The great imitator

B.K. a Moroccan 32-year-old man was admitted to our hospital for abdominal pain and vomiting. He showed an increase of inflammation indexes, abdominal free fluid, axillary, inguinal and abdominal lymphadenitis, pleural effusion, ascites and thickened intestinal walls. The patient also presented alopecia and facial erythema, a positive anti-nuclear antibodies (ANA) test (1:1280). Lastly the diagnosis of systemic lupus erythematosus (SLE) was made. The patient was treated with high doses of corticosteroid; abdominal pain decreased and pleural effusion and ascites disappeared. After several days he started to complain of significant chest pain. He had a troponin increased above 100 ng/mL, modified electrocardiogram, pericardial effusion and edema of ventricular walls as in myocarditis. The patient was treated successfully with cyclophosphamide and pericardial effusion and chest pain disappeared. After 1 month at the hospital the patient was discharged and referred to a rheumatologist for the follow up. Systemic lupus erythematosus is an autoimmune disease in which autoantibodies and immune-complexes damage heart, joints, skin, blood vessels, liver, kidneys and the nervous system. Ninety percent of individual diagnosed with SLE are women. The course is unpredictable with periods of acute illness alternating with periods of remission. This is a typical disease that requires a differential diagnosis, because the symptoms may vary widely and are unpredictable. According to the American College of Rheumatology, which drew up a reference list of 11 symptoms, SLE is confirmed when 4 out of the 11 symptoms are present simultaneously or symptoms overlap on two separate occasions. Treatment can include corticosteroids and antimalarial drugs, intravenous immunoglobulins and cytotoxic drugs such as cyclophosphamide. Our case is exceptional because it is rare for a young man to be affected. He had 5 out of 11 symptoms: malar rash, serositis, arthritis, hematologic disorder and ANA test positive

The non-invasive mechanical ventilation: the experience of the department of Internal Medicine and Critical Area of the Polyclinic Hospital of Modena

Acute respiratory failure (ARF) is a deficiency of the respiratory system that causes an alteration of normal levels of oxygen and/or carbon dioxide in the blood. ARF may be due to alterations in gaseous diffusion in alveolar-capillary level (type “1” acute respiratory failure), or to alterations in the functioning of the respiratory pump (type “2” acute respiratory failure) or to an association of the above causes. ARF specific etiological treatment must be associated to oxygen administration, through ventilation, which may be spontaneous or mechanical (non-invasive or invasive). The actual study describes experience about non-invasive mechanical ventilation in the department of Internal Medicine and Critical Area of the Polyclinic Hospital of Modena, from 2010 to 2014, examining clinical parameters and outcomes. Respiratory failure is a condition in which the respiratory system is not able to adequately carry out its gas exchange functions, such as oxygenation of the arterial blood and/or elimination of carbon dioxide from the venous blood. Conventionally, (1),(2),(3) respiratory failure is defined in case of: Partial pressure of arterial oxygen (PaO2) <60 mmHg; Partial pressure of carbon dioxide in the arterial blood (PCO2)> 45 mmHg; Association of both previous. You can distinguish two types of acute respiratory failure(4)(ARF): ARF type “1”, with gas exchange impairment and hypoxemia (associated with hypo/normocapnia). The pathophysiological mechanism behind is an important intrapulmonary shunt with changes in ventilation/perfusion ratio. Generally diseases responsible for this condition are acute pulmonary edema, ARDS, severe pneumonia and pulmonary embolism. ARF type “2”, with hypoventilation and hypercapnia. It is caused by a reduction of the ventilation volume/minute or by an increase of physiologic dead space. Among the most common diseases there are neuromuscular diseases, myopathies, chronic obstructive pulmonary disease (COPD), bronchial asthma and restrictive lung disease. The two types of respiratory failure are closely connected and can evolve into one another. The ARF therapy can be divided into: Etiological therapy: it is directed to the treatment of the specific cause that induced ARF, it can be delivered with inotropic agents, antibiotics, bronchodilators, steroids etc. Supportive therapy (or symptomatic): aimed at correcting hypoxemia and respiratory acidosis, is indicated in all respiratory insufficiencies and it is based on the administration of O2 and postural therapy. Ventilation can be spontaneous (delivered by low or high flow systems) or mechanical. Mechanical ventilation is classifiable under invasive ventilation (IMV) or non-invasive (NIV). The IMV provides the invasion of the patient’s airways to put them in communication with the respiratory system. It can be through tracheal intubation or tracheotomy and it’s a relevant method adopted by resuscitation intensive departments and partly by respiratory diseases departments. The NIV despite is a method that requires training and experience to be used optimally, it has the advantage to be used in emergency medicine departments and in other departments from specialists who are not resuscitators or pulmonologists. Moreover, compared to the IMV, the NIV offers the following advantages: reduction in the respiratory work, absence of complications related to prosthesis, possibility of avoiding sedation required for the IMV, conservation of laryngeal functions and cost reduction.(5) The NIV techniques most used in emergency medicine departments are CPAP (Continuous positive airway pressure) and BiPAP (or BiLevel - BiLevel positive airway pressure) CPAP provides a predetermined positive pressure, greater than atmospheric, which is maintained constant throughout the respiratory cycle, and it improves oxygenation by increasing the functional residual capacity, favouring the recruitment and the patency of the alveoli excluded from the ventilation and improving the relationship between ventilation and perfusion. The main indications for CPAP are acute cardiogenic pulmonary edema (ACPE), hypoxic and not hypercapnic ARF, obstructive sleep apnea syndrome (OSAS); atelectasis. (8),(9),(10) BiPAP provides two different levels of positive pressure, which are an inspiratory positive airway pressure (IPAP) and an expiratory positive airway pressure (EPAP). BiPAP facilitates the removal of air exhaled and prevents cases of re-breathing of CO2. It also reduces the patient's work of breathing. The main indications to BiPAP are hypercapnic ARF, chronic obstructive pulmonary disease (COPD) exacerbation, pneumonia, neuromuscular disorders, dysfunction of the respiratory center (sedation/intoxication), shock (cardiovascular/septic). (11), (12)Acute respiratory failure (ARF) is a deficiency of the respiratory system that causes an alteration of normal levels of oxygen and/or carbon dioxide in the blood. ARF may be due to alterations in gaseous diffusion in alveolar-capillary level (type “1” acute respiratory failure), or to alterations in the functioning of the respiratory pump (type “2” acute respiratory failure) or to an association of the above causes. ARF specific etiological treatment must be associated to oxygen administration, through ventilation, which may be spontaneous or mechanical (non-invasive or invasive). The actual study describes experience about non-invasive mechanical ventilation in the department of Internal Medicine and Critical Area of the Polyclinic Hospital of Modena, from 2010 to 2014, examining clinical parameters and outcomes. Respiratory failure is a condition in which the respiratory system is not able to adequately carry out its gas exchange functions, such as oxygenation of the arterial blood and/or elimination of carbon dioxide from the venous blood. Conventionally, (1),(2),(3) respiratory failure is defined in case of: Partial pressure of arterial oxygen (PaO2) <60 mmHg; Partial pressure of carbon dioxide in the arterial blood (PCO2)> 45 mmHg; Association of both previous. You can distinguish two types of acute respiratory failure(4)(ARF): ARF type “1”, with gas exchange impairment and hypoxemia (associated with hypo/normocapnia). The pathophysiological mechanism behind is an important intrapulmonary shunt with changes in ventilation/perfusion ratio. Generally diseases responsible for this condition are acute pulmonary edema, ARDS, severe pneumonia and pulmonary embolism. ARF type “2”, with hypoventilation and hypercapnia. It is caused by a reduction of the ventilation volume/minute or by an increase of physiologic dead space. Among the most common diseases there are neuromuscular diseases, myopathies, chronic obstructive pulmonary disease (COPD), bronchial asthma and restrictive lung disease. The two types of respiratory failure are closely connected and can evolve into one another. The ARF therapy can be divided into: Etiological therapy: it is directed to the treatment of the specific cause that induced ARF, it can be delivered with inotropic agents, antibiotics, bronchodilators, steroids etc. Supportive therapy (or symptomatic): aimed at correcting hypoxemia and respiratory acidosis, is indicated in all respiratory insufficiencies and it is based on the administration of O2 and postural therapy. Ventilation can be spontaneous (delivered by low or high flow systems) or mechanical. Mechanical ventilation is classifiable under invasive ventilation (IMV) or non-invasive (NIV). The IMV provides the invasion of the patient’s airways to put them in communication with the respiratory system. It can be through tracheal intubation or tracheotomy and it’s a relevant method adopted by resuscitation intensive departments and partly by respiratory diseases departments. The NIV despite is a method that requires training and experience to be used optimally, it has the advantage to be used in emergency medicine departments and in other departments from specialists who are not resuscitators or pulmonologists. Moreover, compared to the IMV, the NIV offers the following advantages: reduction in the respiratory work, absence of complications related to prosthesis, possibility of avoiding sedation required for the IMV, conservation of laryngeal functions and cost reduction.(5) The NIV techniques most used in emergency medicine departments are CPAP (Continuous positive airway pressure) and BiPAP (or BiLevel - BiLevel positive airway pressure) CPAP provides a predetermined positive pressure, greater than atmospheric, which is maintained constant throughout the respiratory cycle, and it improves oxygenation by increasing the functional residual capacity, favouring the recruitment and the patency of the alveoli excluded from the ventilation and improving the relationship between ventilation and perfusion. The main indications for CPAP are acute cardiogenic pulmonary edema (ACPE), hypoxic and not hypercapnic ARF, obstructive sleep apnea syndrome (OSAS); atelectasis. (8),(9),(10) BiPAP provides two different levels of positive pressure, which are an inspiratory positive airway pressure (IPAP) and an expiratory positive airway pressure (EPAP). BiPAP facilitates the removal of air exhaled and prevents cases of re-breathing of CO2. It also reduces the patient's work of breathing. The main indications to BiPAP are hypercapnic ARF, chronic obstructive pulmonary disease (COPD) exacerbation, pneumonia, neuromuscular disorders, dysfunction of the respiratory center (sedation/intoxication), shock (cardiovascular/septic). (11), (12

Management of polytraumatized patient in Emilia Romagna. Data analysis of nontrauma center Hub Emergency Department

Introduction Trauma still has a great impact in term of morbidity and mortality all over the world. In Emilia Romagna, a region of the north of Italy, the Integrated System of Assistance to Trauma (SIAT) was created to ensure the best management of prehospital and early in-hospital trauma patient. Materials and Methods We reporte and discuss the results of an experimental study done in Emergency Department of Ferrara; datas refer to management of prehospital and early in-hospital trauma patient in the biennium 2015-2016. Results Datas show an increase in cases handled in the hub center instead of in the spoke ones; anyway there was an increasing in centralizing patients in the regional Hub Trauma center. Trauma Team was correctly activated, with an increasing trend. In addition, raising percentage of admission in ICU was associated with the raising percentage of patients treated in emergency medicine ward. Conclusions This article allows us to reflect and discuss about prehospital and in hospital polytraumatized patient path. Thanks to this newborn protocol of centralisation, traumatic patients were uniformly managed in the Western Emilia Romagna SIAT; trauma had a multidisciplinary approach and more appropriate admission. This resulted in optimizing the whole process from the income to the outcome of the patient. Moreover, the hospital of the study showed to be ready to cover the amount of trauma, except for those patients who needed to an hyperspecialistic approach

A case of dyspnea: respiratory failure due to pulmonary arteriovenous malformation

Pulmonary arteriovenous malformations (PAVMs) are abnormal communications between pulmonary arteries and veins. The clinical features suggestive of PAVMs are stigmata of right-to-left shunting (dyspnea, hypoxemia, cyanosis, cerebral embolism, brain abscess), unexplained hemoptysis, or hemothorax. We present a case of a young man who presented to the Emergency Department complaining of dyspnea, polycythemia, and persistent hypoxemia. Angio-computed tomographic scan of the chest detected multiple PAVMs. PAVMs are uncommon in the general population, but they represent an important consideration in the differential diagnosis of common pulmonary problems, including hypoxemia, pulmonary nodules, and hemoptysis

Unusual effectiveness of systemic steroids in Whipple disease.

Not availabl

Case Report: Metastatic breast cancer to the gallbladder

Cholecystitis is one of the leading causes of emergency surgical interventions; the occurrence of metastases to the gallbladder is rare and has only been reported in the literature exceptionally. Metastatic breast cancer to the gallbladder is even less frequent; in fact, breast cancer usually metastasizes to bone, lung, lymph nodes, liver and brain. We report the case of an 83-year-old female patient with a previous history of breast surgery with axillary dissection in 1997, followed by adjuvant chemotherapy due to invasive ductal carcinoma of the left breast. The patient was admitted at the emergency department for sepsis and an episode of acute kidney failure, anuria and fever. Right-upper quadrant abdominal pain triggered by food intake and abdominal tenderness was also present, placing the diagnostic suspicion of biliary sepsis due to acute cholecystitis. The histological examination of the surgical specimen highlighted the presence of metastasis from an infiltrating ductal breast carcinoma with positive hormone receptors. We also report here the results of a review of the literature looking at articles describing cases of gallbladder metastasis from breast cancer

Door-to-needle time in acute ischemic stroke: analysing intra-hospital delays, predictive factors, improving strategies. The experience of Baggiovara hospital (MO, Italy)

Stroke is a syndrome characterized by a sudden and quick development of neurological deficits due to vascular cause. The loss of function could be global, with permanent symptoms, until death, or transient (TIA) if blood supply is rapidly restore. International Task Force defined this acute pathology “a preventable and treatable catastrophe”: it is the third cause of death in developing countries, accounting for 2-4% of the public health budget. Management strategies include: Primary prevention: public information in order to increaseawareness Acute phase management, from the activation of the emergency service tothe rehabilitation and early secondaryprevention Health care for survivors withdisability The starting point of this study is the concept that “time is brain”, enhancing the role of the interval between the onset of symptoms and the final treatment (the “door to needle time”, DNT). This led us to carry a retrospective critical analysis, evaluate the DNT before and after the introduction of an internal protocol, aiming at the standards suggested in literature

Aurea diagnosis of pneumomediastinum. A case report

Pericarditis and spontaneous pneumomediastinum are among the pathologies that are in differential diagnoses when a patient describes dorsal irradiated chest pain: if the patient is young, male, and long-limbed, it is necessary to exclude an acute aortic syndrome firstly. We present the case of a young man who arrived at the Emergency Department for chest pain: an echocardiogram performed an immediate diagnosis of pericarditis. However, if the patient had performed a chest X-ray, this would have enabled the observation of pneumomediastinum, allowing a correct diagnosis of pneumomediastinum and treatment. The purpose of this report is to highlight the importance of the diagnostic process

Renal infarction as an uncommon cause of abdominal pain. A case report

Renal infarction is a rare cause of abdominal pain whose diagnosis is often misunderstood or severely delayed. The difficulty in identifying this time-dependent condition greatly limits the possibilities of therapeutic intervention and determines the loss of renal parenchyma that could have been saved with prompt diagnosis. It is, therefore, essential to include renal infarction in the differential diagnosis in case of abdominal pain and to identify this pathology beforehand. We present a case of a 65-yearold male with atrial fibrillation in therapy with Edoxaban who was admitted to the hospital for acute onset of widespread abdominal pain with nausea, vomit, and a worsening of renal function according to the laboratory tests. An abdominal computed tomography with contrast confirmed the presence of a bilateral renal infarction. The patient developed chronic kidney disease and was discharged on anticoagulant therapy. The aim of this paper is, therefore, to increase physician awareness towards this condition, the best opportunity to diagnose early renal infarction and to establish acute and long-term therapy

Elevated Troponin Serum Levels in Adult Onset Still's Disease

Adult onset Still's disease (AOSD) is a rare inflammatory systemic disease that occasionally may affect myocardium. Diagnosis is based on typical AOSD symptoms after the exclusion of well-known infectious, neoplastic, or autoimmune/autoinflammatory disorders. In the case of abrupt, recent onset AOSD, it could be particularly difficult to make the differential diagnosis and in particular to early detect the possible heart involvement. This latter event is suggested by the clinical history of the four patients described here, incidentally observed at our emergency room. All cases were referred because of acute illness (high fever, malaise, polyarthralgias, skin rash, and sore throat), successively classified as AOSD, and they presented abnormally high levels of serum troponin without overt symptoms of cardiac involvement. The timely treatment with steroids (3 cases) or ibuprofen (1 case) leads to the remission of clinicoserological manifestations within few weeks. These observations suggest that early myocardial injury might be underestimated or entirely overlooked in patients with AOSD; routine cardiac assessment including troponin evaluation should be mandatory in all patients with suspected AOSD