An unusual case of osteoarthritis?

Forestier disease is a condition characterized by calcification and ossification of ligaments and entheses particularly affecting axial skeleton. Diagnosis is difficult and mandates a high suspicion level, but unexpensive and accessible examinations like a simple radiography might provide useful diagnostic clues in these challenging clinical scenarios and improve clinical assistance.

Is it just an obstructive pyelonephritis?

Pyelocaliceal obstruction is a diagnostic challenge, and it is important to identify the obstruction cause. Some patients present extra-renal compressive masses that need further imagiologic investigation and a biopsy, to establish the diagnosis.

Heart failure as a first sign of disseminated tuberculosis.

Tuberculous pericarditis is a rare extra-pulmonary manifestation of tuberculosis observed mainly in developed countries. It usually presents with concomitant tuberculous infection at a different site and, due to the lack of clinical specificity, diagnosis can be difficult. Thus, a diagnostic delay is frequent, entailing increased morbidity and mortality. The authors present a case of disseminated tuberculosis with predominantly cardiac symptoms with multiple negative samples for Mycobacterium tuberculosis, which evolved to constrictive pericarditis. With this case report, the authors emphasize the demand for a high index of suspicion for achieving a diagnosis and the importance of a multidisciplinary approach.

A case report of idiopathic Hemophagocytic lymphohistiocytosis in an immunocompetent adult.

Hemophagocytic lymphohistiocytosis poses a diagnostic dilemma due to the absence of specific clinical and laboratory findings, especially in adults. Despite greater recognition of the disease, secondary idiopathic forms are still reported.

Is it just a simple pneumonia?

Postobstructive pneumonia is a pulmonary infiltrate distal to a bronchial obstruction. It presents a diagnostic challenge, and full attention should be on recognition of this entity, identify, and treating the obstructive lesion and secondary infection. In adults, malignancy is the main cause; however, others etiologies must be investigated.

Not Always (and Only) Heart Failure-A Case Report of Primary Pleural Lymphoma in an Elderly Patient.

Pleural involvement in Non-Hodgkin Lymphoma (NHL) is well documented, but primary pleural lymphomas are extremely rare, occurring mostly in immunosuppressed patients or associated with chronic pleural inflammation. Nevertheless, the pathogenesis and therapeutic approaches to counteract primary pleural lymphomas are still matter of debate. The authors present the clinical case of an 81-year-old female with respiratory and constitutional symptoms. A valvular heart disease and bilateral pleural effusion were known. The study carried out showed a large right pleural effusion; the fluid analysis was compatible with Diffuse Large B-cell Lymphoma (DLBCL), and two lymphomatous masses with pleural origin were found at the ipsilateral hemithorax. Primary pleural lymphoma was considered and chemotherapy was initiated with a good response and evolution. The authors report this remarkable clinical case because of its rarity, its excellent clinical evolution and the absence of an immunodeficiency context.

The Use of Thalidomide in Severe Refractory Anaemia Due to Gastric Antral Vascular Ectasia (GAVE) in Cirrhosis?

Gastric antral vascular ectasia (GAVE) is a rare cause of upper gastrointestinal bleeding associated with cirrhosis. The first-line treatment is endoscopic therapy with argon plasma coagulation (APC). There is a high recurrence rate, but some evidence suggests that thalidomide could play an important role in controlling refractory anaemia due to GAVE. The authors present the case of a cirrhotic patient with a recent diagnosis of GAVE, who underwent multiple endoscopic treatments and blood transfusions because of haematemesis. The patient started thalidomide and 6 months later, there was no recurrence of haematemesis and haemoglobin levels were stable, with no reported adverse effects. LEARNING POINTS: The chronic bleeding associated with gastric antral vascular ectasia (GAVE) presenting with cirrhosis is more severe than that associated with portal hypertensive gastropathy.Argon plasma coagulation remains the first-line treatment, but GAVE has a high recurrence rate.Thalidomide could be an effective and safe option for recurrent bleeding due to GAVE in patients with cirrhosis.

An Unexpected Favourable Evolution of Advanced Stage Cirrhosis.

The elimination of the aetiological factors causing liver injury is an important cornerstone in preventing progression and increasing survival in patients with cirrhosis. The authors present the case of a 63-year-old woman with a history of long-term alcohol abuse and consequent liver cirrhosis. Over the years, the patient presented progressive deterioration with severe malnutrition and had multiple hospital admissions due to decompensated cirrhosis, including refractory ascites, variceal bleeding and an extensive portal vein thrombosis (PVT). Anticoagulant therapy was not initiated due to a high risk of variceal bleeding. She eventually became abstinent, but PVT precluded a liver transplant. Over the following 10 years, her performance status gradually improved, with no new decompensation episodes and liver function normalization, although refractory ascites persisted. Abdominal CT showed spontaneous recanalization of the portal vein and a transjugular intrahepatic portosystemic shunt (TIPS) procedure was performed with gradual improvement of ascites. In this atypical case, an unexpected favourable evolution of advanced stage cirrhosis was observed with long-term improvement in clinical status and liver function, resulting in an estimated 10-year cumulative mortality rate of 99.98% and highlighting the importance of abstinence. Unexpectedly, spontaneous complete repermeabilization of the PVT was also observed, despite its extent and the absence of anticoagulation therapy. LEARNING POINTS: The elimination of the aetiological factors causing liver injury is the cornerstone in preventing decompensation and improving prognosis in patients with cirrhosis.Spontaneous complete recanalization of the portal vein may occur.A transjugular intrahepatic portosystemic shunt (TIPS) is effective in managing some of the major complications of portal hypertension, such as refractory ascites, and provides secondary prophylaxis of oesophageal variceal haemorrhage.