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Platypnea-orthodeoxia syndrome (POS) is a rare condition of positional dyspnea with hypoxemia that can pose a diagnostic challenge to clinicians. We report two cases of POS with different pathophysiologic triggers and similar clinical features. In our report, both patients manifested a severe hypoxemia with low response to increase of fractional inspired oxygen, unremarkable physical examination of the lungs, and no radiological findings of the pulmonary embolism. In both cases, an interatrial communication was found in association with a right-to-left interatrial shunting. Recognition of POS is crucial because symptoms can be quickly relieved by recumbency, unlike other types of hypoxemia. This simple solution may prevent the use of sedative therapy, invasive ventilatory support, and vasopressor agents, which could even exacerbate the right-to-left extrapulmonary shunt and worsen clinical conditions.

Shoshin syndrome is a rare fulminating heart failure caused by thiamine deficiency. In Japanese “sho” means acute damage and “shin” means heart. It consists of a rare and hyperacute manifestation of beriberi that was first described in polished white rice-eating communities in various locations across Asia including China, Japan and Indonesia. In a totally different context, ‘Shoshin’ is a word from Zen Buddhism meaning “beginner’s mind”, which is considered the necessary attitude to approach the Zen practice. This case report is a prime example of clinical manifestations of thiamine deficiency for the presence of both cardiological and neurological disorders, for hyperacute onset of cardiac failure (shoshin syndrome), for the simultaneous involvement of peripheral and central nervous system, and for the dramatic global recovery after thiamine replacement therapy. We therefore explain why the physician should adopt a beginner’s mind in clinical practice.

Insulinoma is an insulin-producing pancreatic neuroendocrine tumor that can be malignant in about 10% of cases. Locoregional invasion, lymph node metastases, or remote metastases are the main criteria of malignant insulinoma. Its incidence in patients with pre-existing diabetes mellitus (DM) is exceptionally rare. In this report, we describe a 66-year-old man with long-standing type 2 DM who presented with recurrent episodes of diaphoresis due to severe hypoglycemia despite the withdrawal of insulin therapy, hypercalcitoninemia, and biochemical and radiological findings suggestive of metastatic malignant insulinoma. Unfortunately, after few days of diazoxide treatment, edema, hypotension, oliguria, and water retention were observed, patient’s clinical status deteriorated rapidly, and he died in our department from acute renal failure.