The Role of Accidental and Therapeutic Hypothermia in Non-Fatal Drowning

A case of non-fatal drowning with a successful outcome despite a submersion time of 25 min is described. Our case report emphasizes the role of accidental hypothermia in the survival of drowning victims with hypoxic brain injury, and supports the use of therapeutic hypothermia in the resuscitation of these patients.

Eosinophilic Fasciitis: an Atypical Presentation of a Rare Disease

Objectives: We report an atypical presentation of eosinophilic fasciitis and provide a concise overview of the literature. Materials and Methods: Clinical and laboratory findings in a patient presenting with fever and skin induration were recorded. A deep muscle biopsy was performed in order to confirm the diagnosis. Results: A spontaneous favourable clinical and radiological evolution was observed. Conclusion: The diagnosis of eosinophilic fasciitis is challenging due to the lack of pathognomonic signs and symptoms. As spontaneous resolution has been described, watchful waiting is defendable depending on the clinical presentation. Although magnetic resonance imaging (MRI) can be useful in establishing the diagnosis, a deep muscle biopsy remains the gold standard diagnostic tool.

Severe Case of Thrombotic Microangiopathy with a Delayed Diagnosis of Atypical Haemolytic Uraemic Syndrome Successfully Managed with Eculizumab

Objectives: To describe the diagnosis and treatment of a severely ill patient presenting with thrombotic microangiopathy (TMA) of unknown cause. Case presentation: An adult female presented to intensive care with abdominal pain and haemorrhagic shock, requiring reanimation. Results: Features of TMA were present, but initial plasma exchange was ineffective. Treatment with the anti-C5 antibody, eculizumab, improved laboratory parameters and organ function, albeit slowly. Eculizumab remains effective and well tolerated after 30 months of treatment. Conclusion: This case demonstrates the complexities and importance of early identification of atypical haemolytic uraemic syndrome in patients presenting with TMA.

Seizure and Profound Hypokalemia: Unusual Presentation of Primary Hyperparathyroidism

A 68-year-old man was admitted because of tonic–clonic convulsion. He had been receiving 200 mg itraconazole for 10 days. He had hypokalaemia (2.2 mEq/l), hypercalcaemia (Cacorr 11.0 mg/dl) and elevated serum parathyroid hormone (PTH, 95 pg/ml). Ultrasound examination of the neck revealed a low echoic tumour. Cessation of itraconazole and fluid supplementation eradicated clinical symptoms and profound hypokalaemia, but serum potassium remained low normal (3.4 mEq/l) and the mild hypercalcaemia and elevated PTH were unchanged. To conclude, a small amount of itraconazole (200 mg) precipitated profound hypokalaemia and seizure in a patient with mild hyperparathyroidism and low normal serum potassium.

Is There More to This Case than Mere Pulmonary Alveolar Proteinosis? A Clinical Case Presentation

Introduction: Pulmonary alveolar proteinosis (PAP) is a rare disease, associated with excess accumulation of surfactant proteins and lipids in the alveoli. Clinical presentation: We report the case of a 46-year-old woman with a combined presentation of PAP, myelodysplasia and recurrent miscarriages. Conclusions: The concomitant presentation of the above might be compatible with a mutation of the haematopoietic transcription factor gene GATA2.

Life-Threatening Adverse Reaction after Self-Initiated, Off-Label Use of High Dose Nicotinamide for the Treatment of Friedreich’s Ataxia

A 40-year old woman, previously known for Friedreich’s ataxia, presented with shock, profound lactic acidosis and hepatic failure after ingestion of a high dose of nicotinamide, the amide form of vitamin B3. On her own initiative, she was taking up to 4.4 g per day of nicotinamide, after having learned the results of a phase 2 study suggesting a potential benefit in Friedreich’s ataxia. The outcome was good with supportive care and withdrawal of nicotinamide.

The Consequences of Not Looking at the Eosinophil Count: Pulmonary Infiltrates and Eosinophilia Syndrome (PIE) Probably Caused by Ciprofloxacin

Objectives: To describe a case of pulmonary infiltrates and eosinophilia (PIE syndrome) probably caused by ciprofloxacin. Materials and methods: A 64-year-old woman was admitted to our department with suspected hospital-acquired pneumonia and treated with antibiotics. She had no symptoms but had peripheral eosinophilia. She had recently been given ciprofloxacin for a urinary tract infection. Results: The patient spontaneously improved after exhaustive negative investigations. Conclusion: We concluded that this patient had PIE syndrome probably caused by ciprofloxacin.

Deep Venous Thrombosis (DVT) in Lower Extremity Amputation as Cause of Pulmonary Embolism

The authors describe the case of a 43-year-old man with a right-leg knee amputation performed 14 years prior. He presented to hospital with dyspnea. A pulmonary embolism was detected. A Doppler ultrasound test showed deep vein thrombosis (DVT), which affected the stump of the amputated limb. When a pulmonary embolism is detected in a patient with an amputated lower limb, an exploration of the stump should be performed to rule out this uncommon complication.

Hydroxychloroquine Myocardial Toxicity in a Patient with Systemic Lupus Erythematosus

Hydroxychloroquine is an antimalarial drug used in many rheumatologic and systemic diseases. Although considered by clinicians to be relatively safe, serious side effects have been documented (retinotoxicity, neuromyotoxicity and cardiotoxicity). We present the case of a 41-year-old woman with systemic lupus erythematosus (SLE) who presented at our institution with acute heart failure after taking hydroxychloroquine for a period of 3 months. An endomyocardial biopsy ruled out myocarditis related to systemic lupus erythematosus but demonstrated pathological changes related to hydroxychloroquine toxicity. It is exceptional to observe such cardiac toxicity after such a low cumulative dose (16 grams). The potential severity and reversibility of this complication underscores the importance of a high level of suspicion and timely diagnosis.

Brucella Non-Neutrocytic Bacterascites in a Patient with Chronic Liver Disease

Objectives: To report a case of Brucella peritonitis. Patient and methods: We describe the case of a patient and present a brief review of the few published reports. Results: The patient had alcoholic cirrhosis of the liver and was diagnosed with Brucella non-neutrocytic bacterascites. Conclusion: Brucellosis is a common zoonosis with worldwide distribution. It is a systemic disease with the potential to predominantly affect one organ or a specific system (focal brucellosis). However, peritoneal focalization of this disease is a very rare presentation.

Disseminated Cerebral and Intradural Extramedullary Spinal Nocardiosis in an Immunocompetent Patient

Disseminated nocardiosis of the central nervous system (CNS) has been rarely reported, especially in the immunocompetent patient. We report a case of cerebral and cervical intradural extramedullary nocardiosis likely to have been the result of disseminated spread from a pulmonary infective focus. Attempts at tissue biopsy and culture of the initial cerebral and pulmonary lesions both failed to yield the diagnosis. Interval development of a symptomatic intradural extramedullary cervical lesion resulted in open biopsy and an eventual diagnosis of nocardiosis was made. We highlight the diagnostic dilemma and rarity of spinal nocardial dissemination in an immunocompetent individual.

A Case of Chronic Mesenteric Ischemia imitating Crohn's disease

Objectives: We present an atypical case of chronic mesenteric ischemia with weight loss as only clinical manifestation and endoscopic findings imitating Crohn´s disease. Materials and Methods: A CT Angiography of abdomen confirmed the diagnosis of mesenteric ischemia after total occlusion of celiac trunk and superior mesenteric artery. Results: The patient died due to severe sepsis, as a result of extended bowel infarction. Conclusions: The diagnosis of chronic mesenteric ischemia requires a high degree of clinical suspicion and can be life-saving if early conducted.

Hyperinsulinaemic hypoglycaemia - a diagnostic challenge. A report of two atypical cases

Objectives: The authors describe 2 atypical cases of patients with hypoglycaemia, suspected for insulinoma. Methods: The 2 reports are accompanied by a concise review of the literature. Results: Patient 1 had a distal pancreatectomy performed for suspected insulinoma, and was diagnosed with a glucagonoma and beta-cell hyperplasia (nesidioblastosis). To the authors’s knowledge, co-existing glucagonoma and nesidioblastosis had not been previously reported. Patient 2 was diagnosed with a benign insulinoma and 5 years later with metastatic disease. Conclusion: The authors conclude that insulinomas are rare entities which often present a diagnostic and therapeutic challenge. In such cases, patient referral to tertiary multidisciplinary centers is recommended.

TAFRO Syndrome in a Patient of South-American Descent

A 31-year-old Caucasian woman of South-American descent was diagnosed with a variant of multicentric Castleman disease (MCD) that has been reported in Japan as Castleman-Kojima disease. This is a systemic inflammatory disorder known as TAFRO Syndrome which includes thrombocytopenia, polyserositis (ascites/pleural effusion), microcytic anemia, myelofibrosis, fever, renal dysfunction and organomegaly, with immunologic disorder, polyclonal hypergammaglobulinemia, and elevated levels of interleukin-6 (IL-6) and the vascular endothelial growth factor present in serum and/or effusions. Optimal therapies are not well established. The patient was treated with methylprednisolone and rituximab. Following the start of treatment, the patient has been asymptomatic for over 8 months.

Chylous Ascites in Systemic Lupus Erythematosus (SLE) Patients

The gastrointestinal system is commonly implicated in Systemic Lupus Erythematosus (SLE). Ascites, produced by several mechanisms has been reported as a systemic manifestation of lupus, but only rarely as an initial presentation of the disease. Its appearance is often insidious and without abdominal pain. Chylous ascites (such as chyle in the peritoneal cavity) has seldom been reported in SLE. We describe a case of chylous ascites in an SLE patient, reviewing the other published cases, its pathophysiology and its management.