Graves’ disease is an autoimmune disorder that results in hyperthyroidism, caused by autoantibodies to the thyrotropin receptor (TRAbs) stimulating thyroid hormone synthesis, giving rise to a variety of systemic manifestations such as goitre, dermatopathy and orbitopathy.  The authors present the case of a 28-year-old man admitted to hospital for a 3-week history of fatigue, shortness of breath, palpitations and diffuse goitre, after recent mild SARS-CoV-2 infection. Laboratory investigation revealed hyperthyroidism with TRAbs elevation. Thyroid ultrasound confirmed a diffusely heterogeneous and irregular thyroid gland and a nodular image below the sternal notch. Thyroid scintigraphy excluded the nodule and confirmed a Graves’ disease pattern. Following the initiation of methimazole, the patient had complete resolution of symptoms and normalization of thyroid values. The results suggest a possible association between Graves’ disease and SARS-CoV-2 infection acting as a trigger. Graves’ disease is an important differential diagnosis to keep in mind when patients present with hyperthyroidism after COVID-19 disease.

Introdução: A doença por coronavírus 2019 (COVID-19) aumentou a pressão assistencial sobre os hospitais. Para contenção da transmissão foram adotadas medidas alternativas de prestação de cuidados às doenças crónicas nomeadamente através do recurso à Telemedicina. A satisfação dos doentes face aos cuidados recebidos associa-se a um melhor prognóstico. Com este estudo pretende-se avaliar a satisfação com os cuidados prestados na consulta telefónica de Medicina Interna. Material e Métodos: Após revisão bibliográfica foi criado um questionário para avaliação da satisfação dos doentes com a consulta telefónica. Foram incluídos todos os doentes que tiveram consulta telefónica de Medicina Interna em Setembro de 2020. O questionário foi aplicado ao próprio doente ou familiar. Resultados: O questionário foi realizado a 81 doentes com idade média de 67,9 anos e predomínio do género masculino (53,1%). O questionário foi respondido pelo próprio doente em 71,6% dos casos. Setenta doentes (86,5%) concordam/ concordam totalmente que a consulta telefónica permitiu ter os cuidados de saúde que necessitavam e 88,8% concorda/ concorda totalmente que é uma forma aceitável de receber cuidados de saúde. A maioria (74,1%) revelou estar satisfeita com a consulta telefónica. Discussão e Conclusão: Apresentamos um novo questionário de satisfação que revelou ter uma boa fiabilidade podendo ser uma importante ferramenta para o futuro. Em geral os doentes atribuíram altos scores totais de satisfação à consulta telefónica, traduzindo-se na sua aceitação como forma alternativa de receber cuidados de saúde. A implementação da Telemedicina durante a atual pandemia permite manter os cuidados de saúde revelando-se uma estratégia promissora.

Introduction The patients with Pulmonary Thromboembolism (PE) stratified as intermediate-high risk with the European Society of Cardiology classification represent an heterogenous population, with the majority having a benign outcome however some evolving in clinical deterioration. Several risk scores have been developed to try and refine the population most at risk but they are deemed sub-optimal. Purpose Our aim was to assess the capacity of the National Early Warning Score (NEWS) in predicting a composite end-point of 30-days cardiovascular mortality, rescue thombolysis and/or haemodynamic instability, in a population of intermediate-high risk PE, as compared with other risk evaluation scores as the PESI and SHIeLD scores. Methods We performed a retrospective analysis between 2014 and 2019 of all patients admitted for intermediate-high risk PE, in a single expert centre. The patients who underwent fibrinolysis as per clinician discretion (without haemodynamically instability or clinical evidence of clinical deterioration) were excluded. Medical records were analysed for clinical data and outcomes. The predictive accuracy of all scores were assessed using the area under curve (AUC) of receiver operating characteristics (ROC) curve. The association between NEWS and composite end-point at 30-days was analyzed using a Cox regression model. Results Of the 1132 patients assessed and admitted with PE, 116 patients fulfilled all inclusion criteria and none of the exclusion criteria and were analysed. The mean age was 69±16 years at time of diagnosis with a female preponderance (62.9%). Most patients were treated with anticoagulation (97.4%), 68% with low molecular weight heparin and the remaining with unfractionated heparin. The average NEWS score was 7±3, the average PESI score was 110±34 and the average SHIeLD score was 14±13. A primary composite end-point occurred in 18 patients (15.5%). The NEWS score showed the greatest predictive power for the occurrence of an event (OR 1.35; 95% CI 1.11–1.64, p=0.003) compared with the SHIeLD score (OR 1.0; 95% CI 1.00–1.07, p=0.035) and the PESI score (OR 1.02; 95% CI 1.00–1.03, p=0.03); it also showed a greatest discriminative capacity with the ROC curve analysis (Figure 1A) demonstrating an AUC of 0.70, vs 0.65 and 0.62 respectively. The survival analysis demonstrated a Hazard Ratio of 1.29 (95% CI 1.10–1.52; p=0.002) signifying a 29% increased risk of an event per each NEWS class increase, with the Kaplan Meier curves widening significantly in the different terciles of the score (Figure 1B). Conclusions In PE patients with intermediate-high risk the NEWS score demonstrated a greater predictive power and discriminative capacity than other commonly used risk scores. The NEWS score may help to identify patients in this risk category who might benefit from a reperfusion strategy, but larger studies are needed to confirm this hypothesis. Funding Acknowledgement Type of funding sources: None.

Protein-losing enteropathy (PLGE) is an uncommon condition with a multifactorial origin, that is characterized by excessive loss of serum proteins into the gastrointestinal tract, resulting in hypoproteinaemia and oedema.  The authors present the case of a 24-year-old man admitted to hospital for a 2-month history of lower extremity oedema and diarrhoea with a secretory pattern. Blood analysis revealed hypoalbuminaemia and iron deficiency anaemia. Liver disease and severe proteinuria were excluded as possible aetiologies. Upper gastrointestinal endoscopy revealed signs of chronic Helicobacter pylori gastritis. After completion of H. pylori eradication, the patient had complete resolution of clinical and laboratory abnormalities. The results suggest the need to consider less frequent aetiologies for peripheral oedema and hypoproteinaemia, such as PLGE, especially those caused by prevalent bacterial agents like H. pylori.

Intraocular lymphoma (IOL) is a rare and life-threatening condition whose aetiology is unclear. Blurred vision, reduced vision, and floaters are common initial symptoms. Posterior vitreous detachment and haemorrhage rarely occur. The authors present the case of a 79-year-old man who initially presented with a 3-month history of fever, night sweats, significant weight loss, bilateral peri-orbital haematoma, red eyes and retro-orbital headache. Physical examination revealed fever, bilateral peri-orbital haematoma, subconjunctival haemorrhage and palpable cervical lymphadenopathy. CT scans detected conical intra-orbital lesions, cervical adenomegalies, expansive lesions in the adrenal glands, and thrombosis of the splenomesenteric confluent and posterior segment of the right branch of the portal vein. These findings were suggestive of a lymphoproliferative disorder. Aspiration cytology of the adrenal mass and inguinal adenopathies was compatible with diffuse large B-cell lymphoma with areas of transformation to Burkitt’s lymphoma. We describe a rare form of lymphoma, and a very unusual presentation of primary intraocular lymphoma with atypical symptoms.