Acalculous cholecystitis: an uncommon form of presentation of Q fever

Acute acalculous cholecystitis is a very rare clinical presentation of Q fever. We report the case of a 38-year-old man who presented with fever associated with elevation of liver enzyme levels and thickening of the gallbladder wall on abdominal ultrasonography and who was initially diagnosed with acute acalculous cholecystitis. Due to the persistence of fever and transaminase elevation despite antibiotic treatment, a liver biopsy was performed. Characteristic "doughnut" epithelioid granulomas were observed, suggesting a diagnosis of granulomatous hepatitis caused by Q fever, which was confirmed by serological methods. Treatment with doxycycline was commenced and the patient subsequently showed rapid clinical improvement, with disappearance of fever and normalization of liver enzyme levels. We review 8 cases of acute cholecystitis associated with Q fever published in the literature and stress the importance of liver biopsy in the etiological diagnosis of patients with prolonged fever and abnormal liver function tests.     

Acalculous cholecystitis: Ascariasis as an unusual cause

Migration of roundworms into the biliary tree is a well-known complication ofAscaris lumbricoides infestation of the intestine. Massive infestation of the hepato-biliary tract is uncommon but can lead to complications if not treated. Here, we report two cases of acalculous cholecystitis caused by ascariasis.     

Dysphagia as an unusual presentation of infective endocarditis

We report a case of a 79-y-old male with enterococcal endocarditis presenting with dysphagia and weight loss. The patient's longstanding underlying bacteremia was thought to have caused pro-inflammatory changes leading to alterations in the neuronal environment affecting peripheral nerve function. Dysphagia improved once antibiotic treatment was initiated.     

Bacterial endocarditis as an unusual presentation of left atrial myxoma

A 72-year-old woman presented with chronic febrile illness and enterococcal bacteraemia, and after a series of exhaustive tests, was shown to have a left atrial mass on transoesophageal echocardiography. Successful resection of the atrial myxoma resulted in full recovery and discharge from hospital. The clinical features and investigative approach are discussed in relation to a review of the literature.     

Hepatic amebic abscess masquerading as acute cholecystitis

Hepatobiliary scintigraphy has disclosed a host of intrahepatic and extrahepatic lesions which mimic gallbladder disease. Two cases of hepatic amebic abscess are reported in which the presentations masqueraded as acute cholecystitis. Correlative, noninvasive imaging rapidly diagnosed both cases and in 1 case identified a serious complication.     

Q fever infectious endocarditis. Apropos of a new case

We report a case of Coxiella burnetii endocarditis in a 42-year old man presenting with a long-known cardiac murmur and an infectious syndrome of several months duration. The aetiological diagnosis, delayed by the lack of knowledge of a primary Q fever, was established by serology. The infection responded to tetracycline combined with cotrimoxazole, but a valve replacement performed for haemodynamic reasons was followed by serious complications. We remind the readers that Q fever endocarditis must be considered as a possible diagnosis in all cases of endocarditis with negative blood cultures and that specific serological examinations in search of anti-phase I antibodies of the IgA type should be performed as soon as possible, using the indirect immunofluorescence technique. Attention is drawn to the different serological responses of the three clinical types of Q fever infection and to the cellular immunity associated with that disease.     

Q fever endocarditis masquerading as Mixed cryoglobulinemia type II. A case report and review of the literature

Background  

The clinical manifestations of Q fever endocarditis are protean in nature. Mixed cryoglobulinemia type II is rarely a facet of the presenting clinical manifestations of Q fever endocarditis.     

Acalculous cholecystitis: a rare presentation of leptospirosis progressing to Weil's disease

Leptospirosis is a zoonotic infection with higher incidence in tropics. Leptospirosis, is known for its variable manifestations, and is a clinical challenge for physicians in the tropics. Experienced clinicians, at times can mistake leptospirosis for non-medical conditions. A few reports of leptospirosis presenting as acalculous cholecystitis was found in review of literature. We intent to highlight acalculous cholecystitis as a rare but clinically significant presentation of leptospirosis.     

Libman–Sacks endocarditis with an unusual presentation

Systemic lupus erythematosus is relatively common medical disorder with female predominance. This disorder can affect any organ system. Cardiac involvement is variable which can include pericardium, myocardium and endocardium. The endocardial involvement commonly affects mitral and aortic valves. This report discusses lupus endocarditis in young man with atypical presentation.     

Myalgia Cruris Epidemica: an unusual presentation of dengue fever

We describe a 5-year-old girl who had sudden onset difficulty in walking after 3 days of febrile illness. In the emergency department her creatine kinase level was elevated but urine myoglobin was normal. She was diagnosed as having benign acute childhood myositis. Because of poor oral intake and dehydration, she was admitted to the pediatric ward. The next day she had a petechial rash over the antecubital fossa, and dengue IgM back was positive. She was treated conservatively and recovered uneventfully. Despite dengue fever being endemic in Malaysia, this is the first case report of myositis following dengue infection in Malaysia.     

Bilateral cortical blindness: an unusual presentation of bacterial endocarditis.

We report the case of a 37-year-old woman who presented to the emergency department with the initial complaint of complete blindness. The patient was found to have bilateral ruptured occipital mycotic aneurysms as a sequela of bacterial endocarditis. This case is unique in several aspects. Although blindness may be a presenting neurologic symptom, it is exceedingly rare. To our knowledge, bilateral cortical blindness secondary to mycotic aneurysm rupture has not been reported previously.     

Metastatic melanoma of the gallbladder： An unusual clinical presentation of acute cholecystitis

Metastatic disease from cutaneous melanoma can affect all organs of the body, and varies in its biological behavior and clinical presentation. We present the case of a 58-year-old man who arrived at our clinic with acute abdominal pain, which, after investigation, was diagnosed as acute cholecystitis. The patient underwent laparotomy and cholecystectomy. Two years ago, he underwent surgical removal of a primary cutaneous melanoma on his right upper back. Pathological examination revealed the presence of malignant melanoma with a metastatic lesion of the gallbladder.     

Cellular immunity in Q fever: specific lymphocyte unresponsiveness in Q fever endocarditis

Human infection with the rickettsia Coxiella burnetii presents as acute influenza-like primary Q fever, subacute granulomatous hepatitis, or chronic endocarditis with hepatitis. To investigate whether persistent infection is associated with a possible immunologic defect, we tested lymphocyte proliferation specific for Coxiella in vitro in peripheral blood mononuclear cells from patients and controls. All four patients with endocarditis had profound lymphocyte unresponsiveness to Coxiella antigens with normal proliferation to control antigens. Hepatitis and primary Q fever were associated with vigorous responses in vitro to Coxiella antigens. Suppression of lymphocyte unresponsiveness was in part mediated by an antigen-nonspecific, glass-adherent cell. We hypothesize that specific T cell unresponsiveness is an important factor in persistent infection with C. burnetii and offer in vitro lymphocyte stimulation as a more specific diagnostic test to distinguish cases of endocarditis among those with chronic hepatitis due to Q fever.     

Hypothermia masquerading as pericarditis: an unusual electrocardiographic analogy

Hypothermia is one of the most common environmental emergencies encountered by physicians that can be associated with a variety of electrocardiographic (ECG) abnormalities. The classic and well-known ECG manifestations of hypothermia include the presence of J (Osborne) waves, interval (PR, QRS, QT) prolongation, varied T-wave abnormalities, and atrial and ventricular arrhythmias. There are less well-defined and known ECG signs of hypothermia that, in fact, may simulate findings of acute coronary ischemia. We describe a case of hypothermia with associated ECG findings mimicking pericarditis. Especially interesting was the challenging presentation and several associated important learning points. Herewith, we also discuss some important ECG and clinical factors that may be used in differentiating the genesis of ST elevations.