European journal of case reports in internal medicine最新文献

{"title":"Piperacillin/Tazobactam Induced Immune-Mediated Anaemia and Thrombocytopenia.","authors":"Agnes-Sophie Fritz, Marten Trendelenburg, Markus Mutke","doi":"10.12890/2025_005460","DOIUrl":"10.12890/2025_005460","url":null,"abstract":"<p><p>Piperacillin/tazobactam (PTZ) is known to cause cytopenia but case reports on PTZ causing combined haemolytic anaemia and thrombocytopenia are scarce. We report on a 56-year-old male who developed severe, immune-mediated thrombocytopenia and anaemia during two treatment episodes with PTZ. After the first exposure, his blood count rapidly returned to normal after discontinuation of PTZ. One year later, in the context of an unintentional re-challenge with PTZ, the level of red blood cells and platelets dropped again causing acute haemolytic anaemia and immune thrombocytopenia. Recovery was delayed after discontinuation of PTZ. PTZ should be considered as a potential cause of immune-mediated bicytopenia.</p><p><strong>Learning points: </strong>Piperacillin/tazobactam can induce immune-mediated haemolytic anaemia and thrombocytopenia.Patients with underlying alteration of the immune system might be at higher risk for bicytopenia.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"12 9","pages":"005460"},"PeriodicalIF":0.0,"publicationDate":"2025-08-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12416790/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145029350","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Misleading Detection of Herpes Simplex Virus Type 1 In A Patient with Paraneoplastic Encephalitis.","authors":"Mirko Lischer, Marten Trendelenburg, Özgür Yaldizli, Nikolaos S Avramiotis, Grischa Marti, Anna Vital","doi":"10.12890/2025_005705","DOIUrl":"10.12890/2025_005705","url":null,"abstract":"<p><p>Encephalitis is a potentially life-threatening condition with infectious or autoimmune aetiologies. Autoimmune encephalitis includes paraneoplastic variants associated with specific onconeural antibodies such as anti-Hu, frequently linked to malignancies. Herpes simplex virus type 1 (HSV-1) is the leading infectious cause in adults. Differentiating between these aetiologies can be challenging. We report the case of an 88-year-old woman admitted with confusion following a fall. Initial evaluation showed clinical signs consistent with encephalitis. During hospitalisation, a seizure was witnessed. Cerebrospinal fluid (CSF) analysis revealed mild pleocytosis, but no infectious agent was detected, and brain imaging revealed no significant abnormalities. After initial improvement under antiepileptic therapy, the patient experienced worsening cognitive dysfunction. Repeat CSF testing 4 weeks after initial symptom onset showed even milder pleocytosis but was positive for HSV-1 and magnetic resonance imaging showed bilateral hippocampal hyperintensities. Analysis of the first CSF sample retrospectively revealed high-titer anti-Hu antibodies. Positron emission tomography-computed tomography scan identified a hypermetabolic lung lesion and para-aortic lymph node, with biopsy confirming the diagnosis of small cell lung cancer. Immunosuppressive and oncologic treatment led to transient improvement, followed by progressive neurological deterioration. Supportive care was ultimately prioritized. This case underscores the diagnostic challenges of encephalitis, especially when autoimmune and infectious features overlap, and diagnostic findings are misleading. Detection of HSV-1 should not delay the investigation of alternative causes of encephalitis in the absence of typical HSV-related features. Early recognition of paraneoplastic encephalitis is critical, as neurologic symptoms may precede the diagnosis of underlying malignancy.</p><p><strong>Learning points: </strong>Onconeural antibodies, such as anti-Hu antibodies, are an under-recognized cause of encephalitis and should be specifically tested for when an autoimmune encephalitis is clinically suspected.Detection of anti-Hu antibodies mandates a comprehensive malignancy workup.A positive herpes simplex virus type 1 polymerase chain reaction in cerebrospinal fluid does not definitively confirm active infection and must always be interpreted in conjunction with the patient's clinical presentation.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"12 9","pages":"005705"},"PeriodicalIF":0.0,"publicationDate":"2025-08-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12416775/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145029347","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cold Agglutinin Disease in the Setting of Pancreatic Adenocarcinoma.","authors":"Hong Phan, Vanita Motiani, Ayema Haque, Sarrah Ali Asghar, Harshank Patel, Zafir Zohab Hussain Khan, Susan Bannon","doi":"10.12890/2025_005587","DOIUrl":"10.12890/2025_005587","url":null,"abstract":"<p><p>Autoimmune haemolytic anaemia (AIHA) is caused by antibody-mediated destruction of red blood cells. There are two broad categories of AIHA: warm and cold, both categorized by the thermal reactivity of the autoantibodies. Cold agglutinin disease (CAD) occurs at temperatures below normal body temperature and primarily involves IgM antibodies. CAD typically occurs secondary to other processes: lymphoproliferative disorders or infection, although it can be rarely idiopathic. We present a case of a 65-year-old male with no past medical history who initially presented with haematuria and proteinuria, along with thrombocytopenia and leukopenia. He reported an unintentional weight loss of more than 9 kg, constipation, and pale-greasy coloured stools. Computed tomography (CT) scan of the abdomen and pelvis revealed findings suspicious for primary pancreatic neoplasm with nodal metastases and early carcinomatosis, severe right hydronephrosis, and distended gallbladder. Direct antiglobulin test (DAT) screening was negative, but an antibody screen was positive. The patient had a positive cold agglutin screen and elevated CA 19-9, carcinoembryonic antigen (CEA), and cyclic citrullinated peptide (CCP) levels, tumour markers used typically for diagnosis of pancreatic cancer. The patient presented with symptoms and laboratory findings suggestive of a complex interplay between haemolytic anaemia and a suspected solid organ malignancy, specifically pancreatic cancer. His elevated tumour markers and positive antibody screen and cold agglutinin screen suggested the possibility of paraneoplastic syndrome secondary to his pancreatic cancer. However, his infectious and autoimmune panel findings further complicated the picture and underscored the multifactorial nature of his condition.</p><p><strong>Learning points: </strong>This case highlights a rare association between autoimmune haemolytic anaemia (AIHA) and pancreatic adenocarcinoma.While AIHA is a known paraneoplastic syndrome of hematologic malignancies, this case report suggests that it may also be a paraneoplastic syndrome for solid tumours.This case report highlights the difficulty of treating AIHA in the setting of comorbidities, suggesting that standard treatment guidelines may not be effective.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"12 9","pages":"005587"},"PeriodicalIF":0.0,"publicationDate":"2025-08-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12416801/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145029383","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Anomalous Origin of the Right Coronary Artery from the Left Main Coronary Artery in A Patient with Non-Specific Chest Pain.","authors":"Ayman F Soliman, Yaqob S Taleb, Fatmah H Alsalman, Osama M Rizk, Bader A Al Benhasan, Muneera O Al Taweel","doi":"10.12890/2025_005701","DOIUrl":"10.12890/2025_005701","url":null,"abstract":"<p><p>Anomalous origin of the coronary arteries is a rare congenital condition that can present as non-specific chest pain or shortness of breath or remain asymptomatic. Early identification is critical as certain variants are linked with a high risk of sudden cardiac death. Here, we report the case of a 53-year-old female with hypertension, hypothyroidism, obesity (class II) and a history of intermittent chest pain radiating to the left arm for two years. A cardiology workup including ECG, cardiac enzymes, echocardiography and CT coronary angiography revealed an anomalous origin of the right coronary artery (RCA) arising from the left main coronary artery (LMCA) with no haemodynamically significant narrowing. This case highlights the significance of advanced imaging techniques in evaluating atypical chest pain, which can reveal critical congenital anomalies of the coronary arteries. Although this anomaly was not associated with ischaemia in our patient, its recognition is vital for appropriate management and risk stratification.</p><p><strong>Learning points: </strong>Advanced imaging techniques are important in evaluating atypical chest pain, which can reveal critical congenital anomalies of the coronary arteries.CT coronary angiography remains an essential tool for diagnosis and risk assessment.Although the right coronary artery was not associated with ischaemia in this case, continued monitoring and cardiovascular risk factor management are essential for long-term prognosis.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"12 9","pages":"005701"},"PeriodicalIF":0.0,"publicationDate":"2025-08-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12416797/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145029329","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Diagnostic and Therapeutic Paradoxes in PCR-Positive, Histopathology-Negative CNS Aspergillosis in A Patient with HIV and Hodgkin Lymphoma.","authors":"Nikolas Kenaya, Joshua Hermiz, Joshua Hailo, Zahra Chehab, Emelia Johnson, Christian Toquica Gahona, Saba Asif","doi":"10.12890/2025_005604","DOIUrl":"10.12890/2025_005604","url":null,"abstract":"<p><strong>Background: </strong>Invasive central nervous system (CNS) aspergillosis is rare among human immunodeficiency virus (HIV)-positive patients due to preserved neutrophil function, despite significant CD4+ T-cell depletion. Diagnosis typically requires histopathologic confirmation, but polymerase chain reaction (PCR) testing has introduced new challenges due to its high sensitivity but limited specificity.</p><p><strong>Case presentation: </strong>We describe a newly diagnosed 43-year-old HIV-positive male with concurrent Hodgkin lymphoma who presented with progressive neurological decline and a ring-enhancing brain lesion. While histopathological analysis of the brain biopsy demonstrated features of HIV-associated leukoencephalopathy, PCR testing paradoxically identified <i>Aspergillus fumigatus</i>; however, histopathological examination failed to demonstrate definitive fungal elements. Despite negative cerebrospinal fluid galactomannan and β-D-glucan assays, empiric voriconazole therapy was initiated in accordance with current treatment guidelines. Over the ensuing month, the patient returned with worsening neurologic status, radiographic lesion progression, and ultimately developed Torsades de Pointes, and multiorgan failure, resulting in death.</p><p><strong>Discussion: </strong>This case underscores the diagnostic and therapeutic complexities of PCR-positive, histopathology-negative CNS aspergillosis in HIV. Overreliance on molecular results without confirmatory pathology may lead to unnecessary antifungal therapy and severe drug toxicity. Additionally, overlapping immunosuppressive conditions-such as HIV and lymphoma-complicate clinical interpretation and management.</p><p><strong>Conclusion: </strong>In HIV-positive patients with CNS lesions, PCR detection of <i>Aspergillus</i> should not independently justify antifungal therapy. Histological confirmation and multidisciplinary evaluation are essential to avoid misdiagnosis and adverse outcomes. This case highlights the urgent need for more precise treatment guidelines on when to initiate and discontinue antifungal treatment in complex immunocompromised populations.</p><p><strong>Learning points: </strong>Polymerase chain reaction positivity for <i>Aspergillus</i> in the absence of histopathologic confirmation presents a major diagnostic dilemma, particularly in human immunodeficiency virus (HIV)-positive patients, where overreliance on molecular diagnostics may lead to misdiagnosis, unnecessary antifungal exposure, and significant toxicity.Empiric antifungal treatment should be re-evaluated when central nervous system lesions progress or fail to improve, as prolonged use of agents like voriconazole can result in serious toxicity, including arrhythmias like Torsades de Pointes; clearer guidelines are needed to define when empiric treatment is appropriate in complex cases.HIV-positive patients with coexisting malignancy require a multidisciplinary, evidence-based approach, as overla","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"12 9","pages":"005604"},"PeriodicalIF":0.0,"publicationDate":"2025-08-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12416789/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145029377","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Novel Mutation of the NOTCH3 Gene in A Young Patient Presenting with an Acute Stroke: Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL).","authors":"Inas Ragab, Meave Higgins, Antonio F Caballero-Bermejo, Karl Boyle, Kai Covin, Leena Abdelmoti","doi":"10.12890/2025_005297","DOIUrl":"10.12890/2025_005297","url":null,"abstract":"<p><p>This report provides a detailed analysis of a singular case involving cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) in a male patient who suffered a stroke. Our investigation delves into the clinical manifestations, genetic foundations, diagnostic complexities, and prognosis associated with CADASIL. As a notable contributor to stroke occurrence in young patients, CADASIL's impact on morbidity and mortality is influenced by stroke-related complications and cognitive decline. Notably, our report highlights a novel genetic variant (C.3025T>C; p.Cys1009Arg) in the <i>NOTCH3</i> gene linked to CADASIL, shedding light on its underlying pathogenesis. Furthermore, our patient exhibited unexpected white matter changes, challenging conventional age-related norms. These findings underscore the essential role of genetic testing and emphasize the potential diversity in CADASIL's clinical presentation. Further exploration is imperative to enhance our understanding of CADASIL and refine diagnostic strategies, thereby facilitating improved patient prognosis and management.</p><p><strong>Learning points: </strong>Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a significant cause of stroke in young patients, with stroke-related complications and cognitive impairment contributing to morbidity and mortality.Increasing awareness of CADASIL's clinical presentation and the availability of genetic testing has led to a rise in reported cases.CADASIL is caused by mutations in the <i>NOTCH3</i> gene, primarily involving missense substitutions and leading to cysteine residue alterations.There have been many pathogenic variants reported around the world and some families might exhibit private pathogenic variants.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"12 9","pages":"005297"},"PeriodicalIF":0.0,"publicationDate":"2025-08-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12416776/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145029321","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Silent Invader: Asymptomatic Rhodococcus Infection Unmasked in A Patient with Ectopic ACTH-Dependent Cushing's Syndrome.","authors":"Shahzeb Saeed, George Fawzy, Ayesha Shah, Molly John","doi":"10.12890/2025_005711","DOIUrl":"10.12890/2025_005711","url":null,"abstract":"<p><strong>Introduction: </strong><i>Rhodococcus</i> species, particularly <i>Rhodococcus equi</i>, are rare opportunistic pathogens that typically affect immunocompromised individuals. These infections usually present with respiratory or systemic symptoms and are often linked to environmental exposure. Asymptomatic <i>Rhodococcus</i> infections are exceedingly rare and pose unique diagnostic and therapeutic challenges.</p><p><strong>Case description: </strong>We report the case of a 29-year-old male who presented with new-onset diabetes mellitus, resistant hypertension and significant weight gain. Physical examination revealed features consistent with Cushing's syndrome. Biochemical evaluation confirmed ACTH-dependent hypercortisolism with an elevated plasma ACTH level, and a lack of suppression on high-dose dexamethasone testing; imaging identified a suspicious pulmonary nodule. Bronchoscopic biopsy revealed no malignancy, however cultures grew <i>Rhodococcus</i> species. The patient denied any respiratory symptoms or environmental exposure. Initial antibiotic therapy with ciprofloxacin and rifampin was started. Follow-up imaging showed rapid enlargement of the pulmonary mass, prompting surgical resection. Histopathology revealed malakoplakia, and repeat cultures again yielded <i>Rhodococcus spp.</i> Antibiotics were adjusted to azithromycin and rifampin, and the patient was started on ketoconazole to manage hypercortisolism.</p><p><strong>Conclusion: </strong>This case highlights the importance of considering opportunistic infections such as <i>Rhodococcus spp.</i> in immunocompromised patients, even in the absence of symptoms. It underscores the diagnostic value of investigating incidental findings in such populations and illustrates the need for prompt, multidisciplinary management to prevent disease progression.</p><p><strong>Learning points: </strong>This case highlights the diagnostic complexity of incidental pulmonary nodules in immunocompromised patients, reinforcing the need for thorough microbiological investigation even in the absence of infection symptoms.It illustrates a rare, asymptomatic presentation of <i>Rhodococcus</i> infection in the context of ectopic ACTH-dependent Cushing's syndrome, a scenario not widely reported in the literature.Practical is given guidance on managing opportunistic infections and evaluating ectopic ACTH sources, aiding internists in navigating similar diagnostic and therapeutic challenges in complex endocrine-infectious overlaps.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"12 9","pages":"005711"},"PeriodicalIF":0.0,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12416799/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145029355","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"When Less Could be More: Successful Treatment of Granulomatous Lymphocytic Interstitial Lung Disease with Azathioprine.","authors":"Ana Laura López, Diego Santiago Fernández Romero","doi":"10.12890/2025_005632","DOIUrl":"10.12890/2025_005632","url":null,"abstract":"<p><strong>Introduction: </strong>Interstitial lung disease is a major complication in patients with common variable immunodeficiency. There are some publications that try to shed light on the pathophysiology of this non-infectious complication, most of them highlight the role of follicular T cells and CD21^low B cells. Moreover, there are no guidelines based on randomized controlled studies on the treatment of patients with interstitial lung disease and the published case series or small uncontrolled studies describe a wide range of response rates to treatment. In this scenario, the decisions are based on expert opinion rather than on robust scientific evidence. This could lead to potential biases associated with expert opinion based on a small number of patients.</p><p><strong>Case description: </strong>We present the case of an adult patient with common variable immunodeficiency and interstitial lung disease. He did not receive rituximab due to an adverse reaction and underwent treatment with azathioprine, achieving prolonged remission after treatment discontinuation.</p><p><strong>Discussion: </strong>If T-cell involvement could be the main underlying cause of this complication, treatment targeting T-cells may possibly be an effective therapeutic option. Our case, complemented with a physiopathology review, suggests a beneficial effect of azathioprine that warrants further research.</p><p><strong>Conclusion: </strong>It is important to keep in mind that patients with common variable immunodeficiency are a heterogeneous group, so no single treatment will be the best for all of them. It is necessary to review the rationale for the increasing use of anti-CD20 drugs in non-infectious complications in patients with common variable immunodeficiency. Such use is based on expert recommendations and not on randomized, controlled studies with quantitative endpoints.</p><p><strong>Learning points: </strong>There are no guidelines based on randomized controlled studies on the treatment of patients with common variable immunodeficiency and interstitial lung disease.The use of rituximab in the treatment of various non-infectious manifestations in patients with common variable immunodeficiency, including interstitial lung disease, could be the result of potential biases associated with expert opinion based on a small number of patients.T-cell involvement could be the main underlying cause of this complication so treatment targeting T-cells may possibly be an effective therapeutic option.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"12 9","pages":"005632"},"PeriodicalIF":0.0,"publicationDate":"2025-07-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12416771/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145029394","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Clever Stroke Mimic: Thrombotic Thrombocytopenic Purpura Without Schistocytes - A Case Report and Literature Review.","authors":"Ko Takamatsu, Chalothorn Wannaphut, Kevin Benavente, Yoshito Nishimura, Christina Chong","doi":"10.12890/2025_005628","DOIUrl":"10.12890/2025_005628","url":null,"abstract":"<p><strong>Background: </strong>Thrombotic thrombocytopenic purpura (TTP) is a life-threatening hematologic emergency caused by ADAMTS13 deficiency, leading to microvascular thrombosis, haemolytic anaemia, thrombocytopenia, and end-organ damage. Neurological symptoms occur in up to 90% of cases and are frequently misdiagnosed as stroke. Prompt recognition and treatment reduce the mortality rate from over 90% to 10-20%.</p><p><strong>Case presentation: </strong>A 70-year-old woman with no significant medical history presented with acute aphasia and right-sided facial and upper extremity numbness. Five days prior, she had experienced fatigue, headache, and bruising. On admission, she had stable vitals with mild aphasia and purpuric ecchymoses noted on examination. Laboratory findings revealed haemolytic anaemia (haemoglobin 7.8 g/dl, lactate dehydrogenase 875 U/l, total bilirubin 2.4 mg/dl), thrombocytopenia (35 ×10⁹/l), and unremarkable coagulation studies (partial thromboplastin time 30 sec, prothrombin time-international normalized ratio 1, fibrinogen 370 mg/dl, D-dimer 2.15 ng/ml). Peripheral smear showed no schistocytes but noted 2+spherocytes. Stroke was ruled out with brain magnetic resonance imaging/magnetic resonance angiography. Given the bicytopenia with possible haemolysis along with new neurological symptoms, TTP was considered in the differential diagnosis. A PLASMIC score of 5 suggested a high probability of TTP. Plasma exchange and corticosteroids were initiated within 5 hours of presentation. ADAMTS13 activity <1% confirmed the diagnosis 4 days after presentation. After five plasma exchange sessions, the patient's platelet count normalized and neurologic deficits resolved by discharge.</p><p><strong>Conclusion: </strong>This case underscores the importance of considering TTP in stroke mimics, even in the absence of schistocytes, if clinical suspicion is high. Early recognition and initiation of treatment significantly improve patient outcomes.</p><p><strong>Learning points: </strong>Start plasmapheresis and high-dose steroids immediately for suspected thrombotic thrombocytopenic purpura (TTP), even if schistocytes are absent when clinical suspicions are high.Recognizing TTP's neurological symptoms mimicking stroke is crucial to avoid misdiagnosis and ensure timely treatment.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"12 9","pages":"005628"},"PeriodicalIF":0.0,"publicationDate":"2025-07-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12416773/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145029304","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Case of Pneumococcal Periaortitis: Periaortitis is not Always Autoimmune.","authors":"Georges El Hasbani, John Wilson, Kenneth Warrington","doi":"10.12890/2025_005633","DOIUrl":"10.12890/2025_005633","url":null,"abstract":"<p><strong>Introduction: </strong>Periaortitis is a rare inflammatory condition with both infectious and non-infectious aetiologies, often presenting a diagnostic challenge. A comprehensive evaluation-including history, physical examination, imaging, and a broad infectious work-up-is essential, as negative blood cultures do not rule out infection, and premature use of glucocorticoids may be harmful in cases of infectious periaortitis.</p><p><strong>Case description: </strong>We report the case of a 70-year-old man presenting with flank pain and periaortitis, in whom positron emission tomography/computed tomography (PET/CT) scan revealed moderate-to-severe ¹⁸F-fluorodeoxyglucose (FDG) uptake. Despite negative cultures, a Karius test and urine antigen confirmed <i>Streptococcus pneumoniae</i> as the causative agent. The patient underwent successful open surgical repair of a mycotic pararenal abdominal aortic aneurysm, followed by targeted antibiotic therapy.</p><p><strong>Discussion: </strong>Pneumococcal periaortitis is a rare condition with few reported cases, though <i>S. pneumoniae</i> has been implicated in various vascular infections including mycotic aneurysms, and diagnostic challenges persist, especially when blood cultures are negative. The Karius Spectrum^™, despite its cost and limited guidance for use, and FDG-PET/CT imaging have emerged as helpful tools in identifying infectious aetiologies, with high maximum standardized uptake value values favouring infection over autoimmune causes, as seen in this case.</p><p><strong>Conclusion: </strong>Infectious periaortitis should be suspected when there is a high uptake of FDG on PET/CT prompting an infectious disease work-up which may include a Karius test.</p><p><strong>Learning points: </strong>Periaortitis may have an autoimmune aetiology; however, an infectious cause should always be considered, particularly when there is high ¹⁸F-fluorodeoxyglucose uptake on positron emission tomography/computed tomography imaging.<i>Streptococcus pneumoniae</i> is a rare cause of periaortitis and has been more commonly reported in association with mycotic aneurysms.Microbial cell-free deoxyribonucleic acid testing, such as the Karius test, may be a useful tool for identifying specific bacteria, especially when blood cultures are negative.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"12 8","pages":"005633"},"PeriodicalIF":0.0,"publicationDate":"2025-07-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12331271/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144816120","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}