European journal of case reports in internal medicine最新文献

{"title":"Cardiac Involvement as First Manifestation of Peripheral T-Cell Not Otherwise Specified Lymphoma.","authors":"Paula Awamleh García, Manuel Emilio Monguió Santín, Carla López Martínez, Susana Hernández Muñiz, Miguel de la Serna Real de Asúa, Rosalía Alonso Trillo, María Isabel Delgado Trillo","doi":"10.12890/2026_006099","DOIUrl":"10.12890/2026_006099","url":null,"abstract":"<p><p>Cardiac involvement as the first manifestation of peripheral T-cell lymphoma not otherwise specified (PTCL-NOS) is extremely rare. We report on a 72-year-old man with hypertension, dyslipidaemia and prediabetes who presented with acute pleuropericarditis, pericardial effusion and conduction abnormalities. Despite initial treatment, his condition worsened. Imaging revealed pericardial/myocardial infiltration and a right atrial mass. Biopsy confirmed PTCL-NOS (CD3+, CD5+, CD7+, high Ki-67). Complications included ileus, pulmonary embolism and neutropaenia. CHOP failed; GemOx was ineffective; he died from hypernatremia. This reported case emphasises the aggressive course, diagnostic challenges and poor treatment response of cardiac PTCL-NOS.</p><p><strong>Learning points: </strong>This case represented a significant diagnostic challenge; the clinical problem was documented by multiple imaging modalities, none of which were sufficient to establish a definitive diagnosis.This case is a clear example of how the most challenging cases require a multidisciplinary team, involving professionals from very different specialties (for example cardiologists, cardiac surgeons, general surgeons, haematologists, radiologists, pathologists), to achieve the correct diagnosis and provide the best possible care for the patient.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"13 5","pages":"006099"},"PeriodicalIF":0.0,"publicationDate":"2026-04-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13166972/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147927771","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":"Postpartum Parsonage-Turner Syndrome with Hourglass Constrictions and Spontaneous Recovery without Surgical Intervention.","authors":"Joanna I Choi-Klier","doi":"10.12890/2026_006571","DOIUrl":"10.12890/2026_006571","url":null,"abstract":"<p><strong>Introduction: </strong>Parsonage-Turner syndrome (PTS), also known as neuralgic amyotrophy, is an uncommon neurologic disorder characterised by acute onset upper extremity pain followed by muscle weakness, atrophy and paraesthesias. Severity of symptoms is variable and can involve any peripheral motor nerves of the brachial plexus. Its occurrence in the immediate postpartum period is exceedingly uncommon.</p><p><strong>Case description: </strong>A 31-year-old G1P1002 with a twin gestation underwent an emergency caesarean delivery for non-reassuring foetal status of twin B following a spontaneous vaginal delivery of twin A. Her pregnancy was complicated by A2 gestational diabetes. Shortly after surgery, the patient experienced right arm numbness, followed by two weeks of severe pain. Upon resolution of pain, she developed profound weakness in the posterior interosseous nerve (PIN) distribution of the right hand. Physical examination revealed loss of finger extension at the metacarpophalangeal joints, weak thumb extension and loss of wrist extension, with decreased sensation to light touch in the radial four digits. Wrist flexion was preserved. Electromyography demonstrated right posterior PIN neuropathy; specialised MR neurography identified multiple hourglass constrictions, pathognomonic for PTS.</p><p><strong>Discussion: </strong>The patient was managed conservatively with analgesics, a trial of corticosteroids, electrical stimulation and occupational therapy. Eleven months after symptom onset, finger extension returned spontaneously.</p><p><strong>Conclusion: </strong>This case highlights the presentation of PTS in the immediate postpartum period following caesarean delivery. Recognition of characteristic clinical features and imaging findings is crucial for accurate diagnosis. Conservative management can result in full functional recovery, though symptom resolution may be delayed.</p><p><strong>Learning points: </strong>Parsonage-Turner syndrome should be considered in postpartum patients presenting with acute severe upper extremity pain followed by weakness, as the condition may be misdiagnosed as cervical radiculopathy, peripheral nerve compression or carpal tunnel syndrome.Hourglass constriction lesions identified on MR neurography are considered pathognomonic for neuralgic amyotrophy, but the presence of these lesions does not necessarily mandate early surgical intervention.Spontaneous neurologic recovery may occur even in patients with hourglass constriction lesions, supporting the importance of individualised management and careful longitudinal reassessment before proceeding to operative treatment.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"13 5","pages":"006571"},"PeriodicalIF":0.0,"publicationDate":"2026-04-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13166987/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147927689","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 Effect of Pyrethroid Ingestion on Butyrylcholinesterase Level.","authors":"Emile Al Katrib, Ayman Karroum, Radwan Zaidan, Mirna Fares","doi":"10.12890/2026_006465","DOIUrl":"10.12890/2026_006465","url":null,"abstract":"<p><p>We report a 45-year-old man who experienced dyspnoea, severe chest pain followed by decreased level of consciousness, and seizure-like symptoms requiring sedation and intubation. The level of high-sensitivity troponin was elevated. The patient was diagnosed in an outside institution with acute coronary syndrome along with infectious meningitis based on studies performed on cerebrospinal fluid (CSF). The patient was transferred to our hospital for further management. Cardiac ultrasound showed dilated cardiomyopathy with decreased ejection fraction. Significant coronary stenosis was excluded by coronary angiography and a polymerase chain reaction neuro-panel on the CSF came back negative. After exclusion of ACS and meningitis, detailed history taking showed that the patient's office at work had been treated with an insecticide. The product used turned out to be deltamethrin, a type II pyrethroid. The butyrylcholinesterase (BChE) level was low. Studies have shown that deltamethrin produces neurotoxicity and cardiovascular complications; however, the effect of deltamethrin on the BChE level and the development of non-ischemic cardiomyopathy remains unclear.</p><p><strong>Learning points: </strong>Pyrethroid intoxication can lead to significant cardiotoxic effects, which necessitate prompt recognition and management.Although pyrethroids primarily act on sodium channels, they may indirectly affect cholinesterase levels, complicating the diagnostic process.Effective management of pyrethroid poisoning relies on early diagnosis, supportive care, and targeted treatment of both neurological and cardiovascular manifestations.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"13 5","pages":"006465"},"PeriodicalIF":0.0,"publicationDate":"2026-04-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13166975/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147927734","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 Thyroid Therapy to Systemic Crisis: PTU-Induced c-ANCA Vasculitis Accompanied by Cold-Agglutinin Disease and Organ Failure.","authors":"Pelagia Kefala-Karli, Theodosia Christou, Elisavet Georgiou, Despina Pavlou, Andreas Kapouralos, Kyriakos Panagi, Konstantina Chalmoukou","doi":"10.12890/2026_006500","DOIUrl":"10.12890/2026_006500","url":null,"abstract":"<p><strong>Introduction: </strong>Propylthiouracil (PTU) is typically used as first line therapy for hyperthyroidism but is associated with a spectrum of adverse effects including vasculitis, that may lead to acute renal failure and exceptionally to pancreatitis, represents the most severe.</p><p><strong>Case description: </strong>Here we present the case of a 43-year-old woman with a history of Graves' disease until recently on PTU therapy, who presented with fever and myalgia complicated by cold agglutinin disease, acute renal failure and pancreatitis. Subsequent laboratory studies and thorough physical examination excluding other causes revealed the presence of antibodies against leukocyte proteinase 3. Prompt initiation of immunosuppressive therapy and plasmapheresis led to immediate improvement of the patient's clinical condition and laboratory tests.</p><p><strong>Conclusion: </strong>Clinicians should maintain a high index of suspicion for autoimmune phenomena in patients receiving PTU even after cessation of the medication. Early recognition, immediate discontinuation of the drug, and timely initiation of immunosuppressive therapy are essential to prevent irreversible organ damage.</p><p><strong>Learning points: </strong>Propylthiouracil is a well described trigger for the development of drug-induced vasculitis, seldom even long after cessation of therapy.In patients presenting with multi-organ failure the differential diagnosis should broaden to include systemic autoimmune vasculitis with atypical features.The cornerstone of therapy in drug induced autoimmune vasculitis is the immediate withdrawal of the offending agent and initiation of immunosuppressive therapy.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"13 5","pages":"006500"},"PeriodicalIF":0.0,"publicationDate":"2026-04-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13166980/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147927840","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 Clinical Challenges of Hantavirus-Associated Acute Kidney Injury.","authors":"Nouha Ghriss, Charlotte Mussini, Sonia Kammoun, Chadi Azar, Pierre Leroy, Franck Pourcine, Nabil Belfeki","doi":"10.12890/2026_006159","DOIUrl":"10.12890/2026_006159","url":null,"abstract":"<p><strong>Introduction: </strong>Hantavirus infection is an uncommon zoonosis in Europe but remains an important cause of acute kidney injury, particularly in patients with environmental exposure to rodents. Renal involvement is the hallmark of the disease, although pulmonary manifestations may coexist and mimic immune-mediated pulmonary-renal syndromes, leading to diagnostic challenges in internal medicine.</p><p><strong>Case description: </strong>A 46-year-old previously healthy man living in a rural area was admitted for acute febrile illness with asthenia and myalgia. Initial investigations revealed severe thrombocytopenia and acute kidney injury with proteinuria and microscopic haematuria. A computed tomography scan of the chest and abdomen showed bilateral pulmonary abnormalities, consistent with an acute pulmonary-renal syndrome. Extensive immunological and infectious investigations excluded autoimmune disease and alternative infectious causes. Hantavirus infection was confirmed by positive IgM and IgG serology, with molecular identification of Puumala virus. Renal biopsy demonstrated moderate acute tubular necrosis with minimal interstitial inflammation and preserved glomeruli. The patient was treated with supportive care only, resulting in rapid clinical improvement and complete recovery of renal function.</p><p><strong>Conclusion: </strong>Hantavirus infection should be considered in patients presenting with acute pulmonary-renal syndrome, thrombocytopenia, and compatible epidemiological exposure. Early diagnosis allows appropriate supportive management, avoids unnecessary immunosuppressive therapy, and is associated with an excellent renal prognosis in Puumala virus infection.</p><p><strong>Learning points: </strong>Hantavirus infection should be suspected in febrile patients with thrombocytopenia and acute pulmonary-renal involvement.Rural or rodent exposure is a critical epidemiological clue for diagnosing hantavirus-associated acute kidney injury.Puumala virus infection is usually self-limited and requires supportive care with an excellent renal prognosis.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"13 5","pages":"006159"},"PeriodicalIF":0.0,"publicationDate":"2026-04-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13166985/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147927859","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":"Recurrent Pleuropericarditis Associated with Mesalazine Therapy Masked by Steroid Use.","authors":"Hakan Demiröz, Hasan Eruzun, Handan Doğan Çakmak, Aydın Can Ulusoy, Yusuf Bünyamin Ketenci, Mehmet Akca, Ahmet Bektaş","doi":"10.12890/2026_006544","DOIUrl":"10.12890/2026_006544","url":null,"abstract":"<p><strong>Introduction: </strong>Mesalazine is a cornerstone therapy for ulcerative colitis (UC). Although generally safe, it can cause rare but life-threatening cardiopulmonary complications such as pleuropericarditis.</p><p><strong>Case description: </strong>We report on a patient with a UC flare who presented with dyspnoea, where concurrent pericardial and pleural effusions were detected. The inflammatory response was likely suppressed by concomitant corticosteroid therapy, which masked the clinical manifestations of mesalazine-induced serositis and delayed diagnosis. Two years later, the patient re-presented with recurrent massive pericardial effusion causing tamponade physiology and pleural effusion. Pericardial fluid analysis revealed a haemorrhagic, neutrophil-dominant profile (95% polymorphonuclear leukocyte, mimicking bacterial infection rather than the typically described eosinophilic pattern. Extensive cultures were negative. Following the discontinuation of mesalazine, rapid clinical and radiologic improvement was observed, confirming drug-induced pleuropericarditis.</p><p><strong>Discussion: </strong>This case highlights that mesalazine-associated pleuropericarditis can be obscured by corticosteroids, leading to diagnostic delays. Furthermore, sterile inflammatory reactions to mesalazine can present with atypical neutrophilic features resembling bacterial infection, necessitating a high index of suspicion in inflammatory bowel disease patients presenting with serositis.</p><p><strong>Learning points: </strong>A high index of suspicion for drug-induced serositis: in patients with inflammatory bowel disease, pleuropericarditis should be evaluated as a potential side effect of mesalazine rather than assuming it is an extraintestinal manifestation, especially when symptoms recur upon drug re-exposure.Corticosteroids may mask drug toxicity: concomitant corticosteroid therapy can temporarily suppress the clinical symptoms and effusion of mesalazine-induced pleuropericarditis, leading to a 'wrong footing error' and delayed diagnosis once steroids are tapered.Atypical laboratory features: mesalazine-induced sterile inflammatory reactions can present with a neutrophil-dominant effusion profile (rather than the typical eosinophilic pattern), which may mislead the clinician towards an infectious aetiology.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"13 5","pages":"006544"},"PeriodicalIF":0.0,"publicationDate":"2026-04-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13166977/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147927728","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":"Acquired Fanconi-Like Proximal Renal Tubulopathy Associated with Klebsiella Pneumoniae Infection.","authors":"Shilpa Suthanthararajan, Margrat Das, Thasneem Ara, Vinoth Kumar, Sujan Vishwanath","doi":"10.12890/2026_006469","DOIUrl":"10.12890/2026_006469","url":null,"abstract":"<p><p>Acquired Fanconi syndrome is a rare proximal renal tubular disorder associated with glucosuria, aminoaciduria, phosphaturia, electrolyte disturbance and metabolic acidosis, usually caused by drugs, toxins, or plasma cell disorders. Although infectious causes are rare, this is a case report of a 68-year-old man with altered sensorium due to metabolic encephalopathy secondary to dyselectrolytemia. Evaluation revealed severe hyponatremia, hypokalemia, hypocalcaemia, hypophosphatemia and hypomagnesemia. Urine examination showed proteinuria, normoglycemic glycosuria, inappropriate urinary electrolyte losses and impaired urine concentrating ability. Arterial blood gas analysis showed a normal anion gap metabolic acidosis with a positive urine anion gap suggesting a renal cause for the acidosis. This clinical and laboratory picture is consistent with Fanconi-like proximal tubulopathy. Radiological imaging showed cavitary lung consolidation and bilateral pyelonephritis. Sputum cultures grew <i>Klebsiella pneumoniae</i>. After excluding the usual causes of acquired Fanconi syndrome, the proximal tubular dysfunction was attributed to systemic infection. Following treatment with appropriate antibiotics for the infection and electrolyte replacement, the patient completely recovered clinically and biochemically. This case documents a systemic <i>K. pneumoniae</i> infection presenting with reversible Fanconi-like proximal tubulopathy highlighting the importance of exploring infectious causes in patients with unexplained proximal renal tubular dysfunction.</p><p><strong>Learning points: </strong>This case describes the first documented case of acquired Fanconi-like proximal tubulopathy secondary to a systemic <i>Klebsiella pneumoniae</i> infection and demonstrates complete reversibility of proximal tubular dysfunction, as evidenced by resolution of dyselectrolytemia after appropriate antibiotic treatment.It extends the spectrum of infectious causes of Fanconi syndrome to include Klebsiella, in addition to previously known causes such as <i>Legionella</i>, <i>Streptococcus pneumoniae</i>, and <i>Leptospira</i>.The electrolyte abnormalities were initially attributed to syndrome of inappropriate antidiuretic hormone secretion secondary to pneumonia before the proximal tubular dysfunction was identified leading to a diagnosis of acquired Fanconi like syndrome.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"13 5","pages":"006469"},"PeriodicalIF":0.0,"publicationDate":"2026-04-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13166976/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147927839","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":"<i>Legionella Micdadei</i> Pneumonia Mimicking Miliary Tuberculosis in an Elderly Traveller: A Diagnostic Challenge.","authors":"Susheel Joshi, Mahima Upadhyay, Bibhush Shrestha","doi":"10.12890/2026_006534","DOIUrl":"10.12890/2026_006534","url":null,"abstract":"<p><strong>Introduction: </strong><i>Legionella micdadei</i> is an uncommon cause of atypical pneumonia and may be underrecognized because routine diagnostic testing primarily identifies <i>Legionella pneumophila</i>. Clinical and radiologic manifestations are variable and, in rare instances, may mimic miliary tuberculosis, creating significant diagnostic uncertainty and potential delays in appropriate therapy.</p><p><strong>Case description: </strong>A 77-year-old male presented with persistent headache, fatigue, decreased appetite, and unintentional weight loss following several weeks of flu-like symptoms after recent travel to Pakistan. Imaging demonstrated innumerable diffuse pulmonary micronodules concerning for miliary tuberculosis. The patient was placed in airborne isolation and empirically treated with anti-tuberculous therapy. Extensive microbiologic testing, including sputum studies and serologic evaluation, was negative. Because sputum samples could not be obtained, bronchoscopy with bronchoalveolar lavage (BAL) was performed. Molecular testing of BAL fluid identified <i>L. micdadei</i>. Anti-tuberculous therapy was discontinued and treatment with levofloxacin was initiated, resulting in rapid clinical improvement.</p><p><strong>Conclusion: </strong>This case highlights a rare presentation of <i>L. micdadei</i> pneumonia with diffuse pulmonary micronodules mimicking miliary tuberculosis. Recognition of this atypical presentation and the use of advanced diagnostic techniques such as bronchoscopy and molecular testing are essential for establishing the correct diagnosis and guiding appropriate management.</p><p><strong>Learning points: </strong><i>Legionella micdadei</i> pneumonia can rarely present with diffuse pulmonary micronodules mimicking miliary tuberculosis, leading to potential diagnostic misinterpretation.Standard urinary Legionella antigen testing primarily detects <i>L. pneumophila</i>; therefore, molecular diagnostics such as bronchoalveolar lavage polymerase chain reaction may be required to identify non-pneumophila species.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"13 5","pages":"006534"},"PeriodicalIF":0.0,"publicationDate":"2026-04-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13166973/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147927750","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":"Acute Intermittent Porphyria Mimicking Severe Coprostasis in a Patient on Opioid Maintenance Therapy.","authors":"Carolin Glatzle, Felix Gerstendörfer, Armon Arpagaus, Flavio Gössi","doi":"10.12890/2026_006584","DOIUrl":"10.12890/2026_006584","url":null,"abstract":"<p><strong>Introduction: </strong>Acute intermittent porphyria (AIP) is a rare hereditary metabolic disorder in haem biosynthesis that presents with severe abdominal pain. Attacks may be triggered by caloric deprivation. Diagnostic delay is common and reflects non-specific clinical presentations, the rarity of the disease and cognitive biases in clinical decision-making.</p><p><strong>Case description: </strong>A 30-year-old woman with opioid and benzodiazepine use disorder presented with abdominal pain and constipation and was initially treated for opioid-induced constipation. Persistent symptoms and hyponatraemia prompted further evaluation, revealing markedly elevated urinary porphyrin precursors. She was diagnosed with AIP and treated with intravenous hemin and high-carbohydrate therapy.</p><p><strong>Discussion: </strong>This case illustrates the diagnostic challenge of AIP when plausible alternative explanations such as opioid-induced constipation are present. Persistent symptoms and hyponatraemia due to SIADH served as key clues prompting diagnostic reassessment. Diagnostic overshadowing may have contributed to delayed recognition in the context of substance use disorder. Concurrent severe malnutrition with caloric deprivation likely triggered the attack via accumulation of neurotoxic haem precursors, underscoring the importance of diagnostic flexibility in atypical or non-resolving cases.</p><p><strong>Conclusion: </strong>This case underscores the need to consider AIP in patients with severe abdominal pain and atypical clinical courses.</p><p><strong>Learning points: </strong>Acute intermittent porphyria (AIP) can present as opioid-induced coprostasis, increasing the risk of diagnostic anchoring and delay.Coexisting factors (opioid therapy, psychiatric comorbidity, malnutrition) may act simultaneously as triggers, mimics and sources of cognitive bias.Reconsidering the initial diagnosis in atypical or non-resolving cases is essential to counter cognitive bias and improve outcomes in rare but treatable conditions.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"13 5","pages":"006584"},"PeriodicalIF":0.0,"publicationDate":"2026-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13166996/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147927825","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":"Pneumoperitoneum Following Perineal Air Insufflation can be Managed Conservatively.","authors":"Mohammad Alabdallat, Ammar Almadani, Murad Alahmad, Ahmad Kloub, Ayman El-Menyar, Sandro Rizoli, Hassan Al-Thani","doi":"10.12890/2026_006464","DOIUrl":"10.12890/2026_006464","url":null,"abstract":"<p><strong>Introduction: </strong>Pneumoperitoneum is commonly associated with a perforated hollow viscus and often prompts emergency surgical intervention. However, not all cases necessitate operative management. A rare but important cause of pneumoperitoneum is air insufflation through the perianal route, which can lead to extensive subcutaneous emphysema and intra-abdominal free air without evidence of visceral perforation.</p><p><strong>Case description: </strong>We present a case of pneumoperitoneum following perianal air insufflation managed conservatively after a thorough clinical and radiological assessment revealed no indication for surgery.</p><p><strong>Conclusion: </strong>This case underscores the importance of distinguishing non-surgical from surgical pneumoperitoneum. Early recognition and appropriate conservative treatment can prevent unnecessary operative interventions and their associated risks.</p><p><strong>Learning points: </strong>High-pressure air insufflation through the rectum is a rare but potentially severe form of trauma.This can lead to pneumoperitoneum that requires exploratory laparotomy in some cases.However, such traumatic pneumoperitoneum can be treated conservatively after excluding the presence of perforation.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"13 4","pages":"006464"},"PeriodicalIF":0.0,"publicationDate":"2026-04-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13078752/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147687538","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}