74 year-old-man, former smoker, with chronic obstructive pulmonary disease GOLD grade 4, group D, with emphysema component, treated in a pulmonary rehabilitation program, on oxygen therapy and nocturnal bi-level positive airway pressure (BiPAP) ventilation. During the night he had a traumatic rib fracture (5–11th right ribs) but still he used BiPAP ventilation during the sleep. In the morning after he presented with a diffuse and massive emphysema in the face, thorax and abdominal regions. On physical examination, the patient presented with massive swelling and crepitus on palpation. A chest computed tomography (CT) scan confirmed a diffuse subcutaneous emphysema and revealed a mediastinal emphysema and bilateral small pneumothorax. A fast resolution of the emphysema was of paramount importance as the patient was severely agitated due to his inability to open both eyes, and the need to reintroduce BiPAP ventilation as soon as possible. It was placed a fenestrated subcutaneous catheter on left hemithorax and a subcutaneous ostomy on right hemithorax for comparative purpose. It was also performed a confluent centripetal massage towards drainage orifices, with immediate and substantial improvement of emphysema, especially in left hemithorax, and progressive ocular opening. Further emphysema absorption occurred during hospitalization.

Alice in Wonderland syndrome (AIWS) is a rare disorder that refers to episodic body image distortions, sometimes associated with altered perception of external space and time. AIWS is mainly associated with viral disease in children as well as migraines and epileptic seizures in adults. Its pathogenesis is still very much unknown and there are not many reported drugassociated cases in medical literature. We describe a case of a 67-year-old woman, with a relevant history of depressive disorder, nontoxic goiter, and dyslipidemia that presented short episodes of altered body perception associated with altered external space perception for a period of one week. Her physical examination was unremarkable and her cerebral computerized axial tomography (cerebral CAT) and blood tests showed no alterations. She had been medicated with sertraline till the previous year and had restarted it in the previous month. She reported similar episodes of body image distortions in the first weeks of initiating sertraline for the first time. The current episode lasted for two weeks and in one year follow-up she reported no recurrence. The patient was diagnosed with AIWS probably induced by sertraline, being the first reported case of the kind.

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Acute intoxications are common causes of admission to the Emergency Department (ED). Flupirtine is a non-opioid analgesic, originally used for acute and chronic pain. Because of several reports of severe liver toxicity, its use was limited to acute pain in 2013 by the European Medicines Agency. Although withdrawn from the European market in March 2018, there are still flupirtine tablets in many households, and most people are unaware of the hazards they might be facing.A 58-year-old man was admitted to the ED after a suicide attempt with 1 g of flupirtine. He was lethargic and confused but presented no focal neurological deficits or other symptoms, and the rest of his clinical examination was unremarkable. His cerebral CAT and blood chemistry showed no alterations. The only remarkable feature was that he had green urine. After a careful literature search, a similar case was found caused by flupirtine intoxication. After 24 hours of vigilance in the ED, he improved his neurological status and his urine lost part of its greenish color. He was then transferred to the Psychiatric Department, where he presented a complete remission of the clinical alterations. A follow-up check-up showed no permanent deficits.