- Email: [email protected]
Case of the month
Case of the Month Submitted by Masami Matsumura, MD Each month, we will present a challenging Case of the Month for The Green Journal readers, who must use their clinical acumen to arrive at the correct answer. We will also post the case each month on the Journal’s web site (http://www.elsevier.com/ locate/ajmselect). Several possible answers may be consistent with the case presentation; use your best judgment. Please send your answer (one per respondent) and indicate the case to which you are responding to The Green Journal at [email protected] or via FAX to (415) 447-2799. Only those answers with a complete mailing address will be considered.
The correct answer will appear in the March issue of the Journal. The first five persons who submit correct answers will receive a free one-year subscription to the Journal. Colleagues of Dr. Matsumura in Kanazawa, Japan are not eligible for this month’s case. We will offer special recognition to the clinicians with the most correct answers at the end of the year. If you would like to contribute a case, please submit a brief synopsis (⬍250 words) to the editorial office. An individual may win only once per calendar year. Am J Med. 2000;108:168. 䉷2000 by Excerpta Medica, Inc.
A
ANSWER TO THE JANUARY CASE OF THE MONTH
19-year-old woman presented with a 7-day history of headache, right-sided neck pain, and fever (39.0⬚C) that began 4 days after her return to Japan from Thailand. While traveling, she had trekked in a forest near Chiang Mai. Her past medical history was unremarkable, and she had no pets. On physical examination, her temperature was 38.2⬚C, her blood pressure was 114/64 mm Hg, and her pulse was 78 beats per minute. She had a maculopapular rash on her face, right cervical lymphadenopathy, and an eschar behind her right ear. The remainder of the physical examination was normal. Laboratory evaluation showed a hemoglobin level of 12.6 g/dL, a leukocyte count of 4,400 per L (69% neutrophils, 21% lymphocytes, and 5% atypical lymphocytes) and a platelet count of 151,000 per L. A urinalysis was normal. The serum aspartate aminotransferase level was 69 U/L, the alanine aminotransferase level was 49 U/L, the lactate dehydrogenase level was 787 U/L, and the C-reactive protein level was 6.0 mg/L. Serum electrolyte and creatinine levels were normal. A chest radiograph and an abdominal ultrasound examination were normal. What is the most likely diagnosis?
168
䉷2000 by Excerpta Medica, Inc. All rights reserved.
Last month’s patient with persistent nausea and vomiting, delayed gastric emptying, and hyponatremia had a nonfunctioning pituitary adenoma leading to central adrenal insufficiency. She had an 8 AM cortisol level of 2.5 g/dL (normal: 5–25 g/dL). She also had evidence of mildly depressed thyroid function and estradiol deficiency; a prolactin level was normal. A computerized tomographic scan of the head showed a 2 ⫻ 2 ⫻ 1.7 cm pituitary mass. She underwent successful transsphenoidal surgery, and her symptoms resolved with hormone replacement. Dr. Kashyap, who submitted the case, pointed out that gastroparesis can be a rare manifestation of adrenal insufficiency (see Valenzuela GA et al. Reversibility of gastric dysmotility in cortisol deficiency. Am J Gastroenterol. 1987;82:1066 –1068). Correct answers to the November case (acute intermittent porphyria) were supplied by Sergio L. Pinski (Chicago, Illinois), Mark R. Goldstein (West Chester, Pennsylvania), Carlos Flombaum (Bronx, New York), Albert Most (Providence, Rhode Island), and Bijay N. Pandey (Belhaven, North Carolina). They will receive a free oneyear subscription to The American Journal of Medicine.
0002-9343/00/$–see front matter PII S0002-9343(99)00441-6
The correct answer will appear in the March issue of the Journal. The first five persons who submit correct answers will receive a free one-year subscription to the Journal. Colleagues of Dr. Matsumura in Kanazawa, Japan are not eligible for this month’s case. We will offer special recognition to the clinicians with the most correct answers at the end of the year. If you would like to contribute a case, please submit a brief synopsis (⬍250 words) to the editorial office. An individual may win only once per calendar year. Am J Med. 2000;108:168. 䉷2000 by Excerpta Medica, Inc.
A
ANSWER TO THE JANUARY CASE OF THE MONTH
19-year-old woman presented with a 7-day history of headache, right-sided neck pain, and fever (39.0⬚C) that began 4 days after her return to Japan from Thailand. While traveling, she had trekked in a forest near Chiang Mai. Her past medical history was unremarkable, and she had no pets. On physical examination, her temperature was 38.2⬚C, her blood pressure was 114/64 mm Hg, and her pulse was 78 beats per minute. She had a maculopapular rash on her face, right cervical lymphadenopathy, and an eschar behind her right ear. The remainder of the physical examination was normal. Laboratory evaluation showed a hemoglobin level of 12.6 g/dL, a leukocyte count of 4,400 per L (69% neutrophils, 21% lymphocytes, and 5% atypical lymphocytes) and a platelet count of 151,000 per L. A urinalysis was normal. The serum aspartate aminotransferase level was 69 U/L, the alanine aminotransferase level was 49 U/L, the lactate dehydrogenase level was 787 U/L, and the C-reactive protein level was 6.0 mg/L. Serum electrolyte and creatinine levels were normal. A chest radiograph and an abdominal ultrasound examination were normal. What is the most likely diagnosis?
168
䉷2000 by Excerpta Medica, Inc. All rights reserved.
Last month’s patient with persistent nausea and vomiting, delayed gastric emptying, and hyponatremia had a nonfunctioning pituitary adenoma leading to central adrenal insufficiency. She had an 8 AM cortisol level of 2.5 g/dL (normal: 5–25 g/dL). She also had evidence of mildly depressed thyroid function and estradiol deficiency; a prolactin level was normal. A computerized tomographic scan of the head showed a 2 ⫻ 2 ⫻ 1.7 cm pituitary mass. She underwent successful transsphenoidal surgery, and her symptoms resolved with hormone replacement. Dr. Kashyap, who submitted the case, pointed out that gastroparesis can be a rare manifestation of adrenal insufficiency (see Valenzuela GA et al. Reversibility of gastric dysmotility in cortisol deficiency. Am J Gastroenterol. 1987;82:1066 –1068). Correct answers to the November case (acute intermittent porphyria) were supplied by Sergio L. Pinski (Chicago, Illinois), Mark R. Goldstein (West Chester, Pennsylvania), Carlos Flombaum (Bronx, New York), Albert Most (Providence, Rhode Island), and Bijay N. Pandey (Belhaven, North Carolina). They will receive a free oneyear subscription to The American Journal of Medicine.
0002-9343/00/$–see front matter PII S0002-9343(99)00441-6