Black Urine and Black Pleural Fluid: A Distinctive Presentation of Metastatic Melanoma

Metastatic melanoma is an uncommon clinical entity which can have an unusual presentation. We describe a patient with metastatic melanoma who presented with diffuse melanosis cutis, black urine and black pleural effusion. Very few medical conditions can cause black discoloration of body fluids, so this should prompt physicians to search for a number of potential underlying causes.

Prasugrel and Acquired Thrombotic Thrombocytopenic Purpura Associated with ADAMTS13 Activity Deficiency

We report a case of a 64-year-old male who, 44 days after starting treatment with prasugrel, presented with severe thrombocytopenia, anemia, renal failure, and severe ADAMTS13 activity deficiency, along with a high titer of autoantibodies to this protease.

Magnetic resonance spectroscopy. Data analysis for clinical applications

This text is taken from the postgraduate thesis, which one of the authors (A.B.) developed for the degree of Medical Physicist in the School on Medical Physics of the University of Florence. The text explores the feasibility of quantitative Magnetic Resonance Spectroscopy as a tool for daily clinical routine use. The results and analysis comes from two types of hyper spectral images: the first set are hyper spectral images coming from a standard phantom (reference images); and hyper spectral images obtained from a group of patients who have undergone MRI examinations at the Santa Maria Nuova Hospital. This interdisciplinary work stems from the IFAC-CNR know how in terms of data analysis and nanomedicine, and the clinical expertise of Radiologists and Medical Physicists. The results reported here, which were the subject of the thesis, are original, unpublished, and represent independent work.

Giant Cell Arteritis Presenting with Bilateral Subdural Haematomas of Arterial Origin

Giant cell arteritis or temporal arteritis is an inflammatory condition affecting medium to large sized vessels, particularly the cranial arteries. A 76-year-old man with no significant past medical history presented to the emergency department with a 3-week history of diffuse headaches associated with fever, loss of appetite, weight loss and general malaise. A CT scan of the brain showed bilateral shallow chronic low density subdural haematomas. A complete laboratory panel was unremarkable except for a raised erythrocyte sedimentation rate and elevated C-reactive protein. A transthoracic echocardiogram and CT scan of the body were unremarkable. MRI of the brain confirmed bilateral old subdural collections and showed marked vessel wall enhancement in the frontal branches of the left superficial temporal artery. A left temporal artery biopsy confirmed giant cell temporal arteritis. We speculate that a vasculitic process in the small subdural arteries may have contributed to our patient’s spontaneous subdural haematomas.

Ventricular Fibrillation in Patient with Multi-vessel Coronary Spasm Four Days after the Initiation of Oral Beta-blocker

We describe a case of ventricular fibrillation occurring in a patient with multi-vessel coronary spasm after the initiation of an oral beta-blocker. A 56-year-old man began to experience chest discomfort and his computed tomography revealed intermediate coronary stenoses. He was administered medications including an oral beta-blocker but suddenly collapsed while walking 4 days later. An automated external defibrillator detected ventricular fibrillation and delivered successful electrical cardioversion. An acetylcholine provocation test after stabilization of the status revealed triple-vessel coronary spasm. Beta-blockers may provoke exacerbation of coronary spasm and result in lethal arrhythmia.

Intravascular Lymphoma as an Uncommon Cause of Anasarca

Objectives: To report a case of intravascular lymphoma (IVL) in a Caucasian patient who presented with anasarca as his sole clinical sign. Material and Methods: A man presented with anasarca-type oedema and fatigue. After excluding heart failure, hepatic cirrhosis, nephrotic syndrome, hypothyroidism, AL-amyloidosis and adverse drug reaction which can all cause oedema, we turned our attention to capillary permeability disorders. Results: Closer review of the bone marrow aspirate demonstrated haemophagocytic histiocytosis, while core, renal and duodenal biopsies showed a B-cell IVL. Conclusion: The differential diagnosis of anasarca, a relatively common clinical sign, should include IVL although the diagnosis may still be challenging.

Left Ventricle Non-Compaction Myocardium and Thrombophilia in a Pregnant Woman

Non-compaction of the ventricular myocardium (NCM) is a genetic cardiomyopathy usually due to mutationof the G4.5 gene located in the Xq28 chromosomal region. This congenital disorder is characterized by pronounced trabeculations and intertrabecular recesses resulting from abnormal embryogenesis between the fifth and eighth fetal weeks. The reported prevalence in the general population is between 0.014% and 1.3%. The classic triad of complications includes heart failure, ventricular arrhythmias and systemic embolic events, although some patients have an asymptomatic form. NCM is commonly diagnosed by echocardiography, but contrast ventriculography, CT and MRI can also be used. Here we present a case of left ventricle NCM, manifested after respiratory infection, in a pregnant patient with congenital thrombophilia and a history of myocardial infarction.

Huge Tracheal Diverticulum in a Patient with Mounier-Kuhn Syndrome

Tracheal diverticulum is a rare benign entity. Tracheobronchomegaly (TBM), also known as Mounier-Kuhn syndrome, is a rare disorder characterized by marked dilation of the trachea and main bronchi, associated with thinning or atrophy of the elastic tissue. Because of the weakened trachea and increased intraluminal pressure related to chronic cough, some patients may develop mucosal herniation leading to tracheal diverticulosis. We report the case of a patient with TBM with a huge tracheal diverticulum, diagnosed by bronchoscopy and computed tomography with three-dimensional reconstruction. To our knowledge this is the largest tracheal diameter described in a patient affected by this syndrome.

Coma caused by Shigella toxin-producing Escherichia coli in the absence of haemorrhagic uraemic syndrome (HUS)

Shigella toxin-producing Escherichia coli (STEC) is well known for its complications such as haemolytic uraemic syndrome (HUS), but neurological symptoms have also been reported. While most cases of infection with STEC occur with concurrent HUS, we describe a patient with severe neurological symptoms in the absence of HUS.

Dysautonomia: an Explanation for the Medically Unexplained?

Objective: To identify dysautonomia as a collection of conditions with variable presentation that may be mistaken for medically unexplained symptoms. Methods: Case series. Results: Tilt table testing and 24 h electrocardiographic monitoring provided useful diagnostic tools to confirm the diagnosis. Conclusion: A greater awareness and recognition of the disorders that result from dysautonomia and recognition of the disability that results from these disorders will improve patients’ quality of life.

Acute Cholecystitis as a Complication After Colonoscopy: A Case Report and Literature Review

Acute cholecystitis after colonoscopy is a rare event, with less than 10 cases described in the literature. We report the case of a male patient with silent gallstones who underwent colonoscopy for follow-up of his Crohn’s disease. The colonoscopy revealed erosions in the terminal ileum, from which biopsies were taken. A sessile polyp 4 mm in diameter at the recto-sigmoid junction was also removed. Less than 24 h after the colonoscopy, the patient complained of upper right quadrant pain, nausea and vomiting. Based on the clinical findings, laboratory data and ultrasonography, we diagnosed acute cholecystitis and excluded any complication after the colonoscopy. Laparoscopic cholecystectomy was performed and the patient was discharged.

A Painless Thoracic Aortic Dissection

Thoracic aortic dissection (TAD) has a very high mortality rate and is often missed due to the atypical presentation of patients. We present a case of a man with chronic hypertension, atrial fibrillation (AF) (on regular warfarin) and a previous endovascular aneurysm repair (EVAR), who presented with dyspepsia and was incidentally found to have a ruptured distal thoracic aneurysm on imaging with no obvious clinical signs on examination, nor abnormalities on admission chest x-ray (CXR).

Increasing Skin Pigmentation Following Severe Head Trauma: All That Glitters Is Not Gold!

We report the case of a 67-year-old man who was admitted to our Intensive Care Unit because of traumatic brain injury. During his prolonged hospitalization, gradual darkening of the skin all over his body was observed. An excess corticotropin (ACTH) production syndrome was considered. The patient’s hormone study showed high levels of ACTH (978 pg/ml) with normal cortisol levels. Extensive clinical and laboratory investigations revealed adenocarcinoma of the colon, which was likely the site of the ectopic ACTH production. This is a very rare manifestation of paraneoplastic syndrome during the course of colon adenocarcinoma. The most important feature of this case report is that this rare syndrome was accidentally discovered, in a patient hospitalized for unrelated reasons, by simple clinical investigation.

A Case Against Fancy Decorated Drinks: Multi-Organ Failure After Drinking a Mojito Cocktail

We present the first case of gastro-intestinal perforation caused by a mint twig decorating a cocktail drink. A 76-year-old man was enjoying his Mojito cocktail on a cruise ship near Mexico when he accidently swallowed a mint twig, resulting in ileum perforation. This led to a cascade of events, eventually resulting in life-threatening multi-organ failure. Given this rare but potentially severe complication and the increasing popularity of decorated drinks, a less ‘fancy’ presentation for cocktails and similar drinks may be warranted.

Paradoxical Deterioration During Anti-Tuberculous Therapy in Non-HIV-Infected Patients with Pleural Tuberculosis: A Pragmatic Approach

We report a case of paradoxical deterioration. A male patient diagnosed with pleural tuberculosis, but who was not infected with human immunodeficiency virus (HIV), experienced clinical deterioration 3 weeks after the initiation of anti-tuberculous treatment. After other diagnoses were ruled out, a paradoxical response to treatment was established and the patient was started on systemic corticosteroids. Paradoxical response to treatment should be considered in patients with clinical deterioration after they start on anti-tuberculous treatment.