European journal of case reports in internal medicine最新文献

{"title":"Haemophagocytic Lymphohistiocytosis: An Uncommon Presentation in Systemic Lupus Erythematosus and Acute Leukaemia.","authors":"Nada Msabri Gharbi, Alex Smithson, He Zhang Lin, Mario Mandis, Diana Carolina Quiroga Parada, Oriana Guevara Vasquez, Gloria De la Red Bellvis","doi":"10.12890/2025_005555","DOIUrl":"10.12890/2025_005555","url":null,"abstract":"<p><strong>Introduction: </strong>Haemophagocytic lymphohistiocytosis (HLH) is a rare and potentially life-threatening hyperinflammatory syndrome, characterised by uncontrolled activation of cytotoxic T lymphocytes, natural killer cells and macrophages, leading to a cytokine storm and subsequent multiorgan damage. While HLH predominantly affects paediatric populations, it is increasingly recognised in adult patients, often occurring in association with malignancies, infections or autoimmune diseases.</p><p><strong>Case description: </strong>We present two distinct adult cases of HLH. Case 1 involves a 21-year-old woman with newly diagnosed systemic lupus erythematosus (SLE), who developed macrophage activation syndrome (MAS)-associated HLH. She presented with prolonged fever, polyarthralgia, malar rash, hepatosplenomegaly, bicytopenia, hypofibrinogenaemia, hypertriglyceridaemia and elevated serum ferritin levels. Case 2 describes a 44-year-old woman with acute monoblastic leukaemia (AML-M5) and malignancy-associated HLH, who presented with fever, malaise, hepatosplenomegaly, hypofibrinogenaemia, hypertriglyceridaemia and hyperferritinaemia. An initial haematological response was achieved; however, disease progression ultimately led to fatal multiorgan failure secondary to neutropenic pancolitis caused by <i>Clostridioides difficile</i> infection.</p><p><strong>Discussion: </strong>Both cases illustrate key clinical and pathophysiological differences in the evolution, management and outcomes of HLH, depending on the underlying cause. While both fulfilled the HLH-2024 diagnostic criteria, they exhibited markedly different responses to therapy and outcomes.</p><p><strong>Conclusion: </strong>These cases highlight the need to suspect HLH in patients with prolonged fever, cytopaenia, organomegaly and high ferritin. Early treatment improves prognosis, especially in autoimmune HLH, where steroids are effective, while malignancy-related HLH often has poorer outcomes.</p><p><strong>Learning points: </strong>Haemophagocytic lymphohistiocytosis (HLH) should be suspected in patients with persistent fever, cytopaenia, organomegaly and markedly elevated ferritin, particularly in the context of autoimmune diseases or haematologic malignancies.Early therapeutic intervention significantly improves prognosis in autoimmune-associated HLH, where corticosteroid therapy is often effective, while malignancy-driven HLH typically carries poorer outcomes despite aggressive treatment.A multidisciplinary approach is essential for HLH management, with treatment strategies tailored to the underlying cause rather than following a uniform protocol.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"12 8","pages":"005555"},"PeriodicalIF":0.0,"publicationDate":"2025-07-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12331282/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144816130","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":"Pyloric Botulinum Toxin for Diabetic Gastroparesis: A Case of Sustained Glycaemic Improvement.","authors":"Luke Bugeja, Lianne Camilleri, John Schembri","doi":"10.12890/2025_005495","DOIUrl":"10.12890/2025_005495","url":null,"abstract":"<p><strong>Introduction: </strong>Diabetic gastroparesis is a gastrointestinal motility disorder defined as a delay in gastric emptying time without any mechanical obstruction. This affects about 40% of patients with type 1 diabetes and up to 30% of patients with type 2 diabetes, especially those with long-standing disease, and arises from dysfunction of the autonomic and enteric nervous systems. Unfortunately, it can cause great difficulty in controlling post-meal glucose excursions because food absorption can become unpredictable in this group of patients. Gastroparesis is therefore linked with fluctuations in glycaemic control due to variable nutrient absorption. This may worsen the extent of gastroparesis, making glucose control even more difficult. Treatment with botulinum toxin injections has been described in clinical trials with doubtful efficacy to abating symptoms associated with gastroparesis.</p><p><strong>Case presentation: </strong>We report a case of how pyloric botulinum toxin injections significantly improved a patient's type 1 diabetic control and gastrointestinal symptoms associated with gastroparesis and is still maintaining improved glucose levels six months after her procedure. Although current data and case studies highlight a potential role for pyloric botulinum toxin injections, no association was found between pyloric botulinum toxin injections and blood glucose control in type 1 diabetics.</p><p><strong>Conclusion: </strong>This article examines a potential promising association between botulinum toxin injection in the pylorus and enhanced diabetic control in type 1 diabetics.</p><p><strong>Learning points: </strong><i>Long-lasting effect:</i> Despite being a temporary intervention, pyloric botulinum toxin injection provided sustained clinical benefit in this case.<i>Glycaemic impact:</i> The treatment significantly improved glucose control and symptoms of autonomic neuropathy in a type 1 diabetic patient.<i>Future potential:</i> Current data lack evidence for glycaemic benefit in type 1 diabetics, highlighting the need for targeted clinical trials.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"12 8","pages":"005495"},"PeriodicalIF":0.0,"publicationDate":"2025-07-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12331266/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144816065","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":"Continuous Irrigation for Refractory Multidrug-Resistant Brain Abscess in two Patients.","authors":"Nguyen Quang Thanh, Nguyen Trung Cap, Vu Dinh Phu, Mac Duy Hung, Nguyen Quoc Phuong, Dong Phu Khiem, Pham Ngoc Thach","doi":"10.12890/2025_005566","DOIUrl":"10.12890/2025_005566","url":null,"abstract":"<p><strong>Introduction: </strong>Brain abscesses remain a significant clinical challenge, particularly in cases involving multidrug-resistant (MDR) organisms or failure of standard surgical and medical therapy. Newer adjunctive techniques, such as continuous irrigation therapy, have been explored to enhance infection control and patient outcomes in these complex scenarios.</p><p><strong>Case description: </strong>We present two cases of brain abscess treated at a tertiary care centre using continuous abscess cavity irrigation after conventional interventions proved insufficient. The first patient, a 15-year-old male, experienced recurrent MDR brain abscesses despite multiple surgical procedures and broad-spectrum antibiotics. Initiation of continuous irrigation, combined with targeted antimicrobial therapy, resulted in rapid clinical stabilisation and marked radiological improvement, with minimal long-term sequelae. The second patient, a 65-year-old female, developed multiple brain abscesses after traumatic brain injury and decompressive surgery. Although continuous irrigation effectively controlled the intracranial infection and imaging confirmed resolution, her neurological recovery was limited due to profound pre-existing brain damage.</p><p><strong>Conclusion: </strong>Continuous irrigation therapy appears to be a valuable adjunct in the management of refractory or MDR brain abscesses, facilitating rapid infection control when conventional treatments are inadequate. However, ultimate neurological outcomes are largely dependent on the extent of underlying brain injury. These cases highlight the importance of considering continuous irrigation in selected patients and underscore the need for further research and multidisciplinary collaboration to optimise management protocols and improve patient outcomes.</p><p><strong>Learning points: </strong>Continuous irrigation with alternating saline and antibiotic solutions is an effective adjunct in the management of refractory or multidrug-resistant brain abscesses.Unfortunately, successful infection control does not always guarantee neurological recovery.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"12 8","pages":"005566"},"PeriodicalIF":0.0,"publicationDate":"2025-07-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12331261/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144816126","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":"Superior Vena Cava Syndrome Mimicking an Allergic Angioedema: A Diagnostic Odyssey from Allergic Reaction to Mediastinal B-Cell Lymphoma.","authors":"Simone Burgener-Enderli, Andreas Schmitt, Stefano Bassetti, Mark Kirsch","doi":"10.12890/2025_005577","DOIUrl":"10.12890/2025_005577","url":null,"abstract":"<p><p>An 18-year-old woman presented to her general practitioner with a history of non-itching facial swelling, erythematous skin rash and a slightly coarse voice for a few days. She denied dyspnoea, B-symptoms and pain. Physical examination revealed generalized facial and neck swelling not involving the tongue or the oral mucous membranes. There was no lymphadenopathy. These findings resulted in the diagnosis of allergic angioedema and in oral treatment with corticosteroids and antihistamines. The swelling responded partially but reoccurred with dose reduction of the corticosteroids. Outpatient referrals to a dermatologist, an endocrinologist and a rheumatologist resulted in confirmation of the diagnosis of allergic angioedema, suspected iatrogenic Cushing syndrome and possible connective tissue disease, respectively. Three months after the first outpatient presentation the patient was admitted to our hospital with severe fatigue and left-sided chest pain. The clinical examination showed the known facial and neck swelling- and a sinus tachycardia (120 bpm) without any fever. Furthermore, the neck swelling seemed to be slightly asymmetrical. This was accompanied by leucocytosis, elevated C-reactive protein, and lactate dehydrogenase. An electrocardiogram showed sinus tachycardia (120/min) with a S1Q3-type. An ultrasound of the neck showed thrombosis of the left jugular vein. Subsequent computed tomography scan of the chest revealed a large mediastinal mass causing acute superior vena cava syndrome. Mediastinal large B-cell lymphoma was confirmed by biopsy. The patient underwent six cycles of DA-R-EPOCH (rituximab, etoposide, prednisolone, vincristine, cyclophosphamide, doxorubicin). Treatment resulted in complete response.</p><p><strong>Learning points: </strong>Vena cava superior syndrome is caused in over 60% of the cases by malignancies (bronchogenic carcinoma, lymphoma, germ cell tumour).Facial swelling, plethora of the upper chest without itchiness and hoarseness are classical symptoms of thoracic central venous obstruction.At every patient visit open-minded clinical reasoning should be used to avoid anchoring bias.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"12 8","pages":"005577"},"PeriodicalIF":0.0,"publicationDate":"2025-07-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12331284/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144816067","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":"Rethinking Glycemic Thresholds: Diabetic Kidney Disease in the Absence of Overt Diabetes.","authors":"Nirmay Sonar, Jarvis Pennington, Mishell Siles Borda, Zaynah Sadiq, Matthew Beasey, Sathiyendram Poobalasingham","doi":"10.12890/2025_005378","DOIUrl":"10.12890/2025_005378","url":null,"abstract":"<p><p>Diabetic kidney disease is traditionally regarded as a complication of chronic hyperglycaemia associated with diabetes. However, the relationship between glycaemic thresholds and the development of diabetic kidney disease is increasingly questioned. We present a case of a 69-year-old woman with progressive renal dysfunction and biopsy findings suggestive of diabetic kidney disease, despite repeatedly normal glycosylated haemoglobin (haemoglobin A1c) and without a clinical diagnosis of diabetes or pre-diabetes. This case highlights the limitations of current haemoglobin A1c thresholds and raises the question of whether diabetic kidney disease can truly develop in the absence of diabetes. Stricter glycaemic criteria may help identify at-risk patients earlier and prevent renal complications.</p><p><strong>Learning points: </strong>Diabetic kidney disease can occur without overt diabetes or pre-diabetes, challenging current diagnostic methods.Reliance on haemoglobin A1c alone may miss at-risk individuals, and stricter glycaemic thresholds may be warranted.The diagnosis of diabetic kidney disease in normoglycemic patients challenges disease definitions and pathogenesis.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"12 8","pages":"005378"},"PeriodicalIF":0.0,"publicationDate":"2025-07-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12331265/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144816066","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":"Hypervitaminemia B12 in the Elderly: A Forgotten Marker of Serious Underlying Diseases.","authors":"Abrar-Ahmad Zulfiqar","doi":"10.12890/2025_005553","DOIUrl":"10.12890/2025_005553","url":null,"abstract":"<p><p>Hypervitaminemia B12, long neglected in clinical practice, is a biological anomaly whose pathological significance remains largely underestimated, particularly in the elderly. While medical attention has historically focused on vitamin B12 deficiency, several recent studies suggest that elevated levels of this vitamin may reveal serious underlying pathologies, such as solid neoplasia, haematological malignancies, chronic liver disease or renal failure. We report the case of a 91-year-old man hospitalized for asthenia, anorexia and altered general condition, in whom vitamin B12 assay revealed major hypervitaminemia (1318 pg/ml). The work-up revealed hepatic cirrhosis of alcoholic origin, complicated by hepatocellular carcinoma which was metastatic from the outset. This case illustrates the potential prognostic value of vitamin B12 dosage, particularly when coupled with C-reactive protein (BCI index), a high value (> 40,000) of which is associated with short-term mortality in patients with advanced cancer. Beyond hepatopathy, hypervitaminemia B12 is associated in the literature with increased haptocorrin release in myeloproliferative syndromes, excess transcobalamins in renal failure, or paradoxical elevation in certain inflammatory diseases. This biological marker, which is easy to obtain, could therefore become part of standardized geriatric assessment, particularly in oncogeriatrics, in order to guide diagnostic and prognostic strategy. The systematic inclusion of vitamin B12 assays in the general assessment of elderly patients, particularly in oncology settings, deserves to be reassessed.</p><p><strong>Learning points: </strong>Hypervitaminemia B12 is an often overlooked but potentially significant marker of serious underlying pathologies-including solid neoplasms, liver disease, renal failure, and hematologic malignancies-especially in elderly patients.The B12 × C-reactive protein (CRP) index, easily obtainable from routine labs, may serve as a prognostic tool in oncology, with values over 40,000 being strongly associated with short-term mortality in advanced cancers.Routine screening for vitamin B12 levels in geriatric assessments should consider both deficiency and excess, with hypervitaminemia prompting systematic diagnostic evaluation to uncover latent or advanced disease.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"12 8","pages":"005553"},"PeriodicalIF":0.0,"publicationDate":"2025-07-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12331276/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144816131","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":"Leukocytoclastic Vasculitis in JAK2-Positive Essential Thrombocythemia: A Case of Cytokine-Driven Urticarial Rash Responsive to Ruxolitinib.","authors":"Murad Aldarayseh, Leonardo Marmolejos, Dalia Al Zoubi, Michelle Cholankeril","doi":"10.12890/2025_005615","DOIUrl":"10.12890/2025_005615","url":null,"abstract":"<p><p>Essential thrombocythemia (ET) is a chronic myeloproliferative neoplasm characterised by sustained thrombocytosis and frequently associated with JAK2 V617F mutations. It is primarily known for its thrombotic and haemorrhagic complications, which dominate its clinical presentation. However, inflammatory and dermatologic manifestations are uncommon and less well recognised. Among these, cutaneous vasculitis - particularly leukocytoclastic vasculitis (LCV) - is a rare and underreported feature. We present the case of a 54-year-old woman with JAK2-positive ET who developed a persistent urticarial rash that coincided with worsening thrombocytosis. Bone marrow biopsy revealed megakaryocytic hyperplasia, confirming the diagnosis of ET. Initially, the patient responded to hydroxyurea, but her disease eventually became refractory, and anagrelide failed to control either her platelet count or symptoms. Her skin rash progressed in parallel with uncontrolled thrombocytosis, and biopsy confirmed LCV. Initiation of ruxolitinib, a JAK1/2 inhibitor, led to haematologic improvement and complete resolution of the vasculitis. This case highlights a rare but clinically significant association between ET and cutaneous vasculitis and suggests a potential role for JAK inhibition in managing such refractory inflammatory manifestations.</p><p><strong>Learning points: </strong>Cutaneous vasculitis is a rare but significant manifestation of essential thrombocythemia.Leukocytoclastic vasculitis may present with urticarial lesions resistant to standard therapy.Janus kinase (JAK) inhibition with ruxolitinib can achieve both haematologic and dermatologic remission in refractory cases.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"12 8","pages":"005615"},"PeriodicalIF":0.0,"publicationDate":"2025-07-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12331274/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144816133","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":"Transient Dysarthria and Hemiparesis in an Adolescent.","authors":"Yasutaka Yanagita, Kiyoshi Shikino","doi":"10.12890/2025_005597","DOIUrl":"10.12890/2025_005597","url":null,"abstract":"<p><p>An adolescent male in his teens had recurrent episodes of transient left lower limb weakness, persisting for three years. These episodes were consistently triggered by specific movements, such as postural changes or movement initiation, occurring multiple times per day. The patient adapted his behaviour to avoid triggering symptoms. Based on the clinical presentation, paroxysmal kinesigenic dyskinesia was diagnosed. Although dysarthria is uncommon in paroxysmal kinesigenic dyskinesia, its presence in this case highlights the condition's clinical variability. Carbamazepine therapy was initiated, which resulted in a significant reduction in the frequency of episodes. This case underscores the importance of recognising movement-triggered transient motor symptoms, including rare symptoms such as dysarthria, to prevent misdiagnosis and unnecessary testing. Early recognition and treatment can significantly improve outcomes and quality of life in patients with paroxysmal kinesigenic dyskinesia.</p><p><strong>Learning points: </strong>Paroxysmal kinesigenic dyskinesia is a rare disorder characterised by brief, recurrent episodes of involuntary movements triggered by sudden voluntary motion.Atypical symptoms such as dysarthria and hemiparesis in paroxysmal kinesigenic dyskinesia may mimic transient ischaemic attacks or structural brain lesions.Anticonvulsants such as carbamazepine are highly effective in treating paroxysmal kinesigenic dyskinesia and can significantly reduce episode frequency and improve quality of life when initiated early.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"12 8","pages":"005597"},"PeriodicalIF":0.0,"publicationDate":"2025-06-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12331277/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144816070","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":"From Fluttering Hearts to Restless Stomach: Navigating Atrial Fibrillation, Ablation and Gastroparesis.","authors":"Rabia Riasat, Anas Atrash","doi":"10.12890/2025_005596","DOIUrl":"10.12890/2025_005596","url":null,"abstract":"<p><strong>Background: </strong>We present a case of severe gastroparesis with pyloric spasm secondary to radiofrequency catheter ablation (RFCA) with a focus on procedural risk factors, prevention, and treatment modalities.</p><p><strong>Case report: </strong>A 39-year-old man with paroxysmal atrial fibrillation underwent RFCA after failed pharmaceutical treatment. The procedure involved three-dimensional mapping and controlled RFCA near the oesophagus. Post-procedure, he developed severe abdominal pain, distention, and vomiting. Imaging revealed stomach distention and pyloric spasm. An upper endoscopy confirmed gastroparesis due to ablation. Metoclopramide was administered, improving food tolerance. However, persistent symptoms led to a gastric emptying study showing delayed emptying, consistent with gastroparesis. Despite treatment with metoclopramide, the patient's symptoms persisted, prompting consideration of esophageal botulinum toxin and medication changes for symptom management.</p><p><strong>Conclusions: </strong>In a patient with no prior history of abdominal symptoms or chronic gastric disorder post ablation presentation of new-onset abdominal distention, pain, and vomiting ablation-induced gastroparesis should be high on the differential and different treatment modalities should be tried if severe symptoms such as postprandial regurgitation persist. Moreover, better oesophageal protection strategies should be implemented, and guidelines be added to procedure performance limiting excessive force, energy, manipulation, and introduction of oesophageal temperature control holding parameters.</p><p><strong>Learning points: </strong>Gastroparesis can be an under-recognized complication of left atrial ablation.Posterior wall ablation near the oesophagus is high-risk for gastrointestinal complications.Symptoms usually persist for 3-6 months but may last long term.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"12 8","pages":"005596"},"PeriodicalIF":0.0,"publicationDate":"2025-06-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12331283/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144816129","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":"The Silent Threat of Wooden Chest Syndrome: Prompt Management of Fentanyl-Induced Muscle Rigidity in the Intensive Care Unit.","authors":"Shreya Devarashetty, Fnu Arty, Anoohya Vangala, Amer Abu Shanab, Doantrang Du","doi":"10.12890/2025_005363","DOIUrl":"10.12890/2025_005363","url":null,"abstract":"<p><strong>Introduction: </strong>Wooden chest syndrome (WCS) is a rare, potentially fatal complication of high-dose fentanyl therapy, characterized by generalized muscle rigidity, reduced chest wall compliance, and acute respiratory distress. Frequently underdiagnosed in the intensive care unit (ICU), WCS poses a significant challenge due to its rapid onset and potential to cause ventilatory failure if not addressed promptly. This case report examines WCS in a postoperative setting, emphasizing its recognition and management to improve patient outcomes.</p><p><strong>Case presentation: </strong>A 49-year-old female with a history of cervical cancer, hypertension, and recent sigmoidectomy developed WCS 8 hours after starting a fentanyl infusion (50 μg/h, total ~400 μg) following an emergent incision and drainage for a 4 × 3 cm neck abscess. Initially stable on pressure-regulated volume control ventilation (peak airway pressure, Ppeak 20 cmH₂O, tidal volume 450 ml), she presented with sudden chest wall rigidity, respiratory rate of 28 breaths/min, and Ppeak rising to 35 cmH₂O, alongside respiratory acidosis (pH 7.28, PaCO₂ 58 mmHg). Fentanyl was stopped, naloxone (2 mg IV) administered, and ventilation shifted to pressure control mode of 25 cmH₂O above positive end-expiratory pressure. Dexmedetomidine (0.5 μg/kg/h) replaced opioids for sedation. Symptoms resolved within 4 hours, enabling a transition to pressure support mode and extubation on postoperative day 2, with discharge to the floor by day 5.</p><p><strong>Conclusion: </strong>This case highlights WCS as a critical, reversible opioid-related complication in the ICU, necessitating vigilance during prolonged fentanyl use (>8 hours). Early detection via ventilator changes (e.g., Ppeak elevation) and swift intervention with naloxone and non-opioid sedation can prevent adverse outcomes. Increased awareness, staff training, and further research are vital to enhance ICU safety.</p><p><strong>Learning points: </strong><i>Early detection is crucial:</i> wooden chest syndrome can manifest as sudden muscle rigidity and rising peak airway pressures within 8 hours of fentanyl infusion, requiring prompt recognition to prevent ventilatory failure.<i>Ventilator changes guide diagnosis:</i> elevated peak pressures with stable plateau pressures signal wooden chest syndrome, distinguishing it from lung pathology, and warrant immediate investigation.<i>Swift management improves outcomes:</i> stopping fentanyl, administering naloxone, and using dexmedetomidine can reverse wooden chest syndrome rapidly, enabling extubation within 48 hours.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"12 8","pages":"005363"},"PeriodicalIF":0.0,"publicationDate":"2025-06-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12331262/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144816068","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}