The Lost Art

Welcome back! You have a first year medical student tagging along and send her to listen to a murmur. She describes a mid to late diastolic rumble heard at the apex. S1 sounds normal and there is no opening snap. You are an old school pharmacologist so you administer inhaled amyl nitrate. The murmur decreases in intensity and duration. As you teach the medical student, you pull out an old pathology slide:

Challenge: What's the murmur? What's the valve defect? What does the slide show?

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Happy Holidays!

I'm taking a break from Case of the Day this week. It's been a pretty busy year, but I thank you all for following along, posting answers and comments, and learning with me. Surprisingly, this blog hit 80,000 hits! Wishing you and your family a warm, safe, and happy holiday season. I'll see you next week. 

-Craig.

1 in 2200

Prenatal ultrasound showed a "heterogenous mass" in the chest concerning for "cystic adenomatoid malformation." After delivery, this X-ray was obtained due to a barrel chest and scaphoid abdomen.

Challenge: What do you think of the prenatal ultrasound interpretation?

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The Sound Must Seem an Echo to the Sense

A 51 year old man with hypothyroidism presents with a confusing constellation of symptoms. He's seen multiple physicians without an answer. Five years ago, he began having tingling, paresthesias, and the feeling of coldness in his feet. Over time, he developed weakness in his lower extremities. All these symptoms started distally and had gradual, proximal, symmetric spread. He has no history of diabetes or alcoholism; his B12 and methylmalonic acid are normal. His primary care physician was baffled. A few years later, he could not even climb stairs, arise from a chair, or grip things strongly in either hand. On exam, muscle weakness is more marked than sensory loss, though he has both; his touch, pressure, vibratory, and joint discrimination are more affected than temperature and nociception. There are no cranial nerve abnormalities, though you do note papilledema. A lumbar puncture shows an elevated CSF protein > 100mg/dL with a normal cell count.

Review of systems is remarkable for erectile dysfunction and unintentional weight loss. The rest of the exam is surprising for hyperpigmented skin, telangiectasias, mild hepatosplenomegaly, and lymphadenopathy. Labs show low testosterone and a serum monoclonal protein. An X-ray is shown below.

(Just focus on the arrow; I know this X-ray is a female, not a male)

Challenge: What's your diagnosis?

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Lumps and Bumps

A 30 year old woman palpates a soft mass in her breast. Ultrasound is shown above. Aspiration yields a milky substance.

Challenge: What's your diagnosis?

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Chips

A man in his 20s is brought in as a trauma victim. He is an unrestrained passenger in a high speed motor vehicle accident. His GCS is 7 and he is intubated in the trauma bay. The patient is hemodynamically unstable with tachycardia and hypotension. An abdominal wall contusion is noted and there are several rib fractures. An exploratory laparotomy for shock is undertaken.

Blood is found in the abdomen. The hemoperitoneum is drained and laparotomy pads are placed in all four quadrants, along the peri-colic gutters, and into the pelvis. A large liver laceration is noted and manual compression of the liver is started. Because of ongoing bleeding, the following procedure is performed with a vascular clamp:

Challenge: What's this procedure called?

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Greece

A 34 year old man presents with ankle pain. The pain is worst when he tries to push off from the ground; it is minimal when his foot touches down. The pain and stiffness is about 2-6 cm above the posterior calcaneus. It is burning, worse with activity, relieved by rest. Since his last visit, he has started to run because you counseled him to get more exercise for weight loss; his BMI is 32. You palpate crepitus when the patient dorsi and plantarflexes the foot.

Challenge: What's the diagnosis?

Image is in the public domain.

Japan

The map above shows the geographic distribution of an important cause of childhood neurologic infection and disability. Mosquitoes are the main vectors, and the primary hosts are pigs and wading birds. In the most common presentation, after a 5 to 15 day incubation period, patients develop fever, rigor, and diarrhea. This is followed by headache, vomiting, and generalized weakness. Finally, there are mental status changes, focal neurologic deficits (paresis, plegia, cranial nerve palsies), and movement disorders. Many patients go into a coma and have respiratory failure. In children, seizures are very common and can be subtle - twitching of a digit, eye movement, or irregular breathing. Labs reflect a mild leukocytosis and hyponatremia. CSF studies show an elevated opening pressure, and thalamic lesions are seen on imaging.

Challenge: What's the disease?

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Germany

This used to be a disease that peaked every few years in the winter and early spring, mostly in school age children. Most of them are asymptomatic or only have mild fever and lymphadenopathy (posterior cervical, posterior auricular, suboccipital). The rash began on the face, but generalized within 24 hours.

Challenge: What's your diagnosis?

Image is in the public domain.

Norway

This patient has AIDS. He developed poorly defined erythematous patches that quickly developed a prominent scale. The scalp, hands, and feet are the worst. Note the warty scales, fissures, and crusts.

Challenge: Eww. You double glove and wear a gown. Even so, you take a shower when you get home. What does he have?

Image is in the public domain.

Turkey

In Turkey, there was an outbreak of this disease in 98 patients. (It's Thanksgiving! Though in actuality, this disease is most prevalent in China, Thailand, Mexico, Argentina, and Bolivia). In the first week after exposure, patients complain of abdominal pain, nausea, vomiting, and diarrhea. Lab tests at this time are unrevealing.

After the first week, patients develop the cardinal symptoms of muscle pain, joint pain, and subjective muscle weakness. The most common muscle groups include the calves, upper arm, neck and shoulder girdle, and forearms. The pain can be so bad, patients do not want to move at all. On exam, they can have fever, subungual splinter hemorrhages, conjunctival or retinal hemorrhages, periorbital edema or chemosis, visual disturbances, and ocular pain. Lab tests show leukocytosis and eosinophilia (which peaks in the third or fourth week of disease). A light micrograph of a muscle biopsy is shown below.

Challenge: What's your diagnosis?

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Skull and Crossbones

Challenge: What are those white things going into the skull? P.S. Ignore the metal dentures.

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Stars

The white bar marks 50 nanometers.

This bug haunts nursing homes, retirement facilities, cruise ships, airplanes, schools, and daycare. It hangs out with shellfish, especially oysters. The incubation time is a day or two and the illness lasts 18-72 hours. Patients develop abrupt onset vomiting and non-bloody diarrhea, accompanied by myalgias, malaise, headache, and fever.

Challenge: What's the bug?

Image is in the public domain.

Cuff

A 60 year old postmenopausal woman with obesity, chronic smoker's cough, chronic constipation, diabetes, and psoriasis on infliximab undergoes a laparoscopic hysterectomy for uterine cancer. She appears to do well postoperatively; she tolerates a diet, ambulates, urinates, and has adequate pain control. Six months after her surgery, however, she presents with pelvic pain, vaginal bleeding, and vaginal pressure. Palpation on a bimanual exam feels like bowel is extruding from the vagina.

Challenge: What happened?

Image of a total laparoscopic hysterectomy shown under GNU Free Documentation License, from Wikipedia.

Picture This

This patient has seen doctors for years without a diagnosis. She has crampy abdominal pain, fatigue, nonbloody diarrhea, weight loss, and fever. She attributes her weight loss to mouth pain and pain with swallowing. A colonoscopic image is shown below as are two interesting skin rashes.

Challenge: What's the diagnosis?

First two images shown under GNU Free Documentation License. Last image is in the public domain.

Store at Room Temperature

Ever since this child was one year old, he has had an "allergy to cold." Exposure to cold environments, even an air-conditioned room, triggers the rash shown above in around seven hours. This is followed by a fever. If blood is drawn 10 hours after the exposure, then the leukocyte count can be over 30,000/microL. This CBC abnormality declines about 12-14 hours later. The baby also develops a red eye and complains of joint aches. All these symptoms usually resolve within 24 hours. In between episodes, the patient's exam is completely normal.

Challenge: What's your diagnosis?

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Spineless

A 60 year old man presents with 6 weeks of back pain. It has been progressively worsening and is worse at night. On examination, there is local tenderness to gentle spinal percussion and decreased range of motion of the back. Neurologic examination of the lower limbs is normal. WBC is normal. ESR and CRP are markedly elevated. Radiographs are shown above.

Challenge: What's your diagnosis?

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Desserts

A 60 year old man with atrial fibrillation, cirrhosis, adrenal insufficiency, and coronary artery disease presents with a severe pneumonia. He is intubated for hypoxemic respiratory failure and admitted to the intensive care unit. His blood pressure is 100/40, heart rate 110, and temp 101. Early goal directed therapy is initiated, and he is bolused 5L crystalloid and started on norepinephrine. His ventilator settings are tidal volumes 400, rate 16, PEEP 5, PS 10, FiO2 50% with SpO2 96%. His CXR shows a multilobar consolidation. His coumadin, propranolol, and ASA are held. Labs show WBC 20,000, hematocrit 12, platelets 40,000, creatinine 1.0, and INR 2.8. His current medication list is: dexmedetomidine drip, hydromorphone drip, norepinephrine drip, albuterol/ipratropium, hydrocortisone, vancomycin, piperacillin-tazobactam, levofloxacin, insulin as needed, lactulose, and subcutaneous heparin. He is kept NPO. On hospital day 3, he drops his hematocrit to 9. An upper endoscopy shows shallow mucosal oozing in the fundus and body of the stomach.

Challenge: What's the diagnosis?

Risk Factors

A 60 year old patient with diabetes, COPD, AML s/p chemotherapy with ongoing neutropenia, history of cholecystectomy, and inguinal hernia presents with a COPD exacerbation. He is treated with nebulizers, high dose steroids, and broad spectrum antibiotics. He slowly improves, but then develops a small bowel obstruction. The surgeons recommend nonoperative management; an NG tube is placed. Because he is slow to improve, a PICC line is ordered and total parenteral nutrition is started. On hospital day 7, he becomes febrile, hypotensive, and tachycardic. He complains of chills and blurry vision. His antibiotics are broadened to cover extended spectrum beta lactamase organisms. He continues to deteriorate clinically.

Fundoscopic exam is shown below:

Challenge: What are you worried about?

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Tiny

A preterm newborn at 34 weeks with meconium aspiration syndrome presents with tachypnea, grunting, mild pallor, and cyanosis. When you glance at the monitor, you note that the QRS voltages are pretty small.

Challenge: What's your diagnosis?

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Crazy

An African American woman initially presents with headache, fever, and "flu-like symptoms." She takes a few days off work, but then starts to develop odd psychiatric symptoms. She has new anxiety, agitation, and bizarre behavior. Her husband thinks she's hallucinating and has delusions. She has gaps in her memory, cannot sleep, and develops strange orofacial dyskinesias. Over the ensuing few days, she has a seizure, becomes mute, and develops stupor with catatonic features. Vital signs show hyperthermia and inconsistent blood pressures and heart rates; over the hospitalization, she has hypertension, hypotension, tachycardia, and bradycardia. Neuro exam shows dystonia and rigidity. CSF shows lymphocytic pleocytosis. EEG shows slow, disorganized activity that does not correlate with abnormal movements. Brain MRI is normal. CT of the abdomen and pelvis is shown below:

Challenge: The diagnosis is made on detecting antibodies to the receptor shown above. What is it?

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Writing

Challenge: This started 6-7 minutes after the inciting factor and will fade in 15-30 minutes. What is it?

Image is in the public domain.

Steal from the Rich

This child often has airway obstruction from his tongue flopping back into his mouth. He also has trouble feeding. You recommend placing him in the prone position and using a nasopharyngeal trumpet to help his breathing until he gets bigger.

Challenge: What's the diagnosis?

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Thought I Fixed It

A patient presents with shortness of breath and an X-ray shown above. His hemodynamics are stable. You recognize the diagnosis and heroically perform a procedure under local anesthesia to correct the pathology. You pat yourself on the back, order an X-ray, and go back to the call room.

Unfortunately, the repeat X-ray is shown below.

The patient has severe cough, dyspnea, and hypoxemia.

Challenge: What happened?

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Egg

Challenge: This is the first structure to appear within the gestational sac and confirms an intrauterine pregnancy. It can be seen at the 5th week of gestation. What is it?

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Socrates

A patient is brought into the emergency department with tonic-clonic seizures. A friend says, "We found some wild vegetables...we thought it was parsley or turnip or carrots or something." She brings in the plant shown above. "He ate a little," she says, "and before he started seizing, he had nausea, vomiting, and abdominal pain. Then he started acting a little confused. When I touched him, he was drenched in sweat." Vital signs show bradycardia and hypotension. Despite initial antiepileptic therapy, he remains in status epilepticus; these seizures are fairly intractable.

Challenge: What is this poisonous plant which acts by GABA antagonism?

Image is in the public domain.

No Cases this Week

Hi Everyone,

Thank you for following Case of the Day. I'm going to take a quick break this week as I am feeling fairly exhausted and behind in coming up with cases. As always, suggestions and ideas are welcomed. New cases will be posted next Monday.

Craig

Plosive

This child is referred to you for a routine tonsillectomy and adenoidectomy. His cleft lip and palate have not been repaired. His pediatrician, however, feels that the tonsils and adenoids are more of a problem because the child has severe OSA and recurrent tonsillitis. When you examine the child, he is able to repeat nasal consonants ("m" "n"). However, with plosives ("Bobby" "puppy"), you hear air escape. You also note air escape with sibilant fricatives ("s" "z" "sh").

Challenge: Would you do the tonsillectomy, adenoidectomy, both, or neither?

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Mask

You meet this child. He does not smile. He does not frown. In fact, his face doesn't move at all. You notice that as he looks around, his eyes never move laterally from side to side. 

Challenge: What's the diagnosis?

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Sangre

A 65 year old man presents with debilitating fatigue and some weight loss. On exam, you note hepatomegaly and splenomegaly. The spleen is pretty remarkable; you feel the inferior border at the pelvic brim and the right border past midline. His past medical history includes a DVT when he had a knee replacement. Otherwise, he's pretty healthy. However, labs are surprising. Hemoglobin is 9g/dL, WBC is 26,000/microL, platelets are 90,000/microL.

Peripheral blood smears are shown below:

You attempt to do a bone marrow aspiration but get a "dry tap." A bone marrow biopsy is shown below; the trichrome stain colors collagen blue.

Challenge: What's your diagnosis?

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Artemis

This patient has a rare disease with an estimated incidence of one case per million per year. Symptoms started two weeks ago with a steady gnawing or boring pain behind the left eye. This was followed by double vision. Your extraocular movement exam is shown above (the center picture is neutral, the patient looks in the direction of the image relative to the center picture).

Labs including CBC, electrolytes, glucose, hemoglobin A1c, liver function tests, ACE, ANA, Anti-dsDNA, Anti-Sm, ANCA, FTA/ABS, lyme serologies, SPEP, ESR, and CRP are normal. A lumbar puncture is performed and all CSF studies are normal.

Contrast-enhanced coronal T1 MRI shown below:

Since you don't know what's going on, you give a trial of steroids, and within 48 hours, the patient's pain has resolved. Within a month, all the eye findings have resolved as well.

Challenge: Now you suspect the diagnosis is...what?

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Wall

Challenge: This patient has an old MI in which wall?

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Labor Day

This is a fetus with massive hydrocephalus in a patient with premature labor at 34 weeks. On digital examination, you palpate the orbital ridge, saddle of the nose, mouth, and chin.

Challenge: What is happening here?

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Hidden

You are a radiologist and get several X-rays sent by the emergency department for young men in their 20s with chief complaint "arrested by law enforcement." You sigh.

Challenge: What's your diagnosis?

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Sniff

A newborn girl presents in the first few days of life with upper airway obstruction and noisy breathing. On feeding, she becomes cyanotic, which resolves when she cries. To help, you try to place a nasal trumpet to relieve obstruction but cannot advance the 6 French catheter. An oral airway helps the obstruction until definitive surgery can occur. CT is shown below.

Challenge: What's the diagnosis?

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Tos

A 30 year old man presents with a week of cough. "It started seven days ago, and at first I thought it was a common cold, but it just didn't get better. I didn't have fever or anything, so I wasn't concerned, but soon my cough started producing this green and yellow sputum." In fact, cough in patients with this disease often lasts 10-20 days. The patient has no shortness of breath, chest pain, hemoptysis, fevers, chills or any other symptoms. He has no other medical problems, medications, or significant social history. The patient reports an up-to-date vaccination on pertussis. On exam, vitals are normal and lungs are clear to auscultation. A lateral film is shown below.

Challenge: You decline to prescribe antibiotics because the clinical presentation most likely suggests what disease caused by which organisms?

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Frog

Challenge: What is this blue, fluctuant swelling?

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Drugs II

A 25 year old man with depression attempts suicide by overdosing on the pills shown above. The pills belong to the father who has "super refractory hypertension." The father doesn't remember exactly what he takes, but says he's "on everything." The patient was found about two hours after ingestion with altered mental status and lethargy. In the ED, he is comatose. He has miosis, hyporeflexia, and hypotonia. A very painful stimulus elicits some movement. Respiratory rate is 6. Heart rate is 45. Blood pressure is 80/40. EKG shows sinus bradycardia.

Naloxone and flumazenil are administered, and no change is noted. The father says he does not take any opiates, barbiturates, or benzodiazepines. Finger stick blood glucose is normal. Blood alcohol level, serum salicylate, acetaminophen level, and standard urine toxicology are negative. CBC, chemistries, LFTs, and coags are within normal limits. CXR is clear. A head CT is negative. ABG initially shows a hypercarbic respiratory acidosis, but even after this is normalized with intubation and mechanical ventilation, no change in mental status is noted.

Challenge: The patient overdosed on one medication. What antihypertensive is the culprit here?

Image is in the public domain.

Drugs I

A 50 year old woman presents with the rash shown above as well as ankle edema. She has a history of hypertension, hyperlipidemia, diabetes, Parkinson's disease, asthma, GERD, gastritis, osteoporosis, osteoarthritis, hepatitis B, gout, and anxiety disorder. Her medications are: metoprolol, lisinopril, atorvastatin, insulin (glargine and lispro), levodopa, amantadine, albuterol inhaler, ranitidine, omeprazole, vitamin D, ibuprofen, fluoxetine, glucosamine, St. John's wort, and feverfew! The culprit for the rash is shown below.

Challenge: What's the culprit?

First image shown under Fair Use. Second image is in the public domain.

Toes

Challenge: The parents of this newborn (12 hours old) ask why the toes are so blue. The child was born at 36 weeks by a normal spontaneous vaginal delivery, but the mother had a prolonged rupture of membranes and is GBS positive.

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