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Introduction: Fatigue is a common, nonspecific symptom with a broad range of etiologies including acute and chronic medical disorders, psychological conditions, medication toxicity, and substance use.

Case report: A 26-year-old woman resorts to the Health Unit with feelings of anguish, sadness, fatigue, crying spells and terminal insomnia with 2 months of evolution. In addition to concerns about her 8-year-old brother with cerebral palsy, she reported her parents were divorcing. She didn’t intend to start medication. She returns 3 weeks later with an analytical study that had no relevant findings. She agreed to start antidepressants. After 6 weeks only sleep had improve. The patient additionally reports that she was followed in adolescence by a thyroid nodule. The dosage of the antidepressant was titrated, and a thyroid ultrasound was requested. Two months later, there was an improvement in the mood complaints, but maintained fatigue. The ultrasound revealed a “solid nodular formation, hypoechoic, lobulated or two nodular formations”. A biopsy of the thyroid nodule was requested. Due to the suspicion of parathyroid adenoma, a measurement of serum calcium and PTH was requested, and both were elevated, favoring this last hypothesis. A general surgery appointment was requested, and the patient underwent a parathyroidectomy, leading to a resolution of the symptoms, namely asthenia.

Discussion: Fatigue is a non-specific symptom, which requires a careful etiological investigation. In this case, although it could have been a result of her mood disorder, there was an organic justification for her asthenia. The Family Physician must be watchful, trying to make a assertive differential diagnosis in cases with symptoms refractory to treatment.

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Background and purpose

Acquired hemophilia A (AHA) is a rare bleeding disorder caused by autoantibodies against coagulation factor VIII (FVIII). The hallmark of this condition is spontaneous mucocutaneous or soft tissue hemorrhage in patients with no previous history of bleeding. AHA occurs more frequently in the elderly and about half of the cases are idiopathic.

Methods

In the beginning of 2020, an 82 year old male with multiple comorbidities and polymedicated, developed an atypical and exuberant stasis dermatitis of the lower legs with superficial hemorrhagic lesions difficult to heal even after therapeutic adjustment. Posteriorly, he presented spontaneous gingival bleeding and subsequent episode of macroscopic hematuria, which led to multiple visits to his family physician (FP) and to the emergency room.

Results

Lab evaluation showed a progressive and isolated prolonged activated partial thromboplastin time (aPTT) and an extremely low FVIII activity (<0.1%), suggesting the presence of an inhibitor. In this context, the patient was admitted in order to investigate a possible underlying condition, and the diagnosis of AHA was confirmed. Therapy with prothrombin complex concentrate and oral corticosteroids was initiated, with progressive decrease in aPTT and clinical resolution.

Conclusions

AHA is a complex and heterogeneous disease. Early recognition and prompt initiation of treatment can be life-saving. As the first contact with health care system, the FP has a crucial role in recognizing clinical manifestations and framing them into a possible diagnosis, to an appropriate approach. This report highlights the need of different specialties’ knowledge and contribution for a better management of daily practice challenges.

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Chikungunya is an arbovirus that causes high fever, headache, joint pains and muscle aches three to seven days after a mosquito bite. Most patients tend to find themselves better the next days or weeks, but some of them can develop joint chronic pain. Description of a clinical case diagnosed in primary health care.

The patient is a 30 years old man born in India who has lived in Girona (Spain) for five years. The last three months suffered with generalized arthralgia predominate in both wrists accompanied by morning swelling and morning stiffness of more than thirty minutes. The blood test showed a VSG discretely elevated, low PCR, negative rheumatic factors. Normal wrist X-rays.

First line treatment with NSAID drugs showed not improvement of the clinic symptoms reason why we switched treatment with prednisone presenting a positive symptomatic response. After asking again, the patient manifested that last December, simultaneously with the beginning of the clinic, he travelled to India to visit his family. He had high fever (39ºC), headache, arthralgia and a rash that lasted a week. He also remembered history of mosquito bites.To confirm the diagnosis we perform detection of IgM ang IgG antibodies against chikungunya virus with both results being positive.

It is important to include Chikungunya virus infection in the differential diagnosis of arthritis if there is a history of travelling to countries with circulating viruses. There is the need to strengthen training of emerging viruses to primary healthcare professionals. Stress the importance of community health education and outreach aimed to travellers and VFR by primary healthcare professionals.

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Background: Chronic inflammatory demyelinating polyneuropathy (CIDP) is an imuno-mediated acquired, neuropathy that targets the peripheral nerves and nervous roots. It is characterized by a progressive or relapse-remitting course, electrodiagnostic or pathologic features of demyelination and glucocorticoid responsiveness. It has multiple variants who share the same pathophysiology of inflammatory demyelination.

Case: This case refers to an 83 year old male who progressively develops symptoms of lower limbs parestesia and hyposthesia with associated balance deficits. His neurological examination revealed mild proprioceptive hyposthesia and hipopalesthesia aswell as sensitive ataxia of the lower limbs. He also showed a positive romberg test and at a later stage diminished reflexes of the lower limbs. Cerebrospinal fluid analysis revealed elevated protein levels, normal white cell count and one band imunofixation as well as slightly elevated Imunoglobulin levels. The head CT scan did not had any remarkable findings and the outpatient electromiography was compatible with demyelinating motor-sensitive peripheral neuropathy. A later hospital electromiography revealed acentuated CIDP.

Discussion: Although it is still necessary to rule out the presence of other immune-mediated neuropathy such as IgM gammopathy Neuropathy, we hereby present an interesting case of a possible rare type of CIDP, the distal and sensory-predominant variant. This variant has a more indolent course characterized by sensory disfunction of the lower extremities, absent reflexes and may even present with ataxia in addition to autonomic symptoms.

Conclusion: Despite being a rare entity, the diagnosis of CIDP is important and must be taken into account in the diagnosis of a polyneuropathy specially due to its responsiveness to immunomodulatory therapies.

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Background and purpose: Eosinophilia is a common finding on asymptomatic patients in Primary health care. It usually relates to diseases that could have high-rate morbidity. Eosinophils have an important role on destroying foreign substances, like parasitic infections, and regulating inflammatory processes, such as allergic reactions. The most prevalent cause of eosinophilia on migrants or tropical travelers is parasitic diseases. Eosinophil count depends on host organism, parasite load and period of disease. High eosinophil count translates into tissue damage and amplification of inflammatory cascade, which in rare cases results into hypereosinophilic syndrome.

Methods: A 40-year-old Gambian man who lived in Girona (Spain) for the past 16-years presents with low eosinophilia on analysis since 2007. Reported a long history of intermittent asthma and is an untreated carrier of Hepatitis B. He visits origin country every 3-4 years. Last trip was 2 months ago. He presents with abdominal pain and distension. No fever, diarrhea, nausea or vomiting. We ordered blood analysis, serologic test and coproculture.

Results: Blood analysis revealed alanine aminotransferase (ALT) of 190U/L and HBV viral load of 877U/ml. Enzyme immunoassay revealed Strongyloides stercoralis. Coproculture revealed cysts of Entamoeba coli and trophozoites of Entamoeba histolytica dispar. Treatment was initiated with Metronidazole and Albendazole, resulting in significant improvement on abdominal pain and resolution of eosinophilia. Coproculture post-treatment was negative.

Conclusions: International travelling has increased transmission of infectious diseases. Primary health care should improve its knowledge around imported eosinophilia, alongside other imported diseases, in order to provide accurate diagnosis and treatment.

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Background and purpose

Diabetic foot pathology (DFP) is one of the most common consequences of metabolic decontrol in type 2 Diabetes Mellitus (T2DM). The treatment is based on the management of the diabetic pathology following healthy habits to ensure metabolic control and checking periodically diabetic foot sensitiveness to detect neurovascular pathology.

Methods

Describe the consequences of suboptimal metabolic control on DFP based on a clinical case with photo report of a 66-year-old patient with pathological background including: T2DM, HTA, obesity and smoking.

Results

The patient arrived in June 2018 to our Primary Health Centre (PHC) with a recent right fifth toe amputation and a bad metabolic control (9.4% Glycated Hemoglobin (HbA1c)). He managed to reduce his HbA1c until 6.2% in September 2018 following our T2DM control guidelines. During the first months of 2020 his adherence to healthy habits declined. By March, his HbA1c increased to 9.8% and consequently suffered a DFP worsening; a new diabetic foot ulcer appeared which needed a first toe amputation. In June 2020, the patient improved his metabolic control, reducing HbA1c values to 7.6%. However, six months later his HbA1c increased again to 9.7% and the DFP worsened requiring a transmetatarsal amputation.

Conclusions

While the patient had an optimal metabolic control, the progression of his DFP diminished. However, as soon as the patient changed his healthy lifestyle, his DFP suffered a significant worsening. Unhealthy habits, therefore, metabolic decontrol have a direct consequence on DFP deterioration.

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Background

Covid-19 infection poses a serious challenge for immune-compromised patients with inflammatory autoimmune systemic diseases.We present a case which occurred during the covid-19 pandemic,in which an infection of Sars-Cov-2 has an impact on the diagnostic hypothesis.

Case Description

A 63 years old female patient with history of allergic rhinitis and asthma,began with dyspnoea,cough,nausea and fatigue in April 2020.Due to worsening of her clinical condition,she was admitted to the hospital.She presented lymphopenia.SarsCov2 swab with a negative result. The lung computed tomography(CT) described aspects of bronchopneumonic infectious process suggestive of sar-cov-2 infection. She started hydroxychloroquine therapy and she repeated the SarsCov2 swab with negative result. In May 2020 she went to the emergency department presenting with fever and musculoskeletal symptoms with migrant arthralgia associated with edema of hands and legs. She presented elevated serum creatine kinase(CK),aspartate aminotransferase(AST),alanine aminotransferase(ALT),and was discharged with diagnostic hypothesis of Arthritis/Reactive Myositis of unclear aetiology, and treated with anti-inflammatory therapy. Due to maintenance of the clinical situation with myalgia, arthralgia, persistent fatigue and dyspnoea for small efforts, she was admitted to the hospital a month later.She needed a supplementary supply of O2 during hospitalization. At the electromyography and magnetic resonance of the pelvis the result was compatible with an inflammatory myopathy.The lung CT described worsening of multifocal opacities configuring geographic areas of peribronovascular and subpleural ground glass. A muscle biopsy was performed and the diagnosis was definitive: Autoimmune polymyositis with positive antiJo1 and antiSSA with interstitial lung disease.The patient began corticotherapy with symptomatic improvement.

Results/Conclusions

This case alerts the physicians about autoimmune diseases which can mimic COVID-19 infection.

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BACKGROUND and PURPOSE: CRPS is a chronic pain condition accompanied by autonomic, inflammatory, sensory, and vasomotor symptoms. CRPS type II involves peripheral nerve injury. Diagnosis is based on the Budapest Criteria, however, its pathophysiology and treatment are not fully defined. The objective of this report is to raise awareness to the correct diagnosis and to the possibility of conservative treatment.

METHODS: Information about patient’s clinical data was obtained through consultation of clinical records. Complementary information was collected by researching databases on this matter.

RESULTS: A 76-year man, diagnosed with Herpes Zoster five months before, presented with swelling, stiffness, erythema, paraesthesia and pain 10/10 of the 2^nd finger of the left hand. The symptoms had been present for several weeks. Daily activities such as buttoning buttons were difficult. On examination, left hand was globally swollen, with emphasis on his 2^nd finger. There was allodynic and hyperalgesic pain response to any palpation. He revealed global mobility loss, with restriction of active and passive movement and tremor. Investigation was performed, no leucocytosis was found, and C-reactive protein (CRP) and sedimentation rate (SR) were negative. The hand X-ray evidenced osteoarthrosis of interphalangeal joints and the ultrasound edema as well as hyperecogeneity of the subcutaneous adipose tissue. Budapest criteria were fulfilled and the diagnose of CRPS was made. He started gabapentin 900mg/day, amitriptyline 10mg/day and physical therapy.

CONCLUSIONS: Chronic pain is among the top complaints in patients who visit primary care. Fast diagnosis, rehabilitation and maximizing quality of life are essential to family doctors’ practice.