Cases from the Osler Medical Service at Johns Hopkins University

Presenting features

A 73-year-old man with a history of lung and bladder cancer presented to the emergency department complaining of 17 days of profound dyspnea on exertion, hoarseness, expiratory wheezes, and cough that was productive of scant white sputum. He denied having fever, hemoptysis, or chest pain. His symptoms started just after being discharged from another hospital where he had presented with urosepsis. His lung cancer was resected surgically more than 10 years ago, with no evidence of recurrence. He did not have a history of exposure to Mycobacterium tuberculosis. His baseline exercise tolerance was normal without any respiratory complaints.Physical examination revealed a thin man who had mildly labored breathing and who was not hypoxic. Monophonic wheezes were noted in the upper lung fields and over the trachea with a prolonged expiratory phase. Chest radiographs showed an elevated right hemidiaphragm consistent with his prior lung surgery, but no infiltrate. Plain film radiographs of the neck showed no narrowing or obstruction of the trachea. Ventilation-perfusion scanning was performed to look for pulmonary emboli. Ventilation scanning revealed severely decreased ventilation to the right lung (Figure 1), as well as marked retention of tracer material in the right lung at 5 minutes. A computed tomographic scan of the chest showed narrowing of the bronchus intermedius (Figure 2).What is the diagnosis?     

Cases from the Osler Medical Service at Johns Hopkins University

Presenting features

A 57-year-old man was seen because of an acutely painful middle finger. For 2 months he had had intermittent pain and numbness in the fingers of both hands that led him to stop operating a printing press at work. His medical history was remarkable only for a 40-year history of cigarette smoking. He was afebrile. Examination revealed an exquisitely tender third finger, cool beyond the proximal interphalangeal joint, with rubor and distal pallor (Figure 1). This and other digits demonstrated nailbeds with splinter hemorrhages (Figure 2). No Janeway lesions or Osler nodes were noted. Pulses were intact at the wrist. The results of initial routine laboratory tests, including an erythrocyte sedimentation rate, were normal. Transesophageal echocardiography revealed no source of embolization.What is the diagnosis?     

Cases from the Osler Medical Service at Johns Hopkins University

A 73-year-old man who had been receiving chronic anticoagulation treatment with warfarin for multiple prior strokes presented to the hospital because of several weeks of pain in his right calf. He also complained of several months of anorexia and weight loss of 20 lbs. On physical examination, he was thin and showed signs of temporal wasting. There was minimal pitting edema in the right leg, with a positive Homans' sign. Lower extremity Doppler ultrasound showed a popliteal thrombus. The morning after admission, he developed an acutely swollen, painful upper extremity and was found to have an occlusive clot in the left subclavian vein. Because these thrombi occurred in the setting of a therapeutic prothrombin time (international normalized ratio, 2.7) on warfarin, he was begun on treatment with intravenous heparin. What is the diagnosis?     

Cases from the Osler Medical Service at Johns Hopkins University

Presenting features

A 50-year-old Guatemalan man with no significant past medical history was admitted to the Barker Medical Service with weight loss over the past two weeks and fever for two days. His physical examination was remarkable for cachexia. His laboratory studies at presentation were notable for pancytopenia with a white blood cell count of 0.7 × 103/ml, hematocrit of 25% and platelet count of 8000. His admission chest radiography was normal. He had urine and blood cultures sent before beginning broad-spectrum antibiotic coverage with piperacillin/tazobactam and gatifloxacin. His peripheral blood smear is shown in Figure 1. What is the diagnosis?     

Cases from the Osler Medical Service at Johns Hopkins University

A 37-year-old woman presented with increasing abdominal pain and jaundice. Six weeks before admission, she developed persistent diarrhea and jaundice of the skin. She also bruised easily, and her gums bled. In the subsequent weeks, her appetite decreased, she was fatigued, and she had nausea, vomiting, and abdominal distension. She had a history of drinking 1 quart of vodka every day for 20 years, with brief periods of abstinence; she stopped consuming alcohol 11 days before admission because it no longer provided symptomatic relief. Her past medical history was also notable for depression, including a suicide attempt 4 years earlier. She did not smoke, use illicit drugs, or have unprotected sexual intercourse. She had received no blood transfusions and had not traveled recently. She took no medications, except for occasional ibuprofen. On physical examination, she was thin and deeply jaundiced, and she trembled and responded slowly to questions. She was afebrile but tachypneic, and she had orthostatic hypotension. Her HEENT examination was notable for scleral and sublingual icterus, as well as crusted blood on her gums and teeth. The jugular veins were flat. The cardiac examination revealed tachycardia (heart rate, 103 beats per minute) without murmurs, rubs, or gallops. The abdomen was nontender and protuberant, with hypoactive bowel sounds; the spleen was not palpable, and there was no fluid wave or caput medusae. The liver percussed to 18 cm, with a smooth edge extending 10 cm below the costal margin. She had cutaneous telangiectases on her chest and bilateral palmar erythema. There was no peripheral edema. The neurologic examination was notable for asterixis. Her stool was guaiac positive. Laboratory studies revealed the following values: hematocrit, 21.2%; white blood cells, 17,310/mm(3); ammonia, 42 micromol/L; serum creatinine, 3.9 mg/dL; serum urea nitrogen, 70 mg/dL; albumin, 2.1 g/dL; total bilirubin, 26.8 mg/dL; alanine aminotransferase, 14 U/L; aspartate aminotransferase, 77 U/L; alkaline phosphatase, 138 U/L; prothrombin time, 103 seconds (international normalized ratio, 10.6); and urinary sodium, <5 mg/dL. Urinalysis revealed an elevated specific gravity and numerous muddy granular casts. Hepatitis A, B, and C serologies were negative. On abdominal ultrasound examination, there was no ascites, and the liver was echogenic. The portal and hepatic veins were patent, and the hepatic arteries were normal. The spleen measured 14 cm. What is the diagnosis?     

Cases from the Osler Medical Service at Johns Hopkins University

PRESENTING FEATURES: A 70-year-old African American man was admitted with a history of fever, chills, and malaise of several days' duration. His past medical history was notable for end-stage renal disease requiring hemodialysis, coronary artery disease, and aortic stenosis requiring a bioprosthetic aortic valve replacement. On the day of admission, the patient was noted to have a shaking chill while undergoing dialysis through his catheter and was admitted to the hospital. He complained of pain at the catheter insertion site, shortness of breath, and dyspnea on exertion, but denied chest pain. On physical examination, the patient had a temperature of 100.4 degrees F, with a heart rate of 64 beats per minute, blood pressure of 127/72 mm Hg, and an oxygen saturation of 97% on room air. He was a mildly obese man in no apparent distress. He had shotty cervical lymphadenopathy and a right subclavian dialysis catheter in place, with erythema and pus at the entry site. His jugular venous pressure was 10 cm H(2)O. Lung examination showed bibasilar rales. Heart sounds were normal, with no rub or gallop. He had a 2/6 systolic ejection murmur best heart at the left sternal border as well as a 3/6 holosystolic murmur at the apex that radiated to his left axilla. Examination of the abdomen and extremities was unremarkable. The patient's neurological examination was unremarkable, and he was alert and oriented to person, place, and time. Laboratory studies showed an elevated white blood cell count of 16,700 cells/microL. His blood urea nitrogen level was 43 mg/dL and his serum creatinine level was 4.9 mg/dL. Multiple blood cultures grew methicillin-resistant Staphylococcus aureus. An admission, chest radiograph showed no infiltrate. An admission electrocardiogram showed normal sinus rhythm with first degree atrioventricular block, left anterior fascicular block, and left ventricular hypertrophy. shows rhythm strips from lead II electrocardiograms 5 months before admission (top), on admission (middle) and 5 days after admission (bottom). What is the diagnosis?     

Cases from the Osler Medical Service at Johns Hopkins University

Presenting features

A 41-year-old man with a past history of alcohol abuse, drug abuse, and smoking (>40 pack-years) presented with chronic epigastric pain and weight loss. During the preceding year, the epigastric pain had worsened progressively and was exacerbated by eating. For the past 3 months, his nausea and vomiting had worsened so that he was no longer able to tolerate solid food. Consequently, he had lost 50 lbs in 1 year. During the 3 weeks before admission, he had daily subjective fevers but no night sweats. He denied any melena, hematemesis, jaundice, or changes in stool color or consistency.His past medical history was remarkable for an episode of massive hematemesis, for which he was admitted to another hospital 3 months ago and found to have a bleeding gastric ulcer. Despite treatment with a proton pump inhibitor, his abdominal pain, nausea, and vomiting worsened after dis-charge. He stopped drinking alcohol after that hospitalization, and he stopped using intravenous drugs 1 month before this admission.On physical examination, the patient appeared wasted. His vital signs were notable for a normal blood pressure with resting tachycardia and an orthostatic increase in pulse rate. His jugular veins were flat. Cardiac and respiratory examinations were normal. The abdominal examination revealed guarding in the epigastric region with hypoactive bowel sounds and no rebound tenderness. His stool was guaiac negative. Laboratory studies revealed a total white blood cell count of 4180/mm³, a hematocrit of 33.1%, a platelet count of 239,000/mm³, a total protein level of 8.3 g/dL, an albumin level of 3.7 g/dL, and antibodies to human immunodeficiency virus (HIV). A computed tomographic scan of the abdomen showed thickening of the antrum with large gastric folds.What is the diagnosis?     

Cases from the Osler Medical Service at Johns Hopkins University

Presenting features

A 50-year-old African American woman presented with bilateral lower extremity pain, a history of falls during the past several months, and personality and behavior changes. She had been in good health until approximately 5 months before admission, when she began to fall with increasing frequency, often while going down a flight of stairs. She described these falls as her “legs giving out” and feeling very heavy and unsteady. There was no head trauma or loss of consciousness. Her daughter noticed that her gait had become somewhat unsteady during the last several months. Her family also noted a change in her personality at this time. Previously, she had been a very tidy person who took great care with her appearance, who was working as a customer service representative. However, she had become less social and very withdrawn. She had been observed putting on dirty clothes after showering, as well as eating constantly. The patient denied any fevers, chills, night sweats, headaches, vision changes, or tinnitus. She also denied any rashes, muscle pain, or intolerance to heat or cold. There was no history of seizure disorder or depression. Her past medical history was notable only for hypertension and being a passenger in a motor vehicle crash 1 year before admission. She denied any alcohol, tobacco, or illicit drug use, and had no travel history other than coming to the United States, as she was originally from Trinidad.On physical examination, she was a moderately obese African American woman with a flat affect, psychomotor slowing, and alopecia of the scalp. She was alert and oriented to person, place, and time, but had a score of 26 out of 30 on the Mini-Mental State Examination. She lost points only for recall; she had no difficulty with serial 7s. Her cranial nerves were intact and her speech was fluent, although sparse, and she did not make any paraphasic errors. Her muscle strength was 5/5 in both the upper and lower extremities. Reflexes were 2+ in the upper extremities and 1+ in the lower extremities, and toes were downgoing bilaterally. She had intact sensation to light touch and pinprick, but markedly diminished proprioception of her lower extremities bilaterally. She had a wide-based gait with a positive Romberg sign and was markedly ataxic. Rectal examination yielded a positive guaiac test with brown stool, normal tone, and no masses. The remainder of the physical examination was normal.Laboratory studies revealed pancytopenia with a hematocrit of 22.7% and a mean corpuscular volume of 118.2 fL. A peripheral smear that was performed on admission, prior to transfusion, revealed macrocytic red cells and hypersegmented neutrophils.     

Cases from the Osler Medical Service at Johns Hopkins University

PRESENTING FEATURES: An 85-year-old black woman presented to the Osler Medical Service complaining of a pruritic, erythematous scaly rash that was on her right thigh and abdomen and that had been worsening over the prior 3 months. She also complained of increasing fatigue, decreased exercise tolerance, and a 5-lbs weight loss. There was no orthopnea, paroxysmal nocturnal dyspnea, fevers, chills, or night sweats. She denied recent travel and exposures to or contact with ill people. Her past medical history was unremarkable. There was no history of eczema, atopy, or dermatologic conditions. Her only medication was a baby aspirin taken daily. On physical examination, she was afebrile, her blood pressure was 110/72 mm Hg, and her pulse was 82 beats per minute with a room air oxygen saturation 98%. She was mildly obese but in no apparent distress. She had 1-cm anterior cervical lymphadenopathy bilaterally and a 1-cm left axillary lymph node. Cardiovascular and chest examination was unremarkable. Her abdomen was soft and nontender, with a faint, erythematous rash that was mildly scaly but nontender in her abdominal skin fold. Her right thigh showed a large erythematous area, approximately 15 x 20 cm, which was scaly with multiple areas of discoloration (Figure 1). There was no palpable mass. She had slight edema in her right leg. Her left thigh was normal. Neurologic examination was nonfocal. Laboratory studies were notable for a white blood cell count of 17,000 cells/microL, with a differential of 46% lymphocytes. The absolute lymphocyte count was 8000 cells/microL. Hematocrit was 28%. Platelet count was normal. A comprehensive metabolic panel was normal. A peripheral blood smear (Figure 2) showed numerous atypical lymphocytes with cerebriform nuclei. Peripheral blood flow cytometry showed the presence of a clonal population of T cells that expressed CD4 and CD5 but showed a loss of CD7. What is the diagnosis?     

Cases from the Osler Medical Service at Johns Hopkins University

A 47-year-old white woman with a history of stage III squamous cell carcinoma of the anus was transferred to Johns Hopkins Hospital for further evaluation of renal failure, hemolytic anemia, and thrombocytopenia. The patient was first diagnosed with squamous cell carcinoma of the anus 1 year before admission. She was treated with external beam radiation of the pelvis and two cycles of mitomycin C-based chemotherapy (a cumulative dose, 34 mg/m(2)). Her clinical course was complicated by Clostridium difficile colitis and myositis successfully treated with prednisone. Three months before admission, the patient developed dysuria. Her creatinine increased from normal to 1.7 mg/dL, and microscopic hematuria was present. A renal ultrasound and an abdominal computed tomographic scan showed no abnormalities or obstruction. One month before admission, she underwent a cystoscopy, which showed only radiation-induced changes in the bladder. Two weeks before admission, the patient became delirious and was taken to a hospital, where she was found to be anemic, with a hematocrit level of 23.7%, and thrombocytopenic with a platelet count of 110,000/mm(3). Her creatinine level was 5.9 mg/dL. Previous values of hematocrit, platelet count, and serum creatinine were normal. On admission at Johns Hopkins Hospital the patient had no complaints. She was afebrile on physical examination and had normal vital signs. Head, neck, chest, cardiovascular, and abdominal examinations were normal. There was skin pallor, but no echymoses or petechiae. She was alert and oriented with normal mental status. Her neurologic examination was normal. Laboratory data showed a white blood cell count of 6390/mm(3), a hematocrit level of 26.5%, and a platelet count of 26,000/mm(3). Her blood urea nitrogen level was 57 mg/dL, creatinine level was 4.0 mg/dL, and lactate dehydrogenase was 550 U/L (reference, 115 to 275 U/L). Urinalysis showed innumerable red blood cells and large protein. A peripheral blood smear showed fragmented red blood cells, schistocytes, no abnormal white blood cells, and few platelets. There was no radiographic or clinical evidence of relapse of her squamous cell carcinoma. What is the diagnosis?     

Cases from the Osler Medical Service at Johns Hopkins University

Presenting features

A 66-year-old man with a history of alcohol-induced cirrhosis was admitted to the Johns Hopkins Hospital with the chief complaints of jaundice and lower extremity swelling. Three weeks before admission, he first noticed gradually worsening jaundice and leg swelling, as well as abdominal distension, fatigue, and anorexia. He denied nausea, vomiting, fevers, night sweats, diarrhea, abdominal pain, hematemesis, hematochezia, and melena.His past medical history was remarkable only for the diagnosis of cirrhosis 8 years before admission, when he had presented with a bleeding esophageal varix. At that time, he decided to abstain from alcohol permanently but to continue smoking cigarettes. His medications at the time of the current admission included spironolactone, megestrol acetate, furosemide, propranolol, pantoprazole, and metoclopramide.On physical examination, he appeared markedly jaundiced and fatigued. He had both scleral and sublingual icterus as well as multiple facial telangiectasias and a right epicanthal xanthoma. His heart and lung examinations were unremarkable. His abdomen was distended but soft and nontender with no organomegaly. He had a palpable fluid wave, shifting dullness, and caput medusae, but no spider angiomata or gynecomastia. His lower extremities showed 2+ pitting edema extending to the lower abdomen. There was no palmar erythema, asterixis, or evidence of hepatic encephalopathy.Initial laboratory studies revealed the following: serum sodium, 130 mEq/L; chloride, 93 mEq/L; ammonia, 97.1 μg/dL; aspartate aminotransferase, 250 U/L; alanine aminotransferase, 102 U/L; alkaline phosphatase, 672 U/L; albumin, 2.8 g/dL; and total bilirubin, 23.6 mg/dL, with a direct fraction of 17.2 mg/dL. The hematocrit was 36.4% with a normal mean corpuscular volume and normal coagulation times. Paracentesis revealed transudative fluid with 303 white blood cells (67% neutrophils), a lactate dehydrogenase level of 93 U/L, a total protein level of 1.4 g/dL, and an albumin level of 0.7 g/dL (serum ascites to albumin gradient, 2.1 g/dL). Hepatitis serologies were negative and the serum alfa-fetoprotein level was 52 ng/mL.A right upper quadrant ultrasound showed ascites around a shrunken, nodular liver with a coarse, heterogeneous echo texture, as well as echogenic material in the region of the portal vein with no portal blood flow. A computed tomographic (CT) scan of the abdomen with three-dimensional reconstruction following the administration of intravenous contrast material (Figures 1 and 2) revealed innumerable indeterminate hypodense lesions measuring 1 cm or less scattered diffusely throughout the liver. In addition, the portal vein was markedly dilated with evidence of thrombus extending both intrahepatically and extrahepatically to the portal confluence.What is the diagnosis?     

Cases from the Osler Medical Service at Johns Hopkins University

Presenting features

A healthy 44-year-old man presented to the Johns Hopkins Hospital after two episodes of nonpurulent hemoptysis, each consisting of approximately one-half cup of blood. The episodes were painless and were preceded by minimal coughing. The blood was bright red and without clots. He denied a recent history of upper respiratory tract infection, chest trauma, chest pain, or nasal/sinus disease. He had a chronic nonproductive “smoker’s cough.” He denied a recent history of fevers, chills, night sweats, hematuria, joint pains, epistaxis, or weight loss, and had no allergies. His past medical history was notable for neurogenic diabetes insipidus and diet-controlled diabetes mellitus. His only medication was intranasal desmopressin acetate. He smoked two packs of cigarettes daily for more than 20 years and rarely drank alcohol.On physical examination, he was afebrile, with normal heart rate and blood pressure. His oxygen saturation was 94% on room air, and his respiratory rate was 16 beats per minute. His lungs were clear to auscultation bilaterally, without evidence of crackles or wheezes. He had bilateral digital clubbing. His white blood cell count was 10,770/mm³, with a normal differential. His hematocrit was 46%, and his platelet count was normal. Blood chemistries and urinanalysis were normal. A posteroanterior and lateral chest radiograph obtained on admission demonstrated moderate diffuse interstitial fibrosis involving the upper and lower lung (Figure 1A and 1B ). What is the diagnosis?     

Cases from the Osler Medical Service at Johns Hopkins University

PRESENTING FEATURES: An 18-year-old white man was admitted to the Osler Medical Service with the chief complaint of back pain. Two weeks prior to admission, the patient developed diffuse and aching upper back pain. Over the next couple of days, he also developed severe anterior chest pain that was somewhat pleuritic in nature but diffuse and extending bilaterally into the shoulders. One week prior to admission, he developed intermittent fevers and night sweats. The patient denied any lymphadenopathy, pharyngitis, sick contacts, shortness of breath, rash, or bleeding. He was seen by a physician and told that he had thrombocytopenia. There was no history of recent or remote unusual bleeding episodes. His medical history was unremarkable except for a childhood diagnosis of attention deficit/hyperactivity disorder. He was not taking any medications and had no history of tobacco, alcohol, or illicit drug use. He had no risk factors for human immunodeficiency virus infection. Physical examination showed that he was afebrile and had normal vital signs. He was a well-appearing man who was lying still because of pain. HEENT examination was unremarkable. There was no pharyngeal erythema or exudates. His lungs were clear. His neck was supple and without lymphadenopathy. Examination of his back and chest revealed no focal tenderness. There was no hepatosplenomegaly, and his skin was without petechiae or rashes. Examination of the patient's joints showed pain on passive and active movement of his shoulders bilaterally, but no frank arthritis. There was no rash, petechiae, or echymoses. Chest radiograph and electrocardiogram were unremarkable. On admission, the laboratory examination was notable for a hematocrit level of 32.5%, with a mean corpuscular volume of 79 fL, and white blood cell count of 2.8 x 10(3)/microL. Platelet count was 75 x 10(3)/microL. A white blood cell differential revealed 7% bands, 53% polys, 34% lymphs, 5% atypical lymphocytes, 2% nucleated red cells, and a few young unidentified cells. His chemistry studies were unremarkable. What is the diagnosis?     

Cases from the Osler Medical Service at Johns Hopkins University. Herpetic keratitis

Presenting features

A 38-year-old man with a history of intravenous drug use was admitted to the hospital for treatment of an arm abscess. He noted that his right eye was “blood shot” and painful, but denied recent ocular trauma. He had photophobia and felt that his vision had become worse. Physical examination revealed a red right eye; there was hyperemia of the conjunctiva without surrounding vesicles, and the cornea was cloudy (Figure 1). Visual acuity was normal in the left eye but decreased (20/200) in the right eye. Fundoscopic examination was otherwise unremarkable. The rest of the physical examination was normal except for a tender painful swelling and cellulitis on the left forearm. Laboratory findings revealed antibodies to human immunodeficiency virus (HIV).What is the diagnosis?     

Cases from the Osler Medical Service at Johns Hopkins University. Zieve syndrome

Presenting features

A 47-year-old African American man was admitted to the Osler Medical Service with a chief complaint of light-headedness. He was a heavy drinker and consumed 2 pints of fortified wine every day. On the day of admission, he had been at home consuming alcohol when he stood up, became lightheaded, and immediately had to sit down. He denied any loss of consciousness, dyspnea, hematemesis, coffee-ground emesis, lower abdominal pain, bright red blood per rectum, or melena, but he recalled a burning epigastric discomfort. The patient's medical history was notable only for a 20-year history of hypertension and recently diagnosed type 2 diabetes mellitus. He was not taking any medications. He had a normal hematocrit of 43% 6 months prior to admission.Physical examination showed a supine heart rate of 115 beats per minute and blood pressure of 165/90 mm Hg, without orthostatic changes. There was scleral icterus and a jaundiced palate, but no other stigmata of end-stage liver disease. His abdominal examination was unremarkable; there were no masses, tenderness, or hepatosplenomegaly. Rectal examination revealed guaiac-negative stool. The chest radiograph and electrocardiogram were unremarkable.On admission, the laboratory examination was notable for the following values: hematocrit, 22.8% with a mean corpuscular volume of 86.7 fL and a red cell distribution width of 25.7%; absolute reticulocyte count, 177,500/mm³; total bilirubin, 4.2 mg/dL; direct bilirubin, 2.3 mg/dL; albumin, 3.3 g/dL; lactate dehydrogenase, 481 U/L; aspartate aminotransferase, 106 U/L; and alanine aminotransferase, 44 U/L. The prothrombin and activated partial prothrombin times were normal. There was no evidence of iron, vitamin B₁₂, or folate deficiency. The patient's haptoglobin level was severely depressed (<6 mg/dL) with a negative direct Coomb test and normal glucose-6-phosphate dehydrogenase activity. A peripheral blood smear was compatible with hemolysis and demonstrated normocytic, normochromic erythrocytes with moderate poikilocytosis, as well as rare spherocytes and target cells Figure 1).On the second day of hospitalization, a lipid panel revealed hypercholesterolemia with a total cholesterol level of 300 mg/dL. Due to the patient's complaint of burning epigastric pain and long history of alcohol consumption, esophagogastroduodenoscopy was performed and revealed grade 1 nonbleeding esophageal varices.What is the diagnosis?