A 47-year-old man presented with fever, a maculopapular rash of the palms and soles, muscular weakness, weight loss, faecal incontinence, urinary retention and mental confusion with 1 month of evolution. Neurological examination revealed paraparesis and tactile hypoesthesia with distal predominance, and no sensory level. Laboratory investigations revealed a venereal disease research laboratory (VDRL) titre of 1/4 and Treponema pallidum haemagluttin antigen (TPHA) of 1/640, positive anti-nuclear antibodies of 1/640 and nephrotic proteinuria (3.6 g/24 h). Lumbar puncture excluded neurosyphilis, due to the absence of TPHA and VDRL. The diagnosis of systemic lupus erythematosus (SLE) was established and even though transverse myelitis as a rare presentation of SLE has a poor outcome, the patient improved with cyclophosphamide, high-dose corticosteroids and hydroxychloroquine. A diagnosis of secondary syphilis was also established and the patient was treated with intramuscular benzathine penicillin G.

Sarcoidosis is a chronic granulomatous disease of unknown aetiology. It can affect any part of the organism, although the lung is the most frequently affected organ. Upper airway involvement is rare, particularly if isolated. Sarcoidosis is a diagnosis of exclusion, established by histological evidence of non-caseating granulomas and the absence of other granulomatous diseases. The authors report a case of a man with sarcoidosis manifesting as a chronic inflammatory stenotic condition of the upper respiratory tract and trachea.

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A n 81-year-old woman with cerebrovascular disease presented to the emergency department with a 1-week history of vomiting. Findings on abdominal examination were notable for normal bowel sounds and the absence of tenderness, rebound, or guarding. A chest radiograph showed a large air-liquid shadow in the inferior retrocardiac position (Panels A and B, arrows), which suggested a large paraesophageal hernia. A computed tomographic scan showed a large retrocardiac mass containing air and liquid (Panels C and D, red arrows) that was consistent with herniation of the stomach into the chest. Thickening of the gastric wall suggested edema (Panel D, white arrow) and compression of the first portion of the duodenum, which caused gastric distention. Hiatal hernias are defined as protrusion of the stomach through the diaphragm into the chest. The degree of displacement can produce obstructive symptoms, as occurred in this patient, and may increase the risk of volvulus. Owing to her generally poor health status, the patient was treated conservatively, with gastric suction performed through a nasogastric tube followed by initiation and advancement of her oral diet, first with clear liquids, then soft foods, and finally solid foods. The vomiting resolved, and the patient was asymptomatic at the time of discharge.