Gangrenous Cholecystitis with Atypical Presentation in an Elderly Diabetic Woman

In elderly patients, numerous factors subsidize the diagnostic challenge and high incidence of complications in this specific population, taking gangrenous cholecystitis as a critical example. The aim of this work is to report an unusual case of gangrenous choleystitis in an elderly diabetic women and its atypical clinical presentation. A 79-year-old female patient came to our observation;her medical history showed nausea and vomiting of about 2 hours which rapidly ended with symptomatic therapy, without recurrence, and a 3-week history of intermittent fever associated with productive cough. No abdominal discomfort was declared. Physical examination of the abdomen was negative. Laboratory analysis revealed leukocytosis with the remaining criteria within the normal range. After 2 days, she started with a mildabdominal pain in the epigastric region that rapidly progressed to the right upper quadrant, right flank and right iliac fossa, without nausea, vomiting or fever. Abdominal computer tomography findings revealed thickness of the gall-bladder and important densification of the vascular bed. Acute cholecystitis was diagnosed. The patient was then submitted to a laparoscopic cholecystectomy under general anaesthesia with findings suggestive of gangrenous acute cholecystitis confirmed by histologic examination of the specimen. Delays in diagnosing acute cholecystitis in specific populations, such as elderly diabetics, result in a higher prevalence of morbidity and mortality due to potentially serious complications as gangrenous cholecystitis. Consequently, the diagnosis should be measured and investigated promptly in order to prevent poor outcomes.

Infective Endocarditis with Negative Cultures:A Defiant Diagnosis

The diagnosis and management of blood culture-negative endocarditis constitute a real clinical challenge and a systemic approach is necessary for a successful outcome. The authors report a case of a female patient aged 26, with previous clinical history of valve disease and heart failure NYHA class II, with decompensation of co-morbidities associated with fever, productive cough, nonselective anorexia and unquantified weight loss with one month of evolution with negative blood cultures. Transesophageal echocardiography revealed the presence of severe pulmonary hypertension and mitral valve vegetations in the context of positive serology for Q fever. Herein, the authors report a case of blood culture-negative endocarditis and present a brief review on the management of this medical condition. We highlighted the diagnostic difficulties of blood culture-negative endocarditis and subacute clinical presentation, which sometimes present with fever of unknown origin and complaints of deterioration of cardiac function, thus creating a challenging differential diagnosis.

Strongyloides stercoralis in an immunocompetent adult:An unexpected cause of weight lost

Strongyloides stercoralis infects at least 100 million humans worldwide each year, but its prevalence is underestimated. It is endemic in hot and humid climates as well as resource poor countries with inadequate sanitary conditions. The rise of international travel and immigration has a positive impact in strongyloidiasis. Due to its unique auto infection life-cycle, Strongyloides may lead to chronic infections remaining undetected for decades. Strongyloidiasis is most often asymptomatic but it has a wide range of clinical presentations. The two most severe forms of strongyloidiasis are hyperinfection and disseminated syndromes. These occur most often in patients with impaired cell mediated immunity. A 42-year-old immunocompetent man presented with chronic watery diarrhea, malaise, upper abdominal pain, anorexia and weight lost. Strongyloides stercoralis was identified in stool samples and duodenal biopsy. The patient was successfully treated with albendazole. The authors report a case of strongyloidiasis hyperinfection in an immunocompetent host 20 years away from an endemic area and make a literature review.