Case 12 – A 35-year-old man with opioid withdrawal

A 35-year-old homeless man is admitted to the medical ward for treatment of an acute asthma exacerbation. He has a medical history significant for chronic severe asthma with multiple hospital admissions as well as tobacco use, heroin abuse, hypertension, and chronic, untreated tinea corporis infection. He is on his third day of supportive treatment with nebulized albuterol, metered-dose inhaled fluticasone, and an oral prednisone taper when he develops nausea, vomiting, and non-bloody diarrhea. He denies chest pain, palpitations, shortness of breath, dizziness, abdominal pain, fevers, or chills. His vital signs are within normal limits, and he has teary eyes with dilated pupils; he is yawning and sneezing intermittently.

What is the most likely diagnosis?

This constellation of signs and symptoms most likely represents opioid withdrawal. Pupillary dilation, lacrimation, rhinorrhea, yawning, piloerection, sneezing, nausea, vomiting, and diarrhea are the most common signs and symptoms of acute opioid withdrawal. Given his history of heroin use, it is likely that the patient was actively using heroin immediately prior to his hospitalization.

What is the epidemiology of this condition?

Approximately 2.4 million people have used heroin in the U.S., as reported in the 1998 National Household Survey on Drug Abuse. Heroin-related emergency department visits more than doubled between 1990 and 1996 to approximately 70,000, according to the U.S. Department of Health and Human Services.

What factors determine the severity and duration of this condition?

The time of onset, severity of symptoms, and duration of symptoms are directly related to the pharmacokinetics of the particular opioid involved. Of the most commonly abused opioids, heroin has an earlier, higher peak of severity (approximately 3 days of abstinence) compared with buprenorphine (4 days) and methadone (7-8 days), as well as a shorter overall duration of withdrawal symptoms.

What is the most appropriate management for this patient?

Methadone is the most widely accepted first-line treatment for opioid withdrawal, although the FDA restricts its use to the management of opioid addiction. A point scoring system of clinical signs can be used, in which a score of zero is given if a sign is absent, a score of one if it is present, and a score of two if it is severe. The signs to be scored include dilated pupils, runny nose, watery eyes, “goose” flesh, nausea or vomiting, diarrhea, yawning, cramps, restlessness, voiced complaints, and increased vital signs. The point total is equated with a total dosage of methadone to be given, in milligrams. The patient should be re-scored and re-dosed at 6-hour intervals. A 24-hour total should be calculated, and then after the patient has been stabilized, should be reduced by 10% per day. After the acute withdrawal period has ended, the patient should be referred to an outpatient opioid maintenance program (ie, a methadone clinic) or an abstinence-based program (eg, Narcotics Anonymous) to prevent further drug abuse and related physical, social, and legal morbidity.

By Brian Ash, MD, Resident in Anesthesia and Perioperative Care, University of California, San Francisco Medical Center; in association with Le TT, Schabelman E, Shivaram A, and Klein J, eds: First Aid Cases for the USMLE Step 2 CK. New York: McGraw-Hill, 2007.

Case 11 – A 45-year-old woman with disseminated disease

A 45-year-old woman from Cincinnati presents to her physician complaining of cough, dyspnea, fevers, and weight loss. She has been HIV positive for 20 years and has been using highly active antiretroviral therapy for the past decade. Although she continues to take her medications, this past year she lost her health insurance and has been unable to see her regular physician. Her temperature is 39°C (102.2°F), heart rate is 90/min, and respiratory rate is 20/min. Chest examination is notable for diffuse rales, while other physical examination findings include hepatosplenomegaly and lymphadenopathy. X-ray of the chest reveals reticulonodular infiltrates with a few calcified granulomas. Laboratory studies show:

CD4 count: 100/mm³
Hemoglobin: 10.0 g/dL
WBC count: 4000/mm³
Platelet count: 50,000/mm³

What is the most likely diagnosis?

Disseminated endemic fungal infection, likely histoplasmosis. The endemic fungi are soil-based fungi seen in particular geographic areas and include histoplasmosis and blastomycosis (Ohio and Mississippi River valleys), coccidioidomycosis (southwestern United States), and paracoccidioidomycosis (Latin America). In endemic areas, these fungi commonly cause asymptomatic infection in healthy patients. In patients with a large inoculum, an acute pulmonary infection is seen. Patients with underlying lung disease can develop chronic cavitary disease, which resembles tuberculosis. In immunocompromised patients, especially those with AIDS, disseminated disease can be life-threatening.

What is the differential diagnosis of this condition?

The differential diagnosis of a febrile wasting disease with lymphadenopathy in a patient with AIDS includes the Mycobacterium avium complex, lymphoma, or miliary tuberculosis. In acute pulmonary cases in patients without AIDS, the differential list also includes sarcoidosis, which can have a very similar clinical presentation.

What is the pathogenesis of this condition?

The endemic mycoses are dimorphic fungi that live in the soil. When the spores are aerosolized and inhaled, they revert to fungal forms and incite a T-cell response that usually clears the infection within 2 weeks. Immunocompromised patients can either develop disseminated disease immediately or as a reactivation of latent infection. Disseminated disease can demonstrate gastrointestinal involvement with ulcerations and polyp development, skin lesions, adrenal involvement, and central nervous system disease.

How is the diagnosis made?

Rapid antigen detection tests can identify the Histoplasma polysaccharide antigen in urine, blood, or bronchoalveolar lavage fluid. Direct visualization and culture of the fungus can be done with blood or tissue samples, although culture may take weeks.

What is the most appropriate management for this patient?

The current recommendation for disseminated histoplasmosis in patients with AIDS is liposomal amphotericin B, followed by itraconazole suppressive therapy for life. The majority of acute pulmonary histoplasmosis infections in immunocompetent patients do not require treatment.

By Melissa Rosenstein, MD, Resident in Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco Medical Center; in association with Le TT, Schabelman E, Shivaram A, and Klein J, eds: First Aid Cases for the USMLE Step 2 CK. New York: McGraw-Hill, 2007.

Case 10 – A 47-year-old man with suicidal ideation

A 47-year-old man was diagnosed with AIDS 3 years ago. Shortly after his diagnosis, he informed his partner of 8 years over the phone; she subsequently hung up on him and refused to speak with him again. Since then he had become progressively more socially isolated from his friends and family and had started drinking heavily. The pain from his peripheral neuropathy is a source of constant agony. On several occasions he has expressed a desire to die to his physician, and against the doctor’s pleas he has stopped taking his antiretroviral medications. He refuses to seek help from a psychiatrist who could treat his depression and help him to cope with his illness. He views his illness as a punishment and sees no good in trying to delay the inevitable. He feels useless and beyond help.

What is the epidemiology of suicide in the United States?

The annual death rate from suicide is higher than the annual death rate from homicide. Suicide is the eighth leading cause of death for adults and the second leading cause of death for college students. Nearly 30,000 suicides occur each year; roughly 1% of the U.S. population commits suicide. For every completed suicide, there are 18 failed attempts. For men, suicides occur more frequently as they age, with a peak at age 75 years; for women, the suicide rate peaks at 40-50 years. Men who commit suicide are most likely to be >45 years old, white, and either separated, divorced, or widowed. Women are more likely to attempt suicide; men are more likely to complete the act. Most people who commit suicide communicate their suicidal intentions to their physician and see their physicians before they die. Research indicates that more than 90% of those who commit suicide have a major psychiatric illness and half are clinically depressed at the time of the act.

What is the relationship between illness and suicide?

Nearly 5% of people who commit suicide have been diagnosed with a serious physical illness. Suicide rates are high among those diagnosed with AIDS, amyotrophic lateral sclerosis, Huntington’s disease, traumatic brain injuries, epilepsy, multiple sclerosis, Parkinson’s disease, and cancer. The suicide rate in patients with AIDS is nearly seven times greater than that in the general population. In many of these medical conditions, pain is often a mitigating factor.

What assessment tools are helpful in identifying suicide risk?

The following mnemonic SAD PERSONS is helpful to remember when assessing patients for suicide risk:

1. Sex (male gender)
2. Age (older)
3. Depression
4. Previous suicide attempt
5. Ethanol abuse
6. Rational thinking loss
7. Social support lacking
8. Organized plan
9. No spouse or partner
10. Sickness

Specific questions that should be asked of a person at risk for committing suicide ought to be direct and give the patient an opportunity to discuss his or her intentions. They include:

1. Have you been feeling like life is not worth living?
2. Have you been having thoughts of harming yourself?
3. Have you developed a plan for taking your life?
4. Do you have access to a weapon or means to commit the act?

By Kristen Vierregger, University of Pennsylvania School of Medicine, Class of 2008; in association with Le TT, Schabelman E, Shivaram A, and Klein J, eds: First Aid Cases for the USMLE Step 2 CK. New York: McGraw-Hill, 2007.

Dr. Tao Le (series editor for the First Aid for the USMLE Step 1) invites you to a free Webinar this Wednesday (Nov 7th) from 8-9pm EDT!

This high-yield talk will cover the basics of the USMLE Step 1 including an overview of the boards, goal setting, high-yield topics in each subject area, study strategies, review resources, and study schedules. There will be an opportunity for a live Q & A session at the end of the talk.

The way it works:

1. Register to hold your place now (space is limited).
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3. Be able to call the conference phone number to listen to Tao’s presentation. This can be done with a home phone, cell phone, or internet phone.
4. Mark your calendar for November 7th at 8:00pm EDT and come with questions!

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Title: First Aid for the USMLE Step 1 by Dr. Tao LeDate: Wednesday, November 7, 2007
Time: 8:00 PM - 9:00 PM EDTSystem Requirements
Required: Windows® 2000, XP Home, XP Pro, 2003 Server, Vista OR
Required: Mac OS® X 10.3.9 (Panther®) or newerReserve your Webinar seat now at:
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https://www.gotomeeting.com/register/634614701

Case 9 – A 35-year-old woman with vaginal discharge

A 35-year-old G1P1 woman presents to her gynecologist complaining of white vaginal discharge with a “cheesy” consistency, itching, and discomfort. Her last menstrual period was 3 weeks ago, and she does not report any new sexual partners. She uses an intrauterine device (IUD) for contraception. Her temperature is 37°C (98.6°F), heart rate is 80/min, and blood pressure is 125/80 mm Hg. Speculum examination reveals erythematous and slightly edematous external genitalia. The vaginal walls are coated with a thick, white discharge, but the cervix appears normal, and the IUD string is visible from the os. A sample is taken, two slides are made, and the pH is determined to be 4.0. The saline-prepared slide shows only epithelial and inflammatory cells, while the potassium hydroxide-treated slide shows pseudohyphae and budding yeasts. There was no odor noted upon treatment with potassium hydroxide.

What is the most likely diagnosis?

Vulvovaginal candidiasis. Classic symptoms are the white, odorless, “cheesy” discharge and vulval swelling, itching, and discomfort. The wet mount, showing the presence of budding yeasts and pseudohyphae, confirms the diagnosis.

What other conditions should be included in the differential diagnosis?

The two other common causes of vaginitis are bacterial vaginosis and trichomoniasis.
Bacterial vaginosis is caused by Gardnerella vaginalis and other anaerobes that are usually suppressed by the dominance of Lactobacillus spp. The most common symptom is a discharge with an unpleasant, “fishy” odor. Wet mount in G. vaginalis infection shows epithelial cells with adherent bacteria (“clue cells”), without the presence of inflammatory cells. Preparation with potassium hydroxide reveals the characteristic amine odor (the “whiff test”).

Trichomoniasis is a sexually transmitted disease caused by the Trichomonas protozoa. The classic presentation is a frothy green discharge. Diagnosis is made by visualizing the motile protozoa on saline wet mount

Less common causes of vaginitis include atopic and contact dermatitis.

What are the common risk factors for this condition?

Associated risk factors of vulvovaginal candidiasis include”

1. Antibiotic use
2. Diabetes mellitus
3. Immunosuppression (steroids, HIV)
4. Oral or barrier contraceptive use
5. Pregnancy

What is the pathophysiology of this condition?

Like Gardnerella, Candida spp. (most commonly C. albicans) are part of the normal vaginal flora. However, when the vaginal pH changes or normal vaginal flora are eradicated by antibiotics, Candida rapidly replaces normal flora and symptoms arise. It can be transmitted sexually, but is not considered a sexually transmitted disease

What is the most appropriate management for this patient?< /span>

This patient has an uncomplicated infection, and her options include 3-7 days of topical azole treatment or single-dose oral fluconazole. A complicated infection is one in a diabetic, immunosuppressed, or pregnant patient; in a patient with a history of recurrence (?4/year) or severe symptoms; or disease caused by a Candida species other than C. albicans. Treatment of complicated infection requires 14 days of a topical azole or 2 days of fluconazole. Fluconazole is contraindicated in pregnancy, and 7 days of topical therapy is recommended.

By Melissa Rosenstein, MD, Resident in Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco Medical Center; in association with Le TT, Schabelman E, Shivaram A, and Klein J, eds: First Aid Cases for the USMLE Step 2 CK. New York: McGraw-Hill, 2007.