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INTRODUCTION: Adrenal insufficiency (AI) is one of the most common potentially life-threatening endocrine complications in people living with human immunodeficiency virus (PLHIV) infection and acquired immunodeficiency syndrome (AIDS). AREAS COVERED: In this review, the authors explore the definitions of relative AI, primary AI, secondary AI and peripheral glucocorticoid resistance in PLHIV. It also focuses on the pathophysiology, etiology, diagnosis and management of this endocrinopathy in PLHIV. A literature review was conducted through Medline and Google Scholar search on the subject. EXPERT OPINION: Physicians need to be aware of the endocrinological implications of HIV infection and its treatment, especially CYP3A4 enzyme inhibitors. A high index of clinical suspicion is needed in the detection of AI, especially in PLHIV, as it may present insidiously with nonspecific signs and symptoms and may be potentially life threatening if left untreated. Patients with overt primary and secondary AI require glucocorticoid replacement therapy. Overt primary AI also necessitates mineralocorticoid replacement. On the other hand, the management of relative AI remains controversial. In order to reduce the risk of adrenal crisis during periods of stress, the short-term use of glucocorticoids may be necessary in relative AI.

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A 47-year-old man, positive for SARS-CoV-2, was diagnosed with acute coronary syndrome (ACS) complicated by myocarditis on a background of COVID-19 pneumonia. He was medically treated for ACS; however, 3 days into his admission, the patient developed neurological complications confirmed on MRI of the brain. MRI showed established infarcts involving a large part of the left temporal lobe and right occipital lobe, with minor foci of micro-haemorrhagic transformation in the left temporal lobe. A left ventricular mural thrombus was then confirmed on echocardiogram, and this was attributed as the cause of his neurological infarct. Further infarctions in the kidneys and spleen, and thrombi in the superior mesenteric and left femoral artery were also identified on imaging of the abdomen. The left ventricular mural thrombus was removed surgically via a midline sternotomy incision under general anaesthesia. Surgery was successful and the patient was discharged to a rehabilitation centre.

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BACKGROUND: Variegate porphyria (VP) is a rare disorder of haem biosynthesis. We report a novel association with hepatitis A infection. PATIENT AND METHODS: A 31-year-old man was diagnosed with acute hepatitis A infection. During recovery, he presented with abdominal pain and a photoaggravated blistering skin eruption. RESULTS: Urine porphyrin precursors were markedly raised with high coproporphyrin III isomer levels. Faecal protoporphyrin levels were markedly increased and a maximum plasma fluorescence emission at 629 nm was noted. DISCUSSION: Acute hepatitis A infection, and the associated metabolic stress exerted on the haem biosynthetic pathway, induced overt presentation of latent VP. LEARNING POINTS: There should be a high index of suspicion for an acute cutaneous porphyria when a photosensitive rash is accompanied by neurovisceral symptoms.Latent porphyria may be overtly manifested after appropriate triggers which stress the metabolic haem biosynthetic pathway. One such trigger demonstrated by this case presentation is acute hepatitis A infection.The diagnostic approach to the investigation of a suspected acute cutaneous porphyria is initially with light-protected samples for urinary porphyrin precursors and plasma for fluorescence scanning. These should be sampled ideally during symptomatic periods. Further specialist analysis with fractionation of urinary and faecal porphyrins is necessary to distinguish between the two different acute cutaneous porphyrias.

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INTRODUCTION: The COVID-19 pandemic has posed major challenges to all aspects of healthcare. Malta's population density, large proportion of elderly and high prevalence of diabetes and obesity put the country at risk of uncontrolled viral transmission and high mortality. Despite this, Malta achieved low mortality rates compared to figures overseas. The aim of this paper is to identify key factors that contributed to these favorable outcomes. METHODS: This is a retrospective, observational, nationwide study which evaluates outcomes of patients during the first wave of the pandemic in Malta, from the 7th of March to the 24th of April 2020. Data was collected on demographics and mode of transmission. Hospitalization rates to Malta's main general hospital, Mater Dei Hospital, length of in-hospital stay, intensive care unit admissions and 30-day mortality were also analyzed. RESULTS: There were 447 confirmed cases in total; 19.5% imported, 74.2% related to community transmission and 6.3% nosocomially transmitted. Ninety-three patients (20.8%) were hospitalized, of which 4 were children. Patients with moderate-severe disease received hydroxychloroquine and azithromycin, in line with evidence available at the time. A total of 4 deaths were recorded, resulting in an all-cause mortality of 0.89%. Importantly, all admitted patients with moderate-severe disease survived to 30-day follow up. CONCLUSION: Effective public health interventions, widespread testing, remote surveillance of patients in the community and a low threshold for admission are likely to have contributed to these favorable outcomes. Hospital infection control measures were key in preventing significant nosocomial spread. These concepts can potentially be applied to stem future outbreaks of viral diseases. Patients with moderate-severe disease had excellent outcomes with no deaths reported at 30-day follow up.

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We report a case of Cogan's syndrome presenting as fever of unknown origin in a 31-year-old woman who was admitted to the hospital with a 7-week history of fever, night sweats and other constitutional symptoms. The diagnosis remained elusive despite numerous investigations, and the patient subsequently developed rash, episcleritis, dizziness and sensorineural hearing loss. While initially thought to be a postinflammatory response to a previous infection, confirmation of the rash as a vasculitis together with the audiovestibular and ocular involvement led to a clinical diagnosis of Cogan's syndrome. This was further corroborated by resolution of her symptoms once immunosuppressive therapy was instituted. Early recognition of Cogan's syndrome is crucial to reducing the risk of serious complications through the timely initiation of treatment.

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A 54-year-old Caucasian woman presented with an episode of loss of consciousness and dysphasia. MRI revealed a number of ischaemic foci indicating an embolic source. Echocardiography showed a mitral valve vegetation. After taking three sets of blood cultures, she was started on empirical treatment for infective endocarditis. The blood cultures remained negative and a presumed diagnosis of culture-negative endocarditis was entertained. However, despite the antibiotic therapy, the patient deteriorated further. Subsequently the patient was found to be positive for antiphospholipid antibodies. Eventually, after a convoluted hospital stay, a diagnosis of antiphospholipid syndrome complicated by Libman-Sacks endocarditis was reached. The patient was treated with steroids and anticoagulation with dramatic improvement.

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The authors report a case of a 20-year-old woman who was diagnosed with pulmonary cystic echinococcosis. She was admitted to hospital with a 1-week history of unresolving cough, coloured sputum with occasional haemoptysis and fever despite oral antibiotics. Radiology revealed a cavitating right lower lobe lung abscess. After 4 weeks of treatment, follow-up radiology showed incomplete resolution. Bronchoscopy revealed a white, avascular cystic lesion in the right lower lobe and serology testing for Echinococcus granulosus was positive. Repeat imaging eventually confirmed the cystic lesion with the 'air bubble'sign. A thorough travel history, a high index of clinical suspicion and close follow-up are essential in making a diagnosis of pulmonary cystic echinococcosis.

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Spider poisoning is rare in Europe, with very few reported cases in the literature. Recluse spider (genus Loxosceles) bites may lead to cutaneous and systemic manifestations known as loxoscelism. We report the second known case of spider bite poisoning in Malta caused by Loxosceles rufescens (Mediterranean recluse spider). A young adult female presented with localised erythema and pain on her left thigh after a witnessed spider bite. Over a few days, the area developed features of dermonecrosis together with systemic symptoms, including fever, fatigue and a generalised erythematous eruption. She was managed by a multidisciplinary team and the systemic symptoms resolved within 6 days, while the skin lesion healed with scarring within 2 months. A recluse spider bite should be considered in patients with dermonecrosis. Although spider bite poisoning is uncommon in Europe, it is important to diagnose and manage it appropriately since it could lead to potentially serious sequelae.

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A 35-year-old woman with a 3-day history of chickenpox, presented to the hospital in septic shock and with multifocal, non-adjacent lesions of necrotising fasciitis. Necrotising fasciitis is a rare yet life-threatening complication of chickenpox. Blood cultures and wound swabs confirmed the presence of Streptococcus pyogenes. The initial emergency management included oxygen, aggressive fluid resuscitation and antimicrobial therapy. Once the patient was stabilised, surgical management ensued. This included debridement and eventual grafting of the necrotic skin lesions. Intensive management and follow-up for 8 weeks were required before the patient was deemed fit for discharge.

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Foreign body aspiration (FBA) is a relatively common and serious condition that can result in a spectrum of presentations ranging from incidental to acutely life-threatening. Described here is a case of aspiration of a tracheo-oesophageal speaking valve through a permanent tracheostomy that went unnoticed for a number of years, and an overview of the technique used for its removal. A 70-year-old ex-heavy smoker with a permanent tracheo-oesophageal fistula presented with a relatively recent history of increasing shortness of breath, sputum purulence and haemoptysis. Further investigation with a CT scan and bronchoscopy revealed the presence of a foreign body within his right lower lobe bronchus which was later removed by advancing a flexible bronchoscope over a rigid one.

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Two clinical cases of aspiration are reported in elderly ladies with differing presentations following inhalation of the same brand of calcium tablet. One of the patients distinctly recalled the choking episode, whereas the other failed to do so making the diagnosis of aspiration difficult. One of the aspirated tablets was successfully retrieved during rigid bronchoscopy after the patient reported several months of cough requiring multiple courses of antibiotics. The other aspirated tablet was coughed up by the patient after the successful treatment of a pneumonia complicated by a parapneumonic effusion.

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BACKGROUND: To carry out a time and motion study of patients presenting at the Emergency Department (ED) by measuring waiting times at the ED dept throughout the day. The objectives were:• to determine whether waiting times are prolonged, and• if prolonged, at which station(s) bottlenecks occur most often in terms of duration and frequency.Results will be compared to the United Kingdom guidelines of stay at the emergency department. METHODS: A group of 11 medical students monitored all patients who attended ED between 0600 hours on the 25th August and 0600 hours on the 1st September 2008. For each 24 hour period, students were assigned to the triage room and the 3 priority areas where they monitored all patient-related activity, movement and waiting times so that length of stay (LOS) could be recorded. The key data recorded included patient characteristics, waiting times at various ED process stages, tests performed, specialist consultations and follow up until admitted, discharged, or referred to another hospital area. Average waiting times were calculated for each priority area. Bottle-necks and major limiting factors were identified. Results were compared against the United Kingdom benchmarks - i.e. 1 hour until first assessment, and 4 hours before admitting/discharge. RESULTS: 1779 patients presented to the ED in the week monitored. As expected, patients in the lesser priority areas (i.e. 2 & 3) waited longer before being assessed by staff. Patients requiring laboratory and imaging investigations had a prolonged length of stay, which varied depending on specific tests ordered. Specialty consultation was associated with longer waiting times. A major bottleneck identified was waiting times for inpatient admission. CONCLUSIONS: In conclusion, it was found that 30.3% of priority 1 patients, 86.3% of priority 2 patients and 76.8% of priority 3 patients waited more than 1 hour for first assessment. We conclude by proposing several changes that may expedite throughput.

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The drug reaction with eosinophilia and systemic symptoms syndrome describes a hypersensitivity reaction to a number of drugs. It is characterized by a triad of fever, rash, and internal organ involvement. Carbamazepine is suspected to be the cause of the drug reaction with eosinophilia and systemic symptoms syndrome in this young man who presented with fulminant hepatitis and an exfoliating rash 8 weeks after starting carbamazepine. Symptoms gradually resolved after stopping carbamazepine and starting systemic steroids.Because we encountered only a few similar cases in the literature, we wish to highlight the importance of recognizing these symptoms as a syndrome that can be fatal, especially if not recognized early.

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Epidemiology, disease patterns, immunology, diagnosis, treatment and control measures of leishmaniasis are described. Various issues relating to leishmaniasis are highlighted: the relative lack of importance given to this disease compared with other infections, climate change and its possible impact on extension of endemicity of this infection, and new diagnostic tests which are improving diagnosis, especially in resource poor areas. Other important aspects discussed include the potential for newer oral therapy to change the way this disease is managed; Leishmania-HIV coinfection and groups at risk; and development of an effective vaccine.

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