Case Questions Flashcards
A37-year-oldman is brought to the emergency department by his wife after having a seizure. He has a1-weekhistory of headaches, blurry vision in his right eye, and muscle painin his arms and neck. He has no history of a seizure disorder, and his vision was normal until the onset of his symptoms1 weekago. He has a history of migraine headaches that occur on a monthly basis and are relieved with ibuprofen.He immigrated from Ecuador6 yearsago and often returns to visit his family. He appears confused. His vital signs are within normal limits.Ophthalmologic examination shows subretinal cysts. An MRI of the brain showsmultiple small,ring-enhancinglesions in the parenchyma. A lumbar puncture is done;cerebrospinal fluid analysis shows numerous eosinophilsand a protein concentration of53 mg/dL. Which of the following is the most likely direct cause of infection in this patient?
A. Ingestion of larva from raw pork
B. Ingestion of undercooked fish
C. Inhalation of airborne spores
D. Ingestion of eggs from cat feces
E. Ingestion of eggs from dog feces
G. Ingestion of larval cysts from raw beef
H. Ingestion of eggs from human feces
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NERVOUS SYSTEM & SPECIAL SENSES: BLOCK 1
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A 37-year-old man is brought to the emer
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A 54-year-old man is brought to the emer
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SESSION
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QUESTION
SEE ANALYSIS
A54-year-oldman is brought to the emergency department because of progressive tingling and weakness in both of his legs for the past two days. The patient reports that his symptoms interfere with his ability to walk. Two weeks ago, he had anupper respiratory tract infection, which resolved spontaneously. His vital signs are within normal limits. Examination shows weakness in the lower extremities withabsent deep tendon reflexes. Reflexes are 1+ in the upper extremities. Sensation to pinprick and light touch is intact. Romberg’s test is negative. Laboratory studies show a leukocyte count of 12,000/mm3. Cerebrospinal fluid analysis results show:
Opening pressurenormalProtein200 mg/dLGlucose70 mg/dLWhite blood cells4/mm3
This patient is at increased risk for which of the following conditions?
TIPS

Paresthesiasaffectingdistalextremities and symmetric ascendingflaccid paralysisin combination with the laboratory findings (CSFwith a high protein level but normalWBCs, i.e.,albuminocytologic dissociation) is highly suggestive ofGuillain-Barré syndrome(GBS).
FEEDBACK
A
Dementia
B
Thymoma
C
Urinary incontinence
D
Respiratory failure
E
Hypertrophic cardiomyopathy
D. Respiratory failure
83%
A common and often devastating complication ofGuillain-Barré syndrome(GBS) isrespiratory failure, which can result if the ascending paralysis involves the respiratory muscles. For this reason, it is crucial to monitor respiratory function, as up to 30% of patients requiremechanical ventilation. While the majority of patients withGBSfully recover over time, ∼ 5% of patients withGBSdie because of acute complications such as respiratory paralysis, pulmonary infection,pulmonary embolism, or cardiac dysfunctio
A previously healthy 6-month-old boy is brought to the emergency department because of irritability and poor feeding for 6 days. He has also not had a bowel movement in 9 days and has been crying less than usual. He is bottle fed with formula and his mother has been weaning him with mashed bananas mixed with honey for the past 3 weeks. His immunizations are up-to-date. He appears weak and lethargic. He is at the 50th percentile for length and 75th percentile for weight. Vital signs are within normal limits. Examination shows dry mucous membranes and delayed skin turgor. There is poor muscle tone and weak head control. Neurological examination shows ptosis of the right eye. Which of the following is the most appropriate initial treatment?
ATTENDING TIPs
Considering the boy’s poor feeding, lack of bowel movements, weak head control, and exposure to honey, he most likely has botulism. Infant botulism is caused by Clostridium botulinum, spores of which may be present in honey. C. botulinum produces a toxin that is absorbed from the gut into systemic circulation. This toxin blocks the release of acetylcholine from the motor end plate, which causes neuromuscular blockade resulting in the symptoms seen here.
FEEDBACK
A. Human-derived specific immune globulin
B. Intravenous penicillin G
C. Intravenous gentamicin
D. Equine-derived antitoxin
E. Plasmapheresis
F. Pyridostigmine
A. Human-derived specific immune globulin
42%
Human-derived botulism immune globulin against the botulinum toxin is the treatment of choice for infant botulism in children < 1 year of age because the risk of a hypersensitivity reaction is lower than with equine-derived antitoxins.
A 34-year-old man with AIDS comes to the physician because of a 2-day history of decreasing vision and seeing black spots in his right eye. He has no pain and the left eye is asymptomatic. He was treated for fungal esophagitis 6 months ago with fluconazole. He was diagnosed with Kaposi’s sarcoma 2 years ago. Current medications include efavirenz, tenofovir, emtricitabine, azithromycin, trimethoprim-sulfamethoxazole, multivitamins, and a nutritional supplement. He is 170 cm (5 ft 7 in) tall and weighs 45 kg (99 lbs);BMI is 15.6 kg/m2. His temperature is 37°C (98.6°F), pulse is 89/min, and blood pressure is 110/70 mm Hg. Examination shows cervical lymphadenopathy. There are multiple violaceous plaques seen over his trunk and extremities. Fundoscopic examination shows granular yellow-white opacities around the retinal vessels and multiple areas of dot-blot hemorrhages. His CD4+ T-lymphocyte count is 36/mm3. Which of the following is the most likely diagnosis?
ATTENDING TIPs
This man with AIDS has an opportunistic infection that causes the retina to have a “pizza pie” appearance.
FEEDBACK
A. Cytomegalovirus retinitis
B. Herpes simplex keratitis
C. Toxoplasma retinitis
D. HIV retinopathy
E. Varicella zoster retinitis
A. Cytomegalovirus retinitis
CMV usually affects patients with CD4 counts below 50. Fundoscopic findings in CMV retinitis are described as a “pizza pie” appearance because of a distinct mixture of red and white lesions. The red spots are retinal hemorrhages. The white spots are fluffy/granular perivascular white opacities around retinal vessels and resemble cotton-wool spots. Vision is initially typically unaffected, but vision loss may occur if the retina detaches, or if the optic nerve or macula are affected.
