An 80-year-old woman is admitted to rule out acute coronary syndrome after recurrent episodes of chest pain. She has not seen a doctor in many years, and her only medication is hydrochlorothiazide. Her blood pressure on admission is 188/120 mmHg, and she is started on labetalol. Her pressure mildly improves, and she is given hydralazine for additional control. She is also started on aspirin and rosuvastatin for risk factor modification. She is discharged and returns to clinic 1 month later complaining of muscle and joint pain, which resolves several weeks after discontinuing one of her medications. Enzyme-linked immunosorbent assay (ELISA) testing reveals a positive anti-histone antibody.
What drug caused this effect?
Hydralazine. This patient has drug-induced lupus, and hydralazine is one of the medications that can cause this effect. Other common drugs that can cause this are procainamide and penicillamine. Up to 5% of patients who use hydralazine long term will show some signs of drug-induced lupus, most of which will have a positive anti-histone antibody. (B) Statininduced myopathy occurs weeks to months after starting the medication, and will present with myalgias but not usually joint pain.
A 49-year-old man with no significant past medical history presents to your clinic for a follow-up after a motor vehicle collision 2 days ago. Immediately after the accident, he presented to the Emergency Department and received a CT scan of his abdomen, revealing an incidental finding of a 1.2-cm right adrenal nodule. He suffered no injuries from the collision and was sent home the same day. On physical examination today, the patient’s temperature is 37.0°C, blood pressure is 112/76 mmHg, and heart rate is 66 beats per minute. The rest of the examination is unremarkable. The results from his metabolic panel are shown below.
Which of the following tests is unnecessary in the workup of this patient’s condition at this time?
Plasma aldosterone and renin levels. Incidental adrenal adenomas are commonly found after CT imaging of the abdomen done for other purposes. History and physical examination in this case are not revealing for a malignancy or hormone hypersecretion. However, certain testing is required to evaluate for potentially functioning adenomas that secrete cortisol (Cushing syndrome), aldosterone (Conn syndrome), or catecholamines (pheochromocytoma). Given that the patient is not hypertensive and his metabolic panel does not show hypernatremia or hypokalemia, no further testing for an aldosterone-secreting tumor is required. (B, C, D) All of the remaining tests should be done to rule out a hormone-secreting tumor.
A 23-year-old college senior is brought to the hospital by her friends for confusion. They state she was fine until yesterday, when she started behaving abnormally. The patient has no subjective complaints. Her temperature is 39°C, blood pressure is 118/74 mmHg, heart rate is 100 beats per minute, and respiratory rate is 18 breaths per minute. Physical examination is notable for neck stiffness and a diffuse maculopapular rash. While the hips are flexed at 90 degrees, there is no pain with knee extension; while the patient is supine, there is no hip flexion with passive neck flexion.
What is the most appropriate next step in management for this patient?
Draw blood cultures and start empiric IV antibiotics. This patient likely has meningococcal meningitis. The complete triad of fever, neck stiffness, and headache are rarely found; however, two of three signs is 95% sensitive for a diagnosis of meningitis. Kernig and Brudzinski signs are typically late presentations and are not sensitive tests. Given the high mortality rate of meningitis, empiric antibiotics should not be delayed. (A) Studies have shown that lumbar puncture can be performed within 2 to 4 hours of starting antibiotics without altering CSF studies. (B) CT scan of the head should be performed before lumbar puncture if the patient is at risk of cerebral herniation (e.g., papilledema on physical examination). (D) Acyclovir should be started if HSV encephalitis is suspected. (E) Ceftriaxone alone is not appropriate empiric antibiotic coverage. Although meningococcal meningitis is suspected, resistant Streptococcus pneumoniae should still be covered with vancomycin. If this patient were older than 50, Listeria should be covered with ampicillin.
A 71-year-old man complains of fever and back pain. He lives in a skilled nursing facility and has no recent sick contacts or animal exposures. On examination, his temperature is 38.4°C, blood pressure is 148/92 mmHg, heart rate is 106 beats per minute, respiratory rate is 18 breaths per minute, and oxygen saturation is 99% on room air. He has diffuse abdominal pain with voluntary guarding, and has significant pain with right hip flexion. A neurologic examination of the lower extremities is normal. A CT scan of the abdomen is performed and shows a left psoas abscess.
Which of the following organisms is most likely responsible?
Staphylococcus aureus. The most common cause of a psoas abscess is S. aureus, and therefore empiric antibiotics should be directed at this organism. (A) In patients with significant risk factors or from an endemic area, TB should be expected (especially if there is vertebral osteomyelitis and other evidence of disseminated disease). (B, C) Although Pseudomonas and E. coli may cause these abscesses, they are much less common than S. aureus.
A 56-year-old man presents with a fever and a productive cough. His previous medical history is unremarkable, and he takes no medications. He is homeless and has been in jail several times. He has a 15 pack-year smoking history and drinks alcohol heavily. Review of systems is remarkable for intermittent fevers, night sweats, and weight loss. On examination, his temperature is 38.9°C and his respiratory rate is 26 breaths per minute. There is dullness to percussion along the right lower lung field with decreased breath sounds over this area on auscultation; the rest of the pulmonary examination is normal. His laboratory values are significant for a hemoglobin of 10.2 g/dL.
Which of the following is the most likely diagnosis?
Tuberculous pleural effusion. Risk factors for TB include immigrants from endemic areas, homelessness, exposure to prisons, health care workers, HIV infection, and exposure to infected individuals, among others. This patient has risk factors in addition to fever, cough, night sweats, and physical examination findings suggestive of a pleural effusion, making TB a potential diagnosis that should not be missed. (A) Communityacquired pneumonia due to Klebsiella is seen more often in alcoholics, and it is possible that this patient has pneumonia with a parapneumonic effusion; however, TB should be suspected based on the risk factors and symptoms. In addition, anemia is a sensitive finding in TB. (C) A pulmonary infection should be suspected over Hodgkin lymphoma given the presence of cough. Of note, lymphoma can present with “B symptoms” that include fevers, night sweats, and so forth. (D) Congestive heart failure causes a transudative effusion, which would not present with fever, night sweats, and so forth. (E) Malnutrition (folate, vitamin B12) as well as alcoholism can cause a macrocytic anemia; however, this patient’s anemia is due to TB.
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