The Ayes Have It

This is the fundoscopic exam of the left eye of a 30 year old man with no symptoms. He has 20/40 vision in this eye. Extraocular movements are intact. Visual fields are intact to confrontation. Pupils are equal, round, and reactive to light. Color vision is intact.

Challenge: What's your diagnosis?

Image shown under Fair Use.

Two for One

Two patients are admitted with the same diagnosis in the summertime, the bug shown above. A third trimester pregnant woman presents with flu-like symptoms, fever, chills, and back pain. Urinalysis is negative. The blood culture grows out the bacteria shown above. Unfortunately, her newborn is greatly affected by the transplacental infection and develops disseminated abscesses in the liver, spleen, lungs, kidney, and brains as well as papular and ulcerative skin lesions.

An 80 year old man develops a subacute course of fever and confusion. There is no nuchal rigidity. A lumber puncture shows a pleocytosis and >25% lymphocytes. CSF protein is moderately elevated to 170 and glucose was mildly decreased. The gram stain is shown above.

Challenge: What organism is shown above?

Image is shown under Fair Use.

Not Enough Information

You are outside at a picnic when a person shouts, "Do we have a doctor here?" You rush over to see a young man with visible dyspnea. He is using his accessory muscles and audibly wheezing. You notice the rash shown below. The person also has periorbital edema and conjunctival swelling. A bystander says that the person is otherwise healthy and has no past medical history and takes no medications.

Challenge: What is your next step in management?

Image is in the public domain.

When I Look in a Microscope, All I See Are Eyelashes

An 80 year old man with a past medical history significant for depression presents with fatigue. About 5 months ago, his wife passed away from colon cancer, and since then, he has had a dramatic change in diet. He doesn't cook for himself and eats mainly fast food. He has also started drinking more alcohol. His exam, including neurologic and psychiatric exam, is completely normal. Labs show anemia, elevated serum bilirubin, elevated LDH, and a low-to-normal absolute reticulocyte count. WBC and platelets are low. The blood smear is shown below.

Challenge: What's the most likely diagnosis? Second most likely diagnosis?

Image shown under Fair Use.

Bruit II

See the previous post for the first part of this case.

You decide to perform surgery on the gentleman described in the previous case. The surgery goes smoothly without any immediate complications. One week after the surgery, however, he begins having unilateral headache on the same side as the surgical repair, improved with upright position. Then, he has two episodes of focal motor seizures, witnessed, followed by a stroke with CT evidence of intracerebral hemorrhage. Imaging of the vessel itself does not show thrombosis or restenosis. This is not hemorrhagic conversion from an embolic stroke.

Challenge: What happened? What is this syndrome called? What is the pathophysiology?

Image is in the public domain.

Bruit I

This is the first part of a two part case.

This is an angiogram from a patient who presents with repeated episodes of 15 minutes of hand and arm numbness. This occurs on the left side and occasionally includes numbness of the cheek. These episodes have been going on for a while, about once or twice a week, all with similar symptoms and time course. They all resolve completely. Finally the patient's wife convinced him to come in and see you.

Challenge: What's the cause of the patient's symptoms (ie. what's the anatomic location of the lesion)?

Image is in the public domain.

Growth

A 15 year old boy is brought in by his mother because he hasn't had his growth spurt yet. She's worried he's not eating enough. Otherwise, past medical history is significant for deafness and a cleft palate. He is doing well at school, but was told by the school nurse that he has red-green color blindness. On review of systems, you find out that he can't smell anything. On physical exam, you note Tanner stage 2, no body hair, and no increased bulk of muscles. His voice has not deepened. Labs show a low testosterone, LH, and FSH.

Challenge: What's your diagnosis?

Now a Chronic Disease

Challenge: These outstanding clinical images are from NEJM, shown under Fair Use, in an article describing a 53 year old gentleman with hypercholesterolemia, hypertriglyceridemia, insulin resistance, and an infectious disease being treated by what class of drugs?

Aegypti

The map above shows the distribution of a disease in 2006. There are many different presentations of this disease including asymptomatic infection. Those with symptoms often have an incubation period of 3-14 days before presenting with fever of 5-7 days, fatigue, headache, retroorbital pain, myalgias and arthralgias. Children sometimes present with GI or respiratory tract symptoms. Labs often show leukopenia, thrombocytopenia, and elevated AST.

The dreaded presentation, however, includes shock, hemoconcentration, marked thrombocytopenia, abdominal pain, vomiting, fever of 2-7 days, and spontaneous bleeding. If you inflate a blood pressure cuff on these patients between the systolic and diastolic pressures for 5 minutes, you'll find petechiae.

Challenge: What's the disease?

Image is in the public domain.