Non-bacterial thrombotic endocarditis and metastatic lung adenocarcinoma.

A 69-year-old Chinese man presented with exertional dyspnoea and subjective left upper limb weakness. Initial clinical impressions were community-acquired pneumonia and cerebrovascular accident. Further imaging studies revealed an incidental mitral valve vegetation and left lung upper lobe nodule likely a lung malignancy with possible lymphangitis carcinomatosis. Appropriate empirical antibiotic treatment for infective endocarditis was instituted early in admission, but multiple blood cultures were negative. The patient progressively developed worsening neurological dysfunction and subconjunctival haemorrhage from recurrent embolic complications despite empirical antimicrobial treatment. Histology finally revealed lung adenocarcinoma after delay in obtaining biopsy due to high procedural risk from recurrent stroke. Unfortunately, before the patient could undergo any systemic oncology treatment, he deteriorated with type I respiratory failure from obstructive pneumonia and eventually demised. Important lessons include the need to consider non-bacterial thrombotic endocarditis as a differential in the appropriate clinical context followed by anticoagulation with systemic treatment as early as possible.

Elevated Right Hemidiaphragm: A Clue in Acute Cholecystitis?

Two patients presented to the Emergency Department with sepsis and vague localising complaints. Both of them had a new elevation of the right hemidiaphragm on chest radiography and were eventually diagnosed with complicated acute cholecystitis on CT imaging. In both cases, the hemidiaphragmatic elevation could not be explained by mass effect as there was no sizable intra-abdominal collection. One of the patients was initially misdiagnosed with pneumonia, resulting in clinical deterioration due to delay in definitive management. Awareness of this phenomenon is essential to avoid pitfalls in patients with acute cholecystitis, especially for those who do not present in a typical manner.

Chronic thrombotic microangiopathy secondary to antiphospholipid syndrome, presenting with severe hypertension and chronic renal impairment.

A 42-year-old woman was referred from a primary care centre for severe hypertension, stage 3A chronic kidney disease and proteinuria. This was associated with a significant obstetric history of pre-eclampsia during her previous two pregnancies. Secondary hypertension was suspected and autoimmune workup was positive for anticardiolipin IgG and lupus anticoagulant. A renal biopsy showed evidence of chronic thrombotic microangiopathy, with electron microscopy features suggestive of fibrillar glomerulonephritis. The diagnosis of antiphospholipid syndrome with antiphospholipid-associated nephropathy was made. She was started on anticoagulation with warfarin, and her hypertension was controlled with lisinopril and amlodipine with subsequent improvement in proteinuria. She remains on regular follow-up to monitor for possible development of malignancy or connective tissue disease.