Organizing Pneumonia and Ulcerative Colitis: A Relationship To Remember.

Ulcerative colitis (UC) is a chronic inflammatory bowel disease characterised by relapsing and remitting mucosal inflammation of the colon. Despite primarily affecting the gastrointestinal tract, UC has various extraintestinal manifestations that often affect other organs and systems. Although pulmonary involvement is uncommon, organising pneumonia (OP), which affects the lung parenchyma, is one of the potential extraintestinal manifestations of UC. We report a case of OP in a 35-year-old male with a longstanding history of UC, well-medicated with sulfasalazine (SSZ). He presented to the emergency department (ED) with complaints of fatigue, coughing, myalgia, thoracalgia and dyspnoea. A chest X-ray showed parenchymal infiltrates and computed tomography revealed bilateral consolidation. Under a preliminary diagnosis of atypical pneumonia, he was treated with an empirical broad-spectrum antimicrobial agent, which did not lead to any clinical, laboratory or imaging improvement. Furthermore, the diagnostic work-up excluded any malignancy or infectious cause. A probable diagnostic hypothesis was OP as an extraintestinal manifestation of UC or as an adverse effect of SSZ therapy. Hence, SSZ was discontinued, and he was successfully treated with corticosteroids, exhibiting significant improvements and recovering completely during the follow-up period. Despite lung involvement in UC being rare, we present this case to emphasise the importance of a thorough differential diagnosis when treating acute respiratory illness in patients with UC, including extraintestinal manifestations of UC, especially OP, even during a period of remission. We also emphasise the importance of early initiation of corticosteroid therapy to prevent major complications and promote recovery.

Strongyloides stercoralis Dissemination and Hyperinfection Associated with Long-Term Steroid Treatment in a Neurosurgical Population.

Strongyloidiasis develops from the infection with Strongyloides stercoralis (Family: Strongylidae) and was recently considered a neglected tropical disease by the World Health Organization due to its global distribution and high burden of infection. Here, we present the cases of two patients under corticosteroid therapy after neurosurgical surgery who developed septic shock-like hyperinfection syndrome due to disseminated strongyloidiasis. The first case is a 77-year-old man from Cape Verde who was diagnosed with an extra-axial right parietal brain mass. He was given dexamethasone and was submitted to a biparietal craniotomy. His condition deteriorated and he was admitted to the intensive care unit (ICU), where he was diagnosed with disseminated strongyloidiasis with hyperinfection. Anthelmintic treatment and corticosteroid therapy were rapidly tapered and stopped. Neurological dysfunction persisted and the patient was transferred to the ward. The patient had died after complications of hospital-acquired pneumonia. The second case is a 47-year-old man from Guinea-Bissau who was diagnosed with a space-occupying lesion in the right temporal region and started treatment with dexamethasone. He underwent a craniectomy with partial excision of the lesion (high-grade glioma). Later his neurologic state worsened, and he was diagnosed with septic shock and hospital-acquired pneumonia. He was admitted to the ICU, the diagnosis of disseminated strongyloidiasis and hyperinfection syndrome was made and he initiated treatment with ivermectin and albendazole. Corticosteroid therapy was tapered. The patient's clinical status deteriorated, and multiple opportunistic infections were diagnosed during the ICU stay, which lead him to die. Clinicians should have a high index of suspicion when in the presence of corticosteroid-treated patients with sepsis. Preventive strategies and subsequent treatment should be considered in patients with a risk of acquisition or dissemination. Treating severe strongyloidiasis is still a clinical challenge and a delayed diagnosis can significantly worsen the outcomes of the patients affected, as seen in the presented cases.

Dermatomyositis: A Cancer Red Flag.

Dermatomyositis is an inflammatory disease that affects muscle strength and causes skin manifestations. There is an increased incidence of cancer in patients with this diagnosis although the pathophysiology of this association is still not completely understood. We report a case of a 65-year-old man who presented to the emergency department with proximal muscle weakness, weight loss, dysphagia, enlarged supraclavicular lymph nodes, an erythematous rash in the malar and supraciliary regions, and papules in the extensor metacarpophalangeal and interphalangeal joints. He had elevated creatine kinase and positive anti-nuclear matrix protein-2 autoantibodies. The skin and muscle biopsies performed confirmed the diagnosis of dermatomyositis. A thorough investigation seeking an associated condition was conducted and a prostate adenocarcinoma was diagnosed. The patient was treated with glucocorticoids and intravenous immune globulin with dysphagia and muscle weakness improvement and therefore allowing hospital discharge. He is currently undergoing oncologic treatment. Myositis-specific antibodies have proved to be extremely useful in the diagnosis, prognosis, and management of patients with dermatomyositis. Various phenotypes of the disease can associate differently with a systemic condition (namely a malignant disease). This case illustrates a rare form of cancer presentation that every clinician, especially those who work in the emergency room or in primary care and therefore have immediate contact with many patients, must be able to recognize.

Syncope Caused by a Head and Neck Cancer Controlled by a Permanent Pacemaker.

Syncope caused by carotid sinus syndrome due to head and neck cancer is rare. We report a case of recurrent syncope as a result of extreme bradycardia requiring pacemaker implantation. The patient began chemotherapy and radiation therapy to treat the underlying cause. When diagnosed early, a positive outcome is expected in these situations. LEARNING POINTS: The differential diagnosis of transient loss of consciousness is frequently evident at clinical examination but may prove to be a challenge.The invasion and direct compression of the carotid sinus is a rare cause of carotid sinus syndrome and presents clinically as syncope.

Emphysematous gastritis associated with gastric cancer: a rare and fatal entity.

Emphysematous gastritis is a rare disease characterised by air in the wall of the stomach due to gas-forming microorganisms. This is a highly lethal entity for which only prompt diagnosis and treatment can avoid mortality. Different factors have been described that disrupt the integrity of the mucosa such as corrosive ingestion, alcohol abuse, recent abdominal surgery or cancer. We report a case of emphysematous gastritis in a 92-year-old woman who presented to the emergency department with abdominal pain, nausea and vomiting. Inflammatory markers were elevated and abdominal X-rays showed intramural gastric air, confirmed by CT scan. The patient received intravenous fluids, nutritional support and broad-spectrum antibiotic with resolution of gastric wall emphysema. However, the diagnosis of poorly cohesive gastric adenocarcinoma was made and the patient was referred to palliative care. This case highlights the importance of prompt recognition of this lethal entity that represents a rare and aggressive presentation of gastric cancer.