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Case of the month
Case of the Month Submitted by A. S. Kashyap, MD Each month, we will present a challenging Case of the Month for 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/ ajmselect). Several possible answers may be consistent with the case presentation; use your best judgment. Please send your answer (one per respondent) to The Green Journal at [email protected] or via FAX to (415) 447-2799. Indicate the case to which you are responding and include your complete address. The correct answer will appear in the next issue of the
Journal. The first five readers who submit correct answers will receive a free one-year subscription to the Journal. Because of the volume of answers we receive, neither correct nor incorrect answers can be acknowledged individually. Colleagues of Dr. Kashyap at the Armed Forces Medical College in Pine, India, 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. Am J Med. 2001;110:401. 䉷2001 by Excerpta Medica, Inc.
A
glycol, and propylene glycol was negative. A urine pyroglutamic acid level was 488 mmol/mol creatinine. What is the most likely diagnosis? What other condition is the patient likely to have?
55-year-old man was being treated for osteoarthritis of the knees with acetaminophen 1,000 mg every 6 hours and diazepam 5 mg twice a day. He had no other medical problems and took no other medications. He did not drink alcohol or use illicit drugs. The patient was referred for medical consultation because he complained of feeling poorly and had developed abnormal breathing and an unusual odor on his breath. On physical examination, his pulse and blood pressure were normal; his respiratory rate was 20 breaths per minute in a Kussmaul pattern; a fruity odor was noted. The rest of the physical examination was normal. An electrocardiogram, complete blood count, and serum levels of glucose, lactate, and creatinine were normal. A serum bicarbonate level was 14 mEq/L and the anion gap was 28 mEq/L. A beta-hydroxybutyrate level was 5.8 mmol/L. The serum acetaminophen level was in the therapeutic range. A serum toxicology screen for alcohol, salicylates, ethylene
䉷2001 by Excerpta Medica, Inc. All rights reserved.
ANSWER TO THE PREVIOUS CASE OF THE MONTH Last month’s patient with weakness and a thigh mass had oncogenous osteomalacia due to a benign hemangiopericytoma. A bone biopsy disclosed osteomalacia. She was treated initially with oral phosphate and 1,25-dihydroxycholecalciferol. Her symptoms and biochemical abnormalities resolved after resection of the mass. Correct answers to the January case (Caroli’s disease) were supplied by previous winners who are not eligible for free subscriptions.
0002-9343/01/$–see front matter 401 PII S0002-9343(01)00669-6
Journal. The first five readers who submit correct answers will receive a free one-year subscription to the Journal. Because of the volume of answers we receive, neither correct nor incorrect answers can be acknowledged individually. Colleagues of Dr. Kashyap at the Armed Forces Medical College in Pine, India, 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. Am J Med. 2001;110:401. 䉷2001 by Excerpta Medica, Inc.
A
glycol, and propylene glycol was negative. A urine pyroglutamic acid level was 488 mmol/mol creatinine. What is the most likely diagnosis? What other condition is the patient likely to have?
55-year-old man was being treated for osteoarthritis of the knees with acetaminophen 1,000 mg every 6 hours and diazepam 5 mg twice a day. He had no other medical problems and took no other medications. He did not drink alcohol or use illicit drugs. The patient was referred for medical consultation because he complained of feeling poorly and had developed abnormal breathing and an unusual odor on his breath. On physical examination, his pulse and blood pressure were normal; his respiratory rate was 20 breaths per minute in a Kussmaul pattern; a fruity odor was noted. The rest of the physical examination was normal. An electrocardiogram, complete blood count, and serum levels of glucose, lactate, and creatinine were normal. A serum bicarbonate level was 14 mEq/L and the anion gap was 28 mEq/L. A beta-hydroxybutyrate level was 5.8 mmol/L. The serum acetaminophen level was in the therapeutic range. A serum toxicology screen for alcohol, salicylates, ethylene
䉷2001 by Excerpta Medica, Inc. All rights reserved.
ANSWER TO THE PREVIOUS CASE OF THE MONTH Last month’s patient with weakness and a thigh mass had oncogenous osteomalacia due to a benign hemangiopericytoma. A bone biopsy disclosed osteomalacia. She was treated initially with oral phosphate and 1,25-dihydroxycholecalciferol. Her symptoms and biochemical abnormalities resolved after resection of the mass. Correct answers to the January case (Caroli’s disease) were supplied by previous winners who are not eligible for free subscriptions.
0002-9343/01/$–see front matter 401 PII S0002-9343(01)00669-6