Metal Fume Fever: An Underdiagnosis.

Metal fume fever (MFF) is an auto-limited acute febrile respiratory syndrome that may mimic an acute viral respiratory disease after exposure to the fumes of metal oxides. Due to the similar presentation of an influenza-like illness, it remains an underdiagnosed disease. It is typically a benign and self-limited entity that resolves over 12-48 hours following cessation of exposure, but symptoms may reoccur with repeated exposure. Supportive and symptomatic care is recommended.

Immunoglobulin a (IgA) Vasculitis in the Elderly.

IgA vasculitis is a small vessel vasculitis mediated by the deposition of IgA immune complexes. It mostly occurs in children and is rare in adults, with increased severity and mortality in the latter. Its aetiology remains largely unknown, and its prognosis depends primarily on the extent of renal involvement. We present the case of a 71-year-old woman with purpuric lesions in both lower and upper limbs associated with fever, abdominal pain, vomiting and blood in her stools for the past month. The patient was diagnosed with IgA vasculitis and the full systemic involvement (renal, dermatological, intestinal, and cerebral) of the disease was identified with excellent response to parenteral corticotherapy.

Severe Pneumonia Caused by SARS-CoV-2: A Novel Cause of Platypnoea-Orthodeoxia Syndrome.

Platypnoea-orthodeoxia syndrome (POS) is a condition characterized by dyspnoea and hypoxaemia while sitting or standing, which improves during decubitus. It is usually caused by intracardiac right-to-left shunting through a patent foramen ovale but may also occur due to pulmonary ventilation-perfusion mismatch of other aetiologies. A new cause of POS was recently described: SARS-CoV-2 pneumonia. We report the case of a 62-year-old man admitted for SARS-CoV-2 pneumonia with respiratory failure. Chest computed tomography angiography showed pulmonary thromboembolism and parenchymal lung changes compatible with COVID-19. He had worsening dyspnoea in a sitting position, relieved by assuming the dorsal position. He was diagnosed with POS after other causes were excluded. POS is an underdiagnosed complication of COVID-19 and is manageable with respiratory rehabilitation. LEARNING POINTS: Platypnoea-orthodeoxia syndrome is an under-recognized condition presenting as a complication of a structural shunt.We describe SARS-CoV-2 pneumonia as a novel cause for this syndrome.It is a reversible syndrome provided there is early diagnosis and initiation of pulmonary rehabilitation.

Caffeine Intoxication: Unregulated, Over-the-Counter Sale of Potentially Deadly Supplements.

Caffeine is an integral part of beverages, food, and medications. Severe intoxication of caffeine is rare, and reports are even scarcer. However, over-the-counter, unregulated sale of performance-enhancing compounds, such as caffeine, turns high-dose consumption into a real concern. Severe intoxication may be fatal, usually by malignant cardiac arrhythmia. We report a case of a 23-year-old university student who accidentally consumed about 100 times the amount present in an expresso of anhydrous caffeine.

Neurological impact of eosinophilic granulomatosis with polyangiitis.

Nervous system (NS) affection may occur in Eosinophilic Granulomatosis with Polyangiitis (EGPA), but its clinical manifestations and pathophysiology are rarely described. Our aims are to characterize central and peripheral NS (CNS/PNS) involvement and compare biological markers in EGPA patients with and without neurological manifestations. Retrospective observational study, including EGPA patients with and without neurological manifestations. Demographics, clinical data, and immunological markers were analyzed. Descriptive and inferential statistics were performed. Sixteen patients were included; 11 (68.8%) of whom were male, with a mean age of 63.38 years; 8 with (Group 1) and 8 without (Group 2) neurological findings. Neurological impairment preceded EGPA diagnosis in 5 patients, and occurred during follow-up in 3 patients after a median of 4.0 years. CNS manifestations observed were stroke (n = 2), bilateral central retinal artery occlusion (n = 1), and compressive dorsal myelopathy due to extradural granulation tissue (n = 1). PNS manifestations were axonal polyneuropathy (n = 3), sensorineural hearing loss (n = 3), and multiplex mononeuropathy (n = 1). Two patients had both PNS and CNS involvement. There were no statistical differences regarding biological markers [eosinophil count, myeloperoxidase (MPO) antibodies titers] between the 2 groups. One patient from Group 1 was unresponsive to treatment and permanent neurological sequelae were observed in 7 cases. EGPA-related NS involvement can be heterogeneous and is responsible for long-term sequelae. In our sample, the main neurological scenarios were peripheral neuropathy, VIII cranial nerve neuropathy, ischemic lesions and compressive myelopathy. Patients with and without neurological manifestations did not differ in eosinophilic count and MPO titer.

Novel anticoagulants in an older and frail population with atrial fibrillation: the effect of inappropriate dosing on clinical outcomes.

PURPOSE: An individualized approach should be taken regarding the use of novel oral anticoagulants (NOAC) in frail and older patients with atrial fibrillation (AF). We hypothesized that there would be a high proportion of underdosed patients among an older and frail population, where bleeding risk is higher. METHODS: We retrospectively analyzed patients admitted to an Internal Medicine ward with a previous diagnosis of AF and discharged with a NOAC (n = 327). We compared survival and incidence of dosing-related events (stroke, systemic embolism, and major bleeding) at 1-year between inappropriately underdosed patients (dose reduction without a formal indication) and the rest of the population. RESULTS: A total of 167 patients (51%) received a reduced dose despite lacking formal criteria for dose reduction. Before adjustment, underdosed patients, in comparison with non-underdosed patients, had a higher mortality at 1 year (HR = 1.6, 95% CI 1.2-2.1, p = 0.003) and a higher combined stroke, systemic embolism, and major bleeding event rate at 1-year (HR = 3.2, 95% CI 1.3-8.0, p = 0.015). After adjustment, combined stroke, systemic embolism, and major bleeding event rate was higher in underdosed patients (HR 3.7, 95% CI 1.1-12.3, p = 0.030), but survival was not different in the adjusted model (HR 1.4, 95% CI 0.9-2.1, p = 0.110). CONCLUSIONS: Underdosed patients have a significant survival disadvantage and this may be due to clinician prescription bias, since this difference does not remain after adjusting for confounders. Combined stroke, systemic embolism, and major bleeding event rate was higher in underdosed patients.