Used to be an Insecticide

Cases are now Monday and Thursday rather than Monday, Wednesday, Friday. See announcement below this post.
A 25 year man is brought into the emergency department by his friends because he is "acting weird." The patient is irritable, angry, and restless. He says, "I can't concentrate or sleep. I'm anxious and sad. I keep eating. I quit 3 days ago, but I can't handle it. This is too much. My friends say I'm going to gain weight and get depressed too."

Challenge: What did he quit?

Image is in the public domain.

Change in Frequency

Hi Everyone,

As some of you may know, I am starting my residency training soon. I was unsure whether to continue this blog given the time constraints of residency, but I decided that it's still educational and fun for me so I will continue. Unfortunately, I need to decrease the frequency of posts from 3 cases a week to 2 a week; each takes me at least half an hour to research and write, and saving that extra time each weekend will be really helpful.

For now, new cases and the answers to the preceding case will appear on Mondays and Thursdays. I think the composition of cases will shift towards adult internal medicine as that is what I'll be seeing and learning, but I will try to keep a diverse mix. The next case will be posted at noon PST today.

Thank you for following along,
Craig

I Never Heard of This Disease

I was browsing UpToDate as I usually do on Thursday evenings and came across this disease. Note, if I don't identify gender in the first line, then it is not an epidemiology clue.

A 40 year old southeast Asian presents to your clinic with yet another episode of right upper quadrant abdominal pain, fever, and chills. Reviewing the chart, you note that he's had these same symptoms many times in the past along with a few episodes of pancreatitis, two liver abscesses that required drainage, and cirrhosis. In social history, you find out that he is poor and lives in a rural area. He does not drink. Physical exam shows jaundice, right upper quadrant tenderness, and hepatomegaly.

A RUQ ultrasound shows ductal dilatation, stones, and hepatic abscesses. CT and cholangiogram are shown below.You treat the patient with fluids, antibiotics, and biliary drainage, but so many stones keep coming out; they're mostly pigmented. Nevertheless, there is no evidence of hemolysis. Endoscopy is limited because of the strictures. Finally, you get surgery to do a cholecystectomy with common bile duct exploration and T-tube drainage.

Unfortunately, the most common causes of death in this disease are sepsis, liver failure, and complications from cirrhosis. There is an increased risk of cholangiocarcinoma.

Challenge: What is this bizarrely named disease?

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Not Good

Challenge: Well...that's not good (yes, it's an EKG). Assuming it is not artifact, what's the differential diagnosis (H's and T's)? What is your next step in management?

Image shown under GNU Free Documentation License.

Pelvic Pain

A 35 year old woman presents with sudden onset right-sided lower abdominal and pelvic pain. She said the pain started when she was "exercising," but upon further inquiry, it occurred when she was having sex. This was accompanied by light vaginal bleeding. Her past medical history is significant for appendectomy at age 20. The only medication she takes is aspirin for knee pain.

On exam, temperature is 38.1, heart rate is 75, blood pressure is 115/85, respiratory rate is 12, O2 sat is 99% on room air. On abdominal exam, right lower abdomen is moderately tender to deep palpation. On vaginal exam, an adnexal mass is barely palpable on bimanual examination. There is minimal cervical motion tenderness.

A serum hCG is undetectable. CBC is normal. Urinalysis is normal. Blood culture, urine culture, and cervical studies are negative for infection. Ultrasound shows an adnexal mass and fluid in the pelvis. A CT is shown below.

Challenge: Oral analgesia as an outpatient is the treatment for this condition if uncomplicated. What is it?

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Nine-Banded Armadillo

This gentleman presents with multiple skin lesions over his entire body. They are erythematous macules, plaques, and nodules. He has generalized nerve damage with decreased sensation throughout. He has a "claw hand," "foot drop," and "claw toes" as well. The treatment for this is a multidrug regimen including rifampin.

The alternate title for this case is "MMMBop."

Challenge: You have to check him for G6PD deficiency before starting which drug?

Image is in the public domain.

Warsaw

Challenge: These two physical findings are seen in what syndrome or sequence? The abnormalities are on the same side of the body.

First image is in the public domain. Second image is shown under Creative Commons Attribution 2.5 License.

Happy Memorial Day!

Hi everyone,

Thank you again for following along these cases. I am going to take a case of the day holiday today because I am out of town for a friend's wedding.

Thanks for understanding,
Craig

Dollars to Euros

A 26 year old woman presents with epilepsy from an unknown cause. She has already seen two neurologists who have been unable to make a diagnosis. For the last two years, she's had daily episodes of witnessed seizure-like activity. The episodes last around 5 minutes with variable motor activity; she thrusts her pelvis out, writhes and trashes, rolls from side to side, or arches her back. During an episode, these motor symptoms wax and wane. Her eyes are always squeezed tightly shut. She sometimes makes vocal noises. She has never had incontinence, cyanosis, or tachycardia with these episodes. She awakens rapidly and reorients quickly without a post-ictal headache. She sometimes recalls what happened during the seizure. No one has noticed any episodes while she is asleep. Antiepileptics have not worked to decrease the frequency of symptoms.

Physical exam is remarkable for profound weakness of the patient's left arm. She barely moves it antigravity and can't exert any force against resistance. When you ask about it, she just shrugs and says "whatever."

Challenge: What's going on?

Cut It Out

You are the pathologist receiving this specimen from the operating room. This patient had encephalopathy, GI bleed, weight loss, and early satiety. Labs show thrombocytopenia, hypoalbuminemia, hyperbilirubinemia, and prolonged PT and PTT. AST, ALT, alkaline phosphatase, and gammaglutamyl transpeptidase are all elevated. A chart biopsy shows that these abnormalities have been going on for years.

Challenge: What serum marker is often elevated in this disease?

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