A 67-year-old female presents with a small mass in the anterior mediastinum on chest computed tomography. A biopsy proves the mass to be a spindle-cell-type or type A thymoma. Subsequently the patient develops fever and severe Coombs-positive haemolytic anaemia. She is initially treated with oral corticosteroids. Because of persistence of the haemolysis subsequent thymectomy is performed. Haemolysis disappears almost instantly and does not return after discontinuation of the oral corticosteroids. Review of the literature reveals only 17 other cases of thymoma-associated autoimmune haemolytic anaemia.
Olmesartan, a well-known and powerful antihypertensive drug, was first described to cause enteropathy in 2012. A possible mechanism may be inhibition of the intestinal immune suppressive effect of transforming growth factor-beta (TGF-β), with a consequential increase of intestinal T-cell inflammation. We present the case of a 60-year-old woman who developed large volume, watery diarrhoea with 8kg weight loss only two weeks after starting olmesartan 20mg daily with a secondary mild acute kidney insufficiency and hypokalaemia. Coeliac serology was negative. Endoscopy revealed no macroscopic lesions. Histology showed increased gastric, duodenal, ileal and colonic intraepithelial lymphocytes with partial duodenal villous atrophy, hence affecting the entire gastrointestinal tract. After cessation of olmesartan, symptoms improved within a week; therefore a diagnosis of olmesartan induced enteropathy was made. Extra immunohistochemical stains to further investigate the underlying pathophysiology were inconclusive.
Streptococcus zooepidemicus is an animal commensal with the potential of zoonotic transmission through ingestion of contaminated dairy products, leading to outbreaks of Post-Streptococcal Glomerulonephritis (PSGN). We report for the first time acute renal failure with need for renal replacement therapy, as a complication of S. zooepidemicus bacteremia resulting from direct horse to human transmission in a young adult. Both clinical disease course and immunohistochemical staining patterns on renal biopsy had some atypical features of PSGN suggesting persistent activation of the alternative complement pathway but no known complement factor dysregulations could be identified.
We present the case of a 48-year-old female carrier of Duchenne muscular dystrophy (DMD) with repeatedly documented levels of elevated troponin T without arguments for cardiac ischaemia. Elevated levels of troponin T are frequently reported in DMD patients and may function as a useful cardiac index to assess dystrophic degeneration of the myocardium in a subclinical stage. Cardiac troponins may help the clinician to diagnose myocardial damage in a very early stage of cardiac impairment independently from skeletal muscle degeneration.
A woman was admitted to the hospital with lymphadenopathy, fever and a generalised exanthema. Laboratory examination revealed leucopenia, anaemia, high sedimentation, elevated CRP and a markedly elevated serum ferritin. Further exploration showed a positive anti-nuclear factor-titre with anti-double-stranded DNA antibodies, positive p-ANCA and a falsely positive syphilis-test. Bone marrow examination revealed an elevated number of phagocytizing macrophages. Diagnosis of secondary haemophagocytic lymphohistiocytosis in a patient with systemic lupus erythematosus was made, a serious and sometimes fatal condition with often repeated exacerbations of the systemic lupus erythematosus that stays active for long periods in spite of the use of immunosuppressive therapy. Haemophagocytic lymphohistiocytosis and systemic lupus erythematosus are sometimes difficult to differentiate because the clinical presentation and laboratory findings are frequently very similar. The diagnosis depends on the clinical picture, blood and bone marrow examination. Bone marrow reveals an elevated haemophagocytosis. In patients with secondary haemophagocytic lymphohistiocytosis, the treatment of the underlying disorder is sometimes sufficient. In some cases there is need for a specific treatment with corticosteroids, intravenous immunoglobulin, immunosuppressive therapy or etoposide.
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