Inferior vena cava (IVC) agenesis is a rare congenital abnormality affecting the infrarenal segment, the suprarenal or the whole of the IVC. It has an estimated prevalence of up to 1% in the general population that can rise to 8.7% when abnormalities of the left renal vein are considered. Most IVC malformations are asymptomatic but may be associated with nonspecific symptoms or present as deep vein thrombosis (DVT). Up to 5% of young individuals under 30 years of age with unprovoked DVT are found to have this condition. Regarding the treatment of IVC agenesis-associated DVT, there are no standard guidelines. Treatment is directed towards preventing thrombosis or its recurrence. Low molecular weight heparin and oral anticoagulation medication, in particular vitamin K antagonists (VKAs) are the mainstay of therapy. Given the high risk of DVT recurrence in these patients, oral anticoagulation therapy is suggested to be pursued indefinitely. As far as we know, this is the first case reporting the use of a direct factor Xa inhibitor in IVC agenesis-associated DVT. Given VKA monitoring limitations, the use of a direct Xa inhibitor could be an alternative in young individuals with anatomical defects without thrombophilia, but further studies will be needed to confirm its efficacy and safety.
Drug-induced liver injury (DILI) is the most common cause of acute liver failure in the Western world. In recent years, natural herbal and dietary supplements have become widely available to the general public and have increased in popularity. Reports of idiosyncratic liver injury caused by such supplements have also increased over the last decade. Horse chestnut is a herb used in dietary supplements primarily for complications of venous insufficiency. Clinically significant acute liver injury has been very rarely associated with its use. We present the case of a 70-year-old man with idiosyncratic horse chestnut-induced liver injury.
Chorea is a hyperkinetic movement disorder characterised by brief involuntary, random, and irregular contractions. It’s caused by multiple conditions, including neurodegenerative diseases, cerebrovascular disease, structural damage to deep brain structures, neoplastic diseases, or metabolic derangements, such as hyperglycaemic states.
We present a case of an 81-year-old woman, with a history of long-term poorly controlled type 2 diabetes mellitus, admitted to the emergency department with hyperkinetic delirium in the last 48h. At examination, she presented with mild right central facial paresis, and involuntary bilateral movement of the four limbs, more prominent on the right side. Laboratory tests showed hyperglycaemia of 799 mg/dl with ketonemia of 5.2 mg/dL and glycated hemoglobin of 11%. Computed tomography (CT) scan of the brain showed bilateral hyperdensity of the corpus striatum. The treatments included glycemic control with insulin, intravenous fluids, and anti-epileptic drugs. A clinical improvement was observed however, the patient continued to show chorea-like movements of the four limbs. The magnetic resonance imaging (MRI) showed a T2-flair and T2-weighted area of hypo-intensity involving bilaterally the striatum corpus and the corresponding signal in T1. She was then diagnosed with hyperglycaemia-associated chorea and improved significantly after initiation and titration of clonazepam and tetrabenazine.
This case report pretends to highlight the importance of considering a rare manifestation of a very common disease. A hyperglycaemic state that can lead to cerebral lesions and specific neurological manifestations.
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