Hemorrhagic Transformation in Patients With Ischemic Stroke and Atrial Fibrillation: To Anticoagulate or Not, That Is the Question.

The management of anticoagulation in patients with ischemic stroke and atrial fibrillation (AF) poses a critical dilemma due to the inherent risk of hemorrhagic transformation. This article presents the case of an 89-year-old male with AF and recurrent ischemic strokes, highlighting the complex challenge of deciding whether to initiate or withhold anticoagulation. After the initial ischemic stroke event, the patient started a direct oral anticoagulant. Subsequent imaging revealed hemorrhagic transformation, leading to the cessation of anticoagulation. Despite multiple hemorrhagic recurrences, balancing thrombotic and bleeding risks remained challenging. Mechanical thrombectomy was performed for a subsequent ischemic stroke due to an absolute contraindication for thrombolysis. The patient's intricate clinical course involved a multidisciplinary approach, resulting in a decision to cautiously resume low-dose anticoagulation combined with left atrial appendage closure. This decision was made after careful consideration of persistent thrombotic risk despite recurrent hemorrhages. The case underscores the complex management dilemma of anticoagulation in elderly patients with AF and recurrent strokes, emphasizing the need for a multidisciplinary approach and individualized decision-making in such challenging scenarios. Further research and guidelines are warranted to establish optimal strategies for (re)initiating anticoagulation in patients with recurrent hemorrhagic transformation.

Intrathoracic Kidney.

Intrathoracic kidney is a very rare finding, representing less than 5% of all renal ectopias. Because of the location of the liver, thoracic kidney on the right side is much less common than thoracic kidney on the left side. Although an increasing number of case reports are being published in the literature, few describe the impact of the ectopia on kidney function. We report the case of a woman with intrathoracic right kidney and chronic kidney disease that was initially misdiagnosed as pneumonia because of its presentation on chest x-ray. We highlight the need to including this condition in the differential diagnosis[2] as the literature rarely links it to changes in kidney function. LEARNING POINTS: Intrathoracic kidney is an extremely rare condition that should be considered in the differential diagnosis of intrathoracic masses.There is a lack of literature on this type of kidney ectopia and its consequences in asymptomatic individuals.

Dance of the Sugar: Two Case Reports of Chorea Associated With Nonketotic Hyperglycemia.

Hyperglycemia-induced chorea/ballism is a rare clinical entity that often occurs in the setting of nonketotic hyperglycemia due to poor glycemic control in elderly patients with a diagnosis of type 2 diabetes mellitus (DM). This condition is typically characterized by hemichorea/hemiballism and unique brain imaging findings in the contralateral basal ganglia. Treatment involves the correction of blood glucose, and most cases resolve without additional therapy. Here we report two cases of this condition in which patients with type 2 DM presented with nonketotic hyperglycemia and typical neuroimaging findings. Although rare, clinicians should be aware of this condition in patients with diabetes who present with sudden abnormal movements since its prompt diagnosis and treatment often lead to a favorable outcome.

AN 84-YEAR-OLD PATIENT WITH CAROLI SYNDROME: WHAT IS THE PROGNOSIS OF THIS CONDITION?

Caroli disease is a rare congenital pathology caused by mutation of the PKHD1 gene (polycystic kidney and hepatic disease 1), also responsible for autosomal recessive polycystic kidney disease. Characterized by segmental and multifocal dilatation of the large intrahepatic bile ducts, classic disease involves only malformation of the biliary tract. The association with congenital hepatic fibrosis is called Caroli syndrome. We describe the case of an 84-year-old man with Caroli syndrome diagnosed in 1997 by liver biopsy. The CT scan revealed massive hepatomegaly, extending to the pelvic region, and almost total replacement of the parenchyma by numerous cystic formations, no evidence of bile duct dilatation, and no ascites or splenomegaly suggestive of portal hypertension. The atypical clinical presentation, with no reported complications, resembles that of a space-occupying lesion with an indolent course, previously misdiagnosed as metastatic neoplasm. LEARNING POINTS: We describe a case of advanced and rare Caroli syndrome with an atypical clinical presentation of a space-occupying lesion with slow progression.The atypical presentation could be misdiagnosed as metastatic neoplasm.

Rectal Bezoar: A Rare Cause of Intestinal Obstruction.

Bezoars are conglomerates of undigested contents that accumulate in the gastrointestinal tract. They can have different compositions, such as fibers, seeds, vegetables (phytobezoars), hair (trichobezoars), and medication (pharmacobezoars). Bezoars are typically caused by an impaired grinding mechanism of the stomach or interdigestive migrating motor complex, but the composition of ingested material can also play a role in their formation. Gastric dysmotility, previous gastric surgery, and gastroparesis are some of the risk factors that can increase the likelihood of developing bezoars. While bezoars are usually asymptomatic and found in the stomach, they can sometimes migrate to the small intestine or colon and cause complications such as intestinal obstruction or perforation. Endoscopy is essential for diagnosis and etiology, and treatment depends on the composition, which can include chemical dissolution or surgical intervention. We present a case of an 86-year-old woman, who had a bezoar located in an unusual location (rectum), most likely due to migration. This condition led to symptoms of intermittent intestinal obstruction and rectal bleeding. However, due to anal stenosis, the patient was unable to expel the bezoar. Its removal was not possible through various endoscopic techniques. Therefore, it was removed via fragmentation, using an anoscope and forceps, due to its hard/stone-like consistency. This case highlights the importance of considering bezoars in the differential diagnosis of gastrointestinal bleeding and illustrates the importance of prompt diagnosis and appropriate techniques for the removal of bezoars.

Tumor Lysis Syndrome Rare Presentation As Uremic Pericarditis: A Case Report.

Tumor lysis syndrome (TLS) is an oncological emergency characterized by the massive destruction of malignant cells and the release of their contents into the extracellular space, which might occur spontaneously or post-chemotherapy. According to the Cairo&Bishop Classification, it can be defined by both laboratory criteria: hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia (two or more); and clinical criteria: acute kidney injury (AKI), convulsions, arrhythmias, or death. We report the case of a 63-year-old man with a previous medical history of colorectal carcinoma and associated multiorgan metastasis. The patient was initially admitted to the Coronary Intensive Care Unit, five days after the chemotherapy session, on suspicion of Acute Myocardial Infarction. Upon admission, he presented without significant elevation of myocardial injury markers, but with laboratory abnormalities (hyperkalemia, hyperphosphatemia, hyperuricemia, and hypocalcemia) and clinical symptoms (sudden sharp chest pain with pleuritic characteristics and electrocardiographic anomalies suggesting uremic pericarditis, and acute kidney injury), all consistent with TLS. The best approach to established TLS is aggressive fluid therapy and a decrease in uric acid levels. Rasburicase proved to be notoriously more effective, both in terms of prevention and treatment of established TLS, thus consisting of the first-line drug. However, in the present case, rasburicase was not available at the hospital level, so a decision was made to initiate treatment with allopurinol. The case evolved with slow but good clinical evolution. Its uniqueness resides in its initial presentation as uremic pericarditis, scarcely described in the literature. The constellation of metabolic alterations from this syndrome translates into a spectrum of clinical manifestations that can go unnoticed and ultimately may prove to be fatal. Its recognition and prevention are crucial for improving patient outcomes.

A Rare Geriatric Diagnosis of Eosinophilic Granulomatosis With Polyangiitis: A Case Report.

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare form of systemic disease characterized by inflammation and necrotizing effects of the small and medium blood vessels. It is a vasculitis found in all age groups and both genders, although its etiology is unknown. The mean age at diagnosis is 40 years, consisting of an uncommon cause of vasculitis in people older than 65 years. It is the least common of the three antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (EGPA, granulomatosis with polyangiitis (GPA), and microscopic polyangiitis). The characteristic features of EGPA include extravascular eosinophilic granulomas, peripheral eosinophilia, and asthma, usually responsive to steroid treatment. In this article, we discuss a case of an 83-year-old male with a history of undetermined etiology of chronic kidney disease, chronic obstructive pulmonary disease (COPD), and severe chronic rhinosinusitis with nasal polyposis. First hospitalized with the suspicion of community-acquired pneumonia (CAP), based on worsening blood eosinophilia and unresolving respiratory symptoms, a suspicion for EGPA was raised. The development of an eosinophilic pleural effusion, later upon admission, was a predominant factor for its confirmation, as it constitutes a rare finding, only present in about 30% of patients. Laboratory tests showed elevated IgE, the presence of antineutrophil cytoplasmic antibodies directed against myeloperoxidase with a perinuclear staining pattern (ANCA-MPO), and the absence of antiproteinase 3 (anti-PR3) ANCA, which were consistent with the diagnosis. A pleural biopsy was then made, revealing fibrosis with the presence of eosinophils, although with no evidence of granulomas. According to the most recent and accepted classification criteria, the "2022 American College of Rheumatology and European Alliance of Associations for Rheumatology (ACR/EULAR) for EGPA," this patient presented with a score of 13 (a score greater than or equal to 6 is needed for the classification of EGPA). Hence, a diagnosis of EGPA was assumed, and the patient was initiated on corticosteroid therapy, with a favorable response. The aim of this article is to present a rare case of EGPA diagnosis made at the age of 83 years old, although there was evidence that could point to this disease years before the diagnosis was made. In the present case, it is important to point out the long diagnostic delay in a geriatric patient, much older than the median age of diagnosis for EGPA, culminating in a curious case of uncommon pleuroparenchymal involvement.

Celiac Trunk Mycotic Aneurysm: Diagnosis and Treatment of a Post-infective Endocarditis Complication.

Pseudoaneurysms could be the dynamic evolution of an infectious break in the arterial wall; in the post-antibiotic era they are uncommon complication following infective endocarditis (IE) and are associated with high rates of morbidity and mortality especially for patients in whom a prompt diagnosis and therapeutic strategy are not performed. In this report, we describe a case of pseudoaneurysm of the celiac trunk developed as a complication of IE. Endovascular treatment is our first-line approach.

Role of percutaneous cholecystostomy in all-comers with acute cholecystitis according to current guidelines in a general surgical unit.

Acute calculous cholecystitis (ACC) is a very common complication of gallstone-related disease. Its currently recommended management changes according to severity of disease and fitness for surgery. The aim of this observational study is to assess the short- and long-term outcomes in all-comers admitted with diagnosis of ACC, treated according to 2013 Tokyo Guidelines (TG13). A retrospective analysis was conducted on a prospectively maintained database of 125 patients with diagnosis of ACC consecutively admitted between January 2017 and September 2019, subdivided in three groups according to TG13: percutaneous cholecystostomy (PC group), cholecystectomy (CH group), and conservative medical treatment (MT group). The primary end point was a composite of morbidity and/or mortality rates; the secondary end points were ACC recurrence, readmission, need for cholecystectomy rates and overall length of hospital stay (LOS). After a median follow-up of 639 days, overall morbidity rate was 20.8% and mortality rate was 6.4%. Death was directly related to AC during the index admission in two out of eight cases. There were no significant differences in primary end point according to the treatment group. Concerning secondary end points, ACC recurrence rate was not significantly different after PC (10.0%) or MT (9.1%); the readmission rates were significantly higher (p < 0.0001) in the MT group (48.5%) and in the PC group (25.0%) than in the CH group (5.8%); need for cholecystectomy rates was significantly higher (p < 0.0001) in the MT group (42.4%) than in the PC group (20.0%); median overall LOS was significantly higher in the PC (16 days) than in the MT (9 days) and than in the CH group (5 days). PC is an effective and safe rescue procedure in high-risk patients with ACC, representing a definitive treatment in 80% of cases of this specific subgroup.