Gastric Cancer With Multiple Bone Metastases: An Uncommon Primary Presentation.

Gastric cancer (GC) is a worldwide health condition of major concern, with gastric carcinoma with signet ring cell features being increasingly reported. A 61-year-old woman was admitted to the Emergency department with back pain, gastrointestinal complaints, and weight loss. A lumbar and hip computed tomography (CT) was performed and revealed multiple suspicious secondary bone lesions. Laboratory test results reported anemia, thrombocytopenia, and elevated alkaline phosphatase. On thoracic-abdominal-pelvic CT, multiple bone lesions suggestive of metastases were visible on the vertebral spine, ribs, pelvic bones, and proximal femurs, but no identifiable primary or visceral lesions were described. Upper endoscopy identified a gastric adenocarcinoma, and both gastric and bone lesions, especially bone lesions, contained a relevant amount of signet ring cells. The patient was referred to the Medical Oncology department, however, her condition evolved unfavorably. GC with restricted bone metastasis is rare at presentation and has a poor prognosis. Despite its infrequency, clinicians should consider GC involvement when evaluating secondary suspicious bone lesions.

A Patient With (Initially) Non-Persistent Vertigo - A Posterior Circulation Stroke Case.

Posterior circulation strokes are responsible for about 20-25% of all ischemic strokes. Recognition and diagnosis of posterior circulation strokes or transient ischemic attacks is more difficult than that of other stroke types, being frequently misdiagnosed in acute setting/emergency evaluation - up to more than three times as often as anterior circulation strokes. In accordance with the guidelines in effect at the time of this case presentation, thrombolysis and medical therapy are the mainstay treatment. Mechanical thrombectomy is emerging as a treatment option in posterior vessel occlusion but randomized clinical trials are still lacking.

Paraganglioma: An Unexpected Diagnosis in a Patient With Cerebral Venous Sinus Thrombosis and SARS-CoV-2 Infection.

Cerebral venous sinus thrombosis (CVST) is the complete or partial occlusion of the main venous sinuses or cortical veins. The most known risk factors are oral contraceptives, pregnancy, thrombophilias, malignancy and infections. The SARS-CoV-2 infection has been associated with a hypercoagulable state and there are some reported cases of CVST in SARS-CoV-2 patients. Although infection is one of the possible causes of CVST, it is important to rule out malignancy. We report a case of a 27-year-old male, with a recent SARS-CoV-2 infection, who went to the emergency department for a severe left occipital headache and was diagnosis with CVST. An etiological study revealed a retroperitoneal mass, compatible with a paraganglioma.

Pneumorrhachis Secondary to an Infected Sacral Decubitus Ulcer.

Pneumorrhachis (PR) is a rare phenomenon, which consists in the presence of air in the spinal canal. There are various aetiologies, being the most common traumatic, non-traumatic and iatrogenic. The diagnosis is primarily done through radiographic findings and it is necessary to understand the mechanism behind its origin. PR secondary to decubitus ulcer (DU) infection is rare. PR is associated with great morbidity and mortality. In selected cases, surgical intervention may be necessary. A 67-year-old woman, dependent, was admitted to the emergency room (ER) and diagnosed with an infected sacral DU, later discharged with antibiotics. She was readmitted to the ER two weeks later, with prostration and fever. On examination, she scored five points on the Glasgow coma scale, had bilateral Babinsky sign and a deep sacral ulcer with bone exposure. A cranial computerized tomography (CT) demonstrated "high cervical and endochannel emphysema in the upper slope of the cervical segment" and the CT scan of the spine showed "endochannel air along the cervical-dorsal and lumbar rachis in an epidural location and inside the dural sac (evoking laceration of the dura mater) (…) and densification of the sacrococcygeal soft tissues (diagnosis of PR secondary to DU infection)". Broad-spectrum antibiotics were started and the patient was evaluated by General Surgery, which described a large sacral ulcer with signs of the previous debridement and bone exposure, with no indication for surgical debridement, only for chemical debridement. Despite all the measures instituted, the patient died in the ER.

Symmetrical Drug-related Intertriginous and Flexural Exanthema (Baboon Syndrome).

Baboon syndrome, also called symmetrical drug-related intertriginous and flexural exanthema (SDRIFE), is an erythematous maculopapular rash that presents in skin folds in a symmetrical pattern. This condition may develop after the patient starts a particular agent. Treatment consists of stopping the associated trigger and medicating with topical or systemic corticosteroids. A 30-year-old man with odynophagia, otalgia and fever was prescribed amoxicillin. He developed erythematous and pruriginous lesions in the cubital fossa and inguinal regions. He attended the emergency department (ED) where he was prescribed penicillin. Lesions continued to progressively worsen with a bilateral symmetrical pattern in the axillary region and later in the nape folds, popliteal regions, and on the perineum and buttocks. The patient presented to the ED for a second time, where he was diagnosed with baboon syndrome and prescribed topical steroids with clear improvement. LEARNING POINTS: It is important to identify adverse drug effects.Baboon syndrome is rare and secondary to the use of particular drugs.The diagnosis is based mainly on the patient's clinical presentation.

Hyponatremia: A Tip of the Iceberg in the Late Diagnosis of Tuberous Sclerosis Associated With Lymphangioleiomyomatosis.

Tuberous sclerosis (TS) is a rare, autosomal dominant, multisystem genetic disease that causes multiple benign tumors in the brain and other vital organs. Rarely, it can be associated with lymphangioleiomyomatosis (LMA) that is characterized by the proliferation of immature smooth muscle cells in the walls of the airways, venules, and lymphatic vessels in the lung. Here, we present the case of a 44-year-old intellectually disabled woman with a history of marked polydipsia who presented to the emergency department with persistent vomiting. She was hemodynamically stable and did not have any fever. The analytical study showed severe and symptomatic hyponatremia. On physical examination, multiple skin lesions compatible with angiofibromas were noted and the diagnosis of TS was made (confirmed with the genetic study). The multiorgan study documented the presence of multiple cystic images in the lung parenchyma associated with LMA. The aim of this case report is to highlight the importance of targeting cutaneous lesions for a rapid diagnosis of this pathology and to identify the etiology of a severe (symptomatic) ionic disorder and referral to a multidisciplinary team.

A Rare Cause of Dyspnoea: Right-sided Bochdalek Hernia in an Adult.

Right-sided Bochdalek hernia (BH) is very rarely diagnosed in adults. It commonly presents with gastrointestinal symptoms (pain, abdominal distension and vomiting). Breathlessness, recurrent chest infections and other pulmonary sequelae can also be present. We report the case of a 92-year-old man with a 3-day history of dyspnoea, fever and thoracic pain and multiple episodes of vomiting. An x-ray was performed, and the diagnosis of a large BH hernia was confirmed by computed tomography of the thorax. The condition may be fatal in cases where the small bowel undergoes necrosis or perforation. An emergent laparotomy was performed, but the patient did not improve clinically and died immediately after the procedure. LEARNING POINTS: Right-sided Bochdalek hernia (BH) is very rarely diagnosed in adults.Misdiagnosis of BH as a tension pneumothorax (which has a similar clinical presentation) can delay treatment and put patients at risk.The outcome of BH depends on the presentation, early diagnosis and emergent intervention.