Acute Ischaemic Stroke in the Context of Neurosyphilis: How Does Antibiotic Therapy Help, and When Should It Be Given?

Introduction: Neurosyphilis (NS) refers to a central nervous system infection caused by Treponema pallidum. In recent years, there has been an increasing incidence of syphilis; however, NS is uncommon compared to the era before the discovery of penicillin. Manifestations are usually non-specific, ranging from asymptomatic cases to syphilitic meningitis, meningovascular syphilis, general paresis and tabes dorsalis. Meningovascular syphilis can cause an inflammatory arteritis of cerebral arteries, leading to vascular occlusion and cerebral infarction. Case description: We report a case of an ischaemic stroke in a patient with several vascular risk factors, presenting with right hemiparesis, hemihypesthesia and dysarthria. Initial computed tomography with angiography of the head and neck was normal; however, magnetic resonance imaging of the brain revealed a thalamic and internal capsule infarct. Serum T. pallidum antibodies were positive, as well as a rapid plasma reagin test. Cerebrospinal fluid analysis confirmed the diagnosis of neurosyphilis, and the patient was treated with ceftriaxone for 14 days due to a penicillin allergy. Discussion and conclusion: Although there is a high prevalence of stroke in patients with NS, this condition is typically underdiagnosed. Untreated NS carries a higher risk of stroke recurrence compared to other risk factors. Therefore, early diagnosis and treatment are essential. This case highlights the importance of considering NS in stroke victims, even in older patients with several additional vascular risk factors, to prevent recurrence and other complications. LEARNING POINTS: Neurosyphilis (NS) can occur at any stage of syphilis infection, and it can be asymptomatic or symptomatic, presenting as syphilitic meningitis, meningovascular syphilis, general paresis or tabes dorsalis.Ischaemic strokes are a frequent complication of NS, occurring in 14% of the cases. However, only 19% of the cases are correctly diagnosed.NS should be considered as a potential cause of stroke, even in older patients with several other vascular risk factors. This is essential to prevent future strokes, as well as dementia and other complications.

Tumor Lysis Syndrome Rare Presentation As Uremic Pericarditis: A Case Report.

Tumor lysis syndrome (TLS) is an oncological emergency characterized by the massive destruction of malignant cells and the release of their contents into the extracellular space, which might occur spontaneously or post-chemotherapy. According to the Cairo&Bishop Classification, it can be defined by both laboratory criteria: hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia (two or more); and clinical criteria: acute kidney injury (AKI), convulsions, arrhythmias, or death. We report the case of a 63-year-old man with a previous medical history of colorectal carcinoma and associated multiorgan metastasis. The patient was initially admitted to the Coronary Intensive Care Unit, five days after the chemotherapy session, on suspicion of Acute Myocardial Infarction. Upon admission, he presented without significant elevation of myocardial injury markers, but with laboratory abnormalities (hyperkalemia, hyperphosphatemia, hyperuricemia, and hypocalcemia) and clinical symptoms (sudden sharp chest pain with pleuritic characteristics and electrocardiographic anomalies suggesting uremic pericarditis, and acute kidney injury), all consistent with TLS. The best approach to established TLS is aggressive fluid therapy and a decrease in uric acid levels. Rasburicase proved to be notoriously more effective, both in terms of prevention and treatment of established TLS, thus consisting of the first-line drug. However, in the present case, rasburicase was not available at the hospital level, so a decision was made to initiate treatment with allopurinol. The case evolved with slow but good clinical evolution. Its uniqueness resides in its initial presentation as uremic pericarditis, scarcely described in the literature. The constellation of metabolic alterations from this syndrome translates into a spectrum of clinical manifestations that can go unnoticed and ultimately may prove to be fatal. Its recognition and prevention are crucial for improving patient outcomes.

AN 84-YEAR-OLD PATIENT WITH CAROLI SYNDROME: WHAT IS THE PROGNOSIS OF THIS CONDITION?

Caroli disease is a rare congenital pathology caused by mutation of the PKHD1 gene (polycystic kidney and hepatic disease 1), also responsible for autosomal recessive polycystic kidney disease. Characterized by segmental and multifocal dilatation of the large intrahepatic bile ducts, classic disease involves only malformation of the biliary tract. The association with congenital hepatic fibrosis is called Caroli syndrome. We describe the case of an 84-year-old man with Caroli syndrome diagnosed in 1997 by liver biopsy. The CT scan revealed massive hepatomegaly, extending to the pelvic region, and almost total replacement of the parenchyma by numerous cystic formations, no evidence of bile duct dilatation, and no ascites or splenomegaly suggestive of portal hypertension. The atypical clinical presentation, with no reported complications, resembles that of a space-occupying lesion with an indolent course, previously misdiagnosed as metastatic neoplasm. LEARNING POINTS: We describe a case of advanced and rare Caroli syndrome with an atypical clinical presentation of a space-occupying lesion with slow progression.The atypical presentation could be misdiagnosed as metastatic neoplasm.

Rectal Bezoar: A Rare Cause of Intestinal Obstruction.

Bezoars are conglomerates of undigested contents that accumulate in the gastrointestinal tract. They can have different compositions, such as fibers, seeds, vegetables (phytobezoars), hair (trichobezoars), and medication (pharmacobezoars). Bezoars are typically caused by an impaired grinding mechanism of the stomach or interdigestive migrating motor complex, but the composition of ingested material can also play a role in their formation. Gastric dysmotility, previous gastric surgery, and gastroparesis are some of the risk factors that can increase the likelihood of developing bezoars. While bezoars are usually asymptomatic and found in the stomach, they can sometimes migrate to the small intestine or colon and cause complications such as intestinal obstruction or perforation. Endoscopy is essential for diagnosis and etiology, and treatment depends on the composition, which can include chemical dissolution or surgical intervention. We present a case of an 86-year-old woman, who had a bezoar located in an unusual location (rectum), most likely due to migration. This condition led to symptoms of intermittent intestinal obstruction and rectal bleeding. However, due to anal stenosis, the patient was unable to expel the bezoar. Its removal was not possible through various endoscopic techniques. Therefore, it was removed via fragmentation, using an anoscope and forceps, due to its hard/stone-like consistency. This case highlights the importance of considering bezoars in the differential diagnosis of gastrointestinal bleeding and illustrates the importance of prompt diagnosis and appropriate techniques for the removal of bezoars.