Case of the Week

This week happens to be a national awareness week for this case. Good luck!

A mother brings her 5 year old child into your clinic this morning, saying that her daughter has been vomiting the entire night. When you look at the child, she appears obtunded and lethargic; she is fairly nonresponsive to stimuli and when she walks, she stumbles about.


Here is her blood smear (Wright's stain) with the abnormal findings indicated by the arrows.

Challenge: If you know that this is not congenital, then the differential narrows down to...what?

Related Questions:
1. What's seen on the blood smear?
2. What's the clinical diagnosis?

Image shown under fair use.

Amabilis

You have just graduated from the Austrian Academy of yodeling, waltz, and pathology. Congratulations! Your first assignment, however, is a grim one. The person shown in the image above passed away due to mysterious causes. Foul play is suspected. You find out a new chef was hired recently, but the guards said that they search everyone for poisons and the chef was clean.

Upon further investigation, you find out that the victim had a special meal prepared for him over a week ago. After a few hours, he felt really sick with a severe right upper abdominal pain, diarrhea, and vomiting. The doctors assure you that they made sure he didn't have any electrolyte or fluid imbalances.

Curiously, these symptoms resolved a few days later, but were replaced by more worrisome ones. He woke up with yellow skin and conjunctiva, exhibited signs of delirium, and even had a seizure. He then went into a coma. He passed away eight days after eating the dinner. Doctors think that he may have had renal failure.

Challenge: It was the chef in the kitchen with the...what?

Related Questions:
1. Why was the mode of death not detected by the guards?
(2. Who is the person shown in the image above?)

Image is in the public domain.

Shiga

A five year old baby is brought in five days after a severe episode of bloody diarrhea. The labs do not look good. Creatinine is elevated, platelets are low, and the baby is anemic. When you look at the RBC's, you see the image above. On exam, you find no neurologic abnormalities.

Challenge: What is the most likely diagnosis?

Related Questions:
1. What are low platelets called?
2. What is seen on the image?

Image shown under fair use.

Proteus

You decide to do some international work in India and at one of the clinics, you see this man. He is about 40. He says that he has had this for a while. The tissue is hard to the touch. He says that he came in today because his urine was milky white. Blood tests show eosinophilia.

Challenge: What is the diagnosis? What is the causative agent?

Image is in the public domain.

Zoo Noses

A 25 year old female spelunker presents to your clinic. Since you are thirsty, you pull out a bottle of water, and as you do so, she gasps in panic and looks terrified.

Challenge: What's the diagnosis?

It'd be impressive if you could figure it out from just that, but you take a more thorough history. The patient says that she's really thirsty but can't look at water. She's been having trouble swallowing. She's salivating and febrile. She thinks she had the flu last week: muscle weakness, loss of appetite, sore throat, headache, low grade fever, and nausea. You request a psychiatric consult which suggests recent hypomanic episodes.

It's a pretty cool case, but she'll die if you can't figure this out. You admit her to your service.

Related Questions:
1. What's up with spelunking?

Scalars and Vectors

In between first and second year, you "volunteer" down in South America, scaling mountains, trekking through rainforests, tanning on beaches, and mingling with the locals. You spend your spare time volunteering in a clinic. One day, this child walks in:

Your language skills aren't too good, but you gather that something might have bit him. A bug or fly maybe? You figure this might be important information, so you have the child draw what he saw. This is what he draws:


Hmm...not bad. You examine the boy more closely. The pertinent finding is his right eye, where he says the bug bit him. He has no other symptoms, but you're a little worried. You draw some blood and see this with a special stain:


Challenge: If left untreated, this patient may develop a cardiac manifestation of the disease. What would that be?

Related Questions:
1. What is the finding in the first image?
2. What is the bug in the second image?
3. What is seen in the third image?
4. What is the diagnosis?

All images are in the public domain.

Basic Immunology

This case idea is contributed by Alex Penn. It is really cool.

As an immunology expert, you are consulted on a two day old boy with a known mutation in the common gamma chain cytokine receptor polypeptide. The boy has been kept in sterile isolation in the hospital after a normal uncomplicated vaginal birth. He presents with weeping and scaling erythroderma. The neonatalogist notes that he has malabsorption and hypoalbuminemia. The team rules out any infectious cause because of the sterile isolation.

Challenge: What is going on here?

Related Questions:
1. What is the significance of the mutation?
2. Why is this more likely to happen in boys rather than girls?

Paint by Numbers

Concerned parents bring in their toddler who has the presentation seen above. This rash extends to the bridge of the nose and a bit around the mouth, but is mostly on the cheeks. When you examine the baby, you find a red rash on the arms and legs. The rash has been there a week, and it gets worse with sun exposure. The child may have had a fever around that time. There have been no new environmental exposures, foods, or pets. You rule out child abuse.

Challenge: What is the disease? What is the cause?

Image shown under GNU Free Documentation License.

Heart

*This case is related to Monday's case (scroll down).

You and your attending see the man you met on the MUNI (in the previous case). The attending says that he would like to start the patient on the following regimen of three drugs:
After starting these drugs, the patient steadily improves. Two months later though, he returns to SFGH with eye complaints. He says that he has blurred vision and sees floaters. Sometimes, he gets the sensation of flashing lights. You measure his visual acuity and it's gotten worse. On fundoscopic exam, you see an intense inflammatory reaction. Your attending says that the patient's symptoms stem from an infection of one of the eight human herpesviruses.

Challenge: Which herpesvirus is causing these eye problems? What is the relationship between the therapy and these eye problems?

Related Questions:
1. What are the drugs shown? What is the regimen called? Hint: that second drug is an analog of cytidine.

Images are shown under GNU Free Documentation License or are in the public domain.

Muni*

You are a fresh third year ready to begin your internal medicine clerkship at San Francisco General Hospital. As you get on the MUNI to get to SFGH, you see a guy sitting across from you with these lesions on his legs and nose:

When you and that man get off at the bus stop, he turns to you and says, "Ah, you must be a student doctor. What do you think I got?"

Challenge: What's the cause of the skin lesion? What else does this person have?

Related Questions:
1. What is the skin lesion called?

Image is in the public domain.

*This will be a two part case! The next part will be released on Wednesday.