Acute Pyelonephritis Associated with Ruptured Abdominal Aortic Aneurysm: An Unusual Presentation.

We describe a rare presentation of acute pyelonephritis associated with a ruptured abdominal aortic aneurysm. A 68-year-old female presented to the emergency department with a 3 day history of cystitis. General examination revealed the acute onset of pain in the left flank accompanied by fever and chills. Blood tests revealed leucocytosis 25,400×109/L and C-reactive protein 495 mg/L (<6.1), while urinary sediment analysis revealed many leucocytes and gram-negative bacteria. The patient was admitted with acute pyelonephritis. On the third day of admission, the urine culture isolated Escherichia coli sensitive to the antibiotic prescribed; however, the patient clinically deteriorated. A computed tomography scan revealed a ruptured abdominal aortic aneurysm involving the left renal artery. The patient underwent an exploratory laparotomy but uncontrollable haemorrhage led to a fatal outcome. This case highlights a rare case of acute pyelonephritis associated with a ruptured abdominal aortic aneurysm. A computed tomography scan or abdominal ultrasound should be considered whenever a patient has acute pyelonephritis with a C-reactive protein >400 mg/L in order to exclude complications and other potentially fatal pathologies. LEARNING POINTS: Acute pyelonephritis can lead to a ruptured abdominal aortic aneurysm.There should be a high index of suspicion for other concomitant acute pathologies in patients with pyelonephritis and a C-reactive protein >400 mg/L.A low threshold for abdominal imaging, either a computed tomography scan or abdominal ultrasound, may allow for the diagnosis of pathologies with a high mortality rate, such as a ruptured abdominal aortic aneurysm, at an early stage and thus result in better prognosis.

When Zoster Virus Hides a Primary Brain Lymphoma.

AIM: To describe an unusual presentation of a primary lymphoma of the central nervous system in a patient who, four months prior to admission, was diagnosed with herpes zoster ophthalmicus (HZO). CASE DESCRIPTION: A 68-year-old man, with a history of HZO, was admitted to the emergency department with nausea and vomiting that had persisted over the previous two weeks. Neurological evaluation showed right ptosis, divergent strabismus and anisocoria. Blood tests showed high c-reactive protein, while serology was negative for human immunodeficiency virus. A brain CT scan revealed three round lesions, slightly hyperdense, periventricular in the occipital and frontal regions, which biopsy revealed to be a diffuse large B-cell lymphoma. The patient started chemotherapy but progression to death was inevitable. CONCLUSION: The authors describe an unusual presentation of primary lymphoma of the central nervous system and urge physicians to be aware of this presentation in order to avoid misdiagnosis. LEARNING POINTS: Herpes zoster ophthalmicus can reflect underlying diseases and lead to misdiagnosis.An occult neoplasm should be considered in an otherwise immunocompetent elderly patient who develops varicella-zoster virus infection.