Clinical manifestations of cancer can be categorized as resulting from direct tissue injury from the primary tumor, distant metastatic spread, or aberrant biological activity, also known as a paraneoplastic syndrome. Soft tissue sarcomas are a rare group of malignant tumors of mesenchymal origin which typically present with direct tissue injury, exerting their harmful potential by compression and mass effect. We describe a rare case of an occult retroperitoneal soft tissue sarcoma presenting with marantic endocarditis. To date, there is a paucity of available medical literature relating sarcoma to marantic endocarditis.
{"title":"A case of marantic endocarditis with systemic emboli in a patient with metastatic soft tissue sarcoma","authors":"D. Reikher, M. Feldman","doi":"10.5430/CRIM.V6N3P6","DOIUrl":"https://doi.org/10.5430/CRIM.V6N3P6","url":null,"abstract":"Clinical manifestations of cancer can be categorized as resulting from direct tissue injury from the primary tumor, distant metastatic spread, or aberrant biological activity, also known as a paraneoplastic syndrome. Soft tissue sarcomas are a rare group of malignant tumors of mesenchymal origin which typically present with direct tissue injury, exerting their harmful potential by compression and mass effect. We describe a rare case of an occult retroperitoneal soft tissue sarcoma presenting with marantic endocarditis. To date, there is a paucity of available medical literature relating sarcoma to marantic endocarditis.","PeriodicalId":72533,"journal":{"name":"Case reports in internal medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-06-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.5430/CRIM.V6N3P6","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45577262","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Kevin Kohm, Lauren Pioppo, Jack Xu, Preston Keiffer, E. Pagan, J. Stoll, M. Danish, C. Fanning, M. Sandel
Methimazole (MMI) is a commonly used medication in the treatment of hyperthyroidism. The side effect profile is extensive and includes the rare but serious side effect of drug associated liver injury. We report the case of a 51-year-old female who presented with painless jaundice several weeks after initiating MMI therapy for treatment of hyperthyroidism complicated by Graves’ orbitopathy. Liver function tests on presentation showed alanine aminotransferase (ALT) 1366 IU/L, aspartate aminotransferase (AST) 853 IU/L, total bilirubin 26.2 mg/dl, alkaline phosphatase 954 IU/L. Workup of structural, infectious, and autoimmune causes of hepatic injury was negative. The patient was therefore found to have MMI associated liver injury. MMI was discontinued and the patient was started on ursodiol, resulting in resolution of her jaundice and improvement of her liver function tests.
{"title":"Methimazole induced hepatotoxicity: A rare adverse reaction","authors":"Kevin Kohm, Lauren Pioppo, Jack Xu, Preston Keiffer, E. Pagan, J. Stoll, M. Danish, C. Fanning, M. Sandel","doi":"10.5430/CRIM.V6N3P1","DOIUrl":"https://doi.org/10.5430/CRIM.V6N3P1","url":null,"abstract":"Methimazole (MMI) is a commonly used medication in the treatment of hyperthyroidism. The side effect profile is extensive and includes the rare but serious side effect of drug associated liver injury. We report the case of a 51-year-old female who presented with painless jaundice several weeks after initiating MMI therapy for treatment of hyperthyroidism complicated by Graves’ orbitopathy. Liver function tests on presentation showed alanine aminotransferase (ALT) 1366 IU/L, aspartate aminotransferase (AST) 853 IU/L, total bilirubin 26.2 mg/dl, alkaline phosphatase 954 IU/L. Workup of structural, infectious, and autoimmune causes of hepatic injury was negative. The patient was therefore found to have MMI associated liver injury. MMI was discontinued and the patient was started on ursodiol, resulting in resolution of her jaundice and improvement of her liver function tests.","PeriodicalId":72533,"journal":{"name":"Case reports in internal medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-06-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.5430/CRIM.V6N3P1","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45754219","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
V. Kaila, Siddharth B. Javia, Nirav C. Thosani, I. Raijman
Background: Intraductal Papillary Neoplasm of the Bile Duct (IPNB) is a rare disease that is characterized by papillary lesions in the intra and extrahepatic biliary tree. Traditional imaging studies may show biliary dilation and/or filling defects. Endoscopic retrograde cholangiopancreatography can demonstrate diffuse bile duct dilatation as well as amorphous filling defects, however visualization of the biliary system can be limited by obstruction by the papillary lesions or mucin. Digital single operator cholangioscopy can be used to aid in diagnosis.Case Presentation: We report two elderly Caucasian males that presented with fatigue and obstructive jaundice. In both cases, the diagnosis of IPNB of was made. In one case, digital single operator cholangioscopy was used successfully to make the diagnosis.Conclusions: We present two cases of IPNB as well as a review of the clinical characteristics of IPNB and the utility of digital single operator cholangioscopy to aid in diagnosis. In IPNB, timely diagnosis is paramount. Traditional imaging studies can be inadequate, digital single operator cholangioscopy allows for quick diagnosis and, if indicated, further intervention.
{"title":"Intraductal papillary neoplasm of the bile duct: two case reports and review of the literature","authors":"V. Kaila, Siddharth B. Javia, Nirav C. Thosani, I. Raijman","doi":"10.5430/CRIM.V6N2P25","DOIUrl":"https://doi.org/10.5430/CRIM.V6N2P25","url":null,"abstract":"Background: Intraductal Papillary Neoplasm of the Bile Duct (IPNB) is a rare disease that is characterized by papillary lesions in the intra and extrahepatic biliary tree. Traditional imaging studies may show biliary dilation and/or filling defects. Endoscopic retrograde cholangiopancreatography can demonstrate diffuse bile duct dilatation as well as amorphous filling defects, however visualization of the biliary system can be limited by obstruction by the papillary lesions or mucin. Digital single operator cholangioscopy can be used to aid in diagnosis.Case Presentation: We report two elderly Caucasian males that presented with fatigue and obstructive jaundice. In both cases, the diagnosis of IPNB of was made. In one case, digital single operator cholangioscopy was used successfully to make the diagnosis.Conclusions: We present two cases of IPNB as well as a review of the clinical characteristics of IPNB and the utility of digital single operator cholangioscopy to aid in diagnosis. In IPNB, timely diagnosis is paramount. Traditional imaging studies can be inadequate, digital single operator cholangioscopy allows for quick diagnosis and, if indicated, further intervention. ","PeriodicalId":72533,"journal":{"name":"Case reports in internal medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-06-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.5430/CRIM.V6N2P25","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43221657","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Diabetic foot ulcer is one of the most frequent complications affecting the diabetic patient. While there has been considerable progress regarding the diagnostic tools and the range of antibiotic choices, the outcome is often unsatisfactory, the presence of peripheral arterial occlusive disease being among the main factors influencing the evolution. This paper describes the management of a patient presenting with an infected foot ulcer and persistent methicillin-resistant Staphylococcus aureus bacteremia, furthercomplicated by spondylodiskitis and infectious endocarditis: the case gives an opportunity to review the literature in search of theoptimal care and the right treatment choices.
{"title":"Case report: Infected foot ulcer and methicillin-resistant staphylococcus aureus bacteremia in a diabetic patient","authors":"M. Goula, P. Felix, M. Mbuyamba, B. Pirotte","doi":"10.5430/CRIM.V6N2P20","DOIUrl":"https://doi.org/10.5430/CRIM.V6N2P20","url":null,"abstract":"Diabetic foot ulcer is one of the most frequent complications affecting the diabetic patient. While there has been considerable progress regarding the diagnostic tools and the range of antibiotic choices, the outcome is often unsatisfactory, the presence of peripheral arterial occlusive disease being among the main factors influencing the evolution. This paper describes the management of a patient presenting with an infected foot ulcer and persistent methicillin-resistant Staphylococcus aureus bacteremia, furthercomplicated by spondylodiskitis and infectious endocarditis: the case gives an opportunity to review the literature in search of theoptimal care and the right treatment choices.","PeriodicalId":72533,"journal":{"name":"Case reports in internal medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-06-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.5430/CRIM.V6N2P20","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47709312","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
G. Lemus-Barrios, J. A. Hoyos-Pulgarín, C. Jiménez-Canizales, Diana Melisa Hidalgo-Zambrano, Fredy Escobar-Montealegre, Á. Mondragón-Cardona, D. A. Medina-Morales
Introduction: Leprosy is a chronic, multisystemic granulomatous infection caused by Mycobacterium leprae. Lucio’s phenomenon is an uncommon reaction consisting of a severe chronic necrotizing vasculitis. The purpose of this article is to present two cases of Lucio’s phenomenon and a review of the literature on its clinical presentation and management.Case Presentation: Two middle-aged men presented with ulcers and ecchymosis in lower extremities, with simultaneous peripheral nerve damage and leonine facies. Both were treated according to World Health Organization recommendations, with a favorable clinical response.Discussion: The clinical characteristics presented in this article make part of the classical description. A proper history and physical examination allowed for a correct diagnostic approach and prompt confirmation of diagnosis, despite the unspecific nature of these signs and symptoms.Conclusions: Leprosy and Lucio’s phenomenon are infrequent conditions that are difficult to diagnose. We suspect this condition to be under-registered. Awareness and a high clinical suspicion are necessary in endemic regions.
{"title":"Lucio’s phenomenon: A report of two cases and review of the literature","authors":"G. Lemus-Barrios, J. A. Hoyos-Pulgarín, C. Jiménez-Canizales, Diana Melisa Hidalgo-Zambrano, Fredy Escobar-Montealegre, Á. Mondragón-Cardona, D. A. Medina-Morales","doi":"10.5430/CRIM.V6N2P15","DOIUrl":"https://doi.org/10.5430/CRIM.V6N2P15","url":null,"abstract":"Introduction: Leprosy is a chronic, multisystemic granulomatous infection caused by Mycobacterium leprae. Lucio’s phenomenon is an uncommon reaction consisting of a severe chronic necrotizing vasculitis. The purpose of this article is to present two cases of Lucio’s phenomenon and a review of the literature on its clinical presentation and management.Case Presentation: Two middle-aged men presented with ulcers and ecchymosis in lower extremities, with simultaneous peripheral nerve damage and leonine facies. Both were treated according to World Health Organization recommendations, with a favorable clinical response.Discussion: The clinical characteristics presented in this article make part of the classical description. A proper history and physical examination allowed for a correct diagnostic approach and prompt confirmation of diagnosis, despite the unspecific nature of these signs and symptoms.Conclusions: Leprosy and Lucio’s phenomenon are infrequent conditions that are difficult to diagnose. We suspect this condition to be under-registered. Awareness and a high clinical suspicion are necessary in endemic regions.","PeriodicalId":72533,"journal":{"name":"Case reports in internal medicine","volume":"11 5","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-04-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.5430/CRIM.V6N2P15","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41290753","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Viral myocarditis is a prevalent disease amongst endemic nations. With increased opportunity of travel, and warmer climates for arthropod-vectors to spread, infectious myocarditis incidence is likely to rise as well. Acute manifestations of myocarditis include fevers, generalized weakness, myalgias, and arthralgias. While death is rare, long-term morbidity related to acute complications plus chronic cardiac structural changes can occur. No current guidelines for long-term myocarditis follow-up and designated treatment strategies exist, and future work in these areas is required.
{"title":"Cardiac MRI use in the diagnosis of acute infectious myocarditis","authors":"H. Wheat, Jamal Hajjari, C. Sullivan","doi":"10.5430/CRIM.V6N2P11","DOIUrl":"https://doi.org/10.5430/CRIM.V6N2P11","url":null,"abstract":"Viral myocarditis is a prevalent disease amongst endemic nations. With increased opportunity of travel, and warmer climates for arthropod-vectors to spread, infectious myocarditis incidence is likely to rise as well. Acute manifestations of myocarditis include fevers, generalized weakness, myalgias, and arthralgias. While death is rare, long-term morbidity related to acute complications plus chronic cardiac structural changes can occur. No current guidelines for long-term myocarditis follow-up and designated treatment strategies exist, and future work in these areas is required.","PeriodicalId":72533,"journal":{"name":"Case reports in internal medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-04-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.5430/CRIM.V6N2P11","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42060133","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
C. Anjo, Gonçalo Coutinho, P. Vasconcelos, G. Silva, A. P. Lacerda
Background: Influenza vaccination, is the cornerstone of influenza epidemics prophylaxis, but there is some evidence of its lower efficacy in the elderly and in some other high-risk groups of the population.Aims and Methods: We analysed the demographic characteristics of the patients (pts) hospitalized in an internal medicine ward (IMw) during the 2016-17 flu season, investigating whether there had been previous prevention, and overall how the infection progressed. All pts admitted to our hospital center, with positive nasopharyngeal swab, from the 1st October 2016 to the 28th February 2017 were recorded (n = 221), from which the inpatient IMw subgroup (31 pts) was selected.Summary of results: Of the 31 selected IMw pts, 61.3% were female and 38.7% male. Their chronic main medical condition included diabetes mellitus type 2 (32.3%) and heart failure (22.6%). Although more than half was previously vaccinated with that year’s vaccine (65.5%), all pts required hospitalization, with a high average length of stay (11.3 ± 5.2 days). H3N2 was the predominant subtype (90.3%). Flu symptoms at admission were present in 80.6% of the pts, and their mean PaO2/FiO2 ratio was 288.9 ± 40.7. We observed an increased in infection severity in patients with asthma, obesity and chronic kidney disease (when compared to controls) with PaO2/FiO2 ratio 284.0 ± 58.7, 95%CI 229.9-338.6, PaO2/FiO2 ratio 242.5 ± 12.0; 95%CI 134.5-350.5 and PaO2/FiO2 ratio 263.0 ± 33.9; 95%CI -41.9-567.9 respectively. No transfers were needed to intensive care, and one only patient required non-invasive mechanical ventilation.Conclusions: During a flu epidemic, there is a constant need for health staff to perform the influenza test in all seeking care pts with respiratory / generalized pains complaints. Preventive use of oseltamivir by the most vulnerable contacts exposed to the virus, even if previously vaccinated, appears to be justifiable.
{"title":"Influenza outbreak - how best to prevent beyond vaccination?","authors":"C. Anjo, Gonçalo Coutinho, P. Vasconcelos, G. Silva, A. P. Lacerda","doi":"10.5430/CRIM.V6N2P1","DOIUrl":"https://doi.org/10.5430/CRIM.V6N2P1","url":null,"abstract":"Background: Influenza vaccination, is the cornerstone of influenza epidemics prophylaxis, but there is some evidence of its lower efficacy in the elderly and in some other high-risk groups of the population.Aims and Methods: We analysed the demographic characteristics of the patients (pts) hospitalized in an internal medicine ward (IMw) during the 2016-17 flu season, investigating whether there had been previous prevention, and overall how the infection progressed. All pts admitted to our hospital center, with positive nasopharyngeal swab, from the 1st October 2016 to the 28th February 2017 were recorded (n = 221), from which the inpatient IMw subgroup (31 pts) was selected.Summary of results: Of the 31 selected IMw pts, 61.3% were female and 38.7% male. Their chronic main medical condition included diabetes mellitus type 2 (32.3%) and heart failure (22.6%). Although more than half was previously vaccinated with that year’s vaccine (65.5%), all pts required hospitalization, with a high average length of stay (11.3 ± 5.2 days). H3N2 was the predominant subtype (90.3%). Flu symptoms at admission were present in 80.6% of the pts, and their mean PaO2/FiO2 ratio was 288.9 ± 40.7. We observed an increased in infection severity in patients with asthma, obesity and chronic kidney disease (when compared to controls) with PaO2/FiO2 ratio 284.0 ± 58.7, 95%CI 229.9-338.6, PaO2/FiO2 ratio 242.5 ± 12.0; 95%CI 134.5-350.5 and PaO2/FiO2 ratio 263.0 ± 33.9; 95%CI -41.9-567.9 respectively. No transfers were needed to intensive care, and one only patient required non-invasive mechanical ventilation.Conclusions: During a flu epidemic, there is a constant need for health staff to perform the influenza test in all seeking care pts with respiratory / generalized pains complaints. Preventive use of oseltamivir by the most vulnerable contacts exposed to the virus, even if previously vaccinated, appears to be justifiable.","PeriodicalId":72533,"journal":{"name":"Case reports in internal medicine","volume":"579 ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.5430/CRIM.V6N2P1","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41315040","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Olmesartan, an angiotensin II receptor blocker, is widely used for the treatment of hypertension. An association of olmesartan use with a reversible, sprue-like enteropathy has recently been recognized. There are also rare reports of olmesartan use and the combination of sprue-like enteropathy and collagenous colitis. We report a case of an elderly female who presented with both severe collagenous sprue and collagenous colitis associated with the use of olmesartan, with complete clinical and histologic recovery after discontinuation of the drug.
{"title":"Olmesartan - associated sprue-like enteropathy and colagenous colitis: A case report and review of literature","authors":"Nivedita Sudhekar, Abrar Ahmed, M. Feldman","doi":"10.5430/CRIM.V6N1P26","DOIUrl":"https://doi.org/10.5430/CRIM.V6N1P26","url":null,"abstract":"Olmesartan, an angiotensin II receptor blocker, is widely used for the treatment of hypertension. An association of olmesartan use with a reversible, sprue-like enteropathy has recently been recognized. There are also rare reports of olmesartan use and the combination of sprue-like enteropathy and collagenous colitis. We report a case of an elderly female who presented with both severe collagenous sprue and collagenous colitis associated with the use of olmesartan, with complete clinical and histologic recovery after discontinuation of the drug.","PeriodicalId":72533,"journal":{"name":"Case reports in internal medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-02-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43040841","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Alyssa L. Arena, Xiangkun Cao, B. Hamilton, D. Chaudhary
Reversible cerebral vasoconstriction syndrome (RCVS) is an uncommon pathology that typically presents with a severe thunderclap headache in middle-aged postpartum females. Our patient was a twenty eight year-old Caucasian female seven months postpartum who presented with a ten day history of severe frontal headaches, myalgia, nausea, and anorexia without fevers. She then developed severe left hemiplegia, dysarthria, and paresthesias. Initial cerebrospinal fluid was significant for lymphocytepredominant pleocytosis, and acyclovir, vancomycin, and doxycycline were started for empiric meningitis. Cultures and marker were pan-negative for viral, bacterial, fungal, and autoimmune etiology. A computed tomography head scan was suggestive of distal right internal carotid artery atherosclerosis and ectasia, highly unusual for a woman of this age with no cardiovascular risk factors. Her hospital course was characterized by insomnia, delirium, worsening overnight headaches, and unusual bradycardic episodes. A computed tomography angiogram confirmed right internal carotid artery and middle cerebral artery M1 and M2 segment narrowing, suggestive of RCVS. A follow-up cerebral arteriogram highlighted right middle cerebral artery M1 segment tapering, confirming this diagnosis. We suspect an additional diagnosis of aseptic meningitis, due to her cerebrospinal fluid findings, which likely exacerbated her clinical presentation. Her refractory headaches eventually improved spontaneously. This presentation of reversible cerebral vasoconstriction syndrome in the context of a late post-partum onset and aseptic meningitis is the first such case to be documented, and we hope to shed some light on this unusual and uncommon disease, as well as some avenues for future research.
{"title":"Reversible cerebral vasoconstriction syndrome (RCVS) in the context of aseptic meningitis in a twenty eight year-old postpartum female","authors":"Alyssa L. Arena, Xiangkun Cao, B. Hamilton, D. Chaudhary","doi":"10.5430/CRIM.V6N1P16","DOIUrl":"https://doi.org/10.5430/CRIM.V6N1P16","url":null,"abstract":"Reversible cerebral vasoconstriction syndrome (RCVS) is an uncommon pathology that typically presents with a severe thunderclap headache in middle-aged postpartum females. Our patient was a twenty eight year-old Caucasian female seven months postpartum who presented with a ten day history of severe frontal headaches, myalgia, nausea, and anorexia without fevers. She then developed severe left hemiplegia, dysarthria, and paresthesias. Initial cerebrospinal fluid was significant for lymphocytepredominant pleocytosis, and acyclovir, vancomycin, and doxycycline were started for empiric meningitis. Cultures and marker were pan-negative for viral, bacterial, fungal, and autoimmune etiology. A computed tomography head scan was suggestive of distal right internal carotid artery atherosclerosis and ectasia, highly unusual for a woman of this age with no cardiovascular risk factors. Her hospital course was characterized by insomnia, delirium, worsening overnight headaches, and unusual bradycardic episodes. A computed tomography angiogram confirmed right internal carotid artery and middle cerebral artery M1 and M2 segment narrowing, suggestive of RCVS. A follow-up cerebral arteriogram highlighted right middle cerebral artery M1 segment tapering, confirming this diagnosis. We suspect an additional diagnosis of aseptic meningitis, due to her cerebrospinal fluid findings, which likely exacerbated her clinical presentation. Her refractory headaches eventually improved spontaneously. This presentation of reversible cerebral vasoconstriction syndrome in the context of a late post-partum onset and aseptic meningitis is the first such case to be documented, and we hope to shed some light on this unusual and uncommon disease, as well as some avenues for future research.","PeriodicalId":72533,"journal":{"name":"Case reports in internal medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-01-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49106176","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Catastrophic antiphospholipid syndrome (CAPS), an infrequent autoimmune disease, manifests as a widespread thrombotic disease with multiorgan failure with a 37% mortality rate. We report 39-year-old Caucasian women, medical history of Systemic Lupus Erythematous (SLE) complicated with APS and proliferative glomerulonephritis under dialysis. Patient was admitted at the ICU with septic shock with thoracotomy dehiscence origin. During the ICU stay, extensive lower limbs ulcers with polymorphonuclear infiltrate and steatonecrosis areas in adipose and muscular tissue. Lab studies: anti-β2-glycoprotein-Iantibody was detected. As probable CAPS diagnosis was made, triple therapy with methylprednisolone, immunoglobulin and anticoagulation immediately was started. Serious vasoplegic shock occurs with failure in vasopressor support increment and the patient died. The authors report an APS with rapid progression to catastrophic stage, rare complication that occurs only in 1% of catastrophic APS. In CAPS treatment, a statistical association between triple therapy and the decrease of mortality rate of patients with CAPS was observed, when compared with other combinations or with none of the treatments included in the triple therapy. Although the case had a lethal outcome, the authors emphasize the use of triple therapy in CAPS and the challenge of treating patients with CAPS and infection where the balance between the need for anticoagulation, aggressive immunosuppression and infection control is difficult to manage.
{"title":"Lethal outcome of catastrophic antiphospholipid syndrome despite intensive triple therapy","authors":"C. Anjo, P. Fortuna, Luís Reis, L. Bento","doi":"10.5430/CRIM.V6N1P13","DOIUrl":"https://doi.org/10.5430/CRIM.V6N1P13","url":null,"abstract":"Catastrophic antiphospholipid syndrome (CAPS), an infrequent autoimmune disease, manifests as a widespread thrombotic disease with multiorgan failure with a 37% mortality rate. We report 39-year-old Caucasian women, medical history of Systemic Lupus Erythematous (SLE) complicated with APS and proliferative glomerulonephritis under dialysis. Patient was admitted at the ICU with septic shock with thoracotomy dehiscence origin. During the ICU stay, extensive lower limbs ulcers with polymorphonuclear infiltrate and steatonecrosis areas in adipose and muscular tissue. Lab studies: anti-β2-glycoprotein-Iantibody was detected. As probable CAPS diagnosis was made, triple therapy with methylprednisolone, immunoglobulin and anticoagulation immediately was started. Serious vasoplegic shock occurs with failure in vasopressor support increment and the patient died. The authors report an APS with rapid progression to catastrophic stage, rare complication that occurs only in 1% of catastrophic APS. In CAPS treatment, a statistical association between triple therapy and the decrease of mortality rate of patients with CAPS was observed, when compared with other combinations or with none of the treatments included in the triple therapy. Although the case had a lethal outcome, the authors emphasize the use of triple therapy in CAPS and the challenge of treating patients with CAPS and infection where the balance between the need for anticoagulation, aggressive immunosuppression and infection control is difficult to manage.","PeriodicalId":72533,"journal":{"name":"Case reports in internal medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-01-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.5430/CRIM.V6N1P13","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46685858","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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