Grit

A 60 year old woman undergoes a multi-level lumbar discectomy for lumbar spinal stenosis. The surgery goes as expected and the patient is brought to the post-anesthesia care unit. In recovery, the patient starts complaining of severe left eye pain. "I can't open my eye," she says, "because it feels like grit or sand is in it." Her visual acuity is roughly baseline. A fluorescein stain is shown below.

Challenge: What's your diagnosis?

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Sunny Side Up

An 18 year old previously healthy woman has several months of an enlarging abdomen; one day, she presents with acute onset severe abdominal pain. She is found to have an ovarian mass which is removed. This is the histopathology:

The gross pathology is shown below. The tan, fleshy portion (green arrow) makes the diagnosis.

Challenge: What is it?

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Look Closely

Challenge: What's the rhythm here?

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Sight

An 80 year old man who never sees a doctor is brought in by his children because of "weird" behavior. He has been running into doors, falling, knocking things off tables, and unable to locate anything. He says there's nothing wrong with his vision and that he's "just fine." When you show him three fingers, he says he sees two. When you do confrontation of his visual fields, it seems random which fingers he says are wiggling. When asked what color shirt his daughter is wearing, he says "red" when she is wearing a green shirt. He seems to genuinely believe what he is saying. A fundoscopic exam is shown above. An MRI makes the diagnosis.

Challenge: What's the diagnosis?

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Q&A

You get called by a public health department in Nova Scotia (or Switzerland, Great Britain, Germany, or southern France). They're wondering if you can help because a number of their sheep and goats have had spontaneous abortions, and some of their cattle have had low birthweight offspring.

"Um...," you say.

Well, they also want your opinion because a few of the farm workers and veternarians have come in sick. Most are men between 30-70 years of age. Some have presented with a self-limited flu-like illness with an abrupt high-grade fever, fatigue, headache, and myalgias. Others have presented with a mild nonproductive cough, fever, and a CXR shown below (A is normal, B is the patient).

Yet others present with hepatomegaly, fever, and increased LFTs. For most patients, the CBC is normal.

Here is the organism:

Challenge: What's your diagnosis?

Both images are in the public domain.

Beautiful Lady

A "beautiful lady" is brought to your emergency department by police for "bizarre behavior." She's red hot with cutaneous vasodilation yet not sweating. Her pupils are nice and dilated. She's anxious, babbling, agitated, dysarthric, and confused. "Everyone looks so small," she says. "It's like a Jonathan Swift book." (Okay, she might not have said that). She is only oriented to person and displays signs of paranoia. She reaches out and grabs invisible objects from the air. Exam shows absent bowel sounds. An EKG shows mild sinus tachycardia, otherwise normal. Finger stick glucose is normal. Labs and blood cultures are pending. A Foley is placed and 500mL of urine comes out.

Challenge: The police mention that she was found with the plant shown above. What's your diagnosis?

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Terms of Service

A 30 year old tennis instructor presents with right arm pain. After doing repetitive overhand serves, he gets forearm fatigue. This is accompanied by swelling, pain, and cyanosis. He notes paresthesias in the fingers occasionally. He also says he can see "blood draining from his arm through his shoulder, neck, and chest wall." A duplex ultrasound confirms your diagnosis. You start the patient on anticoagulation and refer to a surgeon.

Challenge: What's the diagnosis?

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ABC...D

A 5 year old child of French and Dutch descent is referred to your pediatric practice for recurrent febrile episodes of unclear etiology. After an uneventful full-term birth to a healthy 30 year old mother, the patient began having febrile episodes in her first year of life. The episodes happen every 4-8 weeks, lasting 4 days to a week, and in between, the child is normal and healthy. The episodes seem to be triggered by vaccinations, minor trauma, and stress, though they also happen at other times. The patient characteristically gets nasal congestion, sore throat, fatigue, headache, or behavioral changes followed by chills, then a rapid onset fever to higher than 38.5. During these episodes, the patient has palpable tender, rubbery lymphadenopathy, mostly cervical. Occasionally, the child complains of abdominal pain, and twice, went to the operating room where a normal appendix (as well as rest of bowel) was found. Splenomegaly was noted, however. During these episodes, she has symmetric arthritis of larger joints which can linger a few days beyond the cessation of fever. The patient also develops an erythematous, macular rash over multiple parts of the body that sometimes become confluent. Acral lesions are more common than truncal ones. ESR, CRP, leukocytes, and ferritin are elevated during attacks. IgA and IgD are elevated both during and in between attacks.

Many other causes have been worked up, including all infectious etiologies, surgical emergencies, pancreatitis, familial Mediterranean fever, and acute intermittent porphyria, which have all been negative.

Challenge: What is this genetic disorder?

Twitchy

A 50 year old woman with major depressive disorder, iron deficiency, and anemia complains of lower leg discomfort at rest. Movement relieves the discomfort. This discomfort occurs in both legs and is described as "crawling, creeping, pulling, or stretching" deep under the skin. There is no pain, numbness, tingling, or increased sensitivity of the skin. The symptoms are worst at night, about 20 minutes after getting in bed. She also complains of insomnia and daytime sleepiness. A sleep study is negative for obstructive sleep apnea, but finds the trace shown above. The blue is a normal sleep pattern while the red is the patient's sleep pattern. In addition, the patient has sudden jerking leg movements with extension of the toes and flexion of the ankle and knee that last a few seconds but repeat in clusters. The rest of the neurologic exam is normal.

Challenge: What's your diagnosis?

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Ghost

A 20 year old man is involved in a bombing and has penetrating injury to his leg. He is taken immediately to the operating theatre and undergoes an above-the-knee amputation of his leg. Post-operatively, he is admitted to the wards, continued on antibiotics, and started on thromboprophylaxis. During the first few days post-operatively, however, the patient continues to have pain at the site of the amputation requiring high doses of IV opiates. The patient points out exactly where the pain is, and injection of lidocaine relieves the pain. The patient is taken back to the OR and a biopsy is shown below.

Challenge 1: What's the diagnosis here?

Excision of the problem relieves the pain and the patient eventually transfers to a rehabilitation facility. However, even in the rehabilitation facility, the patient complains of burning, electric, aching pain in the amputated limb. X-ray does not show any bone spurs, local tissue oxygen tension is normal, and there is no evidence of infection.

Challenge 2: What's the diagnosis here?

First image of woodcut by Hans von Gersdorff is in the public domain, from Wikipedia; second image shown under Fair Use.