Not Yawns

A young immigrant from Ghana where he lived in crowded camps presents with the lesion seen below:

This is the "mother lesion"; note the red, moist base reminiscent of a raspberry ("framboesia"). It will heal in 3 to 6 months when it will regress into a depigmented pitted scar with dark margins. The patient also complains of arthralgias. Exam shows regional lymphadenopathy and palmar and plantar hyperkeratotic plaques.

Challenge: What's your diagnosis?

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Shock Lung

This chest x-ray is from a 40 year old man with no past medical history who initially presented with sepsis from pyelonephritis (or trauma or a viral pneumonia or pancreatitis or aspiration). He was treated appropriately early on but developed tachypnea, tachycardia, accessory muscle use, and hypoxemia. Note that he has an endotracheal tube. His ventilator settings are assist control with an FiO2 of 80%, a PEEP of 10, and a respiratory rate of 28. His blood gas is pH 7.24, PaCO2 48, PaO2 66. His echocardiogram shows low-normal systolic function, no severe valvular abnormalities, no significant effusion.

Challenge: How do you set the tidal volume on the ventilator?

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Did You Ask About Pets?

A 60 year old man presents with fever, disseminated purpura, hypotension, acute kidney injury, and altered mental status. He is admitted to the intensive care unit, started on broad spectrum antibiotics, and fluid resuscitated. Dermatology is worried that the lesions are becoming purpura fulminans. In the intensive care unit, he has disseminated intravascular coagulation and multiorgan failure. Past medical history is significant for chronic alcoholism. Past surgical history is significant for a splenectomy done for a trauma.

Gram stain is shown below:

This slow growing carbon loving facultative anaerobe takes several days to grow in culture. It is resistant to aztreonam.

Challenge: In the history, you find the patient was bit by...what?

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Essential Oils

A 4 year old who broke into the medicine cabinet is brought to the emergency department with seizures. He has a strong medicinal smell on his breath. On the ambulance ride over, he had nausea, vomiting, and abdominal pain. The parents say the medicine cabinet only had over-the-counter cold remedies. Labs and neuroimaging are unremarkable. His seizures are treated with benzodiazepines. Decontamination of the skin is performed with soap and lukewarm water. The poison control center says activated charcoal is not indicated because the substance is so quickly absorbed. Gastric emptying with syrup of ipecac is contraindicated.

Challenge: About 11,000 exposures are reported to United States poison control centers annually. What is this ingestion?

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Match

Challenge: What's going on here?

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Shear

This CT is from a patient who was involved in an acceleration-deceleration motor vehicle accident. He has a profound coma without increased intracranial pressure.

Challenge: Unfortunately, outcomes are poor with this diagnosis.

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Mustard

A patient with systemic lupus erythematosus and systemic vasculitis is being counseled about taking the drug shown above. Within days to weeks of treatment, she will need her blood count closely followed because she may have decreased granulocytes, followed by thrombocytopenia, followed by anemia. Obviously, this increases her risk of infection. She is also counseled that this drug may cause premature ovarian failure, ovarian fibrosis, and permanent infertility. A pregnancy test is checked because the drug is highly teratogenic. Long-term, she needs to watch for lymphoma and other malignancies as well as cystitis and bladder cancer resulting from a toxic metabolite excreted in the urine.

Challenge: What is the drug?

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Lucky

Challenge: What's that?

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