101 Interesting Cases in Clinical Medicine Khan Abul Kalam Azad, Ahmedul Kabir, Mohammad Robed Amin
INDEX
Page numbers followed by f refer to figure and t refer to table.
A
Abdomen 158
acute 290
computed tomography scan of 109f, 180f, 285f, 307f, 353f
distended 108, 169
lower 63
lump in 270
magnetic resonance imaging of 339f
ultrasound of 155
X-ray of 289f
Abdominal mass, asymptomatic 56
Abscess
Collar stud’ 219
hepatic 47
intra-abdominal 63, 64
paravertebral 314
splenic tubercular 158
tubercular splenic 158
Accidental tongue 12
Acid-fast bacilli 31, 45, 142, 288
stain 187
Acidosis 140
Acquired granulomatous inflammatory disease 175
Acquired immunodeficiency syndrome 142
Actinomyces
genus 46
israelii 46
Actinomycosis 46, 173
disseminated 46
Activated partial thromboplastin time 6, 7, 113, 218, 249
Activated prothrombin complex concentrate 8
Acute respiratory distress syndrome 279, 280, 349, 350
Acute rheumatic fever 38, 39
diagnosis of 39t
Adalimumab 146
Addison's disease 155
Adenocarcinoma 98, 202
colonic 98
Adenosine
deaminase 142, 169, 291
diphosphate 268
Adrenal insufficiency, life-threatening 341
Adrenal mass, bilateral 154, 339, 339f
Adriamycin 85
Adult T-cell lymphoblastic
leukemia 308
lymphoma 308
Adult-onset Still's disease 144, 354
Aedes mosquitoes 187
Agglutination test 261
Alanine aminotransferase 6, 30, 74, 123, 147, 215, 217, 229
Alanine transaminase 194
Albendazole 181, 209
plus praziquantel 273
Albumin 18, 245
Alkaline phosphatase 10, 96, 109, 230, 311
Allopurinol 148
Alpha-fetoprotein 201
Amastigotes 131
Amenorrhea 124
primary 122
American College of Rheumatology 164
Amikacin 336
Amnesia 122
Amphotericin B 216, 303
Anakinra 36, 146
Anasarca 113
Anemia 124, 139, 145, 215, 224, 328
mild 172, 206
moderate 217
severe 6, 140, 150
Angioedema 40
Angioid streaks 265, 265f, 266
Angiotensin-converting enzyme 199, 212, 250
inhibitors 40
Anisochromia 109
Anisocytosis 109
Aniso-poikilocytosis 51
Ankle joints 230
Anorexia 62, 78, 100, 141, 177, 248, 262, 338
severe 343
Antecubital fossa 264f
Antibiotics 100, 260
therapies, unresponsive 359
Antibody
antimitochondrial 194
antiphospholipid 218, 349
profile 71
Anti-cyclic citrullinated peptide 13, 252, 349
Anti-cytomegalovirus 10
Anti-double stranded deoxyribonucleic acid 164, 349
Anti-Echinococcus antibody 271
Antigen antibody 289
Anti-hepatitis
A virus 9
B core 74
C virus 9, 74, 93, 120, 261
E virus 190
Antihistamines 11
Anti-human immunodeficiency virus 91, 142
Antileukemic drugs 198
Antineutrophil cytoplasmic antibody 313
Antinuclear antibody 6, 13, 59, 71, 74, 93, 123, 153, 164, 183, 194, 195, 204, 206, 218, 234, 275, 289, 299, 312, 313, 349
positive 35
Antiphospholipid syndrome 153
treatment of 153
Antiplatelet drug 268
Antiretroviral therapy 132
Anti-ribonucleoprotein 184
Anti-Sjögren's syndrome 35, 134, 289
Anti-smooth muscle antibodies 74, 194
Antistreptolysin O 38, 134
Antithyroglobulin antibody 179
Antithyroid peroxidase 59
Antithyroperoxidase 79
Anti-tissue transglutaminase 83, 161
Anti-tuberculosis
drugs 163
medication 190
Anti-voltage-gated calcium channel 296
Appetite 86
Arsenicosis
chronic 32
management of 33
Artemisinin combination therapy 139
Arteria dorsalis pedis arteries 70
Arthralgia 18, 34, 51, 66, 70, 73, 153, 224, 262, 297
Arthritis 86, 156
Ascites 63, 290
Aspartate aminotransferase 30, 87, 190
Aspiration, ultrasound-guided 64
Ataxia 127
Atriodigital dysplasia syndrome, diagnosis of 333
Atrium, right 249
Atrophic thyroiditis, autoimmune 179, 180
Aura 304
Autoantibody profile 145
Autoimmune disease 153
Autosomal recessive disease 355
Avascular necrosis, steroid induced 27
Azathioprine 21, 144146, 254
Azithromycin 228
B
Back pain 66, 96, 149, 169, 233, 348
history of 86
Balloon dilatation 313
Bartter's syndrome 23
Basal ganglia 59f, 60
Basal meningitis 337
Bee stings, multiple 278, 279
Behçet's disease 142
Bell's palsy 42
Bence-Jones protein 323
Beta-glucocerebrosidase enzyme 124
Bezafibrate 195
Bicytopenia 229, 307
Bilateral medial medullary syndrome 16
causes of 17
Biliary cirrhosis 313
Bilirubin 134
normal 123
Biosynthetic human growth hormone 125
Bladder
disturbance 25
dysfunction 1
tumor, resection of 338, 339
Blastomyces dermatitidis 302
Blastomycosis 302, 341
Bleeding
diathesis 7, 267
episodes 5
gastrointestinal 265
Blisters, multiple 34
Blood
glucose, capillary 138
lipoprotein profile 125
pressure 18, 22, 141, 157, 182, 206, 236, 279
reports, routine 291
sugar, random 267, 304
transfusion 6, 34, 281, 328
history of 260
urea 246
Bone 175, 239
malignancies, primary 92
marrow 234, 242, 302
examinations 75, 194
smear 197f
study 110, 308
suppression 146
mineral density 97, 230, 242
pain 133, 193, 197
scan 98f
Bony metastasis 98
Bortezomib 14
Bowel habit, alteration of 338
Bowel wall edema 290
Brain 175
diffusion-weight image MRI of 16f
magnetic resonance imaging of 50f, 79f, 105f, 106f, 128f, 200f, 237f, 305f
metastasis 239
olivopontocerebellar degeneration, latest magnetic resonance imaging of 128f
Brainstem 16, 107
dysfunction, signs of 16
encephalitis 16
Breast postmastectomy, carcinoma of 175
Breath, shortness of 122, 288, 331
Breathlessness 333
Brittle nail 159f
Bronchiectasis 179
Bronchioloalveolar cell carcinoma 98
Bronchoalveolar lavage fluid 18
Broncholithiasis 156
Brucella 262
abortus 261
melitensis 261
Brucellosis 261, 286
symptoms of 262
Bruch's membrane 265
B-type natriuretic peptide 249
Buccal mucosa, hyperpigmentation of 30f
Budd-Chiari syndrome 282
Bulla-spread sign 34
Bullous pemphigoid 35
Bullous systemic lupus erythematosus 35
Burkholderia 89
pseudomallei 88
growth of 88f
Burr hole, multiple 95
Butterfly rash 133
C
Calcium 100, 134
channel blocker 40
pyrophosphate dihydrate 23
Campylobacter jejuni 85
infection 84
Carbohydrate antigen 203
Carbon monoxide 72
Carboplatin 356
Carcinoembryonic antigen 203, 288
Carcinoma stomach 238
Carcinomatosis cerebri 238
Cardiac cirrhosis 250
treatment of 250
Cardiac defects 335
Cardiac failure 250
Cardiovascular disease 231
Cardiovascular system 265
Cardioverter defibrillator, implantable 248
Carotid artery, internal 94
Carpal bones 334
Castleman disease 235
Cefadroxil 44
Cefixime 34, 352
Ceftazidime 89
Ceftriaxone 336, 352
Celiac disease 222
Cell
count 142, 152
malignant 68, 175
Cellular debris 340
Cellular fibroblastic proliferation 64f
Central nervous system 120, 187, 192, 302
disease 231
tuberculosis 192
Cephalosporin 228
Cerebellar degeneration 201
Cerebellar function 58, 315
Cerebellar signs 128
Cerebellar system 294
Cerebellum 60f, 129
Cerebral infarct, acute 49
Cerebral involvement, nature of 239
Cerebral malaria 139
Cerebral sinus venous thrombosis 282
Cerebral venous sinus thrombosis 305
Cerebrospinal fluid 16, 127, 160, 167, 187, 190, 234
analysis 212
Cerebrovascular accident 107
Cervical lymph node 302
Chemotherapy 175, 338
Chest
computed tomography scan of 19f, 63f, 246
high-resolution computed tomography of 179f, 276f
inspection of 45f
pain 25, 70, 73, 93, 133, 199, 206, 221, 263, 274, 343, 348
exertional 336
percussion 180
radiography of 242
right upper 217
wall pain 149
X-ray 157, 261
Chikungunya 187
encephalitis 187
diagnosis of 188
virus 187
Chlamydia 228
trachomatis 228
Cholecystectomy 325
Cholelithiasis 53
Cholesteryl ester storage disease 124, 125
Cholestyramine 11
Chronic arsenic exposure, signs of 32
Chronic inflammatory
cell 75, 175f
demyelinating polyneuropathy 235
Chronic liver disease 31, 76, 122, 124, 193, 194, 236, 239
diagnosis of 74, 238
Chronic sinusitis 206
history of 179
Churg-Strauss syndrome 20
Chylous ascites 291, 292
Cicatrization 263
Ciliary function test 179
Ciprofloxacin 175
Circumoral paresthesia, history of 1
Cirrhosis 195
Clindamycin 34
Clofazimine 135, 148
Clopidogrel 267
Coccidioidomycosis 341
Coeliac disease 102, 161
Cold abscess 219
formation 319
Cold intolerance 177
Colitis, chronic nonspecific 194
Colonoscopic biopsy 102
Colonoscopy 158, 312, 346
Common bile duct 312
Complete blood count 6, 9, 90, 127, 141, 147, 152, 155, 157, 173, 183, 186, 196, 199, 229, 260, 267, 274, 301, 304, 311, 315, 321, 336, 349
Confusion 336
Conjunctival mucosa 34
Conn's syndrome 23
Connective tissue disease 145, 184
Consciousness 245
Constipation 211
Contraceptives, injectable 108
Convulsion 1, 93
Coombs’ test 35, 109, 183, 194, 225, 298, 328
Coronary artery bypass surgery 250
Corticosteroid 135
intravenous 50
Cotrimoxazole 175
Cough 25, 70, 133, 199, 203, 221, 274, 343
chronic nonproductive 277
history of 66
mild nonproductive 348
persistent 294
Cranial nerves 107, 200
Cranial neuropathy 201, 201
Craniotabes 1
C-reactive protein 13, 18, 39, 63, 87, 113, 134, 141, 147, 172, 199, 206, 252
Creatine kinase 234
Creatine phosphokinase 252, 275, 279
Creatinine kinase level 254
Crohn's disease 346, 347
Crow-Fukase syndrome 234
Cryptococcosis 341
Cryptococcus 176
Cyclophosphamide 85, 121, 146, 151, 207, 254, 293, 310
Cyclosporine 254
Cyst, simple 339
Cystitis 339
Cytopenia 197
Cytoplasmic antineutrophil cytoplasmic antibodies 59, 120, 207, 212
D
Dapsone 135, 148
Darier-Roussy syndrome 148
Dark-field microscopy 107
Deep fungal infection 317
Degenerative disk disease 97
Deglutition 348
Dengue
antibody, positive 113
syndrome 113
Denovo mutation 129
Dental hypoplasia 1
Dentate nucleus 59
Deoxyribonucleic acid 164, 183, 218, 222, 252, 289
Dercum's disease 148
Dermatan sulfate 231
Dermatofibroma 148
Dermatomyositis 175
amyopathic 253
Dexamethasone 151, 356
Dextrocardia 178f, 179f
Diabetes mellitus 175, 340, 357
Diarrhea 100, 159, 211, 280, 343, 348
bloody 297
chronic 81, 221
Diastolic dysfunction 249
Diffuse large cell non-Hodgkin lymphoma 308
Digital subtraction angiogram 94
Disease-modifying antirheumatic drugs 306
Disseminated histoplasmosis 155, 340
management of 341
progressive 155
Disseminated tuberculosis 68, 173, 192, 358
diagnosis of 359
Distal convoluted tubule 23
Diurnal variation 314
Dizziness 108, 118, 224, 245, 278, 351
Domperidone 86
Dorsal spine
compression 314
magnetic resonance imaging of 91f, 106f, 315f, 316f
Dorso-lumbar spine 97
Doxorubicin 121, 137, 293, 310
Doxycycline 228, 352
Drastic weight loss 357
Dress syndrome 115, 116
diagnostic criteria of 116t
Drug abuse 130
intravenous 260, 281
Drug reaction 115
Duodenal ulcer 27
Duodenitis
chronic nonspecific 83
erosive 289
Duodenum 160
Dysarthria 127
Dysautonomia 201
Dysphagia 1, 12, 15, 16, 34, 70, 71, 153, 224
management of 71
Dyspigmentation 147
Dyspnea 277
exertional 12, 274
recurrent 40
Dystonia 4
Dystrophic calcification 175, 264
E
Ear
nose and throat 171
pain 212
Echinococcus granulosus 180, 272, 272f
Echocardiography 169, 304
Edema 224
bipedal 161
Ejection fraction 225
Elbow joints 306
Electrolytes 223
Electrophoresis 52
Elevated protein 337
Emapalumab 355
Encephaloduroarteriosynangiosis 95
Encephalomalacia 4042
Encephalomyelitis 201
Encephalomyosynangiosis 95
Encephalopathy 188
hepatic 122, 236, 239
Endocardial cushion defects 335
Endocrinopathy 234
Endoscopic retrograde cholangiopancreatography 203
Enterobacter 45
Enterococcus 176
faecalis 91
species 358
Enzyme-linked immunosorbent assay 35, 164
Eosinophilia 101, 115, 194, 229
Epidermis, atrophy of 254
Epididymal mass 68f
Epididymo-orchitis, right-sided 192
Epigastrium 301
Epilepsy, secondary 41, 42
Episodes, recurrent 209
Epistaxis 34, 118, 233, 267
Epithelial cell 275
Epithelioid cells 285
Epithelioid histiocytes 340
Epstein-Barr virus 355
Erosions 34
Erythema 147
nodosum 134, 156
leprosum 135
Erythrocyte sedimentation rate 18, 37, 39, 51, 70, 73, 96, 113, 119, 134, 139, 141, 147, 155, 163, 199, 206, 210, 212, 215, 217, 227, 260, 284, 288, 298
Escherichia coli 176, 190, 218
Esophageal stenting 71
Esophageal varices 123
Etanercept 146
Evans syndrome
etiology of 299
primary 299
Ewing's sarcoma 120, 121
Excision biopsy 308
Exercise test 296
Extensive parenchymal lung disease 19f
Extensively drug-resistant tuberculosis 317
Extractable nuclear antigen 7, 35, 71, 134, 153, 184, 234, 275
profile 252
Extracutaneous systemic disease 148
Extrahepatic bile ducts 11
Extrahepatic portal vein obstruction 282
Eye 199
movement, rapid 56
pain 159, 212
red 221
F
Facial hyperpigmented lesions 67f
Facial nerve palsy 212
Facial numbness 199
Fahr's disease 60, 61
diagnosis of 60
Fahr's syndrome 61
Familial erythrophagocytic lymphohistiocytosis 355
Fasting lipid profile 354
Fatal respiratory failure 16
Fatigue 262
Fecal calprotectin 346
Fever 25, 34, 37, 66, 86, 113, 115, 144, 149, 186, 189, 203, 215, 227, 301, 338, 351
and jaundice, prolonged 215
fluctuating 260
history of 96, 152, 169, 294, 343
intermittent 163
low-grade 297
occasional low-grade 100
prolonged 157
recurrent 251
Fiber electromyography, single 295
Fibrin degradation product 227
Fibrinogen degradation product 113
Fibronectin 268
Fibro-osseous lesions, benign 64
Fibrosing mediastinitis 156
Fibrosis 195
Fibrotic ring 45
Fibrous dysplasia 64, 65
Fine needle aspiration cytology 56, 68, 82, 158, 200, 285, 291, 295, 302, 340
Fissure, interhemispheric 237, 237f
Fitz-Hugh-Curtis syndrome 228
Flaccid paraparesis 29
Fludarabine 7
Fluid-attenuated inversion recovery 49
Fluorescent treponemal antibody absorption 107
Flupentixol 7
Folate levels 105
Folic acid supplements 100
Follicle-stimulating hormone 78
Follicular lymphoma 293
low-grade 292
Foot, inversion of 229
Fractures, recurrent 241
Fresh frozen plasma 218
Fundoscopy 127, 229
Fungal infection 155
disseminated 302
G
Gait, hemiplegic 41
Gallbladder 312
Gammaglobulins, elevated titers of 204
Gamma-glutamyl transferase 9
Gastric adenocarcinoma 99, 239
Gastric biopsy 238
Gastric cancer 239
Gastric lymphoma 347
Gastric outlet obstruction 27
history of 27
Gastric ulcer 27
histopathology of 28f
Gastrinoma 347
Gastritis
diffused hemorrhagic 289f
hemorrhagic 289
Gastrointestinal manifestation 102
Gastrointestinal symptoms 154, 280
Gastrointestinal system examination 172
Gastrointestinal tract 123, 175, 203
Gaucher's disease 110, 124
Genetic disorders 305
Genital mucosa 34
Genitourinary tract 175
Genu valgum 229
Giant cell
lesions 64
tumor 64, 65
recurrent 63
Giardiasis 102
Gitelman's syndrome 23
acquired 24
diagnosis of 24
Glanzmann's thrombasthenia 268, 269
Glasgow coma
scale 73, 78, 93, 139, 186, 217
score 191
Glomerulonephritis 20, 110
Glucocorticoid 72, 207
Glycosaminoglycans 230, 231
Gold standard test 289
Gomori methenamine-silver nitrate 302
Goodpasture's syndrome 20
Gottron's papule 252, 254
Gram negative coccobacilli 87
Gram staining 349
Granulocyte predominance 146
Granuloma 68, 89, 291
Granulomatosis 20, 207
Gronblad-Strandberg syndrome 265
Gum bleeding 193
H
Hand
deformity, right 331
radial deviation of 331
Hansen's bacilli 134
Hard palate 154
Head injury 25
Head, computed tomography scan of 298f
Headache 5, 34, 66, 108, 118, 122, 152, 189, 211, 212, 233, 278, 304, 338, 343, 351
frontal 159
Hearing
difficulties 15
impairment 231
Heart
defects, congenital 335
disease 185
ischemic 12
sign 16
Helicobacter pylori infection 239, 345, 347
Heliotrope rash 252
Helminthiasis 102
Hemangioma 339
Hemarthrosis, history of 267
Hematemesis 5, 73, 122, 221, 236, 267, 281, 311, 338, 348
episodes of 240
history of 25
Hematocrit 6, 172
Hematologic tests 223
Hematopoietic stem cell
therapy 72
transplantation 151
Hematuria 5, 224, 267, 297, 308, 338, 343, 348
Hemiparesis 199, 217, 219
Hemoglobin 18, 52, 67, 87, 108, 134, 160, 172, 183, 186, 194, 196, 203, 217, 227, 233, 241, 251, 274, 288, 291, 301, 344
disease 329
electrophoresis 52
H disease 329, 330
normal 152
Hemoglobinopathies 54
Hemoglobinuria 140
Hemolysis 36, 216
Hemolytic anemia
autoimmune 216, 299
hereditary 328
Hemophilia
acquired 8
idiopathic 7
Hemoptysis 66, 73, 199, 206, 267, 348
history of 274
Hemorrhage 138, 305
intracerebral 93, 297
Hemorrhagic disease, life-threatening 269
Heparin sulfate 231
Hepatic cyst 272f, 339, 339f
multiple 271
simple 339
Hepatic failure 250, 313
acute 113
Hepatic fibrosis, congenital 282
Hepatic involvement, acute 228
Hepatitis 115, 192
B 93, 222
B virus 7, 222, 237, 249
infection 154, 222
C virus 7, 249
drug-induced 190
moderate chronic 123
nonspecific reactive 112
Hepatotoxicity 36
High protein, causes of 170
High-frequency repetitive nerve stimulation test 295
Hilar lymphadenopathy, bilateral 148
Hip
joint 26f, 62
pain 62, 63
Histiocytosis 97
Histoplasma
antigen 341
capsulatum 155, 340
Histoplasmosis 340, 341
acute pulmonary 155
chronic cavitary pulmonary 155
Hodgkin's disease 286
Hodgkin's lymphoma 92
Hoffman's sign 294
Holt-Oram syndrome 333, 335
Homer-Wright pseudorosettes 57
Hormone, antidiuretic 170
Horner's syndrome 56
Human immunodeficiency virus 93, 113, 120, 160, 222
disease, stage of 142
infection 131
Human leukocyte antigen 37, 97, 269
Hurler syndrome 230
Hybrid lesions 65
Hydatid cyst
hepatic 179, 270, 271
recurrent 271
Hydatid disease 272
Hydrocephalus 191
Hydroxychloroquine 146, 148, 184, 185, 290
Hypercalciuria 23
Hypercholesterolemia 125
Hyperkeratosis 263
Hyperparathyroidism 242, 326
Hyperpigmentation 30f, 154, 154f
Hyperplasia
benign epithelial 351
nodular regenerative 112
Hypersensitivity syndrome, drug-induced 115
Hypertension 110, 118, 340
Hypertriglyceridemia 125
Hyperviscosity syndrome, causes of 117
Hypocalciuria 23
Hypochloremia 245
Hypochondriac region, right 284
Hypochondrium 109
right 301
Hypochromasia 51
Hypoechoic lesion 286
Hypoechoic parenchyma 9
Hypogammaglobulinemia 272
Hypogastric region 190
Hypoglossal palsy 16
Hypoglycemia 140
Hypokalemia 23, 24
Hyponatremia
mild 245
severe 80
symptoms of 246
Hypopituitarism, partial 80
Hypoplastic upper limb 331
Hypothyroidism 60, 110, 179
primary 80, 170, 179
I
Ifosfamide 121, 356
Iliac bones 64
Iliac fossa, right 86
Imipenem 89
Immotile ciliary syndrome 179
Immunoblot assay 35
Immunochromatographic test 131, 137, 323
Immunoglobulin
intravenous 254, 300
Immunohistochemistry 308
Immunosuppressive drugs 69
Indigestion, chronic 211
Infarction
bilateral 16
hepatic 112
Infections 176
Inflammation, granulomatous 285, 340
Inflammatory bowel disease 83, 161, 222, 286
Inflammatory cell, acute 175
Inflammatory syndrome 156
Infliximab 36, 146
Injection benzathine penicillin 107
Insulin sensitizing agents 195
Interstitial pneumonia 277
nonspecific 277
Intestinal lymphangiectasia, primary 161
Intestinal taeniasis 210
Intracellular pathogens 130
Intracerebral hemorrhage, acute 219, 298f
Intracranial space-occupying lesions 106
Intracytoplasmic sperm injection 180
Intrahepatic bile ducts 11
Intrahepatic cholestasis, benign recurrent 10
Intrauterine death 153
Iron
deficiency anemia 328
profile 52
Isoprinosine 167
Itching 9, 25, 100
Itraconazole 156, 303
Ivermectin 103
J
Jaundice 1, 9, 25, 44, 113, 140, 169, 203, 215, 267, 281, 284, 301, 311
fluctuating 311
history of 221, 297
intermittent 313
recurrent 9
Jejunum 83
Jerky movements, recurrent 166
Joint 175
fixed deformity of multiple 2f
interphalangeal 183
multiple small 37
pain 144, 169, 186, 221, 241, 263, 338, 343
asymmetric 51
multiple 152
swelling, history of 152
Jugular venous pressure 331
Juvenile idiopathic arthritis 3
K
Kala-azar 52, 75, 76, 109, 131, 216, 322, 323, 358
chronic 358
Kartagener syndrome 179181
Kayser-Fleischer ring 2, 123, 166, 191, 229, 311
Keratan sulfate 231
Kidney 89
disease 229
enlarged 307
injury 310
acute 140, 279, 280
left 91
Knee
arthritis 86
joint 144, 230, 306
pain, severe right 22
left 37
Knocked knees, bilateral 229
Knodell score 75
Knuckle rash 252, 253f
Koilonychia 90, 159
Kupffer cells 75
Kyphosis 319
L
Lactate dehydrogenase 113, 225, 312
Lambert-Eaton myasthenic syndrome 201, 295
Lamina propria 84f
Lamivudine 131
Langerhans cell histiocytosis 176
Lax skin 263
Leg
and abdomen, swelling of 248
edema 34
swelling, bilateral 233
ulcer 182
Leishmania 76
donovani 131
bodies 216
Lenalidomide 14, 151
Lepromatous leprosy 176
Leprosy 42, 135
Leptospirosis 115, 299
Lesions, occupying 339
Leukemia 115, 118, 198, 308, 309, 354
acute 299
lymphoblastic 197, 308
chronic myeloid 322
Leukocytosis 96, 146
Leukoerythroblastic blood picture 298
Leukonychia 90, 221
Leukopenia 134, 145, 215
Liddle's syndrome 23
Light-headedness 224
Limb weakness 58, 294
Limbic encephalitis 201
Lip swelling 41f
after treatment, significant improvement of 43f
Lipid profile 304
Lipogranuloma 175
Lipoprotein, high-density 125, 249
Liposomal amphotericin B, doses of 76
Liver 89, 239, 285f
biochemistry of 76
biopsy 10, 75, 77, 110, 123, 124
basis of 122
histopathology report of 312
disease 124
dullness, upper border of 55
enhancement of 227
enzyme 47, 155
abnormalities 250
fibroscan of 10, 110
function test 157, 169, 204, 237, 261, 291, 301, 304, 321, 332, 353
abnormal 146
involvement 32
mass 56
parenchyma 237
right lobe of 339
stiffness 74
upper border of 236
Loin pain 338
Loose skin over axilla, folds of 264f
Low back pain 90, 149, 196
Lower limb 100, 294
edema, acute 44
left 70
right 91
Lower lip, predominantly 40
Lumbar disc herniation 92
Lumbar region, left 63
Lumps 90, 147
and bumps, multiple 147
Lung 175, 239
cancer, small cell 201, 295
involvement 32
nodules 156
Lupus enteritis 164, 290
underlies 290
Lupus vulgaris 68, 175
Luteinizing hormone 123
Lymph node 175, 239, 293, 297, 308
axillary 297
biopsy 302
histopathology of 308
metastatic 201
para-aortic 292
Lymphadenitis 219
granulomatous 301
Lymphadenopathy 115, 146, 149, 307
abdominal 83
intra-abdominal 31f
para-aortic 291
unmasking of cause of 163
Lymph nodes 40
Lymphoblastic lymphoma 308
Lymphocyte 186, 285, 340
count 160
intraepithelial 161
Lymphocytic infiltration, predominantly 337
Lymphohistiocytosis, hemophagocytic 354, 355
Lymphoid cells, dense infiltration of 84f
Lymphoid follicles 83
Lymphoid hyperplasia 292
Lymphoid tissue 85
Lymphoma 91, 115, 120, 158, 175, 176, 308, 309, 354
diagnosis of 351
low-grade 173
Lymphomatous infiltration 309, 310
Lymphopenia 147
Lymphoplasmacytic infiltrate 204
Lymphoproliferative disorder 83, 84f
Lysosomal storage disease 124
M
Macrophages 175
Maculopapular rash, desquamated 114f
Magnesium 22
supplements 24
Magnetic resonance cholangiopancreatography 271, 312
Malabsorption 71, 161
syndrome 84, 102, 222
strongyloidiasis leading to 102
Malaise 34, 115, 262
Malakoplakia 172, 173, 175, 176
Malar rash 352f
Malaria 109, 137
chronic 358
diagnostic test for 138
multidrug resistance 140
severe 139
Mantoux test 83, 134, 147, 155, 157, 225
Mass lesion 173
Massive hepatomegaly 108
Massive lymphadenopathy 172
Mean corpuscular hemoglobin 338
concentration 338
Mean corpuscular volume 215
Measles infection 167
Mebendazole 209
Mediastinal granuloma 156
Mediastinal lymphadenitis 155
Mediastinal lymphadenopathy 173, 174f, 204
Medulloblastoma 120
Melena 5, 73, 236, 267, 311, 338
episodes of 240
Melioidosis 88
disseminated septicemic 88
Melkersson-Rosenthal syndrome 42
Melphalan 151
Menstrual regulation, history of 228
Mental development 196
Meropenem 89
injection 88
Mesenchymal tumor 265
Mesenteric abnormalities 290
Mesenteric vein thrombosis 282
Metabolic bone disease 230
Metabolic diseases 355
Metacarpophalangeal joints 37
Metastasis 339
hepatic 56
Methotrexate 21, 146, 148, 184, 207, 254
Methylprednisolone 156
Michaelis-Gutmann bodies 173, 175, 175f
Microcytic hypochromic
anemia 44, 141
blood 328
Micturition, frequency of 48
Mid-abdominal pain 100
Mitomycin C, doses of 338
Mitral regurgitation, mild 249
Mixing study 7t
Monoclonal gammopathy 234, 321, 324
Monoclonal paraprotein 150
Monocytes 175
Mononuclear cell 87
Mononucleosis, infectious 286
Montoux test 172
Morning stiffness 241
Morning vomiting 25
Motor function 138, 196
Moyamoya disease 95
appearance of 94
causes of 95
familial 95
typical angiographic appearance of 94f
Mucopolysaccharidosis 230
diagnosis of 230
Mucosa, scalloping of 84f
Mucosal edema 289
Multifocal encephalitis 237
Multi-organ involvement 207
Muscle
biopsy 252
bulk 2
hematoma 267
weakness 152
Musculoskeletal
disease 231
examination 251
manifestations 3, 71
sequelae 146
system 6, 306, 348
Myalgia 260
Myasthenia gravis 201, 295
Mycobacteria 142
Mycobacterium
avium 176
bovis 358
leprae 135
tuberculosis 31, 69, 176, 190, 219, 336, 358
Mycophenolate mofetil 21
Myelodysplastic syndrome 175
Myeloid cells 118
Myeloma 118
multiple 150, 242, 322
Myelopathy 107, 201
Myeloproliferative
disease 118
neoplasms 118
Myocarditis 115
Myoclonic jerk 56
movement 167
Myxedema 170
N
Naproxen 348
Nasal intonation 199
Nasal regurgitation 294
Nausea 62, 159, 211, 248, 278, 280
Neck
side of 263
swelling 217
veins, engorged 248
Necrotic neoplasms 46
Needle aspiration cytology 62
Neisseria gonorrhoeae 228
Neoplastic bone lesion 62, 63f
Nephritis, interstitial 115
Nephrotic-range proteinuria 18
Nephrotoxicity 36
Nerve stimulation test, repetitive 296
Nervous system 123
examination 58, 96, 100, 152, 311
Neural leprosy, pure 135
Neuroblastoma 56, 120
adrenal 56
pseudorosettes pattern of 57f
Neuroectodermal origin 120
Neuroleptics 4
Neurologic examination 212
Neurologic manifestation 103
Neurological symptoms 117
Neuromyotonia 201
Neuropsychiatric
abnormality 104
disorders 107
Neurosyphilis 106, 107
Neutropenia 299
Neutrophil 46, 186
Neutrophilic leukocytosis 6, 82, 91, 245, 325
Nevirapine 131
Niclosamide 211
Night sweat 25, 66, 343
Nitrofurantoin 86
NK-cell leukemia 354
aggressive 355
Nodular hepatic tuberculosis 286
Nodular swellings, multiple 90
Nonalcoholic farmer 144
Nonalcoholic fatty liver disease 194
Nonalcoholic steatohepatitis 195
Non-Hodgkin lymphoma 92, 292, 354
Non-sanguineous fluid 44
Nonsmoker and betel-leaf chewer 171
Nonsteroidal anti-inflammatory drug 5, 24, 96, 113, 182, 185, 236, 266, 267, 284, 288, 306, 343, 348
Nontender hepatomegaly 51
Nontender hepatosplenomegaly 229
Nontuberculous mycobacterium infection 317
Normal pressure hydrocephalus 127
Normocalciuria 23
Normocytic anemia 6, 96, 119, 134
Normocytic normochromic anemia 101, 157, 163, 241, 311
Nuclear ribonucleoprotein, small 35
O
Occult blood test 160
Octreotide 162
Odynophagia 171
Offensive dark-colored stool 193
Oligomenorrhea 78
Oliguria 224, 248
Open lung biopsy 246
Ophthalmologic disease 231
Opsoclonus-myoclonus 201
Oral
doxycycline, course of 44
glucose tolerance test 30
moniliasis 68
prednisolone 144
quinine sulfate 137
steroids 116
tolerance tests 223
ulcer 70, 221
ulceration, history of 133
Organomegaly 234
Organs, intra-abdominal 328
Orofacial granulomatosis 42
Orogenital ulcerations 141
Orthopnea 177
Osteoarthritis 13, 236
Osteoarticular manifestations 198
Osteolytic lesions, multiple 150
Osteomalacia 242, 243
Osteomyelitis 89
Osteopenia 3f, 196
severe 198
Osteoporosis 97, 97f, 242, 326
Osteosclerotic myeloma 234
Otitis media, chronic 180
Outpatient department 147, 233
Overlap syndrome 184, 349
P
Pacemaker implantation, permanent 249
Pain, abdominal 25, 44, 51, 62, 117, 189, 190, 193, 203, 211, 221, 227, 263, 284, 288, 311, 313, 325, 326, 348
Pale stool 9
history of 311
Palmar erythema 74f, 117, 248
Palpitation 25, 93, 224, 297, 331
Pancreas 175
Pancreatic ascites 170
Pancreatic calculi, removal of 325
Pancreatitis
autoimmune 204
chronic calcific 325
IgG4-related autoimmune 204
Pancytopenia 281, 355
Papilledema 160
bilateral 217
causes of 161
Paracetamol 186
Paralysis 56
Paraneoplastic cranial neuropathy 201
Paraneoplastic syndrome 16, 201, 202
Paraplegia 314, 317, 318
Paraspinal sympathetic ganglia 56
Parathyroid
adenoma 326, 327
hormone 59, 61, 196, 229, 230, 344
Paratracheal lymphadenopathy 92
Paraventricular white matter 59f
Parenchyma, hepatic 281, 284
Parenchymal lung disease, diffuse 253, 275, 276f
Parent's screening 52
Paresthesia 29, 224
Parietal lobe, left posterior 105
Parkinson's plus syndrome 60
Parkinsonism 4
Parotid gland, bilateral 68
Parvovirus B19 53
Patent foramen ovale 95
Pelvic
collection, moderate 227
infection symptoms 228
inflammatory disease 228
Penicillamine 146
Penicillin 7
Peptic ulcer
causes of recurrent 345
disease 27, 326
Periadenitis 219
Pericarditis 156
suggestive of 228
Perinuclear antineutrophil cytoplasmic antibodies 120, 207, 212
Periodic acid-Schiff 156
Peripheral blood 328
film 13, 53f, 82, 87, 96, 119, 123, 160, 183, 217, 222, 227, 237, 260, 267
Peripheral hypereosinophilia 116
Peripheral nerve
damage 21
thickened 133
Peripheral nervous system 129
Peripheral neuropathy 201
Peripheral primitive neuroectodermal tumors 120
Periportal fibrosis 75
Pes cavus 229
Pharyngeal muscle 254
Phenytoin 7
Phocomelia 334
Phonophobia 189, 304
Photophobia 189, 304
Photosensitivity 34
Pigmentation, abnormal 193
Pitting leg edema, bilateral 12
Pituitary autoimmunity 80
Plasma cell dyscrasia 234
Plasmodium falciparum 139
Platelet 51, 169
aggregation
test 268
lack of 269
alloimmunization 269
functional disorder 268
persistently low 87
Pleomorphic purpura 217
Plethora 118
Pleural effusion, right-sided 114
Pleuritic chest pain, recurrent 277
Pneumococcal vaccine 180
Pneumonia 89
Pneumonitis 115
POEMS syndrome 32, 234
diagnostic for 235t
Polyangiitis 20, 207
microscopic 20
Polyarthralgia 66
Polyarthritis 37, 306
progressive 1
Polyclonal hypergammaglobulinemia 324
Polycystic kidney and liver 307
Polycythemia 118
rubra vera 118
Polymerase chain reaction 131, 187
Polymorphonuclear neutrophils 45
Polymyositis 185
Polyneuropathy 234
Portal hypertension 313
Portal vein 291
thrombosis 281, 282
Postcholecystectomy state 91
Post-head injury 4042
Postictal confusion 122
Postradiotherapy 175
Postural drainage 181
Postural variation 348
Potassium 22
Pott's disease 314, 317, 319
relapsed 318
Praziquantel 211
Prednisolone 85, 151
Prednisone 293, 310
Pregnancy 305
loss 153
Primary care hospital 278
Primigravida 37
Primitive neuroectodermal tumor 120
Probably adrenal metastasis 339
Progressive nodular swellings, history of 44
Prominent spleen 237
Prostate 89
benign enlargement of 358
enlargement of 149
specific antigen 201
Protein
C deficiency 282
symptomatic 282
S deficiency 282, 305
symptomatic 282
S, reduced 305
Proteus 176
Prothrombin time 6
Proton pump inhibitor 193
Proximal interphalangeal joints 251, 5, 306
Pruritus 118, 313
young lady with 311
Pseudomonas aeruginosa 176
Pseudoxanthoma 264
elasticum 265
Psychiatric manifestations 167
Psychiatric symptoms 4
Psychosis, young lady with 182
Pubic hair 124
Puerperium 305
Pulmonary disease 231
severe 156
Pulmonary disorders 246
Pulmonary edema 279f
Pulmonary fibrosis 71
Pulmonary function tests 277
Pulmonary hypertension 71, 72, 185, 332, 334f
risk for 185
Pulmonary manifestation 102
Pulmonary regurgitation, moderate 249
Pulmonary tuberculosis 127, 246, 247, 285
Pulmonary venous congestion 45
Pulmonary-renal syndrome, middle-aged lady with 18
Punctum 147
Pupillary light reflexes 104
Purpura 297
Purpuric rash 133
Pus cells 357
Pyelonephritis with hypertension, recurrent 150
Pyogenic peritonitis 170
Pyrexia 355
Pyuria, persistent 357
Q
Quadriparesis 22
Quadriplegia 15
Quinolones 176
R
Ramsay-Hunt syndrome 213
Rapid diagnostic tests 140
Rash 113, 251, 343, 351
on back 253f
Raynaud's phenomenon 5, 18, 66, 71, 122, 153, 184, 224, 274
Real-time reverse transcriptase 188
Recurrent crying bouts 1
Red blood cell 18, 45, 53, 58, 96, 163, 183, 187
Red granulation tissue 172
Reddish skin nodules, painful 133
Redness 306
Renal and bone marrow 116
Renal dysfunction 308
Renal function 155
test 243, 304, 325, 332
Renal impairment 326
Renal inflammation 21
Renal insufficiency 150
Renal involvement 307
Renal lymphoma 309
Renal stone 326
Renal tuberculosis 358
Renomegaly 306
Residual tumor 338
Resistance 310
Respiratory distress 73, 140, 152, 338, 348
Respiratory rate 18, 236, 331
Respiratory system examination 18, 55, 251
Respiratory tract infection, repeated 230
Retina, Bruch's membrane of 265
Retinal hemorrhage 266
Retroperitoneal fibrosis 204
Retroperitoneum 175
Reynauds's phenomenon, signs of 71
Rhabdomyolysis 279, 280
Rheumatic disease 184
inflammatory 184
Rheumatic heart disease 38
Rheumatoid arthritis 175, 182
Rheumatoid factor test 13, 252
Rhodococcus equi 176
Rib
fractures, multiple 3f
right-sided 64
Ribonucleic acid 167
Rickets 3, 230
with hydrocele 230
Rifampicin 11, 135, 352
Right knee 37
arthralgia 86
arthritis 23
Rinne and Weber test 212
Rituximab 21, 36, 146, 293
Roglobulin antibody 79
Rosacea 42
Round cell tumors 120
Rudimentary distal phalanges 333f
S
Sacroiliac joint infiltration 98f
Sarcoidosis 120, 135
Scanty lymphocyte 148
Scanty micturition 343
Scarring 263
Sclerosing cholangitis 204
primary 313
Sclerosing panencephalitis, subacute 167
Sclerosing sialadenitis 204
Sclerosis
aortic 249
multiple 16, 49, 60
Sclerotic bone lesions 235
Scoliosis 333f
Scrotal edema 291
Scrotum, USG of 68f
Sebelipase alfa 125
Secondary healthcare center 189
Seizure 107
Sensory
disturbance 93
modalities 41, 58
Sepsis 145, 299
overwhelming 75
Septic arthritis 89, 145
Septicemia
with 89
without 89
Serositis 226
Serum 202
albumin 30, 141, 160, 196, 212, 229, 325
level 291
alpha-fetoprotein 109
amylase 203
antinuclear antibodies 10, 261
bilirubin 190, 237, 321
calcium 147, 212, 242, 323
ceruloplasmin 10, 312
copper 105
level 166
cortisol 82
creatinine 18, 63, 134, 147, 157, 163, 190, 206, 241, 246, 270, 298
electrolyte 30, 147, 163, 190, 212, 246t
ferritin, repeat 354
fibrinogen 354
globulin 30
immunoglobulin electrophoresis 323, 323f
lactate dehydrogenase 298
lipase 203
pro-calcitonin 354
protein electrophoresis 97, 322, 322f
sodium 78
uric acid 267
vitamin B12 234
Sexual exposure, unprotected 130, 281
Sharp's syndrome 184
Shawl sign 252
Sheehan's syndrome 80
Shifting dullness 227
Shigella 176
Shock 140
Short stature 122, 230
Shoulder
dislocation, bilateral 3f
joint, right 1
Sickle cell 53
anemia 53
disease 53, 118
Sickle syndromes 53
Sickling test 52
Sinus 219
Situs inversus 180f
Skeletal deformity 229, 230
Skin 278
biopsy 153, 252
changes 66, 234
changes syndrome 234
involvement 116
lesion 21, 107, 154
hyperpigmented 66, 67
manifestations 71
overlying 5
pustule, biopsy of 46
rash 70, 115, 152, 224, 338
thickened 177
with hypertension, malakoplakia of 175
Sleep pattern, abnormal 224
Slit lamp examination 166
Slurring of speech, middle-aged male with progressive 58
Small intestinal disease, immunoproliferative 83, 84
Smoke, puff of 95
Soft stool, frequent passage of 209
Soft tissue 294, 309
density mass 155
mass, removal of 171
Solar keratosis 29
Somatropin 125
Sore throat 141, 146, 297
Speech disturbance 15
Spinal cord 16
Spinal metastasis 92
Spinal tuberculosis 319
types of 319
Spine
generalized osteopenia of 197f
magnetic resonance imaging of 97f, 318f
Spinocerebellar ataxia 128, 129
Spleen 89
Splenectomy scar 74
Splenic aspirate study 323
Splenic lesion 158
Splenomegaly 86
Spontaneous abortion 348
Spontaneous gum bleeding 117, 267
Staphylococcus aureus 176, 183
Status post-splenectomy 75
Steroid therapy 204, 205
Stiff's person syndrome 201
Still's disease, relapsed 146
Stomach
adenocarcinoma of 98
cancer of 99
infiltrating adenocarcinoma of 239
prepyloric mucosa of 345f
Stool
examination 210, 223
incontinence 93
occult blood test 225
Storage disease 110
Straight leg raise test 90
Streptomycin 190
Stroke 93
recurrent 106
Strongyloides stercoralis 27, 102
infection 27
Strongyloidiasis, treatment for 103
Subcutaneous adipose tissue 134
Subcutaneous nodules, multiple 119
Subcutaneous sarcoidosis 148
Subfertility 179
Submammary folds 119
Submandibular lymph node 163
Submandibular lymphadenopathy 171
Submandibular region 90, 172
Sulfonamide 7
Supraclavicular node, right 219
Supraclavicular regions, right 172
Suprahepatic vein 282
Suprarenal gland, right 56
Supraventricular tachycardia 332f
Swallowing difficulty 58
Sweats 262
Swelling 177, 193, 241, 306
generalized 159
nodular subcutaneous 147
Symmetrical sensory motor polyneuropathy 29
Syndrome of inappropriate antidiuretic hormone secretion 246, 247
Synovitis, chronic 87
Systemic amyloidosis
primary 14
treatment for 14
Systemic corticosteroids 175
Systemic lupus erythematosus 6, 20, 68, 110, 164, 184, 218, 225, 254, 275, 290, 300, 307, 349
diagnosis of 111t, 275
manifestation of 275
Systemic lupus international collaborating clinics 164
Systemic sclerosis 71, 153, 185, 349
Systolic dysfunction 225
Systolic functions 242
T
Tacrolimus 254
Taenia 210
saginata 210, 211
asiatica 210
rhynchus 210
solium 210
Taeniasis 211
Takatsuki disease 234
Target cells 51
Target sign 289, 290
T-cell lymphoblastic
leukemia 308
lymphoma 309
Testicular atrophy 248
Testosterone 344
Tetralogy of Fallot 335
Thalidomide 148, 151
Thighs, part of 263
Thoracic surgery, past history of 62
Thrombocytopenia 149, 150, 163, 183, 194, 215, 299
autoimmune 300
immune 299
Thrombocytosis 101, 118
Thrombophilia 282
Thrombotic thrombocytopenic purpura 218
Thyroid 40, 109
function test 13, 82, 160
gland 108, 175
stimulating hormone 123, 134, 203
Thyroiditis, autoimmune 181
Thyroxine 108
total 123
Tinnitus 25, 212
Tissue biopsy 121
histopathology of 84f
Tongue
amyloidosis 14
dorsal surface of 13f
fissure in 41f
middle-aged gentleman with enlargement of 12
nodules over posterior part of 172f
posterior part of 172
smooth 100
with hypertension, malakoplakia of 175
Transient ischemic attacks 95
Transjugular intrahepatic portosystemic shunt 250
Trauma, history of 93, 203
Traumatic brain injury 40
Treponema pallidum 106, 107
antibody 107
hemagglutination assay 228
Tricuspid valve 250
Triiodothyronine 123
Trimethoprim-sulfamethoxazole 176
Tropical sprue 102
Trunk, skin of 34
Tubercle bacilli 286
Tubercular basal meningitis 337
Tubercular epididymo-orchitis 68
Tubercular lymphadenitis, stages of 219
Tubercular peritonitis 170
Tubercular spondylitis 315
Tuberculosis 130, 143, 157, 192, 218, 247, 263, 315, 337, 338, 341, 347
abdominal 192
arthralgia 68
extrapulmonary 247
intestinal 102, 192, 221
isolated hepatic 285
lymphadenitis 68
treatment-completed 20
Tuberculous granulomata 286
Tuberculous lymphadenitis 219
Tumor
cells 293
markers 109
of bone, secondary 242
U
Ulceration 147
Ulcerative colitis 204, 313
Ulcers, multiple 171
Unconsciousness 199, 338
sudden 78
Upper abdomen 51, 270
Upper abdominal
discomfort 108
pain 55, 157
Upper eyelid 251, 294
swelling 252, 253f
Upper gastrointestinal tract 98, 169, 190, 222, 238
endoscopy of 45, 74, 82, 109, 114, 194, 225, 238f, 289f, 302
Upper limb 294
Upper respiratory infection 18
Urinalysis 227
Urinary copper 166
Urinary GeneXpert, positive 359
Urinary incontinence 93, 122, 127
Urinary total protein 275
Urinary tract infection 86, 92, 218
Urine
metanephrine in 56
protein test 18
red-colored 297
retention of 96
routine examination 13, 157, 275, 322
microscopic 6
stream 206
Urosepsis 219
Ursodeoxycholic acid 11, 313
Uterus 124
V
Vaccination 15
Valvular disorders 94
Variceal bleeding 236
Variceal ligation, endoscopic 281
Varicella zoster virus 213
Vascular endothelial growth factor 235
Vascular involvement 32
Vasculitis 218
systemic lupus erythematosus with 350
Venereal disease research laboratory test 93
Ventricular septal defect 332, 334f
Vertebral compressions, multiple 197f
Vertebral fracture 314
Vertigo 25, 212
episodes of 117
history of 93
Vietnamese tuberculosis 88
Vincristine 85, 121, 293, 310
Viral encephalitis 238
Viral illness 355
Viral markers 312
Visceral leishmaniasis 75, 76, 131, 216, 323, 322, 324
diagnosis of 131
Vision
blurring of 93, 159, 233, 304, 336
dimness of 199
double 199, 336
Visual acuity, impairment of 199
Visual disturbance 5, 15, 171, 263, 343, 351
Visual impairment 58
Visual problems 66
Vital signs 119, 212
Vitamin
A 81
C 44
D 59, 81, 229, 230, 244
deficiency 243
resistance 243
Vitiligo 12
Vitronectin 268
Voice, hoarseness of 58
Vomiting 25, 62, 73, 159, 189, 278, 280, 304, 348
and weight loss, middle-aged man with 25
von Willebrand disease 6
von Willebrand factor 268
W
Waldenström macroglobulinemia 117
Waldmann's disease 161
Warfarin 267, 283
Weakness 278
Wegener's granulomatosis 20
Weight gain and breathlessness 177
Weight loss 34, 154, 157, 169, 199, 206, 211, 233, 262, 338
Whipple's disease 176
White blood
cell 44, 58, 82, 87, 160, 163, 169, 186, 189, 267, 270, 298
count 119
Whitish segments, per anal discharge of 210f
Whitmore's disease 88
Whole blood transfusions, multiple units of 221
Willebrand factor 6
Wilson's disease 3, 124, 191, 230, 312
diagnosis of 4
hepatic 4
Woven bone, curvilinear trabeculae of 64f
Wrist joint 306
X-ray of 2
X
Xanthoma 176
Z
Zidovudine 131
Ziehl-Neelsen stain 134
Zollinger-Ellison syndrome 345
×
Chapter Notes

Save Clear


CRIPPLED YOUNG BOY WITH RECURRENT CRYING BOUTSCASE 1

Contributors: Rhishikesh Thakre,
Naveen Jain
Reviewers: Shailaja Mane,
Anupama S Borker
 
CASE SUMMARY
A 14-year-old young boy, the third child of non-consanguineous parents presented with multiple joint pain, swelling and fixed deformities for 6 years, difficulty of speech for 6 years and progressive generalized wasting of whole body for 5 years. In the beginning, he had intermittent feverish feeling which was not documented, used to come once or twice daily, each time lasted for 3–4 hours, subsided sometimes spontaneously and sometimes after taking antipyretics. Feverish feeling persisted for almost 1 year. He also had asymmetric, progressive polyarthritis of large and small joints. It started initially with the large joints (at first in right elbow, followed by right shoulder joint and subsequently right hip joint). There was no morning stiffness, no involvement of distal interphalangeal (DIP) joints and never complained of back pain. He developed fixed joint deformities in multiple joints for the last 3–4 years. There was progressive wasting of proximal and distal muscles of all four limbs and trunk, leading him to be completely bedridden for the last 1 year. There was no history of circumoral paresthesia, numbness in hands or feet, craniotabes, dental hypoplasia and no ears, nose and throat (ENT) ailment. Additionally, he had difficulty in speech for the last 6 years; it initially started with slurring, and later on, it deteriorated progressively leading to incomprehensible sounds. Moreover, he had emotional lability with frequent crying bouts for the last 1 year. There was no history of temper tantrums, depression, hyperactivity or disinhibition. There was no history of dysphagia, jaundice, convulsion, bowel and bladder dysfunction. There was no consanguinity of marriage, and family history of similar illness was absent. Multiple consultations were made where he was diagnosed as a case of motor neuron disease.
On examination, he was grossly emaciated, body built was below average, undernourished, irritable with frequent cry and vitals were stable. The GALS screening revealed that gait could not be examined.2
zoom view
Figs. 1A and B: (A)Torticollis, tortipelvis with swelling and fixed deformity of multiple joints; (B) Gray color ring in the upper part of the limbus.
Arm—dystonia present in both hands, and he had spastic torticollis; legs—on inspection, tortipelvis was present, (Fig. 1A) and multiple joints were swollen, tender and deformed. Fixed deformity was present in both knees and both ankle joints; spine—on inspection from behind scoliosis was present, and spinal movement elicitation was not possible. Examination of the nervous system revealed speech: uttered incomprehensible sounds, intact cranial nerves, muscle bulk were reduced in all four limbs, muscle tone increased, muscle power and reflexes could not be elicited. Plantar responses were flexor bilaterally, sensory function and coordination could not be done appropriately. Examination of the eyes showed the presence of gray colored ring in the upper part of the limbus of both eyes (Fig. 1B). Slit-lamp examination revealed Kayser Fleischer ring in both eyes. Other systemic examination findings were unremarkable.
Investigations showed: Hb level—11.9 g/dL, white blood cells (WBCs)—9,500/cumm (N: 77.8%, L: 18%), platelet (PLT)—393,000/cumm, erythrocyte sedimentation rate (ESR) in first hour—10 mm, urine R/M/E—normal, bedside dipstick test showed trace protein, serum electrolytes—normal, C-reactive protein (CRP)—normal, serum bilirubin—0.93 mg/dL, aspertate aminotransferase (AST)—67 U/L, alanine aminotransferase (ALT)—55 U/L, alkaline phosphatase (ALP)—140 U/L, serum albumin—3.52 g/dL, total protein—7.84 g/dL, corrected calcium—7.5 mg/ dL, serum inorganic phosphate—3.17 mg/dL (normal: 4.7 mg/dL), parathormone—41.2 pg/mL (11–67 pg/mL), spot calcium: creatinine—0.60: 1 (normal: <0.14). Ultrasonography (USG) of W/A—normal. X-ray of chest and upper part of the body posteroanterior view revealed: generalized osteopenia, multiple rib fractures with callus formation in the shaft of fourth to seventh ribs in right side, scoliosis toward left, fracture of right humerus and bilateral shoulder dislocation (Fig. 2A). X-ray of lumbosacral spine anteroposterior and lateral view—severe osteopenia and fracture of neck of left femur; X-ray of wrist joint and hand showed coarse trabeculation.3
zoom view
Figs. 2A and B: (A) Chest X-ray posteroanterior view showing generalized osteopenia, multiple rib fractures with callus formation in shaft of 4th to 7th rib in right side. Scoliosis towards left with bilateral shoulder dislocation; (B) Magnetic resonance imaging (MRI) of brain showing hyperintensity in bilateral thalamo-ganglionic capsular area.
 
QUESTIONS
  1. What is the diagnosis?
  2. What are the special investigations you need to carry out?
 
DISCUSSION
For this boy, our differential diagnoses were:
  • Juvenile idiopathic arthritis (JIA)
  • Rickets
  • Wilson's disease.
Some special targeted investigations were carried out to reach the diagnosis: Serum ceruloplasmin—45 mg/dL (normal: 200–600 mg/dL), 24 urinary copper 179 mg/24 hours (>100 mg/24 hours confirms Wilson's disease), magnetic resonance imaging (MRI) of brain showed prominent capsuloganglionic area, ventricles and extraventricular spaces, and hyperintense bilateral thalamo-ganglionic capsular area (Fig. 2B).
Final Diagnosis: Wilson's Disease (Neuropsychiatric and Musculoskeletal Presentation)
The patient's treatment was started with penicillamine and zinc acetate tablets, calcium, vitamin D injection and baclofen tablet. His condition improved remarkably. Within 6 months he was able to walk, and started going to school.
Wilson's disease is a hereditary disorder of the liver and brain. Different types of psychiatric features may be the first presentation of the disease. High index of suspicion is necessary to come up with a straightforward diagnosis.
It rarely presents with musculoskeletal manifestations also when there is accumulation of copper.1 Involvement of large joints, such as knee joint pain, effusion, radiological chondrocalcinosis in young adults and early 4osteoarthritic changes in imaging should be investigated carefully keeping the diagnosis of Wilson's disease in mind. Psychiatric manifestations may precede neurological symptoms of Wilson's disease in 20% of the cases. This patient initially presented with dysarthria and subsequently emotional lability. Afterwards on the basis of significant biochemical abnormalities and the presence of Kayser-Fleischer ring, he was diagnosed as a case of Wilson's disease.
A patient exhibiting neurologic signs or symptoms associated with Kayser-Fleischer rings and ceruloplasmin levels of less than 20 mg/dL confirms a diagnosis of Wilson's disease. Hepatic copper concentration of more than 250 mg/g of dry weight and a low serum ceruloplasmin level are enough to make a diagnosis of hepatic Wilson's disease.2
Chelating agents and medications are used to block copper absorption from the gastrointestinal tract. Zinc and penicillamine are the main treatment options. Trientine, another chelating agent which is more tolerated than penicillamine, can be used. Several other medications are used to combat symptoms, for example, baclofen for dystonia, neuroleptics to treat psychiatric symptoms, levodopa for Parkinsonism and antiepileptics for seizures.
REFERENCES
  1. Yu H, Xie JJ, Chen YC, Dong Y, Ni WZY. Clinical features and outcome in patients with osseomuscular type of Wilson's disease. BMC Neurol. 2017;17(1):34.
  1. Jameson JL, Kasper DL, Longo DL, Fauci AS, Hauser SL, Loscalzo J. Harrison's principles of internal medicine. 20th ed. New York: McGraw Hill Education.  2018. pp. 2982–4.