Mom Wants Antibiotics

A mother brings her 14 year old boy into the clinic because he's been complaining of a fever, sore throat, and headache. He also has pain when chewing; he hasn't been eating much. He says it hurts when he drinks apple juice or orange juice. On exam, you see this at his right neck:


As a well-trained medical student, you ask the mother to step outside while you ask the boy about sex, drugs, and rock-and-roll. He whispers, "Well, there is this one thing...my balls really hurt." You see that he has a swollen left testicle and swollen inguinal lymph nodes on the left side.

Challenge: What is the causative agent of this disease?

Related Questions:
1. What is seen in the image?
2. What is the testicular finding called?

Image shown under fair use.

Something You Won't See

These skin lesions were preceded by symptoms of abrupt high fever, aching, and vomiting. The lesions started at the mouth and face, then moved to the arms, hands, and rest of the body over a week. The palms and soles are affected, and the lesions are all about the same size. In the most common type of this disease, these skin lesions will fill up with pus and either remain discrete or merge together into sheets.

Challenge: Why is this disease notable?

Image is in the public domain.

Darling

You are doing an away fourth year rotation in Cincinnati. Why? You're not sure either. You meet a chicken farmer who is HIV positive with the finding seen above. Here's a silver stain:


Challenge: Certainly, many things could be on the differential. But what's your top suspicion?

Related Questions:
1. What's seen in the first image?
2. What's seen in the second image?

Both images are in the public domain.

Mad Scientist

You are playing around with a slide. While heating it, you pipet a bit of phenol plus this:


You then wash it a bit with water and acid alcohol before adding:


This is what you see:

This picture is a clinical correlation:


Nothing can be cultured out.

Challenge: What is the diagnosis?

Related Questions:
1. What's the stain used?
2. What is the significance of nothing being cultured out?

All images are in the public domain.

Back to School

As fall approaches, mothers start bringing their kids into the clinic for routine check-ups and vaccinations. One mother brings her eight year old son in. On exam, you find tender lymph nodes along the neck and axilla on the left. He says it hurts when you palpate them. You see this on his left shoulder:


You notice the child has a mild fever. You ask him about symptoms and he just says, "I feel sick." You look at the mother. She says, "I think he's faking it to get out of going to school. You should have seen him playing with his grandmother's kittens two weeks ago. He was full of energy."

Challenge: What is the cause of this disease?

Related Questions:
1. How might you describe the skin lesion?
2. What is the diagnosis?

Image shown under fair use.

A Thousand Words

Darkfield microscopy, 400x

Challenge: How is this disease transmitted?

Related Questions:
1. What is seen in the first image?
2. What is seen in the second image?
3. What is the diagnosis?

First image is in the public domain.
Second image is shown under fair use.

Reliance

A 20 year old woman is brought in by a concerned neighbor to the emergency room. The neighbor reports that she was found vomiting and confused. On exam, the patient has a temperature of 40 C (104 F) and a blood pressure of 85/50. She looks like she has a big sunburn, but as this is San Francisco, that's sort of odd. You get some labs and notice an elevated serum creatinine, AST, ALT, and a platelet count of 80,000/mm2.

This would be the causative agent:

Challenge: What's the diagnosis?

Related Questions:
1. What is seen in the Gram stain?

First image shown under fair use.
Second image shown under GNU Free Documentation License.

Trolley

You are wandering the hills of downtown San Francisco when suddenly Sean Connery in a Hummer closely chased by Nicolas Cage in a Ferrari pass by, causing a massive motor vehicle accident, even involving a trolley.

You're a first responder for one of the victims, a young man who is bleeding profusely from his legs. You accompany him to the ER and when the doctor finds out you're a medical student, he invites you into the OR. In the OR, they have to transfuse a significant amount of whole blood. The surgery proceeds without complications, but near the end of the two hour surgery, the patient becomes hypoxic, tachycardic, hypotensive, and febrile. You see elevated peak airway pressures and frothy pink airway secretions around the endotracheal tube. You draw some blood and a cell count shows eosinophilia and neutropenia. JVP is not elevated. B-type natriuretic peptide is <100 pg/ml.

You look over at the anesthesiologist who says, "Oh, the hypothesized etiology of this disorder is anti-granulocyte antibodies and/or granulocyte priming."

Challenge: This incident can be described with a specific acronym. What is it?

Related Questions:
1. At the end of the surgery, what happened? What general condition do the peak airway pressure and secretions suggest?
2. Why was the JVP and BNP important?
3. This could have been a deleted scene from what 1996 movie?

Minerva's Owl Flies at Dusk

A young woman presents to the clinic. She has involuntary fast jerking movements of her face and all her limbs. They are uncoordinated and include facial grimacing and an unstable gait. She has a history of painful joints. On heart exam, you hear this:

http://casematerials.googlepages.com/COTD1.mp3

Challenge: What's the diagnosis?

Related Questions:
1. What is the heart murmur?
2. What is the movement disorder?
3. What is the pathophysiology of this disease?
4. What famous 19th century philosopher said the phrase in the title of today's case?

The mp3 audio file is linked under Fair Use. It can be freely downloaded from an American College of Cardiology website; this mp3 has been edited with the program Audacity. The specific source will be indicated in the solution to this case.

Named After a Swede

A 48 year old woman presents for a routine check-up. Since you are mindful of your Foundations of Patient Care (FPC) training to ask about sexuality, you ask her if she has any questions or concerns about her sexual functioning. She mentions that she gets some vaginal dryness, but noticing your anxiety, declines a pelvic exam. As you ask about other changes in her health, she says that she feels like she has "meth mouth", though she claims she stopped using that stuff over a decade ago. When you look at her oral cavity, you notice pretty advanced tooth decay. "Oh and one more thing," she says, "I feel like I get sand in my eyes a lot."

A lip biopsy shows this:


Challenge: Diagnosis?

Related Questions:
1. What is the cause of her tooth decay? What's the medical term for it?
2. What's shown on the biopsy?

Image shown under GNU Free Documentation License.

Nagini

A 30 year old man comes into your clinic because of this rash shown above. He says that it began around his bellybutton and has spread to his back, his chest, and now his arms. He says, "The rash started a few days ago, but I haven't had any contact with anything new or different. I mean, last week, I got bit by that stupid Arizona coral snake again, but I took some micrurus antivenin. When I was bitten by it last year, I took the same antivenin, so I know I'm not allergic to either the snake or the meds."

On exam, you find no mucosal or pharyngeal lesions. The patient has a temperature of 39 C but he says his temperature has been fluctuating a lot. He also complains about painful knees, wrists, ankles, and shoulders. You notice no swelling in those joints. He says his muscles have been feeling weak. The rest of the exam is normal.

Challenge: What is the diagnosis?

Related Questions:
1. How would you describe that skin lesion?
2. What is the joint complaint called?
3. What type of reaction is this? That is, what is the pathogenesis?

Image is in the public domain.

Case of the Day

One of my interests is how to learn the process of differential diagnosis. I got really interested in the Case of the Day for our neuroscience block and decided to pursue this project. The goals are:
-To encourage active learning and investigation as educational methodologies.
-To introduce diseases and their clinical findings, including images.
-To review material for the boards.

Material may be loosely based around my current curriculum (I will be starting with several immunology and microbiology cases). This website will be updated with a new case every Monday, Wednesday, and Friday. When I post the new case, I will also post the solution to the previous case in the discussion thread of that blog. You can post any questions, comments, suggestions, arguments, or guesses; you can also email them to me.

I put together all the material on this website; I try to find images in the public domain but will show images under Fair Use otherwise. My sources for each case will be posted along with the solution. I hope this is a useful resource.