Asthma III

A 36 year old presents with several months of fever, weight loss, malaise, fatigue, and a new wrist drop. All of his medical problems started about 16 years ago, he says. He was diagnosed with allergic rhinitis when he was 20, eczema when he was 24, and asthma when he was 28. At age 32, he was admitted with pulmonary opacities, an eosinophilic pleural effusion, and peripheral eosinophilia. They didn't know what to make of it, diagnosed him with an asthma exacerbation, and sent him home.

His asthma is poorly controlled on moderate doses of inhaled corticosteroids. He has required several courses of systemic glucocorticoids to control his symptoms. He's had multiple exacerbations requiring ED visits, hospitalizations, but no intubations.

His allergic rhinitis has been evaluated by an ENT and the endoscopic image is shown above. The white arrow points to the middle turbinate and the red arrow points to the nasal septum. The black arrows represent the findings. The patient also says he gets recurrent sinusitis.

Most recently, the patient complains of the skin finding shown above on his elbow. It is tender, nodular, and subcutaneous. On exam, you also note a foot drop.

Challenge: Making the diagnosis is important as cardiac complications can be serious. What do you think this is?

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Asthma II

You are a pediatrics intern on your first day of clinic. Now you get third year medical students running around for you! You send a medical student to see a 2 year old who is "fussy." The medical student comes back about an hour and a half later, fumbling through pages of notes. He says this is a 2 year old with no significant past medical history and a normal birth history who presents with irritation that started about an hour ago. He was in his crib, unmonitored, when he began to cry. The parents don't know what was wrong and brought him into urgent care. The child has had a nonproductive cough.

You wonder why that history took an hour and a half to obtain. You also wonder what's on the five other scribbled pages of the medical student's notes. Oh well.

The student reports a definite wheeze, but he only heard it on the left side. There were decreased breath sounds on that side too. You're not sure why, but the medical student got chest X-rays, shown above. The right CXR is expiratory and the left CXR is inspiratory. The CXR does not improve with bronchodilators.

The med student hedges on the assessment and plan. The differential diagnosis, he says, is asthma definitely, and also...

Challenge: Your student hesitates, waiting for you to fill in the more likely diagnosis which is what?

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Asthma I

This week is not only pulmonary week, it is asthma week.

The CXR and CT shown above are from a patient referred to you because she has asthma that just won't go away. She is 30, but she had asthma since she was a child. Every year, she gets a few exacerbations with bronchial obstruction, fever, malaise, cough productive of brown mucous plugs, and occasional hemoptysis. Her blood counts always show peripheral eosinophilia. Wheezing is present. These episodes are only minimally responsive to bronchodilators such as albuterol and ipratropium, but they respond well to systemic steroids. Pulmonary function tests show airflow obstruction, air trapping with a reduced FEV1, and increased residual volume. Improvement is minimal with a bronchodilator. A skin test shows reactivity to Aspergillus antigens, serum antibodies against Aspergillus are positive, and serum total IgE is elevated >1000 ng/mL.

Challenge: The referring doctor asks what antibiotics he should use for this infection?

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Separation

(Click to enlarge)

Challenge: What is your diagnosis?

Image is in the public domain.

Hugs and Kisses

This girl is short for her age. She was also diagnosed with a horseshoe kidney.

Challenge: What is the most common cardiovascular anomaly in patients with this disease?

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Where's the Lesion?

A 20 year old presents with a seizure. He says he felt a rising roller-coaster sensation in his stomach, a feeling of deja vu along with intense fear, and a weird smell. Then his roommate noticed he had a behavioral arrest with staring that lasted 30-120 seconds. The patient was unaware and unresponsive during this time, but he did have stereotyped purposeless fidgeting of his hands. At this time, the roommate called 911. The patient does not remember anything.

Challenge: If you were to guess where the lesion is, what would you say?

The Answer is Cancer III

A 35 year old woman presents to her gynecologist and is incidentally found to have a cystic ovarian mass. She is asymptomatic, but ovarian cystectomy is recommended to prevent torsion, rupture, and a 0.2-2% chance of malignant transformation, usually into a squamous cell carcinoma.

Challenge: What's the diagnosis?

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The Answer is Cancer II

In the third image, those black spots all appeared within the time span of weeks. The base of some of those lesions is erythematous. They are itchy.

Challenge: What's the most likely cancer causing these skin manifestations?

Related Questions:
1. What does the first image show? What's the differential diagnosis of this finding?
2. What does the second image show?
3. What is the third image called? What are those spots?

First image shown under Creative Commons Attribution Share-Alike License 3.0. Second and third images shown under Fair Use.

The Answer is Cancer

These are two separate patients with the same disease. The other finding is hepatomegaly. When scanned, a liver mass is found. The patient, unfortunately, has dementia. His estranged daughter says, "Well, he had some sort of minor surgery years ago, but he never told me what it was for."

Challenge: One unifying diagnosis connects the reason for the prior surgery, the current presentation now, and the liver mass. The median survival for this patient is 4.4 months; the five-year survival is 3%.

Note: I got this case idea from a morning report during a preliminary medicine interview.

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Backwards

Yes, this week was indeed cardiac week. Here's an easy one. Next week I'll find some good challenging cases!

Challenge: What happened to this patient?

First image shown under Fair Use. Second image shown under GNU Free Documentation License.