Arr!

Happy Halloween!

Captain Jack Sparrow arrrrives at your arrmergency deparrrrtment, needing arrrgent care. You spy some missing teeth when he cries, "Bring me a noggin of rum, now won't you matey?" He looks pretty pale and you notice his gums be bleedin'. When ye eyeball his tongue, you be seeing somethin' like this:


Now, this lubber ain't the pirate in your clinic, but the tongue looks about the same.

Challenge: What be your treatment for this here condition?

Image is in the public domain.

How Now Brown Cow

A 55-year-old immigrant from France without known history of IV drug use or structural heart disease presents with the signs and symptoms of infective endocarditis. You isolate an unusual organism, a Gram positive coccus susceptible to penicillin that is non-hemolytic on blood agar. It grows in 40% bile but not 6.5% NaCl and hydrolyzes esculin but not arginine.

Your attending tells you to do a colonoscopy.

Challenge: What is the organism? Why the colonoscopy?

Poison

Since the last three were poisons, I wanted to finish this week with a last poison case. Originally, I was going to do radiation poisoning, but the symptoms are too nonspecific. So onto this case, which is an important one to know since it's common...

A college student brings his roommate into the ER. The roommate is confused and disoriented. This is what he looks like:


The patient is sweaty and pale. The roommate says he's been vomiting and lethargic all day. You get some labs and they indicate AST 5000 IU/L and ALT 6000 IU/L. PT is elevated. The roommate says the patient was well a couple days ago.

Challenge: What is the pharmacologic treatment?

Related Questions:
1. What does the image show?
2. What's the diagnosis? What is the biochemical pathophysiology?

Image is in the public domain.

Jeopardy

Alex Trebek: This compound is highly toxic with an LD50 of about 10mg. It's featured in lots of books and movies as an extremely bitter colorless compound found in nature. Its mechanism of action is to act on a ligand-gated chloride channel. Thus, you might expect that soon after exposure, the muscles in the head and neck begin to contract involuntarily. Soon, the patient will look like this painting below (which depicts a similar disease). Death occurs in hours from asphyxiation, and there is no antidote.


Challenge: What is...? (the compound shown above)

First image shown under GNU Free Documentation License.
Second image is in the public domain. It is a painting by Sir Charles Bell of a disease with a similar clinical picture.

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.