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  • Rosa Alves, Bruno Sousa, Francisco d'Orey, Pedro Sequeira, Ana Oliveira, Tiago Judas

    Sarcoidosis is a chronic multisystemic inflammatory disease of unknown aetiology. Virtually any organ or system can be involved, resulting in a wide range of clinical presentation. Pleural sarcoidosis is rare. Pleural effusion can only be attributed to pleural sarcoidosis in the presence of pleural non-caseating epithelioid granulomas and after excluding other granulomatous diseases. Anthracosis is a pneumoconiosis associated with thoracic adenopathies and bronchial disease, and it is usually asymptomatic. The authors present a case of a middle-aged man hospitalized due to cough, right-sided pleuritic chest pain and trepopnoea.

  • Sherif Monib, Mohamed Elkorety

    Lactating adenomas are benign breast tumours which normally present in the peripartum period. Aetiology, pathogenesis, best diagnostic modality and management are not yet clear in the literature. We present a case of a 32-year-old pregnant patient who was re-referred to us with a progressively increasing left breast lesion, pre-existing prior to pregnancy, which was found to be a huge lactating adenoma.

  • Sarah Micallef, Kelvin Cortis, Claude Magri

    Liver metastases from neuroendocrine tumours (NETs) are usually seen on cross-sectional imaging at presentation. In such cases, curative surgical resection is usually not possible given that most patients have bilobar disease. Various locoregional approaches are now widely available that enable local control of disease and management of systemic symptoms. These include trans-arterial embolization (TAE), trans-arterial chemoembolization (TACE), selective internal radiotherapy and thermal ablation.
    We describe a rare case of hepatic necrosis after TAE in a 61-year-old woman with a metastatic NET. Cross-sectional imaging showed extensive necrosis affecting segments VII and VIII of the liver. This occurred secondary to thrombosis in the portal vein branches to these segments, confirmed on a Doppler ultrasound scan. The mechanism of portal vein thrombosis after TAE could be due to the presence of occult arterioportal anastomoses. These allow transit of the embolizing agents into the portal vein branches supplying the treated segments and subsequent thrombosis.

  • João Pedro Abreu, Joana Esteves, Maria Teresa Boncoraglio, Francisca M Pereira, Carla Costa, Carlos Oliveira

    Hypersensitivity pneumonitis is understood to be a delayed allergic reaction to the repeated exposure of a usually innocent inhaled agent, causing inflammatory damage to the pulmonary parenchyma, alveoli and terminal bronchioles. With ongoing exposure, it can cause respiratory compromise and pulmonary fibrosis. Recognizing the heterogeneity of the causative agents and the low incidence of the disease, we considered it important to report the case of a greenhouse worker who developed aCladosporium sp. related hot-tub lung hypersensitivity pneumonitis. We believe it to be the first reported case of a greenhouse occupational hypersensitivity pneumonitis due to Cladosporium sp.

  • Ana Lima Silva, Daniela Antunes, Joana Cordeiro Cunha, Renato Nogueira, Diana Fernandes, Tatiana Salazar, Carla Madureira Pinto

    Superior mesenteric artery syndrome (SMA syndrome) or Wilkie’s syndrome is a rare etiology of duodenal obstruction due to compression of the third portion of the duodenum between the superior mesenteric artery and the aorta. Physical and laboratory findings are often non-specific but imaging methods are useful for diagnosing the condition. A 46-year-old female patient presented to the outpatient clinic of our internal medicine department with a 2-year history of epigastric pain, nausea, early satiety and weight loss of 15 kg. Previous studies were inconclusive. The patient underwent computed tomography enterography and its findings were consistent with SMA syndrome. Currently the patient is being followed by General Surgery and Nutrition and is under nutritional measures in order to optimize her body mass index to decrease possible surgical complications.This case report emphasizes the importance of clinical suspicion and careful investigation when considering less common etiologies for frequent gastrointestinal symptoms.

  • Syed Haseeb Raza Naqvi, Ishfaq Ahmed, Pir Sheeraz Ali, Jehan Zab, Han Naung Tun

    Persistent left superior vena cava (PLSVC) is the most common variation of anomalous venous return to the heart and present in 0.1–0.5% of the general population. The left anterior cardinal veins typically obliterate during early cardiac development but failure of involution results in PLSVC. It is an asymptomatic congenital anomaly, usually discovered while performing interventions through the left subclavian vein or during cardiovascular imaging. PLSVC can be associated with cardiac arrhythmias and congenital heart disease. We present two cases of PLSVC: first, a 68-year-old male who presented with complete heart block, for which a temporary pacemaker was initially inserted followed by a permanent pacemaker; second, a 53-year-old female with a history of hypertension and ischemic cardiomyopathy with a left ventricular ejection fraction of 25%, and a survivor of sudden cardiac death, who underwent an implantable cardioverter-defibrillator (ICD) for secondary prevention.
    Both cases of PLSVC were detected incidentally during the transvenous approach to the heart. PLSVC was suspected by the unusually left medial position of the lead, while cineflouroscopy showed the venous trajectory toward the coronary sinus and drainage into the right atrium. It is technically difficult to cross the wire through the tricuspid valve when coming from the PLSVC and coronary sinus without making a loop in the right atrium, which is known as a wide loop technique.
    PLSVC is an uncommon anomalous anatomical variant and should be recognized appropriately by specialists who frequently carry out procedures through the left subclavian vein, such as implantation of permanent pacemaker, ICD and cardiac resynchronization therapy. It should also be recognized that wide loop formation of the right ventricular lead in the right atrium is helpful to cross the tricuspid valve and to affix the lead in the right ventricle.

  • Gonçalo Miranda, Ana Catarina Dionísio, Constança Azevedo, Eduardo Carvalho, Miguel Semião, Vítor Branco, Miguel Castelo-Branco

    Emphysematous hepatitis is a rare entity characterized by the replacement of hepatic parenchyma by gas, leading to acute liver failure. Often it occurs in patients with diabetes mellitus, liver disease or a recent history of abdominal surgery. We present a case of emphysematous hepatitis in a 74-year-old man with no recognizable risk factors. Despite the early broad-spectrum antimicrobial therapy and supportive care, the condition progressed to a fatal outcome, as seen in other case reports. Early recognition of this condition and rapid and aggressive management may improve patient outcomes.

  • Henry Yung, Keshav Sharma, William Flowers, Malcolm Marquette, Laura Starace, Clare Sander, Rowan Burnstein, Jurgen Herre

    Plastic bronchitis is a rare condition characterised by endobronchial cast formation. We report the case of a 53-year-old women who deteriorated following an elective bronchoscopy procedure. She developed refractory ventilatory failure and required repeated bronchoscopy, which identified thick tenacious casts as the cause of her airway compromise. She did not respond to conventional therapies including endoscopic clearance, mucolytic therapy and nebulised tissue plasminogen activator (TPA). Total parenteral nutrition and a fat-free enteral diet were instituted while the patient was on extracorporeal membrane oxygenation (ECMO), which led to substantial improvement in her condition and demonstrated the importance of dietary strategies in this case.

  • Attout Hassene, Amichi Sofia, Josse Françoise, Appavoupoule Vincent, Randriajohany Andrey, Thirapathi Yogananda

    Cannabis is one of the most widely used illicit drugs in the world. Its use is associated with several short- and long-term side-effects such as changes in mood, impaired memory, impaired attention, depression and anxiety, and it is correlated with schizophrenia. Cannabinoid hyperemesis syndrome (CHS) is characterized by chronic cannabis use, cyclic intractable nausea and vomiting, and compulsive hot bathing. Patients are typically diagnosed with CHS only after multiple medical evaluations. Recent research has identified type 1 cannabinoid receptors in the intestinal nerve plexus that have an inhibitory effect on gastrointestinal motility. This effect may explain hyperemesis in cannabis users. The thermoregulatory role of endocannabinoids may be responsible for compulsive hot bathing. We describe the cases of two young men seeking repeated emergency room care with recurrent nausea and vomiting. Abstinence from cannabis led to resolution of vomiting symptoms and abdominal pain.

  • Noel Lorenzo Villalba, Abrar-Ahmad Zulfiqar, Yasmine Maouche, Zaida Cordoba Sosa, Maria Belen Alonso Ortiz, Emmanuel Andres

    We report the case of a 23-year-old woman evaluated for asthenia and lymphocytopenia. Clinical examination was unremarkable but laboratory tests showed the presence of CD4 lymphocytopenia. Secondary causes of CD4 lymphocytopenia were ruled out and a previous diagnosis of idiopathic CD4+ T-cell lymphocytopenia was retained. CD4 lymphocytopenia has persisted for 11 years now but the patient has been clinically asymptomatic.

  • Ana Rita Barradas, Francisco Albuquerque, Mariana Constante, Margarida Fonseca, Filipe Correia, João Lopes Delgado

    Syncope caused by carotid sinus syndrome due to head and neck cancer is rare. We report a case of recurrent syncope as a result of extreme bradycardia requiring pacemaker implantation. The patient began chemotherapy and radiation therapy to treat the underlying cause. When diagnosed early, a positive outcome is expected in these situations.

  • Débora Sousa, Pedro Raimundo

    Amoxicillin is a semi synthetic beta-lactam antibiotic that belongs to the penicillin family. It is the most prescribed antibiotic in the world. It has few side effects, even though hypersensitivity reactions may occur, with potential life-threatening effects. The authors present the case of a 63 years-old male admitted in the emergency department with a two-week history of fever and occipital headache. The symptoms began after he started antibiotic prophylaxis with amoxicillin for a dental procedure. Cerebrospinal fluid analysis was suggestive of aseptic meningitis and the patient improved quickly after discontinuation of the drug. The patient’s previous medical history highlighted a similar episode after he had started taking amoxicillin as part of a scheme for the treatment of a Helicobacter pylori infection. Aseptic meningitis is an extremely rare adverse reaction of amoxicillin, with only 16 cases reported in literature.

  • Sumeet Yadav, Michelle Talukder, Jacky Duong

    Hemiplegic migraine (HM) is a rare type of migraine which presents with motor and sensory impairment like a cerebrovascular accident (CVA). We present a case of a 36-year-old female, with a prior CVA treated with alteplase, who presented to the emergency department with stroke-like symptoms with a duration of 1 hour. The NIH Stroke Scale score was 22 at presentation. The patient received alteplase under the supervision of a neurologist after head CT confirmed no bleed. Further work-up revealed no acute or remote ischaemia or infarction. This case demonstrates the importance of a thorough history, intercommunication between health systems and integrated Electronic Medical Records (EMR) for early diagnosis and management of HM.

  • Niryinganji Révérien, Mountassir Shuruk, Siwane Abdellatif, Tabakh Houria, Touil Najwa, Kacimi Omar, Chikhaoui Nabil

    Emphysematous pancreatitis is a rare and fatal complication of acute necrotizing pancreatitis. We report a radioclinical observation of a 61-year-old female patient who consulted for epigastric pain radiating to the back, associated with vomiting and elevated lipasaemia more than 3 times the normal value. The abdominal computerized tomography (CT) scan carried out on the fourth day of hospitalization, based on worsening of the clinical condition, showed pancreatic necrosis associated with the presence of air bubbles. Percutaneous puncture of a peripancreatic collection was positive for Escherichia coli. A diagnosis of emphysematous pancreatitis was established. The clinical and biological evolution of our patient was favourable with antibiotic treatment.

  • Deeba Ali, Arnaud Detroz, Yilmaz Gorur, Lionel Bosquee, Noel Lorenzo Villalba, Benoît Cardos

    We reported a case of measles-induced acute disseminated encephalomyelitis (ADEM) in a 40-year-old immunocompetent adult. The patient presented a week after the development of respiratory symptoms and a cutaneous rash, and was admitted to hospital for altered mental status. Blood tests showed hyperleukocytosis, thrombopenia and cytolysis. A lumbar puncture was consistent with acute meningitis and the patient was initially treated with antiviral and wide broad-spectrum antibiotics. Serology and PCR for measles came back positive.

  • Ali Mir, Marzieh Lashkari, Fatemeh Jafari, Behnam Molavi

    In the present report, we describe our experience with a 44-year-old male with abnormal retroperitoneal primitive neuroectodermal tumours (PNETs) in our hospital, who was operated on with a spindle cell neoplasm diagnosis.

  • Minoodokht Bavarsad Karimi

    Pulmonary arterial hypertension (PAH) is one of the main complications of sickle cell disease (SCD) and imparts significant risk during pregnancy. Here, we report the outcome of undetected PAH in a pregnant woman with SCD. The patient presented with severe progressive dyspnoea with echocardiographic findings of high pressure in the pulmonary artery in the 37th week of pregnancy. Despite an emergency caesarean section, both mother and neonate died. Regular cardiovascular check-up is essential for SCD patients and careful prenatal care should include cardiovascular evaluation. PAH during pregnancy is associated with high mortality and morbidity. As there is no proof that new advanced therapies decrease the risks, early diagnosis in pregnant patients with underlying disease, like sickle cell anaemia, is essential and termination of pregnancy should be considered.

  • Erika Poggiali, Davide Bastoni, Eva Ioannilli, Andrea Vercelli, Andrea Magnacavallo

    Coronavirus disease 19 (COVID-19) is a worldwide infection which was recently declared a global health emergency by the WHO Emergency Committee. The most common symptoms are fever and cough, which can progress to pneumonia, acute respiratory distress syndrome (ARDS) and/or end-organ failure. Risk factors associated with ARDS and death are older age, comorbidities (e.g., hypertension, diabetes, hyperlipidaemia), neutrophilia, and organ and coagulation dysfunction. Disseminated intravascular coagulation and coagulopathy can contribute to death. Anticoagulant treatment is associated with decreased mortality in severe COVID-19 pneumonia. In this report we describe two patients with COVID-19 pneumonia who developed venous thromboembolism.

  • Mohammad Darvishi, Sana Rashidi, Setayesh Abazari

    Tuberculosis is one of the major health problems in developing countries affecting different organs such as bone and joints. One of the most important involvements of osteoarticular tuberculosis is that of the sacroiliac joint. In addition, its incidence has increased over the past several years. Early diagnosis is necessary to prevent further disorders such as neurological and surgical complications. We report a tuberculous arthritis case in the right sacroiliac joint, which developed after penicillin injection.
    The patient was a 32-year-old man admitted to Besat hospital, Tehran, Iran. He complained of pain, erythema and swelling in his right buttock starting approximately 17 years previously, after a penicillin injection, which was followed by the emergence of an orifice with yellow secretions. Over the years, the secretions continued but the pain, swelling and erythema were resolved. At the time of admission, his vital signs were stable and normal. In the physical examination, an orifice with a small amount of yellow secretion was detected on the right buttock as claimed by the patient. Lung auscultation was clear. No lymphadenopathy was detected. Laboratory data were normal.
    During hospitalization, initial antibiotic therapy was prescribed. After Mycobacterium tuberculosis was detected in culture, a 4-drug anti-TB therapy encompassing rifampin, isoniazid, ethambutol and pyrazinamide was prescribed for 18–24 months, in addition to daily vitamin B6 and pantoprazole.

  • Danny Epstein, Wisam Andrawis, Ari M Lipsky, Hiba Abu Ziad, Moshe Matan

    We describe a case of a young man admitted to due to mild COVID-19 infection. During his hospitalization in an isolation ward, he had no respiratory distress or fever but developed symptoms consistent with anxiety and insomnia. Despite the appropriate supportive intervention, on hospital day 7, he attempted suicide by jumping from the third-floor ward. The patient was urgently operated and transferred to level I trauma center under strict isolation. Our findings emphasize the importance of mental health aspects during the treatment of patients during the COVID-19 pandemic.  

  • Ahmed A Mohamad, Muhammed Zahid, Adeel Ahmad Khan, Belal Alani, Mustafa Khalil, Abazar Saeed, Abdel-Naser Elzouki

    Introduction: Kikuchi-Fujimoto (KF) disease is a rare and self-limiting disorder of unknown aetiology characterized by cervical lymphadenopathy (CLN) and fever. The pathophysiology remains unclear and may be triggered by an infectious agent leading to a self-limiting autoimmune process. There are no confirmatory laboratory tests and lymph node biopsy is required to differentiate KF disease from other serious conditions.
    Materials and methods: We report 11 cases of KF disease diagnosed at Hamad General Hospital, Qatar, between 2006 to 2016. The diagnosis is based on clinical presentation, investigations and histopathological examination of lymph nodes.
    Results: All patients had painful neck swelling (average duration of 2.9 weeks) and 10 had fever (average duration of 3.2 weeks). Five patients developed mild leucopenia which resolved completely. HIV and tuberculosis (TB) screening including sputum for AFB, a PPD skin test and chest x-ray was done for all patients and came back negative. Autoimmune screening was done for all patients and excluded any rheumatological disease. Ultrasound and CT of the neck confirmed cervical lymphadenopathy. Except for hepatomegaly in one patient, CT scans of the chest and abdomen were negative for any lymphadenopathy or organomegaly (performed in seven patients). Diagnosis was confirmed on lymph node excision biopsy. Histopathological examination showed findings consistent with the diagnosis of histiocytic necrotizing lymphadenitis (KF disease).
    Conclusion: KF disease should be kept in mind for patients presenting with fever and CLN. Lymphoma, TB and autoimmune diseases like systemic lupus erythematosus should be excluded in such patients.