Venous thoracic outlet syndrome: When exercising may be discouraged.

Thoracic outlet syndrome results from neurovascular compression at the thoracic outlet. Clinical presentation varies according to the predominantly compressed structure, determining its subtype: neurogenic, venous, or arterial. The neurogenic subtype is the most common, affecting 90% of patients, while the vascular subtype is rarely found in practice. We present two case reports of young patients with upper extremity deep vein thrombosis in the setting of venous thoracic outlet syndrome: one due to an anatomic variant, the second an effort thrombosis due to repeated upper arm exercise. These reports depict uncommon clinical scenarios, which imply significant morbidity if not identified and timely treated.

Hidden Hunger: A Pellagra Case Report.

Pellagra is a deadly nutritional disease caused by niacin deficiency. Although practically eradicated in developed countries, it still affects vulnerable populations. The diagnosis is based on the presence of characteristic dermatitis in sun-exposed areas, diarrhea, and dementia. We report the case of a woman with a clinical picture of hyperpigmentation and hyperkeratinization in exposed areas of the skin, watery diarrhea, and progressive disorientation with disorganized speech. The anamnesis revealed a poor diet regimen composed almost exclusively of cassava root meals. Alternative diagnosis was excluded and nicotinamide supplementation was introduced with progressive resolution of symptoms until complete recovery. This case report highlights the need to maintain a high index of suspicion in the presence of characteristic symptoms for timely diagnosis of this deadly condition with a simple but dramatic curative treatment.

Should the Management of Embolic Stroke in the Elderly Be Changed if They Also Have COVID-19?

INTRODUCTION: A strong association between stroke and atrial fibrillation (AF) has been demonstrated. Anticoagulation for the prevention of stroke in high-risk patients has the benefit of improving the life expectancy, quality of life, autonomy and social functioning of the patient. The COVID-19 pandemic poses challenges for stroke patients because of the association between SARS-CoV-2 infection and thromboembolic risk. CASE DESCRIPTION: We describe the case of an 84-year-old female patient admitted due to an embolic stroke and non-anticoagulated AF. Her admission symptoms were sensory-motor aphasia and severe right limb paresis with an NIHSS score of 24. The diagnosis of embolic stroke (namely, total anterior circulation infarct; TACI) was made. Her stroke was extensive so she was not started on anticoagulation. During hospitalization, new embolic events occurred and a concomitant diagnosis of COVID-19 was made with progressive respiratory dysfunction followed by multiorgan failure. The patient died despite appropriate treatment. DISCUSSION: The prognosis of elderly patients with cardioembolic stroke depends on anticoagulation administration. The NIHSS score on admission of our patient meant anticoagulation therapy was not appropriate. The diagnosis of COVID-19 contributed to the patient's death. LEARNING POINTS: Anticoagulation should be considered in stroke patients with total infarction and atrial fibrillation.There is an association between COVID-19 and thromboembolic stroke.Elderly patients with stroke and COVID-19 are at higher risk of death.

Symptomatic Pneumocephalus as a Complication of Lumbar Epidural Anaesthesia.

INTRODUCTION: Lumbar epidural anaesthesia is a commonly used technique for analgesia during labour. One of the rare complications of this technique is pneumocephalus. CASE DESCRIPTION: We report the case of a 35-year-old female admitted to the Emergency Department with severe headache associated with fast head movements. Five days previously she had a eutocic delivery and lumbar epidural anaesthesia was performed. A brain computed tomography (CT) scan showed pneumocephalus and she was admitted to the hospital ward. A brain CT scan on the fourth day of hospitalization showed resolution of ventricular pneumocephalus. DISCUSSION: The most frequently occurring symptom with pneumocephalus is headache associated with fast brain motion resulting from air injection and meningeal irritation. When there is clinical suspicion of pneumocephalus, a brain CT scan should be performed for the diagnosis. LEARNING POINTS: Pneumocephalus is the presence of air in the intracranial cavity and its development after spinal or epidural anaesthesia is extremely infrequent.Headache that occurs in the setting of lumbar epidural anaesthesia should not be labelled as post-dural puncture headache.The suspicion of pneumocephalus, based on the characteristics of the headache, should be maintained to obtain an emergent brain CT scan.

Two Dabigatran Fast Reversals in a 4-month Period - a Case Report.

INTRODUCTION: Idarucizumab is available for immediate reversal of dabigatran-induced anticoagulation in life-threatening bleeding or urgent surgery in patients with non-valvular atrial fibrillation (nvAF). CASE DESCRIPTION: We report a case of an 85-year-old female treated with dabigatran for nvAF, submitted to two fast reversal procedures with idarucizumab in a 4-month period. In the first emergency episode, the patient was admitted due to a fall-related cerebral haemorrhage and subdural haematoma. There was a fast reversal of the effects of dabigatran after idarucizumab administration, which allowed stoppage of the bleeding and a decrease in intracranial pressure, with full patient recovery. Four months later, the patient revisited the hospital complaining of diffuse abdominal pain while on the same antithrombotic therapy. Physical examination showed signs of peritoneal irritation and the use of idarucizumab to reverse the effects of dabigatran was decided upon to secure normal bleeding conditions before surgery. DISCUSSION: Idarucizumab is an efficient, safe and feasible option for dabigatran-treated nvAF patients, when urgent anticoagulant effect reversal is needed. LEARNING POINTS: Clinical situations requiring urgent reversal of the anticoagulant effects of non-vitamin K antagonist oral anticoagulants are expected to be relatively rare but the existence of antidotes enables the clinical management of these situations.Even in independent urgent circumstances occurring over a short period of time, the repeated use of idarucizumab promptly and safely reverses the dabigatran anticoagulant effect without compromising the patient's clinical outcome.The development and implementation of specific anticoagulation reversal protocols and better guidance on using baseline coagulation tests are needed to ensure timely and appropriate use of this new therapeutic option.

Acquired von Willebrand Syndrome and Chronic Anaemia: A Different Diagnostic Approach.

Heyde's syndrome is a form of acquired von Willebrand syndrome that consists of bleeding from intestinal angiodysplasia in the presence of aortic stenosis (AS). An association with obstructive hypertrophic cardiomyopathy, rather than AS, by a similar mechanism has also been described. We report the case of a 78-year-old woman with chronic anaemia and hypertrophic obstructive cardiomyopathy in whom intestinal angiodysplasia with active bleeding was identified by an unconventional method. In this case, the authors describe a different approach to reach the correct diagnosis. LEARNING POINTS: In patients with anaemia due to gastrointestinal bleeding, a high level of suspicion is crucial to identify the haemorrhagic focus.Intestinal angiodysplasia is associated with acquired von Willebrand syndrome.Acquired von Willebrand syndrome secondary to hypertrophic obstructive cardiomyopathy occurs by the same mechanism of aortic stenosis.