Cazuistica

MEDICAL PRACTICE

Case presentation

Herpes Zoster in a child with intrauterine Varicella-Zoster virus exposure: a case report

Abstract

Herpes zoster in children is a rare condition, especially in immunocompetent patients. Intrauterine exposure to varicella-zoster virus has been described as a possible predisposing factor for later viral reactivation. We present the case of a 6-year-old child with no significant medical history, unvaccinated against varicella, whose mother had varicella during pregnancy. The disease onset was characterized by fever and a unilateral vesicular eruption involving the left lumbar dermatome, without associated pain. Initially, only topical treatment was recommended, while antiviral therapy with Acyclovir started later due to persistent fever and worsening skin lesions. The patient was subsequently reevaluated in the family physician’s office, where the clinical examination did not support bacterial superinfection. The evolution under antiviral and symptomatic treatment was favorable. Considering the occurrence of herpes zoster in an apparently immunocompetent child, additional laboratory investigations and pediatric evaluation were recommended to exclude an underlying condition. This case highlights the importance of thorough medical history taking, including maternal history during pregnancy, in the diagnostic approach to pediatric herpes zoster. Periodic clinical reassessment and individualized therapeutic management play an essential role in family medicine practice.

Keywords: herpes zoster, maternal varicella, congenital varicella infection

MEDICAL PRACTICE

Case presentation

Scarring alopecia: basal cell carcinoma or discoid lupus?

Abstract

This case study describes the evolution of a 60-year-old female patient who presented to her family doctor with a patch of scarring alopecia on the parietal region, which developed approximately one year ago following a scalp injury. Her personal history included essential hypertension and grade I obesity. Local examination revealed an area of scarring alopecia with a whitish, atrophic central area crossed by arborized vessels. Based on these clinical findings, basal cell carcinoma was suspected. The atypical clinical presentation led the family doctor to continue investigations, and ultimately a skin biopsy revealed vascular degeneration of the basal cells (interface dermatitis), accompanied by a lymphocytic infiltrate and, implicitly, a diagnosis of discoid lupus erythematosus.

Keywords: cicatricial alopecia, discoid lupus erythematosus, family medicine

MEDICAL PRACTICE

Case presentation

PANDAS syndrome – from symptom to diagnosis. Perspectives from the practice of the family doctor

Abstract

PANDAS syndrome (Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections) is a clinical entity characterized by the sudden and severe onset of obsessive-compulsive symptoms (OCD) and/or tics in prepubertal children, with an episodic evolution, temporally associated with an infection with beta-haemolytic streptococcus group A and with the presence of neurological abnormalities such as motor hyperactivity or choreiform movements.

In everyday practice, the family doctor is often in the position of observing the first signs of an acute onset disorder, before the family reaches a doctor of another specialty. In this context, PANDAS poses a particular challenge: the symptomatology appears suddenly, is intense, sometimes dramatic, and the parents frequently present frightened, looking for a clear explanation. The family doctor must, therefore, have the ability to recognize situations in which an apparently trivial infection can trigger a rapid and profound behavioural change.

We present the case of a 5-year-old girl, born at term, with normal psychomotor development, who was brought to the consultation for the sudden onset of involuntary motor manifestations and significant behavioural changes, which occurred one week prior to presentation.

Keywords: PANDAS syndrome, streptococcal infection, family doctor

MEDICAL PRACTICE

Case presentation

Addressing the manifestations of atherosclerotic disease in family medicine – case presentation

Abstract

Atherosclerotic disease is the substrate of cardiovascular diseases caused by atheromatous plaque. One of its consequences is peripheral arterial disease, which affects different arterial territories. Arterial disease of the lower limbs is one of the pathologies frequently encountered in the practice of family physicians. This condition requires a well-structured management plan and a multidisciplinary approach. We will present the case of a young adult man with arterial damage to the lower limbs, with details on aspects related to diagnosis, non-drug and drug therapy, and follow-up in the family physician’s office.

Keywords: lower extremity arterial disease, family physician

MEDICAL PRACTICE

Case presentation

When to investigate fever – suspicion of tropical etiology in acute respiratory infections: case report

Abstract

Tropical infectious diseases are infectious pathologies encountered in tropical and subtropical regions, particularly in Africa, Asia, and Central and South America. Under the umbrella of “tropical infectious diseases,” there is a prominent group of four illnesses: malaria, yellow fever, typhoid fever, and dengue fever. Bacteria, viruses, parasites cause these diseases and are often transmitted through vectors (such as mosquitoes, ticks, flies) or via contaminated food and water sources. The main contributing factors that facilitate the transmission of these diseases are: a warm and humid climate year-round, poor socio-economic conditions, and limited access to clean water and adequate healthcare services. Tropical infectious diseases can majorly impact public health, especially in endemic areas. However, with globalization and the increasing frequency of international travel, the risk of these diseases appearing in other parts of the world is also growing. For this reason, early diagnosis and preventive measures are essential.

Keywords: tropical infectious diseases, Dengue fever, yellow fever, typhoid fever, malaria, endemic areas

MEDICAL PRACTICE

Case presentation

Management of alopecia areata in the family medicine’s practice: case report

Abstract

Alopecia areata (AA) is an autoimmune disease characterized by non-scarring hair loss from the scalp, face, or body. It usually occurs in a single area and is self-limiting, but it can rarely progress to total alopecia. The interaction between genetic factors and an environmental trigger causes AA. The diagnosis is clinical, and there are several topical treatment options available; in severe cases, systemic immunosuppressive therapy may be used. AA is often associated with other autoimmune diseases such as atopic dermatitis, vitiligo, thyroid disorders, and mental health issues. Approximately 50% of individuals will recover from AA, but the progression is unpredictable.

We present the case of a 25-year-old female patient who presented to her family physician with a round alopecic patch of approximately 4 cm on the right frontoparietal area of the scalp. The patient underwent several laboratory investigations, was screened for depression and anxiety, and was referred to a dermatologist. She began treatment with topical minoxidil and oral food supplements for hair. The patient will be closely monitored in the following period to track the progression or regression of the disease. Patients affected by alopecia areata have higher rates of depression and anxiety. The family physician plays a significant role in managing the disease: guiding the patient towards investigations, conducting specialist examinations, making differential diagnoses, and monitoring the patient’s evolution. Close monitoring of the disease progression is important for evaluating treatment efficacy and adjusting therapeutic approaches if necessary. Given the psycho-social impact that alopecia areata can have on patients, a mental health assessment is essential. The family physician plays a crucial role in identifying anxiety and depression issues, providing support, and guiding patients toward mental health specialists.

Keywords: alopecia areata, psycho-social impact, disease management, close monitoring

MEDICAL PRACTICE 

Complementary medicine

Clinical case presentation: Leriche Syndrome

Abstract

Leriche syndrome and peripheral arterial disease as clinical-biological entities are difficult to manage in the family doctor’s office. The family doctor, as the patient’s first contact with the medical system, has the role of contributing to an early diagnosis, to advise the patient and relatives about the importance of adherence to treatment but also to offer them psycho-emotional support. Early detection of the diagnosis offers the possibility of an early treatment and thus slowing down the evolution of the disease. The complications of this disease engage multiple professional and social implications; the complexity of the care and the costs generated are getting higher and the patient can become a burden for society and the family. The presented case intends to highlight the attribution of the family doctor in the management of a patient diagnosed with Leriche syndrome, a patient known for a long time with peripheral arterial disease and to emphasize the importance of the risk factors management for this condition at the level of the family medicine office.

Keywords: Leriche syndrome, peripheral arterial disease management in family medicine

MEDICAL PRACTICE 

Case presentation

Caring for a patient with a vegetative state – a challenge for the family doctor

Abstract

The vegetative state of a late resuscitated patient is a great challenge for professionals. Care provided by palliative units’ teams involves: passive mobilisation, patients’ assessment, management of therapeutic plan, investigations, social and spiritual evaluation.  When a patient with a vegetative state is discharged home, the all of these responsibilities falls on the shoulders of a single person, usually a family, sometimes helped by other people from the family. The primary family caregiver must meet all the requirements of the multidisciplinary palliative care team. The general practitioner should be involved in helping and coordinating the primary caregiver in order to assure a correct and effective outcome. Therefore, the general practitioner, which otherwise is rarely meeting this kind of situations, should update his knowledge about specific requirements: tracheostomy, gastrostomy, decubitus lesions, changing and caring for the urinary probe.

Keywords: vegetative status, palliative care, patient’s home, family doctor, coordinator

Acrocyanosis is a peripheral functional disorder that occurs in the extremities (fingers or toes and face). The physio-pathological mechanism is explained by the appearance of vasospasm in the small vessels in dermis as a result of the presence of some triggering factors: cold, toxic, medication, etc. Some of the medication used in oncological pathology can be correlated with the occurrence of vasospasm followed by the presence of acrocyanosis.We present the case of a 71-year-old patient who comes to the general practitioner for pain in the toes (V), followed by the presence of a purple-colored swelling of these extremities, with remission of symptoms in the inclined position and with the intensification of symptoms in the antigravity position. The swelling evolves over the course of a few days into an ulcerative and later necrotic lesion. The first indication of the vascular surgeon’s is the bilateral amputation of the toes. From the patient’s personal pathological history, we note essential arterial hypertension stage II with very high additional risk, type 2 insulin-requiring diabetes mellitus, chronic venous insufficiency CEAP 2 and adenocarcinoma of the right breast operated in 2007 and 2018, radio-chemotherapy, recurrent. Notable from the patient’s treatment is the following medication: insulin, metformin, gliclazidum, nebivolol, amlodipine and the oncology medication fulvestrant and abemaciclib, the last one is being recently introduced into the treatment. By correlating the anamnestic data with the laboratory examination and Doppler echo of the lower limbs, the diagnosis of acrocyanosis is made in the context of therapy with abemaciclib. This therapy is stopped and a type 3 phosphodiesterase inhibitor – cilostazol – is introduced. The evolution under the established measures is favorable with the closure of the ulcerative lesions, with the formation of a crust at the level of the necrotic areas, with self-removal, without further scarring and with the disappearance of the antigravity acrocyanosis.

Keywords: acrocyanosis, treatment, drug, ulcerative lesion