CONTEMPORARY INTERNAL MEDICINE

Clinical Case Studies

Volume 1

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CONTEMPORARY INTERNAL MEDICINE

Clinical Case Studies

A collection of cases from The Ohio State University Hospitals discussed by faculty of the Department of Internal Medicine

Volume 1

Edited by

Juan Bowen, M.D., and Ernest L. Mazzaferri, M.D. The Ohio State University

Columbw, Ohio

PLENUM MEDICAL BOOK COMPANY NEW YORK AND LONDON

Library of Congress Cataloging in Publication Data

Contemporary internal medicine.

Includes bibliographies and index. 1. Internal medicine-Case studies. I. Bowen, Juan. II. Mazzaferri, Ernest 1.,

1936- . [DNLM: 1. Internal Medicine-case studies. WB 115 C761] RC66.C66 1988 616'.09 88-22379

ISBN-13: 978-1-4615-6715-8

001: 10.1007/978-1-4615-6713-4

e-ISBN-13: 978-1-4615-6713-4

© 1988 Plenum Publishing Corporation

Softcover reprint of the hardcover 15t edition 1988

233 Spring Street, New York, N.Y. 10013

Plenum Medical Book Company is an imprint of Plenum Publishing Corporation

All rights reserved

No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfIlming,

recording, or otherwise, without written permission from the Publisher

This volume is dedicated to the past physicians of The Ohio State University Department of Internal Medicine, our role models, who at the turn of the century fIrst established the tradition of excellence in

clinical medicine at our institution, and to our students and future colleagues for their perceptive questions, criticism, and stimulation

Starling-Loving Hall By Robert L. Hummel

Contributors

STANLEY P. BALCERZAK, MD, FACP, Director of Hematology and Oncology, Professor of Medicine, The Ohio State University, Columbus, Ohio

PHILLIP F. BINKLEY, MD, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio

JUAN BOWEN, MD, Director of General Medicine, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio

JAMES H. CALDWELL, MD, FACP, Professor of Medicine, The Ohio State University, Columbus, Ohio

EDWARD A. COPELAN, MD, Asistant Director, Bone Marrow Transplantation Unit, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio

FERNANDO G. COSIO, MD, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio

MARY E. FONTANA, MD, Associate Professor of Medicine, The Ohio State University, Columbus, Ohio

JACK M. GEORGE, MD, Director of Endocrinolo~ and Metabolism, Professor of Medicine, The Ohio State University, Columbus, Ohio

N. PAUL HUDSON, MD, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio

SETH M. KANTOR, MD, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio

ROBERT KIRKPATRICK, MD, Director, Liver Service, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio

CALVIN M. KUNIN, MD, FACP, Frank E. and Mary W. Pomerene Professor of Infectious Diseases, Professor of Medicine, The Ohio State University, Columbus, Ohio

JANET M. LEIBY, MD, Director, Ambulatory Oncology Unit, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio

vii

viii Contributors

RAYMOND D. MAGORIEN, MD, Associate Professor of Medicine, The Ohio State University, Columbus, Ohio

WILLIAM E. MAHER, MD, Hospital Epidemiologist, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio

ERNEST L. MAZZAFERRI, MD, FACP, Chairman, Department of Internal Medicine, Professor of Medicine and Physiology, The Ohio State University, Columbus, Ohio

DONALD L. McNEIL, MD, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio

EARL N. METZ, MD, FACP, Vice Chairman, Department of Internal Medicine, Charles A. Doan Professor of Medicine, The Ohio State University, Columbus, Ohio

STEVEN D. NELSON, MD, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio

ERIC R. PACHT, MD, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio

JOSEPH F. PLOUFFE, MD, FACP, Associate Professor of Medicine, Associate Professor of Medical Microbiology, The Ohio State University, Columbus, Ohio

JAMES M. RYAN, MD, Director, Nuclear Cardiology, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio

FRED B. THOMAS, MD, FACP, Director, Gastroenterology Training Program, Professor of Medicine, The Ohio State University, Columbus, Ohio

PIERRE L. TRIOZZI, MD, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio

DOUGLAS B. VAN FOSSEN, MD, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio

MARK D. WEWERS, MD, Assistant Professor of Medicine, The Ohio State University, Columbus, Ohio

Preface

Read with two objectives: first, to acquaint yourself with the current knowledge of a subject and the steps by which it has been reached; and secondly, and more important, read to understand and analyze your cases.

William Osler, The Student Life

What follows is a collection of cases-or more aptly, the stories of our patients and friends who have been seen at The Ohio State University Hospitals where our faculty have provided their care and about whom this volume is written. Today many fear that our patients are being moved from center stage while we are being distracted by the technology of medicine.This volume was written with patients in mind. The idea is that the most intriguing questions and the most rewarding answers begin and end at the bedside. This is a story of our patients, told by expert clinicians and spiced with commentary along the way. This volume in no way at­tempts to be comprehensive. Instead, it is like the practice of medicine, scattered, somewhat disjointed, while at the same time intensely personal and focused upon whatever problem the patient brings to us. The discussions are not so much about disease entities as they are about patients with problem". The two are uniquely dif­ferent. For instance, when the physician suspects hepatitis, not every imaginable cause can be actively investigated. Instead, tests and procedures are discriminate­ly chosen, a part of medicine that is still more art than science. The cases presented in this book are discussed in a format that shows the art of medicine in a framework of science. In all, 25 cases, both the common and the unusual, are presented. Each is summarized with the author's comments, which emphasize the important histori­cal features and salient physical diagnostic points. This is followed by a discussion of the contemporary issues, including pathophysiology, diagnosis, treatment, and prognosis, as they related to the patient's case. References selected are those which the author considers the best or most important recent citations on the subject. This is the first of a series of volumes that will present our most interesting and challenging patients in a case study format. We hope the practicing clinician will fmd this book useful.

Juan Bowen, MD Ernest L. Mazzaferr~ MD, FACP

ix

Acknowledgment

The editors wish to thank Dr. Earl N. Metz for his editorial assistance in the preparation of this book. His wisdom, thoughtfulness and careful reading of the manuscript are deeply appreciated. The authors also wish to thank Luanne Frey and Teresa Moynihan for their expert secretarial assistance.

x

Contents

Case 1 Chronic Liver Disease and Neurologic Abnormalities .................. 1 FredB.Thomas, MD, FACP

In this case study of Wilson's disease, the author discusses contemporary views of its pathophysiology and clinical features, along with the differential diagnosis of chronic liver disease.

Case 2 Dyspnea and Rapidly Enlarging Goiter ......................................... 18 Ernest L. Mazza/erri, MD, FACP

A patient with Hashimoto's thyroiditis and thyroid lymphoma provides the framework for a discussion of these increasingly more common disorders. The author includes a summary of the clinical approach to nodular goiter.

Case 3 Atheroembolic Disease Mimicking Systemic Vasculitis ............... 33 Fernando G. Cosio, MD

This case highlights the clinical and laboratory features of atheromatous embolic disease of the kidneys, emphasizing laboratory features of the disease which may lead to diagnostic confusion.

Case 4 E~hrocytosis ••••....•.•..••.•..•••••..••..•••..••..•....•..••..•.••.....•....••.................. 45 Stanley P. Balcerzak, MD, FA CP

A patient with polycythemia furnishes the setting for a discussion of the pathophysiology, differential diagnosis, and treatment of a classic problem in internal medicine.

Case S Obstructive Sleep Apnea ................................................................... S9 Eric R.Pacht, MD

A patient with snoring, nightmares, and palpitations during sleep provides the basis for a discussion of the current concepts

xi

xii

Case 6

in the diagnosis and treatment of obstructive sleep apnea, an important but frequently misdiagnosed condition.

Contents

Dyspnea and Cirrhosis ........... __ •••••••••••••••••••••••••••••••••••••••••••••••••••••••• 70 Mark D. Wewen, MD

A case of alpha-I-antitrypsin deficiency is reviewed by an author who has done pioneering work in this area. The inheritance, pathophysiology, and clinical features of the disorder are discussed in detail.

Case 7 Chest Pain in a Young Man ............................................................... 82 James M. Ryan, MD

This case study of a young patient with coronary artery disease emphasizes the logical evaluation of this common problem. The author analyzes testing strategies based on current concepts of medical decision-making.

Case 8 A Reactive Arthropathy ••••••••••••••••••.••.••.•••••••••••••••••••••••••••••.•••••••••.•••• 95

Case 9

N. Paul Hudson, MD

A patient with low back pain and joint complaints sets the stage for a discussion of the distinctive features, diagnosis, and treatment of the sero-negative spondyloarthropathies.

Community Acquired Pneumonia • __ •..••••••••••••••••.•••.••..•••....••••...••••• 104 Joseph F. Plouffe, MD, FACP

In this case study of a patient with pneumonia, the author reviews the current diagnostic and treatment decisions involved in this common and difficult clinical problem.

Case 10 Lens Subluxation and Tall Stature ••••••••••••••••••••••••••••••••••••••••••••••••• 116 Juan Bowen, MD

A patient with Marfan syndrome is the motivation for a discus­sion of the clinical features, diagnosis, and pathophysiology of this important disorder.

Contents xiii

Case 11 Breast Cancer in a Premenopausal Woman .................................. 128 Jane M. Leiby, MD and Earl N. Metz, MD, FACP

This case study highlights the major contemporary clinical issues surrounding this tragic problem which is among the most difficult dilemmas facing the practicing physician.

Case 12 Recurrent Fever, Chills, Pyuria, and Bacteriuria in an Adult Male Following Urinary Catheterization ........................................ 140

Calvin M. Kunin, MD, FACP

A case study of chronic prostatitis leads to a discussion of the causes, contemporary diagnostic approaches, and treatment of recurrent urinary tract infections.

Case 13 Fever and Bloody Diarrhea .••................................•.....••..•................. 148 William E. Maher, MD

A patient with infectious bloody diarrhea is presented with emphasis on the essential epidemiologic and clinical features. Recently recognized pathogens such as Campylobacter jejuni are discussed.

Case 14 Chest Pain and Heart Murmur in a Young Woman ..................... 159 Mary E. Fontana, MD

This is a case of mitral valve prolapse, the most common heritable disorder of connective tissue with cardiovascular manifestations. The author discusses the causes, cardiac dynamics, diagnosis, and complications of mitral valve prolapse.

Case 15 Peptic Ulcer Disease .......................................................................... 176 James H. Caldwell, MD, FACP

A patient with peptic ulcer disease provides the backdrop for a discussion of recent developments in the etiology, patho­physiology, diagnosis, and treatment of this common problem.

xiv Contents

Case 16 Microcytic Anemia ............................................................................. 191 Pierre L. Triozzi, MD

A case of thalassemia provides the framework for a discussion of the distinctions between iron deficiency anemia, hemoglobin­opathies, and other reasons for microcytosis.

Case 17 Recurrent Abdominal Pain and Edema ......................................... 202 Donald L. McNeil, MD

In this case of hereditary angioedema, the crucial clinical distinction between this life-threatening disease and other urticarial disorders is discussed.

Case 18 Hepatitis in a Chinese Student ....................................................... .216 Roberl Kirkpatrick, MD

This discussion focuses on the clinical evaluation of chronic hepatitis, with emphasis on the appropriate interpretation of serological tests for hepatitis.

Case 19 A Woman with Rheumatoid Arthritis .............................................. 227 Seth M. Kantor, MD

The author reviews pertinent clinical issues in the diagnosis and treatment of rheumatoid arthritis.

Case 20 Aortic Stenosis .................................................................................... 240 Doug/as B. Van Fossen, MD

The clinical features, natural history, and current therapy of obstructive aortic valvular disorders are discussed in the context of a patient with aortic stenosis.

Case 21 A Case of Weakness and Fatigue in a Teenager •••.•.....•••..•••..•••••••.. 259 Jack M. George, MD

A patient with Addison's disease provides the circumstances for a clinical discussion of acute and chronic adrenal insufficiency.

Contents xv

Case 22 Practical Approach to Syncope ........................................................ 266 Steven D. Nelson, MD

A common and potentially serious clinical problem is discussed from the vantage point of the electrophysiologic derangements that may cause syncope.

Case 23 Tbrombocyto:penia ............................................................................. 280 EdwardA. Copelan, MD

A patient with idiopathic thrombocytopenia gives insight into our contemporary understanding of the pathophysiology, diagnosis, and treatment of the immune thrombocytopenias.

Case 24 New Onset of Dyspnea in a Middle-Aged Man .............................. 290 Phillip F. Binkley, MD

A patient with dilated cardiomyopathy provides the basis for a discussion ofthis disorder. The author summarizes innovative diagnostic and therapeutic approaches which have been developed in the past decade.

Case 2S Test Case ............................................................... _ ............................ 301 Raymond D. Magorien, MD

A patient with acute myocardial infarction forms the framework for an approach to the contemporary management of this disorder. The author provides a step-by-step guide to management in a question-and-answer format.

Index ... _ .................................................................................................................. 313