Nephrocalcinosis fortuitously discovered: the role of surreptitious self administration of diuretics.

Background: Furosemide is a drug widely used for several medical conditions and could be used without medical prescription. Furosemide-related nephrocalcinosis can occur regardless of age, although the risk is higher in premature infants. The defining characteristic of nephrocalcinosis is generalized calcium deposition in the kidney. The most useful imaging studies for evaluation are ultrasonography and computed tomography (more effective in detecting calcification). Case Presentation: A 32-year-old woman with a history of depressive syndrome was admitted for evaluation of fortuitously discovered nephrocalcinosis and hypokalemia. The studies performed revealed the presence of a metabolic alkalosis with discrete hyperreninism/hyperaldosteronism but normal ratio, normotension and urinary study showed elevated sodium, chloride, potassium and calcium fluctuating in different determinations. Surreptitious diuretic intake was suspected and urine analysis revealed doses equivalent to 80-120 mg. The patient was advised to discontinue all diuretic treatment; she was adequately supplemented with potassium and she was followed-up in outpatient clinics. During the follow-up, clinical and analytical improvement was noted, which led to the discontinuation of supplementation. Conclusion: Surreptitious diuretic intake is a clinical condition to rule out in patients with chronic hypokalemia, metabolic alkalosis with elevated urinary sodium and chloride. The relation between surreptitious diuretic intake and nephrocalcinosis has not been fully elucidated in adults.

Recurrent Episodes of Hypokalaemia during Treatment with Inhaled Beta-2 Agonist Revealing Gitelman Syndrome, an Uncommon Clinical Entity.

A 28-year-old female patient was hospitalized for mild-moderate hypokalaemia which was persistent despite discontinuation of beta-2 agonist bronchodilator treatment. Her past medical history was relevant for two episodes of severe hypokalaemia after active inhaled beta-2 agonist treatment for asthma crisis. Investigations revealed increased potassium in spot urine with a transtubular potassium gradient <4. A 24-hour urine analysis showed hypophosphaturia, hypocalciuria, hypomagnesuria and normal urine prostaglandins in favour of Gitelman syndrome. Oral potassium supplementation was started and genetic studies were recommended. LEARNING POINTS: An exhaustive aetiological work-up should be performed in young patients with persistent hypokalaemia after withdrawal of bronchodilators.Gitelman syndrome should be suspected in any patient with unexplained hypokalaemia, metabolic alkalosis, and a normal or low blood pressure.

Hemofilia adquirida como manifestación inicial de recidiva de adenocarcinoma colorrectal / Acquired hemophilia as the initial manifestation of colorectal cancer's recurrence

Resumen Presentamos el caso de un varón de 86 años con un hematoma espontáneo en el músculo ilíaco izquierdo y diagnóstico previo de cáncer de colon en 1998 (estadio pT3N0M0), tratado quirúrgicamente mediante colectomía transversal, considerado en remisión completa. Tras realización de estudios complementarios se demostró la presencia de autoanticuerpos inhibidores del Factor VIII que confirmaron el diagnóstico de hemofilia adquirida. Durante el ingreso el paciente presentó un sangrado digestivo bajo que conllevó al descubrimiento de recidiva del adenocarcinoma colorrectal tratado previamente. Respondió de forma favorable a la terapia inicial con corticoides sistémicos y el complejo coagulante anti inhibidor que incluye el Factor VII activado [FEIBA].

Abstract We report the case of an 86-year-old man presenting with a spontaneous hematoma in the left iliac muscle and previous diagnosis of colon cancer in 1998 (stage pT3N0M0) treated with transverse colectomy and considered in complete remission. After a complete study, it was possible to identify the presence of Factor VIII inhibitors antibodies that confirmed the presence of acquired hemophilia. During hospitalization the patient presented a lower gastrointestinal bleeding leading to the diagnosis of recurrence of a previously treated colorectal adenocarcinoma. He responded to initial therapy with systemic corticoids and anti-inhibitory coagulant complex which includes activated VII Factor [FEIBA].

[Acquired hemophilia as the initial manifestation of colorectal cancer's recurrence]. / Hemofilia adquirida como manifestación inicial de recidiva de adenocarcinoma colorrectal.

We report the case of an 86-year-old man presenting with a spontaneous hematoma in the left iliac muscle and previous diagnosis of colon cancer in 1998 (stage pT3N0M0) treated with transverse colectomy and considered in complete remission. After a complete study, it was possible to identify the presence of Factor VIII inhibitors antibodies that confirmed the presence of acquired hemophilia. During hospitalization the patient presented a lower gastrointestinal bleeding leading to the diagnosis of recurrence of a previously treated colorectal adenocarcinoma. He responded to initial therapy with systemic corticoids and anti-inhibitory coagulant complex which includes activated VII Factor [FEIBA].

Presentamos el caso de un varón de 86 años con un hematoma espontáneo en el músculo ilíaco izquierdo y diagnóstico previo de cáncer de colon en 1998 (estadio pT3N0M0), tratado quirúrgicamente mediante colectomía transversal, considerado en remisión completa. Tras realización de estudios complementarios se demostró la presencia de autoanticuerpos inhibidores del Factor VIII que confirmaron el diagnóstico de hemofilia adquirida. Durante el ingreso el paciente presentó un sangrado digestivo bajo que conllevó al descubrimiento de recidiva del adenocarcinoma colorrectal tratado previamente. Respondió de forma favorable a la terapia inicial con corticoides sistémicos y el complejo coagulante anti inhibidor que incluye el Factor VII activado [FEIBA].

Idiosyncratic Drug-Induced Neutropenia and Agranulocytosis in Elderly Patients.

Agranulocytosis is a rare, but serious and life-threatening hematologic disorder in elderly patients. Idiosyncratic drug-induced agranulocytosis (IDIA) has been classically defined by a neutrophil count below 0.5 × 109/L. The annual incidence of IDIA in Europe is about 1.6-9.2 cases per million inhabitants. Increasing age and female sex have been considered as risk factors for the development of this condition. Besides, it is well known that older people take on average more drugs than younger people. This condition is most often associated with the intake of antibacterial agents, antiplatelets, antithyroids, antipsychotics, antiepileptics and nonsteroidal anti-inflammatory drugs (NSAIDs). Initially, agranulocytosis may present without symptoms, but may quickly progress to a severe infection and sepsis. The causative drug should be immediately stopped. In febrile patients, blood cultures and where indicated, site-specific cultures should be obtained and early treatment with empirical broad-spectrum antibiotics started. Even with adequate treatment, the mortality rate is higher in elderly patients reaching up to 20%. Hematopoietic growth factors have proven to be useful as they shorten the duration of neutropenia. However, data on neutropenia and agranulocytosis in the elderly meeting the criteria of evidence-based medicine are still poor in the literature. This review analyzes the results of our experience as well as other published studies of the universal literature.

Idiopathic CD4+ T-cell Lymphocytopenia: Report of a Case 11 Years after Diagnosis.

We report the case of a 23-year-old woman evaluated for asthenia and lymphocytopenia. Clinical examination was unremarkable but laboratory tests showed the presence of CD4 lymphocytopenia. Secondary causes of CD4 lymphocytopenia were ruled out and a previous diagnosis of idiopathic CD4+ T-cell lymphocytopenia was retained. CD4 lymphocytopenia has persisted for 11 years now but the patient has been clinically asymptomatic. LEARNING POINTS: CD4+ T-cell lymphocytopenia needs to be meticulously evaluated and secondary causes ruled out.The patient has been clinically asymptomatic for 11 years.Measurement of CD4 subsets twice yearly seems to be appropriate.

Anosmia and Dysgeusia in the Absence of Other Respiratory Diseases: Should COVID-19 Infection Be Considered?

We describe two elderly patients evaluated at emergency departments for anosmia/dysgeusia in the absence of any other respiratory symptoms prior to or upon admission. In the current epidemiological context, clinical and biological work-up led to a diagnosis of COVID-19 infection. Unfortunately, one of the patients died during hospitalization, but the other recovered and was discharged. LEARNING POINTS: In the current epidemiological situation, anosmia and dysgeusia in the absence of other respiratory conditions should be carefully evaluated.Special attention should be given to patients with non-classic COVID-19 symptoms in order to reduce transmission and protect health providers.

Intellectual Disability, Falls and Gait Disturbances: A Misdiagnosis.

We report the case of a 27-year-old man presenting with slowly progressive extrapyramidal dysfunction and learning disability considered to have a syndromic intellectual disability. The re-evaluation of the clinical features and the investigations performed led to the diagnosis of atypical pantothenate kinase-associated neurodegeneration (PKAN). LEARNING POINTS: Patients with an intellectual disability should be carefully evaluated.In the evaluation of a patient with extrapyramidal dysfunction for several years, with gradual progression, spasticity and psychiatric disturbances, PKAN should be considered.

Tuberculosis as a Cause of Rapid Salivary Gland Swelling in the Elderly - A Case Report.

A 77-year-old man was admitted to the internal medicine department for a 5-day history of progressive preauricular swelling. Two lines of antibiotic treatment failed to achieve any improvement. Fine needle aspiration cytology was conducted and smear staining with the Ziehl-Neelsen stain as well as a PCR test were positive for Mycobacterium tuberculosis. These results were confirmed with culture of the sample. A diagnosis of tuberculosis parotitis was made and anti-tuberculous drugs were initiated. LEARNING POINTS: In patients not responding to usual antibiotic treatment, other rare causes of parotitis should be suspected.Fine needle aspiration cytology was an important procedure in establishing the diagnosis.

Hypocalcemia Revealing an Enteropathy-Associated T-cell Lymphoma.

BACKGROUND: Enteropathy-associated T-cell lymphoma (EATL) is a rare and aggressive type of extranodal T-cell lymphoma (TCL) arising in the gastrointestinal (GI) tract and represents 5-8% of all T-cell non-Hodgkin lymphomas (NHL) and 10-25% of primary intestinal lymphomas. CASE PRESENTATION: We reported a 78-year-old woman presenting with severe hypocalcemia. Investigations confirmed vitamin D and iron deficiency as well as hypoalbuminemia. Celiac disease was suspected and confirmed, but despite intravenous calcium and magnesium supplementation and a gluten-free diet, normal electrolyte levels were never reached. Intestinal perforation was the clue to the diagnosis of enteropathy-associated T-cell lymphoma (EATL). CONCLUSION: Hypocalcemia can result from multiple conditions. In patients not responding to adequate supplementation, further investigations should be performed to diagnose the underlying condition.