Abiotrophia defectiva is a rare agent of endocarditis and subacute presentation may delay the diagnosis. We present the case of a 41-year-old male who was admitted to the hospital for further investigation regarding a consumptive syndrome with microcytic anaemia. Past medical history included new-onset mitral insufficiency followed by an ischaemic stroke due to small vessel disease. Thoraco-abdominal computed tomography revealed a splenic infarction. In the presence of two ischaemic events associated with mitral valve disease of unknown aetiology, we considered the possibility of subacute endocarditis. Blood cultures were positive for Abiotrophia defectiva, and transoesophageal echocardiography confirmed the diagnosis. As a subacute presentation of endocarditis, the paucity of symptoms caused a five-month delay in diagnosis. New-onset valvular disease and a stroke in an otherwise healthy young patient should always prompt proper investigation. This case highlights several complications caused by septic emboli of undiagnosed and untreated endocarditis.

Leishmania infantum, a zoonotic vector-born parasite, is endemic in the Mediterranean region, presenting mostly as visceral (VL), but also as cutaneous (CL) and mucosal leishmaniasis (ML). This study aimed to describe the epidemiological and clinical aspects of the CL and ML cases diagnosed in mainland Portugal between 2010 and 2020. Collaboration was requested from every hospital of the Portuguese National Health System. Cases were screened through a search of diagnostic discharge codes or positive laboratory results for Leishmania infection. Simultaneously, a comprehensive literature search was performed. Descriptive statistics and hypothesis testing were performed using IBM^® SPSS^® Statistics. A total of 43 CL and 7 ML cases were identified, with a predominance of autochthonous cases (86%). In CL, immunosuppressed individuals constituted a significant proportion of patients (48%), and in this group, disseminated CL (22%) and simultaneous VL (54%) were common. In autochthonous cases, lesions, mostly papules/nodules (62%), were frequently observed on the head (48%). The approach to treatment was very heterogeneous. ML cases were all autochthonous, were diagnosed primarily in older immunosuppressed individuals, and were generally treated with liposomal amphotericin B. The findings suggest a need for enhanced surveillance and reporting, clinical awareness, and diagnostic capacity of these forms of leishmaniasis to mitigate underdiagnosis and improve patient outcomes. A holistic One Health approach is advocated to address the multifaceted challenges posed by leishmaniases in Portugal and beyond.

Urinary diversion after cystectomy using autologous intestinal segments has been the gold standard treatment in several urinary tract diseases. The most frequent metabolic consequence is hyperchloremic metabolic acidosis, due to ammonium hydrogen and chloride ions absorption in exchange for the excretion of bicarbonate and sodium ions in the bowel conduit. Sodium-glucose co-transporter-2 (SGLT2) inhibitors are a class of antihyperglycemic agents that block the reabsorption of filtered glucose in the renal proximal convoluted tubules, promoting greater urinary glucose and sodium excretion. The authors describe two cases of patients with bowel conduit and mild/severe hyperchloremic metabolic acidosis, after starting SGLT2 inhibitors. Both were presented with mild acute kidney injury, moderate hyperglycemia, normal ketoacids, normal lactate and normal anion gap. Clinical and laboratory normalization were reached after this drug was withdrawn and fluid support therapy was applied. We hypothesize that SGLT2 inhibitors could exacerbate chronic hyperchloremic metabolic acidosis in these patients, by enhance sodium loss and volume depletion, subsequent acute kidney injury (AKI), increase renal chloride elimination due to sodium loss and subsequent chloride/bicarbonate bowel exchange. Rebound hyperglycemia due to bowel absorption and bicarbonate renal elimination through Na+-H+exchanger 3 (NHE3) suppression, could also contribute. This association needs further investigation.