Treatment of intracardiac thrombi using ultra-slow low-dose thrombolytic therapy: A case report.

A 57-year-old male with previously known severe primary mitral regurgitation was admitted to the intensive care unit (ICU) due to massive venous thromboembolism, associated with right ventricular dysfunction and two large mobile right atrial thrombi. Due to deterioration in his clinical condition despite standard treatment with unfractionated heparin, it was decided to use an ultra-slow low-dose thrombolysis protocol, which consisted of a 24-hour infusion of 24 mg of alteplase at a rate of 1 mg per hour, without initial bolus. The treatment was continued for 48 consecutive hours, with clinical improvement and resolution of the intracardiac thrombi and no complications. One month after ICU admission, successful mitral valve repair surgery was conducted. This case demonstrates that ultra-slow low-dose thrombolysis is a valid bailout treatment option in patients with large intracardiac thrombi refractory to the standard approach.

Metastatic Lung Cancer with Multiorgan Thrombosis and Budd-Chiari Syndrome: A Rare Case.

Arterial thrombosis and Budd-Chiari syndrome are rare conditions in lung cancer patients. We report the case of a 53-year-old woman who presented with respiratory symptoms, lumbar pain, weight and appetite loss, and an x-ray showing a lung nodule and diffuse micro-opacities. She was diagnosed with lung neoplasia with extensive lung, liver, lymph node and bone metastases. After discharge she was readmitted with a respiratory infection, and as her condition deteriorated, computed tomography was performed and revealed ischaemic areas in the spleen and kidney, and venous thrombosis, related to Budd-Chiari syndrome, with hepatic ischaemia. Despite hypocoagulation, her clinical condition deteriorated and she died soon afterwards. LEARNING POINTS: Acute ischaemic arterial events are rare in cancer patients.Budd-Chiari syndrome associated with lung cancer is rare.Both presentations have a poor prognosis, so early diagnosis and intervention are imperative.

Symmetrical Drug-related Intertriginous and Flexural Exanthema (Baboon Syndrome).

Baboon syndrome, also called symmetrical drug-related intertriginous and flexural exanthema (SDRIFE), is an erythematous maculopapular rash that presents in skin folds in a symmetrical pattern. This condition may develop after the patient starts a particular agent. Treatment consists of stopping the associated trigger and medicating with topical or systemic corticosteroids. A 30-year-old man with odynophagia, otalgia and fever was prescribed amoxicillin. He developed erythematous and pruriginous lesions in the cubital fossa and inguinal regions. He attended the emergency department (ED) where he was prescribed penicillin. Lesions continued to progressively worsen with a bilateral symmetrical pattern in the axillary region and later in the nape folds, popliteal regions, and on the perineum and buttocks. The patient presented to the ED for a second time, where he was diagnosed with baboon syndrome and prescribed topical steroids with clear improvement. LEARNING POINTS: It is important to identify adverse drug effects.Baboon syndrome is rare and secondary to the use of particular drugs.The diagnosis is based mainly on the patient's clinical presentation.

Disseminated Tuberculosis: A Case of Multiple Spread Mass.

Disseminated tuberculosis is associated with significant morbidity and mortality. It results from a lymphohematogenous dissemination of mycobacterium tuberculosis (MT) and its atypical clinical presentation often delays the diagnosis. Diagnosis is established by identifying MT obtained from a biopsy sample in culture or acid-fast smear. Evidence suggests an initial two-month phase of four-drug therapy followed by a two-drug phase for six to nine months. A 61-year-old man presented with back lumbar pain. He presented two masses, a left parasternal and a left axillary masses with approximately 6 cm each. He referred a 21% weight loss, anorexia and asthenia. His computed tomography revealed recent lumbar fractures and a left paravertebral space-occupying lesion; hilum and upper lobe masses; inflammatory/infectious micronodules; mediastinal adenomegaly, hypodense lesions in the spleen, sternum and left scapula. Magnetic resonance imaging revealed lumbar vertebral fractures, an anterior epidural collection, left iliac psoas muscle liquid collection. A mass puncture and biopsy were performed, resulting in a positive detection of MT in nucleic acid amplification (NAA). The patient started on quaternary antibacillary therapy with isoniazid, rifampin, pyrazinamide and ethambutol. Bronchofibroscopy revealed an hypervascularized and infiltrated submucosa. Later, histopathology was compatible with chronic granulomatous inflammatory process and bronchial lavage molecular test was positive for MT. At the moment, he is under two-drug antibacillary therapy with isoniazid and rifampin and masses are regressing.

Thyroid Disease Spectrum in the Emergency Department.

We present two cases of thyroid hormone alterations revealing clinical emergencies that require early diagnosis and prompt treatment. The first patient, a 56-year-old woman, presented in the emergency room with psychomotor agitation, disorientation and headache. She was very agitated, incapable of standing still, looked very thin, feverish, tachycardic and presented no alteration at neurological examination with negative meningeal signs. Analyses revealed a severe hyperthyroidism. She initiated propylthiouracil 100 mg 8/8 h. After six months, thyroid function was normal. The second patient, a 54-year-old woman, was transferred from the Psychiatry Department due to memory and behavior changes for the past two weeks. She presented visual and auditive hallucinations and inadequate daily behavior. Analyses revealed a severe hypothyroidism. She was medicated with levothyroxine 100 ug/day. At the third month, she presented normalized thyroid function, normal thyroid ultrasound and an increased antithyroperoxidase antibody.

A Rare Cause of Dyspnoea: Right-sided Bochdalek Hernia in an Adult.

Right-sided Bochdalek hernia (BH) is very rarely diagnosed in adults. It commonly presents with gastrointestinal symptoms (pain, abdominal distension and vomiting). Breathlessness, recurrent chest infections and other pulmonary sequelae can also be present. We report the case of a 92-year-old man with a 3-day history of dyspnoea, fever and thoracic pain and multiple episodes of vomiting. An x-ray was performed, and the diagnosis of a large BH hernia was confirmed by computed tomography of the thorax. The condition may be fatal in cases where the small bowel undergoes necrosis or perforation. An emergent laparotomy was performed, but the patient did not improve clinically and died immediately after the procedure. LEARNING POINTS: Right-sided Bochdalek hernia (BH) is very rarely diagnosed in adults.Misdiagnosis of BH as a tension pneumothorax (which has a similar clinical presentation) can delay treatment and put patients at risk.The outcome of BH depends on the presentation, early diagnosis and emergent intervention.