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Background and aim

Axillary trichomycosis, also called trichobacteriosis, is a skin infection caused by bacteria of the genus Corynebacterium spp., especially by C. flavescens. It affects the hair of the armpits, also of the pubis and perianal region and, exceptionally, of the scalp.

Its prevalence is higher in tropical countries, with humid and warm climates. Excess sweating, inadequate hygiene and not shaving favor its appearance. It affects young adults, and more in men than women.

The suspected diagnosis is established by clinical findings, complementary techniques such as Wood's light, direct vision under the microscope, and dermoscopy.

Case summary

23-year-old man with no relevant history, non-smoker. Refers that for two months the armpit hair has a yellowish coloration, thicker texture and increased body odor. Denies itching, or lesions in another part of the body.

On examination, mucoid sheaths adhered to the hair shaft, thick and irregular, some covering all the hair. The root and the skin are not affected. There is a bad smell. Visualization with dermoscopy: white-yellowish masses with a waxy appearance, adhered to the hair. Rest of exploration without relevance.

Hygiene of the area, shaving and application of topical antibiotic ointment for 10 days was recommended.

Conclusion

Axillary trichomycosis is an underdiagnosed entity in primary care clinics. The general practitioner must know the use of dermoscopy since it is a useful, fast and cheap technique to support the clinical diagnosis, by identifying characteristic signs of this entity.

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Backgrounds and purpose:

Multiple myeloma, although a rare disease, is the second most common hematologic malignancy and represents 1% of all cancers. The average age of presentation is around 65 years, being exceptional in those under 30 years. Bone pain is the most frequent symptom on multiple myeloma, being the initial manifestation in 60-80% of cases, predominantly in the spine. It usually manifests as a mechanical pain, which respects the night's rest.

Case presentation

We describe the case of a 52-year-old male with no relevant medical history who presents to the emergency department complaining of nonradiating mechanical low back pain since two weeks, with good night rest and without improvement despite of the use of opioids. Physical examination was unremarkable except for tenderness of the lower lumbar vertebrae.

After x-ray evidence of vertebral fracture of L1 and L3 and, in the absence of medical history that could justify these findings, we decided to extend the study, finding severe bycitopenia and lytic lesions on vertebrae, ribs and sternum on CT scan. These results progressively guided to the final diagnosis of Multiple Myeloma.

Conclusion

In reference to this case, low back pain was the initial symptom and the reason for consultation, with the typical characteristics described above. Multiple Myeloma is also associated with a significant morbidity due to its end-organ destruction. Therefore, this pathology must be part of the differential diagnosis of lower back pain, always supported by an adequate clinical assessment.

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Background and Purpose: Flagellated dermatitis (FLD) is characterized by pruritic papules, papulovesicles or plaques that occur in an erythematous flagellated pattern that most commonly affects the trunk. One of the major causes of FLD is the consumption of raw or undercooked shiitake mushrooms (SM). Even though it is a common occurrence in Asia (local delicacy) it is rare in Western countries.

Methods: Case Report.

Results: 74-year-old man with a personal history of Hypertension, Type 2 Diabetes and Dyslipidemia treated with Indapamide, Metformin and Atorvastatin. Presented with a dorsal rash associated with intense itching with 3 days of evolution that appeared spontaneously, denying other signs or symptoms. A history of changes in usual medication, sun exposure or possible allergens was also denied. After further investigation, he revealed having ingested SM 4 days before. On objective examination, bullous erythematous lesions were observed with linear stretches in a flagellated pattern in the region of the back, shoulders and arms. He was medicated with topical corticosteroids and oral antihistamine with complete resolution of the condition.

Conclusions: This case demonstrates the multiplicity of entities that the Family Doctor (FD) deals with in its daily practice. Although FLD by SM is not a common occurrence, a detailed clinical history combined with its characteristic presentation leads to the diagnosis. In an increasingly globalized world, food consumption of another regions is becoming more common and it is important that the FD recognizes this type of pathologies that can be treated and oriented in the primary health care services.

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Background and purpose: Rapidly progressive dementias are a heterogeneous group of diseases that present with cognitive, behavioural and/or motor disturbance. A detailed workup is essential since there are treatable causes.

Methods: Descriptive case presentation

Clinical Case: A previously healthy 58-year-old woman presented with episodes of confusion, disorientation and forgetfulness, with a progressive worsening in the previous 6 months. In the past month, she had persecutory delirium and visual hallucinations, with mood swings.

She answered with circumstantial speech, always turning to her son for support and clues when asked direct questions. She denied any health problem. Her mini mental state examination showed problems in all areas but language, with a score of 12 (12 years of schooling). Her laboratory workup and head CT were normal.

She was then seen by Neurology and Psychyatry and was started on medication, assuming a mixed episode in a bipolar spectrum disorder.

She kept worsening for another month and was admitted to the Neurology inpatient department. An extensive investigation was performed excluding reversible causes of dementia. After 2 months she was transferred to a continued care unit, requiring help for most basic daily activities. She died of pneumonia before a definitive diagnosis was reached.

Conclusions: This case is an example of a cognitive disorder that presented in a young patient and required a multidisciplinary approach. However, even with an inpatient investigation, the etiology was never identified after 10 months since the initial symptoms, reminding us of the limitations we still have in current medical care.

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BACKGROUND AND PURPOSE

Scabies is an infestation by the mite Sarcoptes scabiei hominis. It is a relatively common consultation in general practice. It affects all ages and socio-economical status. Diagnosis is usually clinical, but can sometimes be difficult. In these cases, confirmation by microscope or biopsy is possible but requires an infrastructure usually not available in a primary care center. Dermoscopy can be a more accessible additional tool.

METHODS

Case presentation: A 26-year-old patient went to the primary care physician due to itching in the flexor aspects of the wrists, sides of the fingers and waist with an eruption and erythematous papules on the wrists. Based on the history and physical examination a diagnosis of scabies was made. Hygienic measures and an application of permethrin cream 5% at night two consecutive weeks were recommended to the patient and her cohabitants. After a slight improvement, the patient consulted again 15 days later due to the reappearance of the symptoms. Are we facing a recurrence of the infestation or the persistence of disease-free scabies nodules? Could it be a disease other than scabies?

RESULTS

Dermoscopy showed the mite's head inside a burrow known as a "delta wing" sign. This confirmed the presence of an active parasite within the burrows. A case of resistance was suspected and a treatment with two oral doses of ivermectin was recommended.

CONCLUSIONS

Dermoscopy can be a useful, fast and accessible diagnostic tool helpful to identify unclear scabies cases by the general practitioner.

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Background

Polymyalgia rheumatica (PMR) is chronic inflammatory condition that affects manly elderly individuals. The diagnosis is based in symptomatology and exclusion of potential diseases.

Methods

Male, 71 years old. Personal history: arterial hypertension, diabetes mellitus, heart failure, atrial fibrillation, sleep apnea. Medication: furosemide 40mg, Carvedilol 25mg, spironolactone 100mg, Metformin 500mg, Rivaroxaban 20mg.

The patient resorted to family doctor (FD) due to myalgias, asthenia and worsening dyspnea pattern. Blood test revealed normochromic normocytic anemia.

Symptoms worsened and patient went to hospital. There, due to febrile peaks (38.9ºC) and absence of an outbreak of infection, were collected blood cultures and started ceftriaxone empirically. Later was detected aortic murmur and a traumatic wound in the lower limb. The patient started clindamycin and was hospitalized with suspicion of infective endocarditis vs erysipelas. Analytically: Hemoglobin 9.6g/dL, without leukocytosis, PCR 20.21mg/dl, VS 116mm. Blood cultures were negative and digestive endoscopies normal. After 10 days of antibiotics, PCR decreased (17mg/dl), maintained VS 100mm and Hemoglobin reached 8.4mg/dl. The symptoms evolved into significant fatigue, cervical and scapular arthralgias, proximal myalgia and occipital headache. Observed by Rheumatology, PMR diagnosis was considered and started prednisolone. Autoimmune study was negative.

Results

After 6 days of high-dose corticotherapy there was significant improvement of symptomatology and patient was discharged with prednisolone 40mg maintenance dose.

Conclusions

PMR diagnosis can be a challenge for the family doctor. The identification of fast and marked deterioration of the general condition as well as the therapeutic test with corticotherapy can avoid an unnecessary investigation.

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Introduction: PFAPA syndrome usually occurs in childhood and it´s characterized by Periodic Febrile episodes, associated with Aphthous stomatitis, Pharyngitis and cervical Adenopathies. Between episodes children are asymptomatic. The diagnosis is made by clinical features and by exclusion.

The authors pretend to alert that PFAPA, a underknown entity, is the one of the most common periodic fever syndromes.

Case report: A 3-years-old boy, with adequate growth and development for his age, presents since 19 months born, episodes of periodic fever, associated with recurrent pharyngitis/tonsillitis and cervical adenopathies. He was treated with multiple antibiotics with poor response and was asymptomatic between episodes.

The recurrent episodes and ineffective therapeutic generated anxiety to parents. In coincidence with a new febrile episode, oral corticosteroid therapy was started with drastic improvement in symptoms.

PFAPA syndrome was suspected so a paediatric appointment was requested, other causes of periodic fever syndromes were excluded and the diagnosis of PFAPA syndrome was made.

Conclusion: This report has a typical presentation of PFAPA, the onset was before the age of 5, with characteristic periodic symptoms, and healthy condition between episodes.

As expected in PFAPA, treatment with antipyretics and antibiotics is ineffective. The response to corticosteroids is excellent, reduces febrile episodes, supports the diagnosis, but doesn’t prevent new episodes.

More than a rare entity, PFAPA syndrome is underdiagnosed. PFAPA diagnosis is crucial because allows to reduce anxiety and improve quality of life of children and family members, as well reduce health costs and avoid unnecessary antibiotic treatments.

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Background and purpose: Respiratory disease is common and mostly managed in primary care. The most frequently employed therapeutics are inhalers which vary in type. Multidose Inhalers (MDIs) contain harmful greenhouse gases which have a disproportionate effect on the carbon footprint of healthcare. The NHS estimates inhalers account for 3% of their entire carbon footprint and have identified inhaler prescribing as a target to achieve “net zero” by 2040. The carbon footprint of inhalers prescribed in Irish General Practice is not known nor is the potential carbon savings by switching to more environmentally friendly alternatives such as dry powder inhalers (DPIs).

Methods: The carbon equivalent of prescribed inhalers in a mixed rural urban GP practice was determined retrospectively January – June 2020. An educational team intervention was performed aiming to switch MDIs to DPIs where appropriate, with patient counselling and consent and in line with best practice. Inhaler prescribing was re-audited July -December 2020 and the carbon equivalent difference estimated.

Results: At baseline the practice prescribed 84% MDIs to 16% DPIs. After the intervention this was reduced to 70% MDIs to 30% DPIs. The carbon equivalent difference was 3,575 kgC02 per month. Over the six months of the duration of the audit this equated to saving approximately 21, 448 kg of CO2.

Conclusions: Targeting inhaler prescribing offers the potential to significantly improve the carbon footprint of Irish healthcare. The carbon saved in this audit was the equivalent of driving around the globe twice or charging almost 3 million smart phones. DPIs may also improve compliance, improve drug delivery and reduce waste.

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BACKGROUND AND PURPOSE

Chronic cough is a common reason for consultation in primary care, hence why family physicians need to manage its diagnosis and treatment. After considering and treating the main causes, other less common diagnosis need to be considered, requesting a chest radiograph and other tests depending on the suspected diagnosis.

Interstitial lung diseases are a heterogeneous group of pathologies that usually present themselves in the form of chronic cough and exertional dyspnoea. If suspected, a high-resolution CT scan (HRCT scan) needs to be requested by the general practitioner.

METHODS

Case presentation: A 74-year-old woman with a history of hypothyroidism and phobia treated with venlafaxine visited her family physician after 2 months of cough that had been treated without improvement, exertional dyspnoea, arthromyalgia and fever. She was sent to the emergency department, where pneumonia, Covid-19 and lung cancer were discarded in the following days. An interstitial lung disease was considered as the most likely diagnosis, with compatible images in the HRCT scan. At that time, the psychiatrist removed venlafaxine and cough improved.

RESULTS

Venlafaxine induced interstitial lung disease is a rare condition which turned to be our main diagnosis option, based on the compatible CT scan images and the clinical improvement when removing venlafaxine. This conclusion still needs to be confirmed with further studies.

CONCLUSION

A complete medical record, emphasizing in the history of exposure to toxic substances and drug-related diseases, is of utmost importance when considering the cause of chronic cough. Patients with interstitial lung diseases will benefit from an early diagnosis, which highlights the importance of early suspicion.

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Background and Purpose: Pulmonary thromboembolism (PTE) results from the obstruction of the pulmonary arteries by a thrombus. The clinical presentation is extremely variable but 90% of the patients present with recent onset dyspnea, chest pain or discomfort and syncope.

Methods: The patient (female, 84 years old) was clinically interviewed. Her clinical history, available on the Portuguese national health digital platform, was surveyed.

Results: The patient has Hypertension, Type 2 Diabetes mellitus, Varicose veins, and a recent clavicle fracture. She visited our family health center for a leg ulcer treatment and had a collapse. Subjectively she denied any symptoms, stating “I’m fine, I just want to have the dressing changed and get going”. The objective examination showed a regular pulse, BP 109/63 mmHg, apparently normal pulmonary auscultation (difficult to perform due to the presence of a shoulder spica) and O2 Sat.: 86-90%. After effective communication, she agreed to go to the ER: diagnostic investigations showed mild anaemia, d-dimers 25892 ng/mL, pro-BNP 342 mg/dL, Troponins 140 pg/mL and C-reactive protein 11.98 mg/dL. Computed tomography angiography showed extensive pulmonary thromboembolism of the main pulmonary arteries.

Conclusions: During the state of emergency caused by the COVID 19 Pandemic, Family Physicians were forced to ponder with the maximum care ER referrals, facing opposition from patients and other healthcare providers. Upon clinical suspicion of PTE, an emergency referral is warranted, given that the untreated mortality of the disease is 30%.