Birds of a Feather

Challenge: What do all these have in common: quinidine, amiodarone, erythromycin, pentamidine, voriconazole, levofloxacin, TCAs, haloperidol, sorafenib, risperidone, methadone, ondansetron, and protease inhibitors?

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Two Patients

A 30 year old G3P1 African-American woman with BMI 35kg/m2 and a past medical history of hypertension presents for a prenatal visit. Her prior baby was a 37 week 10 pound newborn who was admitted to the NICU for respiratory distress syndrome, hypoglycemia, hypocalcemia, hypomagnesemia, and polycythemia.

Challenge: Why?

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March Fracture

A runner increases her activity significantly after joining the college track team. A few weeks into her routine, she starts complaining of intermittent forefoot pain that occurs only with running, jumping, and dancing. The pain worsens until it occurs constantly with weight-bearing. On exam, you note point tenderness and swelling. When you hold the toe in line with the foot without angulation, pushing the toe into the metatarsal produces pain.

The first X-ray (A) is taken at this visit. The second X-ray (B) is taken 4 weeks later. The third X-ray (C) is taken 3 months later.

Challenge: What's your diagnosis?

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Band

Challenge: Your medical student thinks this is a band in a patient with myelodysplasia, but you know better; what is it?

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Happy Pi Day!

Challenge: This finding is associated with which cancers?

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Holes

This patient presented with vision loss, hearing loss, and a gradual confusion. The visual loss is monocular, restricted just to part of the visual field. Fundoscopic examination shows a sectoral pattern of retinal opacification. A T1 MRI is shown above.

Challenge: What's the rare diagnosis?

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Puffy

Only 20-25 cases of this disease have been described in the literature in the post-antibiotic era. A 10 year old girl is involved in a car accident where she has some mild facial trauma. Her head CT at the time is only notable for some sinusitis; she is observed for 24 hours and then discharged home. She then presents again to the emergency department with forehead swelling, headache, fever, chills, and rhinorrhea. Exam shows a minimally tender area of doughy, puffy edema. Her cranial nerve exam is normal. She has an elevated WBC count, ESR, CRP, and the CT shown above.

Challenge: What's the diagnosis?

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V

An adolescent presents to your pediatrics clinic with fatigue. Her parents think she just doesn't like gym class, but she truly has exercise intolerance, myalgias, and poor endurance. On exam, you note muscle swelling and weakness after brief periods of intense isometric exercise. However, after a short break, the patient can resume physical activity without significant symptoms. Over the next few visits, you check CKs and they are always elevated; she also has intermittent myoglobinuria.

Challenge: What's the autosomal recessive disease described here?

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