Journal of Clinical Case Reports

A 15 years old boy was admitted to educational center hospital in southeast of Iran named Zahedan, because of dyspnea, pleuretic chest pain, on productive cough, low grade fever, weight loss about 2 kg during 3 months, malaise, and a big testis.

Psoriasis is a chronic lifelong inflammatory dermatosis related to an anomaly of the proliferation and the differentiation of epidermal cells. Its first description dates back to 1808 by the British Robert William in his treatise of skin diseases.

Cyclospora cayetanensis is an emergent parasite traditionally associated with diarrhoea in travellers to endemic countries. Several cases of cyclosporiasis were also reported in non travellers associated with imported food and waterborne outbreaks. Recently, only sporadic cases were described in Europe, probably because it’s underdiagnosed. Cyclospora is a protozoan very difficult to identify. It’s not detected in specimen routinely tested for ova and parasite, if not explicitly requested. Other reasons include morphologic similarities of Cyclospora cayetanensis oocysts with those of Cryptosporidium; necessity of proficiency in parasitology and probably because its notification is not obligatory in all countries.
We report one case of acquired cyclosporiasis in Portugal in an immunocompromised boy, that is, to the best of our knowledge, the first reported in our country. Cyclosporosiasis should be considered in all persons with persistent or remitting-relapsing diarrheal illness, regardless of immunological status and explicitly requesting testing for this parasite.

We report a 60-year-old woman with locally advanced mucinous carcinoma of the breast with sudden growth acceleration. A pea-sized mass developed into an ulcerated large tumor within 1 month. After counseling the patient a modified radical mastectomy was performed. Histological examination revealed a mucinous carcinoma without axillary lymph node involvement. Estrogen and progesterone receptors were not detected in the tumor. Pure mucinous carcinoma generally has a less aggressive growth pattern as defined by tumor size, adherence to the overlying skin/bottom fasciae, estrogen and progesterone receptor positive and absence of primary axillary lymph node metastases. This case showed completely similar features to all of the typical biological features of mucinous carcinomas.

Chiropractic manipulation is a popular form of alternative therapy used in the treatment of acute and chronic pain. Neurological complications are uncommon, occurring in 1 per million cervical manipulations. We report a case of a 35-year old man who developed a C3/C4 quadraparesis, shortly after chiropractic manipulation to his neck for acute on chronic neck pain. A CT scan of his cervical spine showed a large central disc protrusion at C3/4 causing severe cord compression and underwent urgent C3/4 cervical decompression with fusion. He improved neurologically and after a period of inpatient rehabilitation he has discharged home, 3 weeks after presentation, independent in mobility and self care with minimal residual upper limb weakness, which resolved over the next few months. Even though neurological complications of spinal manipulation are well recognised, our case demonstrates the
dangers of this popular form of alternative therapy that is generally seen to be benign.
Lessons: Chiropractic manipulation is a popular form of alternative therapy used in the treatment of acute and chronic pain and neurological complications are uncommon, occurring in 1 per million cervical manipulations. Even though neurological complications of spinal manipulation are well recognised, our case demonstrates the dangers of a therapy that is generally seen to be benign.
If the complication is identified as a neurological emergency, excellent functional recovery occurs.
This case highlights the potential pitfalls of this form of treatment and the need for more strict medical control to minimise the risk of complications, especially at the cervical level.
Introduction: Chiropractic spinal manipulation involves a high-velocity thrust to rapidly adjust joints and correct spinal misalignment and relieve pressure on nerves to allow them to function. Neurological complications of cervical manipulations are considered rare, occurring in 1 per million cervical
manipulations [1]. Most complications reported of this therapy are case reports of vertebral artery dissection [2], disc herniation [3] and cervical fracture [4], but there have been reports of Brown-Sequard syndrome due to cord contusion [5], acute paraplegia due to ischaemia [6] and hemiplegia due to a spinal epidural haematoma [7]. Even though neurological complications of spinal manipulation are well recognized [8,9] our case demonstrates the dangers of this popular form of alternative therapy.

One of the challenges in acute stroke management is accurately differentiating between actual ischemic events and other conditions that mimic stroke. In a cohort of 821 consecutive patients admitted to an acute stroke unit, 13% were incorrectly diagnosed as stroke [1]. In another cohort of 411 patients, it was estimated that 19% of patients presenting to the emergency department with stroke-like symptoms ultimately have other diagnoses such as a postictal state, metabolic disturbances, and systemic infections [2]. Regardless of the actual percentage, it is clear that not all cases of acute stroke-like symptoms are true strokes and other mimics should be considered. One such mimic is factitious disorder.
Factitious disorder is a psychiatric condition in which afflicted individuals exaggerate symptoms and even endorse medical illness, or psychological trauma in order to draw attention or sympathy to themselves. The DSM-IV criteria for this disorder are: 1) Intentional production or feigning of physical or psychological signs or symptoms; 2) The motivation for the behavior is to assume the sick role; and 3)
External incentives for the behavior such as economic gain or avoiding legal responsibility as seen in malingering, are absent [3].
Here, we present a case of a patient who was diagnosed with factitious disorder after he presented to two different institutions with acute stroke-like symptoms and received tissue plasminogen activator
(t-PA) twice within the span of 3 weeks.

Diabetic myelopathy is a common pathological finding in patients with diabetes mellitus, but its manifestations can be masked by advanced diabetic neuropathy. This case illustrates that it should be suspected in all diabetic patients with subacute progressive symptoms affecting all extremities even in the absence of dysfunction of bowel/bladder sphincters.

Poorly differentiated malignant neoplasms confined to the spleen are rare. Their rarity and broad differential diagnosis in the setting of splenomegaly may create a diagnostic dilemma, in this case approached with splenectomy.

This case highlights extensive progression of a relatively rare disease. In our case summary we highlight the progression of a bilateral adrenal hemangioma progressing to a size significant enough to cause
severe pain and partially compressing the IVC. Adrenal hemangiomas of this significance are rare, and mass effect to this degree is also an underreported phenomenon. To our knowledge this is the first case of
a symptomatic bilateral adrenal hemangioma causing mass effect.

Glanzmann’s thrombasthenia is a rare autosomal recessive hemorrhagic disorder caused by abnormal platelet glycoprotein complex (GP IIb-IIIa) presenting with hemorrhagic symptoms. Pregnancy is not uncommon because fertility is not affected but an association is rare. Also delivery often results in haemorrhage. Newborn thrombocytopenia is occasionally severe, but is always transitory. We report a 21-year old primigravida, who underwent vaginal delivery at term with IUGR and Oligohydramnios. Glannzmann’s thrombasthenia was characterized by aggregation and this patient went undiagnosed till adolescence until evaluated for puberty menorrhagia which is uncommon. She received single donor platelet transfusion during the intrapartum period along with tranexemic acid. Platelet transfusion may result in alloimmunization and make successive transfusions less effective. We did not use Factor VII in the intrapartum period due to cost and suspected fetal effects. Postnatally she had hematuria settled on the 2nd day with conservative management. We present this case because of association of Glanzmann’s thrombasthenia with IUGR and oligoamnios the only reported case so far.

Hypertension with hypokalemia, especially in a patient off diuretics, suggests a secondary hypertension due to an increase in mineralocorticoid activity, for example, primary increases in renin, aldosterone, or nonaldosterone mineralocorticoid secretion or an increased mineralocorticoid-like effect.
Mineralocorticoid Receptors (MR) preferentially bind cortisol. A mineralocorticoid effect of cortisol is avoided in some tissues by expression of 11-Beta Hydroxysteroid Dehydrogenase type 2 (11 BHSD2), the enzyme responsible for transformation of cortisol to its 11-keto derivative (cortisone), which has minimal affinity for MR receptors. Only when cortisol is converted to the inactive cortisone can aldosterone bind to the MR. Rare congenital deficiency of 11 BHSD2 or its inhibition by licorice consumption mimics hyperaldosteronic state.