CPS and Image dx

Question 1

Neutropenic fever QUID

Answer 1

1- Definition of neutropenic fever: Fever >38.3 or sustained > 38 during an hour

    And Absolute neutrophil count (ANC) 0.5 x 10 expo 9

Question 2

2- What’s the Rx of Neutropenic fever

Answer 2

: Cover gram negative , gram positive and Pseudomonas. Use Cefepime and Levofloxacin if patient unstable
Can also use Ciprox and augmentin orally if patient stable.

Question 3

QUID of HSV hepatitis

Answer 3

HSV can cause Hepatitis in immunocompromised patient as well CMV, EBV and Parvovirus B19.In the case of HSV ,it known as anicteric hepatitis with more increased of AST than ALT and normal bilirubin.

Question 4

Warning during treatment of HSV ?

Answer 4

High dose of acyclovir in the rx of HSV can result in renal failure. So close monitoring is mandatory

Question 5

Anaerobes sepsis, where to check

Answer 5

Sepsis with anaerobes, check GI or GU source for the primary infection,Skin soft tissue ear and nose for the rest.

Question 6

Factor associated to anaerobic bacteremia

Answer 6

\: factors causing immunosuppression
Diabetes
Corticosteroid
Cancer
Splenectomy
Liver disease
Organ transplant
Immunosuppression
ETOH abuse
Hematologic disorders

Question 7

Quid of Brugada syndrome

Answer 7

Brugada Syndrome: Sus decalage du segment ST en V1 V2 V3 associe a un bloc de branche

Question 8

7- Causes of J waves in EKG:

Answer 8

7- : hypothermia
Hypercalcemia
Neurology injury
Brugada syndrome

Question 9

8- Risk factor of Urothelial carcinoma

Answer 9

: smoking and chemicals exposure

Question 10

Undifferentiated fever after travel in Asia

Answer 10

initial considerations include malaria
enteric (typhoid or paratyphoid) fever
scrub or murine typhus
leptospirosis
melioidosis  cellulitis and pneumonia
and diseases associated with arboviruses, such as dengue or Japanese encephalitis

Question 11

10- Pleiocystosis:

Answer 11

WBC > 5000 in CSF

Question 12

Megaloblastic anemia

Answer 12

Megaloblastic anemia: 5% of neutro have 5 lobes , 1% have 6 lobes

Question 13

Legionella pneumonia

Answer 13

12- Legionella causing Pneumonia and hemoptysis in patient with Hx of Goodpasture (antiglomerular basement membrane disease)
Clue : Hyponatremia and lymphopenia
DX via culture ( Charcoal Yeast extract Agar) by Broncho alveolar lavage Ch. (NEJM March 1 2018)

Question 14

13- Cogan’s syndrome

Answer 14

: Interstial keratitis and vestibular auditory dysfunction (NEJM March 1 2018)

Question 15

Rhinofacial Enthomophthromycosis

Answer 15

14- Rhinofacial Enthomophthromycosis: Remember the Chinese guy with nasal and maxillofacial swelling. Bug: conidiobolus coronatus
Rx :itraconazole, trimethoprim–sulfamethoxazole, and a 10% potassium iodide solution for 6 months (March 1 2018)

Question 16

Ulnar artery mycotic aneurism

Answer 16

Ulnar artery mycotic aneurism in a patient with endocarditis: DX via CT angiography. Rx surgical repair of the aneurism and ceftriaxone (March 22 2018)

Question 17

HIV patient with Mass on the right side of the face

Answer 17

: DX lymphoma in HIV patient (March 22 2018)

Question 18

Appendiceal Pinworms

Answer 18

Appendiceal Pinworms in young patient with symptoms of acute appendicitis (Enterobius vermicularis) Dx done during the procedure : (NEJM March 29 2018)

Question 19

Cutaneous diphtheria

Answer 19

Cutaneous diphtheria in a child returning from a trip in Sierra Leone. Dx done via skin swab showing gram positive bacilli and ELEK test or immunodiffusion test showing that strain of bacteria produces toxin. Rx with clarithromycin (NEJM March 29 2018)

Question 20

Painless unilateral testicular mass in 85 yo man

Answer 20

. DX : Testicular TB (NEJM March 29 2018)

Question 21

Xanthogranulomatous pyelonephritis

Answer 21

; chronic pyelonephritis caused by obstructive staghorn calculus and recurrent infection with Proteus Mirabilis. Calyceal dilation on CT (NEJM March 8 2018)

Question 22

homocystinuria

Answer 22

New onset seizure in patient hospitalized at BWG with MRI showing venous sinus thrombosis .DX Homocystinuria. Clue : Marfanoid features, downward dislocation of the lens B/L and deficient in cystathione B synthase. (NEJM March 08 2018)

Question 23

EEG changes in Hypothermia

Answer 23

EEG changes in Hypothermia : J waves or Osborn waves also seen in Hypercalcemia , Brugada syndrome{bloc de branche droit et ST segment elevation in V1v2 and V3} and neurologic injury ( NEJM Feb. 1 2018)

Question 24

Phlegmasia Cerulea Dolens

Answer 24

Phlegmasia Cerulea Dolens with Compartment Syndrome due to extensive venous thrombosis (blue limb) (NEJM Feb 15 2018)

Question 25

HHV 6 encephalitis

Answer 25

65 yo man with confusion after stem cell transplantation in CLL treatment.DX: HHV 6 encephalitis done by CSF PCR.Patient died in the hospital (NEJM Feb 15 2018)

Question 26

Gossypiboma

Answer 26

Two pelvic masses in woman wha has undergone 2 CSections : DX Gossypiboma or foreign object like surgical left behind during the procedures.Symp: lower abdominal bloating , CT shows the 2 masses ( NEJM Feb 22 2018)

Question 27

Hematometrocolpos

Answer 27

Hematometrocolpos in teenager: Increased abdominal girth in teen with primary amenorrhea .Physical exam reveals no perforation of the hymen. Rx : Hymenectomy (NEJM 22 2018)

Question 28

Pure red cell aplasia caused by Parvovirus B19 and Warm autoimmune hemolytic anemia.

Answer 28

35 yo woman with headache, anemia and subjective fever: Anemia is aregenerative and increased indirect bilirubin: DX: Pure red cell aplasia caused by Parvovirus B19 and Warm autoimmune hemolytic anemia. (NEJM 22 2018)

Question 29

Poland syndrome:

Answer 29

The Poland syndrome is a rare congenital condition that is characterized by the unilateral absence or underdevelopment of chest-wall muscles and by limb abnormalities, including syndactyly or brachydactyly, on the affected side .Rx plastic surgery(NEJM January 4 2018)

Question 30

Pneumomediastinum

Answer 30

Pneumomediastinum Associated with Influenza A Infection. The patient received noninvasive ventilatory support and was treated with zanamivir for influenza and piperacillin–tazobactam for bacterial superinfection. Dx by throat swab. After 15 days , no more pneumomediastinum (NEJM January 4 2018)

Question 31

ZES

Answer 31

70 yo man with 3 mo hx of diarrhea , weight loss and epigastric pain and Hepatic mass on CT: Zollinger Elisson syndrome. Case show an increase gastrin level but you have to ask a gastric PH to confirm if less than 2 you have a primary hypergastinemia( ZES) ( NEJM January 4 2018)

Question 32

cowpox skin infection

Answer 32

Young girl with necrotic black lesion on the face : DX cowpox infection . Also differential diagnosis :cutaneous anthrax, Tularensis, and Bartonella Henselae. No specific Rx( NEJM January 11 2018

Question 33

Iris abscess

Answer 33

Iris abscess in patient with endocarditis and staph aureus bacteriemia( NEJM January 11 2018)

Question 34

Adenovirus respiratory failure

Answer 34

Rapid respiratory failure in 35 yo woman with hx of leukemia treated with cord blood transplantation. DX Adenovirus infection confirmed via nasal swab( NEJM January 11 2018)

Question 35

Butterfly glioma

Answer 35

Patient seen with 5-hour history of weakness in the left arm, drooping on the right side of the face, slurred speech, and urinary incontinence. CT: Butterfly glioma ( NEJM January 18 2018)

Question 36

Rib fracture associated with Pertussis

Answer 36

Rib fracture associated with Pertussis ; Dx done via nasopharyngeal culture. Rx with azithromycin and surgical repair of lung hernia ( NEJM January 18 2018)

Question 37

B12 deficiency and neuro complication

Answer 37

B12 deficiency producing balance problem and confusion . Subacute combined degeneration with post column and lateral part of spinal cord. ( NEJM January 18 2018)

Question 38

SBeta hemoglobinopathy

Answer 38

Patient with SBeta hemoglobinopathy with calcified spleen and bilirubin stone ( pigment stone)
( NEJM Jan 25 2018)

Question 39

Creutzfled Jacob disease or spongiform encephalopathy.

Answer 39

54 yo patient seen with cognitive decline and functional deterioration, Cerebellar symptom like ataxia and nystagmus , hyperreflexia and startle myoclonus.Creutzfled Jacob disease or spongiform encephalopathy. CSF with 14-3-3 and tau protein markers of Prion disease.MRI show lesions includind hyperintensity of the cortex, pulvinar and dorsomedial thalamic nuclei, and basal ganglia ( NEJM Jan 25 2018)

Question 40

Bouveret’s syndrome:

Answer 40

Bouveret’s syndrome: Bouveret’s syndrome is an uncommon form of gallstone ileus that is characterized by a gastric outlet obstruction caused by impaction of a gallstone in the pylorus or proximal duodenum after its passage through a cholecystoduodenal fistula. Dx with the Rigler’s triad: pneumobilia, small bowel obstruction and ectopic gallstones (NEJM April 5 2018)

Question 41

Hand foot and mouth disease

Answer 41

Hand foot and mouth disease in adults: cocksakievirus, Associated with myocarditis, encephalitis and meningitis (NEJM April 5 2018)

Question 42

PRES

Answer 42

Patient with confusion and forgetfulness developed acutely seen in hospital. Dx PRES due to secondary hypertension due to obstructive nephropathy by HBP aggravated by consumption of anticholinergic drugs.Physio patho of PRES is vasogenic edema and and direct endothelial damage. Can also be caused by Sepsis, eclampsie and drugs like Tacrolimus and cyclosporine( calcineurin inhibitor) and sirolimus.Headache and vision problem can also be a part of the symptoms. (NEJM April 5 2018)

Question 43

Chondroblastic Osteosarcoma

Answer 43

Pulmonary Metastases from 42- Pulmonary Metastases from Chondroblastic Osteosarcoma in 21 YO woman in complete remission after chemotherapy (NEJM April 12 2018)

Question 44

Inferior Vena Cava Filter complication

Answer 44

Embolization of Struts from an Inferior Vena Cava Filter in left prevertebral space and right ventricular trabeculae and one 1 mm in Ureter the latter causing flank pain. Fracture of inferior vena cava filters is a potential complication of these devices.They leave them in place (NEJM April 12 2018)

Question 45

BEHCet’s disease

Answer 45

A 48-Year-Old Woman with Recurrent Venous Thromboembolism and Pulmonary Artery Aneurysm.Pulmonary artery aneurysm that was most likely due to the Hughes–Stovin syndrome.Patient with DVT and B/L PE the latter unresponsive to warfarin , apixaban and enoxaparin with increased ESR and CRP. Three phases are described in the Hughes–Stovin syndrome: an initial phase characterized by venous thrombophlebitis, a second phase characterized by formation of large pulmonary and bronchial aneurysms, and a third phase characterized by aneurysmal rupture that leads to massive hemoptysis and death, DD for pulmonary artery aneurism include Behcet’s, Takayasu, infection as TB and Syphilis, pulmonary hypertension, lung cancer and trauma (pulmonary artery catheterization), PDA.Lessons learned : Inflammatory conditions like Behcet can cause thrombosis caused by the inflammatory state rather than hypercoagulable state. In this case , you have to treat it with drugs aiming to fight the inflammatory state. (NEJM April 12 2018)

Question 46

Minocycline induced pigmentation of the sclera

Answer 46

Minocycline induced pigmentation of the sclera .It s used in the treatment of Inflammatory arthritis such as RA. Metabolites of the drug can form insoluble complexes with melanin or with Iron. Rx stop the drug. 85 yo woman with grayish discoloration of the sclera (NEJM April 19 2018)

Question 47

Winter pattern

Answer 47

Chest pain in 36 yo with EKG showing Winter pattern= ST segment depression in precordial leads with Tall T waves. It’s a characteristic sign of LAD occlusion. To better see ST segment abnormality in EKG, also draw the imaginary isoelectric lign. (NEJM April 19 2018)

Question 48

TCA Intoxication

Answer 48

Cardiac arrest causing by TCA intoxication: EKG in crucial : large QRS complex > 140 ms in RBB and more than 160 ms in LBB. Positive R wave in AVR= Ventricular tachycardia , dextrocardia, lead misplacement or certains toxidromes. Prolonged QTc interval more than 440 in men more than 460 in woman.Broad positive R wave in V1 = RBB QTC interval = QT/square root of RR en S
Mangement of TCA intoxication :1- ABC with fluid resuscitation and o2 supplementation
2-Gastric decontamination : Activated charcoal 1g /kg of body weight or 10 g per 1g of TCA in blood. You can also give 50 to 100 g stat 3- Give sodium Bicarb : if QRS > 100 ms or R/S in AVR > 0.7 or R in AVR >3 mm loading dose 50-100 mg iV start ie one to 2 ampules of 50 ml of 8.4% solution then 150 meq in one liter of DW 5% 150 to 250 ml per hour until arterial PH is between 7.45-7.55 while monitoring level of K+. Assess EKG for narrowing of QRS
Vasopressor: TCA can induce hypotension resistant to crystalloids and sodium bicarb . Continuous infusion of Norepinephrine 8 to 12 micrograms per minute until MAP>65 or systolic pressure >95
intra veinous lipid emulsion if patient is unstable that is refractory to the above intervention
IF QTC is long give Magnesium sulfate
DD for cardiac arrest: Cardiac, neurology, metabolic, trauma and toxicologic(NEJM April 19 2018)

Question 49

Lithium induced nephropathy

Answer 49

mostly tubulointersticial with small cysts in kidney parenchyma. In the case patient developed nephrogenic diabetic insipidus with hypernatremia and low osmolarity of urine.The numerous small cysts in cortex and medulla of both kidneys are key elements to the Dx of Tubulointersticial nephropathy due to lithium used. Normal urine osmolarity between 500-850 (NEJM March 15 2018)

Question 50

Osgood schlatter

Answer 50

Young man with pain in both knees. Xray showing sclerosis and fragmentation of tibial tubercle.Dx Osgood schlatter syndrome , DD possible osteochondrosis(NEJM March 15 2018)

Question 51

Tako Tsubo cardiomyopathy

Answer 51

Tako Tsubo cardiomyopathy : clue cardiac problem including chest pain and apical ballooning plus normal coronary arteries. Underlying causes of Takosubo : Endocrine: Thyrotoxicosis, Pheo and adrenal crisis, neurologic conditions : stroke and subarachnoid hemorrhage,
Induction of general anesthesia, drugs like venlafaxine , EPi and nortryptiline. Toxico: cocaine use.
In this case , It can be caused by pheochromocytoma. Why hypocalcemia in pheo crisis ? adrenomedullin expression causes increased osteoblast activity and leading to ca sequestration. Adrenomedullin is also vasodilator. Patient with cardiogenic shock reveals to be caused by Tako Tsubo due to pheochromocytoma. Anytime you see a patient with hx of thyroid cancer , rule out medullary thyroid cancer and think or MEN 2a. You have to know that Medullary thyroid cancer does not respond to Radio active iodine therapy (NEJM March 15 2018)

Question 52

Child with herpetic withlow

Answer 52

Child with herpetic withlow= HSV 1 lesions on finger . Due probably to fingers sucking and gingivostomatitis caused by JSC 1 infect the fingers. Looks like bacterial cellulitis but it’s not Traitement is done with acyclovir or valcyclovir ( NEJM Feb 8 2018)

Question 53

neck abcess due to branchial cleft sinus

Answer 53

Persistent neck abcess due to branchial cleft sinus.Embryologically branchial apparatus is responsible for the formation of the head and the neck . You can treat the abcess with antibiotic but you have to remove the branchial remnant. Diagnostic is done via CT of neck and barium esophagography ( NEJM Feb 8 2018)

Question 54

congenital rubella

Answer 54

Neonate with thrombocytopenia , cataracts and hepatosplenomegaly = congenital rubella TORCH was the principal diagnosis to think with the O stands for other such HIV, varicella , Parvovirus and syphilis
Lue for syphilis: irregularity of the long bone metaphysis
CMV: Thrombocytopenia , hepatosplenomegaly, periventricular calcification, hearing loss
Toxo:chorioretinitis and diffuse intracranial calcifications
RUBella : CMV plus cataract ( microcephaly like ZIKA) ( NEJM Feb 8 2018)

Question 55

Idiopathic intra cranial pressure

Answer 55

Clue for increased intracranial pressure : Papilledema with optic disk swelling . Optic disk swelling can be caused by papillitis ( optic neuropathy or injury of the optic nerve) and papilledema caused by increase intracranial pressure. Both can cause visual problem but papillitis will start with impairment of color vision( dyschromatopsy), decreased visual acuity , peripheral visual defect and afferent pupillary defect. However papilledema will start with defect of nasal peripheral field. Papilledema is caused by increase intracranial pressure. It can be Idiopathic in the case of pseudotumor cerebri and secondary to : brain tumor, cavernous sinus thrombosis or connectivitis like Behcet and SLE vasculitis, In case of SLE , because of the vasculitis you are at increased risk of developing cerebral veinous thrombosis. Aseptic meningitis is also a feature of SLE.So it’s a case of vision disturbance and headache in a patient with hx of meningitis 21 months ago treated with high dose prednisone = Increased intracranial pressure due to SLE and glucorcoticoid use. Meningeal inflammation can cause an increased intracranial pressure by decreasing the absorption of CSF. The definitive diagonosis was : Idiopathic intracranial hypertension associated with lupus and corticoid use. Normally glucocorticoid cause gain of weight and the latter favors IICP( NEJM Feb 8 2018)

Question 56

Giant cells arteritis

Answer 56

stenosis of artery ostia in myocardial infarction, think about arteritis not atherosclerosis
Arteritis of large and medium vessels : Giant cells arteritis in sonogram you will see halo ( denoting vascular wall edema ) and skip lesions( segment of affected and unaffected vessels)
MI and PAD caused by giant cell arteritis ( Interactive case) An unusual cause of leg pain ( NEJM December 4 2017)

Question 57

Pneumatosis cystoides intestinalis

Answer 57

Pneumatosis cystoides intestinalis.Connection with ischemic intestinal disease and IBD, lung disease , Mechanical ventilation and endoscopic procedures.Patient complaint of abdominal fullness. (NEJM december 4 th 2017)

Question 58

Echtyma gangrenosum

Answer 58

-Echtyma gangrenosum: cutaneous infection by pseudomonas aeruginosa occurring in patient with immunodeficiency particularly those with on chemo for leukemia or diabetes . Lesions appear like violaceus pustule( hemorrhagic patch with erythematous border) and fever. Treat with ceftazidine and Gentamycin (NEJM december 4 th 2017)

Question 59

Hydrandenitis suppurativa

Answer 59

Multiple painful lesions inguinal and axillary region resistant to the treatment by antibiotics. Hydrandenitis suppurativa ( NEJM December 21 2017)

Question 60

Metastatic melanoma

Answer 60

Patient seen with nausea , abdominal pain and coffee ground emesis. Endoscopy reveals Multiple masses in the duodenum with histologic confirmation of Metastatic melanoma. But the problem no cutaneous lesion was found priorly. (NEJM December 21 2017)

Question 61

Marconnel sign

Answer 61

Extra bet: Marconnel sign: hypokinesis of the middle and base of the Right ventricle due to right heart strain. Seen In PE. In this case , we have a patient with chest pain and ST segment depression in V1 v2 v3 and elevated troponin 0,21. So we classify the case based on the chest pain characteristics and finding in troponin and EKG and focal wall motion abnormality. Chest pain in 41 yo woman with hx of cardiac risks , recent miscarriage : spontaneous coronary dissection . Link with pregnancy : Increased progesterone causes intimal tear. There is also a link with Ehler denlos, Marfan and fibromx dysplasia. (NEJM 21 december 2017)

Question 62

Taloromyces Marneffei

Answer 62

Disseminated ombilicated papules in patient with HIV living in china or India; Dx;Infection with a fungus called Taloromyces Marneffei. Now the infection is common in patients with defect in cell mediated immunity such as patient with organ transplantation. Treat with amphotericin B ( NEJM December 28 2017)

Question 63

Normal pressure hydrocephalus

Answer 63

• Normal pressure hydrocephalus: Gait disturbance: short stepped narrow based gait
  Dementia and urinary incontinence. MRI shows: dilated ventricle Treat with VPS measured by Evan’s ratio It’s a ratio between the width of frontal horns of lateral ventricle over the internal diameter of the skull . Must not exceed 0.31. CSF with normal pressure (NEJM December 28 2017)

Question 64

Microangiopathic hemolytic anemia

Answer 64

Microangiopathic hemolytic anemia is caused by TTP , HUS, eclampsia, malignant hypertension and valvulopathy.Low haptoglobin, anemia,high LDH and shistocytes in peripheral smear more than 1% ( sur 100 erytrocytes per field). The final dx was PNH every time you have ,Coombs negative hemolysis and thrombosis and abdominal pain in a setting of recent pregnancy and OCP use =PNH . Macrocytosis is also common in PNH. In PNH, intravascular hemolysis occurs, releasing free hemoglobin into the plasma. It is believed that the release of free hemoglobin leads to scavenging of nitric oxide, which triggers smooth-muscle dystonia and can cause episodic abdominal pain Treat with eculizumab or allogeneic bone marrow transplantation. Eculizumab is a monoclonal antibody blocking c5 so no MAC can be formed to destroy RBC, it also promotes survival. Bone barrow is reserved for patient with myelodysplastic syndrome or aplastic anemia. In this case bone marrow biopsy must be done before initiation of bone marrow transplantation. IN PNH absence CD 55 and CD 59 by flow cytometry. (NEJM December 28 2017)

Question 65

invasive ductal carcinoma

Answer 65

Patient seen with stiffness of the nipple and hyperchromic ( pigmented) macule.Breast palpation and mammo and US did not show anything. However skin biopsy of the macule revealed a invasive ductal carcinoma with positive estrogen and progesterone receptor. (NEJM November 2 2017)

Question 66

Onychomycosis

Answer 66

-Onychomycosis can be linked with HIV. In fact Onymychosis is really common most caused by Trichophyton rubrum. But most of the time , it typically starts in the distal portion of the nail. When you see a white nail lesion starting in proximal part of the nail with rapid progression to the distal nail, check out a HIV infection. . (NEJM November 2 2017)

Question 67

Patient with RUQ pain and slight icterus

Answer 67

Patient with RUQ pain and slight icterus: Lab shows predominance of indirect bilirubin in an adult. You have to think to 2 diseases Gilbert disease and hemolysis but remember in both disease indirect never goes over 5 mg. In this case the patients has an increase Mean corpuscular hemoglobin concentration , it’s typical of Hereditary spherocytosis you can confirm it with osmotic fragility test and flow cytometry for determination of EMA eosin 5 maleimide. Gilbert can be confirm via genetic testing called uridine diphosphoglucuronate-glucuronosyltransferase 1A1 (UGT1A1) genotyping. But it has to be homozygocity to be positive. In this case , the clue resided in the elevated indirect bilirubin, the increase MCHC , family hx of gallstones in the father , the RUQ pain is due to pigmented gallstones caused by the hemolysis.In peripheral smear you can see the spherocytes, but never forget that in case of warm autoimmune hemolytic anemia, you can find spherocytes.In this case there is common event : the acute cholecystitis that brought the patient in the ED but the cause of this gallstone formation is uncommon and we found it based on the result of the CBC.There is a link between lipid bilayer and cytosketon protein any mutation touching on of this protein will disrupt the RBC normal morphology: spectrin alpha and B, Ankyrin, Band 4,2 band 4,1 and Band 3. There are called cytoskeletal protein. The red blood cells will become like sphere and will be destroy in the spleen resulting in splenomegaly. You have to know that flow cytometry test or EMA binding test is based on the presence of Band 3. Consequently, this test will allow to confirm the absence of Band 3, that means this protein is really important in the comprehension of the disease. Even in normal Hb , you can have the disease,we call that a compensated hemolytic anemia.For moderate and severe spherocytosis, splenectomy is the treatment. The teaching point is you can hemolysis without anemia. (NEJM November 2 2017)

Question 68

Compartment syndrome

Answer 68

Compartment syndrome in IV drug user, After taking drug patients lie down on the ground for 13 hours. Two causes of compartment syndrome crush injury and immobilization. The clue is the absence of pulse in a limb with swelling and pain. (NEJM November 9 2017)

Question 69

gold thread acupuncture

Answer 69

• Be aware of gold thread acupuncture practiced by Chinese during acupuncture, They insert gold treat in the joint to fight against joint pain. In this the true diagnosis of the patient was Rhumatoid arthritis. (NEJM November 9 2017)

Question 70

West Nile encephalitis

Answer 70

West Nile encephalitis: Patient with agitation and coma and flaccid paralysis (NEJM November 9 2017)

Question 71

Popeye sign

Answer 71

Popeye sign: Rupture of the tendon of the Biceps (NEJM November 16 2017)

Question 72

Falciform ligament sign:

Answer 72

Falciform ligament sign: seen in case of pneumoperitoneum in the setting of perforation of an abdominal viscus . It’s better seen on CT like a vertical band. Remember falciform ligt connect the liver to anterior abdominal wall(NEJM November 16 2017)

Question 73

copper associated myeolopathy

Answer 73

Copper deficiency myelopathy: in this case the myelopathy involved the cervical , thoracic and lumbar spinal cord and also we have problem with the spinothalamic tract (hypoesthesia) with the corticospinal tract and the dorsal column and also problem of bladder incontinence which a lesion between the Pons and sacral spinal cord. The clue for diagnosis above is : bypass surgery (bariatric surgery) the use of dental adhesive containing zinc, zinc prevents absorption of copper by the enterocytes located in the duodenum and the use of valproic acid. Valproic acid can lower blood copper. Some words on bariatric surgery: Roux-en-Y gastric bypass that resulted in the creation of a small proximal stomach pouch that was directly connected to the midjejunum and thus bypassed most of the stomach, duodenum, and proximal jejunum — the portion of the digestive tract that is critical for fat and mineral absorption. Therefore, the procedure produced a malabsorptive state that can result in numerous nutritional deficiencies, including deficiencies in vitamins A, B1, B2, B6, B9, B12, D, and E, as well as iron, copper, and other micronutrients. Remember that celiac disease can cause copper deficiency and the hereditary form of copper deficiency is called Menkes disease.Vit E deficiency can also cause neurologic symptom.(NEJM November 16 2017)

Question 74

Strawberry Gingivitis

Answer 74

• Strawberry Gingivitis: caused by Granulomatosis with polyangiitis. Serology test C anca was positive and by ELISA(Enzyme link immunosorbent assay) antiproteinase 3 was positive. They treat it with cyclophosphamide and Prednisolone ( NEJM November 23 2017 )

Question 75

molluscum contagiosum

Answer 75

Kid with atopic dermatitis and topical corticosteroids develop umbilicated papule: Pox virus infection , molluscum contagiosum. Probably caused by alteration of epidermal barrier leading to increased risk of viral infection and also the use of topical glucocorticoid. In this case they just stopped the glucocorticoid therapy. ( NEJM November 23 2017

Question 76

TTP

Answer 76

Patient with headache , anemia and thrombocytopenia and fever , first episode after an Accident and the second one after an infection. Dx was combined hereditary ( Schulman Upshaw syndrome)and acquired TTP. Remember in TTP, you have a deficient in ADAMTS 13 protein , a disintegrin and metalloproteinase with a transpondin motif 1 member 13) shortly said it a protease capable of chop up multimers of WV into stranded WV. The disease can be acquired( antibody directed against ADAMTS 13) or inherited(Upshaw Shulman syndrome) (NEJM, November 23 2017)

Question 77

Koebner Phenomenon

Answer 77

EKG inducec Koebner Phenomenon: this phenomenon can be explained by a resurgence of new lesion of psoriasis after mechanical irritation of the skin. In this case , right after the EKG, patient develops now skin lesion with characteristics of psoriasis. (NEJM November 30 2017)

Question 78

non cardiogenic pulmonary edema

Answer 78

Opioid user develops loss of consciousness and respiratory problem right after intoxication: Non cardiogenic pulmonary edema. Remember in this case , patients also develop aspiration pneumonitis from gastric content aspiration. It’s different aspiration pneumonia due to aspiration of oropharyngeal content. (NEJM November 30 2017)

Question 79

Mycobacterium infection and autosomal dominant IFNγR1 deficiency

Answer 79

Non mycobacterium tuberculosis in 2 family members due to Autosomal dominant IFNγR1 deficiency. In the case Mycobacterium Genavense was the cause of the disease and the mother reveals a hx of BCG disease in childhood and osteomyelitis and lymphadenopathy. Canaries can be also infected M genavense and could be responsible for the infection. (NEJM september 14 2017)

Question 80

pulmonary foreign body granulomatosis:

Answer 80

pulmonary foreign body granulomatosis: patient presented with dyspnea and characteristically image on chest xray and CT. Is caused by presence of crospovidone in opioids used by the patient. Oral medication containing talc and cellulose could also be responsible. No treatment available ( NEJM september 28 2017)

Question 81

Eagle’s syndrome

Answer 81

Triad : cervical pain, dysphagia and sensation of foreign object in the throat,It is caused by the elongation of the styloid process or ossification of the stylohyoid ligament. ( NEJM september 28 2017)

Question 82

Campylobacter bacteremia in a patient with presumed autoimmune hepatitis.

Answer 82

in cirrhosis you can have iron overload and infection with Vibrio vulnificus, Campylobacter Jejuni and fetus can adopt a spiral form( corkscrew) and curved form in lab. Can also cause bacteremia in patient. In this , they present a patient with hx of autoimmune hepatitis and cirrhosis who developped fever , Jaundice , acute liver failure and bacteremia caused by c Jejuni( NEJM september 28 2017)

Question 83

squamous cell carcinoma of the mouth

Answer 83

most common cancer of oral cavity : squamous cell carcinoma, there is a link with tobacco.Don’t forget keratin pearls during the biopsy analysis (NEJM september 21 2017)

Question 84

Intraoccular infection with a trematode

Answer 84

Patient from Mexico in trematode in his eye. ( NEJM september 21 2017)

Question 85

disseminated gonococcal infection

Answer 85

15 % of patients with psoriasis have the articulation manif before skin manif. Dx differential of patient presented with acute osteoarticular pain
1- Injury
2- Osteoarthrits
3- RA and SLE
4-Psoriatic arthrits
5-Cristal induced arthropathy
6-Reactive arthritis
7-Infectious arthritis including lyme, parvovirus, shikungunya and gonococcal infection. VIral cause of arthritis include shikungynya, parvovirus, HeP B and C.In the same case the patient has sterile pyuria causes are: Urogenital TB, chlamydia, gonorrhea and recently treated GU tract infection
Summary: Patient presented with pain in her right thumb and both ankles 2 weeks after having nonprotected sex with a male guy. DX septic arthritis due to disseminated gonococcal infection( NEJM september 21 2017)

Question 86

Young person with pleuritic chest pain after travelling in porto rico and cave exploration.

Answer 86

When probability of pulmonary embolism is low by using weils criteria: first test to do is Ddimer. In the diagnosis of PE first thing to do is the weils criteria, if the possibility is unlikely next step will be a d dimer but if the possibility is high check symptoms for DVT if yes do US of legs if positive no further test need. IF there is no symptom for DVT or if the US leg is negative next step is ventilation perfusion scan.If d dimer is positive no further test is needed. But in the case DDimer was positive and a CTA was done. Causes of elevated Ddimer: PE, infection, inflammation and Malignancy.Don’t forget the link between Histoplasmose and Bat guano and bird excrement, lives in soil and grows at 25 degrees. Dx done via urine antigen test and biopsy of mediastinal nodes. In Histo patho they found a necrotizing granulomatous infection. Treatment with itraconazole. Amphotericin B is reserved for more severe infection. Remember weils criteria less than 4 PE unlikely more than 4 PE likely. Criteria 2 = 3 points symptoms of DVT and an alternative diagnosis than PE is less likely. 1,5 point: Heart rate > 100, Previous DVT and immobilization more than 3 days or surgery in the previous 4 weeks 1 pt Hemoptysis and cancer
( september 21 2017)

Question 87

Crusted scabies

Answer 87

Highly contagious, patient came primarily with prutitus and scaly rash. Treat with oral ivermectin and Salycylic acid (NEJM August 3, 2017)

Question 88

Xanthomas in Familial Hypercholesterolemia

Answer 88

young man presented with nodules on extensor surface and pressure surfaces such as buttocks and LDL 600. Familial hypercholesterolemia is the DX. It s caused by mutation in several genes including LDL receptor and apolliprotein B(NEJM August 3, 2017)

Question 89

Churg strauss syndrome ANCA is positive in only 40%

Answer 89

Cough and shortness of breath = Differential diagnosis includes Upper respiratory tract infection, pneumonia, fluid overload and asthma. Anemia can cause shortness of breath but no cough , allergy can cause cough but not the shortness of breath unless there is asthma associated. asthmalike symptoms worsened with the use of glucocorticoid: Strongyloidiaisis, mostly affect people living in developing countries. Remember strongyloides stercoralis and allergic bronchopulmonary aspergylosis(recurrent asthma exacerbations, but they may also have fever, a productive cough, or even hemoptysis.) are secondary causes of asthma. In this patients we have hypereosinophilia. There are several categories of disease associated with eosinophilia: infectious (particularly with invasive helminths), respiratory (e.g., asthma and eosinophilic pneumonia), gastrointestinal (e.g., eosinophilic gastroenteritis), allergic (e.g., allergic bronchopulmonary aspergillosis, eczema, and asthma), inflammatory vascular (e.g., eosinophilic granulomatosis with polyangiitis, previously known as the Churg–Strauss syndrome), and malignant (e.g., leukemia and lymphoma).Other possibilities include adrenal insufficiency and idiopathic hypereosinophilic syndrome. Final Diagonosis was eosinophilic granulomatosis with polyangitis ( churg strauss syndrome) ( NEJM august 3 2017)

Question 90

Insulin induced lypohypertrophy

Answer 90

Insulin induced lypohypertrophy: can be caused by the anabolic effect of insulin. Risk is poor glycemic control because of poor absorption of insulin in the zone of hypertrophy. Prevention: rotation on the site of injection and also use finer needles. In the case it appears like two red massees in the patient’s belly (NEJM August 10 2017)

Question 91

Kartagener syndrome

Answer 91

Patient with dextrocardia and infertility presented with left side pneumonia. Dx; Kartagener’s syndrome. Symptoms are situs inversus, recurrent sinusitis, and bronchiectasis.This syndrome is a form of primary ciliary dyskinesia( NEJM August 10 2017)

Question 92

congenital pancreatic cyst.

Answer 92

pseudocyst is a complication of pancreatitis. In children one cause of pancreatitis can be traumatic. most of pseudocyst resolve on their own but if they persist more than 3 months a drainage is mandatory.Congenital pancreatic cyst should also be considered (Congenital pancreatic hamartoma (multicystic adenomatoid hamartoma).NEJM August 10 2017)

Question 93

GVHD

Answer 93

Graft versus host disease affecting the eye after hematopoietic stem cell transplant in patient with AML( NEJM August 17 2017)

Question 94

Eczema herpeticum

Answer 94

Eczema herpeticum, an eruption of a viral infection on a preexisting site of skin disease — typically, atopic dermatitis. Eczema herpeticum is most commonly caused by HSV.( NEJM august 17 2017)

Question 95

Mononucleosis

Answer 95

Patients with fever and multiple subacute lymphadenopathy: Lymphoma-Multicentric castleman disease either idiopathic and caused by HHV 8, infection HIV, Mono and CMV. Also considered EBV associated lymphoma (NEJM August 17 2017)

Question 96

Acute afebrile neutrophilic dermatosis in RA

Answer 96

also called sweets syndrome. Is characterized by erythematous plaques in palms. It s a complication of RA. DX differential include drugs eruption, vasculitis and infection process (NEJM August 24 2017)

Question 97

Mesenteric ischemia

Answer 97

Can be caused either by arterial or venous thromboembolism (NEJM August 24 2017)

Question 98

CMV pneumonitis complicated of Pancytopenia

A 63-Year-Old Woman with Fever, Hypotension, and Hypoxemia

Answer 98

histoplasmosis and blastomycosis typically cause nodular pulmonary lesions and coccidioidomycosis usually causes cavitary lesions, and these lesions were not present on imaging studies of the chest in this patient. Aspergillosis, which also tends to cause nodular or cavitary disease, is seen primarily in patients with hematologic cancer, particularly those with prolonged neutropenia. adenovirus would be the most likely to explain this patient’s fever, ground-glass opacities, and elevated aspartate aminotransferase level. CMV was detected via shell vial culture and CMV DNA load.(NEJM In this case, we have a patient with respiratory symptoms and signs, pancytopenia and fever and no response with antibiotics in a setting of immunosuppresion:Diagnostic differential: TB-PCP- Viral infection Human herpes virus, EPstein Barr, CMV Adenovirus-Fungal infection Histo-blasto- cocci and aspergilosis- babesiosis (August 24 2017)

Question 99

Extra: holster sign

Answer 99

Rash on hips seen in dermatomyositis (NEJM August 24 2017)

Question 100

Eosinophillic bronchitis

Answer 100

Patient with chronic cough, obstructive defect in pulmonary function test and bronchial nodule during bronchoscopy with eosinophilic infiltration in biopsy. (NEJM August 31 2017)

Question 101

Sturge weber

Answer 101

You have capillary malformation on the skin called port wine birthmark and capillary venous malformation in the brain causing atrophy, stroke and seizure, can lead to glaucoma. (NEJM august 31 2017)

Question 102

Patient with chest pain due acute cholecystitis plus choledocolithiasis.

Answer 102

In a patient with acute chest pain, the presence of PR-segment depressions in some leads (II, III, and aVF) and an elevated PR segment in lead aVR may be indicative of acute pericarditis.Approach of the patient with chest pain: Cardiac disease including acute pericarditis and coronary disease ( takotsubo), vascular including aortic dissection and mesenteric ischemia in this case the pain was subxiphoid, celiac artery dissection, arcuate ligament syndrome can also be considered it’s a congenital disease where the median arcuate ligament of the diaphragm crosses over the celiac artery, and this results in extrinsic compression of the vessel and associated mesenteric ischemia, the pain can also be thromboembolic like in EP, gastric pain can be A gastric ulcer, biliary colic, and a Schatzki’s ring may each lead to pain in the subxiphoid area that may occur after eating. and the last one is parietal pain due hespes zoster for example. Remember acute mesenteric ischemia, you will have elevated lipase and amylase.The diagnosis was an acute cholecystitis / choledocolithiasis. In acute cholecystitis , the blockade is located in the cystic duct and in choledocholithiasis it’s located in the common bile duct. Cause of pigment stones: hemolytic anemia and alcoholism. but the patient has cholesterol stone, one factor associated with it is infection with H pylori and H Hepaticus.(NEJM august 31 2017)

Question 103

Cerebrous cavernous malformation

Answer 103

have to know they can be associated with skin lesions and also can cause seizure. The Patient head CT looks terrible with multiple hole in the brain (NEJM July 6 2017)

Question 104

Unmasking Ptosis in Both Eyes in myasthenia gravis

Answer 104

There is approximately equal innervation of the levator palpebrae superioris muscles in both eyelids. In the context of asymmetric ptosis, increased motor impulses to compensate for ptosis on the more affected side flow to both eyelids, which can be sufficient to mask mild ptosis on the less affected side. With manual elevation of the affected eyelid, the need to sustain eyelid elevation is relieved, and these motor impulses are attenuated, which unmasks ptosis of the other eyelid.This patient also had an increased acetylcholine receptor antibody (NEJM July 6 2017)

Question 105

third degree av block causes

Answer 105

Rule out lyme disease cardiac sarcoidosis, myocarditis, Lyme disease, erlichisis,hyperkalemia, and hypothyroidism
( NEJM July 6 2017)

Question 106

Giant cell myocarditis

Answer 106

Patient presented with exertional chest discomfort and dyspnea: Cardiac causes,pulmonary and systemic. Cardiac causes include bradyarrhythmias, heart failure due to cardiomyopathy, valvular heart disease, and acute myocarditis or pericarditis.pulmonary disease (e.g., chronic obstructive pulmonary disease, reactive airway disease, and interstitial lung disease) and systemic causes that might contribute to ischemia independent of coronary artery disease, such as anemia and hyperthyroidism.Later the patient will present third degree AV block; see cause 3 degree av block in the list above. The definitive diagnosis was a infiltrative myocarditis caused giant cell myocarditis. Multincleated giant cell in biopsy of the heart two possibilities: Cardiac sarcoidosis and giant cell myocarditis. to make the difference between the two in sarcoidosis you will have presence of granuloma and in giant cell myocarditis presence of eosinophiles.the recognition of clinical findings that suggested inflammatory or infiltrative disease, particularly the occurrence of both slow (complete heart block) and fast (ventricular tachycardia) arrhythmias, (NEJM July 6 2017)

Question 107

Salt and pepper skin changes

Answer 107

It;s like a vitiligo skin changes but it’s caused by scleroderma . NEJM July 13 2017)

Question 108

Mobile aortic thrombi

Answer 108

(NEJM July 13 2017)

Question 109

Endocervical carcinoma in pregnant woman

Answer 109

(NEJM July 13 2017)

Question 110

Evolution of fulminans purpura

Answer 110

Due to infection neisseria Meningitidis. FP will cause an ulcer during evolution ( NEJM June 1 2017)

Question 111

Dysphagia right after occipitocervical fusion procedure

Answer 111

Patient with atlantoaxial subluxation had benefit a occipitocervical fusion procedure. Right after the procedure patient developped dysphagia. It was caused by hyperflexion of the upper cervical spine decreasing the oropharyngeal space. They just redo the procedure and correct the anatomical abnormality.(NEJM june 1 2017)

Question 112

Spiraling out of control =Leptospirosis

Answer 112

cough dyspnea and myalgia : Influenza and other viral , bacterial Legionella and mycoplasma.
Later patient develops hemoptysis: Staph aureus and and leptospira interrogans. dont forget goodpasture’s disease and TB if symptoms are chronic
Later he develops intersticial nephritis : Lepto, legionella and mycoplasma can do so
smoker: smoking is a risk for bronchial infection
Carabinnoids: allow colonisation of respiratory tract by aspergillus and other molds that could be detrimental for immunocompromised patient.
Tree in budding pattern : It ;s a bronchial disease with debris fillling the airways. It can be caused by Mycobacterium TB and fungal infection can also be caused by viral infection
Sepsis with negative culture : TB infection
Patient develops increased Lipase: Legionella, Mycoplasma , adenovirus or adenovirus
The definitive diagnosis was Leptospirosis. 65% of rats trapped live in Baltimore have antibody to L interrogans.
Weil’s syndrome (Weil’s disease), which is characterized by renal failure, jaundice, and hemorrhage and has a 5 to 15% mortality rate.Pulmonary involvement in lepto: Diffuse alveolar hemorrage and ARDS (NEJM june 1 2017)

Question 113

large arachnoid cyst

Answer 113

june 8 2017

Question 114

Mondor’s disease

Answer 114

Mondor’s disease, a superficial thrombophlebitis of a vein in the anterolateral thoracoabdominal wall, is typically benign and self-limited. Causes are rauma, breast surgery, and extensive physical activity (NEJM June 1 2017)

Question 115

Kid with hypocalcemia and fear of choking

Answer 115

Patient with fear of shoking and low calcemia. Diffrential for Hypocalcemia can be caused by the precipitation of calcium into insoluble salts, which can occur in acute pancreatitis, rhabdomyolysis, or the tumor lysis syndrome.1 Hypocalcemia can also be caused by several medications, such as bisphosphonates, calcitonin,2 and trisodium phosphonoformate (foscarnet).Disorders of vitamin D metabolism or action also commonly cause hypocalcemia. Vitamin D is synthesized in the dermis or absorbed from dietary sources. It is then converted to 25-hydroxyvitamin D in the liver. The conversion from 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D, the active form of vitamin D, is catalyzed in the renal tubules by 1α-hydroxylase, which is stimulated by PTH. Disorders of vitamin D include diminished substrate due to limited dietary intake or limited sun exposure, severe liver disease that interferes with 25-hydroxylation of vitamin D, and chronic kidney disease that leads to a diminished level of 1,25-dihydroxyvitamin D. Conditions caused by a genetic mutation of 1α-hydroxylase (vitamin D–dependent rickets type 1) or a genetic mutation of the vitamin D receptor (vitamin D–dependent rickets type 2 or hereditary vitamin D–resistant rickets) can also lead to hypocalcemia ( NEJM june 8 2017)

Question 116

Kid with hypocalcemia and fear of choking

Answer 116

Hypoparathyroidism is also a cause : could be infiltrative in Hemochromatosis and and wilson disease, congenital like Digeorge syndrome or mutation in calcium sensing receptor or in PTH gene, could be autoimmune in the context of autoimmune polyglandular syndrome type 1 with the triad candidiasis, hypoparathyroidism and adrenal insufficiency, hypo or hypermagnesemia and also post surgey.
Other cause is pseudoparathyroidism caused by PTH resistance where you have high PTH but low calcium
In healthy persons, PTH binds to the PTH receptor, which triggers a signal-transduction cascade involving the α subunit of the stimulatory G protein (Gsα). This leads to increased production of cyclic adenosine monophosphate (cAMP), increased calcium reabsorption in the distal renal tubules, decreased phosphorus reabsorption in the proximal renal tubules, and increased calcium mobilization due to bone resorption. Definitive diagnosis: pseudohypoparathyroidism

Question 117

Perirenal extramedullary hematopoieisis

Answer 117

seen in a patient with myelofibrosis, rimlike perirenal image is seen in CT and during biopsy, the diagnosis was confirmed. most of the extramedullary hematopoieisis occurs in liver and spleen. (NEJM june 22 2017)

Question 118

coronary vasospasm

Answer 118

Printzmetal angina in a patient who is a smoker. Diagnosis was done by using acetylcholine that provokes the spasm in coronary artery. Treatment with calcium blocker. During catherization you can see a nonobstructive stenosis (NEJM 22 JUNE 2017)

Question 119

59 year patient with leg weakness and numbness

Answer 119

Processes involving the peripheral nervous system that can result in weakness include disorders of the muscle fiber, neuromuscular junction, nerve, or anterior horn cell.Peripheral nerves is made up of two nerves the first one starting in ventral horn, dorsal root, dorsal ganglia and wind up in mx spindle the second one starting in ventral horn , ventral root also called alpha motor neuron and goes in the periphery of the muscle.Mononeuritis multiplex affects peripheral nerves in a multifocal, often asymmetric pattern and is manifested by dysfunction in the distribution of individual peripheral nerves. It is associated with a variety of infections, inflammatory disorders, and cancers, as well as collagen vascular diseases (e.g., rheumatoid arthritis).CSF analysis, the severity of the abnormalities was striking, but a markedly diminished glucose level, a markedly elevated protein level, and lymphocytic pleocytosis can be seen in a wide range of diagnoses, including tuberculosis,1,2,9,10 sarcoidosis,4,5 and carcinomatous, lymphomatous, or leukemic meningitis.The final diagnosis was Diffuse large B cell neurolymphomatosis, Dx done via nerve root biopsy specimen NEJM June 22 2017)

Question 120

Achenbach’s syndrome

Answer 120

Achenbach’s syndrome is characterized by paroxysmal spontaneous subcutaneous bleeding in the fingers and hands. Although the cause is unknown, it is a self-limiting condition.(June 29 2017 NEJM)

Question 121

Eye injury due to firecrackers

Answer 121

NEJM June 29 2017

Question 122

HIV 1 encephalopathy

Answer 122

Men having sex with men patient seen in the clinics for confusion: Diferrential diagnosis: Psychosis, Metabolic-Wernike encephalopathy, or B12 deficiency,cocaine or Heroin use, Neoplasia such as CNS lymphomadue Epstein Barr virus or metastasis from Kaposi sarcoma, could be infectious such as Herpes virus,varicella zoster, CMV or HIV PML or HIV encephalopathy. Regarding this patient the definitive diagnosis was HIV 1 encephalopathy . Dolutegravir was introduced in the regimen because of good CNS penetration.(NEJM June 29 2017 )

Question 123

Spondylolisthesis

Answer 123

Spondylolisthesis : ant sliding of a superior vertebra over an inferior one. Can be post traumatic. When it occurs in the axis its called Hangman’s fracture (NEJM May 4 2017)

Question 124

Back pain in 80 yo patient

Answer 124

consideration in the case: patient with back pain. Age: Prostate cancer with metastasis, smoker lung ca with metastasis, Pacemaker placement : Risk of infection travel to Asia : risk of tuberculosis. In the case the patient also had basal cell carcinoma but BCC rarely metastasized in the vertebra. In that same case CRP and ESR were elevated this raises concern of infectious, inflammatory and Cancer .MRI should be performed for this patient but because of the pacemaker, it should’nt be done. CT imaging shows destruction of two contiguous vertebra, this pattern is more consistent with osteomyelitis than Cancer, bugs causing osteomyelitis staph aureus, Gram negative baccilli and streptococcus. ANd also if there is spinal surgery and devices placement Coagulase-negative staphylococci and Propionibacterium acnes (NEJM May 4 2017)

Question 125

Back pain in 80 yo patient

Answer 125

exposure to livestock or to unpasteurized dairy products= brucellosis likely. Other possibilities include infection with endemic fungi, such as Cryptococcus neoformans, Histoplasma capsulatum, Blastomyces dermatitidis, or Coccidioides immitis. Rare cases of vertebral osteomyelitis have also been reported with Burkholderia pseudomallei, and TB. All these infections are linked with travelling abroad. calcification are seen on chest CT: tuberculosis, histoplasmosis, coccidioidomycosis, and sarcoidosis. Sarcoidosis and histoplasmosis are rare causes of vertebral osteomyelitis. Through biopsy we finally come to the conclusion : Cocciiodomycosis : Arizona trip and pneumonia before the back pain. Vertebral osteomyelitis with disk involvement: bacterial if not TB or cocciodomycosis, treatment is done with amphotericin B followed by itraconazole or fluconazole. Liposomal ampho B is better to prevent renal toxicity (NEJM May 4 2017)

Question 126

amelanotic melanoma

Answer 126

Skin lesion without any discoloration, can be confused with pyogenic granuloma and warts or ulcers (NEJM May 11 2017)

Question 127

Binaural Tympanic-Membrane Perforations after Blast Injury

Answer 127

The dude was standing near a mortar rack when somebody ignited it accidentally. Blast injury with perforation of both tympannic membranes (NEJM May 11 2017)

Question 128

Palpable purpura

Answer 128

Causes of purpura: it;s caused by extravasation of blood from damaged blood vessels. Could be non palpable and palpable.Cause of palpable purpura includes thrombocytopenia, systemic illnesses like amyloidosis,infection, hypercoagulable state and nutritionnal deficiency like scurvy or sun exposure known as solar purpura or it could be idiopathic such as schamberg’s disease. Palpable purpura is always caused by small vessel vasculitis, in this case it;s always come with arthritis.let’s have a look on vasculitis. first you have to know if it’s involved large, medium or small vessel. For large vessels vasculitis it’s the aorta and its branches so no purpura will be seen. Regarding medium sized vessels, the irrigate large portion of the skin and vasculitis of medium sized vessels tend to cause skin ulcers , livedo and racemosa.Palpable purpura is a feature a small vessel vasculitis. The second things to do is evaluate organs to have a clear idea of extent and severity of the disease, Hematuria means glomerulonephritis, respiratory symptom such hemoptysis means alveoar hemorrage and abdominal pain means mesenteric artery problem and symptom meas vasculitic neuropathy.All small vessel vasculitis can touch these organs. remember causes of skin lesion vasculitis include cancer , infection and inflammatory process.(NEJM May 11 2017)

Question 129

Palpable purpura

Answer 129

Two types of vasculitis Primary and Secondary vasculitis cause of secondary include: INfection: Rocky mountain spotted fever, bacterial endocarditis and meningoccemia
drugs: cocaine combined to levimasole an adulterant of cocaine, lesions involve ears
Inflamatory condition such as sjogren, SLE or chron in the case of our patient
Primary vasculitis are divided in 2 categories: Anca vasculitis and immune complex associated vasculitis . Anca associated vasculitis are 3 diseases: eosinophilic granulomatosis with polyangitis( shurg strauss), Microscopic polyangitis and granulomatosis with polyangiitis.
Immune mediated are: drugs(TNF @ inhibitor), Cryoglobulinemia and IGA vasculitis.Cryoglobulinemic vasculitis can be idiopathic but is typically seen in association with hepatitis C virus infection and is less commonly seen with systemic lupus erythematosus, Sjögren’s syndrome, or hepatitis B virus infection but you will have low C4. There is a link with strep infection. In biopsy any patient with small vessel vasculitis will present with leukocystoclastic vasculitis
Cutaneous manif in Chron : Pyoderma gangrenosum, Erythema nodosum and neutrophilic dermatosis. Remember that granulomatosis with polyangiitis gives symptom of the respiratory tract and renal involvement and PR3 positive whereas microscopic polyangitis gives only lung intersticial disease MPO positive same as eosinophilic granulomatosis with polyangiitis.. ( NEJM May 2011)

Question 130

Large sized vessel vasculitis

Answer 130

takayasu and giant cell arteritis

Question 131

Medium sized vessel vasculitis

Answer 131

PAN no pulmonary involvement

Question 132

scarlet fever and sand paperlike rash

Answer 132

The finding of acute streptococcal pharyngitis along with the diffuse rash led to a diagnosis of scarlet fever. The rash of scarlet fever is a delayed-type hypersensitivity to an exotoxin and therefore occurs in persons who have had a previous exposure to Streptococcus pyogenes. (May 18 2017)

Question 133

Tuberous sclerosis

Answer 133

Tuberous sclerosis complex is an autosomal dominant condition that affects cellular differentiation and proliferation. The condition is characterized by the development of hamartomatous lesions that can affect many organ systems, including the central nervous system, eyes, skin, and kidneys. Facial angiofibromas consist of blood vessels and fibrous tissue. Periungual fibromas are benign tumors that are composed of connective tissue and typically appear in the second decade of life or later. Patients with this condition often have renal involvement, including the formation of angiomyolipomas or extensive renal cysts. (NEJM May 18 2017)

Question 134

Key feature waxed and wane skin lesion in a patient with many travels and high ALP and Pulselessness

Answer 134

exposure to camel and goats: risk of infection with brucellosis
Travel in Thailand during heavy rainfall: risk of infection with Burkholderia pseudomallei, the gram-negative bacillus that causes melioidosis. clinical manif are similar to mycobacterial infection but you must have some predisposing condition such as heavy alcohol use, lung disease, or advanced diabetes, can cause skin manif but pneumonia is the most common manifestation of melioidosis.
In Morocco and thailand there is a risk of contamination by M tuberculosis via elephant contact. It;s a zoonotic transmission.
Skin infection in new england includes Francicella tularensis infectioneschar at the site of the arthropod bite
: This patient is at risk for exposure to several thermally dimorphic fungi, including Penicillium marneffei, which is endemic in Thailand, and Histoplasma capsulatum and Blastomyces dermatitidis, which cause disease in New England. P. marneffei infections mostly occur in immunocompromised hosts, so this diagnosis is unlikely to be the cause of illness in this patient
Leishmania is a protozoan that is transmitted by sandflies found in Morocco, and it can cause chronic cutaneous lesions and granulomatous changes.
Swimming in fresh water; shistosomiasis
other considerations are non infectious causes such as giant cell arteritis but the age of the patient is less than 50 but Takayasu fit normally because it affects girl less than 40.The important has been seen in the biopsy that show granulomatous pattern. So sarcoidosis was also a differential diagnosis,the pulseless event occurring in the arms gives away the dx. Angiography is performed and occlusion of left subclavian artery has been noted. The elevated ALP is due as an acute phase reactant and treatment with glucorticoid has been initiated (NEJM MAy 18 2017)

Question 135

Key feature waxed and wane skin lesion in a patient with many travels and high ALP and Pulselessness

Answer 135

exposure to camel and goats: risk of infection with brucellosis
Travel in Thailand during heavy rainfall: risk of infection with Burkholderia pseudomallei, the gram-negative bacillus that causes melioidosis. clinical manif are similar to mycobacterial infection but you must have some predisposing condition such as heavy alcohol use, lung disease, or advanced diabetes, can cause skin manif but pneumonia is the most common manifestation of melioidosis.
In Morocco and thailand there is a risk of contamination by M tuberculosis via elephant contact. It;s a zoonotic transmission.
Skin infection in new england includes Francicella tularensis infectioneschar at the site of the arthropod bite
: This patient is at risk for exposure to several thermally dimorphic fungi, including Penicillium marneffei, which is endemic in Thailand, and Histoplasma capsulatum and Blastomyces dermatitidis, which cause disease in New England. P. marneffei infections mostly occur in immunocompromised hosts, so this diagnosis is unlikely to be the cause of illness in this patient
Leishmania is a protozoan that is transmitted by sandflies found in Morocco, and it can cause chronic cutaneous lesions and granulomatous changes.
Swimming in fresh water; shistosomiasis
other considerations are non infectious causes such as giant cell arteritis but the age of the patient is less than 50 but Takayasu fit normally because it affects girl less than 40.The important has been seen in the biopsy that show granulomatous pattern. So sarcoidosis was also a differential diagnosis,the pulseless event occurring in the arms gives away the dx. Angiography is performed and occlusion left subclavian artery has been noted. The elevated ALP is due as an acute phase reactant and treatment with glucorticoid has been initiated (NEJM MAy 18 2017)

Question 136

Auer Rods

Answer 136

All acute myelogenous leukemia can have auer rods but when they are abundant it’s a sign of acute promyelocytic leukemia. Treat with all trans retinoic. Can be identified through bone marrow aspiration.APL is linked with DIC ( NEJM May 25 2017)

Question 137

A galloping heart

Answer 137

The S4 sound is created by the vibrations of the left ventricle during atrial contraction as blood is ejected into a stiff, noncompliant ventricle and is best heard over the apex, with the bell of the stethoscope.cause of s4 aortic stenosis, hypertension and Hypertrophic obstructive cardiomyopathy.Remember concentric hypertrophy. A small stick taped to the chest of a patient who had a prominent S4 sound allowed for the visualization of a double apical impulse( NEJM May 25 2017)

Question 138

Patient with uterine mass

Answer 138

DIfferential diagnosis : Uterine Myoma-Leiomyosarcoma- smooth muscle tumors of uncertain malignant potential (STUMP)- Adenomyosis-Uterine adenocarcinomas( NEJM May 25 2017)

Question 139

On the cusp

Answer 139

Endocarditis ( NEJM May 25 2017)

Question 140

Regression of Coronary Atherosclerosis with Medical Therapy

Answer 140

Regression of Coronary Atherosclerosis with Medical Therapy ( NEJM April 6 2017)

Question 141

Gartner’s duct

Answer 141

A Gartner’s duct cyst is a benign vaginal cystic structure that arises from the vestigial remnant of the mesonephric (wolffian) duct, which, during male embryogenesis, forms the seminal vesicles, vas deferens, and epididymis ( NEJM April 6 2017)

Question 142

Patient with anemia , renal insufficiency and hypercalcemia.

Answer 142

Patient with hypercalcemia, anemia and kidney disease
this triad is seen in Multiple myeloma
Chronic kidney disease can also cause anemia
Anemia and Kidney disease can be seen in hrombotic microangiopathy, systemic lupus erythematosus, or hemolysis with pigment nephropathy. Hypercalcemia can cause Insipidus nephrogenic diabetes and dehydration leading to acute kidney failure
Two causes of hypercalcemia PTH dependent or PTH independent. PTH independent causes are seen in malignancy,excessive ingestion of vitamin D or calcium, granulomatous disease (e.g., sarcoidosis, tuberculosis, histoplasmosis), medication use, or endocrinopathic conditions (e.g., adrenal insufficiency or hyperthyroidism).
fatigue, sweats, and weight loss suggest a systemic disorder. In the case, you can see multiple cystic lesion in bone but UPEP and SPEP are normal so MM is unlikely.lytic bone lesion can be seen in Paget’s disease but ALP will be elevated. DIsease causing granuloma include TB, sarcoidosis, some case of lymphoma , fungal infection. Regarding this case the final diagnosis was sarcoidosis. You can have bone involvement in sarcoidosis with the mimicring a MM..The initial imaging test of choice when considering the diagnosis of sarcoidosis is chest radiography, which shows abnormal findings in 90 to 95% of cases.A measurement of serum 1,25-dihydroxyvitamin D3 level was omitted from the hypercalcemia evaluation but may have been informative. Although measurement of 1,25-dihydroxyvitamin D3 level is not mandatory in all cases of hypercalcemia, it is indicated in a patient who has low serum PTH and 25-hydroxyvitamin D levels. when it’s elevated check a granulomatous disease.

Question 143

Dyskeratosis congenita

Answer 143

Triad: Nail dystrophy, skin finding and mucosal leukoplakia. Short telomere is the cause. you can give Danazol to lenghten telomeres. Can lead to marrow failure and pulmonary fibrosis (NEJM 13 2017)

Question 144

Primary oxaluria type 1

Answer 144

Primary hyperoxaluria type 1 is a rare autosomal recessive disorder of glyoxylate metabolism that leads to recurrent urolithiasis alone or in combination with nephrocalcinosis. ( NEJM 13 2017)

Question 145

Patient with leg swelling , hydronephrosis and lymphadenopathy above and below the diaphragm and a bulky mass retroretroperitoneal mass

Answer 145

Nonmalignant causes of massive retroperitoneal lymphadenopathy are rare and include sarcoidosis, Castleman’s disease (angiofollicular lymph-node hyperplasia), retroperitoneal fibrosis, and reactive or infectious causes. Hodgkin’s lymphoma is a possibility in this case, since patients can present with a primary bulky abdominal mass. Definitive diagnosis is Folicular lymphoma for this patient. The patient came for leg swelling and hydronephrosis . But the lymphadenopathy seen on the CT scan gave the diagonosis.It’s a non hodgkin lymphoma. ( NEJM 13 2017)

Question 146

candida esophagitis

Answer 146

Long-term treatment with antibiotics can be a risk factor in immunocompetent patients. (NEJM April 20 2017)

Question 147

Osteopetrosis

Answer 147

mutations in one of several genes lead to impaired osteoclast function and failure of bone resorption. Complications can include cranial nerve compression, brittle bones, and bone marrow failure(NEJM April 20 2017)