dilation in the absence of mechanical obstruction or toxic megacolon. The phenotype associated with secretory diarrhoea is rare and is related to increased potassium channel activity in the colon, inducing excessive potassium loss, with increased sensitivity to normal serum aldosterone levels. The recommended therapy is potassium-sparing agents. We present the case of an 85-year-old patient who was admitted at the emergency department with prostration, abdominal distension and diarrhoea, corresponding to functional colonic dilation precipitated by severe hypokalaemia. Resolution of the condition only occurred after spironolactone was administered for suspected primary hyperaldosteronism, which was not proved as the patient showed normal aldosterone serum levels. The pathophysiological mechanism of abnormal potassium secretion in this scenario corresponds to ‘relative hyperaldosteronism’ caused by increased sensitivity of colonocytes to aldosterone.

Dumping syndrome (DS) is a debilitating entity with gastrointestinal and vasomotor symptoms due to rapid gastric emptying. It is a rare complication of Nissen fundoplication in adults.
We report the case of a patient with oesophageal compressive symptoms (dysphagia, oesophageal food impaction and regurgitation) and frequent episodes of sweating and hypoglycaemia after a Nissen fundoplication to treat gastroesophageal reflux disease. Investigation revealed severe oesophagogastric stenosis and excluded insulinoma and other causes of hypoglycaemia. An oral glucose tolerance test and gastric emptying scintigraphy were performed, supporting the diagnosis of DS.

Disease in atypical organ locations can mimic other pathologies, hampering the right diagnosis. Such conditions may even be emergencies, like appendicitis. Subhepatic appendix is a very rare entity which may be caused by caecum dehiscence failure. The authors present the case of a 55-year-old immunocompetent man admitted to the Emergency Department with sepsis and severe hypoxaemia. Chest x-ray showed right lower lobe infiltrate, and community-acquired pneumonia was diagnosed. The patient was started on broad-spectrum antibiotics, but he continued to deteriorate and after 3 days developed abdominal complaints. Exploratory laparoscopy revealed an abscess caused by perforated subhepatic appendicitis.
Subhepatic appendicitis presents a diagnostic challenge and its clinical presentation may mimic that of other entities. This case highlights an atypical presentation, where the early development of inflammatory lung injury mimicked common pneumonia. Maintenance of a high index of suspicion and knowledge of these atypical locations is crucial.