A 70-year-old man with known cardiovascular risk factors, presented with acute onset expression aphasia, agraphia, dyscalculia, right-left disorientation and finger agnosia, without fever or meningeal signs. Stroke was thought to be the cause, but cerebrovascular disease investigation was negative. Interviewing the family revealed he had undergone yellow fever vaccination 18 days before. Lumbar puncture revealed mild protein elevation. Cultural examinations, and neurotropic virus serologies were negative. Regarding the yellow fever virus, IgG was identified in serum and cerebrospinal fluid (CSF), with negative IgM and virus PCR in CSF. EEG showed an encephalopathic pattern. The patient improved gradually and a week after discharge was his usual self. Only criteria for suspect neurotropic disease were met, but it's possible the time spent between symptom onset and lumbar puncture prevented a definite diagnosis of yellow fever vaccine-associated neurological disease. This gap would have been smaller if the vaccination history had been collected earlier.
A 24-year-old man presented to the emergency department with fever, maculopapular rash, myalgia and polyarthralgia, thoracic pain and dry cough, which had been present for 24 h. At the time of observation he had high fever (39°C), maculopapular rash on the torso, arms and legs proximally, axillary adenopathies and pharyngitis. Laboratorial data showed elevated inflammation markers (leukocytosis, C reactive protein of 44 mg/dL, erythrocyte sedimentation rate of 120 mm), elevated transaminases, lactate dehydrogenase, ferritin levels (>2000 ng/mL) and rising troponin. ECG had sinus rhythm and ST elevation in leads V1-V5. Thoracic radiography revealed bilateral interstitial infiltrate confirmed by CT scan. Echocardiographic findings included diffuse hypokinesia of the left ventricle and impaired systolic function. After the investigation of an infectious or autoimmune aetiology was negative, the diagnosis of adult-onset Still's disease was considered. The patient was put on a 60 mg/day prednisolone regimen with remission of symptoms and normalisation of systolic function and ECG.
Wunderlich syndrome is a rare clinical entity characterised by spontaneous renal haemorrhage that can be life-threatening and requires emergency attention. The most frequent aetiologies are renal tumours and vascular diseases. The authors report a case of a patient admitted with hypovolaemic shock due to a retroperitoneal haematoma in the context of polyarteritis nodosa (PAN). Prognosis of untreated PAN is very poor with 13% 5-year survival rate. Therefore, early recognition of disease and proper treatment with immunosuppressors will prevent catastrophic complications and improves survival.
Onychomatricoma is a rare benign tumour of the nail matrix first described in 1992, and since then, no more than 80 cases have been reported. Despite distinct clinical characteristics, it is frequently misdiagnosed as onychomycosis partly due to remaining an unknown entity. The authors present the case of a patient with a 30-year history of nail abnormalities with more recent growth to alarming dimensions.
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