Clinical Correlation Recommended

A 70 year old woman with a history of mastectomy presents to the emergency department with back pain for a month. A gadolinium-enhanced MRI is shown below.

Challenge: What's the concern?

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Organelle

These infants all have the same syndrome. Note the high forehead, epicanthal folds, and hypopolasia of supraorbital ridges and midface. This autosomal recessive disorder is noted early in infancy. Patients have hepatomegaly, cirrhosis, and biliary dysgenesis. They also have calcific stipping of the patellae, hips, and other epiphyses. Some have glomerulocystic kidney disease, cataracts, and pigmentary retinopathy. They all have profound hypotonia and weakness with absent reflexes, severe hearing and vision impairment, and neonatal seizures. Developmental delay is profound. Life expectancy is less than six months.

Challenge: What's the unfortunate diagnosis?

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Nerves?

Your neurology practice gets two referrals from a rheumatologist. The first is a 30 year old woman with Churg-Strauss syndrome who presents with the following physical exam finding:

Note the wrist drop in the left hand and dorsiflexion weakness in the right hand. You also notice as she enters the exam room that she has an unusual gait. She lifts one knee higher than the other as she walks, a sort of "foot-slapping" step.

Another patient, a 50 year old woman with microscopic polyangiitis has this finding on exam:

She also has a foot drop.

Challenge: What's this constellation of neurologic symptoms called?

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A Single Drop

A 35 year old G5P1 woman currently pregnant with a 32 week fetus through IVF presents for a routine obstetric visit. Her obstetric history is only significant for a second-trimester low-lying placenta. A transvaginal ultrasound is shown below:

Note the posterior placenta with a linear sonolucent area with color flow Doppler. You admit the patient, give betamethasone and perform frequent fetal heart monitoring. You make a plan to deliver the fetus by emergency C-section if the patient goes into labor, premature rupture of membranes, repetitive variable decelerations refractory to tocolysis, or vaginal bleeding accompanied by fetal heart rate changes. You schedule a C-section at 36 weeks.

Challenge: What's the diagnosis?

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The Goose

A 55 year old Caucasian man with obesity and GERD gets an endoscopy for erosive esophagitis.

Challenge: Images shown above confirm the diagnosis of what?

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Wrong Consult

You are a surgeon moonlighting as a consultant in a hospital in the southwestern U.S during the early fall. The emergency department calls you to see a patient with acute abdomen. He was in his usual state of health, even working in his garage and storage shed 6 hours ago. Since then, he has developed severe abdominal pain with abdominal muscle rigidity. He also has muscle pain in his extremities and back, tremor, weakness, headache, nausea, and vomiting. Vital signs are normal though the patient is quite diaphoretic. Abdominal exam shows muscle rigidity and tenderness. Bowel sounds are normal. Labs are non-specific and include hematuria, leukocytosis, and elevations in CPK, glucose, and liver enzymes. A CT scan was negative for acute cholecystitis or acute appendicitis. EKG and troponins are negative.

On exam, you note this rash on the patient's leg:

Challenge: What's the diagnosis?

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Cheesesteak

This FISH analysis comes from a 50 year old radiology technician who presented to his primary care physician with fatigue, weight loss, and abdominal pain. He has splenomegaly on exam but no lymphadenopathy. Laboratory tests show a remarkable leukocytosis with myelocytes and segmented neutrophils. There is also an absolute basophilia and absolute eosinophilia. He also has thrombocytosis and a normochromic, normocytic anemia.

Challenge: What's your diagnosis?

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