Q Fever Spondylodiscitis: A Rare Manifestation of a Challenging Disease.

Coxiella burnetii causes Q fever, which is found worldwide and can be acute or chronic. This case report describes a 72-year-old man whose bilateral lower limb pain revealed a paravertebral abscess at L2-L3 due to Q fever spondylodiscitis. Surgical drainage of the abscess was performed and medical treatment is ongoing. Q fever is endemic in Portugal and transmitted by inhalation of aerosols containing spores from infected animals (cattle, goats and sheep) or by ingesting cottage cheese or unpasteurized milk. It has an incubation period of 2-3 weeks and 60% of patients are asymptomatic with only 2% needing hospitalization. Primary infection can manifest in any organ and most cases are self-limiting (self-limited febrile illness, atypical pneumonia or acute hepatitis). Less than 1% of cases evolve to chronic disease, presenting as osteomyelitis or endocarditis. Chronic disease poses a diagnostic challenge and spondylodiscitis has an insidious evolution. Diagnosis requires microbiological and clinical confirmation. Serological and polymerase chain reaction tests are used for diagnosis. Acute disease is usually treated with doxycycline for 3 weeks to avoid evolution to chronic disease. Chronic disease requires 18-24 months of doxycycline with hydroxychloroquine. Acute disease can recur so follow-up is essential as chronic Q fever can result in morbidity and mortality. In Portugal Q fever is a notifiable disease due to the epidemiological risk. LEARNING POINTS: Coxiella burnetii spondylodiscitis is rare so clinicians should be aware of it.The diagnosis of Q fever is challenging, especially chronic disease that presents with endocarditis, osteomyelitis or spondylodiscitis.Spondylodiscitis treatment is particularly challenging and may need neurosurgical intervention.

Reversible Neurological Adverse Reaction to Apixaban.

Prescriptions for the novel oral anticoagulant factor Xa inhibitors (rivaroxaban, apixaban, edoxaban) have equalled or exceeded those for vitamin K antagonists in many clinical settings requiring chronic anticoagulation, and those of injectable heparins for deep vein thrombosis prophylaxis. The authors report the case of an 80-year-old woman followed by her cardiologist for permanent atrial fibrillation who was prescribed apixaban. Within a few days the patient developed neurological symptoms of imbalance and non-vertiginous dizziness, headache, confusion/disorientation and asthenia. Her symptoms began to resolve after the drug was stopped, with return to baseline function within 72 h. The plasma concentration of apixaban was 4 times higher than the laboratory upper limit of normal. Symptoms did not recur when the patient was switched to rivaroxaban therapy. LEARNING POINTS: Prescribing of the novel oral anticoagulant factor Xa inhibitors is increasing.Reversible neurological effects may occur in some patients, for instance in those with advanced age or chronic renal failure.

Giant Cystic Mediastinal Lymphangioma.

Cystic lymphangioma mainly occurs in children and develops from the lymphatic vessels. The present study reports the case of a 36-year-old female patient with a giant cystic mediastinal lymphangioma. She was asymptomatic and the diagnosis was accidental. Imaging studies are important for referral to the Cardio-Thoracic Surgery Department for surgical intervention in order to remove the lesion. It is important that in the case of an enlargement of the mediastinum observed in a thoracic X-ray, the possible diagnosis takes into consideration various hypotheses. Early diagnosis may prevent further growth and infiltration of structures that hinder the surgical approach. LEARNING POINTS: Cystic lymphangioma corresponds to approximately 0.7 to 4% of all mediastinal tumours.They are usually asymptomatic and, in adults, the diagnosis is accidental.After an imaging study with computed tomography and nuclear magnetic resonance, patients are usually candidates for surgical excision.

[Fulminant Emphysematous Pyelonephritis Secondary to Urothelial Neoplasia with Reno-Colic Fistula]. / Pielonefrite Enfisematosa Fulminante Secundária a Neoplasia Urotelial com Fístula Renocólica.

The emphysematous pyelonephritis is a uncommon and potentially fatal entity. The recognition of this condition enables the early correct management of patients. Diabetes and ureteral obstruction are the main risk factors identified. We present the case of a patient with no relevant risk factors or prior medical history, in which the reason of admission to the emergency department was back pain, eventually evolving into septic shock in the early hours. The imaging tests identified the presence of peri-renal and subcutaneous gas which guided the medical team to the right diagnosis (emphysematous pyelonephritis secondary to fistulized urothelial neoplasia) and the optimal surgical treatment. However, in the post-operative period the patient died, as the clinical condition and laboratory test results performed during the admission were predicting. It should also be mentioned that this same case illustrated a bacteraemia by Sphingomonas Paucimobilis (acquired in the community) with cavitated damage to lungs (probable septic embolism).

A pielonefrite enfisematosa é uma entidade pouco frequente e potencialmente fatal. O reconhecimento desta patologia permite a correta orientação precoce dos doentes. A diabetes e a obstrução ureteral são os principais fatores de risco identificados. Apresenta-se o caso de uma doente saudável, sem fatores de risco conhecidos, em que o motivo de ida ao serviço de urgência foi apenas uma dor lombar, acabando por evoluir com quadro de choque séptico nas primeiras horas. Os exames imagiológicos permitiram identificar a presença de gás perirrenal e subcutâneo o que orientou o correto diagnóstico (pielonefrite enfisematosa secundária a neoplasia urotelial fistulizada) e tratamento cirúrgico. Contudo, e como o estado clínico e analítico à admissão e no pós-operatório faziam prever a doente acabou por falecer. De referir ainda que este mesmo caso documenta uma bacteriemia por Sphingomonas paucimobilis (adquirida na comunidade) com lesões cavitadas a nível pulmonar (provável embolismo séptico).