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Background: A "thrombus in transit" is a relatively rare diagnosis involving a thrombus in a patent foramen ovale. Patent foramen ovale occurs in about 25% of the population. A thrombus in transit may lead to paradoxical arterial emboli in the cerebral circulatory system and the extremities, as well as other locations., Case Description: A 60-year-old male patient with severe pneumonia sepsis appeared to have a thrombus in the right atrium, extending into the left atrium through a patent foramen ovale. The patient was treated with therapeutic anticoagulants. Cerebral embolization occurred despite this, with extensive cerebral ischaemia. The patient ultimately died from multiple organ failure., Conclusion: A thrombus in transit may be treated with heparins, thrombolysis or by surgical removal of the thrombus. The optimum treatment must be decided for each individual patient. The mortality rate of this condition is high (16-36%).

IgG4-related systemic disease is a new clinical entity with a large variety of clinical symptoms that can affect almost all organs. The best known manifestations are retroperitoneal fibrosis and autoimmune pancreatitis. We present 3 patients aged 71, 83 and 70 years, with malaise, fatigue and swellings suggestive of a malignancy. However, histopathology of these swellings showed infiltration with plasma cells. Increased serum IgG4-levels confirmed the diagnosis 'IgG4-related systemic disease'. All patients responded well to treatment with glucocorticoids. IgG4-related systemic disease is often mistaken for malignancy because of similar presenting symptoms. The diagnosis can easily be confirmed by high serum protein levels, high serum IgG4-levels and infiltrates of IgG4-positive plasma cells. Response to treatment with glucocorticoids is good, as is the prognosis. IgG4-related systemic disease should be part of the differential diagnosis when patients present with malaise, high protein-levels and multi-organ involvement. Rapid diagnosis can prevent unnecessary surgical procedures for malignancy.