Missing the early signs of thiamine deficiency. A case associated with a liquid-only diet.

BACKGROUND: Wernicke encephalopathy (WE) predominantly occurs in alcoholic patients. Few case reports have described this diagnosis as a result of dieting. The diagnosis is often missed or delayed resulting in permanent and severe neurologic sequelae and even death. The typical neurological signs may be absent or missed during the early stages of thiamine deficiency. CASE REPORT: A 23-year-old female presented to the hospital with confusion, bilateral lateral rectus palsy, and ataxia. Based on the typical neurological triad, WE was suspected. The brain MRI was also typical for WE. Prompt clinical improvement was seen within days after intravenous thiamine supplementation. A detailed medical history revealed that during the past 3 months she had been following a liquid-only diet and had lost about 30 kg. During that time, she had visited the emergency department on multiple occasions due to fatigue, nausea, and vomiting. CONCLUSION: A high level of suspicion is required by physicians to recognize that fatigue, nausea, and vomiting may represent early signs of thiamine deficiency in patients at risk for nutritional deficiencies. Empirical thiamine supplementation may be reasonable in such cases.

Lower lobe pneumonia presenting as singultus (hiccups).

BACKGROUND: Persistent hiccups can be a debilitating symptom and many such patients present to the emergency department seeking relief. A variety of serious conditions have been associated with persistent hiccups. Cases of pneumonia as a cause of hiccups have been rarely described. CASE PRESENTATION: A 79-year-old male patient presented to the hospital due to persistent hiccups for 4 days. Despite lack of new respiratory symptoms or fever, a chest x-ray demonstrated a left lower lobe consolidation, which was also confirmed with a chest CT. The patient was treated with levofloxacin and at 1-month follow-up hiccups had completely resolved, while a repeat chest CT demonstrated resolution of the consolidation. CONCLUSIONS: The presentation of pneumonia in elderly patients may be atypical and may lack the symptoms and signs observed in younger patients. Hiccups may be the main presenting symptom of pneumonia.

Atypical Presentation of IgA Nephropathy Mimicking Acute Pyelonephritis.

BACKGROUND: IgA glomerulonephritis may present with hematuria, flank pain, and fever. This clinical presentation may be easily confused with acute pyelonephritis. CASE REPORT: We present the case of a 25-year-old female with a typical clinical presentation for acute pyelonephritis (high fever, left flank pain, left costovertebral angle tenderness, hematuria, elevated inflammatory markers, and a hypoenhancing region in the left kidney on contrast-enhanced computed tomography). However, urine and blood cultures were both negative, the serum creatinine was elevated, and the urinalysis revealed significant proteinuria and dysmorphic red blood cells. A kidney biopsy confirmed a diagnosis of IgA nephropathy. She was treated with a combination of lisinopril and methylprednisolone, with good response. CONCLUSION: Gross hematuria, especially in the absence of pyuria or bacteriuria, should raise the suspicion for underlying IgA nephropathy, even if the rest of the clinical presentation is typical for a urinary tract infection. The presence of significant proteinuria, red blood cell casts, and dysmorphic red blood cells are useful clues suggesting glomerular disease.

A rare case of acute transverse myelitis associated with Staphylococcusaureus bacteremia and osteomyelitis.

INTRODUCTION: Direct intramedullary infections are considered very rare. Only few reports of Staphylococcus aureus myelitis have been published. CASE PRESENTATION: Our patient, a 79-year-old male, presented with a 2-day history of high-grade fever and high inflammatory markers and progressively developed tetraplegia during hospitalization. Lumbar puncture revealed cerebrospinal fluid pleocytosis and a spinal cord MRI revealed transverse myelitis at the level of C3-C5 and possible osteomyelitis of C5-T1. Two blood cultures were positive for methicillin-sensitive S. aureus. Despite control of the infection, there was no neurologic improvement. DISCUSSION: The morbidity of infectious myelitis can be severe. Considering the rarity of S. aureus myelitis, experience gained from case reports is important. A brief review of the available literature is provided.