Giant Cell Arteritis Presenting as Multiple Ischaemic Strokes: A Successful case of Endovascular Treatment.

Giant cell arteritis (GCA) may manifest with aggressive intracranial stenosis resistant to medical therapy, and patients may develop refractory neurologic deficits and cerebral infarcts, making GCA a life-threatening condition. We report the case of a 68-year-old woman recently diagnosed with GCA, medicated with prednisolone 60 mg daily. Two weeks later, the patient was admitted to our Stroke Unit after a sudden episode of global aphasia. Magnetic resonance angiography showed two recent ischaemic lesions, besides an erythrocyte sedimentation rate of 17 mm/hour. A cerebral angiography revealed bilateral stenosis and dilation in the petrous, cavernous and supraclinoid segments of internal carotid arteries (ICA). The patient was started on intravenous methylprednisolone pulses (250 mg daily for five days). Computed tomography (CT) angiography and Doppler ultrasound showed severe vascular disease affecting multiple territories, without significant intracranial involvement. The hypothesis of GCA with extracranial vasculitic involvement was considered as the aetiology of ischaemic cerebral infarctions in multiple territories and, given the severity of the disease, it was decided to add tocilizumab. Despite this, the patient evolved with significant worsening neurological deficits and a CT scan confirmed the presence of new vascular events. Endovascular treatment (EVT) with balloon angioplasty was conducted on both ICAs, with improved calibre and downstream filling. After that, the patient presented sustained clinical improvement, without recurrence of any ischaemic events at the one-year follow-up. This clinical case stands out for the importance of EVT as an effective therapy in patients with medically refractory GCA with symptomatic intracranial stenosis, improving their prognosis. LEARNING POINTS: Giant cell arteritis may manifest with aggressive and symptomatic intracranial arterial stenoses.Endovascular treatment is an effective intervention to prevent ischaemic complications in intracranial giant cell arteritis.

Pain in an Internal Medicine Ward: An Undervalued Reality?

Introduction Pain is prevalent in most pathologic situations that require healthcare and is very common in hospitalised patients. However, there is limited evidence about the prevalence and the actual management of pain in medical wards. The aim of this work was to evaluate and characterise pain management in an internal medicine ward. Methods Retrospective analysis of clinical data of patients consecutively discharged from the internal medicine ward of a central tertiary hospital over a period of five months in 2018. Results 199 patients evaluated, the median age was 78 years and 63% were female. Of these, 14% had a previous diagnosis of chronic pain, 24% were on chronic pain medication, and in 29% medication was interrupted. Pain was noted in medical records of 118 patients, with moderate to severe intensity in 67%. Among those, 71% had pain occurrence registered in the medical notes but not characterised in duration in 61%. The most common attributed etiologies of pain were musculoskeletal (16%), visceral (9%), and headache (8%); no identifiable cause was specified in 57%. In the group of patients reporting pain, 63% received analgesics. Opioids were used in 35% and 47% of patients with moderate and severe pain, respectively. At discharge, 12 patients were still referred pain, 16 had pain listed as a diagnosis, 45 were medicated for pain, and eight were referred for pain consultation. Conclusions Despite being highly prevalent in the internal medicine ward, pain is still under-recognised, undervalued, and under-treated. Education of healthcare staff and adoption of treatment protocols is essential to improve care for these patients.

Acute reversible toxic encephalopathy during capecitabine and oxaliplatin treatment.

INTRODUCTION: Capecitabine is a fluoropyrimidine commonly used in the treatment of colorectal cancer which may cause central nervous system toxicity, namely cerebellar dysfunction. CASE REPORT: We describe a 77-year-old man undergoing adjuvant treatment of colon cancer with capecitabine and oxaliplatin who presented with acute cerebellar ataxia and encephalopathy that progressed to coma. Diagnosis of toxic encephalopathy was made after the exclusion of alternative causes of neurological dysfunction and complete resolution of clinical findings with permanent discontinuation of chemotherapy. DISCUSSION: When patients with cancer develop symptoms and signs of central nervous dysfunction, metabolic and infectious causes plus tumor involvement of central nervous system must be sought. However, chemotherapy may also cause toxicity to the central nervous system. Capecitabine is no exception, although cerebellar dysfunction is rarely reported. CONCLUSION: Although rare, capecitabine-induced encephalopathy may be severe and physicians should be aware of this possible side effect.

Blind spot: blindness as initial presentation of subarachnoid haemorrhage.

A 47-year-old Caucasian man with arterial hypertension was admitted after a seizure. At the emergency department, he presented with high blood pressure, bilateral vision loss (evidenced by unresponsiveness to threatening stimuli), right hemiplegia and severe agitation. The brain CT angiography showed a diffuse basal cisterns subarachnoid haemorrhage with a ruptured basilar aneurysm. He was admitted for neurovascular procedure and embolisation. The patient's neurological examination improved but blindness persisted. A funduscopic examination revealed a left eye vitreous haemorrhage and diffuse retinal haemorrhages in the posterior pole. Assuming the haemorrhages were the cause of blindness, Terson syndrome was diagnosed. The patient underwent vitrectomy surgery being discharged 5 days later maintaining left eye blindness and able to count fingers from 1 m distance with the right eye. Two months after discharge, he was re-evaluated at our clinic with left eye blurred vision and almost normal right eye visual acuity.

Breaking bad news: experiences and preferences of advanced cancer patients at a Portuguese oncology centre.

The disclosure of information to patients about diagnosis and prognosis and other aspects of care is still a matter of debate. We have conducted a study in advanced cancer patients about their experiences and preferences concerning this issue. A questionnaire was developed and completed during the first appointment in the outpatient clinic of an oncology centre's palliative care unit, before the patient had any contact with the staff of the unit. The study was conducted on a convenience sample of 47 patients. We found that 34 (72%) of those patients thought they had been informed of their diagnosis, most of them by the hospital doctor. However, not all stated the diagnosis in a manner clearly showing that they were aware of the nature of their disease. Most patients were with a family member when the diagnosis was disclosed, which is what the majority had preferred. Of the 13 uninformed patients, only one preferred to remain uninformed. Most patients (89%) participated in decisions concerning treatment, although only 68% thought they should have participated. Some 39 patients (83%) were informed that they were being referred to the palliative care unit, but surprisingly only eight had received an explanation of the unit's function. We concluded that, although most patients had been informed of their disease, there remains many problems, the most important of which, in our view, is the difference between the information provided and the patients' needs.

Lyme borreliosis in Portugal caused by Borrelia lusitaniae? Clinical report on the first patient with a positive skin isolate.

BACKGROUND: Borrelia lusitaniae was isolated from an Ixodes ricinus tick in Portugal in 1993 for the first time. Further, this borrelia genospecies has been found in ixodid ticks collected around the coasts of southern Portugal and North Africa. Its reservoir has not been defined yet. B. lusitaniae was isolated once until now from a patient with a long standing and expanding skin disorder. PATIENT AND METHODS: A 46-year-old Portuguese woman presented with a skin lesion on the left thigh which had evolved slowly over ten years. The patient reported limb paraesthesias, cramps, chronic headaches, and cardiac rhythm disturbances. History of tick bites was negative nor had the patient ever noticed a skin lesion comparable with erythema chronicum migrans. Skin biopsies were taken for histological evaluation, culture and DNA detection. Antibodies to borrelia were searched by indirect immunofluorescence assay and Western-blot. RESULTS: A bilateral carpal tunnel syndrome and local synovitis was diagnosed. Dermato-histology was normal, serology was negative. Spirochaetal organisms were cultured from a skin biopsy and identified as B. lusitaniae. The patient improved after a 2-week course of intravenous ceftriaxone; the skin lesions did not expand further. CONCLUSIONS: This culture confirmed skin infection by B. lusitaniae in a patient from Portugal suggests an additional human pathogen out of the B. burgdorferi sensu lato complex in Europe, particularly in Portugal.

Primary amyloidosis as a cause of microvascular angina and intermittent claudication.

Primary systemic amyloidosis or AL amyloidosis is a rare condition characterized by extracellular deposits of fibrils composed of fragments of immunoglobulin light chains. Widespread deposition of this amyloid in tissues interferes with their normal function and leads to multiple organ failure. Clinical manifestations are highly variable due to the wide range of organs involved. The heart is affected in 90% of cases; in 30% of these, cardiac dysfunction is the form of presentation and in 50% it is the cause of death. The commonest form of cardiovascular manifestation is congestive heart failure due to restrictive cardiomyopathy caused by extensive interstitial infiltration of amyloid into the myocardium. Occasionally, it can present as angina, due to infiltration of amyloid into the walls of small vessels. The authors describe the case of a patient in whom the disease presented simultaneously with heart failure and effort angina, as well as intermittent claudication.