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Case of the month
Case of the Month Submitted by Glenn A. Hirsch, MD, Sanjay Saint, MD, MPH, and William D. Chey, 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 editors@ amjmed.org 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 August issue of the Journal. The first five persons who submit correct answers will receive a free oneyear subscription to the Journal. Colleagues of Dr. Hirsch in Ann Arbor, Michigan, are not eligible for this month’s case. 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;109:65. 䉷2000 by Excerpta Medica, Inc.
A
left upper quadrant of the abdomen that was internally heterogeneous and contained within the mesentery. There was a hiatal hernia, fluid in the posterior mediastinum and surrounding the stomach, and free intraperitoneal fluid, but no air. A repeat hemoglobin level after fluid resuscitation was 8.3 g/dL. What is the most likely diagnosis?
62-year-old woman with rheumatoid arthritis presented to the emergency department with the relatively sudden onset of fever, nausea, vomiting, and diarrhea. Her only medications were occasional nonsteroidal anti-inflammatory agents. On physical examination, her temperature was 37.6⬚C, blood pressure was 153/80 mm Hg, pulse rate was 94 per minute, and respiratory rate was 18 breaths per minute. The remainder of the examination was notable only for evidence of mild dehydration; the abdominal examination was normal. A complete blood count showed a leukocyte count of 16,600 per L (84% neutrophils, 11% lymphocytes, and 5% monocytes), a hemoglobin level of 15.7 g/dL, and a platelet count of 374,000 per L. A serum creatinine level was 0.5 mg/dL. She was treated with fluids; her symptoms resolved, and she was discharged to home. She returned the next day with the same symptoms; while being evaluated, she developed a cough and acute abdominal pain. Her vital signs were a temperature of 37.0⬚C, a blood pressure of 77/40 mm Hg, a pulse rate of 150 per minute, and a respiratory rate of 20 breaths per minute. She had diffuse abdominal tenderness with guarding; the stool was brown, but had evidence of occult blood. A complete blood count showed a leukocyte count of 18,600 per L (76% neutrophils, 18% lymphocytes, 5% monocytes, and 1% eosinophils), a hemoglobin level of 12.8 g/dL, and a platelet count of 369,000 per L. A serum creatinine level was 0.6 mg/dL. An abdominal ultrasound examination revealed an 8 ⫻ 5 ⫻ 12 cm heterogeneous mass that was anterior to (and compressing) the proximal abdominal aorta, which ranged from 6 to 7 mm in diameter. A computerized tomographic scan was notable for a mass in the
䉷2000 by Excerpta Medica, Inc. All rights reserved.
ANSWER TO THE MAY CASE OF THE MONTH Last month’s patient with a chylous pleural effusion and dystrophic nails had the yellow nail syndrome, usually characterized by the triad of dystrophic yellow nails, lymphedema, and pleural effusions, although not all patients have all three characteristics. Lymphoscintigraphy (in which colloidal antimony sulfide with 99mTc was injected into the web space between the great and second toes) showed defective lymphatic drainage to hypoplasia or aplasia of the lymphatic channels of the lower extremities. The disorder is of unknown pathogenesis (A Hershko et al. “Yellow nail syndrome.” Postgrad Med J. 1997; 73:466 – 468). Correct answers to the April case (Plummer-Vinson syndrome) were supplied by R. K. Marwah (El Paso, Texas), Ajit N. Babu (St. Louis, MO), Shirwan Mirza (Auburn, NY), N. A. Anthony (Washington, IL) and Daniel Goodenberger (St. Louis, MO). They will receive a free one-year subscription to the American Journal of Medicine.
0002-9343/00/$–see front matter 65 PII S0002-9343(00)00466-6
with a complete mailing address will be considered. The correct answer will appear in the August issue of the Journal. The first five persons who submit correct answers will receive a free oneyear subscription to the Journal. Colleagues of Dr. Hirsch in Ann Arbor, Michigan, are not eligible for this month’s case. 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;109:65. 䉷2000 by Excerpta Medica, Inc.
A
left upper quadrant of the abdomen that was internally heterogeneous and contained within the mesentery. There was a hiatal hernia, fluid in the posterior mediastinum and surrounding the stomach, and free intraperitoneal fluid, but no air. A repeat hemoglobin level after fluid resuscitation was 8.3 g/dL. What is the most likely diagnosis?
62-year-old woman with rheumatoid arthritis presented to the emergency department with the relatively sudden onset of fever, nausea, vomiting, and diarrhea. Her only medications were occasional nonsteroidal anti-inflammatory agents. On physical examination, her temperature was 37.6⬚C, blood pressure was 153/80 mm Hg, pulse rate was 94 per minute, and respiratory rate was 18 breaths per minute. The remainder of the examination was notable only for evidence of mild dehydration; the abdominal examination was normal. A complete blood count showed a leukocyte count of 16,600 per L (84% neutrophils, 11% lymphocytes, and 5% monocytes), a hemoglobin level of 15.7 g/dL, and a platelet count of 374,000 per L. A serum creatinine level was 0.5 mg/dL. She was treated with fluids; her symptoms resolved, and she was discharged to home. She returned the next day with the same symptoms; while being evaluated, she developed a cough and acute abdominal pain. Her vital signs were a temperature of 37.0⬚C, a blood pressure of 77/40 mm Hg, a pulse rate of 150 per minute, and a respiratory rate of 20 breaths per minute. She had diffuse abdominal tenderness with guarding; the stool was brown, but had evidence of occult blood. A complete blood count showed a leukocyte count of 18,600 per L (76% neutrophils, 18% lymphocytes, 5% monocytes, and 1% eosinophils), a hemoglobin level of 12.8 g/dL, and a platelet count of 369,000 per L. A serum creatinine level was 0.6 mg/dL. An abdominal ultrasound examination revealed an 8 ⫻ 5 ⫻ 12 cm heterogeneous mass that was anterior to (and compressing) the proximal abdominal aorta, which ranged from 6 to 7 mm in diameter. A computerized tomographic scan was notable for a mass in the
䉷2000 by Excerpta Medica, Inc. All rights reserved.
ANSWER TO THE MAY CASE OF THE MONTH Last month’s patient with a chylous pleural effusion and dystrophic nails had the yellow nail syndrome, usually characterized by the triad of dystrophic yellow nails, lymphedema, and pleural effusions, although not all patients have all three characteristics. Lymphoscintigraphy (in which colloidal antimony sulfide with 99mTc was injected into the web space between the great and second toes) showed defective lymphatic drainage to hypoplasia or aplasia of the lymphatic channels of the lower extremities. The disorder is of unknown pathogenesis (A Hershko et al. “Yellow nail syndrome.” Postgrad Med J. 1997; 73:466 – 468). Correct answers to the April case (Plummer-Vinson syndrome) were supplied by R. K. Marwah (El Paso, Texas), Ajit N. Babu (St. Louis, MO), Shirwan Mirza (Auburn, NY), N. A. Anthony (Washington, IL) and Daniel Goodenberger (St. Louis, MO). They will receive a free one-year subscription to the American Journal of Medicine.
0002-9343/00/$–see front matter 65 PII S0002-9343(00)00466-6