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?

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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?

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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.

Craig

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?

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Timely

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?

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Bones

Challenge: What endocrine disease does this patient have?

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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?

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