Holiday Week!

Happy Thanksgiving, everyone! Unfortunately, I am on call this Thursday, but I wish you all a warm and happy holiday. No cases this week; we'll see what I come up with next Monday. Thank you for following along.

Craig

Chicken or the Egg?

A 30 year old adult presents with what he thinks is asthma. He used to think he was allergic to chicken, but has been eating chicken okay. He gets short of breath and wheezy when he encounters bird feathers and eggs.

Challenge: Believe it or not, this syndrome has a name - what is it? What is the causative factor?

Image of chicken and egg illustration from the 14th century is in the public domain, from Wikipedia.

It's Greek to Me

A four year old child presents to your child neurology clinic with vomiting and syncope. The parents say he loses consciousness and muscle tone during these strange episodic events. They generally happen at night and last more than five minutes; some even last more than 30 minutes. His pediatrician's note says that during a witnessed episode, he had pallor, miosis, incontinence, coughing, hypersalivation, and tachycardia. He had some staring and eye deviation.

EEG is shown below (his is the second strip):

MRI of the brain is normal.

Challenge: What syndrome is described?

Image shown under Fair Use.

Collision

A man is brought in by ambulance after a motor vehicle accident with a dramatic open chest wound. The wound is on the left chest. During inspiration, the wound makes a big sucking noise and the mediastinum swings to the right. During expiration, the mediastinum returns to midline. When you look into the wound, during expiration, the injured lung inflates.

Challenge: What's going on here?

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

You Nailed It

Challenge: What is this autosomal dominant disorder?

First three images shown under GNU Free Documentation License, fourth image is in the public domain.

False Positive

A 60 year old man who is several weeks out from a bone marrow transplant for multiple myeloma develops fever, shortness of breath, tachycardia, and hypotension. He is started on vancomycin, levofloxacin, and piperacillin-tazobactam and then admitted to the intensive care unit. His lactate is elevated, and he is fluid resuscitated. A flu test is negative. A diagnostic test is sent to look for a specific polysaccharide in the serum that would change the antibiotic management. It comes back positive, but your infectious disease consultant says, "Wait, that test could be a false positive."

Challenge: What is the test and why is it unreliable here?

Image of bone marrow transplant shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Also Infects Dolphins

You volunteer with a medical mission to see outpatients in a clinic in Brazil (or Colombia, Suriname, Venezuela, Guyana, French Guiana, Ecuador, Peru, Bolivia, Costa Rica, or Mexico). You get a rash (pun not intended) of forest workers, farmers, hunters, and fishermen between 40 and 70 with the following findings:

The histology is shown below:

Challenge: What's your diagnosis?

First three images shown under Fair Use. Fourth image is in the public domain.

Looks Normal

A young woman with anxiety comes in because she says her heart beat is irregular. Her father has a history of atrial fibrillation and her mother has a history of a heart attack. Her EKG is shown above.

Challenge: How would you read this EKG?

Image shown under Fair Use.

Terms of Agreement

A 20 year old G3P0 woman presents with left lower abdominal pain and vaginal discharge. She says she sometimes feels warm at night but hasn't had a marked fever. "I've had PID in the past, and this just isn't the same," she says. You are unable to do a complete pelvic exam because of significant adnexal tenderness. Because of this, you order pelvic imaging which is shown above. A CBC shows leukocytosis, and pregnancy test is negative. She undergoes surgery and cultures grow out a polymicrobial mix of E.coli, aerobic streptococci, Bacteroides, and Prevotella.

Challenge: What is the diagnosis?

Image shown under Fair Use.

Strange Behaviors

A 60 year old man with depression is brought in by his wife for strange behaviors while he's asleep. His wife says that over the last few years, she's noticed repeated episodes of vocalization and movement while he's asleep. The movements last less than a minute long but are purposeful; she says she's seen him throw a ball. He often makes benign hand gestures, and occasionally punches or kicks. He sometimes shouts or yells. Most times, he doesn't awaken, but occasionally he wakes up momentarily before falling back asleep. He usually remembers his dreams, and when he awakes, he might be briefly confused, but orients quickly. All these episodes happen during the EEG shown above. For social history, he did not graduate high school, he currently smokes a pack a day, and he has some pesticide exposure from farming. Review of systems is remarkable for anosmia and constipation.

Challenge: In a decade, he is diagnosed with Parkinson's disease, but what does he have now?

Image is in the public domain.