A 54-year-old man presents with significant eye pain. On further investigation, he recalls multiple episodes of sinusitis. On physical examination, he is noted to have a saddle-nose deformity, a tender, erythematous, and swollen ear, and mild inspiratory stridor. On eye examination, the patient has evidence of scleritis.
What is the most likely diagnosis?
Relapsing polychondritis. (B) Syphilis, granulomatosis with polyangiitis (GPA), and relapsing polychondritis can all present with saddle-nose deformity. The distinguishing feature of relapsing polychondritis is the ear involvement with damage to the auricular cartilage. (C) GPA can present with scleritis, recurrent sinusitis, and pulmonary involvement, but the pulmonary involvement is much more likely to affect lower airways. The patient’s inspiratory stridor is more suggestive of upper airway involvement such as tracheobronchomalacia, a life-threatening complication of relapsing polychondritis. (A) Sarcoidosis is less likely to present with the above combination of cartilage inflammation of the ear and scleritis. (D) Polyarteritis nodosa is a vasculitis that presents with generalized symptoms (fatigue, weakness, etc.) and skin rash (ulcerations, palpable purpura, livedo reticularis, etc.).
Shortly after a total thyroidectomy performed for follicular carcinoma, a 61-year-old woman is extubated. Her voice is initially hoarse, and shortly afterward there is a shrill high-pitched noise with each inspiration and she is observed to be gasping for air. There are no signs of swelling at the surgical site. The patient continues to have difficulty breathing and is re-intubated.
What is the most likely etiology of her symptoms?
Nerve injury. Patients undergoing total thyroidectomy are at risk for developing a variety of complications. In this case the patient presents with signs of bilateral recurrent laryngeal nerve injury leading to vocal cord paresis, which is suggested by hoarseness and the development of stridor requiring re-intubation. Ultimately she will require direct laryngoscopy for visualization of the vocal folds to assess for paralysis. (A) While accidental removal of the parathyroids may lead to hypocalcemia, this effect would not be expected so rapidly after surgery and would not be expected to result in hoarseness or stridor. (B) Infection with Haemophilus influenzae may lead to stridor in pediatric patients, but this individual’s history of recent surgical intervention makes acute infection less likely. (D) There was no report of swelling at the surgical site, so a hematoma would be unlikely. (E) Anaphylaxis refers to immediate hypersensitivity to a foreign antigen. While anaphylaxis secondary to anesthesia medications is possible, it would have been expected to occur earlier in the patient’s time course.
A 46-year-old man with a lifelong history of asthma develops worsening shortness of breath and a productive cough over the past 2 weeks. Laboratory samples are drawn in the Emergency Department and are shown below.
A chest x-ray shows parenchymal infiltrates and evidence of bronchiolar dilation.
What is the most likely cause of his pneumonia?
Aspergillus. Allergic bronchopulmonary aspergillosis is a hypersensitivity reaction found most frequently among individuals with asthma or cystic fibrosis. Eosinophilic pneumonia is one manifestation of aspergillosis in such individuals. Aspergillus may be cultured from the sputum of such patients and septated hyphae may be seen under microscopic examination. Chest radiography will show infiltrates, atelectasis, and signs of bronchiectasis.
(A, B) Mycoplasma and S. pneumoniae are common causes of pneumonia, but would not produce eosinophilia. (C) Klebsiella pneumoniae is a common cause of pneumonia among individuals who have aspirated. (E) While acute onset of HIV may present with respiratory tract symptoms, it is not commonly associated with peripheral eosinophilia and radiographic findings suggestive of pneumonia.
A 22-year-old man presents with abdominal pain for the last 4 years. The patient reports that the pain improves with defecation. He denies nausea, vomiting, diarrhea, and weight loss. The patient has an extensive family history of colon cancer (several of whom were diagnosed before the age of 40). Colonoscopy reveals hundreds of polyps in the colon and rectum.
Which is the risk of colon cancer in this patient’s lifetime?
100%. This patient has familial adenomatous polyposis (FAP), an autosomal dominant disease in which patients typically have a first-degree relative with early onset colon cancer. Patients diagnosed with FAP should be offered total proctocolectomy at the time of diagnosis since the vast majority will develop colon cancer at the age of 45 and 100% will develop colon cancer in their lifetime. FAP patients should also get routine surveillance upper GI endoscopies as they are at an increased risk for gastric and duodenal carcinomas.
A 24-year-old man presents to the hospital after a near drowning. He has a history of a seizure disorder and experienced a seizure while swimming in his pool. He is currently alert but having difficulty breathing. His temperature is 37.3°C, blood pressure is 110/72 mmHg, heart rate is 134 beats per minute, and respiratory rate is 32 breaths per minute. He has no jugular venous distention, and other than being tachypneic, he has a normal physical examination. An arterial blood gas shows a PaO2 of 85 mmHg on supplemental oxygen with a face mask set to a fraction of inspired oxygen of 50%. A chest x-ray is ordered and shows bilateral infiltrates.
Which of the following is the correct diagnosis?
Acute respiratory distress syndrome (ARDS). This patient meets criteria for ARDS: he has bilateral infiltrates on chest x-ray, a PaO2/FiO2 ratio <200, and pulmonary edema that cannot be explained by heart failure (neck veins not distended). (A) Whereas ARDS is a potential complication of near drowning, heart failure is not; in addition, the lack of jugular venous distention argues against heart failure. (B) This patient is tachypneic with positive chest x-ray findings; therefore, his hypoxemia is not from hypoventilation. (D) Aspiration pneumonitis and pneumonia can lead to ARDS; however, this patient currently meets the definition of ARDS, making this the better answer.
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