Journal of Medical Case Reports

Isolated cases of epicarditis are rare. Thus far, all have occurred with constrictive physiology as most cases involve both parietal and visceral pericardium. We report the first case of asymptomatic epicarditis that involved only the visceral pericardium presenting without constrictive physiology. A 71-year-old male with a history of atrial fibrillation, coronary artery disease, pericardial effusion, type-2 diabetes and hypothyroidism presented with 5 weeks of fatigue and 1 day of dizziness. Physical examination was significant for pallor and tachycardia. Laboratory analysis revealed a hemoglobin count of 7.2 g/dl and iron deficiency anemia. The patient was transfused and evaluated by endoscopic ultrasound. A polypoid mass in the gastric cardia was found and later diagnosed as gastric adenocarcinoma (staged as T1N0M0). The pericardial effusion was evaluated with transthoracic echocardiography which showed a 2.0 × 2.7 cm mass associated with the right atrium. Transesophageal echocardiography confirmed the mass but did not reveal constrictive physiology. Whole-body contrast computed tomography failed to demonstrate metastatic disease. Biopsy of the cardiac mass revealed epicarditis without parietal pericardium involvement. Partial gastrectomy was performed to remove the gastric adenocarcinoma. This is the first reported case of asymptomatic epicarditis. Our case was especially unusual because the epicarditis presented as an incidental cardiac mass. The clinical picture was complicated due to the concomitant presence of gastric adenocarcinoma and chronic pericardial effusion. This case demonstrates that epicarditis should be considered in the differential diagnosis of cardiac masses.

Brucellosis is a systemic infectious disease which is still a challenging medical problem in rural areas such as northern China. It rarely occurs in urban areas such as Shenzhen in southern China. Osteoarticular involvements are frequently seen in brucellosis, and rarely is arthritis the only clinical presentation. We report a case of hip septic arthritis caused by Brucella melitensis in an urban area of Shenzhen, China. A 29-year-old Chinese woman, Han ethnical group presented to our hospital with left hip pain persisting for one month. She had a history of contact with goats one month before admission. Her clinical examination showed marked tenderness and limited movement of her left hip. Further imaging showed effusion of her left hip joint. Inflammatory markers including erythrocyte sedimentation rate (ESR) and c-reactive protein (CRP) were raised. Our clinical diagnosis was septic arthritis of the left hip. A left hip arthroscopy was performed and the culture was positive for Brucella melitensis. She returned to normal activity after completing a standard antibiotic regimen, including gentamicin at 120mg daily for 2 weeks, doxycycline at 100mg daily and rifampicin at 450mg for a total of 12 weeks. Brucellosis is endemic in some rural areas of China, but rare in urban areas such as Shenzhen in southern China. However, more cases will be expected in urban areas due to increasing migration within China. Physicians should consider brucellosis as one of the differential diagnosis of arthritis. Early surgical intervention is recommended to prevent further joint destruction.

In the current treatment landscape for non-small cell lung cancers, epidermal growth factor receptor-tyrosine kinase inhibitors have emerged as a well-established treatment option for patients with advanced or metastatic disease. This is particularly true for those with commonly occurring epidermal growth factor receptor mutations. However, the therapeutic efficacy of these agents for so-called rare epidermal growth factor receptor mutations, and in particular those characterized by a high degree of complexity, such as double mutations, remains a subject of clinical uncertainty. In this context, we present the case of a 64-year-old man of Moroccan descent, a lifelong non-smoker, diagnosed with metastatic non-small cell lung cancer characterized by a complex epidermal growth factor receptor mutation encompassing L858R and S768I. The patient subsequently underwent afatinib-based treatment, showing notable clinical results. These included a remarkable overall survival of 51 months, with a median progression-free survival of more than 39 months. This case report is a compelling testimony to the evolving therapeutic landscape of non-small cell lung cancers, providing valuable insight into the potential therapeutic efficacy of epidermal growth factor receptor-tyrosine kinase inhibitors in the realm of rare and complex epidermal growth factor receptor mutations.

Soybean allergy is one of the most common food allergies especially among children. The Food Allergen Labeling and Consumer Protection Act (FALCPA) in the US requires the labeling of soy lecithin because it is derived from soybeans and may contain a number of IgE-binding proteins, possibly representing a source of hidden allergens. Here we describe a pediatric case of soy allergy misunderstood as drug allergy. An 11-year-old Caucasian girl was referred to our Allergy Unit because of the delayed appearance of an itching papular rash at the site of an injection of benzathine benzylpenicillin delivered by prefilled syringe. A skin test with benzathine benzylpenicillin and detection of serum-specific IgE to penicilloyl V, penicilloyl G, ampicillin and amoxicillin were negative. From her past medical history we know that, at the age of three years, she presented with edema of the lips and difficulty in breathing after eating a soy ice-cream. For that reason, she underwent a skin prick test with soybean that was negative and a serum-specific IgE to soybean test that was weakly positive (0.21KU/L). She underwent an oral provocation test with soy milk that yielded a positive result. We describe a case of a patient with a delayed reaction to soy as a hidden allergen in a benzathine benzylpenicillin prefilled syringe. This case shows that lecithin contaminated by soy proteins and used as an excipient in drugs can cause reactions in patients with soy allergy. For that reason, the source of lecithin should always be specified among the constituents of drugs to avoid a source of hidden allergens and difficulties in the allergy work-up.

In foreign language syndrome, patients switch from their native language and fixate for a period of time on a second language. There have been few reported cases. The language switch typically occurs postoperatively and spontaneously resolves after a short period of time. The primary cause of this switching remains unclear. There is speculation about the involvement of anesthesia, but its specific influence remains unclear. A 17-year-old Dutch Caucasian male lost the ability to understand and speak Dutch for 24 hours after an orthopedic surgery, combined with a brief confused state including disorientation of place and the inability to recognize his parents. During the period, he communicated in English, which he had learned during school classes but had never spoken outside of school. Further follow-up, including neuropsychological examination, revealed no indication of cognitive impairment. The exact pathophysiology of foreign language syndrome remains unclear, most specifically whether it is a syndrome of its own or a phenotype of emergence delirium. There is still much to be learned, and further research is needed.

Perivascular epithelioid cell tumors are defined by the World Health Organization as “a collection of rare mesenchymal tumors composed of histologically and immunohistochemically distinctive perivascular epithelioid cells.” Whereas localized perivascular epithelioid cell tumor is typically benign and treated successfully with surgical resection, prognosis for patients with advanced or metastatic perivascular epithelioid cell tumor is unfavorable, and there is no standard curative treatment. We report a Caucasian case of metastatic perivascular epithelioid cell tumor previously treated with chemotherapy and surgery with elevated surface expression of programmed cell death ligand 1. Based on this result, treatment via immune checkpoint inhibition with the monoclonal antibody pembrolizumab was pursued. After 21 cycles, the patient sustained a complete response. Therapy was stopped after the 40th cycle, and she was moved to surveillance. She remained disease free 19 months off treatment. This case report of a patient with perivascular epithelioid cell tumor treated successfully with programmed cell death protein-1 targeted therapy suggests that programmed cell death ligand-1 levels should be measured in patients with perivascular epithelioid cell tumor and immunotherapy considered for recurrent or metastatic patients. Future phase II/III studies in this disease should focus on sequencing of surgery and immunotherapy with a design of curative intent.

Sclerosing mucoepidermoid carcinoma with eosinophilia is a rare morphological variant of thyroid carcinoma associated with Hashimoto’s disease. To date, only three such tumors have been reported in the minor salivary glands. We describe the first case, to the best of our knowledge, of recurrent sclerosing mucoepidermoid carcinoma with eosinophilia in the minor salivary glands of the upper lip. A 61-year-old Japanese man was referred to our hospital with a mass in his median upper lip of four years’ duration. An examination of his median upper lip revealed a well-defined tumor measuring 9×12mm in diameter, which was subsequently resected. Three years after the first surgery, the tumor recurred and was resected. Both tumors were confirmed by histopathology to be sclerosing mucoepidermoid carcinoma with eosinophilia. Neither recurrence nor metastasis was observed in three and a half years of follow-up after the second surgery. Our findings indicate that sclerosing mucoepidermoid carcinoma with eosinophilia can originate in the minor salivary glands and may be clinically or pathologically misdiagnosed as other conditions.

Granulomatosis with polyangiitis is a systemic inflammatory disease characterized by necrotizing vasculitis that affects small- and medium-sized blood vessels. Granulomatous inflammation affects the lungs, ears, nose, and throat, and commonly affects the kidneys, although the retroperitoneal tissue is rarely affected. Several studies have reported an increased risk of venous thromboembolism. Early diagnosis and treatment are of vital importance due to the rapid progression of the disease. We present the case of a 66-year-old Moroccan man followed for bilateral jugular thrombosis. Cavitary pulmonary nodules and retroperitoneal fibrosis with thrombosis involving several vascular territories were detected on thoracoabdominopelvic computerized tomography scan. Laboratory analyses revealed that the patient was positive for cytoplasmic antineutrophilic antibodies. The diagnosis of granulomatosis with polyangiitis was retained. Treatment with glucocorticoids and immunosuppressive agents resulted in significant clinical and radiological improvement over the following months. We describe the diagnostic steps and the difficulty of managing this patient. Rare manifestations, such as retroperitoneal fibrosis, have been reported in the literature in association with granulomatosis with polyangiitis, and should not delay the diagnosis and treatment of granulomatosis with polyangiitis owing to its severity.