Internal Medicine Insights 🧠

Up to 1/3 of patients Diffuse alveolar hemorrhage may not have hemoptysis

🩺 Clinical Challenge A previously healthy middle-aged man presented with high-grade fever and rigors. Initial workup showed leukocytosis, thrombocytopenia, and elevated liver enzymes. Our initial differential diagnosis included: • Disseminated intravascular coagulation (DIC) • Thrombotic thrombocytopenic purpura (TTP) • Hemophagocytic lymphohistiocytosis (HLH) • Viral hemorrhagic fever Given that we practice in an endemic area, Crimean-Congo hemorrhagic fever (CCHF) was strongly suspected, and PCR returned positive, confirming the diagnosis. Take-home message: In endemic regions, always include CCHF in the differential diagnosis of acute febrile illness with thrombocytopenia and transaminitis. Early suspicion is essential for prompt isolation, appropriate supportive management, and protection of healthcare workers.

The second case A previously healthy young woman presented with acute flaccid paralysis due to profound hypokalemia (K⁺ 1.6 mmol/L). After stabilization, ABG revealed hyperchloremic normal anion gap metabolic acidosis, suggesting distal renal tubular acidosis. With no GI losses or offending medications, a focused history uncovered sicca symptoms. Autoimmune testing confirmed primary Sjögren syndrome (anti-SSA/SSB positive). A reminder that Sjögren syndrome may initially present with renal involvement before classic sicca symptoms become the chief complaint.

Another interesting case A young female presented with fever, vomiting, abdominal pain, and markedly elevated pancreatic enzymes, consistent with acute pancreatitis. Initial evaluation excluded common etiologies, including gallstones/structural biliary disease, drug-induced pancreatitis, and autoimmune pancreatitis. Further history revealed a probable scorpion sting four days before symptom onset while living in a rural endemic area. In the absence of other identifiable causes, the diagnosis was considered probable scorpion sting-associated acute pancreatitis, highlighting the importance of obtaining a thorough exposure history in cases of unexplained pancreatitis.