Year 2024, Volume 8 - Issue 6

Background: Marantic endocarditis and Trousseau's syndrome are historically linked with pancreatic cancer. The patient had catastrophic embolic events which caused multi organ infarct due to underlying advanced pancreatic cancer. Doctors should be aware of early signs and symptoms of pancreatic cancer and conduct necessary clinical assessments and investigations that can prevent any severe complications. Case Presentation: A middle-aged healthy gentleman who presented with left-sided weakness, slurred speech, left-sided sensory neglect, mild headache, and fever. CT head showed acute right-sided temporal ischemic changes with subsequent magnetic resonance imaging (MRI) head showed multiple infarcts in the brain. A transesophageal echocardiogram reported possible MV vegetation. MRI of the liver was done due to deranged LFTs which showed multiple liver metastasis with a primary mass in the tail of the pancreas. Left leg ultrasound Doppler showed a large left leg deep vein thrombosis involving the femoral vein as he complained of left leg pain for 2 months and went to GP with right leg pain 3 months ago which was treated as a right ankle sprain. The clinical events explained that most likely he developed Trousseau's syndrome 3 months ago and the embolic phenomena were due to rare Marantic endocarditis (Non-bacterial thrombotic endocarditis) secondary to pancreatic cancer. Ultrasound-guided biopsy of liver metastasis was planned, but sadly the patient passed away the next day. Conclusion: The diagnosis of early pancreatic cancer with imaging poses a challenge sometimes, therefore the pancreatic protocol of CT or MRI is the first line of investigation. Moreover, the cause of unprovoked thrombo-embolism should be investigated to rule out any underlying malignancy.

Background: Failure to treat persistent hypothyroidism despite the use of adequately prescribed doses of levothyroxine should be evaluated for malabsorption and nonadherence to medication. Previous literature suggested that orally administered levothyroxine showed maximum absorption at or near 2 hours. This rapid absorption suggests the use of a 2-hour levothyroxine absorption test as an alternative to long, cumbersome protocols. Limited data are available measuring free thyroxine (FT4) levels at 2 hours after oral administration of 1,000 mcg of levothyroxine. Case Presentation: Six patients who continued to have hypothyroidism despite taking ostensibly high doses of levothyroxine underwent a 2-hour protocol levothyroxine absorption test. All patients were given 1,000 mcg of levothyroxine, and serum levels of thyroid-stimulating hormone (TSH), FT4, and free triiodothyronine (FT3) were measured at 0, 60, and 120 minutes. All patients showed an increasing trend in FT4 in subsequent samples at 60 and 120 minutes, compared to baseline values, providing strong evidence of peak levothyroxine absorption at 2 hours. Five patients had raised baseline TSH levels, indicating nonadherence to treatment, and one had normal baseline TSH levels, indicating adherence to levothyroxine therapy on prior test scheduling, with increased FT3 and FT4 levels in subsequent samples at 60 and 120 minutes. Conclusion: We conclude that the rapid levothyroxine absorption test, using a 2-hour protocol, is a more convenient method to differentiate nonadherence from malabsorption. Moreover, scheduling the patient will result in adherence to levothyroxine therapy in some patients.

Background: Gallstone ileus is a rare complication of cholelithiasis caused by a bilioenteric fistula. Besides clinical examination, computer tomography (CT) scan is considered a radiological diagnostic procedure. Case Presentation: A 68-year-old male patient presented with epigastralgia, nausea, and emesis. The abdomen was distended and diffusely painful to palpation with peritoneal irritation. Auscultation showed raised peristaltic sounds. CT scan showed aerobilia, distension of the stomach, duodenum, and proximal jejunum, and inside it a 3.5 cm calcified round foreign body. Exploratory laparoscopy showed jejunum obstruction and chronic inflammation of the gallbladder. Lifting the small bowel through a small laparotomy was performed for gallstone removal. After recovery a delayed cholecystectomy and fistula closure followed. Hospital stays were short and complication-free. Conclusion: There are no guidelines for the management of gallstone ileus yet because of a limited number of reported cases. Most of the bilioenteric fistulas are located between the gallbladder and duodenum. In cases of biliocolonic fistula, causing obstruction in the colon endoscopic or conservative therapy can also be performed with a success rate of 26%. Surgical treatment is still a common procedure in emergency cases.

Background: Histoplasmosis is caused by Histoplasma capsulatum which can lead to a broad spectrum of disease. Culture remains the gold standard till date; however, this is a slow-growing fungus that may take a considerable time before a conclusion can be made. This case highlights the importance of careful bone marrow evaluation to identify the fungal bodies, especially in the presence of increased hemophagocytic activity. Case Presentation: We present a 36-year-old man with newly diagnosed retroviral disease, presented with fever, pancytopenia, and hepatosplenomegaly. Bone marrow aspirate smear showed increased hemophagocytic activity with the presence of intracellular organisms. Trephine biopsy showed similar features with the presence of fungal bodies detected via Periodic acidSchiff stain. Conclusion: In conclusion, bone marrow examination plays a crucial role in the diagnosis of some fungal infections, especially in centers where culture or serological tests are not readily available.

Background: Jugular vein phlebectasia is a rare entity seen in children and is often an incidental finding presenting as a soft, cystic painless neck swelling that becomes prominent on coughing or straining and disappears on rest. It is usually managed conservatively. Case Presentation: We report a case of an 8-year-old boy who visited us on an outpatient basis with a history of cough with neck swelling. Doppler ultrasound helped clinch the diagnosis of bilateral jugular venous phlebectasia. Conclusion: It is paramount that clinicians consider this differential of jugular phlebectasia for neck swellings to avoid unnecessary investigations.