BMJ case reports
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This report concerns a case of torsades de pointes (TdP) associated with the concomitant administration of methadone and voriconazole in a patient with comorbid medical conditions. A 57-year-old man, with a medical history of human immunodeficiency virus, infective endocarditis, hepatitis C and orbital Aspergillus infection, was admitted to the intensive care unit following several episodes of TdP. The patient was being treated with methadone for opioid addiction and had started taking voriconazole 2 weeks prior for orbital Aspergillosis. ⋯ The pronounced inhibitory impact of voriconazole on methadone metabolism via the cytochrome P450 (CYP)2B6 isoenzyme was identified as a probable cause of the arrhythmia. Voriconazole was subsequently temporarily withheld and the methadone dose was significantly reduced. The patient received an implantable cardioverter-defibrillator, did not experience additional episodes of TdP during hospitalisation, and was discharged from the hospital on day 13.
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Mediastinitis caused by oesophageal perforation usually presents as a severe disease that can quickly progress to sepsis and death. We report a case with an indolent form of mediastinitis, caused by fish bone ingestion, which was successfully and exclusively treated with antibiotics. ⋯ The diagnosis was difficult to obtain because of this atypical clinical presentation. The chest computed tomography scan combined with the thoracic pain and the history of fish bone ingestion allowed us to confirm the diagnosis and initiate treatment.
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GH Whipple described a 36-year-old physician in 1907 with gradual loss of weight and strength, stools consisting chiefly of neutral fat and fatty acids, indefinite abdominal signs and a peculiar multiple arthritis. The patient died of this progressive illness. Whipple called it intestinal lipodystrophy since he observed accumulation of large masses of neutral fats and fatty acids in the lymph spaces. ⋯ The detection of PAS-positive histiocytes in the small intestine remains the mainstay of the diagnosis, although Whipple's disease without gastrointestinal involvement is described. We illustrate a case in which, retrospectively, the clinical presentation would have been typical for Whipple's disease. However, the clinical presentation and the histological examinations of lymph nodes, liver biopsies and ascites initially were misinterpreted as sarcoidosis with consecutive immunosuppressive therapy and progressive worsening of the patient's health presenting at least as sepsis with endocarditis.
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A 15-year-old asymptomatic girl was found to have a large left lower chest wall mass associated with chest wall invasion on an opportunistic chest radiograph. The tumour was excised and shown to be a clear cell sarcoma. Adjuvant chemotherapy was administered and she was disease free at her 10 month follow up.