Clinical Medicine Insights. Case Reports最新文献

Introduction: Polydrug overdose, defined as the simultaneous ingestion of multiple toxic substances, is increasingly encountered in emergency departments. Overlapping toxidromes often obscure the causative agents, complicating diagnosis and management. Acetaminophen (APAP) overdose can cause hepatotoxicity through N-acetyl-p-benzoquinone imine (NAPQI) formation, metoclopramide may precipitate acute extrapyramidal symptoms, and metronidazole can induce neurotoxicity, typically a cerebellar syndrome.

Case summary: Young adult male medical student intentionally ingested 12 g of APAP, 170 mg of metoclopramide, and 8 g of metronidazole. He presented 24 hours later with repeated vomiting, tremor, rigidity, dysarthria, gait ataxia, and transient confusion. Vital signs were stable; laboratory tests showed transaminase elevation and coagulopathy. Peak AST/ALT were 100/76 U/L and INR peaked at 1.74. Management included oral N-acetylcysteine for APAP toxicity, intravenous diphenhydramine and diazepam for extrapyramidal symptoms, supportive ICU care, and psychiatric intervention. Coagulopathy was corrected with fresh frozen plasma. Neurological and hepatic abnormalities resolved within 72 hours, and the patient remained asymptomatic at 2-week follow-up. The patient recovered fully after N-acetylcysteine and supportive care, illustrating the diagnostic challenges of overlapping toxidromes.

Conclusion: This case highlights the diagnostic and therapeutic challenges of polydrug overdose with overlapping toxidromes. Rapid identification and agent-specific management, including NAC for APAP, symptomatic therapy for metoclopramide and metronidazole toxicity, and supportive care, resulted in full recovery without long-term sequelae. Emergency clinicians should maintain high suspicion for multiple co-ingestants and use targeted interventions to optimize outcomes.

Background: Ataxia telangiectasia (A-T) is an uncommon autosomal recessive disorder, affecting 1 to 2 individuals per 100 000 live births. It results from mutations in the ATM gene. Patients typically present with progressive cerebellar ataxia, oculocutaneous telangiectasia, recurrent sinopulmonary infection, and predisposition to malignancies.

Case presentation: This is a 10 year-old boy with recurrent chest infections and progressive gait imbalance since the age of 4, accompanied by ocular telangiectasia. Laboratory investigations revealed elevated serum alpha-fetoprotein (AFP) and hypogammaglobulinemia. Brain MRI showed cerebellar atrophy, and chest CT revealed pulmonary consolidation. These findings, together with clinical features, confirmed the diagnosis of A-T.

Clinical discussion: Also referred to as Louis-Bar Syndrome, Ataxia-telangiectasia (A-T) is a multisystem genetic disorder characterized by a wide range of clinical manifestations. Diagnosis is based on a synthesis of clinical assessments and laboratory results, with genetic testing serving as the definitive method for confirmation. Management strategies are predominantly symptomatic and supportive, emphasizing immunoglobulin replacement therapy, immunization protocols, antibiotic administration for infection prevention, and vigilant surveillance for malignancies.

Conclusion: This case emphasizes the importance of considering A-T in children with recurrent chest infections and neurological symptoms. Early diagnosis facilitates timely supportive care, including immunization, pulmonary management, malignancy surveillance, and genetic counseling for families.

Background: Uterine fibroids are common benign smooth muscle tumours that may complicate pregnancy with pain and pressure symptoms. While conservative management is preferred due to the risk of haemorrhage and pregnancy loss, antepartum myomectomy may be indicated in selected cases with intractable symptoms.

Case presentation: We report 2 cases of successful antepartum myomectomy performed in the second trimester for severe, unrelenting pain secondary to large fibroids. The first case involved a 27-year-old primigravida at 15 + 2 weeks' gestation with a 22 × 16 × 17 cm pedunculated fibroid causing respiratory compromise. The second case involved a 41-year-old multigravida at 14 weeks' gestation with multiple fibroids, the largest measuring 19 × 21 cm. Both patients underwent open myomectomy following multidisciplinary evaluation and counselling. Estimated blood loss was minimal, and postoperative recovery was uneventful. Pregnancies progressed to term, resulting in favourable maternal and fotal outcomes.

Conclusion: Antepartum myomectomy, though rarely indicated, can be safely performed in well-counselled, carefully selected patients with severe symptoms and favourable fibroid characteristics. Preoperative imaging, multidisciplinary planning and meticulous surgical technique are crucial for optimal outcomes.

Background: A growing number of patients suffering from neurocognitive symptoms related to COVID-19 were observed as the pandemic progressed. This article addresses severe neurological manifestations in healthy individuals with COVID-19, which were not previously identified in the absence of comorbidities or respiratory symptoms.

Case presentations: The 3 patients, aged between 15 and 27 years old, had no relevant medical history and were not on any chronic treatments. They presented different neurological symptoms (pseudobulbar affect, excessive crying, paracusia, fatigue and sleep problems, anxiety, depression, alexithymia, dementia, aggressive behavior, panic attack, etc) for a period of 2 weeks to 4 months and were treated with different medications. Clomipramine, Zolpidem and Clonazepam were effective in treating these patients.

Conclusion: Even in healthy young individuals with COVID-19, severe neurocognitive manifestations could appear with possible long-term consequences. Further research is needed to expand the knowledge on mechanisms, targeted therapeutic strategies and predictors identifying at-risk groups.

Introduction: Adult-Onset Still's Disease (AOSD) is a rare inflammatory disease. It usually causes high fevers, joint pain, a fleeting rash, and very high ferritin levels. The symptoms can mimic infections, autoimmune disorders, or cancers, so it can be hard to diagnose. Liver involvement is common but usually mild. Severe hepatitis is rare.

Case presentation: We report a 24-year-old woman who had 3 weeks of daily high fevers, a temporary salmon-pink rash, sore throat, muscle pain, and joint pain. Her blood tests showed high white blood cells with mostly neutrophils, persistent monocytosis, severely elevated liver enzymes, and very high ferritin. Tests ruled out infections, autoimmune diseases, and cancers. She met criteria for AOSD, and her glycosylated ferritin was low. The patient responded rapidly to intravenous methylprednisolone, but relapsed with polyarthritis upon tapering, which resolved completely within 48 hours of initiating anakinra.

Discussion: This case highlights the diagnostic challenges of AOSD presenting predominantly with hepatic involvement and atypical laboratory features such as persistent monocytosis. Recognition of extreme hyperferritinemia as a diagnostic clue can prevent delays in diagnosis. The dramatic response to IL-1 blockade underscores cytokine dysregulation as a central pathogenic mechanism.

Conclusion: Clinicians should consider AOSD in patients with febrile hepatitis and extreme hyperferritinemia. Early initiation of biologic therapy targeting IL-1 can achieve rapid remission, improve quality of life, and prevent complication.

Introduction: Calcium channel blocker (CCB) overdose, particularly with dihydropyridines like amlodipine, can cause profound vasodilatory shock and multi-organ dysfunction. Such poisoning often requires aggressive critical care interventions.

Case presentation: A 23-year-old Ethiopian man attempted suicide by ingesting ⩾300 mg of amlodipine (plus diclofenac). He developed refractory hypotension, bradyarrhythmia, acute kidney injury, and non-cardiogenic pulmonary edema. He subsequently required intubation and suffered a cardiac arrest.

Management and outcome: He received standard supportive therapy: Intravenous (IV) crystalloid boluses, calcium gluconate, escalating vasopressors (norepinephrine/epinephrine), and high-dose insulin-glucose infusion with potassium supplementation. Despite multiorgan failure (renal failure, pulmonary edema) and arrest, he recovered gradually over 2 weeks with full neurologic return. Corticosteroids, diuretics, and broad-spectrum antibiotics were adjunctively used.

Conclusion: This case illustrates that even a massive amlodipine overdose with multiorgan failure and arrest can be survived with early, multimodal intensive care. It showcases the need for early recognition of CCB toxicity and prompt use of therapies such as high-dose insulin and extracorporeal support if needed.

Statins are a class of drugs that are vital for lowering blood lipid levels and reducing the risk of both primary and secondary cardiovascular diseases. These drugs are generally considered safe; however, some individuals may experience side effects, such as muscle pain, headache, fatigue, myopathy, and gastrointestinal disorders. One of the less frequently reported side effects of statins is visual disturbances. We report the case of a 51-year-old woman who developed persistent headache, blurred vision, and diplopia shortly after initiating Atorvastatin. These visual disturbances recurred when treatment was switched to Rosuvastatin and Lovastatin. Comprehensive neurological evaluation, including brain MRI, was unremarkable. All symptoms resolved completely after permanent discontinuation of statin therapy, indicating a rare but significant statin-associated visual adverse event. Due to the significance of reporting this complication, this study aims to present a case of a patient who experienced visual impairment associated with the use of atorvastatin, rosuvastatin, and, to a lesser extent, lovastatin.

Hypoparathyroidism-induced hypocalcemia represents a rare cause for psoriasis exacerbation through various mechanisms including disruption of calcium-dependent keratinocyte differentiation and proliferation pathways. Epidermal barrier function and normal keratinization processes are normally maintained by normal calcium levels, where its deficiency can end in abnormal inflammatory processes and impaired skin homeostasis. We present a 52-year-old Egyptian male with chronic post-surgical hypoparathyroidism who developed severe psoriatic plaques during periods of profound hypocalcemia (7.2 mg/dL). Marked improvement of skin lesions as well as normalization of calcium levels were achieved through psoriasis therapy along with aggressive calcium, demonstrating the therapeutic importance of addressing underlying metabolic abnormalities in dermatological conditions, especially psoriasis.

Purple Urine Bag Syndrome (PUBS) is an uncommon but notable clinical phenomenon primarily observed in patients with long-term indwelling catheters. This syndrome is characterized by a striking purple discoloration of the urine collection bag, often indicative of an underlying urinary tract infection (UTI) and associated metabolic processes. PUBS occurs due to the breakdown of indoxyl sulfate, a tryptophan metabolite, by specific bacteria present in the urinary tract. In this report, we present the case of a 73-year-old female with a chronic Foley's catheter, later developed PUBS, accompanied by symptoms of lower abdominal pain, fever, and reduced urine output. Urine culture identified Klebsiella pneumoniae, a common uropathogen, as the causative organism. This case highlights the clinical presentation, pathophysiology, and management of PUBS in a patient with long-standing catheterization, along with a brief review of existing literature on the condition. Prompt recognition and targeted antibiotic therapy, alongside supportive measures, were essential in managing the infection and alleviating symptoms.

Background: Acro-osteolysis is a less common radiological condition characterized by resorption of the distal phalanges, presenting as terminal tuft or band-like resorption.

Case presentation: A 37-year-old female housekeeper with a 6-month history of progressive fingertip pain, swelling, dactylitis, and skin tightening affecting the upper limbs, face, and trunk, without Raynaud's phenomenon. Physical examination revealed sclerodermatous changes. Laboratory findings showed normal C-reactive protein, calcium, parathyroid hormone, and vitamin D levels, but positive anti-SSA antibody, suggesting an autoimmune etiology. Nailfold capillaroscopy indicated scleroderma with dilated capillary loops and avascular areas. Radiographs confirmed band acro-osteolysis in the first, second, and fifth digits bilaterally and the third digit of the left hand. A technetium-99m bone scan revealed increased radiotracer uptake in the affected digits. Whole-body imaging and serum protein electrophoresis ruled out malignancy. A deep skin biopsy confirmed systemic scleroderma with dermal fibrosis and collagen deposition. The patient was treated with prednisolone and mycophenolate mofetil, with close outpatient follow-up.

Conclusion: Our report is among the few reported cases of "band acro-osteolysis" without Raynaud's phenomenon in systemic scleroderma. This case highlights an atypical presentation of systemic scleroderma with band acro-osteolysis and dactylitis, emphasizing the importance of recognizing uncommon manifestations for early diagnosis and intervention. The multifactorial pathogenesis, involving vascular dysfunction and inflammation, underscores the need for personalized management to prevent complications.