Acute pancreatitis is a sudden inflammation affecting the exocrine region of the pancreatic parenchyma. Infectious etiologies are rare. Here we report an exceptional case of a 44-year-old woman from a rural area who was referred to our hospital with fever and abdominal pain. A physical examination revealed pale skin and epigastric tenderness. Thoracoabdominal computed tomography revealed a Balthazar score of D. Serum laboratory findings revealed hemolytic anemia, hepatic cytolysis, and high C-reactive protein level. Calcium and lipase levels were normal. There was no history of recent trauma, alcohol consumption, or drug intoxication. The diagnosis of “query” pancreatitis was confirmed by serological Coxiella burnetii positivity. Oral doxycycline 200 mg daily was initiated. The clinical evolution was favorable. To our knowledge, no association between acute pancreatitis and hemolytic anemia caused by C. burnetii was reported previously. Q fever must be considered in cases of acute pancreatitis, especially when the patient is from a rural area or has a high-risk profession.

Background:Multiple autoimmune syndrome (MAS) is a rare entity, defined by the association of three autoimmune diseases in the same patient. MAS can be classified into three groups.Objectives:The objective of this work was to describe the autoimmune diseases profile in MAS in An Internal Medicine Department.Methods:We report a retrospective analysis including 14 cases of MAS seen in The Internal Medicine Department at Taher Sfar Hospital, Mahdia, TUNISIA over a period of 10 years.Results:We followed 14 patients with MAS. They were 14 women. The mean age of patients was 52 years. SAM was type 3 in 12 patients (85%), type 2 in one patient (7.1%) and one patient satisfied both type 2 and type 3 MAS criteria (7.1%). No cases of MAS type 1 had been reported. We found 13 patients with 3 associated autoimmune diseases and one patient with 4 associated autoimmune diseases. The autoimmune diseases were: Sjögren’s syndrome in 14 patients (100%), Hashimoto’s thyroiditis in 11 cases (78%), systemic lupus erythematosus in 7 cases (50%), Addison’s disease in 4 cases (28, 5%), scleroderma, thymoma, vitiligo, Biermer and primary biliary cholangitis each in one case (7.1%).Conclusion:Multiple autoimmune syndrome remains a rare but probably under-diagnosed entity. Thus, in patients with autoimmune disease, initial investigation and follow-up of clinical signs and biological stigmas of other autoimmune diseases should be cautious.Disclosure of Interests:None declared

Aim: We are reporting a case of an unusual presentation of granulomatosis with polyangiitis (GPA) with liver involvement. Case presentation: A 45-year-old male patient presented with erythematous plaques on the face and bilateral nasal obstruction. On physical examination, the patient had a ring-shaped squamous plaque on the face. The laboratory findings revealed an accelerated erythrocyte sedimentation rate at 100 mm/h, an elevated C-reactive protein at 66 mg/L, hyper gamma globulinemia 16 g/L and an elevated alkaline phosphatase (twice the upper normal limit). The craniofacial and thoracoabdominal computed tomography (CT) -scans showed ethmoid and maxillary sinusitis, low facial bone density, multiple mediastinal and hilar lymphadenopathy, diffuse small pulmonary nodules, and hepatomegaly. A cutaneous lesion biopsy, the nasal mucosa, and the liver showed a chronic inflammatory granulomatosis process with necrosis. Serum anti-neutrophil cytoplasmic antibody (ANCA) against PR3 was positive. The clinical, biological, radiological, and histological findings substantiated the diagnosis of GPA. The patient received systemic steroids combined with cyclophosphamide pulses on days 1, 14 and 28 and then he was lost to follow-up.  Two-years later, he presented with a cardiac failure and skin ulcer in the right lower limb. A nasal endoscopic exam showed nasal septum cartilage perforation with resorption of the middle and inferior nasal concha. Two weeks later, he developed a diffuse alveolar hemorrhage and was therefore transferred to the intensive care unit but died of respiratory failure 3 days later. Conclusion: Clinicians should be aware of GPA atypical clinical manifestations.

We describe here the third reported case of anaphylaxis after ingestion of some leavers of Moringa oleifera, causing a widespread angioedema, a respiratory distress, and an elevation of serum tryptase. M. oleifera leaves were confirmed as the causative allergen by prick testing with fresh leavers.