© Department of Continuing Medical Education, Christian Medical College, Vellore
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Learning Cases January 2005

STUDY 1: MEDICINE - CASE OF THE MONTH

A Young Alcoholic

Courtesy: Department of Medicine, CMC, Vellore.

HISTORY

• A 23 year old man who has been consuming country liquor of 500 to 600 ml per day for the past 7 to 8 months.
• Initially used to consume with friends and then gradually started drinking alone.
• Had stopped going to work for about one month and was drinking at home.
• Came to casualty in acute respiratory distress
• Had been having mild difficulty in breathing for about 10 days
• Had taken little food for the 3 days preceding the onset of symptoms
• Had consumed more than his usual quota the day before coming to the hospital in the company of friends
• Complained of mild retrosternal and upper abdominal pain – no history of radiation of pain
• No fever/ cough
• No past history of similar complaints

ON EXAMINATION

• Pulse 120/ mt; blood pressure 90 systolic in casualty
• Respiratory rate 36 per minute; deep sighing respirations
• Elevated JVP and CVP more than 15 cm
• General and systemic examinations otherwise normal

1. What is your diagnosis?

   The diagnosis on admission was
   
   * Alcohol abuse with alcoholic cardiomyopathy
   
   * Systemic inflammatory response syndrome
   - sepsis/acute pancreatitis
   - metabolic acidosis
   
   

2. What investigations would you ask?

   On Admission ABG pH 6.938
   PCO2 10.6
   PO2 221.1
   HCO3 2.1
   ABE - -27.0
   SAT 99.3
   Patient shifted to MICU because of severe metabolic acidosis; given intravenous soda bicarbonate
   
   OTHER INVESTIGATIONS:
   Hb 12.8 TC 12500 DC Bf 2 N78 L20
   RBS 81 Na 133 K 5.4 Cl 97 creat 1.0
   urine acetone 1+
   Anion gap 34 [normally 10 to 12 mmol/L]
   LFT 1.9/1.5/6.8/4.3/279/107/76
   Serum amylase 117
   

3. What is the differential diagnosis?

   Differential diagnosis for metabolic acidosis in alcohol consumers:
   * Lactic acidosis secondary to septic shock
   Methanol intoxication
   Ethylene glycol intoxication
   Diabetic ketoacidosis
   Salicylate poisoning
   

4. What further investigations would you like?

   Further investigations:
   Serum lipase 453
   Ultrasound abdomen: mild enlargement of liver; hypodensity and bulkiness in the head of pancreas
   

5. What is your final diagnosis?

   Final diagnosis:
   Alcohol dependence state
   Acute pancreatitis
   Alcoholic ketoacidosis
   Young hypertension under evaluation
   

6. What do you know about Alcoholic ketoacidosis?

   Alcoholic ketoacidosis:
   First described by Dillon et al in MCNA 1940
   Occurs in chronic ethanol abusers- usually has a binge culminating in severe vomiting
   Causes dehydration acute starvation and ketoacidosis
   Common accompaniments: alcoholic hepatitis, gastritis, pancreatitis, infections
   
   Clinical spectrum:
   No gender preponderance
   Most commonly present with nausea [76%], vomiting [73%] and abdominal pain [62%]
   Breathlessness is a presenting feature in 20%
   Presenting signs: tachycardia [58%], tachypnea [49%], abdominal tenderness [43%]
   

7. What are the laboratory findings in alcoholic ketoacidosis?

   Laboratory findings:
   High anion gap metabolic acidosis
   May have compensatory hyperventilation and pH in the normal range
   May have metabolic alkalosis secondary to vomiting
   Ratio of 3 hydroxybutyrate to acetoacetate is higher than in DKA – hence the negative urine nitroprusside reaction
   Hypoglycemia or hyperglycemia can occur
   

8. What is the pathogenesis?

   Pathogenesis:
   Main pathogenic factors: ethanol, starvation, vomiting, ? relative insulin deficiency
   Patients with pancreatitis may have depressed insulin secretion
   Concomitant alcoholic hepatitis can also result in metabolic disturbances
   

9. What is the biochemical basis of ethanol in alcoholic ketoacidosis (AKA)?

   Biochemical basis of ethanol in AKA:
   Ethanol is metabolised to acetaldehyde by alcohol dehydrogenase
   Acetaldehyde is oxidised to acetate and this forms a substrate for ketone formation
   Shift of the NADH/NAD equilibrium towards NADH –decrease gluconeogenesis from lactate and increase the ratio of 3-OHB to AcAc
   Isocaloric substitution of ethanol for CHO causes mild to moderate ketosis
   
   OTHER CONTRIBUTORY FACTORS:
   Acute starvation- due to increased lipolysis
   Vomiting produces dehydration, decreased renal function& retention of 3 OHB and AcAc in blood; circulatory collapse can cause lactic acidosis
   

10. What is the treatment of AKA?

    Treatment:
    Correcting the metabolic and fluid abnormalities
    Parenteral thiamine, saline, glucose and potassium salts
    Patients with pH below 7.0 or 7.1 may benefit from NaHCO3
    No role for the use of insulin unless there is a confusion between DKA and AKA
    

Acknowledgement: Submitted by Dr. Naveen, Department of Medicine III, CMC, Vellore.

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STUDY 2: SURGERY

CASE OF THE MONTH

Courtesy: Department of Surgery, CMC, Vellore.

HISTORY

A middle aged lady presented with a recent onset 6x6 cm swelling in the right breast with nipple retraction and multiple mobile nodes in the axilla.
Click on the picture to enlarge.

1. What is the clinical diagnosis?

   Carcinoma right breast.
   
   

2. How is the diagnosis confirmed?

   FNAC of the lump on the right side. FNAC revealed infiltrating duct carcinoma
   
   

3. What are the necessary pre-operative investigations?

   Routine pre-operative investigations
   Chest X-ray - to look for lung secondaries
   Liver function tests- raised alkaline phosphatase
   Ultrasound abdomen- to look for liver metastasis
   Mammogram of the opposite (left) breast.
   Bone scan - to look for bone secondaries
   
   

Mammogram done of the left breast is shown below. Click on the picture to enlarge.





4. What is the diagnosis?

   Mammogram reveals cluster of microcalcification.
   
   

5. How do you proceed?

   
   Treatment on the left side:
   Wire localisation of the lesion and wide excision.
   Specimen is sent back to radiology to confirm if the microcalcification is within the specimen.
   Further treatment depends on final histopathology.
   
   
   
   Treatment on right side:
   Total mastectomy+ Axillary lymph node dissection
   Adjuvant chemotherapy and radiotherapy.
   

6. What is the vital point to remember from this case?

   In a case of carcinoma breast, preoperative investigations include a mammogram of the opposite breast, before proceeding with treatment on the affected side.
   
   

Acknowledgement: Submitted by Dr. Deepak Abraham, Department of Surgery VI, CMC, Vellore.

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STUDY 3: RADIODIAGNOSIS - X-RAY OF THE MONTH

What's the Diagnosis?

Courtesy: Department of Radiodiagnosis, CMC, Vellore.

A elderly man presents with Neck Stiffness, headache and vomiting. Contrast CT images are given below.

Click on the pictures to enlarge.

1. What are the findings in this contrast CT?

   Thick enhancing meninges with subarachnoid exudates seen at sellar, suprasellar and basal cisterns.
   Early - maybe normal or with mild hydrocephalous
   Effaced cisterns.
   
   

2. What is the diagnosis?

   Meningitis.
   
   


A elderly lady presents with seizures and headache. Click on the pictures to enlarge.





3. What are your findings?

   Multiple small calcified foci in the cerebral parenchyma.
   Four stages:- vesicular, colloidal vesicular, granular nodular and nodular calcified.
   

4. What is the diagnosis?

   Calcified cysticercus granulomata
   

Acknowledgement: Submitted by Dr. Sudhir, Department of Radiodiagnosis, CMC, Vellore.

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