Seronegative Celiac Disease - A Challenging Case.

Celiac disease is an inflammatory disorder of the small intestine caused by sensitivity to gluten. This enteropathy results from the interaction between genetics, autoimmunity, and an environmental trigger (gluten). It can manifest at all ages. We present a case of a 76-year-old woman with nausea and vomiting for six months. She reported asthenia, weight loss, and a brief period of diarrhea without blood or mucus. The search for evidence of infection, tumours, and endocrinopathies was negative, as well as the immunological study, including antibodies for celiac disease. Upper endoscopy with biopsies revealed villous atrophy. Capsule endoscopy showed macroscopic features suggestive of celiac/Whipple's disease. Duodenal biopsies were reviewed, and Whipple's disease was considered unlikely. The genetic analysis was positive for HLA DR7-DQ2. After one year on a gluten-free diet, there was a clinical and histological improvement. The diagnosis of seronegative celiac disease is complex and requires the exclusion of other causes of villous atrophy, as well as a histological improvement after one year of treatment. The genetic test has a high negative predictive value.

Heart Failure: From Typical Clinical Manifestations to the Surprising Final Diagnosis.

The authors report a case of an 80-year-old woman with multiple cardiovascular risk factors, with exuberant acute congestive heart failure at admission. Fever, anemia, and an increase in inflammatory parameters were present, with imaging suggesting a respiratory infection as the main reason for decompensation. Empirical antibiotic therapy was instituted, with no clinical improvement even after escalation to broad-spectrum antibiotics and non-invasive ventilation with high support pressures, with no possibility of weaning. Due to maintenance of symptoms, a transthoracic echocardiogram was performed, revealing a large left atrial myxoma, obstructing the mitral valve in diastole. This case illustrates the potential severity of these benign tumors and their ability to mimic symptoms that are often evaluated in the daily life of an internist. The high clinical suspicion led to a diagnosis that was surprising due to its rarity and severity, with the patient being urgently referred for cardiac surgery.

Pyogenic liver abscess: uncommon presentation.

Pyogenic liver abscess is a rare entity, but it is fatal when untreated. With a peak incidence in the fifth decade of life, its early recognition and intervention are key to successful treatment and better prognosis of patients. In recent years, its approach has been enhanced by the use of percutaneous drainage, improved imaging techniques and a better microbiological characterisation, allowing for a more appropriate use of antibiotics. Clinical manifestations are variable and depend on the size of the abscess, the condition of the patient, associated diseases and possible complications. Among the most common symptoms that stand out are the pain in the upper quadrants of the abdomen, high fever, nausea and vomiting. The authors present the case of a patient who developed an atrial flutter as the initial presentation of a hepatic abscess that imagiologically mimicked a hepatic tumour.

Intralobar pulmonary sequestration: diagnostic expertise.

An obese 22-year-old man with a history of recurrent respiratory infections presented to the emergency room with left pleuritic chest pain, productive cough with mucupurulent sputum and an axillary temperature of 37.7°C. Blood work showed elevated inflammatory parameters and chest X-ray was relevant for heterogeneous infiltration in the left base and opacity of the left costophrenic angle. An angio-CT scan revealed areas of bilateral consolidation with presence of an arterial branch originating from the aorta to the collected area of the left lower lobe, consistent with a respiratory infection grafted on a intralobar pulmonary sequestration of the left lung base. The infectious process was treated and the patient was planned for a lower left lobectomy.

Trazodone in the elderly: risk of extrapyramidal acute events.

Trazodone is a second-generation atypical antidepressant exercising selective inhibitory action on the transport of serotonin. It also has an antagonist effect, similar to nefazodone, on the 5HT1 and 5HT2 receptors, probably due to the therapeutic effects of such substances. It is very effective in the treatment of depression, in anxiety and insomnia. Its known side effects mainly occur with prolonged use of daily doses of 150-200 mg. The ability to enhance drowsiness may be associated with some risk in elderly patients. This clinical case illustrates an acute extrapyramidal event induced by a low dose of trazodone.