A Case of Febrile Polyphagia With an Underlying Paraneoplastic Limbic Encephalitis.

A 57-year-old female with a history of malignant mixed Müllerian tumors of the uterus and ovaries developed a fever of unknown origin and neuropsychiatric symptoms. Her EEG showed slow activity in the left temporal region, and brain magnetic resonance imaging revealed limbic encephalitis, leading to the diagnosis of classic paraneoplastic limbic encephalitis (PLE). During our investigation into the underlying cause of the patient's condition, we conducted a PET-CT scan, which revealed the presence of several hypermetabolic lymph nodes. One of these lymph nodes underwent a biopsy, and the results confirmed the presence of metastatic cells, indicating the likelihood of carcinoma, most probably adenocarcinoma of the gynecological tract. PLE should be considered as one of the differential diagnoses in patients with a history of cancer and acute-to-subacute neuronal and psychiatric dysfunction.

Hypomagnesaemia - One Cause To Remember!

A 71-year-old female presented with 5 days of diarrhoea and asthenia. Past medical history of rheumatoid arthritis, arterial hypertension, hypertrophic cardiomyopathy and chronic gastritis was treated with leflunomide, deflazacort, esomeprazole, carvedilol and spironolactone. At admission, the patient's physical examination showed signs of dehydration. Lab results revealed leucocytosis, increased C-reactive protein, hypomagnesaemia, hypocalcaemia and hypokalaemia. A presumption of acute infectious diarrhoea causing hypomagnesaemia with hypocalcaemia and hypokalaemia was made. She was started on ciprofloxacin, IV hydration and electrolyte supplementation with an adequate response. However, magnesium levels fell repeatedly. After excluding other causes for hypomagnesaemia, chronic use of proton pump inhibitors (PPIs) was considered a plausible cause therefore PPI was discontinued, with normalisation of magnesium levels. Hypomagnesaemia is a common disturbance, mainly caused by diarrhoea, gastrointestinal malabsorption, medications, alcoholism and volume expansion. Clinical manifestations include neuromuscular symptoms, cardiovascular manifestations, hypokalaemia and changes in calcium metabolism. PPI-related hypomagnesaemia has been described in later years particularly in chronic use cases, with a medium prevalence of 27%, but further studies remain necessary to clarify its pathophysiologic mechanism. Since PPIs are widely used, it is essential to be aware of hypomagnesaemia as a possible side effect, particularly in refractory cases and after excluding other common causes. LEARNING POINTS: PPIs-related hypomagnesaemia should be a concern, especially in cases with refractory hypomagnesaemia and after excluding other common causes.Formal indication for PPIs use should be revised in most patients.

Cerebral Venous Thrombosis and Its Clinical Diversity.

Cerebral venous thrombosis (CVT) is a serious medical condition which is difficult to diagnose because of its wide range of clinical presentations. The symptoms can vary from an isolated headache to coma. Here, we present the case of a 76-year-old female patient with a history of immune thrombocytopenic purpura, arterial hypertension, and pulmonary embolism. The diagnosis of CVT was challenging because the initial form of disease presentation mimicked a transient ischemic attack (transient aphasia and right hemiparesis). Therapeutical decisions were also a challenge because, at the time of the diagnosis, the patient was suffering from severe thrombocytopenia (29 × 109/L), which had to be taken into account. After multidisciplinary discussions, therapeutic subcutaneous enoxaparin was started, resulting in a progressive and significant neurological recovery. In presenting this case, our primary goal is to point out that CVT can be difficult to diagnose because of its wide range of clinical presentations. Headache (a symptom that was never present in this case) is the most frequent complaint, occurring in 90% of cases. Following diagnosis, an etiological study is required.

Association of Statins With Functional Outcome and 30-Day Mortality in Patients With Intracerebral Hemorrhage.

Aim The effect of statins is well established in cardiac and cerebrovascular diseases. However, its impact on intracerebral hemorrhage (ICH) is unclear. We aim to identify an association of pre-ICH statin treatment and statin use during admission for ICH with functional outcome at discharge and 30-day mortality. Material and methods A retrospective cohort study was held in patients with ICH admitted to our stroke unit over a year period. Demographic characteristics, risk factors and cardiovascular diseases, Glasgow Coma Scale (GCS), National Institutes of Health Stroke Score (NIHSS), systolic blood pressure (SBP) at admission, cholesterol levels and radiologic findings were analyzed to explore the association between pre-ICH and inpatient statin use with outcomes. The primary endpoint was functional outcome defined as modified Rankin Score (mRS) at discharge and 30-day mortality. We performed a univariate analysis and the variables with statistical significance were included in a multivariate analysis to control for confounding covariates. Results The study included 78 patients, 33 (42.31%) had previous statin intake history, of which 13 (39.39%) maintained statin intake during hospitalization. Regarding functional outcome we did not report a statistically significant difference between groups. In the "pre-ICH statin use" group a decreased 30-day mortality (6.06%, p = 0.009) was observed. In this group it was also noted higher antiplatelet medication use (33.33%, p = 0.006), higher GCS at admission (13-15: 84.38%, p = 0.018) and deep ICH (81.82%, p = 0.030). However, 30-day mortality had no impact in multivariate regression (Odds ratio (OR) 4.535, 95% Confidence Interval (CI) = 0.786-26.173, p = 0.091). In the group that maintained statin treatment during hospitalization no deaths were registered (p = 0.020) and there was no association with functional status. Multivariate regression analysis was not performed due to sample size. Conclusion The only association demonstrated in this study was lower 30-day mortality with pre-ICH statin use and continued statin treatment during admission. However, this was not confirmed by multivariate regression analysis. There were no differences between groups concerning cholesterol values, results that can be explained by the pleiotropic and immunomodulatory effect of statins. However, prospective studies are needed to prove the benefit of the statins in ICH.

Intrathoracic Acute Cholecystitis.

The authors present the case of a 51-year-old woman with no history of surgical or traumatic injury or accident, who presented with right hypochondrium and epigastric discomfort, malaise, nausea, loss of appetite and episodes of dark urine and greenish stools. Initial laboratory work-up revealed elevated inflammatory markers including leucocytosis with left shift and C-reactive protein, and a slight elevation of gamma-glutamyltransferase and alkaline phosphatase, with no other significant alterations. Computed tomography (CT) showed intrathoracic acute cholecystitis with a large diaphragmatic hernia. A literature search revealed only one other case of acute cholecystitis complicated by intrathoracic gallbladder due to a non-traumatic diaphragmatic hernia. Symptoms are uncharacteristic and the absence of pain or fever, explained by the altered location of the gallbladder, makes the diagnosis a challenge. LEARNING POINTS: Only one other case of acute cholecystitis complicated by intrathoracic gallbladder due to a non-traumatic diaphragmatic hernia has been reported.Uncharacteristic symptoms make the diagnosis of intrathoracic acute cholecystitis a challenge.