Tongue`s surface in Prolonged antibiotic use

Which of the following conditions is the skin finding shown in the picture associated with?

• A) Prolonged antibiotic use
• B) Sjögren's syndrome
• C) Addison's disease
• D) Chronic gastroesophageal reflux
• E) Malignant melanoma

The answer is A. 

(Black tongue) Black hairy tongue results from hyperplasia of the filiform papillae with deposition of keratin on the surface. The condition causes the tongue to have ..............

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malignant external otitis

 A 72-year-old patient withlong-standing Type 2 diabetes mellitus presents with complaints of pain in his right ear with purulent drainage. On physical exam, the patient is afebrile. The pinna of the left ear is tender, and the external auditory canal is swollen and edematous. The peripheral white blood cell count is normal. The organism most likely to grow from the purulent drainage is :

• a. Pseudomonas aeruginosa
• b. Staphylococcus aureus
• c. Candida albicans
• d. Haemophilus influenzae
• e. Moraxella catarrhalis

 The answer is a.

Ear pain and drainage in an elderly diabetic patient must raise concern about malignant external otitis. Presence of swelling and inflammation of the external auditory meatus strongly suggests this diagnosis. This infection usually occurs in older diabetics and is almost always caused by organism Pseudomonas aeruginosa.

Haemophilus influenzae and Moraxella catarrhalis frequently cause otitis media but not external otitis.

Acute otitis externa with the canal somewhat narrowed from edema and obstructed by desquamating epithelium, soft cerumen, and purulent discharge; this must be removed to visualize the tympanic membrane and to allow ototopical therapy to penetrate to all the superficially infected areas of the canal skin.

Superior vena cava syndrome

A 72-year-old man who was overweight and had a history of hypertension and heavy smoking presented with a swollen neck. He had no dysphagia. He reported that he had experienced increased snoring and daytime sleepiness during the previous 3 weeks.
An otolaryngologic examination was unremarkable except for an unusually narrow upper airway. On inspection, the patient's hands were swollen and showed signs of pitting edema (Figure 1A). Inflammatory parameters and complete blood count were normal.

Contrast-enhanced computed tomography scans of the neck and chest revealed an enlarged retropharyngeal space (Figure 1B) and a mass compressing the superior vena cava (Figure 1C). A transthoracic needle biopsy showed a non–small-cell carcinoma. Radiotherapy resulted in clinical improvement and a rapid reduction in compression of the superior vena cava.

The exact incidence of superior vena cava syndrome remains unknown, It has mainly malignant causes.
Nonmalignant causes can include aneurysm of the aorta, thromboses after implanted intravascular catheters or fibrosing mediastinitis.

Classically, compression of the superior vena cava leads to visible swelling and venous distension in the face, neck, chest and upper limbs. Other symptoms of varying severity can occur, from cough, hoarseness and dyspnea to headache, confusion and visual symptoms. In patients who are overweight, swelling of the neck may go unnoticed, and signs such as obstructive sleep apnea or edema of the upper limb may point to the diagnosis.

Characteristic shape of Molluscum contagiosum infection

A 4-year-old preschooler presents with the skin lesions shown here. The area affected is just below the chin on the child's right side. The lesions have been present over the last month, and the child has reported no symptoms associated with them. The most likely diagnosis is

• A) varicella


• B) herpes zoster


• C) Rhus dermatitis


• D) molluscum contagiosum


• E) scabies

 The answer is D. (Molluscum contagiosum) 

Molluscum contagiosum is a common, superficial viral infection of the skin that typically occurs in infants and preschoolers. The incidence decreases after the age of 6 to 7 years. The condition can be spread via sexual contact in young adults.
The lesions are dome-shaped, waxy, or pearly-white papules with a central white core and are 1 to 3 mm in diameter. Frequently, groups of lesions are found. The lesions may resolve spontaneously. Treatment involves removal with a sharp needle or curette, application of liquid nitrogen, antiwart preparations, electrodessication and curettage, or trichloroacetic peels for extensive areas. Typically, infants or young preschool-age children should not be treated aggressively.

Typical flesh-colored, dome-shaped and pearly lesions

Uvular Necrosis after Endoscopy

This 28-year-old man presented with a sore throat 72 hours after undergoing upper endoscopy. The patient had a 6-month history of intermittent solid-food dysphagia; upper endoscopy revealed a Schatzki ring. A wire was placed endoscopically, and a 20-mm Savary dilator was passed over the wire uneventfully.
The patient felt well after the procedure and was discharged home. He noted a mild sore throat, starting 24 hours after the procedure. When it persisted, he presented for evaluation.
Physical examination revealed necrosis of the distal uvula. No specific therapy was given, and acetaminophen was recommended for discomfort. The patient reported that the tip of the uvula spontaneously sloughed off the next day, and the discomfort resolved completely. He has had no further solid-food dysphagia.

Uvular necrosis is a rare event that can occur after upper endoscopy or direct laryngoscopy. The symptoms are generally mild, and the recovery is usually complete. The mechanism of injury is thought to be impingement of the uvula by the instrument against the hard palate or posterior pharynx, leading to ischemia. Uvular injury has also been reported as a result of aggressive oropharyngeal suctioning.

Thoracic Kidney

A 74-year-old man with diabetes and hypertension was referred to the hospital for evaluation of a mass in the right side of the chest, identified on a radiograph (Panel A, arrows). He reported no pulmonary problems and no history of chest trauma. Physical examination was unremarkable. Reformatted coronal (Panel B) and sagittal (Panel C) computed tomographic scans show the right kidney (large arrows) and part of the liver protruding above the diaphragm (small arrows) and into the posteromedial aspect of the right hemithorax through the foramen of Bochdalek (arrowheads indicate the defective fusion of the diaphragm).

Thoracic kidney is a rare congenital anomaly. Because of the location of the liver, thoracic kidney on the right side is much less common than thoracic kidney on the left side. Thoracic kidney is twice as common in men as in women. Typically, the presence of a thoracic kidney is asymptomatic and requires no intervention, as in this case.

Triad of Kartagener syndrome

 A 14-year-old boy presents with a history of chronic sinusitis and frequent pneumonias. On physical examination, the patient has normal vital signs and is afebrile. He has mild frontal and maxillary sinus tenderness with palpation. Transillumination of the sinuses is normal. Heart sounds are best heard on the right side of the chest. The boy is coughing copious amounts of yellowish sputum. Which of the following is the most likely diagnosis?

• a.Cystic fibrosis
• b.Kartagener syndrome
• c.Pulmonary dysplasia
• d.Tuberculosis
• e.Pulmonary hypertension

 The answer is b."Kartagener syndrome"
Kartagener syndrome is the inheritable disorder of dextrocardia, chronic sinusitis (with the formation of nasal polyps), and bronchiectasis. Patients may also present with situs inversus.The disorder is due to a defect that causes the cilia within the respiratory tract epithelium to become immotile. Cilia of the sperm are also affected.

Frontal and Chest x-ray showing dextrocardia "the typical radiographic sign of Kartagener's syndrom" and bronchiectasis.

Dumping syndrome after peptic ulcer surgery

A 44-year-old man with a history of peptic ulcer surgery presents with palpitations, tachycardia, lightheadedness, and diaphoresis after eating a meal. The symptoms typically begin 30 min after eating.Which of the following is the most likely diagnosis?

• a.Malabsorption
• b.Peptic ulcer recurrence
• c.Gastric carcinoma
• d.Gastritis
• e.Dumping syndrome
• f.Esophagitis

The answer is (e).

Some patients with a history of ulcer surgery experience the dumping syndrome 30 min after eating. They present with palpitations, tachycardia, lightheadedness, and diaphoresis after eating a meal due to the rapid emptying of hyperosmolar gastric contents into the small intestine.
Dumping syndrome is also called rapid gastric emptying which occurs when the undigested food bypass the  stomach and transported or "dumped" into the small intestine too rapidly.

Common sites for Morton's neuromas

Morton's Neuroma is a painful condition of the forefoot that is caused by the entrapment of the common intermetatarsal nerve as it passes through the forefoot to the toes. Morton's Neuroma was first described by Dr. Morton, a Viennese physician, in 1876.
Where are most Morton's neuromas found?

A) In the tarsal tunnel
B) At the first metatarsal phalangeal joint
C) The second and third interdigital space
D) At the attachment of the plantar fascia
E) At the head of the fifth metatarsal

Answer and Discussion

The answer is C.

The interdigital spaces of the foot are common sites for painful neuromas, a condition termed Morton's neuroma. The second and third common digital branches of the medial plantar nerve are the most frequent sites for development of interdigital neuromas. Morton's neuromas develop as a result of chronic trauma and repetitive stress, as occurs in persons wearing tight-fitting or high-heeled shoes. Pain and paresthesias are usually mild at onset and are located in the interdigital space of the affected nerve. In some cases, the interdigital space between the affected toes may be widened as a result of an associated ganglion or synovial cyst. Pain is noted in the affected interdigital space when the metatarsal heads of the foot are squeezed together. Injection with 1% lidocaine (Xylocaine) can assist in confirming the diagnosis.

The symptoms of Morton's neuroma include the following;

• A dull achy sensation in the forefoot, usually between the 3rd and 4th toes.
• Pain that increased with the time a person spends on their feet, particularly in high heels and narrow fitting shoes.
• Pain that is not relieved by rest. Neuroma pain takes several minutes to hours to subside.
• Numbness of the 3rd and 4th toes.
• A sensation of walking on something, such as a bunched up sock
• .Occasionally, a snapping sensation or electrical shock sensation (Muldier's Sign).

The digital nerve(1) running in the narrow space between the metatarsal bones where it splits into two(2) and where a Mortons Neuroma is usually found.

Review this baby; IS IT A BOY OR A GIRL?

History

A midwife calls the neonatal intensive care unit asking for an urgent review of a baby born 10 minutes ago. At delivery they thought it was a boy and said this to the parents. Now they are not so sure because although the baby appears to have a penis, there is no obvious scrotum and they cannot feel the testes. The baby seems otherwise normal and there was nothing remarkable about the pregnancy. It is the parents’ first child.

Examination

There are no dysmorphic features and examination of the cardiovascular, respiratory and abdominal systems are normal. The weight is 3.1 kg. There is a 1.5 cm phallus (normal in term newborn males 2.5 cm) with a single perineal opening at the base of the phallus "which is a penis-shaped object such as a dildo, or a mimetic image of an erect penis". There is pigmentation of the labioscrotal folds, which are fused with no obvious vaginal opening. There are no palpable gonads, including in the inguinal canals. The anus is normally positioned. The baby’s external genitalia can be seen in the figure below.

 Questions Are :

•  Is this a boy or a girl?
•  What is the most likely diagnosis and the differential?
•  What investigations are needed?

Case Discussion

At this stage, no one can or should say whether this baby is a boy or a girl. It is imperative not to guess as it could be either a virilized female (a normal girl exposed in utero to excess androgens) or an undervirilized male. Disorders of sexual differentiation (DSD) are a medical and social emergency and families find it exceptionally difficult not knowing the sex of their baby. Pending urgent tests they should not name the baby or register the birth.
In the absence of palpable gonads, but with evidence of virilization with a small phallus and pigmentation, it is most likely that this is a virilized female. Much the commonest aetiology is congenital adrenal hyperplasia (CAH).

If the baby is an undervirilized male,there is a much larger differential, including disorders of gonadotrophin production (e.g. Kallman syndrome), defects of testosterone synthesis and end-organ insensitivity due to androgen receptor abnormalities. With very severe undervirilization, it is possible that the sex of rearing should be female. Such babies need urgent referral to a specialist centre with a team of endocrinologists, urologists, geneticists and psychologists.

Congenital adrenal hyperplasia is a group of autosomal recessive inborn errors of metabolism (IEM) (therefore commoner if parents are consanguineous), within the adrenal steroidogenic pathways that produce mineralocorticoids (aldosterone), glucocorticoids (cortisol) and androgens (testosterone). 95 % of cases are due to 21-hydroxylase deficiency (21-OHD) that catalyses late steps in the first two pathways. The consequences are the same as for any IEM – deficiency of the end product, continued drive through the pathway, build-up of precursors and diversion down alternative pathways. Lack of cortisol causes hypoglycaemia and a poor stress response. Elevated precursors divert to the androgen pathway and testosterone virilizes both male and female fetuses. Most babies are also aldosterone-deficient. Those missed at birth (usually virilized boys) classically present in the second week of life with a salt-wasting (Addisonian) crisis – vomiting and shocked with severe hyponatraemia, hyperkalaemia and acidosis.
Patients with 21-OHD need lifelong steroid replacement, initially with hydrocortisone and fludrocortisone (a mineralocorticoid analogue), and endocrine monitoring.

The timing of any surgery to reduce clitoromegaly and create a vaginal orifice is controversial.

*Investigations in the first few days consider the differential diagnosis and monitor for complications:
• karyotype – result in 48 hours if laboratory warned
• pelvic and abdominal ultrasound – extremely helpful and immediately available
• 17-hydroxyprogesterone – sent after 48 hours as raised in all newborns
• full male hormone profile
• urine steroid profile – confirms site of block in steroidogenic pathway
• electrolytes and glucose – from day 2; monitor bedside glucose
• plasma renin activity – best estimation of salt status.

KEY POINTS

1- Never guess the sex of a newborn baby with abnormal genitalia.
2- Virilization of a female infant is almost always congenital adrenal hyperplasia due to 21-hydroxylase deficiency.

A case of Chromoblastomycosis

A 55-year-old man presented with vegetating lesions on the right foot that had been slowly enlarging during the past several years ;The photo:

  On physical examination, several nodular and verrucous lesions were seen in the distal region of the foot. The patient lived in a rural area and had walked barefoot for most of his life. Analysis of a skin-biopsy specimen revealed clusters of small, round, thick-walled, brown sclerotic bodies in the stratum corneum (muriform cells), which are diagnostic for chromoblastomycosis.
Chromoblastomycosis is a chronic, soft-tissue fungal infection commonly caused by Fonsecaea pedrosoi, Phialophora verrucosa, Cladosporium carrionii, or F. compacta. The infection occurs in tropical or subtropical climates and often in rural areas. The fungi are usually introduced to the skin through cutaneous injury from thorns, splinters, or other plant debris. The patient was treated with multiple surgical excisions and itraconazole for 24 months with a complete resolution of symptoms.

ECG of Supraventricular tachycardia

A 36-year-old white female nurse comes to the ER due to a sensation of fast heart rate, slight dizziness, and vague chest fullness. Blood pressure is 110/70. The following rhythm strip is obtained, which shows which of the following?

• a.Atrial fibrillation
• b.Atrial flutter
• c.Supraventricular tachycardia
• d.Ventricular tachycardia

The answer is (c).

Paroxysmal supraventricular tachycardia due to AV nodal reentry typically displays a narrow QRS complex without clearly discernible P waves, with a rate in the 160 to 190 range. The atrial rate is faster in atrial flutter, typically with a classic sawtooth pattern of P waves, with AV conduction ratios most commonly 2:1 or 4:1, leading to ventricular rates of 150 or 75 per min.

Atrial fibrillation would show an irregularly irregular rhythm without discrete P waves. Wide QRS complexes with rate greater than 100 would be expected in ventricular tachycardia.

Carbon monoxide poisoning in 20-year old fireman

A 20-year-old fireman comes to the emergency room complaining of headache and dizziness after helping to put out a garage fire. He does not complain of shortness of breath, and the arterial blood gas shows a normal partial pressure of oxygen. Which of the following is the best first step in the management of this patient?

• a.Begin oxygen therapy
• b.Obtain chest x-ray
• c.Obtain carboxyhemoglobin level
• d.Obtain CT scan

The answer is c.

With symptoms of headache and dizziness in a fireman, the diagnosis of carbon monoxide poisoning must be addressed quickly. A venous or arterial measure of car-boxyhemoglobin must first be obtained, if possible, before oxygen therapy is begun.
The use of supplementary oxygen prior to obtaining the test may be a confounding factor in interpreting blood levels. Oxygen or even hyperbaric oxygen is given after blood for carboxyhemoglobin is drawn.

Chest x-ray should also be obtained. It may be normal or show a pattern of nonpulmonary edema, or aspiration in severe cases. Central nervous system imaging would not be indicated, and there are no diagnostic patterns that are specific to carbon monoxide poisoning.

Classic description of Normal-pressure hydrocephalus

A 75-year-old man is brought in to your office by his wife. She complains that he is not the same over the last 6 months. His memory is failing him, he has difficulty walking (especially when he initiates walking), and he is incontinent of urine. Which of the following is the most likely diagnosis based on his history?

• A) Alzheimer's disease
• B) Parkinson's disease
• C) Normal-pressure hydrocephalus
• D) Pick's disease
• E) Progressive supranuclear palsy

The answer is (C). 

Normal-pressure hydrocephalus (NPH) is a cause of dementia in the elderly. It may be caused by previous insult to the brain, usually as a result of a subarachnoid hemorrhage or diffuse meningitis that presumably results in scarring of the arachnoid villi over the brain convexities where cerebrospinal fluid (CSF) absorption usually occurs. However, elderly NPH patients seldom have a history of predisposing disease.
NPH classically consists of dementia, apraxia of gait, and incontinence, but many patients with these symptoms do not have NPH. Typically, motor weakness and staggering are absent, but initiation of gait is hesitant—described as a “slipping clutch” or “feet stuck to the floor” gait—and walking eventually occurs. NPH has also been associated with various psychiatric manifestations that are not categorical. NPH should be considered in the differential diagnosis of any new mental status changes in the elderly.

CT or MRI and a lumbar puncture are necessary for diagnosis. On CT or MRI, the ventricles are dilated. CSF pressure measured by a lumbar puncture is normal. A limited improvement after removing about 50 mL of CSF indicates a better prognosis with shunting. Radiographic or pressure measurements alone do not seem to predict response to shunting. Shunting CSF from the dilated ventricles sometimes results in clinical improvement, but the longer the disease has been present, the less likely shunting will be curative.

Picture for Klinefelter syndrome

The patient in the picture presents with gynecomastia and infertility. On exam, he has small, firm testes. Which of the following is correct?
a.The patient is likely to have low levels of gonadotropins

b.The patient has Turner syndrome

c.His most likely karyotype is 47 XXY

d.The patient will have normal sperm count and testosterone level

The answer is (c).

The picture of infertility,gynecomastia, and tall stature is consistent with Klinefelter syndrome and an XXY karyotype. The patient has abnormal gonadal development with hyalinized testes that result in low testosterone levels and elevated levels of gonadotropin. Turner syndrome refers to the 45 XO karyotype that results
in abnormal sexual development in a female.

Chickenpox infection

A 25 years old teacher develops fever and an itchy rash over her face and chest. on exam : multiple papules and vesicles in varying stages of development. 1 week later she complains of cough and is found to have an infiltrate on x-ray.the most likely etiology of the infection?

• a. Streptococcus pneumoniae
• b. Mycoplasma pneumoniae
• c. Pneumocystis carinii
• d. Varicella virus
• e. Chlamydia psitacii

 The answer is d.

Varicella pneumonia develops in about 20% of adults with chickenpox. It occurs 3 to 7 days after the onset of the rash. The hallmark of the chickenpox rash is papules, vesicles, and scabs in various stages of development. Fever, malaise, and itching are usually part of the clinical picture. The differential can include some coxsackievirus and echovirus infections, which might present with pneumonia and vesicular rash. Rickettsialpox, a rickettsial infection, has also been mistaken for chickenpox.

About anaerobic infection

A 40-year-old alcoholic develops cough and fever. Chest x-ray shows an air-fluid level in the superior segment of the right lower lobe. Which of the following is the most likely etiologic agent?

• a. Streptococcus pneumoniae
• b. Haemophilus influenzae
• c. Legionella
• d. Anaerobes
• e. Mycoplasma pneumoniae

The answer is " d ".

Of the organisms listed, only anaerobic infection is likely to cause a necrotizing process. S. pneumoniae capsular type III pneumococci have been reported to cause cavitary disease, but this is unusual.
The location of the infiltrate suggests aspiration, also making anaerobic infection most likely. The superior segment of the right lower lobe is the one most likely to develop an aspiration pneumonia.

McRoberts Maneuver for Shoulder Dystocia

A 26-year-old woman is having difficulty delivering her 1st child. You suspect shoulder dystocia and ask the mother to stop pushing and notify your staff. The next appropriate step is ?

• A) place the mother in the left lateral position
• B) perform McRoberts' maneuver
• C) apply fundal pressure
• D) the Rubin maneuver (reverse Woods screw)
• E) perform a cesarean section

Answer and Discussion

The answer is B. 

 The recommended sequence for reducing shoulder dystocia begins with calling for help and asking the mother to stop her pushing efforts. The first step is the McRoberts' maneuver, in which assistants hyperflex the mother's hips against her abdomen, thereby rotating the symphysis pubis anteriorly and decreasing the forces needed to deliver the fetal shoulders.

A recent retrospective study found this maneuver to be the safest and most successful technique for relieving shoulder dystocia. An assistant can add gentle posterolateral suprapubic pressure while the physician continues moderate posterior traction on the fetal head. Fundal pressure should be avoided, because it tends to increase the impaction.

Azithromycin is the treatment of choice for Bordetella pertussis

Which of the following medications is considered the treatment of choice for Bordetella pertussis infection?

• A) Penicillin
• B) Ciprofloxacin
• C) Azithromycin
• D) Tetracycline
• E) Cefuroxime

Answer and Discussion

Recent epidemiologic studies have shown that the incidence and prevalence of Bordetella pertussis infection in adults are much greater than previously reported. In studies of adults with chronic cough, 20% to 25% were found to have serologic evidence of recent B. pertussis infection. However, pertussis is rarely considered in adults because the signs and symptoms are nonspecific.

Apart from a prolonged cough, there are no specific symptoms suggestive of pertussis in older individuals who have been immunized. With this in mind, pertussis should be considered in the differential diagnosis of persistent cough in previously immunized children and adults.

-Administration of erythromycin or other macrolide (azithromycin or clarithromycin) may be a consideration in patients presenting with persistent cough. Prophylaxis of exposed persons before culture or serologic results are available would be another consideration. Early treatment with a macrolide should limit the spread of infection to persons whose immunity has waned or in unimmunized children. The acellular vaccine may allow booster immunization, which can be a method of preventing B. pertussis infection after immunity from the pertussis vaccination has waned.
So;The answer is C.

Satellite cells in skeletal muscle proliferate and regeneration

A 5-year-old boy sustains a tear in his gastrocnemius muscle when he is involved in a bicycle accident. Regeneration of the muscle will occur through which of the following?
a.Differentiation of satellite cells
b.Dedifferentiation of myocytes into myoblasts
c.Fusion of damaged myofibers to form new myotubes
d.Hyperplasia of existing myofibers
e.Differentiation of fibroblasts to form myocytes

 The answer is a.
Satellite cells in skeletal muscle proliferate and reconstitute the damaged part of the myofibers. They are supportive cells for maintenance of muscle and a source of new myofibers after injury or after increased load. There is no dedifferentiation of myocytes into myoblasts (answer b), or fusion of damaged myofibers to form new myotubes (answer c). Hypertrophy, not hyperplasia
(answer d),occurs in existing myofibers in response to increased load.

Proliferation of fibroblasts may occur in the damaged area but leads to fibrosis, not repair of skeletal muscle. Fibroblasts do not differentiate into myocytes (answer e). The multinucleate organization of skeletal muscle is derived developmentally by fusion and not by amitosis (failure of cytokinesis after DNA synthesis). Mitotic activity is terminated after fusion occurs. In the
development of skeletal muscle, myoblasts of mesodermal origin undergo cell proliferation. Myocyte cell division ceases soon after birth. Myoblasts, which are mononucleate cells, fuse with each other end to end to form myotubes. This process requires cell recognition between myoblasts, alignment, and subsequent fusion.