When a Histologic Diagnosis Becomes Factitious: A Case of Munchausen Syndrome.

Recurrent episodes of hypoglycemia are uncommon in non-diabetic patients. The workup investigation must confirm hypoglycemia and distinguish between endogenous versus exogenous hyperinsulinism. Simultaneous measurements of plasma glucose, insulin, C-peptide, and a screen for oral hypoglycemic agents should be performed. According to the results, further imaging studies may be necessary. A 43-year-old woman suffering from recurrent hypoglycemia presented to the emergency room (ER) with a hypoglycemic coma. She has had multiple episodes of documented hypoglycemia for the last 13 years. The case was initially investigated, and laboratory studies revealed endogenous hyperinsulinism. Screening for sulfonylureas, anti-insulin and anti-insulin receptor antibodies were negative. Body imaging and positron emission tomography (PET) with 68Ga-DOTANOC did not show evidence of an insulinoma. The patient was submitted to a pancreatectomy, which revealed nesidioblastosis in the histologic examination. Since then, the patient became hyperglycemic but the insulin doses were progressively reduced until new episodes of hypoglycemia recurred and the insulin was stopped. Again, inappropriately high levels of insulin were found at the time of hypoglycemic episodes. Computed tomography (CT) and PET scans did not find evidence of an insulinoma. A C-peptide was later found to be negative and insulin ampoules were found in her possession, making a diagnosis of a factitious disorder. Although rare, factious disorders are frequently overlooked and challenging to diagnose. Since they are very resource and time-consuming, self-inflicted illnesses should always be considered and ruled out beforehand.

Morbimortality and Six-Month Survival Among Elderly Patients Treated With Noninvasive Mechanical Ventilation in an Intermediate Care Unit: A Retrospective Evaluation.

BACKGROUND: Noninvasive mechanical ventilation (NIMV) has been established as a successful therapeutic option for patients with acute respiratory failure (ARF) with a specific etiology. OBJECTIVES: This study evaluated the morbimortality of patients with ARF treated with NIMV in a medical intermediate care unit (UCINT) to identify factors associated with higher in-hospital mortality, six-month mortality, and three- and six-month hospital readmission rates. METHODS: This retrospective cohort study included elderly patients admitted for ARF and treated with NIMV in the UCINT between 2015 and 2019. RESULTS: In the sample of 102 patients, the median age was 84.2 (±5.5) years, and 57% were women. In total, 28% were on long-term oxygen therapy, and 68% had a do-not-resuscitate order. At admission, the median Charlson comorbidity index and Barthel index of activities of daily living were 7 [6; 8] and 30 [20; 57,5], respectively. The simplified acute physiology score II was 39.1±10.7, and 92% of patients had type 2 ARF. Median days on NIMV and days in UCINT were 10 [6; 16] and 6 [3; 10], respectively. The main conditions requiring UCINT admission for NIMV were heart failure, pneumonia, and exacerbation of the chronic obstructive pulmonary disease. The NIMV failure rate was 7%. At discharge, the average Barthel index was 35 [10; 55]. The in-hospital mortality rate was 23%. DISCUSSION:  Older age, higher simplified acute physiology score II, higher Charlson comorbidity index, and higher number of days on NIMV were associated with higher in-hospital mortality. Long-term oxygen therapy was associated with higher three-month mortality. A higher Barthel index at the time of hospital discharge was associated with a higher six-month readmission rate. CONCLUSION: NIMV can be used successfully in elderly patients and less studied ARF etiologies, such as pneumonia.

Bone Marrow Granulomatosis in Acute Q Fever.

Reported cases of Q fever in people living in urban areas after occasional contact with farm animals or infected pets such as dogs and cats have been increasing. The diagnosis of Q fever is usually laborious due to unspecific and variable clinical manifestations. The most common clinical presentation is an influenza-like illness with varying degrees of pneumonia and hepatitis. Acute hepatitis is more frequent than pneumonia in countries where the disease is endemic, such as in Portugal. We report a case of acute Q fever with hepatic and bone marrow involvement presented as fever of unknown origin (FUO) in a 56-year-old sportive hunter man. Typical fibrin ring granulomas (doughnut granulomas) were found in the bone marrow biopsy and were essential for the diagnosis. Bone marrow involvement is considered a rare manifestation of Q fever. Coxiella infection activates a granulomatous inflammatory response that can lead to persistent immune cell activation. Doughnut granulomas are not pathognomonic but they are highly specific for the diagnosis of Q fever.