Whipple's disease is caused by a ubiquitous Gram-positive bacillus, Tropheryma whipplei. The disease is extremely rare, with only 1,000 cases reported worldwide. Classic Whipple's disease is characterized by a multisystemic involvement with joint (arthralgias) and gastrointestinal (abdominal pain, diarrhea, and weight loss) symptoms.We present a case of a 48-year-old male who had a constitutional syndrome associated with an exuberant bilateral pleural effusion. The small bowel biopsy identified a rod-shaped bacterial cologne in the macrophage cytoplasm, positive for periodic acid-Schiff (PAS) staining, and the polymerase chain reaction (PCR) exam identified the DNA of Tropheryma whipplei. The patient was medicated with two weeks of endovenous antibiotherapy with ceftriaxone 2 g per day, followed by one year of oral trimethoprim 160 mg and sulfamethoxazole 800 mg twice daily. He presented good evolution with total resolution of symptoms.

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Hemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening clinical syndrome, caused by an unregulated activation of cytotoxic T cells and macrophages. In adult patients, it is generally triggered by an underlying disease, with a significant proportion of cases being associated with malignancies (mainly lymphoma). The triad of fever, cytopenias, and hepatosplenomegaly is usually present, but, in severe cases, most patients will have a syndrome resembling sepsis and multiple organ failure, requiring admission into a critical care unit. We present a case of a 33-year-old healthy male patient, who presented with fever, malaise, and lower gastrointestinal bleeding. Upon admission, he was hypotensive and had elevated inflammatory markers, pancytopenia, and liver damage. Due to worsening shock of presumed septic and hemorrhagic origin, he was admitted to our ICU. An extensive diagnostic work-up was performed, including a bone marrow aspirate that revealed active hemophagocytosis and pleural effusion analysis that revealed abundant NK-Cells, phenotypically compatible with aggressive NK-Cell lymphoma. Anti-inflammatory and neoplastic treatments were immediately initiated, with a partial and transient response. Nonetheless, he developed refractory shock and medullary aplasia and died twenty days after being admitted. Although it is uncommon in adults, HLH is an important sepsis differential diagnosis to be aware of because it necessitates specific and timely treatment. Further investigation to determine and treat the possible underlying causes, including occult malignancies, is of paramount importance.

Vitamin B12 deficiency affects multiple systems, including the central and peripheral nervous systems, producing a vast spectrum of neurological symptoms. It is particularly important due to its insidious presentation and because it can evolve to spastic paraplegia with permanent sequelae. The authors describe a case of a woman with asthenia, bilateral lower limb weakness, urinary retention, and faecal incontinence, with no structural cause on imaging studies. Blood tests showed anaemia (haemoglobin: 6.8 g/dL) and vitamin B12 deficiency (<100 pg/mL). After upper digestive endoscopy compatible with chronic atrophic gastritis and positive for anti-intrinsic factor antibodies was obtained, the diagnosis of subacute combined degeneration due to vitamin B12 deficiency in the context of pernicious anaemia was admitted. Although this entity is a rare cause of myelopathy, it is a frequent manifestation of vitamin B12 deficiency. Clinical suspicion is fundamental since the reversibility of the neurological lesion is dependent on early treatment.