7 Detective Cases of the Week
#1: Vienna
In 1881, Sir William Osler, MD, CM, 1st Baronet, described this clinical triad: An African American patient looking about 60 years old is brought in from the streets with altered mental status. He looks sick. In his pockets, he has a couple packs of cigarettes, a bottle of Vodka, insulin syringes, and crack cocaine (he has really large pockets). He is febrile, tachycardic, hypotensive. On exam, he is altered, not answering appropriately; pupils are sluggish, he has no focal neurologic deficits, but he does have nuchal rigidity.
On pulmonary exam, you hear decreased breath sounds at the right base. A chest X-ray is shown below:
On cardiac exam, you note a systolic murmur at the right upper sternal border. The echo tech is rolling the machine by so you grab it and take a look:
The abdominal exam is remarkable only for a LUQ scar. The extremities are normal. A rectal exam is normal. Here are the blood cultures:
Challenge: Name three disease processes occurring here. Name the organism. There’s your triad.
Highlight the following lines to see answer:
The Austrian’s syndrome (as described by Osler) is pneumococcal endocarditis, meningitis, and pneumonia. Sources: UpToDate; meddean.luc.edu, cardiovascularultrasound.com.
#2: Antibiotics
An older gentleman comes in with a productive cough and shortness of breath. By nursing protocol, he gets an EKG, shown above. You make a clinical diagnosis of community acquired pneumonia and write a prescription for moxifloxacin. There are no TB risk factors. Your attending, aghast, says that’s not appropriate!
Challenge: Why?
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The fluoroquinolones, especially moxifloxacin, levofloxacin, and gemifloxacin can prolong the QT interval. Here, the QTc is already 513, and so there is a high risk of Torsades de pointes. Sources: UpToDate; askdrwiki.com.
#3: Taurus
This rash is seen on the back of the neck of an eighty year old woman who has HTN, DM, dyslipidemia, COPD, arthritis, urinary incontinence, GERD, and migraines. Her medication list spans two pages. Lesions are noted in flexural areas, the groin, the axillae, and the mouth. They are itchy. A diagnostic procedure is done and results are shown below:
Challenge: What’s your most likely diagnosis?
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This is bullous pemphigoid. The second image shows immunofluorescence for autoantibodies to epidermal basement membrane, leading to subepidermal blisters. Sources: UpToDate; healthcare.uiowa.edu; missinglink.ucsf.edu.
#4: Don’t Miss It
An 80 year old smoker with coronary artery disease s/p 2 vessel coronary artery bypass graft, hyperlipidemia, and congestive heart failure presents to the emergency department with rapid onset severe periumbilical abdominal pain, nausea, and vomiting. There is mild abdominal distension but no rebound, tenderness, or guarding. The patient’s mental status is slightly worse than baseline. A rectal exam is positive for fecal occult blood. A CT is shown below.
Challenge: What’s your most likely diagnosis?
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This is acute mesenteric ischemia. The CT image shows gas in the portal venous system (blue circle), lack of contrast in the superior mesenteric artery due to thrombosis (blue arrow), and extensive pneumatosis intestinalis (red arrows). Sources: UpToDate; LearningRadiology.
#5: Indigo
Whoa, this came out of a Foley catheter.
Challenge: What’s going on?
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This is purple urine bag syndrome. GI flora break down amino acide tryptophan into indole which is absorbed in the portal circulation and converted to indoxyl sulfate. This is excreted in the urine where it can be broken down to indoxyl if an alkaline environment and certain bacteria (Providencia spp, Klebsiella, Proteus) are present. The breakdown products indigo and indirubin appear blue and red. This is a benign condition but may signify a urinary tract infection. Sources: UpToDate; bmj.com.
#6: Windowing Your CT
A 70 year old woman with diabetes presents with fevers, chills, flank pain, abdominal pain, nausea, and vomiting over the last week. Labs show hyperglycemia, leukocytosis, acute renal failure, and pyuria.
Imaging is shown above. Panel A is an abdominal radiograph. Panel B is a CT scan in soft tissue window. Panel C is an air window.
Challenge: What are the two most likely organisms that cause this disease?
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The imaging shows abnormal collection of air around the right kidney. This is emphysematous pyelonephritis, a gas-producing necrotizing infection of the renal parenchyma or perirenal tissue, usually due to E.coli or Klebsiella (rarely Candida). Sources: UpToDate; nature.com.
#7: Scar (Not Eschar)
This is a particularly challenging case. The images above are from a patient who noted acute onset nonpitting edema of the arm. This later became a symmetric induration with puckering, giving the irregular, woody texture of the skin of an orange peel. The disease spares the hands and feet. When you raise the affected limb, visible indentations appear along the course of the superficial veins. The patient also complains of arthritis. Labs surprise you with an eosinophilia.
Challenge: What is your diagnosis?
Highlight the following lines to see answer:
This is eosinophilic fasciitis or Shulman’s syndrome. It is characterized in the early phase by limb or trunk erythema and edema and later by collagenous thickening of the dermis and subcutaneous fascia. The skin shows a peau d’orange appearance and the finding with raising the limb is called the groove sign due to sparing of the epidermis and superficial dermis. Sources: UpToDate; dermatology.cdlib.org.
Craig Chen is an anesthesia resident at Stanford. He has been writing regularly for Cases of the Day and Asceplion since his first year at UCSF School of Medicine. All images shown are under fair use.
