Observing and recording that which may be relevant and disseminating it through a concrete and well-written text are the teachings of Charles Darwin (1809-1882) and William Osler (1849-1919). Darwin published one of the greatest scientific books of all time, On the Origin of Species (1859), which was the result of multiple observations written down by the author on a daily basis. For his part, Osler was an outstanding doctor, a great semiologist, the father of modern medicine, and did not waste a moment to write down his scientific concerns and make them public.

Introduction. Splenic rupture associated with thrombocytopenic purpura caused by infectious mononucleosis is extremely rare. The evolution of patients with infectious mononucleosis associated with Epstein-Barr virus is favorable, self-limiting and does not require specific therapeutic interventions. The symptoms are well tolerated and have a low frequency of complications. Case presentation. Female 12-year-old patient presenting with diffuse abdominal pain, distension, nausea, tegument pallor and unquantified fever for two days. Upon admission to the emergency department, hemodynamic decompensation, purpuric lesions and ecchymosis in the limbs were observed. Laboratory and cabinet studies were carried out to confirm anemia, thrombocytopenia and splenic hematoma. Finally, an exploratory laparotomy was performed considering the possibility of hemoperitoneum. Results. The patient presented with splenomegaly, broken subcapsular hematoma, bleeding of 4000mL and accessory spleen lobe with splenic rupture. Conclusions. Spontaneous splenic rupture is a rare but possible complication of infectious diseases. However, its association with thrombocytopenic purpura is extremely rare.

Introduction: Congenital saccular cyst is a rare but benign lesion, caused by a dilated laryngeal sac full of mucus that does not communicate with the laryngeal lumen. Its definitive treatment is surgical according to the literature. Objective: To review the literature and report a case of congenital laryngeal saccular cyst, as well as its treatment by endoscopic approach and radiofrequency, which is most easily found in our country. Materials and methods: Presentation of a case report and literature review in PubMed and Tripdatabase using the described keywords. Results: This is a rare condition with an incidence of 1.82 cases per 100 000 live births. Diagnosis is achieved by laryngeal endoscopy, images or clinical review. The case reported here corresponds to a newborn patient with respiratory distress and stridor, who was diagnosed with laryngeal saccular cyst that was resected surgically by means of endoscopy and radiofrequency, with no subsequent recurrence. Discussion: Understanding this disease is highly important to achieve proper diagnosis and provide treatment using the resources available in our country, such as radiofrequency. Conclusions: Despite the lack of case reports, knowing the characteristics of congenital saccular cyst is necessary to indicate proper treatment based on the available resources. It is possible to perform endoscopic resection of this lesion if it is <3cm by means of radiofrequency, which is a safe and effective method.

Introduction: Spontaneous pneumomediastinum (SPM) is defined as the presence of air in the mediastinum. It is a rare entity considered benign and self-limiting, which mostly affects young adults. Its diagnosis is confirmed through clinical and radiological studies. Case description: 21-year-old male patient with cough and greenish expectoration for four days, associated with dyspnea, chest pain, fever and bilateral supraclavicular subcutaneous emphysema. Chest X-ray suggested pneumomediastinum, which was confirmed by tomography. The patient was hospitalized for observation and treatment. After a positive evolution, he was discharged on the sixth day. Discussion: SPM is a differential diagnosis in patients with chest pain and dyspnea. Its prevalence is lower than 0.01% and its mortality rate is low. It should be suspected in patients with chest pain and subcutaneous emphysema on physical examination. Between 70 and 90% of the cases can be identified by chest X-ray, while confirmation can be obtained through chest tomography. In most cases it does not require additional studies. Conclusion: SPM is a little known cause of acute chest pain, and rarely considered as a differential diagnosis; it is self-limited and has a good prognosis.

Acute thoracic aortic dissection is caused by a tear in the intimal lining of the aorta, and is a symptom of acute aortic syndrome. The dissection allows the blood to pass through the rupture and separates the tunica intima from the tunica media or the tunica adventitia, creating a false intravascular light. Early diagnosis directly affects the chances of survival, since it is a medical emergency that can lead to death, even with optimal treatment. The following report presents the case of a 26-year-old man with a history of Marfan syndrome, retrosternal lancinating pain[LM1] , nausea, vomiting, and medium effort dyspnea that evolved to orthopnea, perioral cyanosis, murmur of aortic insufficiency and mitral systolic murmur. Complementary studies (chest x-ray, electrocardiogram, angiography, tomography, and echocardiogram) were performed, obtaining a diagnosis of Stanford type A ascending aortic dissection. Surgical treatment was indicated to replace the aortic root using a composite prosthesis and Bentall and De Bono coronary reconstruction. During the procedure, right coronary button destructuration occurred, so it was necessary to perform a venous bypass with a left internal saphenous venous hemoduct. Weaning extracorporeal circulation was achieved and then low expenditure of refractory character (despite vasopressor support at maximum dose), refractory ventricular fibrillation and asystole were observed. The patient did not recover and died as a consequence of acute transoperative myocardial infarction. The treatment for ascending aortic dissection remains a therapeutic challenge. Timely diagnosis is directly related to life expectancy in patients who suffer from this condition, hence the importance of proper diagnosis and management.

Introduction. Paracoccidioidomycosis (PCM) is a chronic granulomatous disease caused by the dimorphic fungus known as Paracoccidioides brasiliensis. This entity compromises mainly the lungs, but can spread to other organs, with particular trophism, through oral mucosa, adrenal glands, lymph nodes, among others. Case presentation. This paper reports the case of a male patient with pulmonary PCM treated at the Hospital Universitario de Santander. The patient was admitted with initial suspicion of active pulmonary tuberculosis due to the presence of multiple cavitations and nodules of random distribution in the lung parenchyma observed in the chest tomography, and subsequent isolation of yeasts compatible with Paracoccidioides. Amphotericin B deoxycholate was administered without favorable outcomes and development of septic shock by extended spectrum Klebsiella pneumoniae. In spite of multi-conjugate antibiotic management, the patient presented multiple organ failure syndrome with fatal outcome at 21 days of hospitalization.

Introduction. Mucocele is a dilatation of the vermiform appendix characterized by viscous mucoid material secretion. Its incidence is low —0.2-0.3% to 0.7% of the total of the appendectomies—, therefore, it is considered as a rare entity, which affects mainly women with a ratio of 4:1. Diagnosis is often incidental, and its management is surgical based on histology. Clinical case. 69-year-old male patient who presented with abdominal pain of 5 days of evolution in the right iliac fossa, accompanied by anorexia, nausea and unquantified fever. Physical examination revealed positive Mc Burney’s and Blumberg’s signs, indicating peritonism. Appendectomy and appendiceal raffia were performed using the Parker-Kerr technique. Intraoperative findings included an appendicular tumor with a thick base and mucoid content. The histopathological study showed a cecal appendix structure with coagulative necrosis of the mucosa and the wall, as well as mucosa with focal deposit of mucoid material. The patient was discharged after 8 days without further complications. Conclusion: Studies on appendicular mucocele are scarce, and due to its complications, radiological controls at a shorter time interval, and even early surgical treatment, are necessary to avoid complications such as intestinal obstruction, peritoneal bleeding or pseudomyxoma.

The most frequent elective procedure in general surgery in adults is cholecystectomy. During the procedure, many abnormalities may be found in the gallbladder and the common bile duct, being agenesis of the gallbladder the most uncommon, which can be difficult to manage even for an experimented surgeon. This type of malformation has the lowest incidence in the bile ducts, with only about 400 cases reported in the literature (1). The following article presents the case of a 44-year-old patient with a clinical picture of abdominal pain in the upper right quadrant, a clinical history of jaundice and acholia, with elevation of the liver profile (direct hyperbilirubinemia) and high probability of choledocholithiasis. The imaging studies (ultrasonography and magnetic resonance imaging of the bile ducts) did not detect any finding in the gallbladder. In consequence, endoscopic retrograde cholangiopancreatography (ERCP) was performed, but stone extraction was not achieved, therefore, a stent was required.

Introduction: Delusional infestation is a rare psychiatric disorder defined as a condition in which the patient has the unshakable belief and perception of being infested with parasites. Its treatment is difficult, and frequently includes antipsychotic medications (such as olanzapine or aripiprazole). Non-pharmacological treatment, particularly psychotherapy, can be used for less severe cases. Dermatologists and psychiatrists must take a multi-disciplinary approach (preferably in a psycodermatology dedicated clinic) since this type of patients sometimes refuse treatment. Case description: A 53-year-old female businesswoman describes a clinical history of five years of visual hallucinations, depressive symptoms, and generalized pruritus, along with the use of toxic substances to “clean” her skin and cloths. She reports similar symptoms in some relatives but they were not evaluated. Blood tests and analyses of the “specimen” brought by the patient were performed, yielding negative results. The patient had never been assessed by any specialist, and showed disoriented during the consultation. Follow-up was not possible due to the reluctance of the patient to follow the indications and seek psychiatric treatment. Moreover, the patient did not respond to further communication attempts. Discussion: Delusional infestation is an uncommon disease that endangers the patients and the people around them. Its treatment is difficult and long, and not conducting proper follow-up is a great risk. Its prevalence and incidence is variable and generally unknown. It can affect the patient, their next of kin, pets or the environment, and the “pathogen” can be a living organism or an inanimate object. Conclusion: This case is important as it shows the hardships of treatment, adequate follow-up and care, as well as the need to improve how these patients are approached. Additionally, both classical and uncommon signs and symptoms could be observed as the patient stated that her relatives were affected (possible delusional infestation by proxy).