Wunderlich's syndrome as a manifestation of polyarteritis nodosa.

Wunderlich syndrome is a rare clinical entity characterised by spontaneous renal haemorrhage that can be life-threatening and requires emergency attention. The most frequent aetiologies are renal tumours and vascular diseases. The authors report a case of a patient admitted with hypovolaemic shock due to a retroperitoneal haematoma in the context of polyarteritis nodosa (PAN). Prognosis of untreated PAN is very poor with 13% 5-year survival rate. Therefore, early recognition of disease and proper treatment with immunosuppressors will prevent catastrophic complications and improves survival.

Adult-onset Still's disease presenting as myopericarditis.

A 24-year-old man presented to the emergency department with fever, maculopapular rash, myalgia and polyarthralgia, thoracic pain and dry cough, which had been present for 24 h. At the time of observation he had high fever (39°C), maculopapular rash on the torso, arms and legs proximally, axillary adenopathies and pharyngitis. Laboratorial data showed elevated inflammation markers (leukocytosis, C reactive protein of 44 mg/dL, erythrocyte sedimentation rate of 120 mm), elevated transaminases, lactate dehydrogenase, ferritin levels (>2000 ng/mL) and rising troponin. ECG had sinus rhythm and ST elevation in leads V1-V5. Thoracic radiography revealed bilateral interstitial infiltrate confirmed by CT scan. Echocardiographic findings included diffuse hypokinesia of the left ventricle and impaired systolic function. After the investigation of an infectious or autoimmune aetiology was negative, the diagnosis of adult-onset Still's disease was considered. The patient was put on a 60 mg/day prednisolone regimen with remission of symptoms and normalisation of systolic function and ECG.

Hepatic haemangiomatosis: multinodular liver in an asymptomatic elderly man.

A 66-year-old man, overweight and a heavy drinker, was sent to our clinic to investigate multiple liver nodules detected on ultrasound. The patient had no symptoms, and physical examination was unremarkable. Laboratory evaluation disclosed an isolated two-fold increase of γ-glutamyltransferase. The MRI revealed multiple millimetric hypervascular nodules suggestive of liver haemangiomatosis, though malignancy could not be ruled out. Liver biopsy was consistent with hepatic haemangiomatosis. We discuss the differential diagnosis and therapeutical approach of a patient with hepatic haemangiomatosis involving the entire liver without associated symptoms or liver dysfunction.