Diagnostic approach of pneumonia in an elderly patient with comorbidities--case report.

Dyspnea is one of the symptoms that has a major impact on patients' health, with a negative influence on the quality of life. The main causes of dyspnea are cardiac, pulmonary and mixed (cardiac or pulmonary). There are several other causes such as metabolic conditions (acidosis), pain, neuromuscular disorders, otorhinolaryngeal disorders, anxiety, panic disorders and hyperventilation. Acute pneumonia in the elderly is a common occurrence and its incidence grows as the elderly population increases. We report the case of a 76 years old patient with a known cardiovascular condition, recently hospitalized for right pulmonary infarction. He presented to our clinic for influenced general state, rest dyspnea, fever, shiver, and productive cough in the last two days. Current medication included oral anticoagulants and triple antihypertensive treatment (responsible for his low blood pressure). Laboratory results showed a nonspecific inflammatory syndrome with leukocytosis and neutrophilia and mild normochromic normocytic anemia; D-dimers were within normal range, fibrin degradation products 1+; myocardial enzyme testing showed no alteration, and BPN (beta natriuretic peptide) was 790 pg/ml. Chest X-ray showed diffuse bilateral reticular shadows (more pronounced on the right side) and left costodiafragmatic opacification. It appears that age-related increase in morbidity and mortality in community-acquired pneumonia is not due to age per se, but to interactions between the immune system, systemic diseases and nutritional factors. Community-acquired pneumonia in the elderly is known to have a high mortality. Although the diagnosis can be easy, the physician must also investigate for less obvious causes of dyspnea such as the presence of comorbidities and fragility of the elderly patient.

[Toxic cause febrile neutropenia]. / Neutropenia febrila de cauza toxica.

Agranulocytosis is an acute disease with severe leucopenia, especially with low neutrophils, elements with an essential role in the organism's defense. It is more frequent at adult age (between 30 to 70 years of age) especially in women. We present the case of a 84 years old patient that, following passive exposure to pesticides, develops a severe neutropenia with a fast response to the administration of Methylprednisolone and granulocyte colony-stimulating factor (G-CSF-Filgrastim 48MIU/0.8mL/day, for three days). The diagnostic certainty was set by the bone marrow puncture which excluded a possible aleukemic acute leukemia or a myelodysplastic syndrome.

[Early diagnosis in hypertrophic cardiomyopathy--case report]. / Importanta diagnosticului precoce în cardiomiopatia hipertrofica.

Disproportionate heart muscle enlargement compared with little or no chamber enlargement are characteristic for hypertrophic cardiomyopathy (HCM). The clinical course of HCM is highly variable. Many patients are asymptomatic or mildly symptomatic and may be relatives of patients with known disease. Unfortunately, the first clinical manifestation of the disease may be sudden death, frequently occurring in children and young adults, often during or after physical exertion. We present 2 cases of HCM who emphasize the variability of clinical and ECG modifications and underline the importance of routine echocardiography in patients with atypical cardiac symptoms in order to identify the disease and prevent high risk for sudden death.

[When is it a diagnosis of overlap syndrome?]. / Când punem diagnosticul de sindrom overlap?

The connective tissue diseases comprise a group of syndromes of unknown etiology affecting as many as 1 person in 40, often with a predilection for the female sex. Included are: systemic lupus erytematosus (SLE), polymyositis and dermatomyositis, Sjögren syndrome, scleroderma and the vasculitis (polyarteritis nodosa, Wegener's, giant cell arteritis). There are patients who are not easily defined; having features overlapping with those of other connective tissue diseases. A variety of terms such as mixed connective tissue disease, undifferentiated connective tissue syndrome and overlap syndrome have emerged to describe such patients. Although many of these overlap syndromes are unlikely to have life-threatening consequences, they may be extremely debilitating and distressing, significantly reducing quality of life for the patient and his or her family. We present the case of a patient initially diagnosed with dermatomyositis and who eventually evolved to overlap syndrome by developing SLE.