Microscopic colitis, a forgotten condition: a clinical case and review of the literature.

OBJECTIVE: Microscopic colitis is a not uncommon chronic inflammatory disease of the colon, characterized by watery, non-bloody diarrhea, which is often forgotten and misdiagnosed. CASE PRESENTATION: In this paper, we present a puzzling case of relapsing chronic diarrhea triggered by non-steroidal anti-inflammatory drug (NSAID) abuse, smoking, inappropriate antibiotic use, and secondary Clostridium Difficilis infection. Several tests were performed during hospitalization, all of which were negative apart from fecal calprotectin (> 6,000 mg/kg, normal values < 50 mg/kg) and a positive Clostridium Difficilis toxin test. Since Vancomycin treatment did not bring about the expected response, colonoscopy was performed, which led to diagnosis, targeted therapy, and clinical resolution. Targeted therapy with budesonide and probiotics was initiated leading to resolution of the diarrhea. CONCLUSIONS: This case study shows how actual diagnosis may be delayed not only due to having to perform differential diagnosis with chronic inflammatory diseases, but also because certainty can only come from histological evidence, which takes time to obtain, especially when the disease's multifactorial nature is considered (smoking, NSAID abuse, oral proton pump inhibitors, inappropriate antibiotic use, and Clostridium difficilis infection).

The complexity of immunology: a rare adverse event following a Pfizer-BioNTech vaccine booster shot.

OBJECTIVE: Several mRNA vaccines have been developed to tackle the global pandemic. Despite their remarkable clinical efficacy, they are not devoid of severe short- and long-term adverse events. CASE PRESENTATION: In this paper, we describe a rare delayed adverse event (arterial and venous renal thrombosis with myocardial injury) in an otherwise healthy adult female, which occurred three months after she received a booster shot of Pfizer COVID-19 vaccine.  The patient was successfully treated for subacute renal ischemia with intra-arterial urokinase, and her myocardial injury was diagnosed with imaging (contrast-enhanced thoracic CT and cardiac magnetic resonance) and percutaneous coronary intervention. Deferred post-vaccine myocarditis was diagnosed and resolved with steroid therapy. CONCLUSIONS: In this paper, we report a useful clinical case for the pharmacovigilance database. Although scientific evidence confirms that the benefits of vaccination far outweigh the risk of adverse events, we would like to point out how important watchful observation is in the medium and long term, especially when the subject belongs to a specific risk category.

Midodrine and albumin as a possible "winning pair" in managing paracentesis-induced circulatory dysfunction: a clinical case report.

BACKGROUND: Paracentesis-induced circulatory dysfunction (PICD) is a "silent killer syndrome" occurring after large volume paracenteses (LVPs). We here report an unusual case of PICD induced by right heart failure recognized and managed successfully. CASE PRESENTATION: A 60-year-old woman was admitted to our Emergency Department for worsening dyspnea and hypoxia. Her medical history enclosed a chronic heart failure with reduced ejection fraction and post-stroke dysarthria associated to right hemiplegia. Clinical and laboratory examination defined a severe right-heart failure unresponsive to high-dose diuretic therapy. Diagnostic and therapeutic paracentesis was thus performed determining, initially, a progressive normalization of the abdominal volume, followed, subsequently, by a severe hypotension associated with an acute kidney injury (AKI) combined with severe hyponatremia associated with a normal cardiac output. In the hypothesis of a PICD, abdominal drainage and diuretic therapy were interrupted, reninemia sampling was performed, resulting in diagnostic, and treatment with albumin and norepinephrine was started. The latter was tapered and then replaced with Midodrine that conferred the possibility to reach clinical and laboratory stability, allowing relocation in a cardiological rehabilitation. PICD represents an independent predictor of mortality. Midodrine's prophylactic use in PICD has been suggested as a cheaper alternative to albumin, as it appears to improve renal perfusion and reduce ascites with better clinical handling, as demonstrated in our patient. CONCLUSIONS: Our clinical case wants to show how not all PICDs are secondary to hepatic dysfunctions with Midodrine playing a possible therapeutic role by counteracting the pathophysiological mechanism in a rapid and non-invasive way, representing a valid therapeutic option in adjunction to albumin.

Ischemic stroke with cardiac involvement in aortic thromboembolism.

An aortic thrombus may be detected by using transesophageal echocardiography after an embolic event. Clinical features are variable and may include cardiac and neurologic symptoms, such as the stroke. We report a case of a woman with an acute ischemic stroke, a myocardial infarction and a free floating aortic thrombus.

Acute pancreatitis in emergency department.

Acute abdominal pain is one of the most frequent conditions in patients presenting to the Emergency Department (ED). Acute pancreatitis (AP) is a common abdominal disorder with problematic diagnosis because of the lack of a gold standard diagnostic test. Determination of serum amylase levels was considered a screening test, but recent studies have shown an important group of emergency department patients who have normoamylasemia. Other clinical laboratory tests, such as urinary screening, could be useful to decrease misdiagnosed cases of AP in an emergency situation, whereas, to confirm the clinical suspicious, radiological imaging may add specificity. On admission in ED stratifying patients into different categories, according to severity score systems, may be helpful for an appropriate management.

[Results of endoscopic biliary drainage in primary tumors of the common bile duct (cholangiocarcinoma)]. / Risultati del drenaggio biliare endoscopico nei tumori primitivi della via biliare principale (colangiocarcinomi).

Endoscopic drainage is an effective therapy for palliation of patients with bile duct carcinoma. From November 1987 to November 1994 112 patients with cholangiocarcinoma were observed. The success rate of the procedure was 94.5%. The biliary drainage was successful in 99% of patients (in 4% of patients the complete biliary drainage was obtained with the aid of a transhepatically inserted guide-wire with the "rendez-vous" procedure). In 15 patients an intraluminal radiation therapy with Iridium-192 was associated. The morbility was 13% and the 30-days mortality 11%. A surgical operation was performed in 26% of patients with radical intent. The mean survival time in patients treated only endoscopically was 208 days for patients with lesions of the distal and middle third of the bile duct and 281 days for patients with hilar cholangiocarcinoma. In patients with intraluminal radiation therapy the mean survival time was 357 days, with a significative difference with the only endoscopically treated group (357 vs 238 days, p < 0.05). We conclude that endoscopic drainage is a safe and effective management for patients with cholangiocarcinoma and it does not preclude definitive surgical treatment in appropriate candidate.