Case Reports in Medicine The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Ulcerative Colitis Activity Presenting as Fever of Unknown Origin, in a Patient with Longstanding Disease under Continuous Treatment with Mesalazine Mon, 18 Jul 2016 12:42:15 +0000 Background. The presence of ulcerative colitis (UC) with no bowel symptoms, as fever of unknown origin (FUO), is uncommon. Objective. To describe the case of an 80-year-old woman who presented with fever, with a history of UC under treatment with mesalazine. Case Presentation. She was admitted due to fever lasting for 12 days with no associated symptoms. Seven years earlier, she was diagnosed with UC. After an extended workup for FUO that failed to reach the diagnosis, she underwent a gallium-67 scintigraphy. This revealed a persistent diffuse concentration of gallium-67 in the ascending colon at 24-hour imaging that remained stable at 48- and 72-hour imaging without any topographic change after the use of laxatives. Considering the results and in the absence of another diagnosis, the patient was treated with 30 mg prednisone daily and mesalazine, as treatment of active UC. Subsequently, the patient’s condition improved markedly and the fever retreated. One month later, she was reevaluated with a gallium-67 scintigraphy with total absence of gallium-67 concentration in the ascending colon. Conclusion. UC activity must be included in the differential diagnosis of FUO in patients with longstanding disease, since fever may present alone, with no other manifestations. Panagiota Voukelatou, Elissavet Sfendouraki, Theodoros Karianos, Sofia Saranti, Dimitrios Tsitsimelis, Ioannis Vrettos, and Andreas Kalliakmanis Copyright © 2016 Panagiota Voukelatou et al. All rights reserved. Diversification of Antitumour Immunity in a Patient with Metastatic Melanoma Treated with Ipilimumab and an IDO-Silenced Dendritic Cell Vaccine Mon, 18 Jul 2016 08:19:14 +0000 Indoleamine 2,3-dioxygenase (IDO) expression in dendritic cells (DCs) inhibits T-cell activation and promotes T-cell differentiation into regulatory T-cells. Moreover, IDO expression promotes resistance to immunotherapies targeting immune checkpoints such as the cytotoxic T lymphocyte antigen-4 (CTLA-4). Here, a patient with metastatic melanoma pretreated with ipilimumab, an anti-CTLA-4 blocking antibody, was vaccinated with IDO-silenced DCs cotransfected with mRNA for survivin or hTERT tumour antigens. During vaccination, T-cell responses to survivin and hTERT tumour antigens were generated, and a certain degree of clinical benefit was achieved, with a significant reduction in lung, liver, and skin metastases, along with a better performance status. T-cell responses against MART-1 and NY-ESO-1 tumour antigens were also detected in the peripheral blood. The patient also mounted an antibody response to several melanoma proteins, indicating diversification of the antitumour immunity in this patient. The identification of such serum antibody-reacting proteins could facilitate the discovery of tumour neoantigens. Mouldy Sioud, Marta Nyakas, Stein Sæbøe-Larssen, Anne Mobergslien, Steinar Aamdal, and Gunnar Kvalheim Copyright © 2016 Mouldy Sioud et al. All rights reserved. Pulmonary Talcosis in an Immunocompromised Patient Thu, 30 Jun 2016 15:41:16 +0000 The first case of pulmonary talcosis or talc pneumoconiosis related to inhalation of talc during its extraction and processing in mines was described by Thorel in 1896. Pulmonary talcosis is most commonly seen secondary to occupational exposure or intravenous (IV) drug abuse and, occasionally, in excessive use of cosmetic talc. Based on literature review, there has been an increase in reported incidents of pulmonary talcosis due to various forms of exposure to the mineral. We report an 82-year-old man who is diagnosed with Philadelphia chromosome positive pre-B cell acute lymphoblastic leukemia (ALL) treated with palliative imatinib who presented with chronic hemoptysis and dyspnea shortly after his diagnosis. His symptoms were initially thought to be due to an infectious etiology due to his malignancy, immunocompromised state, and radiographic findings until high-resolution computerized tomographic (HRCT) findings showed a diffuse pulmonary fibrosis picture that prompted further questioning and a more thorough history inquiry on his exposure to causative agents of interstitial lung disease. Very often, patients do not recognize their exposure, especially in those whose exposure is unrelated to their occupation. Our case emphasizes the need for thorough and careful history taking of occupational and nonoccupational exposure to known causative agents of interstitial lung disease. Thanh-Phuong Nguyen, Sowmya Nanjappa, Manjunath Muddaraju, and John N. Greene Copyright © 2016 Thanh-Phuong Nguyen et al. All rights reserved. Sanguineous Pericardial Effusion and Cardiac Tamponade in the Setting of Graves’ Disease: Report of a Case and Review of Previously Reported Cases Wed, 29 Jun 2016 15:12:59 +0000 Introduction. Pericardial effusion in the setting of hyperthyroidism is rare. We present a patient with Graves’ disease who developed a sanguineous pericardial effusion and cardiac tamponade. Case Description. A 76-year-old man presenting with fatigue was diagnosed with Graves’ disease and treated with methimazole. Two months later, he was hospitalized for uncontrolled atrial fibrillation. Electrocardiography showed diffuse low voltage and atrial fibrillation with rapid ventricular rate. Chest radiograph revealed an enlarged cardiac silhouette and left-sided pleural effusion. Thyroid stimulating hormone was undetectable, and free thyroxine was elevated. Diltiazem and heparin were started, and methimazole was increased. Transthoracic echocardiography revealed a large pericardial effusion with cardiac tamponade physiology. Pericardiocentesis obtained 1,050 mL of sanguineous fluid. The patient progressed to thyroid storm, treated with propylthiouracil, potassium iodine, hydrocortisone, and cholestyramine. Cultures and cytology of the pericardial fluid were negative. Thyroid hormone markers progressively normalized, and he improved clinically and was discharged. Discussion. We found 10 previously reported cases of pericardial effusions in the setting of hyperthyroidism. Heparin use may have contributed to the sanguineous nature of our patient’s pericardial effusion, but other reported cases occurred without anticoagulation. Sanguineous and nonsanguineous pericardial effusions and cardiac tamponade may be due to hyperthyroidism. Peter V. Bui, Sonia N. Zaveri, and J. Rush Pierce Jr. Copyright © 2016 Peter V. Bui et al. All rights reserved. Anesthetic Management in a Gravida with Type IV Osteogenesis Imperfecta Tue, 28 Jun 2016 10:32:05 +0000 Osteogenesis imperfecta (OI) is an inherited disorder of the connective tissues caused by abnormalities in collagen formation. OI may present many challenges to the anesthesiologist. A literature review reveals a wide range of implications, from basic positioning to management of the difficult airway. We present the anesthetic management of a 25-year-old gravid woman with OI, fetal demise, and possible uterine rupture, admitted for an exploratory laparotomy. Elizabeth Vue, Juan Davila, and Tracey Straker Copyright © 2016 Elizabeth Vue et al. All rights reserved. Overlapping of Serotonin Syndrome with Neuroleptic Malignant Syndrome due to Linezolid-Fluoxetine and Olanzapine-Metoclopramide Interactions: A Case Report of Two Serious Adverse Drug Effects Caused by Medication Reconciliation Failure on Hospital Admission Tue, 28 Jun 2016 08:23:48 +0000 Antipsychotic and antidepressant are often used in combination for the treatment of neuropsychiatric disorders. The concomitant use of antipsychotic and/or antidepressant with drugs that may interact can lead to rare, life-threatening conditions such as serotonin syndrome and neuroleptic malignant syndrome. We describe a patient who has a history of taking two offending drugs that interact with drugs given during the course of hospital treatment which leads to the development of serotonin syndrome overlapped with neuroleptic malignant syndrome. The physician should be aware that both NMS and SS can appear as overlapping syndrome especially when patients use a combination of both antidepressants and antipsychotics. Faizan Mazhar, Shahzad Akram, Nafis Haider, and Rafeeque Ahmed Copyright © 2016 Faizan Mazhar et al. All rights reserved. Rapidly Progressing Refractory Hodgkin Lymphoma: A Case Report and a Possible Explanation Sun, 26 Jun 2016 10:02:31 +0000 Introduction. Hodgkin lymphoma is a highly curable lymphoid malignancy; however treatment of a significant number of patients remains challenging. Case Report. The authors present an unusually rapidly progressing case of refractory advanced stage classical nodular sclerosis subtype Hodgkin lymphoma with unfavorable prognosis. A 66-year-old male patient was refractory for first-line doxorubicin, bleomycin, vinblastin, dacarbazine (ABVD) treatment with persistent disease; therefore physicians changed treatment for dexamethasone, cytarabine, and cisplatin (DHAP) and later ifosfamide, gemcitabine, and vinorelbine (IGEV) regimen. Unfortunately the patient developed acute kidney and respiratory failure and died after 6 months of treatment. Current and retrospective histological examination of the patient’s lymph node biopsy, skin lesion, and autopsy revealed the same aberrantly expressing CD4 positive nodular sclerosis subtype Hodgkin lymphoma. Conclusion. Aberrant expression of T-cell antigens on the Hodgkin and Reed/Sternberg cells could be associated with inferior outcome. T-cell associated antigens should be investigated more often in patients not responding sufficiently to treatment and hence treatment should be intensified or targeted therapy (brentuximab vedotin) should be considered. Ádám Jóna, Gábor Irsai, Sándor Barna, Gábor Méhes, Árpád Illés, and László Váróczy Copyright © 2016 Ádám Jóna et al. All rights reserved. Simultaneous Chronic Invasive Fungal Infection and Tracheal Fungus Ball Mimicking Cancer in an Immunocompetent Patient Thu, 23 Jun 2016 12:02:50 +0000 Fungal infections of the lung are uncommon and mainly affect people with immune deficiency. There are crucial problems in the diagnosis and treatment of this condition. Invasive pulmonary aspergillosis and candidiasis are the most common opportunistic fungal infections. Aspergillus species (spp.) are saprophytes molds that exist in nature as spores and rarely cause disease in immunocompetent individuals. In patients with immune deficiency or chronic lung disease, such as cavitary lung disease or bronchiectasis, Aspergillus may cause a variety of aspergillosis infections. Here we present a case of a 57-year-old patient without immunodeficiency or chronic lung disease who was diagnosed with endotracheal fungus ball and chronic fungal infection, possibly due to Aspergillus. Bronchoscopic examination showed a paralyzed right vocal cord and vegetating mass that was yellow in color, at the posterior wall of tracheal lumen. After 3 months, both the parenchymal and tracheal lesions were completely resolved. Erdoğan Çetinkaya, Mustafa Çörtük, Şule Gül, Ali Mert, Hilal Boyacı, Ertan Çam, and H. Erhan Dincer Copyright © 2016 Erdoğan Çetinkaya et al. All rights reserved. ST Segment Elevation with Normal Coronaries Wed, 15 Jun 2016 09:42:56 +0000 Noncardiac causes should be kept in the differential while evaluating ST elevation on EKG. Rarely abdominal pathologies like acute pancreatitis can present with ST elevation in the inferior leads. Once acute coronary syndrome is ruled out by emergent cardiac catheterization alternative diagnosis should be sorted. Abdominal pathologies, like acute pancreatitis and acute cholecystitis, can present with ST elevation in the inferior leads. Treating the underlying condition would result in resolution of these EKG changes. Pooja Sethi, Ghulam Murtaza, Ashwini Sharma, and Timir Paul Copyright © 2016 Pooja Sethi et al. All rights reserved. Simultaneous Clear Cell Sarcomas of the Duodenum and Jejunum Tue, 07 Jun 2016 08:04:55 +0000 Clear cell sarcoma (CCS) is an uncommon tumor that usually presents as an extremity mass but can rarely manifest as a gastrointestinal tumor with a diverse spectrum of symptoms, most commonly related to a mass effect or ulceration. Herein we report a case in which two separate tumors, one in the duodenum and the other in the jejunum, present concurrently. The subject presented with symptomatic anemia and underwent imaging and endoscopic studies that culminated in the discovery of the two lesions. He subsequently underwent operative treatment with resection of both tumors and made an unremarkable recovery. The resection specimen consisted of two separate clear cell sarcomas with negative margins. Under microscopic evaluation, they demonstrated nested growths of epithelioid cells with scattered spindled cells infiltrating the enteric wall. The neoplastic cells were positive for S100 with scattered expression of Melan A. Florescence in situ hybridization revealed a translocation at the EWRS1 locus. He was disease-free for 30 months following the procedure; then he developed a rapidly progressing metastatic disease with subsequent death 4 months later. Maitham A. Moslim, Gavin A. Falk, Michael Cruise, and Gareth Morris-Stiff Copyright © 2016 Maitham A. Moslim et al. All rights reserved. Cardiac Arrest and Gastrointestinal Bleeding: A Case of Medical Heuristics Mon, 06 Jun 2016 08:18:57 +0000 Insufficient clinical data from patients is a major cause of errors in medical diagnostics. In an attempt to make a diagnosis, initial clinical information provided to the physician may be overly relied on as the only information required in making diagnosis leading to anchoring. Failure to rely on differential diagnoses in spite of new signs and symptoms or rethinking of initial hypothesis may lead to fixation on a certain diagnosis, which may lead to significant morbidity and mortality. In the event that there is an anchoring heuristic, like in our patient, it is important to consider differential diagnoses; however, it is not wrong to rely on some form of anchor. We report a case of a 62-year-old male with a history of multiple medical conditions and a history of acetaminophen overdose who presented to the hospital with large amounts of coffee ground emesis. He was subsequently transferred to the liver transplant center on discovery that he was in fulminant hepatic failure and died two days later in spite of aggressive medical treatment. Tokunbo Ajayi and Jerome Okudo Copyright © 2016 Tokunbo Ajayi and Jerome Okudo. All rights reserved. Intracavitary Irradiation as a Safe Alternative for Cystic Craniopharyngiomas: Case Report and Review of the Literature Sun, 05 Jun 2016 06:26:11 +0000 Craniopharyngioma treatment remains a challenge for clinicians and patients. There are many treatment alternatives; however one of them (intracavitary irradiation) seeks to control this type of benign brain tumor using minimally invasive techniques, with the specific aim of avoiding causing significant damage to important structures surrounding the sellar/suprasellar region. We present the case of a 3-year-old patient with a predominantly cystic craniopharyngioma who underwent intracavitary irradiation by stereotactic placement. Using this approach, the patient showed a successful response with remission of headaches and hydrocephalus. A reduction in the size of the cyst was achieved, without deterioration of visual fields, with no hormonal supplementation being needed, and with no evidence of focal neurological signs. Alejandro Enriquez-Marulanda, Melibea Sierra-Ruiz, Luz Maritza Pabón, and Javier Lobato-Polo Copyright © 2016 Alejandro Enriquez-Marulanda et al. All rights reserved. Medical Management for the Treatment of Nontuberculous Mycobacteria Infection of the Parotid Gland: Avoiding Surgery May Be Possible Wed, 01 Jun 2016 12:29:40 +0000 Infection with nontuberculous mycobacteria (NTM) is uncommon in the head and neck; therefore there is no clear consensus on treating these infections. Our objective was to report our experience with a unique case of NTM infection of the parotid in an immunocompetent patient, in order to determine appropriate management through our experience with this pathology. A 57-year-old man, known for numerous comorbid diseases, presented to our institution complaining of right parotid swelling and pain. A computed tomography (CT) of the neck showed a multiloculated collection in the inferior portion of the right parotid gland, compatible with abscess formation. This abscess was drained by interventional radiology (IR) but required repeat drainage twice due to lack of initial improvement. He was treated with several antibiotics as culture results initially indicated Gram-positive bacilli and then Mycobacterium species, with final identification by a reference laboratory as Mycobacterium abscessus. Imipenem was initiated with amikacin and clarithromycin. His infection clinically and radiologically resolved after 5 months of antibiotherapy. In our case, the patient improved following intravenous antibiotic therapy. Our experience demonstrates that appropriate antibiotherapy can lead to resolution of Mycobacterium abscessus infection in the parotid without the risks associated with surgical intervention. Emily Kay-Rivest, Sarah Bouhabel, Matthew Thomas Oughton, and Michael Peter Hier Copyright © 2016 Emily Kay-Rivest et al. All rights reserved. A Rare Complication of Herpes Zoster: Segmental Zoster Paresis Mon, 30 May 2016 07:56:37 +0000 Herpes zoster is a common presentation in both the community and emergency department; however segmental zoster paresis is a rare complication that can lead to misdiagnosis. We present a case of a 74-year-old Indian gentleman with a background of well controlled diabetes mellitus, hypertension, and ischaemic heart disease who presented with sudden right lower limb weakness. This was preceded by a 5-day history of paraesthesia starting in the right foot and ascending up the right lower limb. On examination, there was a characteristic vesicular rash in the L2/3 region with MRC grading 3/5 in the right hip flexors. The rest of the neurological examination was unremarkable. MRI of the spine did not show any evidence of spinal disease. The patient was initiated on IV acyclovir with improvement of the lower limb weakness to MRC grading 5/5 as the vesicles improved. This is an interesting case as it highlights a rare presentation of zoster: segmental motor paresis that recovered fully with resolution of the rash. It shows the importance of recognizing motor neuropathy as a complication of shingles as it has a very good prognosis with most patients regaining full motor function of the affected limb with treatment. Hooi Khee Teo, Mayank Chawla, and Manish Kaushik Copyright © 2016 Hooi Khee Teo et al. All rights reserved. A Palpable Painless Axillary Mass as the Clinical Manifestation of Castleman’s Disease in a Patient with Hepatitis C Disease Sun, 22 May 2016 11:23:32 +0000 Introduction. Castleman’s disease (CD) is a rare lymphoproliferative disorder. CD is divided into two clinical subtypes: the most common unicentric and the less usual multicentric subtype. The majority of unicentric CD affects the mediastinum, while neck, abdomen, and axilla are less common locations. Case Presentation. Herein, we describe a rare case of unicentric CD in the right axilla in a 36-year-old white male with a medical history of hepatitis C virus infection admitted to our hospital due to palpation of a painless mass in the right axilla. Complete excision of the lesion was performed and, one year after the diagnosis, patient was free of the disease. Conclusions. Although infrequent, it is important to include CD in the differential diagnosis when evaluating axillary lymphadenopathy particularly in young patients with a low-grade inflammation process and chronic disease even in the absence of an abnormal blood picture or organomegaly. Athanasia K. Papazafiropoulou, Angeliki M. Angelidi, Antonis A. Kousoulis, Georgios Christofilidis, Chariklia Sagia, Liountmila Kaftanidou, Kassiani Manoloudaki, Aikaterini Tsavari, Georgios Kranidiotis, Alexandros Kamaratos, and Andreas Melidonis Copyright © 2016 Athanasia K. Papazafiropoulou et al. All rights reserved. Quinine-Induced Disseminated Intravascular Coagulation Mon, 16 May 2016 08:28:17 +0000 Every drug comes with some side effect. It is the benefit/risk ratio that determines the medical use of the drug. Quinine, a known antimalarial drug, has been used for nocturnal leg cramps since the 1930s; it is associated with severe life-threatening hematological and cardiovascular side effects. Disseminated intravascular coagulation (DIC), albeit rare, is a known coagulopathy associated with Quinine. It is imperative to inquire about the Quinine intake in medication history in patients with coagulopathy, as most patients still consider it a harmless home remedy for nocturnal leg cramps. In this report, we present a case of coagulopathy in a middle-aged woman, who gave a history of taking Quinine for nocturnal leg cramps, as her home remedy. Early identification of the offending agent led to the diagnosis, prompt discontinuation of the medication, and complete recovery and prevented the future possibility of recurrence. Firas Abed, Ramkaji Baniya, and Ghassan Bachuwa Copyright © 2016 Firas Abed et al. All rights reserved. Impacted and Fractured Biliary Basket: A Second Basket Rescue Technique Wed, 11 May 2016 14:30:28 +0000 A 59-year-old woman was treated with ERCP, ES, and biliary plastic stent, for large and multiple common bile duct stones. During a second ERCP basket extraction was impacted with a round entrapped stone. The basket handle was cut off; a metal sheath of extraendoscopic lithotriptor was advanced over the basket. The mechanical lithotripsy was complicated with basket traction wires fracturing, without breakage of the stone. A rescue standard basket was pushed until it caught the basket/stone complex. Using this method disengagement of the whole fractured basket/stone complex was achieved without need of surgery. It is the third case reported in the English literature. Mohammed Amine Benatta, Ariane Desjeux, Marc Barthet, Jean Charles Grimaud, and Mohamed Gasmi Copyright © 2016 Mohammed Amine Benatta et al. All rights reserved. Idiopathic Pulmonary Vein Thrombus Extending into Left Atrium: A Case Report and Review of the Literature Thu, 05 May 2016 12:01:10 +0000 Pulmonary vein thrombosis (PVT) is rather an uncommon condition which presents nonspecifically and is usually associated with lung malignancy and major pulmonary surgery. Rarely could no cause be found. It causes increased pulmonary venous pressure leading to pulmonary arterial vasoconstriction and subsequent pulmonary arterial hypertension and subsequently can cause cor pulmonale if not addressed in timely fashion. Other associated complications like peripheral embolization and stroke have also been reported. This case emphasizes the importance of maintaining high index of clinical suspicion especially when CT pulmonary angiogram is negative for pulmonary embolism. Muhammad Asim Rana, Nicholas Tilbury, Yashwant Kumar, Habib Ahmad, Kamal Naser, Ahmed F. Mady, and Awani Patel Copyright © 2016 Muhammad Asim Rana et al. All rights reserved. Bone Cutting Forceps: A Safe Approach for Saving Strangulated Penis Thu, 28 Apr 2016 14:03:32 +0000 Penile strangulation is considered a rare andrological emergency that may lead to a wide range of complications. Penile strangulation may be related to mental retardation in children or hypersexuality, abnormal sexual preferences in adults. This case report shows a 23-year-old male who presented to the emergency room with agonizing pain related to a metallic ring placed at the base of the penis for more than 8 hours during an attempt of masturbation. Removing this metallic ring and saving the patient’s penis from gangrene without causing injury were very challenging. Patient was successfully managed and had an uneventful recovery. Mohamed Ahmed Abd El Salam, Ahmed Gamal, and Hossam Elenany Copyright © 2016 Mohamed Ahmed Abd El Salam et al. All rights reserved. The Side Effects of Facial Implants Tue, 26 Apr 2016 14:24:29 +0000 This case report is about a 64-year-old woman who presented at the Emergency Walk-in Center with palpebral edema as well as various erythematous plaques in supraciliary and malar areas that have been gradually worsening a couple of days prior to presentation. While talking about history, the patient mentioned she was attending, for about four months, an Esthetic Private Clinic, where she was injected in various sessions with Metacrill®, as a facial lift, for beauty purpose. Due to suspecting an allergic reaction to the Metacrill and the failure of the initial treatments, she was referred to the dermatologist. After failed attempts to treat the patient with corticosteroids and antibiotics, the patient was sent for autoimmunity consultation at the hospital where she received an immunosuppressive treatment with Tacrolimus and was not presenting new symptoms ever since. Adela Ioana Uta, Claudia Elena Uta, Lia Anguelova Valentinova, and Carlos Isanta Pomar Copyright © 2016 Adela Ioana Uta et al. All rights reserved. Fixation Improvement through Biofeedback Rehabilitation in Stargardt Disease Sun, 24 Apr 2016 09:24:35 +0000 Stargardt disease is the most common hereditary macular degeneration in juveniles. It is characterized by macular dystrophy associated with loss of central vision in the first or second decade of life, a “beaten-metal” appearance in the fovea or parafoveal region, yellowish flecks around the macula or in posterior area of the retina, progressive atrophy of the bilateral foveal retinal pigment epithelium, and the “dark choroid” sign on fundus fluorescein angiography in most cases. We report a case of Stargardt disease in a 26-year-old Caucasian female submitted to rehabilitative training with microperimetry MP-1 to find a new preferred retinal locus (PRL) and to train her to better her quality of life. Best corrected visual acuity, mean retinal sensitivity, fixation, bivariate contour ellipse area, and speed reading were evaluated before and after the training and results were discussed. G. Scuderi, F. Verboschi, D. Domanico, and L. Spadea Copyright © 2016 G. Scuderi et al. All rights reserved. Bronchiolitis Obliterans Organizing Pneumonia as an Initial Presentation of Systemic Lupus Erythematosus: A Rare Case Report and Literature Review Thu, 21 Apr 2016 07:55:09 +0000 The etiology of bronchiolitis obliterans organizing pneumonia (BOOP) remains controversial. While it has been reportedly associated with several connective tissue disorders, there are only rare reports of BOOP associated with systemic lupus erythematosus (SLE). Herein, we report a 56-year-old female patient who presented with dyspnea on exertion, cough, fever, and joint pain of her left wrist and fingers as initial symptoms. Laboratory tests revealed positivity for anti-nuclear antibody, anti-Ro, and anti-double strand DNA antibody. In this case, the patient with SLE had respiratory illness as the initial symptom due to BOOP in the absence of clear etiology. The diagnosis of BOOP was confirmed by thoracic surgery biopsy. Her respiratory symptoms and radiologic findings significantly improved following prednisolone treatment. Hung-Ping Wang, Chun-Ming Chen, Yih-Yuan Chen, and Wei Chen Copyright © 2016 Hung-Ping Wang et al. All rights reserved. Pericardial Metastasis Induced Tamponade from Urothelial Carcinoma: A Rare Entity Mon, 11 Apr 2016 09:56:14 +0000 Urothelial carcinoma in a few cases may result in cardiac metastasis. A rare presentation of this condition is its diagnosis as a result of cardiac tamponade. Tamponade is an unusual entity as a result of urothelial carcinoma and has only been reported in four cases. There have also been only a total of fifteen cases of cardiac metastasis from this form of malignancy. It is through this discussion that we emphasize the importance of early detection and monitoring of cardiac symptoms with the implementation of echocardiogram imaging. Although not feasible in all patients it may be considered in those presenting with cardiac and pulmonary symptoms. In this case we discuss the presentation of a 71-year-old gentleman with a history of urothelial carcinoma after cystectomy and while on chemotherapy presented with new onset atrial fibrillation and later was diagnosed with cardiac tamponade as a result of malignant metastasis. Rafay Khan, Waqas Jehangir, Sunil Tulpule, Mohamed Osman, Shilpi Singh, and Shuvendu Sen Copyright © 2016 Rafay Khan et al. All rights reserved. A Case of Atrial Tachycardia Circulating around a Left Atrial Roof Scar with Diabetes Mellitus and Renal Failure on Hemodialysis Mon, 11 Apr 2016 09:47:58 +0000 Introduction. Little is known about the effects of volume change by hemodialysis (HD) and mechanical stress caused by an anatomical structure being in contact with the left atrium on the progression of atrial remodeling. We experienced a case of atrial tachycardia (AT) in a patient who had left atrial (LA) scarring at the LA roof and a low-voltage area with slow conduction around the LA scar as components of AT circuit. Here, we present the conceivable hypothesis of the LA scar and the low-voltage area formation. Our concept can be useful in developing a strategy for ablation in a patient with chronic renal failure (CRF) on HD. Case Report. A 65-year-old man with CRF on HD was referred for AT ablation. Three-dimensional electroanatomical mapping revealed that the AT conducted around an LA scar in a counterclockwise fashion. There was a slow conduction area at the superior side of the LA scar, where the AT was terminated during the ablation. Computed tomography indicated a close relationship between the LA and the anatomical structures (ascending aorta and pulmonary artery). Conclusion. Volume change by HD and close contact of anatomical structures to the LA can promote atrial remodeling, resulting in AT occurrence. Naoko Hijioka, Masashi Kamioka, Hitoshi Suzuki, and Yasuchika Takeishi Copyright © 2016 Naoko Hijioka et al. All rights reserved. Poststernotomy Osteomyelitis Presenting with Severe Sepsis and Rhabdomyolysis Sun, 10 Apr 2016 08:21:06 +0000 A 39-year-old male, who recently underwent a composite valve graft of the aortic root and ascending aorta for bicuspid aortic valve and aortic root aneurysm, was hospitalized for severe sepsis, rhabdomyolysis (creatine kinase 29000 U/L), and severe liver dysfunction (AST > 7000 U/L, ALT 4228 U/L, and INR > 10). Cardiac magnetic resonance imaging (MRI) findings were consistent with sternal osteomyelitis with a 1.5 cm abscess at the inferior sternotomy margin, which was contiguous with pericardial thickening. Aspiration and culture of this abscess did not yield any organisms, so he was treated with vancomycin and cefepime empirically for 4 weeks. Because this patient was improving clinically on antibiotics and did not show external signs of wound infection, there was no compelling indication for sternectomy. This patient’s unusual presentation with osteomyelitis and rhabdomyolysis has never been reported and is crucial for clinicians to recognize in order to prevent delays in diagnosis. Eugene M. Tan, Melissa Lyle, Kelly Cawcutt, and Zelalem Temesgen Copyright © 2016 Eugene M. Tan et al. All rights reserved. Sacroiliitis and Polyarteritis Nodosa in a Patient with Familial Mediterranean Fever Thu, 07 Apr 2016 11:08:26 +0000 Familial Mediterranean fever (FMF) is an autoinflammatory disorder with autosomal recessive inheritance, characterized by recurrent fever and episodes of serositis. The condition is known to be caused by mutations in the MEFV (Mediterranean FeVer) gene, located in the short arm of chromosome 16. While more than 310 sequence variants in the MEFV gene have been described to date, the diagnosis is still established clinically. FMF may be accompanied by sacroiliitis and various forms of vasculitis. The most common forms of associated vasculitis are Henoch-Schonlein purpura and polyarteritis nodosa (PAN). We have presented here a fairly rare case of FMF, accompanied by both sacroiliitis and PAN. Yunus Ugan, Atalay Doğru, Hüseyin Şencan, Mehmet Şahin, and Şevket Ercan Tunç Copyright © 2016 Yunus Ugan et al. All rights reserved. An Extraordinary Cause of the Sucking Difficulty: Ecthyma Gangrenosum Wed, 06 Apr 2016 12:44:19 +0000 Ecthyma gangrenosum is a cutaneous lesion often associated with pseudomonas aeruginosa bacteremia, even though it may develop without bacteremia and may originate from other bacterial and fungal organisms. Pseudomonas aeruginosa bacteremia or sepsis, which mainly affects immunocompromised patients, frequently occurs in hospitals. This lesion typically occurs on the extremities and gluteal and perineal regions. In this report we present a case of ecthyma gangrenosum in a premature newborn occurring secondary to pseudomonas sepsis causing sucking dysfunction due to tissue loss in the lip, soft palate, and tongue. Nesrin Ceylan, Nihat Demir, Selami Kocaman, Erdal Peker, and Oğuz Tuncer Copyright © 2016 Nesrin Ceylan et al. All rights reserved. Encephalopathy Associated with Autoimmune Thyroid Disease: A Potentially Reversible Condition Tue, 05 Apr 2016 13:39:20 +0000 Autoimmune thyroid disease may occasionally associate with unspecific neurological symptoms, which are more commonly insidious, include cognitive or behavioural symptoms, and may associate with tremor, myoclonus, or ataxia. We report a 61-year-old female patient who presented with chronic headache, insidious mood, and cognitive disturbance which evolved in a few months to dementia associated with exuberant limb myoclonus. Diagnostic workup revealed high anti-thyroid peroxidase antibody titers and an inflammatory CSF profile, and it was negative for other possible etiologies. Treatment with steroids induced significant improvement. The diagnosis of encephalopathy associated with autoimmune thyroid disease is still controversial given the fact that the clinical presentation and diagnostic workup are unspecific, the pathophysiology is still undetermined, and the diagnosis is mostly of exclusion. No direct correlation is found between anti-thyroid antibody titers and clinical presentation, and it is currently speculated that other still unrecognized antibodies may be responsible for this clinical entity. It is extremely important to recognize this entity because it is potentially treatable with immunotherapies. It is also increasingly recognized that clinical improvement with first-line treatment with steroids may be absent or incomplete, and other immunotherapies as immunosuppressants, intravenous immunoglobulin, or plasma exchange must be attempted in the clinical suspicion of EEAT. Inês Correia, Inês B. Marques, Rogério Ferreira, and Lívia Sousa Copyright © 2016 Inês Correia et al. All rights reserved. A Giant Intrathoracic Malignant Schwannoma Causing Respiratory Failure in a Patient without von Recklinghausen’s Disease Mon, 28 Mar 2016 14:09:39 +0000 We report an unusual case of a thoracic opacity due to a huge mediastinal malignant schwannoma which compressed the whole left lung and the mediastinum causing respiratory failure in a 73-year-old woman without von Recklinghausen’s disease. Although the tumor was resected, the patient failed to wean from mechanical ventilation and died one month later because of multiple organ dysfunction syndrome. Epameinondas Angelopoulos, Konstantinos Eleftheriou, Georgios Kyriakopoulos, Kalliopi Athanassiadi, Dimitra Rontogianni, and Christina Routsi Copyright © 2016 Epameinondas Angelopoulos et al. All rights reserved. Thyroid Carcinoma Showing Thymic-Like Differentiation Causing Fracture of the Trachea Sun, 27 Mar 2016 13:52:28 +0000 Thyroid carcinoma showing thymic-like differentiation (CASTLE) comprises a rare neoplasm of the thyroid gland which arises from ectopic thymic tissue or remnants of brachial pouches. CASTLE is regarded as an indolent neoplasm with a favorable prognosis, irrespective of its metastatic potential. Diagnosis is difficult as clinicopathological features have not been yet well-defined. Radiological findings are not specific and only immunohistochemical positivity for CD5 and CD117 staining is highly suggestive of CASTLE. Despite lack of universally accepted treatment recommendations, the mainstay treatment includes thyroidectomy and systematic lymph node dissection. We report a case of CASTLE tumour with very uncommon characteristics developed in a 76-year-old man, who presented with rapidly deteriorating dyspnea and severe cough, resulting in respiratory failure. At surgery, a suspicious looking tumour arising from the upper pole of the right lobe of the thyroid gland, surrounding the trachea and displacing the right common carotid artery, was identified. The patient underwent en bloc resection of the tumour with the thyroid gland and regional lymph node dissection. This is the first reported case of CASTLE causing tracheal ring fracture. Aikaterini Marini, Meletios Kanakis, Konstantinos Valakis, Nikolaos Laschos, Maria Chorti, and Achilleas Lioulias Copyright © 2016 Aikaterini Marini et al. All rights reserved.