We present the case of a male patient, 34 years old, non-smoker, presenting repeatedly in the past 2 years in emergency and cardiology departments for episodes of palpitation accompanied by faitness. One of the electrocardiograms recorded in emergency department captures bigeminated ventricular premature heartbeats. A cardiac magnetic resonance imaging (MRI) examination in May 2019 showed increased thickness of left ventricle during systole and contrast enhancement in the middle of cardiac wall at the base of the heart, considered initially as hypertrophic non-obstructive cardiomyopathy. The reinterpretation of MRI suggested that the changes were typical for cardiac sarcoidosis. Investigations performed later showed increased angiotensin-converting enzyme (ACE); thoracic computed tomography (CT) scan showed nodules and micronodules bilateral in upper lobes with moderate mediastinal lymph node enlargement and bronchoalveolar lavage (BAL) showed lymphocytic alveolitis with normal CD4/CD8 ratio, normal lung function with normal diffusing capacity. Even without biopsy, but based on CT scan, BAL and ACE, the patient was diagnosed as sarcoidosis with lung and cardiac involvement and was started on oral corticosteroids (methylprednisolone 32 mg/day). The diagnosis of cardiac involvement as initial presentation of sarcoidosis is difficult, due to limited knowledge about the disease among cardiologists and radiologists. Though, a recurrent arrhythmia, potentially severe, in a young patient in the absence of an alternative cause, should raise the suspicion for sarcoidosis with cardiac involvement, with a potential severe outcome in the absence of treatment.

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Clostridium difficile is an anaerobic bacterium than can colonise the lower intestine and cause enterocolitis in susceptible patients. Clostridium difficile infection (CDI) is typically a nosocomial infection, favoured by treatment with antibiotics (especially with broad-spectrum drugs), proton pump inhibitors, but also comorbidities, old age and prolonged hospitalisation. Based on the observation that in the past years, the frequency of nosocomial CDI has increased in the Institute of Pulmonology, Bucharest, this retrospective observational study aimed to analyse the characteristics of admitted patients who develop CDI, in order to identify possible particular features and risk factors. Accordingly, medical files from 80 patients admitted from January 2015 to August 2017 were analysed for demographic data, respiratory diagnosis, comorbidities, blood tests, treatments prescribed, time of CDI onset, evolution and outcome. The number of patients studied was 29 in 2015, 16 in 2016 and 35 in 2017, with slight male predominance. Totally, 54 patients (67.5%) had tuberculosis (pulmonary or pleural), 12 had lung cancer, five had respiratory infections, two had chronic obstructive pulmonary disease and seven had other diseases. All patients but nine were receiving antibiotics: tuberculosis drugs, cephalosporins, fluoroquinolones and beta-lactams. About half of the patients received proton pump inhibitors. Most patients had several comorbidities. Mean time since admittance to onset of diarrhoea was 20 days. CDI was treated with metronidazole or vancomycin. The evolution was favourable in 90% of patients, but eight patients (10%) died This study highlights a high frequency of CDI in patients treated for tuberculosis. Due to insufficient data, no epidemiological consideration could be made. Further studies are needed to assess the relationship among tuberculosis, tuberculosis treatment and CDI.

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