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At autopsy, the patient's lungs were hyperinflated and showed marked mucus plugging. No water was found in her lungs. The prosector concluded that she was dead when she hit the water. An empty broncho-dilator inhalation device was found in her purse. Her mother later confirmed that she was having an acute asthma attack and was on her way to get her presciption refilled at her North Kansas City physician's office.
One month later, or 2 months before death, the patient was admitted to the hospital for the first time.
Upon presentation, her skin rash was generalized, purple and mottled. Hemorrhages were present in the sclera and gums. Her blood pressure was 110/75, and her temperature was 40o C. Laboratory examinations revealed leukopenia, with 3,400 white blood cells per cubic mm., anemia with 12.5 gm hemoglobin and 3.8 million red blood cells per cubic mm, hematuria, and 3+ albuminuria. Treatment with penicillin produced some improvement, and the patient was discharged from the hospital.
She was re-admitted 12 days before death with recurrence of all previous signs and symptoms. In addition, there was swelling of the popliteal spaces, and an electrocardiogram showed evidence of carditis. Leukopenia was now severe, WBC were 1,200 per cu. mm., of which 66% were segmented neutrophils and 19% stab forms.
Case 1:
Clinical vignette 1
A 28 year-old female was driving on I-435 North on January 2, 1990. A passing motorist noticed her car go off the Kansas River bridge into the water. He stopped, dived into the freezing water, pulled her from the car, and began CPR. An ambulance soon arrived and continued resuscitative efforts. She was life-flighted to KUMC, where she was pronounced dead on arrival. Discussion topics
Case 2:
Clinical vignette 2
An obese, 38-year-old woman noted swelling of the neck 3 months before admission.
She complained of easy fatigability, slight difficulty swallowing and cold
intolerance. Deep tendon reflexes were depressed. Her mother had a history
of goiter.
Upon physical examination, her blood pressure was 146/80, pulse 80/min.
and temperature 37oC. The thyroid was diffusely enlarged without nodularity.
There was no exophthalmos or lid-lag. The skin and hair were normal. The
initial clinical impression was "goiter".
Laboratory examination revealed a decreased T4 , with thyroid stimulating
hormone (TSH) increased. A thyroidectomy was performed. The surgical pathologist
received a 4 x 2 x 2.4 cm. segment of thyroid weighing 22 grams. The parenchyma
was tan and fleshy, with the consistency and general appearance of a lymph
node. The pathologic diagnosis was Hashimoto thyroiditis.
Discussion topics
Case 3:
Clinical vignette 3
A 24-year-old women's illness began one year before death, with weight loss and fatigue. About 7 months later a red rash appeared over the bridge of her nose and the exposed areas of the skin. This was followed in two days by joint pains. All symptoms were intensified by sun exposure. About a month later, enlarged lymph nodes and a sore tongue appeared and, a month after this, chills, fever, nausea and vomiting.Topics for discussion
References
Case 4:
Clinical vignette 4
The patient was a 24 year old female medical student from Peru. She had received a tuberculosis vaccination with BCG vaccine as a child. Upon entering the University of Kansas School of Medicine, she was told she had to take a skin test with the purified protein derivative (PPD). She tried to refuse, but was told it was a requirement. She allowed the nurse to administer the test. Upon examination 3 days later, she had a half-dollar sized, indurated lesion on her forearm. The skin had begun to slough.
The patient lived for approximately six months, and was hospitalized five times. Pneumonia was diagnosed on his first hospitalization; cytomegalovirus was cultured from bronchoscopy specimens, and Pneumocystis cariniiwas simultaneously identified cytologically. He was successfully treated with trimethoprim/sulfa for pneumocystosis, but two months later developed recurrent pulmonary infiltrates. Culture of specimens obtained by bronchoscopy then grew Mycobacterium avium intracellulare (MAI). The CD-4 count at that time was <10 per microliter. He was treated with isoniazid, ethambutol and rifampin, but multiple sputum and blood cultures continued to be positive for MAI. His anti-mycobacterial chemotherapy was changed to ansamycin, which also failed to eradicate the organism.
The patient was anorectic and weighed less than 120 lbs at his death. He ultimately died of respiratory failure; at his request, no resuscitative efforts were undertaken.