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Local anesthetics are widely used by various medical professionals. Although their usefulness is unquestionable, as with any medication, there is a possibility of iatrogenic effects. When local anesthetic systemic toxicity occurs, it might be a life-threatening condition. Knowing its existence and how to act when it arises is crucial. The clinical presentation is wide-ranging, but globally it affects the neurological and cardiovascular system, with cardiac arrest being the extreme of its presentation. The treatment is mainly supportive with an attempt to reverse the effects of the anesthetic by administering a lipid emulsion. Here, we present a clinical case of difficult management with many complications., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Lavado et al.)

Gastric volvulus can be defined as an abnormal rotation of the stomach. It can be both an emergency and a chronic intermittent problem. Being such a rare clinical entity and a difficult condition to diagnose, it is commonly diagnosed at the time of surgery or even at autopsy. We present the case of an 82-year-old independent female with a past medical history of hiatal hernia, who came to the emergency department with hematemesis and severe epigastric pain. An abdominal CT scan revealed an organoaxial stomach volvulus within the intrathoracic cavity. After initial treatment with gastric decompression, IV fluids and proton pump inhibitors, the patient was informed that the surgical intervention would be the only definitive curative treatment for her condition and denied the procedure. She was then discharged after clinical and analytical improvement. She was offered a conservative treatment and follow up by the internal medicine team. After a few months, the patient reported moderate improvement of her symptoms and less episodes of epigastric pain. She was pleased with the conservative management and denied any surgical or invasive procedures. A proximity contact was established with the family doctor, which she maintains. This case report is proof that rare entities can happen to patients presenting common symptoms and better resolutions come from multidisciplinary approaches., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Rodrigues et al.)

Acute disseminated encephalomyelitis (ADEM) is a demyelinating disorder that usually affects the central nervous system (CNS) after an infection and/or vaccination. It is more common in infancy. Here we present a case of late onset ADEM. A 71-year-old male was admitted to the emergency department due to speech difficulty and somnolence. Upon neurological examination he had a mixed aphasia. He performed a brain computed tomography which showed multiple white matter hypodense lesions. After admission to the neurology ward, he performed a lumbar puncture which showed a mildly inflammatory cerebrospinal fluid, negative serological testing and negative oligoclonal bands. Brain magnetic resonance imaging (MRI) confirmed the presence of multiple T2 hyperintense lesions, extensive bilateral frontoparietal lesions with abundant perilesional edema, four with gadolinium enhancement in an open-ring pattern and no mass effect. Anti-aquaporin 4 antibody, virologic and bacteriologic blood testing, screening of autoimmune disorders and occult neoplasm were all unremarkable. He was treated with intravenous methylprednisolone (1 gr) during five days and started to recover, maintaining a slight verbal fluency deficiency. Post-treatment brain MRI showed reduction of previous lesions, corroborating the probable inflammatory/demyelinating etiology. After discharge he maintained follow-up at the neurology outpatient clinic and he is currently asymptomatic with no new lesions and further reduction of the previous ones on follow-up MR scan. Both clinical follow-up of the patient, revealing a monophasic course with complete recovery, and temporal evolution of his brain lesions were essential to establish a diagnosis of ADEM in a septuagenarian patient, in whom other diagnoses have to be considered., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2019, Ferro et al.)