Herpetic Esophagitis: A Cause of Dysphagia in a Malnourished Patient.

Herpetic esophagitis (HE) is an esophageal infection caused by herpes simplex virus (HSV). Although less common, it can occasionally affect immunocompetent hosts. It can manifest as odynophagia and/or dysphagia and should lead to an investigation by upper digestive endoscopy with a biopsy. The authors report a case of a 65-year-old man with a past medical history relevant for schizophrenia, oligophrenia, and malnutrition, and no other history or evidence of immunosuppression, who presented with severe dysphagia over weeks and recent episodes of food aspiration with consequent pneumonia. An upper gastrointestinal endoscopy was performed, revealing severe stenosis at the level of the gastroesophageal junction with scar tissue, not transposable with the endoscope. The biopsy led to the diagnosis of hepatic esophagitis. Despite the immunocompetent status (excepting only the risk factor malnutrition) and treatment with acyclovir, with initial clinical improvement, the patient died a few weeks after diagnosis after multiple respiratory complications such as nosocomial infection. This case highlights that herpetic esophagitis is sometimes observed in immunocompetent hosts. HE has a self-limited course, with severe complications more frequent in immunosuppressed patients. However, it is also important to suspect this condition in immunocompetent patients and look for risk factors, given the potential morbidity this disease entails. In this group of patients, the presence of predisposing factors and associated comorbidities, such as malnutrition, alcohol consumption, or use of corticosteroids, have been associated with the development of viral esophagitis (including HE). HE remains a clinical challenge, especially in patients with risk factors for immunosuppression, such as malnutrition, as in the reported case.

Malignant Peritoneal Mesothelioma: A Case Report.

Malignant peritoneal mesothelioma (MPM) is a rare tumor of the serous membranes of the peritoneum and has been linked to exposure to asbestos and other risk factors. The clinical manifestations are vague, with a wide clinical spectrum, predominantly related to the abdominal involvement of the disease. Localized mesothelioma is an uncommon manifestation of the disease. Common symptoms include abdominal pain or abdominal distention, nausea, anorexia, and weight loss. Rarely, patients present with paraneoplastic syndrome. Due to the nonspecific symptoms, many patients already have advanced disease at the time of diagnosis. The authors report a case of a 75-year-old female patient who presented with symptoms of asthenia, anorexia, progressive paleness, and weight loss lasting five months. She reports later new-onset symptoms of diffuse abdominal pain and diarrhea associated with nausea. Laboratory tests showed anemia, mild leukocytosis, thrombocytosis, elevated C-reactive protein (CRP), and elevated liver enzymes. An abdominal and pelvic computed tomography (CT) scan revealed marked tissue thickening of an irregular and striated configuration of the leaflets and peritoneal reflections in an omental cake pattern, and a chest CT scan showed multiple bilateral pulmonary nodules, suggesting diffuse malignant disease. A CT-guided biopsy of a peritoneal implant was performed, establishing the diagnosis of malignant peritoneal mesothelioma. Due to rapid clinical deterioration, the patient did not receive any systemic treatment, surgery, or radiotherapy and was transitioned to comfort care. As in the presented case, most cases of MPM have diffuse peritoneal involvement at the time of diagnosis, although extra-abdominal involvement is very rare. This disease presentation is associated with high morbidity and mortality compared to cases of localized disease. There is no specific imaging diagnostic modality or valuable tumor markers for MPM. Although a CT scan remains important in the diagnostic approach, the changes found are not specific. Radiographically, MPM may present as mesenteric or parietal peritoneal nodules, visceral peritoneal thickening, ascites, or omental masses. Although these features may raise suspicion of MPM, a biopsy is necessary to confirm the diagnosis. Therefore, due to the rarity of this disease and its nonspecific signs or symptoms, MPM is difficult to diagnose, and the prognosis remains poor.

A First Sign Not to be Missed: Cutaneous Metastasis from Breast Cancer.

Cutaneous metastasis has a frequency of 1 to 10% among all metastatic cancer forms and breast cancer accounts for 30% of all cases. We report the case of a 73-year-old woman who presented with 4 skin lesions distributed across the upper trunk and abdomen; these had developed over a period of 12 months. Over the previous 6 months she had also developed anorexia, asthenia and weight loss. Upon investigation, a nodular mass was found in the left breast. Skin and breast mass biopsy were performed. Histology confirmed the diagnosis: infiltrating lobular breast cancer with cutaneous metastasis. The patient underwent hormonal treatment, mastectomy and radiotherapy. In rare cases, cutaneous metastasis appears as the first clinical manifestation of breast cancer. It is therefore crucial for patients and health professionals alike to be aware of new skin lesions. Cutaneous metastasis is a diagnostic sign of cancer that, it must be emphasised, is not restricted exclusively to later forms of the disease. LEARNING POINTS: Although breast cancer has the highest cutaneous metastasis rate among internal malignancies, cutaneous metastases actually occur in only a small minority of breast cancer patients. In rare cases, skin metastasis may appear as the first clinical manifestation of breast cancer.The clinical presentation of cutaneous metastasis from breast cancer can be varied, and therefore warrants greater awareness in clinical practice.Cutaneous metastasis from breast cancer typically carries a less unfavourable prognosis than cutaneous metastasis from other internal malignancies.

Psychiatric Symptoms and Benzodiazepine Use Mask a Patent Foramen Ovale-Related Stroke: A Cautionary Tale.

Neurological and psychiatric diseases often present with overlapping features. Patients are sometimes seen by internal medicine, neurology and psychiatry clinicians and time can be important for determining whether a condition is organic or not. The authors present the case of a 31-year-old woman admitted to the emergency department with altered mental status and incomprehensible speech. She had a previous history of anxiety and smoking and was under therapy with benzodiazepines and combined hormonal contraceptives. After an acute neurological disorder was ruled out, the patient was transferred to the psychiatry department, where she was re-evaluated after 12 hours of observation and benzodiazepine washout. As speech impairment and confusion were still present, she was transferred to the Stroke Unit. A bilateral thalamic lesion containing a small focal haemorrhage and a moderate grade right-to-left shunt were identified. A patent foramen ovale was confirmed leading to the final diagnosis of acute ischaemic infarction secondary to a paradoxical embolism. Medical therapy was preferred over percutaneous closure. Risk factors were removed (smoking and hormonal contraceptives), and after the patient recovered completely acetylsalicylic acid 100 mg daily was initiated. LEARNING POINTS: Psychiatric symptoms and medication often mask organic conditions, so observation and re-evaluation are key.There are new guidelines for the treatment of patent foramen ovale-related strokes, but not all patients fit the guidelines.A relationship between stroke in the young adult, smoking and hormonal contraceptives should always be considered.

The Perfect Storm: A Case of Non-Uremic Calciphylaxis.

Calciphylaxis is a severe condition associated with chronic kidney disease. We describe a rare case of non-uremic calciphylaxis in a 79-year-old woman with prosthetic aortic and mitral valves, chronic kidney disease and anaemia, who presented with painful skin lesions on her left leg. She was taking warfarin, calcium and iron supplements, and had been recently diagnosed with oligoarthritis and started on prednisolone, all factors associated with calciphylaxis. Despite treatment, the lesions rapidly progressed to large ulceration and sepsis, and pain management was challenging. Calciphylaxis was confirmed following a second skin biopsy but the patient died from septic shock and multi-organ failure. This case highlights the challenges associated with the diagnosis and treatment of calciphylaxis despite a high level of suspicion. LEARNING POINTS: The number of reported cases of calciphylaxis, once considered very rare, is increasing.Physicians should be aware of new information concerning the condition.Treatment includes a low antibiotic threshold, comprehensive pain management and efficient wound care.

Listeria monocytogenes as a Cause of Spontaneous Bacterial Peritonitis.

Spontaneous bacterial peritonitis is a common and often serious complication of long standing ascites in the presence of advanced liver disease. We report a case of a 74-year-old woman with alcoholic cirrhosis admitted to our emergency department with a 1-week history of diffuse abdominal pain and increased abdominal perimeter. On physical examination, she had a significant abdominal distention and a positive fluid wave consistent with ascites. A diagnosis of spontaneous bacterial peritonitis was made and empiric therapy with ceftriaxone was started but the patient's condition worsened. Four days later Listeria monocytogenes was detected in peritoneal fluid culture and ampicillin was initiated according to in vitro sensibility test. The patient completed 14 days of treatment with clinical and laboratory improvement. Listeria is an uncommon cause of spontaneous bacterial peritonitis. Clinicians should be aware of the uncommon agents of spontaneous bacterial peritonitis, mainly when there is not a proper response to therapy.

Vasculitis and Steroid Psychosis: A Case Report and Review of Literature.

Corticosteroids have become the cornerstone of therapy for many pathologies such as vasculitis. Steroid psychosis is a known complication of corticosteroids therapy, although infrequent. We describe a case of psychosis secondary to corticosteroids in a 69-year-old man with large-vessel vasculitis without previous history of psychiatric pathology. He was diagnosed with large-vessel vasculitis and the treatment started with prednisone 1 mg/kg/day. One week later, the patient presented with behavior change: emotional lability, disorientation and aggressiveness. The symptoms worsened for hallucinatory activity and cognitive deficit. After exclusion of other causes, the diagnosis of psychosis secondary to corticosteroids was assumed. It was decided to wean corticosteroids and start new therapy with methotrexate and tocilizumab and introduction of antipsychotic therapy. The patient had a good outcome with disease remission and had no further neuropsychiatric symptomatology. Systemic corticosteroids are widely used, sometimes with a low concern of its potential adverse effects. So it is important that physicians are aware of the potential for their adverse effects and the need to monitor disease activity and drug toxicity.

Resistencia a drogas antituberculosas en Caracas, Venezuela; 2001-2006 / Antituberculosis drug resistance in Caracas, Venezuela; 2001-2006

Para establecer la sensibilidad de las cepas de Mycobac-terium tuberculosis aisladas en Caracas, entre 2001 y 2006, fueron probadas utilizando el método colorimétrico para determinar las Concentraciones Inhibitorias Mínimas (CIM). De las 324 cepas, 46 (14,2%) mostraron resistencia a una o más drogas. Encontramos resistencia de alto nivel (CIM 8 µg/ml) y bajo nivel (CIM 1-4 µg/ml) a Estreptomicina en 6 (1,8%) y 25 (7,7%) de las cepas, respectivamente. Se encontró resistencia a Isoniacida de bajo nivel (MIC 0,125 - 0,5 µg/ml) en 8 (2,5%) y de alto nivel (MIC 1,0 µg/ml) en 15 (4,6%) de las cepas estudiadas. Hallamos 13 (4,0%) cepas resistentes a Rifampicina (RIF) (5 µg/ml) y 11 (3,4%) a Etambutol (10 µg/ml). De los 17 (5,2%) aislamientos resistentes a dos o más drogas, 12 (3,7%) fueron resistentes a INH y RIF (definido como multirresistencia, MDR). De las 12 cepas MDR, 11 fueron aisladas a partir de esputo y una de líquido pleural. Este estudio muestra un incremento en la prevalencia de la resistencia a las drogas antituberculosas en Caracas, especialmente las cepas MDR. Este aumento apunta hacia la necesidad de una encuesta na-cional, para evaluar el panorama real de la resistencia.

To asses drug susceptibility of Mycobacterium tuberculosis strains isolated from 2001 to 2006 in Caracas. Available strains were tested using colorimetric method to determine the Minimal Inhibitory Concentrations (MIC). Of 324 strains, 46 (14,2%) showed resistance to one or more drugs. High-resistance (8 µg/ml) and low-resistance (1-4 µg/ml) to Strep omycint was found in 6 (1,8%) and 25 (7,7%) strains, respectively. Isoniazid (INH) low-resistance (MIC 0.125 - 0.5 µg/ml) were found in 8 (2,5%) and high-resistant (MIC at 1.0 µg/ml) in 15 (4,6%), Rifampicin resistance (RMP) (5 µg/ml) in 13 (4%), and Ethambutol resistance (10 µg/ml) in 11 (3,4%) of the strains. Of the 17 (5,2%) isolates resistant to two or more drugs, 12 (3,7%) were resistant to INH and RMP (defined as multidrug resistance, MDR). Of these 12 MDR strains, 11 were isolated from sputum and one from pleu ral fluid. This study shows an increased prevalence of resistance to anti-tuberculosis drugs in Caracas, especially the prevalence of MDR strains, raises an urgent need of a proper nationwide survey to evaluate the true picture of resistance.