Search

Chorea is a hyperkinetic movement disorder characterised by brief involuntary, random, and irregular contractions. It’s caused by multiple conditions, including neurodegenerative diseases, cerebrovascular disease, structural damage to deep brain structures, neoplastic diseases, or metabolic derangements, such as hyperglycaemic states. We present a case of an 81-year-old woman, with a history of long-term poorly controlled type 2 diabetes mellitus, admitted to the emergency department with hyperkinetic delirium in the last 48h. At examination, she presented with mild right central facial paresis, and involuntary bilateral movement of the four limbs, more prominent on the right side. Laboratory tests showed hyperglycaemia of 799 mg/dl with ketonemia of 5.2 mg/dL and glycated hemoglobin of 11%. Computed tomography (CT) scan of the brain showed bilateral hyperdensity of the corpus striatum. The treatments included glycemic control with insulin, intravenous fluids, and anti-epileptic drugs. A clinical improvement was observed however, the patient continued to show chorea-like movements of the four limbs. The magnetic resonance imaging (MRI) showed a T2-flair and T2-weighted area of hypo-intensity involving bilaterally the striatum corpus and the corresponding signal in T1. She was then diagnosed with hyperglycaemia-associated chorea and improved significantly after initiation and titration of clonazepam and tetrabenazine. This case report pretends to highlight the importance of considering a rare manifestation of a very common disease. A hyperglycaemic state that can lead to cerebral lesions and specific neurological manifestations.

Drug-induced liver injury (DILI) is the most common cause of acute liver failure in the Western world. In recent years, natural herbal and dietary supplements have become widely available to the general public and have increased in popularity. Reports of idiosyncratic liver injury caused by such supplements have also increased over the last decade. Horse chestnut is a herb used in dietary supplements primarily for complications of venous insufficiency. Clinically significant acute liver injury has been very rarely associated with its use. We present the case of a 70-year-old man with idiosyncratic horse chestnut-induced liver injury. LEARNING POINTS: Idiosyncratic drug-induced liver injury is one of the most challenging liver disorders. Herbs and natural dietary supplements are widely popular and should be considered when evaluating liver injury of unknown origin. Patients may not consider herbs and supplements to be drugs with the potential to cause adverse effects, requiring a more careful medication history.

Inferior vena cava (IVC) agenesis is a rare congenital abnormality affecting the infrarenal segment, the suprarenal or the whole of the IVC. It has an estimated prevalence of up to 1% in the general population that can rise to 8.7% when abnormalities of the left renal vein are considered. Most IVC malformations are asymptomatic but may be associated with nonspecific symptoms or present as deep vein thrombosis (DVT). Up to 5% of young individuals under 30 years of age with unprovoked DVT are found to have this condition. Regarding the treatment of IVC agenesis-associated DVT, there are no standard guidelines. Treatment is directed towards preventing thrombosis or its recurrence. Low molecular weight heparin and oral anticoagulation medication, in particular vitamin K antagonists (VKAs) are the mainstay of therapy. Given the high risk of DVT recurrence in these patients, oral anticoagulation therapy is suggested to be pursued indefinitely. As far as we know, this is the first case reporting the use of a direct factor Xa inhibitor in IVC agenesis-associated DVT. Given VKA monitoring limitations, the use of a direct Xa inhibitor could be an alternative in young individuals with anatomical defects without thrombophilia, but further studies will be needed to confirm its efficacy and safety. LEARNING POINTS Up to 5% of young individuals under 30 years of age with unprovoked deep vein thrombosis (DVT) are found to have this condition. Therefore, these types of anomalies should be actively looked for, particularly in young patients with DVT. Treatment with low molecular weight heparin or oral anticoagulation medication is the mainstay of therapy, directed towards preventing thrombosis or its recurrence. A direct factor Xa inhibitor could be a possible alternative to vitamin K antagonists in these patients, despite the lack of clinical evidence supporting its use at the moment.

Cobalamin deficiency is a common cause of anaemia frequently presenting with an insidious onset of manifestations. Pancytopenia and hemolysis are rarely described in the literature. We report a case of a 73-year-old woman presenting with fatigue, anorexia and significant weight loss, found to have megaloblastic anaemia in association with pancytopenia and hemolysis. Work-up revealed vitamin B12 deficiency secondary to pernicious anaemia caused by atrophic gastritis.

Background: Atherosclerotic plaque leading to internal carotid stenosis greater than 50%, accounts for about 10 to 15% of all acute ischemic stroke (AIS) causes. Stenosis identification and severity is frequently estimated by Duplex ultrasound (DUS) assessment. Symptomatic carotid disease is defined as focal neurologic symptoms with sudden onset and related to the appropriate carotid artery cerebral distribution. It includes established acute ischemic stroke, one or more transient ischemic attacks characterized by focal neurologic dysfunction or transient monocular blindness, in the preceding 6 months of the carotid stenosis identification. Revascularization should be considered in symptomatic patients with a carotid artery stenosis of 50–69% and recommended in symptomatic patients with a stenosis of 70–99%. In our clinical practice it is seen frequently the indiscriminate use of DUS in the etiological study for AIS. Therefore, we consider the possibility of such an exam being excessively performed, since most patients may have no indication for DUS assessment. Objectives: (1) estimation of symptomatic carotid artery disease prevalence in hospitalized patients with the diagnosis of AIS and ≥ 50% carotid stenosis; (2) determination of carotid artery revascularization in this subgroup of patients; (3) evaluation of the centre clinical practice and to determine a real estimative of the therapeutic impact associated with DUS in patients with AIS. Methods: Retrospective observational cohort study of patients admitted with established AIS within the year of 2017 and followed for an additional 12 month period. Inclusion criteria: a definite diagnosis of AIS (based in symptoms within 24 hours’ period and/or image in CT scan suggestive of AIS), date of hospitalization within the mentioned timeframe and patients who underwent carotid DUS within the first 6 months after the event. No hemorrhagic stroke or transient ischemic attacks were considered in this study. Results: Of the 198 stroke patients, 144 (72%) underwent Doppler ultrasound. The average age was 78 years, 50% were male and 23.6% had previous stroke. From the total 144 included patients, only 18 (12.5%) had stenosis ≥50%, and 9 (6.25%) had ipsilateral lesions to the carotid stenosis. The remaining had lesions contralateral to the stenosis or lacunar strokes. Considering this, 6.25% of patients were assumed to have symptomatic carotid disease. None underwent surgical intervention for various reasons (e.g. high risk procedure, contraindications, high degree disability and/or multiple comorbidities). Conclusions: The present study reinforces the idea that etiological study of AIS is essential, and DUS appears as a first line exam. However, we emphasize that DUS should only be performed in patients with non-disabling AIS (mRS score 0–2) who are candidates for vascular intervention.