Zombie

You live in Papua New Guinea. You meet a patient who was normal up to a year ago when he developed tremors, ataxia, and postural instability. You remember him well; he was shaking so hard that he looked like he was shivering. Because of worsening tremors and ataxia, he became nonambulatory six months ago. At that time, he was noted to have myoclonus, choreoathetosis, and fasciculations. Unfortunately, you are unable to diagnose the disease, and he progresses to dementia. Exam shows frontal release signs and dysarthria. He ultimately succumbs to pneumonia.

Challenge: What's the diagnosis? Happy Halloween!

Cat and Mouse

A 30 year old G1P0 pregnant woman brings in her pet rat. "He's acting so weirdly," she says. Apparently, the rat "Ralph S Mouse" is normally terrified of cat urine. The woman owns a cat as well. However, lately, the mouse has been attracted to cat urine. His other fears of loud sounds, snakes, and strangers are not abolished.

Challenge: You tell the pregnant woman that she must not do what?

Image is in the public domain.

Vanished

Challenge: What's the diagnosis? (Click to zoom)

Image is in the public domain.

Hot Cross Buns

A 55 year old man is initially diagnosed with Parkinson's disease. He has bradykinesia, rigidity, postural instability, and an irregular jerky action tremor of the arms. Parkinson's was initially diagnosed by his primary care physician when he had multiple falls at home. Since then, however, he's developed extensor plantar responses, severe anterior flexion of the spine (camptocormia), anterocollis, and dysphagia. With these progressive changes, he is sent to you.

When you begin talking to the patient, you note hypophonic monotony. His wife says his voice has also undergone an increase in pitch and gained a quivering, strained element. She's also noticed a weird change in his sleep; he talks, shouts, and occasionally even strikes out into the air. When he awakes, he says he had a vivid, frightening dream. He also has a high-pitched inspiratory noise during his sleep; he is being worked up for obstructive sleep apnea. On review of systems, you find that he has symptomatic orthostatic hypotension, erectile dysfunction, and urinary dysfunction. He does not seem to exhibit any cognitive changes.

Here is a T2 weighted MRI:

Challenge: What's your diagnosis?

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Curving of Joints

This drawing from 1841 depicts an infant with contractures of multiple joints. This heterogeneous group of disorders is characterized by degeneration of motor neurons. Most cases are neurogenic (disorders of the CNS, genetic syndromes, and chromosomal aberrations), but a small fraction result from primary muscle disease. Severity is variable.

Challenge: What is this?

Image is in the public domain.

Tired, Heavy Legs

This 60 year old obese smoker complains of aching and swelling of his legs, especially when standing or seated for a prolonged time. The pain is not relieved with rest. His past surgical history is significant for bilateral knee replacements for osteoarthritis.

Challenge: What's your diagnosis?

Image is in the public domain.

Doesn't Belong Here

A 40 year old woman presents with urinary frequency, urgency, dysuria, and urinary retention. She's seen multiple physicians who have ruled out UTI, interstitial cystitis, and kidney stones. Here symptoms are recurring, happening mostly around her menses. She denies fevers, chills, weight loss, and hematuria. A pelvic ultrasound is negative for hydronephrosis but does note ovarian cysts. Finally, she undergoes a cystoscopy which shows this on the posterior bladder wall:

Challenge: What is it?

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Sorting Wool

This farmer says that he usually has a few cuts or abrasions from his work, but this presentation is new. When it began, it was small, painless, but itchy. It then enlarged into a "blister" and eroded into the finding shown above.

This disease can progress to larger involvement with lymphadenopathy and lymphadenitis as shown below:

Challenge: This began about a week after exposure to what?

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Obliquity

You are observing this adolescent patient from the back while he bends forward at the waist until the spine is parallel to the horizontal plane. The feet are together, knees straight ahead, arms hanging free.

Challenge: What is this device?

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