En mann i 50-årene med brystsmerter og synkope.

BACKGROUND: A man in his fifties with hypertension and no other previous health problems was admitted to the hospital after frequent episodes of retrosternal squeezing chest pain, and an episode of syncope. A recent computer tomography coronary angiography demonstrated normal coronary arteries with no atherosclerosis. CASE PRESENTATION: During admission, the patient developed several episodes of chest pain lasting five to fifteen minutes followed by non-sustained ventricular tachycardia, and initially no ST elevation in the electrocardiogram (ECG). He had normal findings on ECG and magnetic resonance imaging of the heart. During hospitalisation, ST elevations in the ECG were observed in relation to chest pain. Due to ST elevation, invasive coronary angiography was performed, revealing a suspected culprit lesion in the left anterior descending artery, treated with percutaneous coronary intervention (PCI). Despite PCI, he had persistent episodes of chest pain with ST elevation and non-sustained ventricular tachycardia. Vasospastic angina was suspected. INTERPRETATION: The clinical presentation is classical for vasospastic angina. After treatment with calcium channel blocker together with long-acting nitrate, there were no new episodes of chest pain or non-sustained ventricular tachycardia. Because of non-sustained ventricular tachycardia with haemodynamic instability and syncope, an implantable cardioverter-defibrillator was implanted.

A man in his fifties with dry cough and pleural effusion. / En mann i 50-årene med tørrhoste og pleuravæske.

BACKGROUND: Pulmonary tuberculosis is a major public health issue worldwide and is frequently overlooked, particularly in our part of the world. More caution with regard to symptoms could facilitate faster diagnosis, better treatment, and decreased morbidity and mortality. CASE PRESENTATION: We describe the disease course in a middle-aged man presenting with non-productive cough, right-sided pleural effusion and fatigue. Approximately 3 months passed before he was diagnosed with pulmonary tuberculosis and pleuritis. Because of his mild symptoms and non-specific radiographic findings, he was initially treated with antibiotics covering typical and atypical pneumonia, resulting in some improvement which led to a delay in diagnosis. Thoracic CT examination eventually revealed right upper lobe cavitation, increasing right-sided pleural effusion, right-sided mediastinal and hilar lymphadenopathy, and thickened right-sided pleura and pericardium. Induced sputum samples confirmed growth of M. tuberculosis, the mycobacterium tuberculosis complex was confirmed with PCR analysis, and direct microscopy showed acid-fast bacilli. The patient was successfully treated with standard tuberculostatic drugs: rifampin, isoniazid, pyrazinamide and ethambutol. INTERPRETATION: Tuberculosis is frequently overlooked, both in hospitals and in primary care. Symptoms may be mild or non-characteristic in the early stage, and a simple chest x-ray is unsuitable to exclude the diagnosis.