Halil Yildiz

To chew or not to chew: that's the question

A 25-year-old Somalian man was referred to the department of internal medicine because of nausea, vomiting and jaundice of recent onset. On physical examination, he was frankly icteric without clinical signs of chronic liver disease. Laboratory data showed evidence of acute hepatitis. Viral serologic tests for hepatitis A, B, C and E were negative. Antinuclear antibodies (ANA) were positive (titre 1 : 1280; speckled pattern, NV < 1 : 40) as well anti-actin antibodies (titre 75 UA, NV < 20). A liver biopsy was performed and showed a feature compatible with toxic hepatitis. On further questioning, the patient admitted to daily chew Khat when he was living in Somalia. We concluded to Khat-induced toxic hepatitis together with high-titre anti-nuclear antibody mimicking serologic patterns of auto-immune hepatitis.

Acute pyelonephritis and renal vein thrombosis: A case report and review of the literature

A 68-year-old female presented with a week history of fever and generalized weakness. Clinical examination, blood work and urinalysis were compatible with sepsis due to acute pyelonephritis. Urine cultures were positive for Escherichia coli and blood cultures were negative. After 5 days of antibiotic therapy with cefuroxime, inflammatory parameters (CRP level and white blood cell count) remained highly elevated. Abdominal CT scan showed right kidney pyelonephritis with renal and perirenal abscess and right renal vein thrombosis. The patient improved after percutaneous drainage of the perirenal abscess and anticoagulation treatment. She was discharged on hospital day 14.

Venous thromboembolism associated with acute cytomegalovirus infection: epidemiology and predisposing conditions

Background: Venous thromboembolism has been reported in association with cytomegalovirus (CMV) infection both in immunocompromised and immunocompetent patients. In this population, it is yet undetermined whether CMV alone provokes VTE or other predisposing conditions are involved. Materials and methods: 1007 VTE patients consecutively recruited in one academic hospital were analyzed retrospectively in order to identify acute CMV infection. Acquired and inherited risk factors were screened. Only adults and immunocompetent patients were included. Results: Among 1007 consecutive VTE patients, we identified 10 patients with synchronous acute CMV infection. Patients with coexistent VTE and acute CMV infection were younger (37.5 years vs. 56.6 years; p = 0.0088) and exhibited a female predominance (90% vs. 56%; p = 0.026), in comparison to the whole cohort. Hereditary thrombophilia was identified in 9 out of 10 patients. Acquired risk factors for VTE like estrogens administration and pregnancy were equally prevalent in patients with and without CMV infection. Conclusion: Acute CMV infection is a potential contributor to VTE whenever other prothrombotic conditions are required. This should help clinicians to privilege a limited duration of anticoagulant treatment like in other provoked VTE.

Liver granulomatosis: a case of Chlamydophila pneumoniae infection

Abstract An 18-year-old man was referred to the Internal Medicine ward because of a 2-week history of intermittent high fever, weight loss and cough. Clinical examination revealed hepato-splenomegaly and multiple lymph nodes swelling while laboratory tests showed elevated C-reactive protein, gamma glutamyl transferase and lactate dehydrogenase. All serologic testes for auto-immune antibodies, viruses and bacteria were negative except for Chlamydophila pneumoniae. An 18-FDG PET computed tomography scanner showed hypermetabolism in the liver, spleen and lymph nodes. We therefore conducted a liver biopsy that demonstrated non-necrotizing granulomas. We conclude to a C. pneumoniae infection associated with a granulomatous hepatitis. After treatment with Doxyciclin the patient had no more fever, hepatosplenomegaly resolved and blood testes normalized. This case report is to our knowledge the first report of a granulomatous hepatitis associated with C. pneumoniae respiratory infection.

Statin-induced rhabdomyolysis mimicking polymyositis on (18)F-FDG PET imaging.

A 80-year-old man was admitted because of diffuse muscle pain. One month before presentation, he began experiencing muscle pain. Since an acute myocardial infarction 20 years earlier, he has receiving simvastatin. Muscle testing confirmed severe proximal weakness, bilaterally. Laboratory data displayed elevated creatine kinase peaking at 40650 UI/l (normal ,200 UI/l) and mildly elevated C-reactive protein. Antinuclear antibodies and antibodies to RNP and Jo1 were negative. A F-FDG PET (Fig. 1) in antero-posterior maximal intensity projection mode (Fig. 1A and E) and fused transaxial PET-CT slices (Fig. 1B–D and F–H) was performed to screen for a malignant tumour, responsible for inflammatory polymyositis. No tumoural uptake was disclosed, but intense hypermetabolic activity was demonstrated in muscles of the extremities, pelvis, and thoracic wall (Fig. 1A–D). A statin-induced myopathy was postulated. Two weeks after simvastatin withdrawal, pain had disappeared. A second F-FDG PET performed 6 weeks later confirmed that muscular hypermetabolic activity had cleared (Fig. 1E–H). Statins are hypolipidaemic agents used for primary and secondary prevention in people at risk of cardiovascular disease. Myopathy, a well-known side effect of statins, vary from asymptomatic creatine kinase elevation to severe rhabdomyolysis as illustrated in this case. Although more prevalent at the beginning of treatment, myopathy may even

Minimal change disease associated with malignant pleural mesothelioma: case report and review of the literature

A 77-year-old man with a history of asbestos exposure was admitted to our internal medicine division for generalised weakness, fatigue, loss of weight, night sweats and difficulty for breathing since 3 months. Clinical examination revealed left fine crackles and bilateral leg oedema. Blood test showed elevated C reactive protein level at 142 mg/L, lactate dehydrogenase level at 421 UI, creatinine level at 5.75 mg/dL. Serum albumin level at 30 g/L, urinalysis showed significant proteinuria at 6.4 g/L. Chest X-ray showed left pleural effusion. Renal ultrasonography was normal. Thoracic CT and positron emission tomography showed mediastinal enlargement with lymphadenopathies and left pleural effusion and thickening. A pleural biopsy showed features compatible with malignant epithelioid mesothelioma. Renal biopsy showed minimal change disease and acute tubular necrosis. A diagnosis of malignant mesothelioma associated with minimal change disease and acute tubular necrosis secondary was then made. Given the poor general condition, palliative care was initiated and the patient died from respiratory failure 3 months later.

An unexpected complication of bacillus Calmette-Guérin therapy

A 78-year-old man presented with a history of fever and night sweats of 1-month duration. His relevant medical history was a transitional-cell bladder cancer treated with intravesical instillation of bacillus Calmette–Guérin (BCG) 5 months previously. Abdominal palpation revealed a pulsatile mass in the left lower quadrant. Laboratory tests only showed an elevated C-reactive protein at 5.7 mg/dl. Contrast-enhanced CT scan of the abdomen demonstrated a saccular aneurysm of the infra-renal aorta (Fig. 1) suggestive of mycotic aneurysm. An aneurysmal resection was then performed. Aerobic and anaerobic culture of the aortic tissue remained negative but a Ziehl–Nielsen stain was positive consistent with a mycobacterial infection. Acid-fast culture and PCR were positive for Mycobacterium bovis. The diagnosis of mycotic aneurysma following intravesical BCG therapy was then retained. Vascular complications after intravesical instillation of BCG, a live attenuated strain of Mycobacterium bovis, are extremely rare. Haematogenous or lymphatic spread is the most common hypothesis proposed to explain an arterial infection by M. bovis. Both medical and surgical approach are requested in the management of BCGinduced mycotic aneurysm. A combination with at least three antituberculous agents for 9–12 months is recommended. Pyrazinamide should not be used due to widespread resistance of M. bovis.

Man with bilateral inguinal lymphadenopathy

Clinical introduction A 37-year-old man with history of lymph node tuberculosis presented with bilateral inguinal swelling with night sweats but no fever for 2 weeks. He had a cat but he had no history of scratches. He had an extraconjugal sexual intercourse a few weeks before. Physical examination revealed 5 cm tender, erythematous and painful bilateral inguinal adenopathy (figure 1A) and a small ulceration at the base of the penis (figure 1B). Vital signs were normal. Figure 1 (A) Inguinal lymphadenopathy. (B) Ulceration at the base of the penis. Question What is the most likely diagnosis? Toxoplasmosis Tuberculosis Cat-scratch disease Lymphogranuloma venereum Syphilis

Dermatomyositis with anti-TIF1-γ antibodies

We report the case of a 61-year-old Turkish male patient who presented to our dermatology outpatient clinic with a 1-year history of swelling and pruritic erythema rash of the face and trunk. He reported associated myalgia and arthralgia of the knees and wrists. Two months before presentation, he developed muscle weakness of upper limbs and dyspnoea. On review, he was noted to have unintentional weight loss (5 kg over 2 months) and increasing fatigue. His medical and family histories were unremarkable. His medications included omeprazole daily and vitamin B12 injections. Prior to presentation to our clinic, his general practitioner treated the patient with antihistamines, topical steroids (Elocom) and a short course of oral corticosteroid therapy which only provided temporary relief. Laboratory data demonstrated C reactive protein 6 mg/L (normal value (NV) <5 mg/L), haemoglobin 11.9 g/dL (NV 13–18 g/dL), lactate dehydrogenase 467 U/L (NV 135–225 U/L), creatinine phosphokinase 295 U/L (NV 30–190 U/L), Aspartate transaminase (GOT) 75 U/L (NV 8–31 U/L), Glutamate pyruvate transaminase (GPT) 66 U/L (NV 5–31 U/L); white blood count, ionogram, lipid profile, renal function, thyroid …

TINU-associated Fanconi syndrome: a case report and review of literature

BackgroundTubulo-interstitial Nephritis and Uveitis (TINU) syndrome is a rare oculo-renal inflammatory disease. Renal tubular defects are usually found, but full proximal tubular abnormalities have rarely been described.Case presentationWe report the case of a 55-year old woman, native from Morocco, presenting with bilateral, non-granulomatous, anterior uveitis, mild renal insufficiency, leucocyturia and glycosuria. Further work-up showed hypophosphatemia and hyperphosphaturia, hypouricemia and hyperuricosuria, and hyper aminoaciduria, consistent with Fanconi syndrome. A kidney biopsy was obtained and showed diffuse interstitial infiltrates with tubular necrosis. The patient improved after the initiation of a corticosteroid therapy, with tapering dose.ConclusionsWe reviewed the literature and found nine similar cases. This association mostly occurs in adult woman, without current evidence for an ethnic predilection, unlike previously reported. The renal prognosis seems favorable after corticosteroid therapy, even in case of severe renal injury. Nonetheless mild tubular defects may persist after treatment or spontaneous remission.