Circumvention

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.

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

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.

Theft

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.

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.

Lethal

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?

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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.

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.