Bug Juice

A patient with Staph endocarditis (not yet speciated) who has been receiving the antibiotic shown above for 3 days develops the rash shown below. Mucosal surfaces are spared. A dermatologist takes a biopsy and the pathologist notes linear IgA deposition at the dermal-epidermal junction of the basement membrane zone.

Challenge: Discontinuation of the drug leads to resolution of the rash - what drug is it?

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

Malocclusion

Most cases of this autosomal dominant disease are sporadic. Patients have strabismus, hearing loss, and acne vulgaris. Birth weight and length are above the 50th percentile, though linear growth slows during childhood.

Challenge: What's your diagnosis?

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Self-Exam

Challenge: What's the diagnosis?

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Limes

A 25 year old bartender (or celery farmer or child playing in a wild parnsip field) presents with the rash shown above. He normally sleeps during the daytime and works at night and doesn't have the rash. Last weekend, however, he went out sailing and developed erythema, edema, and bullae on his hands a day later. They are painful but not pruritic. After the acute rash resolves, the patient has some hyperpigmentation of the skin lasting for months.

Challenge: What's the diagnosis?

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Dreaded II

This 55 year old man with Peutz-Jeghers syndrome underwent an ERCP for nausea, vomiting, and abdominal pain. The arrow shows the common bile duct. The arrowhead shows the pancreatic duct.

Challenge: What's your diagnosis?

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Dreaded I

This CT scan is taken from a 50 year old African American man with diabetes, smoking, obesity and a history of partial gastrectomy. He initially presented with asthenia, weight loss, anorexia, insidious gnawing epigastric pain, jaundice, and dark urine.

Challenge: What's the diagnosis?

Image is in the public domain.

Bile

All these children had their diagnosis made on liver biopsy as infants. They have tried or are taking ursodiol, rifampin, and cholestyramine. Some are better by school age, though a small minority go to liver transplantation. When getting a liver, it's important for the anesthesiologist to know that they may have cardiac anomalies, especially peripheral pulmonic stenosis. Most have unusual vertebrae as well. Some are short, have renal disease, or have pancreatic insufficiency.

Challenge: What's the common underlying disease?

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Breaking Big Tobacco

As a wonderful family physician, you convince one of your patients to quit smoking. You transition them to a medication for smoking cessation which enhances CNS noradrenergic and dopaminergic release. You tell the patient to start the medication a week before their quit date and to take it for three months. The side effects are insomnia, agitation, dry mouth, and headache.

Challenge: What's the medication?

Image is in the public domain.