Case of the Day

The art, science, history, and process of differential diagnosis is fascinating to me. Although this blog is not meant to hone that skill per se, it reflects my interest in pattern-recognition, heuristics, and fun medical trivia. For those interested in a deeper methodological study of the DDX, there are many other textbooks, articles, and resources on this (I personally enjoyed reading Clinical Problem Solving by NEJM).

This project was inspired by one of my best teachers, Dr Andy Josephson of UCSF neurology who had a very similar set-up during our neuroscience block in the first year of medical school, about ten years ago. We all learn differently, and for me, it was a really sticky way of adhering the reams of knowledge we had to acquire to my brain. I began this blog as a way of active learning, to encourage myself to read UpToDate, collect images, and keep track of diseases I wanted to know more about. Indeed, over the last ten years, I've kept scraps of paper and email drafts containing lists of diseases, signs, symptoms, and syndromes that come up for patients I meet, lectures I attend, articles I read, and conversations I have. Some of the diseases still on the list that I wanted to write a Case of the Day on but didn't get to include: tinnitus, splenic vein thrombosis, percheron stroke, cavitary pulmonary nodules, CMV pneumonitis, IBS, isopropyl alcohol intoxication, MCA CVA (insular ribbon sign), basal ganglia CVA (comma sign), sterile pyuria, anaphylaxis, air embolism, compartment syndrome (abdominal and extremity), quinidine effect, bupropion overdose. I'm not sure where these come from; they're just culled over time.

I've learned an incredible amount from this blog, and I hope you have gained something too. I have such great appreciation for my readers. I've had about 350,000 pageviews, mostly from the U.S., but also Canada, France, India, Brazil, the UK, Ukraine, Australia, Algeria, and Israel. In these thousand medical mysteries, I procured 1127 pictures. My backup file of the entire blog contents is 1445 pages long (my answers document is 188 pages). I'm sure I spent at least several weeks of my life working on this project. It's been wild.

I've never been good at saying goodbye to things, but it's time for me to move onto other projects despite the time invested and momentum built here. I may go through the cases someday and make small adjustments or organizational changes. With time, some of the medical information here may become obsolete or change, but I hope it remains a useful resource for readers.

Thank you all for your time, your kind words, and your participation. It has meant a great deal to me. Please feel free to contact me (I will reply to any comments) and I wish you all the best in your futures.

Craig Chen MD

1000

Wow! This is actually the last Case of the Day. I made it to 1000 cases over 9 years! I'll write a post after this just to tie things up, but this will be the last medical mystery. I never meant for Case of the Day to last forever, and it's been an incredible amount of work to get here. I'm pretty happy to say there are more cases here than most textbooks and all of them are backed by reasonable references.

This last case I actually wrote at the very beginning, nine years ago. It was sort of a prototype which I never published. There is some poetry in having it bookend this project. I will write more in a closing post, but thank you all for reading, responding, learning, and teaching me.

With respect, love, and passion,
Craig

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A 30 year old man with a history of "allergies" presents for an infertility workup because he and his wife have been unsuccessful in getting pregnant for over a year. Her workup is apparently normal. When you ask the husband, he notes that he has a chronic cough and mild shortness of breath. You wonder about cystic fibrosis and order a chest X-ray:

Challenge: What syndrome does he have?

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Last Few Cases

Sorry, I was on call yesterday, and Case of the Day totally slipped my mind. Here's a pretty good one on a disease that was on critical care boards. This week is busy for me but I'll put up answers for the last few cases soon.

A patient with leukemia undergoes an autologous hematopoietic stem cell transplant. Two weeks later, she develops a temperature of 38.5C and a maculopapular rash initially concerning for graft-versus-host disease. She feels short of breath, and her room air saturation is only 84%. Review of systems is positive for diarrhea, but stool infectious workup is negative. Chest X ray shows bilateral air-space opacities. Her blood cultures, urinalysis, and sputum are negative; a procalcitonin is normal. A bronchioalveolar lavage is performed which is unremarkable. Her echo does not show heart failure though she does have some edema, weight gain, and ascites. Labs show hypoalbuminemia.

Challenge: What is your diagnosis?

Well?

ECG Wave Maven has been my go-to resource for great EKG's. Created by Beth Israel Deaconness Medical Center in 2001, it has an incredible number of fascinating cardiograms, cases, and explanations. It's an unsurpassed repository for learning and education, and I hope you check it out.

This EKG comes from a middle aged man with vague chest pain. Initial troponins are negative.

Challenge: What does the EKG show? (Click for full image)

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Exit Here

This CT scan is from a young woman with a pulsatile supraclavicular mass on the left side. She also gets pain with exertion in that arm. Sometimes, she gets pallor, paresthesias, and coldness in her left hand, and she was initially diagnosed with Raynaud's but wants a second opinion. There is no history of trauma. She has no other medical problems. Her pulses on that arm are diminished. There is no musculoskeletal tenderness.

Challenge: This is the least common version of what syndrome?

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Fall

Challenge: When does this go away?

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Delay

A 50 year old smoker comes in with severe headache, altered mentation, and this CT scan. He goes to interventional radiology for a procedure. Over the next several days, he slowly improves. A week later, though, he suddenly gets worse. He becomes more confused and somnolent. CT and EEG do not explain his neurologic exam. Ultrasound confirms the diagnosis.

Challenge: What do you suspect?

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Postpartum

A woman has postpartum hemorrhage from placenta previa after a spontaneous vaginal delivery. Despite adequate resuscitation, she has persistent hypotension and spends several nights in the ICU. Eventually, she is discharged home, though her blood pressures remain quite low. She has some symptoms of orthostasis but really wants to go home. On her first postpartum visit, she notes that she hasn't been lactating. A few weeks later, she also complains of fatigue and anorexia. A year later, she has persistent oligomenhorrhea.

Challenge: What syndrome do you suspect?

What'd I Miss?

Challenge: What kind of highly unstable fracture is shown above?

P.S. Taking a break on cases this weekend, back on Monday.

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Sphygmomanometer

I can't believe I've written 9 years of cases, almost a thousand of them, and didn't get to this one. This is the the kind of medical trivia I like.

You pump this blood pressure cuff on the arm of a patient to 200mmHg. The phone rings and you go and answer it. The BP cuff is left inflated for three minutes, and the patient begins having adduction of the thumb, flexion of the MCP joints, extension of the IP joints, and flexion of the wrist.

In addition, when you tap the patient just anterior of the ear, she gets contraction of the ipsilateral facial muscles.

Challenge: What's going on? What two signs are described above?

Image is in the public domain.

Sign Here

Challenge: What does the arrow indicate?

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My Fair Lady

My goal for the last handful of cases on this blog is to actually post a case a day; it always bothered me a little to have a blog titled "Case of the Day" that was only running twice or thrice weekly posts. This may not actually happen, but I'm trying to go out with a bang.

These CT images are from an older Caucasian woman infected with a nontuberculous mycobacterium. She has a chronic cough but no known chronic lung disease. She tries to hide her cough.

Challenge: What syndrome is this?

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Africa

This disease is common in rural Africans, but can also be seen with travelers returning from Africa or the east Caribbean. It presents as a mild illness with headache, fever, and myalgias. Solitary or multiple eschars as shown above are common, along with regional lymphadenopathy. There may be a scant generalized rash, and uncommonly, subacute neuropathy or myocarditis.

Challenge: What is your diagnosis?

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Post-Op

An obese (BMI 40) man with diabetes, peripheral artery disease, and tobacco abuse undergoes a CABG. He actually had a prior cardiac surgery to repair an aortic valve five years ago. Over the last year, he developed increasing shortness of breath. Workup revealed coronary disease so he underwent a redo sternotomy and bypass graft with an internal mammary artery.

Postoperatively, he has fever, tachycardia, and persistent chest pain. There is crepitus and edema of the chest wall as well as a crunching sound synchronous with the heart beat and heard by auscultation. White count is elevated.

Challenge: That weird crunching sound has a name - what is it? Also, what's the diagnosis?

Vessel

This vessel starts at the junction of the left subclavian and left internal jugular veins, passes lateral to the aortic arch, and drains into the right atrium via the coronary sinus.

Challenge: What is this rare anomalous vessel?

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Whoops

A 70 year old patient comes in with septic shock. She is febrile, tachycardic, hypotensive, tachypneic, and hypoxemic. Her labs show a leukocytosis, elevated lactate, and elevated procalcitonin. Chest X-ray shows a right lower lung focal opacity. She is fluid resuscitated with 5 liters of crystalloid but still has refractory hypotension. The emergency medicine intern puts in a right internal jugular central venous catheter to start norepinephrine. Later, a KUB is taken which is shown above.

Challenge: What complication happened here?

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DDX

A rapid response alert is called in labor and delivery. You rush in to find a woman who has just delivered who appears in acute respiratory distress. The obstetrician says, "she had postpartum bleeding from uterine atony, but I don't think she's lost more than a liter of blood." You can't get a history because the patient can barely speak. On exam, her breath sounds are very tight; she's not moving much air, and you hear expiratory wheezes. Her blood pressure and heart rate are fine. She's maintaining a sat of 90% with oxygen by face mask. Fluids are wide open along with oxytocin.

Challenge: She received one other medication which is causing her clinical presentation. What is it?

Image is in the public domain.

No Biopsy Needed

This patient also has bilateral parotid gland enlargement and facial nerve palsies. His review of systems is notable for fever and arthritis. He was seen by an ENT recently who ruled out parotid tumor. Apparently pathology showed granulomas.

Challenge: What's your diagnosis?

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Ventilators III

This unresponsive patient was intubated for airway protection.

Challenge: What is your goal with the ventilator?

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Ventilators II

A patient with severe COPD presents with an acute exacerbation. He is intubated for hypercapneic respiratory failure and has the waveform seen above. Over the next hour, he develops significant hemodynamic instability. Suddenly, he has a cardiac arrest, and you immediately start CPR and follow ACLS.

Challenge: What is your next intervention (with the ventilator)?

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Ventilators I

By request, some ICU topics. This mode of ventilation is occasionally used in medical, surgical, or trauma patients with acute respiratory distress syndrome. The advantage is that it allows the patient to be awake or lightly sedated, spontaneously ventilating. Its high mean airway pressures aid alveolar recruitment.

Challenge: What kind of mode is this?

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Yuck

This man presents with an erythemaous genital papule that evolved into a pustule and eroded into an ulcer. The ulcer is 1-2cm in diameter, painful, with an erythematous base. The borders of the ulcer are clearly demarcated and the base has a gray-yellow exudate. The patient also has inguinal lymphadenitis. Aspiration of the lesion is shown above.

Challenge: What is this?

Image shown under Fair Use.

Studying for ICU Boards

I'm studying for my critical care boards this week so next case will be next Monday. Also, just as a heads up, I am thinking of winding down this blog; we're getting close to reaching a thousand cases total. Thanks for reading!

Craig

Test

You are a medical student rotating on ICU, and on your first day, you witness a test. An intubated patient is put onto 100% oxygen for 10 minutes. An ABG and electrolytes are checked and normal. His vital signs, including temperature, are normal. He is then taken off the ventilator and observed for ten minutes. A repeat ABG is sent.

Challenge: What test did you just witness?

Harlequin

An adult patient develops severe hypoxemia from a pneumonia and goes into cardiac arrest. He is successfully resuscitated with the machine shown above. The following day, it is noted that a sat probe on his right forefinger and a sat probe on his ear reads 75% whereas a sat probe on the toe reads 98%. He does have a right femoral arterial cannula and an ABG drawn there reads a PaO2 of 150mmHg. However, when you do a fresh ABG stick from the right radial artery, the PaO2 is 40mmHg.

Challenge: What machine is he on?

Image is in the public domain.

Musculoskeletal II

This happened while blocking a basketball shot. There is loss of sensation in a "shoulder badge" distribution.

Challenge: What's going on here?

Image shown under Fair Use.

Musculoskeletal I

This child's deformities involve the proximal bones more than the distal ones. He also has macrocephaly and midface hypoplasia.

Challenge: What autosomal dominant disorder is seen here?

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Biochemistry

Uh oh, it's the glycogen metabolism pathway.

The classic infantile form of this disease presents in the first few months of life with cardiomyopathy and severe generalized muscular hypotonia. At the median presentation age of four months, infants will have cardiomegaly, respiratory distress, muscle weakness, feeding disorders, and failure to thrive. Standard metabolic labs will be normal, but serum creatine kinase will be elevated.

A late onset juvenile or adult form presents without cardiac problems. The age of presentation varies, but the presentation is primarily skeletal myopathy eventually leading to respiratory failure. Children might present with delayed gross motor development, and adults might present with progressive limb girdle weakness (starting with hip flexors). Creatine kinase will be elevated as well.

Challenge: What autosomal recessive disease is this?

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Taking Another Break

Hi everyone,

Thank you all for participating in the last few weeks of cases. It's been a lot of fun but I'm going to take a break to recharge and study for my critical care boards. I'll be back next Monday with new cases.

Craig

Scandinavia II

A 77 year old woman of Scandinavian descent presents with subacute fever, fatigue, and weight loss. She has been undergoing a workup for fever of unknown origin. She is finally referred to a neurologist because of a new headache. The characteristics of the headache, though, are nonspecific. She also has some jaw claudication with a rapid onset of pain once she starts chewing. Still, no diagnosis is made until she presents to the emergency room with transient monocular visual loss. There was a temporary partial field cut that returned when she was in the ER. The ophthalmologic exam was unremarkable.

Challenge: You better make the diagnosis before she has permanent visual loss; what is this?

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Scandinavia I

A 75 year old woman presents with "aches and pains." She complains of soreness and stiffness in her shoulders and hips in the morning. This can last from half an hour to an hour. Her neck and torso are also affected. The symptoms are symmetric. This all started pretty abruptly. The symptoms are so bad she has trouble dressing herself; once, she couldn't even get out of bed. She can't abduct her shoulders past 90 degrees. Nevertheless, she has normal muscle strength. During the rest of the day, the stiffness and ache occurs if she has been sedentary and tries to do something. She also has the findings in the image above. Social history is significant for being of Scandinavian descent. Review of systems is notable for malaise, fatigue, depression, anorexia, weight loss, and low-grade fever.

Challenge: What is your diagnosis?

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Pace Yourself

This EKG is from a patient with a dual chamber pacemaker that presents to the emergency room with presyncope. The resident says, "It's a paced rhythm, we can't interpret it."

Challenge: But you reply, "The patient's presyncope is from...what?"

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Diagram

This diagram is sometimes used by surgeons and anesthesiologists in cardiothoracic surgery and trauma.

Challenge: What is it?

Sounds Like a Magic Spell

Sorry for the late post - my call was busier than I expected.

That's one large boggy pustule on the scalp. It's tender and painful. It's seen mostly in children ages 5-10. Persistent disease can lead to alopecia.

Challenge: What is it?

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This Little Piggy Went to the Market

This patient complains of a burning pain in the space indicated radiating to the toes. The pain is worse when walking on hard surfaces or wearing tight shoes. Sometimes if she is active, the third and fourth toes become numb. Palpating the interspace and squeezing the metatarsal joints causes a clicking sensation. Ultrasound confirms the diagnosis. You begin conservative treatment with padded shoe inserts and physical therapy. You advise that further treatments can include injections of glucocorticoids and local anesthetics and surgery.

Challenge: What is it?

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Food

A 23 year old woman with a history of diabetes, hypertension, chronic pain, phobias, major depressive disorder, and alcohol dependence is brought in by her sister who is worried about an eating disorder. Her sister says the patient will eat unusually large amounts of food from time to time. The patient says she "just can't help it" and will eat rapidly until uncomfortably full, even when she is not hungry. The sister says the patient often eats alone because she feels ashamed and guilty. This has been happening once or twice a week for many months. Nevertheless, the patient denies purging, fasting, or excessive exercise.

Challenge: What is the most accurate diagnosis?

The Greatest

The top brain is a normal brain. The bottom brain shows the gross pathology of a professional athlete who developed cognitive impairment, behavior and personality changes, depression, speech and gait abnormalities, and Parkinsonism at the end of his life. Note the severe dilation of the second and third ventricles, marked atrophy of the medial temporal lobes, and shrinkage of the mammillary bodies.

Challenge: What kind of sports did he likely participate in?

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Dough

"so went Satan forth from the presence of the Lord and smote Job with sore boils from the sole of his foot unto his crown"

Ever since this patient was a child, he's had skin problems. In his first few weeks of life, he had a papulopustular crusted rash on his face, scalp, upper trunk, and buttocks. He was diagnosed with atopic dermatitis. He didn't have any wheezing, food allergies, or hayfever, though, and there's no family history of atopic dermatitis. He's also had lots of skin infections, including abscesses, furuncles, cellulitis, and lymphadenitis. Oddly enough, sometimes he has infections that lack classic signs of inflammation; they don't always manifest with erythema, warmth, or tenderness.

His other medical problems include recurrent sinus and middle ear infections. He's had pneumonia once requiring hospitalization. He's had weird teeth; he kept his primary teeth leading to two rows of teeth. This was later corrected by a dentist. He has scoliosis. He's had a few orthopedic surgeries for fractures from minor trauma.

Challenge: What's your diagnosis?

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The Nose Knows

Challenge: What is it?

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Postpartum

This contrast-enhanced CT is from a young G2P2 woman who just had a vaginal delivery. She had a previous C-section but elected for a vaginal birth after Cesarean (also called trial of labor after Cesarean). After a long labor, she delivered a healthy baby successfully, but subsequently had persistent bleeding and abdominal pain.

Challenge: What's the diagnosis?

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Crystal Clear

You are examining specimens in the lab and come across this one. The clinical correlation says, "Patient with Burkitt's lymphoma, undergoing first round chemotherapy, now with acute kidney injury."

Challenge: You don't have much information to go on, but what do you think this is?

Tick Tock

This rash occurred in an 8 year old child who was traveling around the United States with his family. He presented with fever, headache, malaise, myalgias, and arthralgias. He also complained of abdominal pain, but ultrasound ruled out appendicitis. This rash developed about three days after the onset of the other symptoms. The rash is blanchable and began at the wrists and ankles. You also note some pedal edema. There is no meningismus. The CBC shows a normal white blood cell count, but thrombocytopenia. Sodium is on the low side. Blood cultures are negative.

Challenge: Time's running out...What's your diagnosis?

Atropine

You are an emergency physician attending in a busy ER. A resident comes up to you with this EKG and says it's from a person who was "found down." She administered atropine but there was no increase in heart rate.

Challenge: Why not?

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No Cases This Week

Sorry! I don't have my things together this week so no cases. I will try to get back on track next weekend.

Craig

What's the Surgery?

A middle aged patient presents with acute onset persistent severe epigastric abdominal pain. The pain radiates to the back and is relieved by sitting up or bending forward. It is accompanied by nausea, vomiting, and dyspnea. Exam shows diffuse tenderness, abdominal distension, and hypoactive bowel sounds. He is admitted to the hospital for supportive management.

Unfortunately, overnight, he develops fever, tachypnea, tachycardia, and hypotension. He is transferred to the critical care unit and started on norepinephrine and vasopressin for septic shock after adequate fluid resuscitation. A CT is shown below:

He has acute kidney injury and acute respiratory distress syndrome requiring intubation, but over the next few weeks, he is stabilized and eventually extubated. Four weeks after the initial presentation, he still has chronic low grade fever, nausea, lethargy, and inability to eat.

He then undergoes surgery even though the mortality rate is somewhere between 4-25% and complications include intra-abdominal fluid collections, bleeding, fistulas, incisional hernias, poor glucose control, and need for enzyme therapies.

Challenge: What was the operation?

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Frozen

A 35 year old woman with a history of type 1 diabetes mellitus and anxiety is referred to you because of a "Frankenstein gait." When she enters your office, you note an awkward wide-based unsteady gait with a tendency to fall in a fashion like a log tumbling down. She also has pronounced lumbar lordosis. On exam, she has extreme truncal stiffness and generalized rigidity. When you palpate her lumbar, trunk, and proximal limb muscles, you find sustained muscular contractions of both agonist and antagonist muscles. She says the symptoms initially started in the low back and came on gradually, eventually involving the proximal limbs. When her walk started changing, she developed a lot of anxiety about going outside and being in public. Now, activities of daily living are becoming challenging.

In addition, she gets muscle spasms that seem triggered by sudden movement, noise, or emotional upset. These spasms begin in the truncal muscles and spread to the extremities. She has one in your office and you note the muscles becoming tight and rock-hard. Palpating it is like palpating a board. The rest of your motor and sensory exam is normal.

Challenge: What's your diagnosis?

Name That Object II

Challenge: What do you see here?

Image shown under Creative Commons Attribution Share-Alike License.

Name That Object I

I prefer ones made out of glass; the plastic versions just don't feel as slippery. This syringe is normally filled with air or sterile saline.

Challenge: What is this particular type of syringe used for?

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2 4 6 0 1

In multiple studies including a recent JAMA article, I have been shown to reduce the duration of mechanical ventilation and ICU stay compared to my more traditional counterparts. I'm sometimes used in procedural sedation (even as anesthesia for awake craniotomies!). Other times, you might find me hanging with benzos for that drunk patient sobering up. Sometimes, I am given as a loading dose, and I can cause either hypertension or hypotension, to the confusion of many medical students. Avoid me if the patient has heart block or bradycardia, though.

Challenge: Who am I?

Image is in the public domain.

Normal

As you review this EKG, you note the T-wave inversions in leads V1-V3, the vertical QRS axis (+90 degrees), and the early precordial transition.

Challenge: These findings are normal for what kind of patient?

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Aging

A 55 year old woman presents with complaints of pain with sex. She's noticed vaginal dryness, burning, and irritation as well as yellow discharge. In addition, she has dysuria and increased urinary frequency. On exam, you note scarce pubic hair, diminished elasticity and turgor of the skin, and fusion of the labia minora. Vaginal pH is 6.

Challenge: What's your diagnosis?

Kiss and Tell

This is a peripheral blood smear from an adolescent presenting with malaise, headaches, fever, and sore throat.

Challenge: What do you expect to find on the neck exam?

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No Cases this Week

I'm feeling slightly burnt out. I'm going to take this week off for some self-care. I hope you do too. I'll try to get answers up soon for the last several cases. See you next week.

Craig

Refresher IV

This disease represents the rule of 2's: it occurs in 2% of the population, the male:female prevalence is 2:1; it occurs within 2 feet of the ileocecal valve, and it can be two inches in length.

Challenge: What is the diagnosis?

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Refresher III

A 35 year old G1P0 woman who has not received prenatal care presents at 34 weeks of gestation. She has no prior medical history, but she is obese. She presents because of leg swelling, back pain, right upper quadrant abdominal pain, headache, gastroesophageal reflux, and fatigue. Her blood pressure is 150/100. Her labs show a hemoglobin of 10, platelets of 150,000, a normal creatinine, and normal liver function tests.

Challenge: What parts of her presentation makes this disease "severe"?

Refresher II

I'm not sure if this counts as a refresher type case, but it's an important one nonetheless.

The top two panels of the MRI were taken two days after admission. The lower two panels were taken two weeks after admission.

This patient presents with acute onset focal neurologic deficits. He is altered with hemiparesis, dysphagia, aphasia, ataxia, and seizures. He also has been running a high fever.

Challenge: When you perform the lumbar puncture, what diagnostic test should you order?

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Refresher I

I got a request for a few more basic cases. I'll see what I can do.

Challenge: In a patient with Raynaud phenomenon, thromboembolic disease, and renal insufficiency, what does the rash above signify?

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White Bile

A young woman presents with right upper quadrant abdominal pain. Ultrasound shows a stone in the cystic duct. You take her to the operating room for a cholecystectomy. You find a quite distended gallbladder, but what surprises you is that when you aspirate fluid from the gallbladder, it is colorless and mucoid.

Challenge: What's the diagnosis?

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

But Why?

A 30 year old previously healthy woman who is 11 weeks pregnant complains of heat intolerance, sweating, and anxiety. On examination, you note tachycardia and hand tremor. Her pregnancy has been notable for morning sickness and a slower weight gain than expected. A brilliant diagnostician, you send off thyroid function tests. Serum free T4 and T3 are slightly elevated. TSH is reduced.

The next time you see the patient, before you start any therapy, she is 15 weeks gestation. She says her symptoms have completely disappeared.

Challenge: How do you explain this?

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

Holy Fire

I apologize there was no Monday case this week.

A 10 year old child with a history of eczema presents with a rash on his leg. He scratches that leg quite a bit and scrapes it like any ten year old does. But this is the first time he's had anything this severe. It developed quite quickly and is accompanied by fevers and chills. Note that the lesion is very well demarcated and it is raised compared to the surrounding skin.

Challenge: What is the diagnosis?

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Chemo II

Three months after finishing this ruby red chemotherapy regimen, a patient develops shortness of breath. He gets tired even after climbing a flight of stairs. He's noticed some swelling of his legs. At night, he props himself up with pillows to avoid waking up gasping for air.

Challenge; What chemotherapeutic agent caused this?

Image is in the public domain.

Chemo I

A patient starts developing numbness and tingling in the fingertips and feet. There isn't much pain, but you do note some mild distal weakness. On exam, you can't really get deep tendon reflexes, not even an ankle jerk. Vibration perception is quite poor. On review of systems, the patient complains of colicky abdominal pain and constipation. You send the patient to nerve conduction studies and electromyography and find that there is a symmetric axonal neuropathy.

Challenge: What chemotherapeutic agent caused this?

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