Monday, December 29, 2014


Four patients show up to your emergency department. You send standard urine drugs-of-abuse screens on all of them.

Patient A took amphetamines five days ago.
Patient B ingested 2L of water right before providing a sample; he used cocaine several hours before.
Patient C takes rifampin, finished a course of ciprofloxacin for a UTI, eats poppy seeds, drinks quinine in tonic water, and takes LSD.
Patient D says he is a chronic pain patient who ran out of methadone. You do a more specific urine drug test that is positive for methadone but not for 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine.

Challenge: What can you tell me about the tests for these patients and what they mean?

Image of opium field shown under Fair Use, from Wikipedia.

Thursday, December 25, 2014

Happy Holidays!

Dear readers,

Thank you for following along Case of the Day! I know that cases have been a little spotty here and there, and I apologize. I am pretty happy to have almost 900 cases (my solutions document is 170 pages long). I will be taking today and next Thursday off for the holidays, but there should be a new case on Monday. Next year, I will try to be a little more cognizant of posting cases and solutions on time. At some point, I will probably retire this blog, but there are still a few more mysterious and fascinating diseases I want to cover. Wishing you and your family happy holidays.

Craig Chen

Monday, December 22, 2014

Fad Diet

A 50 year old man with hyperlipidemia decides to make up a diet consisting entirely of the fruit shown above and juice from the fruit. He presents with aches and pains all over, and his CK is quite elevated. FYI, this is not a real diet.

Challenge: What fruit is shown above and what is the cause of the CK elevation?

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Monday, December 15, 2014


A patient with CML presents with a WBC of 200,000. His vitals are stable. He is a little bit confused so you perform the maneuver shown above, then get a laboratory test. Unfortunately, your respiratory therapist forgets to put the sample on ice.

Challenge: What abnormality do you expect?

Image shown under Fair Use.

Thursday, December 11, 2014

Leaky Pipes

A 65 year old smoker undergoes a procedure to secure the pathology shown in panel A. After the procedure, the fluoroscopy shows the image in panel B. This requires a revision of the procedure, which is shown in panel C.

Challenge: What's the pathology shown in panel B?

Image shown under Fair Use.

Monday, December 8, 2014


Along with the finding above, the ultrasound of the fetus shows a massive midline thoracoabdominal wall defect. There is a large wide-based amnioperitoneal sac inserting onto the placental chorionic plate; there's no umbilical cord. There is severe scoliosis, malrotation of the limbs, and club feet. The maternal AFP is markedly elevated.

Challenge: Unfortunately, this disease is lethal; what is it?

Image shown under Fair Use.

Thursday, December 4, 2014

Super Mario

About half an hour after ingesting a few of these, a young man presents with euphoria and sensory disturbances. On presentation, he has tachycardia and dilated pupils. His symptoms subside after about six hours.

Challenge: What is the active compound and what drug is it related to?

Image shown under Creative Commons Attribution Share-Alike License.

Monday, December 1, 2014

Holy Water Sprinkler

The following images are from patients undergoing chemotherapy, who have uncontrolled HIV, or who are taking high dose steroids. They all presented with seizures or focal neurologic signs.

Panel A is a CT scan, panel B is a T2-weighted MRI.

This is a coronal T1-weighted MRI.

This CT was obtained in a patient who had a stroke.

Challenge: What's the diagnosis?

Images shown under Fair Use.

Tuesday, November 25, 2014

Holiday Week!

Happy Thanksgiving, everyone! Unfortunately, I am on call this Thursday, but I wish you all a warm and happy holiday. No cases this week; we'll see what I come up with next Monday. Thank you for following along.


Thursday, November 20, 2014

Chicken or the Egg?

A 30 year old adult presents with what he thinks is asthma. He used to think he was allergic to chicken, but has been eating chicken okay. He gets short of breath and wheezy when he encounters bird feathers and eggs.

Challenge: Believe it or not, this syndrome has a name - what is it? What is the causative factor?

Image of chicken and egg illustration from the 14th century is in the public domain, from Wikipedia.

Monday, November 17, 2014

It's Greek to Me

A four year old child presents to your child neurology clinic with vomiting and syncope. The parents say he loses consciousness and muscle tone during these strange episodic events. They generally happen at night and last more than five minutes; some even last more than 30 minutes. His pediatrician's note says that during a witnessed episode, he had pallor, miosis, incontinence, coughing, hypersalivation, and tachycardia. He had some staring and eye deviation.

EEG is shown below (his is the second strip):

MRI of the brain is normal.

Challenge: What syndrome is described?

Image shown under Fair Use.

Thursday, November 13, 2014


A man is brought in by ambulance after a motor vehicle accident with a dramatic open chest wound. The wound is on the left chest. During inspiration, the wound makes a big sucking noise and the mediastinum swings to the right. During expiration, the mediastinum returns to midline. When you look into the wound, during expiration, the injured lung inflates.

Challenge: What's going on here?

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Monday, November 10, 2014

You Nailed It

Challenge: What is this autosomal dominant disorder?

First three images shown under GNU Free Documentation License, fourth image is in the public domain.

Thursday, November 6, 2014

False Positive

A 60 year old man who is several weeks out from a bone marrow transplant for multiple myeloma develops fever, shortness of breath, tachycardia, and hypotension. He is started on vancomycin, levofloxacin, and piperacillin-tazobactam and then admitted to the intensive care unit. His lactate is elevated, and he is fluid resuscitated. A flu test is negative. A diagnostic test is sent to look for a specific polysaccharide in the serum that would change the antibiotic management. It comes back positive, but your infectious disease consultant says, "Wait, that test could be a false positive."

Challenge: What is the test and why is it unreliable here?

Image of bone marrow transplant shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Monday, November 3, 2014

Also Infects Dolphins

You volunteer with a medical mission to see outpatients in a clinic in Brazil (or Colombia, Suriname, Venezuela, Guyana, French Guiana, Ecuador, Peru, Bolivia, Costa Rica, or Mexico). You get a rash (pun not intended) of forest workers, farmers, hunters, and fishermen between 40 and 70 with the following findings:

The histology is shown below:
Challenge: What's your diagnosis?

First three images shown under Fair Use. Fourth image is in the public domain.

Thursday, October 30, 2014

Looks Normal

A young woman with anxiety comes in because she says her heart beat is irregular. Her father has a history of atrial fibrillation and her mother has a history of a heart attack. Her EKG is shown above.

Challenge: How would you read this EKG?

Image shown under Fair Use.

Monday, October 27, 2014

Terms of Agreement

A 20 year old G3P0 woman presents with left lower abdominal pain and vaginal discharge. She says she sometimes feels warm at night but hasn't had a marked fever. "I've had PID in the past, and this just isn't the same," she says. You are unable to do a complete pelvic exam because of significant adnexal tenderness. Because of this, you order pelvic imaging which is shown above. A CBC shows leukocytosis, and pregnancy test is negative. She undergoes surgery and cultures grow out a polymicrobial mix of E.coli, aerobic streptococci, Bacteroides, and Prevotella.

Challenge: What is the diagnosis?

Image shown under Fair Use.

Thursday, October 23, 2014

Strange Behaviors

A 60 year old man with depression is brought in by his wife for strange behaviors while he's asleep. His wife says that over the last few years, she's noticed repeated episodes of vocalization and movement while he's asleep. The movements last less than a minute long but are purposeful; she says she's seen him throw a ball. He often makes benign hand gestures, and occasionally punches or kicks. He sometimes shouts or yells. Most times, he doesn't awaken, but occasionally he wakes up momentarily before falling back asleep. He usually remembers his dreams, and when he awakes, he might be briefly confused, but orients quickly. All these episodes happen during the EEG shown above. For social history, he did not graduate high school, he currently smokes a pack a day, and he has some pesticide exposure from farming. Review of systems is remarkable for anosmia and constipation.

Challenge: In a decade, he is diagnosed with Parkinson's disease, but what does he have now?

Image is in the public domain.

Monday, October 20, 2014


A young man with difficulty smelling presents because his sense of smell has changed. He's "worried about a tumor." He also has nasal congestion, sinus fullness, and fatigue. He has no fever or pain. Exam of his nostrils shows the finding above in the middle meatus. This is resected and the gross pathology is below:
Challenge: What's shown?

Both images shown under Fair Use.

Thursday, October 16, 2014


A 65 year old man with hypertension, hyperlipidemia, history of stroke, congestive heart failure, and atrial fibrillation is brought in by EMS with shortness of breath and palpitations. Defibrillator pads are placed. His rhythm is shown above. His blood pressure is 100/50, and he is given amiodarone 150mg IV push. He converts to a normal sinus rhythm and blood pressures improve.

You then get called by the nurse because he became suddenly unresponsive. He has the same rhythm, shown above. His defibrillator pads are still on. The noninvasive blood pressure cuff cannot pick up a reading, and you cannot feel femoral or carotid pulses.

Challenge: What do you do?

Image is in the public domain.

Monday, October 13, 2014


A 35 year old woman with major depressive disorder is brought in with an overdose. She took a whole bottle of her antidepressants in an attempt to end her life. She currently complains of nausea and vomiting. She has some CNS depression and tremor but is protecting her airway. She has no muscle rigidity. Her vital signs are stable. EKG is normal sinus rhythm. Glucose is normal. Acetaminophen, salicylate, and ethanol levels are undetectable. Pregnancy test is negative. You give a single dose of 50g activated charcoal.

Challenge: What was the ingestion?

Image is shown under Creative Commons Attribution Share-Alike License.

Monday, October 6, 2014


Sorry! This week has come around and I have neglected to prepare cases of the day. Unfortunately, the free time I usually count on to write cases disappeared this last week. I apologize, but we'll both take this week off. Thanks for following!


Thursday, October 2, 2014


A patient on a fad diet who does not eat oils, meat, eggs, and leafy vegetables presents with a spinocerebellar syndrome. She has ataxia, hyporeflexia, and loss of proprioceptive and vibratory sensation. She also has anemia with evidence of hemolysis. She starts taking vitamins and her symptoms improve.

Challenge: What's the most likely diagnosis?

Image is in the public domain.

Monday, September 29, 2014

Call It

On this single photon emission computed tomography (SPECT) brain scintography, normal is the top figures and abnormal is the bottom figures. What a hot nose!

Challenge: What does his ancillary test show?

Image is in public domain.

Thursday, September 25, 2014

Reverse Engineering II

A 51 year old woman taking the compound shown above is cautioned not to take it long term because of risks for stroke, venous thromboembolism, breast cancer, and cholecystitis.

Challenge: What is the drug and what is she taking it for?

Image is in the public domain.

Monday, September 22, 2014

Reverse Engineering I

Can you figure out from the treatment what the disease is?

A 20 year old on a liver transplant list is taking the drug above. His parents remind him to take the drug on an empty stomach since absorption can be decreased by as much as 50% if taken with food. He takes 1000mg daily in divided doses. When he first started the medication, a lot of caution was taken because of his penicillin allergy. Luckily, he didn't get early sensitivity reactions which are usually characterized by fever, cutaneous eruptions, lymphadenopathy, neutropenia, and thrombocytopenia. He has had some proteinuria, but luckily, his kidney function has remained stable since the drug is renally metabolized. He gets routine blood counts to monitor for aplastic anemia. He gets 24 hour urine collections with his hepatologist to make sure he is compliant with treatment. His child neurologist and ophthalmologist are optimistic that he will get a liver transplant.

Challenge: What's the drug and what's the disease?

Image is in the public domain.

Thursday, September 18, 2014


An obese 30 year old woman with Type II diabetes presents with groin pain. She had an inguinal hernia repair six months ago, but now regrets it. She has had multiple orthopedic surgeries in the past (the last one a year ago) but never had a problem like this. A few weeks after the hernia repair, she was doing well, but about two months out, she began having symptoms again. The pain is an episodic throbbing and burning sensation that begins with prickling pain. It's worse with activity and hyperextension of the hip. It's relieved by recumbency and hip and thigh flexion. Sometimes even just touching the wound or coughing can trigger pain. She also notices numbness over the thigh.

Challenge: What's your diagnosis?

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Monday, September 15, 2014

Glassmakers Soap

A 40 year old is referred to you for evaluation of Parkinson's disease. He presents with dyscoordination, loss of balance, and confusion. He is on a fad diet of meat, fish, poultry, dried fruit, and nuts. He works in the steel and welding industry. He is a nonsmoker but does drink occasional alcohol. He uses marijuana as well.

Challenge: This is toxicity of the element shown above: what is it?

Image shown under Creative Commons Attribution Share-Alike License.

Thursday, September 11, 2014

It's Not Easy Being Green


Challenge: What medication has this sedated ICU patient been on?

Image shown under Creative Commons Attribution Share-Alike License.

Monday, September 8, 2014


A 50 year old man presents with shortness of breath and a cough two days after taking the substance above. He also has melanoptysis (that is, black sputum). He has thermal burns on his thumbs. He is hypoxic and a bronchoscopy is performed. The bronch shows bloody lavage. Cell count shows eosinophilia. The CXR and CT are shown below.

Challenge: What's the diagnosis?

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

Thursday, September 4, 2014


This young healthy football player sustained a "knee injury." He is supine, hip flexed to 45 degrees, knee flexed to 90 degrees, and foot in neutral position.

Challenge: Where is the lesion?

Image shown under Fair Use.

Monday, September 1, 2014

Labor Day 2014

Happy Labor Day!

A 25 year old G1P0 woman delivers a healthy baby girl at 39 weeks gestation. She has a history of gestational diabetes mellitus, hypothyroidism, and polyhydramnios. She had spontaneous rupture of membranes about a day and a half ago. She receives the drug above after delivery. About half an hour later, she develops shivering, then a fever. She receives acetaminophen and these symptoms abate after three hours.

Challenge: What medication is shown above?

Image is in the public domain.

Thursday, August 28, 2014

A Rare Disease in Other Mammals

A 30 year old African American woman with hypertension presents to you because of heavy and prolonged menstrual bleeding as well as pelvic pain. She is G4P1 with 3 miscarriages. Menarche was at 9 years of age. She eats a lot of beef and red meats. Review of systems is positive for urinary frequency. A transvaginal ultrasound is shown above.

Challenge: What's your diagnosis?

Image shown under Fair Use.

Monday, August 25, 2014

Pre and Post

The arrow points to a sporadic congenital developmental lesion whose pathogenesis is not well understood. Patients usually present between ages 10 to 40. Children are more likely to present with intraparenchymal or subarachnoid hemorrhage whereas adults can present either with a bleed or a seizure.
This angoigram shows the lesion after treatment.

Challenge: What are we looking at?

Both images shown under Fair Use.

Friday, August 22, 2014

Prickly Heat

I apologize for the irregularity of cases. Since taking my board exams, I have been swamped in our cardiac surgery ICU and this blog has been neglected. However, as the light at the end of the tunnel nears, we will get back on track with cases of the day on Mondays and Thursdays. Here's one to tide you over until next week. In fact, we found this rash on an ICU patient and consulted dermatology.


This benign rash is a common finding in newborns, especially in warm climates. Occasionally, the rash is associated with an inflammatory response, shown below.

Challenge: What's your diagnosis?

Both images shown under Fair Use.

Monday, August 11, 2014


You are a hospital administrator and hear about a rash of strange illnesses. A number of travelers and immigrants are presenting about a week after returning from abroad with abrupt onset fever, chills, and general malaise. Some also have weakness, severe headache, muscular back pain, nausea, vomiting, diarrhea, or abdominal pain. Although patients have a high fever, they have a relative bradycardia. Most have a nonproductive cough and a sensation of a lump or "ball" in the back of their throat. Over the following few days, these patients develop worsening stupor, hypotension, conjunctival hemorrhages, and easy bruising. Sites of blood draws keep oozing, though most do not have any overt signs of GI bleed or hematuria. Labs usually show leukopenia, thrombocytopenia, liver enzyme abnormalities, and coagulopathies.

Challenge: What are you worried about?

Image is in the public domain.

Thursday, August 7, 2014


Challenge: What endocrine disease does this patient have?

Image shown under Fair Use.

Monday, August 4, 2014

Double Edged Sword

A mother brings her 4 year old child into the emergency department because he ingested an unknown number of pills. She said she was at the pharmacy when another customer spilled a ton of pills onto the ground. Her child ate a bunch of them, but no one could identify which pills they were. That happened about an hour ago.

The child is vomiting and complains of abdominal pain. He is admitted to the hospital, and in the next few hours, he develops diarrhea, hematemesis, melena, and letheragy. He is aggressively treated for hypovolemic shock, and his metabolic acidosis begins to correct. The vomitus and stool are dark gray and green.

On hospital day 2, the patient seems to be doing better; many of his GI symptoms have abated. He does have some hyperventilation and oliguria, and fluid resuscitation continues.

On hospital day 3, he suddenly gets worse. The patient gets tachycardic, hypotensive, and pale. He starts developing a coagulopathy. He seems to have all kinds of shock; initially, it looks like hypovolemic shock, but then the picture appears to be distributive. Finally, his heart starts giving out and he develops cardiogenic shock. He has a profound metabolic acidosis, and lactate is quite elevated. He has recurring hematemesis and melena. He is intubated, and his oxygenation begins to fail. His CXR suggests acute lung injury. His creatinine and liver enzymes begin to rise. He becomes quite somnolent and needs minimal sedation on the ventilator.

Over the next two weeks, he is resuscitated and makes a slow recovery. However, about 3 weeks after the ingestion, he develops acute bowel obstruction and undergoes surgery where scarring is noted at the gastric outlet.

Challenge: Assuming this is all caused by one medication, what is it?

Image shown under Fair Use, from Wikipedia.

Thursday, July 24, 2014

Taking Boards!

Hi everyone,

Thanks for participating! I'm taking my board-certification exam next week so I'm going to take a break from cases for a week. We will be back soon!


Monday, July 21, 2014


 The patient's fingers are on the right; the control is on the left.

In panel B, the patient's hands are on the left. The control is on the right. Panel C shows the hands after treatment.

Challenge: What disease is shown here?

Images shown under Fair Use.