Minoxidil

A 52 year old male presents with splenomegaly, fatigue, weakness, weight loss, pancytopenia, and a smear shown above.

Challenge: What is the diagnosis and what stain is shown in the image above?

Image shown under fair use.

A New Development

In pediatrics clinic, you see a 12 month old girl. As you take a history, you get more and more concerned. The girl was born at term after an uneventful pregnancy and delivery. Both the charts and parent history indicate development was normal for the first 6 months. However, there was deceleration of head growth beginning at 5 months. Today, the parents say the girl has lost developmental milestones. "She woke up and was no longer speaking." There is a loss of acquired fine motor, intellectual, and communicative abilities. As you're talking to the parents, her movements are interesting. Her hands keep moving in a "hand wringing and squeezing" fashion; they seem purposeless. Eventually, this girl may have impaired language, psychomotor retardation, ataxia, growth failure, epilepsy, disorganized breathing pattern, and autonomic nervous system dysfunction.

Challenge: This is a genetic disease only seen in girls. What is it?

Changes to this Blog

Hi everyone,

There will be some minor changes to this blog due to the busy-ness of third year clinical rotations. I will still aim to have new cases every Monday, Wednesday, and Friday, but I may occasionally omit one if I just don't have time. I cannot guarantee what time of day the case will be posted; in the past, I tried to get them up in the morning, but that seems a little more difficult now. Lastly, Wednesday cases will be abbreviated; I am thinking they will be shorter than regular, just an image or quick vignette. That will save me a lot of time.

Good luck!
Craig

Secondary to What?

A 20 year old patient with no significant family history presents with hypertension. The last health care visit was two years ago and findings were all within normal limits. You're worried that this isn't essential hypertension (after all, how could that be a case of the day?). You draw some labs and find that the patient has hypokalemia and metabolic alkalosis. Both renin and aldosterone are low. Urinary free cortisone is modestly decreased and the ratio of cortisol to cortisone is only modestly elevated. Well, that's odd.

The only other remarkable finding on history and physical is that the patient is chewing tobacco. You counsel the patient on related health consequences and the patient replies, "Yeah, I know, I started chewing this stuff a year ago and I've been going through a ton of it. I only like this brand too."

Challenge: What's the cause of the hypertension?

Mimic

A 50 year old presents to your office after a recent trip to Cape Cod. He reports fever, night sweats, myalgia, arthralgia, nausea, vomiting, and fatigue. On exam, you note hepatosplenomegaly. Lab findings show anemia, thrombocytopenia, and conjugated hyperbilirubinemia. Frustrated with these non-specific findings, you order a blood smear, shown above.

Challenge: What is the vector for this disease?

Image shown under fair use.

Poor Prognosis

This is the breast of a 50 year old woman who presented with pain. It is tender, firm, and enlarged, but no masses are felt. The skin feels "thickened." There is no fever or leukocytosis.

Challenge: What's the unfortunate diagnosis here?

Image is shown under fair use.

Happiness

An adolescent is brought into your emergency department by ambulance. On exam, you note hypertension, tachycardia, hyperthermia, and diaphoresis. He is agitated, hyperactive, anxious, almost delirious. Electrolytes show hyponatremia. A tox screen is negative for cocaine, amphetamine, and methamphetamine. A finger stick for glucose does not show hypoglycemia. An anonymous caller to the hospital tells you that the patient is one of his friends, and this was his first time, and he was really grinding his teeth earlier so they were worried.

Challenge: What's the diagnosis?

Long Island

It's another long day at the laboratory, staring at blood smears, culturing bacteria, analyzing blood gases. At about 3PM, your intern says, "Oh no! I've got to run. Can you take a look at this last sample for me? I really got a family emergency." He hands you an unlabeled specimen, grabs his golf clubs, and rushes out the door.

You have no idea what this is, but you take a look at it under the microscope:

Finally, you locate the doctor who sent this sample in. After telling him your impression, he says, "I knew it! This guy was brought in after a suicide attempt, and I was sure he drank a gallon of that stuff. I'm gonna get him a Long Island Iced Tea. You want one too?"

Challenge: Before you celebrate, you should be able to explain how the Long Island Iced Tea would help the patient.

Related Questions:
1. What are you looking at? What does the image show?
2. How did the person attempt suicide? What did he drink?

Image shown under fair use.

Timing is Everything

A 35 year old woman presents with pleuritic chest pain and dyspnea. Her X-ray is shown above; the diagnosis is easy. But as you are about to discharge her, you see something interesting in her medical chart. She has presented with the same diagnosis every month for the last six months. Though the idea of Munchausen's or factitious disorder crosses your mind, you realize that the diagnosis was confirmed every time. She also denies self-inflicting this. As you focus on the past medical history, you realize she's gotten this problem every 28 days.

Challenge: What's the diagnosis?

Image shown under fair use.

*Note: I'm on vacation Monday, so the next case will be next Wednesday.

Scents

A high-class "escort" is rushed to your emergency room complaining of headache, nausea, anxiety, and a metallic taste in her mouth. Things sound fishy since she was scheduled to testify against an unnamed politician of some repute next week. On exam, you detect a bitter almond odor on her breath. Her skin is a cherry red color. The following labs are normal: fingerstick glucose, acetaminophen, salicylates, pregnancy (though that would have made this even more juicy), EKG, and cooximetry. There is an anion gap acidosis.

Challenge: What is the mechanism of action? What is the antidote?

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So in researching this case, I found out a bunch of smells related to drug overdoses. I don't actually expect anyone to attempt this.
Challenge: What are the drug overdoses associated with the following smells?

1. Fruity or acetone-like
2. Garlic
3. Mothballs
4. Kerosene
5. Freshly mown hay
6. Rotten eggs
7. Wintergreen

Here's the "Word Box" (note, some odors have more than one related agents and some agents have more than one odor!)
phosgene, arsenic, selenium, naphthalene, ethanol, chloroform, methyl salicylate, isopropyl alcohol, organophosphates, parathion, hydrogen sulfide.

Vintage

Challenge: Who is this man and what is the birthmark on his forehead called?

Image is in the public domain.

Currant Jelly

This is the last case involving a specific association between a "Boards-useful" catch-phrase and a disease. The next few cases will be a little wacky, then back to your regularly scheduled programming.

Looks delicious yes?

Challenge: If a patient's sputum was this color, what would be the causative organism of the pneumonia?

Image shown under fair use.

Blister

A middle age person reported flaccid bullae that began in the oropharynx and then spread to the skin. Since the bullae rupture easily, this image shows only erosions. The lesions are painful and there is a fear of secondary infection.

Challenge: What's the disease? What's the cause? What's the treatment?

Image shown under fair use.