PAIN IN THE BACK

History A 75-year-old woman presents to her general practitioner (GP) complaining of severe back pain. This developed suddenly a week previously after carrying a heavy suitcase at the airport. The pain is persistent and in her lower back. She has had increasing problems with back pain over the past 10 years, and her family have commented on how stooped her posture has become. Her height has reduced by 10 cm over this period. Her past medical history is notable for severe chronic asthma. She takes courses of oral corticosteroids, and use steroid inhalers on a regular basis. She fell 2 years ago and sustained a Colles’ fracture to her left wrist. She developed the menopause at age 42 years. She smokes 30 cigarettes a day, and drinks four bottles of wine a week. Examination She has a thoracic kyphosis. She is tender over the L4 vertebra. She has a moon-face,abdominal striae and a number of bruises on her arms and thighs. She is not anaemic, and examination is otherwise unremarkable. Questions • What is the likely diagnosis? • How would you manage this patient? ANSWER This woman has vertebral collapse due to osteoporosis. The symptoms of osteoporosis are deformity, localized pain and fracture. The loss of height is typical, and is usually noted more by others than the patient. The back pain is due to collapse of the vertebrae. This can occur spontaneously or in association with a recognized stress such as carrying a heavy load. Examination confirms loss of trunk height, thoracic kyphosis and proximity of the ribs to the iliac crest. The differential diagnoses of osteoporosis! • Multiple myeloma • Metastatic carcinoma, particularly from the prostate, breast, bronchus, thyroid and kidney • Osteomalacia • Hyperparathyroidism • Steroid therapy or Cushing’s syndrome This patient has several risk factors for osteoporosis. Firstly she is aged 75 years, and ageing is associated with bone loss. Secondly she has been postmenopausal for over 30 years. Premenopausal ovarian production of oestrogens help to preserve bone mass. Thirdly she has been on oral and inhaled corticosteroids for her asthma for years. Finally, excess alcohol intake may also be a factor. Her red cells are macrocytic, which is consistent with heavy alcohol intake. Alcohol can lead to an increased incidence of falls and fractures. She has no clinical evidence of thyrotoxicosis or hypopituitarism which can cause osteoporosis. This woman should have blood tests to exclude myeloma, cancer and metabolic bone disease. Patients with myeloma are anaemic with a raised ESR and a monoclonal paraprotein on serum protein electrophoresis. In contrast to metabolic bone diseases biochemical measurements (serum calcium, alkaline phosphatase and parathormone (PTH)) in osteoporosis are normal. She should have plain X-rays of her spine. Collapse of the vertebral body will manifest as irregular anterior wedging affecting some vertebrae and not others (L1 and L4). A dual-energy X-ray absorptiometry (DEXA) scan can be performed to assess the severity of the osteoporosis, but treatment is indicated anyway with a fracture at this age. She should have her dose of corticosteroids reduced to the minimum required to control her asthmatic symptoms, using the inhaled routes as far as possible. She should be started on calcium and vitamin D supplements and a bisphosphonate to try to reduce her bone loss. Oestrogen-based hormone replacement therapy is only used for symptoms associated with the menopause because of the increased incidence of thromboembolism and endometrial carcinoma. Newer treatments for osteoporosis include strontium and parathyroid hormone. Key Points: • Osteoporosis is common in the elderly. • Bone loss is more rapid in women than in men. • DEXA scan is the method of choice of screening for osteoporosis. • There are increasingly effective treatments available for the treatment of osteoporosis.

General Medicine • Orthopedic Surgery + 3 more

HEADACHES AND CONFUSION

History A 28-year-old black South African theatre nurse in London is admitted to the emergency department complaining of headaches and confusion. Her headaches have developed over the past 3 weeks and have become progressively more severe. The headaches are now persistent and diffuse. Her friend who accompanies her says that she has lost 10 kg in weight over 6 months and has recently become increasingly confused. Her speech is slurred. While in the emergency department she has a generalized tonic–clonic convulsion. Examination She is thin and weighs 55 kg. Her temperature is 38.5°C. There is oral candidiasis. There is no lymphadenopathy. Examination of her cardiovascular, respiratory and gastrointestinal systems is normal. Neurological examination prior to her fit showed her to be disorientated in time, place and person. There were no focal neurological signs. Funduscopy shows bilateral papilloedema Questions • What is the cause for this woman’s headaches, confusion and fits? • What is the underlying diagnosis? • How should this woman be further investigated and treated? ANSWER This woman has cerebral toxoplasmosis secondary to HIV infection. This condition is caused by the protozoan Toxoplasma gondii which primarily infects cats but can also be carried by any warm blooded animal. In the West, 30–80 per cent of adults have been infected by ingesting food or water contaminated by cat faeces, or by eating raw meat from sheep or pigs which contain Toxoplasma cysts. After ingestion by humans the organism divides rapidly within macrophages and spreads to muscles and brain. The immune system rapidly controls the infection, and the cysts remain dormant. The primary infection is generally asymptomatic, but can cause an acute mononucleosis-type illness with generalized lympadenopathy and rash. It may leave scars in the choroid and retina and small inflammatory lesions in the brain. If the host then becomes immunocompromised the organism starts proliferating causing toxoplasmosis. This is an AIDS-defining illness, but is relatively rare in solid organ transplant recipients. Cerebral toxoplasmosis usually presents with a subacute illness comprising fever, headache, confusion, fits, cognitive disturbance, focal neurological signs including hemiparesis, ataxia, cranial nerve lesions, visual field defects and sensory loss. Movement disorders are common due to involvement of the basal ganglia. CT or magnetic resonance imaging (MRI) will usually show multiple bilateral ring-enhancing lesions predominantly located near the grey–white matter junction, basal ganglia, brainstem and cerebellum. The clinical and radiological differential diagnoses include lymphoma, tuberculosis and secondary tumours. Anti-toxoplasma antibody titres should be measured, but are not always positive. The other clues in this case to the diagnosis of HIV infection include the patient’s country of origin, the weight loss and oral candidiasis. The headaches and papilloedema are caused by raised intracranial pressure from the multiple space-occupying lesions. The hyponatraemia is due to the syndrome of inappropriate antidiuretic hormone (ADH) secretion (SIADH) consequent to the raised intracranial pressure. This woman should be started on anticonvulsants to prevent further seizures. Treatment is started with high-dose sulfadiazine and pyrimethamine together with folinic acid to prevent myelosuppression. There should be a rapid clinical and radiological improvement. In cases that have not responded within 3 weeks, a biopsy of one of the lesions should be considered. Cerebral toxoplamosis is uniformally fatal if untreated, and even after treatment neurological sequelae are common. The patient should be counselled about HIV infection and consented for an HIV test. Her HIV viral load and CD4 count should be measured, and antiretroviral drugs started. She should be advised to contact her previous sexual partners so that they can be tested and started on antiretroviral therapy. She should also tell her occupational health department so that the appropriate advice can be taken about contacting, testing and reassuring patients. The risk of HIV transmission from a healthcare worker to a patient is very small. KEY POINTS • Toxoplasmosis is the most common opportunistic infection of the central nervous system in patients with AIDS. • Patients can present with headache, confusion, fits and focal neurological deficits. • The clinical and radiological response to treatment is usually rapid.

General Medicine • Virology + 1 more

SWELLING IN THE NECK

History A 38-year-old man presents to his general practitioner (GP) complaining of a painless lump on the right side of his neck. This has been present for about 2 months and seems to be enlarging. He has had no recent throat infections. He has been feeling generally unwell and has lost about 5 kg in weight. The patient has also developed drenching night sweats. Simultaneously he has noticed severe generalized itching. He has had no significant past medical history. He is an accountant, and married with three children. He neither smokes nor drinks alcohol and is not taking any regular medication. Examination His temperature is 37.8°C. There is a smooth, firm 3 % 4cm palpable mass in the right supraclavicular fossa. There are also lymph nodes 1–2 cm in diameter, palpable in both axillae and inguinal areas. His oropharynx appears normal. There are multiple excoriations of his skin. His pulse rate is 100/min regular and blood pressure 112/66 mmHg. Examination of his cardiovascular and respiratory systems is normal. On abdominal examination, there is a mass palpable 3 cm below the left costal margin. The mass is dull to percussion and it is impossible to palpate its upper edge. Neurological examination is normal. Questions • What is the likely diagnosis? • How would you investigate and manage this patient? ANSWER Transient small nodes in the neck or groin are common benign findings. However, a 3 % 4cm mass of nodes for 2 months is undoubtedly abnormal. Persistent lymphadenopathy and constitutional symptoms suggest a likely diagnosis of lymphoma or chronic leukaemia. Sarcoidosis and tuberculosis are possible but less likely diagnoses. Lymph nodes are normally barely palpable, if at all. The character of enlarged lymph nodes is very important. In acute infections the nodes are tender and the overlying skin may be red. Carcinomatous nodes are usually very hard, fixed and irregular. The nodes of chronic leukaemias and lymphomas are non-tender, firm and rubbery. The distribution of enlarged lymph nodes may be diagnostic. Repeated minor trauma and infection may cause enlargement of the locally draining lymph nodes. Enlargement of the left supraclavicular nodes may be due to metastatic spread from bronchial and nasopharyngeal carcinomas or from gastric carcinomas (Virchow’s node). However, when there is generalized lymphadenopathy with or without splenomegaly, a systemic illness is most likely. The typical systemic symptoms of lymphoma are malaise, fever, night sweats, pruritus, weight loss, anorexia and fatigue. Fever indicates extensive disease, and may be associated with night sweats. Severe skin itching is a feature of some cases of lymphoma and other myeloproliferative illnesses. The incidence of lymphoma is greatly increased in patients who are immunosuppressed,such as organ transplant recipients and patients with HIV infection. • Infections: infectious mononucleosis or ‘glandular fever’ (caused by Epstein–Barr virus infection), toxoplasmosis, cytomegalovirus infection, acute HIV infection, tuberculosis, brucellosis and syphilis. • Inflammatory conditions: systemic lupus erythematosus, rheumatoid arthritis and sarcoidosis. • Lymphomas or chronic lymphocytic leukaemia. Major differential diagnosis of generalized lymphadenopathy The most likely clinical diagnosis in this man is lymphoma. The patient should be referred to a local haemato-oncology unit. He should have a lymph-node biopsy to reach a histological diagnosis, and a computed tomography (CT) scan of the thorax, abdomen and bone marrow to stage the disease. CT scanning is a non-invasive and effective method of imaging retroperitoneal, iliac and mesenteric nodes. Positron-emission tomography (PET) combined with CT increases the sensitivity for detecting disease (Fig. 35.1), and is useful for assessing response to treatment. The patient will require treatment with radiotherapy and chemotherapy. Radiotherapy alone is reserved for patients with limited disease, but this patient has widespread disease. He should be given allopurinol prior to starting chemotherapy, to prevent massive release of uric acid as a consequence of tumour lysis, which can cause acute renal failure. Key Points • The character and distribution of abnormal lymph nodes is helpful in reaching a diagnosis. • Lymphadenopathy affecting two or more separate groups of nodes suggests lymphoma or a systemic infection. • CT–PET scanning allows accurate staging of disease and assessment of maintenance of remission in response to treatment.

General Medicine • General Surgery + 1 more

ABDOMINAL PAIN

History A 74-year-old woman has a 10-year history of intermittent lower abdominal pain. The pain has been colicky in nature and is associated with a feeling of distension in the left iliac fossa. It is generally relieved by passing flatus or faeces. She tends to be constipated and passes small pieces of faeces. Four years previously she passed some blood with her bowel motion and had a barium enema performed. This is shown in Fig. 36.1. Over the last week her pain has worsened and now she has continuous pain in the left iliac fossa and feels generally unwell. Her appetite has been poor over this same time. She has not had her bowels open over the last 2 days. In her previous medical history she had a hysterectomy for fibroids 20 years ago. There is a family history of ischaemic heart disease and diabetes mellitus. She lives alone and does her own cooking and shopping. Examination She has a temperature of 38.5°C and is tender with a vague impression of a mass in the left iliac fossa. There is no guarding or rebound tenderness and the bowel sounds are normal. Her pulse is 84/min and blood pressure is 154/88 mmHg. There are no abnormalities to find in the respiratory system. Questions • What is the likely diagnosis? • What should be the initial management? ANSWER This woman has diverticulitis. Colonic diverticula are small outpouchings which are most commonly found in the left colon. They are very common in the elderly Western population probably due to a deficiency in dietary fibre. Symptomatic diverticular disease has many of the features of irritable bowel syndrome. Inflammation in a diverticulum is termed diverticulitis. In severe cases, perforation, paracolic abscess formation or septicaemia may develop. Other potential complications include bowel obstruction. formation of a fistula into rectum or vagina, and haemorrhage. The barium enema from 4 years ago shows evidence of diverticular disease with outpouchings of the mucosa in the sigmoid colon. This would be consistent with the long-standing history of abdominal pain of colonic type and tendency to constipation. The recent problems with increased pain, tenderness, fever, raised white cell count and CRP and a mass in the left iliac fossa would be compatible with an acute exacerbation of her diverticular disease. In her case there is no evidence of peritonitis which would signal a possible perforation of one of the diverticula. The differential diagnosis, with the suggestion of a mass and change in bowel habit, would be carcinoma of the colon and Crohn’s disease. In the absence of evidence of perforation with leak of bowel contents into the peritoneum (no peritonitis) or obstruction (normal bowel sounds, no general distension), treatment should be based on the presumptive diagnosis of diverticulitis. A colonoscopy should be performed at a later date to exclude the possibility of a colonic neoplasm. A CT scan of the abdomen will delineate the mass and suggest whether there is evidence of local abscess formation. Treatment should include broad-spectrum antibiotics, intravenous fluids and rest. Further investigations are indicated, including electrolytes, urea and creatinine, glucose, liver function tests and blood cultures. Repeated severe episodes, bleeding or obstruction may necessitate surgery. Key Points: • Diverticular disease is a common finding in the elderly Western population and may be asymptomatic or cause irritable bowel syndrome-type symptoms. • Diverticular disease is a common condition; its presence can distract the unwary doctor from pursuing a co-incident condition. • Diverticulitis needs to be treated with antibiotics to reduce the chance of complications such as perforation or fistula formation occurring

General Surgery • Surgical Gastroenterology + 1 more

HIGH BLOOD PRESSURE

History A 36-year-old woman is referred by her general practitioner (GP) to a hypertension clinic.She was noted to be hypertensive when she joined the practice 2 years previously. Her blood pressure has been difficult to control and she is currently taking four agents (bendrofluazide, atenolol, amlodipine and doxazosin). She had normal blood pressure and no pre-eclampsia during her only pregnancy 9 years previously. There is no family history of premature hypertension. She smokes 20 cigarettes a day and drinks less than 10 units a week. She is not on the oral contraceptive pill. She works part time as a teaching assistant. Examination She is not overweight and looks well. Her pulse rate is 68/minute and blood pressure 180/102 mmHg. There is no radiofemoral delay. There are no café-au-lait spots or neurofibromas. Examination of the cardiovascular, respiratory and abdominal systems is normal. The fundi show no significant changes of hypertension. Questions • What is the diagnosis? • How would you further manage this patient? ANSWER This woman has hypertension due to renovascular disease. The vast majority of cases of hypertension are due to essential hypertension. Risk factors for essential hypertension include a family history of hypertension, obesity and lack of exercise. She does not have paroxysmal symptoms of sweating, palpitations and anxiety to suggest a phaeochromocytoma. There are no clinical features to suggest coarctation of the aorta (radiofemoral delay) or neurofibromatosis (café-au-lait spots/neurofibromas). Serum potassium is not low making Conn’s syndrome or Cushing’s syndrome unlikely. The principal abnormality is the modestly raised creatinine suggesting mildly impaired renal function. The absence of haematuria and proteinuria excludes glomerulonephritis. Therefore renovascular disease needs to be considered. The absence of a renal bruit does not exclude the possibility of renovascular disease. The renal angiogram shows bilateral fibromuscular dysplasia (FMD). The commonest cause of renovascular disease is atherosclerotic renal artery stenosis (ARAS).This is common in elderly patients with evidence of generalized atherosclerosis (peripheral vascular disease and coronary artery disease). Ultrasound will often show small kidneys, and renal impairment is common. ARAS is a common cause of end-stage renal failure in the elderly. At this woman’s age atherosclerotic renovascular disease is very unlikely. FMD is the second most common cause of renovascular disease. The commonest form is medial fibroplasia with thinning of the intima and media leading to formation of aneurysms alternating with stenoses, leading to the classic ‘string of beads’ appearances on angiography. It predominantly affects young and middle-aged women with a peak incidence in the fourth decade of life. Cigarette smoking is a risk factor. FMD usually presents with hypertension, but can rarely present with ‘flash’ pulmonary oedema. FMD can also affect the carotid arteries causing a variety of neurological symptoms. Treatment is with percutaneous transluminal renal angioplasty. Unlike atheromatous renovascular disease, the hypertension in FMD cases is often cured leading to complete cessation of blood pressure medication. Restenosis is rare. KEY POINTS • FMD is an important cause of hypertension in young and middle-aged women. • Renal artery angioplasty will improve or even cure hypertension in many patients with FMD. • FMD is a very rare cause of end-stage renal failure.

General Medicine • Nutrition & Dietetics + 1 more

SWELLING ON THE LEGS

History A 34-year-old woman presents to her general practitioner (GP) complaining of a rash. Over the past 2 weeks she has developed multiple tender red swellings on her shins and forearms. The older swellings are darker in colour and seem to be healing from the centre. She feels generally unwell and tired and also has pains in her wrists and ankles. She has not had a recent sore throat. Over the past 2 years she has had recurrent aphthous ulcers in her mouth. She has had no genital ulceration but she has been troubled by intermittent abdominal pain and diarrhoea. She works as a waitress and is unmarried. She smokes about 15 cigarettes per day and drinks alcohol only occasionally. She has had no other previous medical illnesses and there is no relevant family history that she can recall. Examination She is thin but looks well. There are no aphthous ulcers to see at the time of the examination. Her joints are not inflamed and the range of movement is not restricted or painful. Examining the skin there are multiple tender lesions on the shins and forearms. The lesions are raised and vary from 1 to 3 cm in diameter. The fresher lesions are red and the older ones look like bruises. Physical examination is otherwise normal. Questions • What is the diagnosis? • What are the major causes of this condition? ANSWER This patient has erythema nodosum, in this case secondary to previously undiagnosed Crohn’s disease. Erythema nodosum is due to inflammation of the small blood vessels in the deep dermis. Characteristically it affects the shins, but it may also affect the thighs and forearms. The number and size of the lesions is variable. Lesions tend to heal from the centre and spread peripherally. The rash is often preceded by systemic symptoms – fever,malaise and arthralgia. It usually resolves over 3–4 weeks, but persistence or recurrence suggests an underlying disease. Diseases linked to erythema nodosum! Streptococcal infection Lymphoma/leukaemia Tuberculosis Sarcoidosis Leprosy Pregnancy/oral contraceptive Glandular fever Reaction to sulphonamides Histoplasmosis Ulcerative colitis Coccidioidomycosis Crohn’s disease The history of mouth ulcers, abdominal pain and diarrhoea strongly suggests that this woman has Crohn’s disease. She should therefore be referred to a gastroenterologist for investigations which should include a small-bowel enema and colonoscopy with biopsies. Treatment of her underlying disease with steroids should cause the erythema nodosum to resolve. With no serious underlying condition, erythema nodosum usually settles with non-steroidal anti-inflammatory drugs. KEY POINTS • Patients presenting with erythema nodosum should be investigated for an underlying disease. • Erythema nodosum is most often seen on the shins but can affect the extensor surface of the forearms or thighs.

General Medicine • Clinical Immunology + 2 more

ABDOMINAL PAIN

History A 25-year-old woman presents to her general practitioner (GP) complaining of pain in her right loin radiating in to the right iliac fossa. The pain developed 24 h earlier and has become progressively more severe. She has not had her bowels open for 3 days. She feels alternately hot and cold and is sweaty. She has no pain on passing urine and no urinary frequency. Her last menstrual period was 3 weeks ago. She has had the occasional episode of acute cystitis, approximately on a 2-yearly basis. She has no other significant past medical history. Examination She looks unwell and is febrile at 38.5°C. Her pulse rate is 112/min, and blood pressure 104/66 mmHg. Examination of the cardiovascular and respiratory systems is otherwise unremarkable. She is tender to palpation in the right loin and right iliac fossa. There is guarding, and rebound in the right iliac fossa. Bowels sounds are sparse. Questions • What is the diagnosis? • How would you manage this patient? ANSWER This woman has acute appendicitis. Acute appendicitis classically presents with a short history of central abdominal pain which rapidly localizes to the right iliac fossa. There is guarding and ‘board-like’ rigidity and rebound tenderness in the right iliac fossa. Untreated, some cases will resolve spontaneously, whereas others will perforate leading to localized or generalized peritonitis. Rarely a delayed diagnosis may result in acute appendicitis progressing to an appendix mass consisting of a haemorrhagic oedematous mass in the ileocaecal region. In this woman the right iliac fossa symptoms and signs together with the raised white cell count and CRP are consistent with appendicitis. The symptoms of loin pain and presence of blood and protein in the urine mimicking a urinary tract infection suggest the appendix may be retrocaecal. Patients with retro-ileal appendicitis often have little abdominal pain, but irritation of the ileum can lead to severe diarrhoea and vomiting. Patients may also present with subacute intestinal obstruction due to intestinal ileus, or urinary retention due to pelvic peritonitis. The treatment is appendicectomy as soon as urinary tract infection has been excluded. Ultrasound or computed tomography (CT) scanning can be performed if there is uncertainty as to the clinical diagnosis. However a significant number of patients will have a normal appendix removed. Differential diagnosis of acute appendicitis! • Retrocaecal appendicitis can mimic acute pyelonephritis. • In young women ectopic pregnancy and gynaecological pathology can mimic appendicitis. • Elderly patients may present with atypical symptoms and signs. KEY POINTS! • In young adults the differential diagnoses include irritable bowel syndrome, nonspecific mesenteric adenitis, ruptured ectopic pregnancy, twisted or haemorrhagic ovarian cysts, infection of the Fallopian tubes and urinary tract infections. • In older patients perforated peptic ulcers, diverticulitis, Crohn’s disease and carcinoma of the colon are important differential diagnoses.

General Surgery • Surgical Gastroenterology + 1 more

POSTOPERATIVE DETERIORATION

History The medical team is asked to review a postoperative surgical patient. A 62-year-old lady had been admitted 10 days previously to have a right hemicolectomy performed for a caecal carcinoma. This was discovered on colonoscopy which was performed to investigate an iron-deficiency anaemia and change in bowel habit. She is otherwise fit with no significant medical history. She is a retired teacher. She neither smokes nor drinks alcohol and is on no medication. Her preoperative serum creatinine was 76&mol/L. The initial surgery was uneventful, and she was given cefuroxime and metronidazole as routine antibiotic prophylaxis. However the patient developed a prolonged ileus associated with abdominal pain. On postoperative day 5, the patient started to spike fevers up to 38.5°C and was commenced on intravenous gentamicin 80 mg 8 hourly in addition to the other antibiotics. Over the next 5 days the patient remained persistently febrile, with negative blood cultures. In the last 24 h, she has also become relatively hypotensive with her systolic blood pressure being about 95 mmHg despite intravenous colloids. Her urine output is now 15 mL/h. Examination She is unwell and sweating profusely. She is jaundiced. Her pulse rate is 110/min regular, blood pressure 95/60 mmHg and jugular venous pressure is not raised. Her heart sounds are normal. Her respiratory rate is 30/min. Her breath sounds are normal. Her abdomen is tender with guarding over the right iliac fossa. Bowel sounds are absent. Questions • What are the causes of this patient’s acute renal failure? • How would you further investigate and manage this patient? ANSWER This patient has postoperative acute renal failure due to a combination of intra-abdominal sepsis and aminoglycoside nephrotoxicity. Her sepsis is due to an anastomotic leak with a localized peritonitis which has been partially controlled with antibiotics. Her sepsis syndrome is manifested by fever, tachycardia, hypotension, hypoglycaemia, metabolic acidosis (low bicarbonate) and oliguria. The low sodium and high potassium are common in this condition as cell membrane function becomes less effective. The elevated white count is a marker for bacterial infection and the low platelet count is part of the picture of disseminated intravascular coagulation. Jaundice and abnormal liver function tests are common features of intraabdominal sepsis. Aminoglycosides (gentamicin, streptomycin, amikacin) cause auditory and vestibular dysfunction, as well as acute renal failure. Risk factors for aminoglycoside nephrotoxicity are higher doses and duration of treatment, increased age, pre-existing renal insufficiency, hepatic failure and volume depletion. Aminoglycoside nephrotoxicity usually occurs 7–10 days after starting treatment. Monitoring of trough levels is important although an increase in the trough level generally indicates decreased excretion of the drug caused by a fall in the glomerular flow rate. Thus, nephrotoxicity is already established by the time the trough level rises. This patient needs urgent resuscitation. She requires transfer to the intensive care unit where she will need invasive circulatory monitoring with an arterial line and central venous pressure line to allow accurate assessment of her colloid and inotrope requirements. She also needs urgent renal replacement therapy to correct her acidosis and hyperkalaemia. In a haemodynamically unstable patient like this, continuous haemofiltration is the preferred method.The patient also needs urgent surgical review. The abdomen should be imaged with either ultrasound or computed tomography (CT) scanning to try to identify any collection of pus.Once haemodynamically stable, the patient should have a laparotomy to drain any collection and form a temporary colostomy. Key Points: • Postoperative acute renal failure is often multifactorial due to hypotension, sepsis and the use of nephrotoxic drugs such as aminoglycosides and non-steroidal anti-inflammatory drugs (NSAIDs). • Aminoglycoside drugs are extremely valuable for treating Gram-negative infections, but levels must be monitored to avoid toxicity. • Sepsis syndrome must be recognized early and treated aggressively to reduce the morbidity and mortality of this condition.

General Medicine • General Surgery + 1 more

ABDOMINAL DISCOMFORT

History A 64-year-old woman is referred to outpatients with a 6-month history of mild abdominal discomfort. This has been intermittent and involved the right iliac fossa mainly. There has been no particular relation to eating or to bowel movements. Over this time her appetite has gone down a little and she thinks that she has lost around 5 kg in weight. The intensity of the pain has become slightly worse over this time and it is now present on most days. Over the last 6 weeks, she has developed some new symptoms. She has developed a different sort of cramping abdominal pain located mainly in the right iliac fossa. This pain has been associated with a feeling of the need to pass her motions and often with some diarrhoea. During these episodes, her husband has commented that she looked red in the face but she has associated this with the abdominal discomfort and the embarrassment from the urgent need to have her bowels open. There is no other relevant previous medical history. She has smoked 15 cigarettes daily for the last 45 years and she drinks around 7 units of alcohol each week. She has noticed a little breathlessness on occasions over the last few months and has heard herself wheeze on several occasions. She has never had any problems with asthma and there is no family history of asthma or other atopic conditions. She worked as a school secretary for 30 years and has never been involved in a job involving any industrial exposure. She has no pets. She has lived all her life in London and her only trip outside the UK was a day trip to France. Questions • What diagnoses should be considered? • What investigations should be performed? ANSWER The symptoms she describes raise the possibility of a 5-hydroxytryptamine (5-HT)-secreting carcinoid tumour. The typical clinical features of the carcinoid syndrome are facial flushing, abdominal cramps and diarrhoea. Sometimes there is asthma and right-sided heart valve problems. The symptoms are characteristically intermittent and may come at times of increased release on activity. Skin changes may be persistent. The CT scan of the liver shows a space-occupying lesion in the liver likely to represent a metastasis to the liver. Fluid-containing cystic lesions are of lower density. Other secondary tumours would give a similar appearance. Carcinoids do not generally produce their symptoms until they have metastasized to the liver from their original site, which is usually in the small bowel. In the small bowel the tumours may produce local symptoms of obstruction or bleeding. The symptoms of carcinoid tumours are related to the secretion of 5-HT by the tumour.The diagnosis depends on finding a high level of the metabolite 5-hydroxyindole acetic acid (5-HIAA) in a 24-h collection of urine. Histology can be obtained from a liver biopsy guided to the correct area by ultrasound or CT. The symptoms can be controlled by antagonists of 5-HT such as cyproheptadine or by inhibitors of its synthesis p-chlorophenylalanine, or release, octreotide. The tumour can be reduced in size with consequent lessening of symptoms by embolization of its arterial supply using interventional radiology techniques. When odd symptoms such as those described here occur, the diagnosis of carcinoid tumour should always be remembered and investigated. In real life, most of the investigations for suspected carcinoid turn out to be negative. Carcinoid tumours can occur in the lung when they act as slowly growing malignant tumours. From the lung they can eventually be associated with left heart-valve problems. The other typical carcinoid features occur only after metastasis to the liver. Key Points: • Intermittent skin flushing, diarrhoea, wheezing and abdominal cramps are symptoms of the carcinoid syndrome. • All these symptoms have much commoner causes. • Metastasis to the liver is present before the symptoms of carcinoid syndrome occur.

Oncology • General Medicine + 1 more

BLISTERS ON THE SKIN

History An 83-year-old man presents to his general practitioner (GP) having developed multiple blisters on his skin and mouth. The blisters have appeared over 2 days. They tend to burst rapidly to leave a large red sore lesion. The patient has lost about 5 kg in weight over the past 3 months and has a poor appetite. He feels generally unwell. He has also noticed that his bowel habit has become erratic and has noticed some blood in his bowel motions. He has previously been fit and had no significant past medical illnesses. He lives alone and neither smokes nor drinks alcohol. He is taking no regular prescribed medication and has not bought any medication from a pharmacy or health food outlet except some multivitamin tablets since he felt unwell. Examination He looks emaciated and unwell. There are blisters spread all over his skin and sores within his mouth. Most of the blisters appear to have burst. His pulse rate is 102/min, irregularly irregular and blood pressure 160/78 mmHg. Examination of his heart and respiratory system is otherwise normal. There is a 6 cm hard nodular liver edge palpable, and also a hard mobile mass present in the left iliac fossa. On rectal examination there is some bright red blood mixed with faecal material on the glove. Questions • What is the diagnosis of the skin disease? • What is the cause of this condition in this patient? ANSWER This patient has pemphigus vulgaris. This is a blistering disease where the level of the blister is within the epidermis. The superficial nature of the blister means that the blisters are prone to burst leaving a glistening red base which bleeds easily. The epidermis at the edge of the blister is easily dislodged by sliding pressure (Nikolsky sign). Erosions in the mouth are also common. Associated diseases include carcinoma, lymphoma, thymoma, systemic lupus erythematosus and certain drugs such as penicillamine and captopril. This elderly man also has hepatomegaly. With the rectal bleeding and microcytic anaemia, it is likely that he has a left-sided colonic neoplasm. The raised alkaline phosphatase suggests secondary metastases in his liver. He needs an ultrasound to image his liver and a colonoscopy to visualize his colon. He should be referred to a surgeon to assess if palliative surgery is appropriate.Pemphigus is itself life-threatening either due to insensible fluid losses or septicaemia as a result of infection of the exposed blisters. The sore mouth and eroded skin need careful nursing. Treatment is with high doses of corticosteroids, and cytotoxic drugs may need to be added. Main differential diagnoses of blistering diseases! • Pemphigoid: the level of bullae is deeper (subepidermal) and the blisters are larger and rupture less often than in pemphigus. • Erythema multiforme: there are target-shaped lesions with central blisters, often with generalized erythema and mucosal ulceration (Stevens–Johnson syndrome). This is often associated with herpes simplex virus infection, certain drugs, e.g. sulphonamides and neoplasms. • Dermatitis herpetiformis: there are vesicular lesions over the elbows, knees and face. Vesicles are smaller than blisters (!0.5 cm) and often ruptured by itching. This rash is associated with coeliac disease. • Miscellaneous blistering disorders: diabetes mellitus, herpes gestationis and familial blistering disorders. • Pemphigus is often associated with underlying serious medical conditions. • Pemphigus may be fatal usually due to septicaemia as a result of super-added infection of blisters and immunosuppressive treatment.

General Medicine • Immunology + 2 more