CA LÂM SÀNG 15

Major takeaway
Antisocial personality disorder can be diagnosed in patients >18 years old. It is characterized by aggressive behavior toward people and animals, destruction of property, lack of remorse, illegal activity, and lying.
Main explanation
Antisocial personality disorder is characterized by a pervasive pattern of disregard for, or violation of, the rights of others. An impoverished moral sense or conscience is often apparent, as well as a history of crime, legal problems, and/or impulsive and aggressive behavior.

The DSM-V criteria for antisocial personality disorder are as follows:
A) A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by 1 of the following 7 features:
1. Failure to obey laws and norms by engaging in behavior which results in criminal arrest, or would warrant criminal arrest;
2. Lying, deception, and manipulation, for profit tor self-amusement;
3. Impulsive behavior;
4. Irritability and aggression, manifested as frequently assaults others, or engages in fighting;
5. Blatantly disregards safety of self and others;
6. A pattern of irresponsibility; and
7. Lack of remorse for actions
B) The individual is at least age 18.
C) There is evidence of conduct disorder with onset before age 15.
D) The occurrence of antisocial behavior does not occur in the context of schizophrenia or bipolar disorder.

Avoidant personality disorder is characterized by the fear of criticism and embarrassment, social withdrawal, and a preoccupation by fear of rejection. Treatment options include psychotherapy (initially individualized and then followed by group therapy) combined with antidepressants or anxiolytics.

Borderline personality is characterized by unstable moods, high impulsivity, and self-destructive behavior. Another key finding is splitting, seeing others as either all good or all bad. They feel alone inside and have multiple suicide attempts over seemingly trivial things. Self-mutilation is another common finding in borderline patients.

Although conduct disorder also presents in a similar manner, this diagnosis is reserved for minors, and at 20 years of age, this patient is considered an adult. Conduct disorder is a childhood disorder characterized by anti-social behavior including stealing, fighting, destroying property and forced sexual activity.

Schizoid personality disorder is characterized by the inability to form close relationships, social withdrawal, and lack of sexual interests. Typically, they are unable to show emotion and are happy to be alone. Treatment options include antipsychotics initially to resolve behavior as well as supportive psychotherapy.

Chlamydia trachomatis is a common sexually transmitted infections, but is most likely to present with a painful discharge, and there would most likely be no clue cells.

Major takeaway
Gardnerella vaginalis is a pleomorphic rod that often causes bacterial vaginosis. The diagnosis of Gardnerella vaginalis is made by the identification of clue cells on saline wet mount. Clue cells are vaginal epithelial cells covered with bacteria.

Main explanation
Gardnerella vaginalis is a pleomorphic rod that often causes bacterial vaginosis. It is typically found in sexually active women and is commonly asymptomatic. The most common presenting symptom is a homogenous, thin, grayish-white discharge from the vagina. Trichomonas vaginalis and Gardnerella vaginalis have similar clinical presentations, and can both cause frothy, gray or yellow-green vaginal discharge, pruritus, and produce a positive whiff-test. The diagnosis of Gardnerella vaginalis is made by the identification of clue cells on saline wet mount. Clue cells are vaginal epithelial cells covered with bacteria. This condition can be treated with metronidazole or clindamycin.

Neisseria gonorrhoeae is a common sexually transmitted infections, but is most likely to present with a painful discharge, and there would most likely be no clue cells.

Staphylococcus aureus is part of the normal skin flora. It can cause inflammatory processes such as skin infections or abscesses, as well as toxin-mediated disease. Toxic shock syndrome should be suspected in women who wear tampons when menstruating.

Streptococcus agalactiae, also known as group B streptococci, frequently colonizes the human genital tract. It can be vertically transmitted from mother to child, causing neonatal sepsis and meningitis.

Acyclovir is an antiviral medication that is primarily used in the treatment of herpes simplex virus infections. Genital herpes cannot be cured, but acyclovir can reduce pain and frequency and severity of outbreaks.

Oral azithromycin would be used to treat for chlamydia, not bacterial vaginosis. Chlamydia is a sexually transmitted infectioncaused by the bacterium Chlamydia trachomatis.

Oral fluconazole is a recommended treatment regimen for vulvovaginal candidiasis, which would present with “cottage-cheesedischarge” and signs of vaginal inflammation, such as erythema, pruritus, and pain.

Major takeaway
Bacterial vaginosis is a polymicrobial infection caused by an overgrowth of anaerobic organisms. Treat with oral metronidazole 500mg by mouth for 7 days.

Main explanation
This patient’s symptoms and physical examination are consistent with a diagnosis of bacterial vaginosis. Bacterial vaginosis is a polymicrobial infection caused by an overgrowth of anaerobic organisms, such as Gardnerella vaginalis and Lactobacillus species, that replace normal Lactobacillus flora. Women typically complain of abnormal vaginal discharge with a “musty” or “fishy” odor. Amsel’s criteria are used to evaluate for bacterial vaginosis; the presence of 3 out of 4 criteria establishes the diagnosis:
1. Abnormal thin, gray to white noninflammatory discharge
2. Presence of clue cells on microscopic examination
3. Vaginal fluid pH > 4.5
4. Positive whiff test: Fishy odor of vaginal discharge before or after addition of 10% potassium hydroxide
This patient is symptomatic and meets 4 out of 4 Amsel’s criteria; therefore, she should be treated for bacterial vaginosis. The most commonly recommended treatment regimen is Metronidazole 500 mg by mouth for 7 days.

An incidental finding of bacterial vaginosis in a woman who is not pregnant may not require treatment; however, this patient is symptomatic and thus should be offered treatment.

Asthma is characterized by wheezing, cough, and dyspnea as a result of reversible bronchoconstriction. Diagnosis is made with pulmonary function testing showing reversal of obstruction with bronchodilators.

Small cell lung carcinoma is a prominent lung malignancy in patients who are smokers. Found centrally in the pulmonary architecture, small cell is associated with paraneoplastic syndromes such as Lambert Eaton syndrome and Cushing syndrome. Major risk factor is smoking.

Major takeaway
Histoplasmosis is a fungus endemic to the Ohio and Mississippi river valleys. Suspect histoplasmosis in patients with respiratory symptoms and a cavitary lung lesion.
Main explanation
Histoplasma capsulatum is a type of fungi that are endemic to the Ohio and Mississippi rivervalleys. The fungi lies within the ground and is associated with bat and bird droppings. Histoplasmosis commonly affects patients who are immunocompromised (such as patients receiving systemic chemotherapy or acquired immune deficiency syndrome patients). Most symptoms occur within 2 weeks of exposure. Symptoms can vary widely and include flu-like symptoms, erythema nodosum, cavitary pulmonary lesions, and granulomas. Disseminated histoplasmosis can lead to hepatosplenomegaly and shock. Diagnosis is done by urine or blood antigen testing. Treatment include itraconazole in cases of localized histoplasmosis or amphotericin B in severe cases. Note that the pulmonary lesions seen in histoplasmosis either are stable or have a doubling time of more than two years.

Streptococcus pneumoniae is a gram positive cocci and is the most common cause of lobar pneumonia. S. pneumoniae can be diagnosed with a sputum culture. Chest radiographs will show lobar involvement.

Asbestosis is a substance commonly found within the insulation of old homes. Asbestosis causes restrictive lung disease and increases the risk of bronchogenic carcinoma and mesothelioma.

An ectopic pregnancy is unlikely in this patient because her pregnancy test is negative. A pelvic ultrasound also did not show a gestational sac or fetus.

Endometriosis may also cause a lot of similar symptoms that occur in patients with pelvic inflammatory disease. However, this patient has purulent vaginal discharge and Gram stain suggestive of a bacterial infection.

There is no history of any vaginal bleeding and her pregnancy test was negative. Her clinical symptoms and laboratory results indicate pelvic inflammatory disease.

An ovarian cyst may present with symptoms if it becomes large enough or torsion develops. This patient has no evidence of a palpable mass and ultrasound examination does not show any changes in the ovaries.

Major takeaway
Pelvic inflammatory disease (PID) is the most likely diagnosis in a patient who presents with a history of symptoms associated with gonorrhea or chlamydia but has not been treated.

Main explanation
Pelvic inflammatory disease (PID) is a complication of untreated sexually transmitted infectionsof the vagina and cervix due to bacteria ascending the reproductive tract into the uterus and fallopian tubes.The two most common causes of PID are chlamydia and gonorrhea, both of which can cause vaginal discharge, bleeding between menses, and dyspareunia. Once PID develops, patients develop lower abdominal pain, cramps, or aches, which are often associated with vaginal discharge. In a female patient who is presenting with acute lower abdominal painand vaginal discharge with or without fever, PID must be considered due to the considerable morbidity associated with the disease. PID is the most likely diagnosis in a patient who presents with a history of symptoms associated with gonorrhea or chlamydia but has not been treated. Remember, that both chlamydia and gonorrhea may be “silent” infections in women and can, therefore, be asymptomatic and get missed. PID can present as lower abdominal/pelvic pain and vaginal discharge due to infection with chlamydia and gonorrhea.

IFNβ is a cytokine produced by antigen-presenting cells and epithelial cells in response to viral infections. It is used in the treatment of multiple sclerosis.

IL-3 is secreted by activated T cells. It stimulates the differentiation of multipotent hematopoietic stem cells into myeloid progenitor cells, as well as their subsequent proliferation.

IL-5 is secreted by helper T cells and mast cells. Because IL-5 mediates eosinophil activation, anti-IL-5 antibodies are under investigation for use in conditions such as asthma, hypereosinophilic syndromes, atopic dermatitis, Churg-Strauss syndrome, and nasal polyposis.

IL-6 is secreted by T cells and macrophages as an acute phase reactant. Atlizumab (also known as Tocilizumab) is an anti-IL-6 monoclonal used in the treatment of rheumatoid arthritis.

Major takeaway
TNFα monoclonal antibodies such as Infliximab, adalimumab, and certolizumab pegol are biologic therapies used in the treatment of Crohn disease.

Main explanation
This patient has the classic signs and symptoms of inflammatory bowel disease (IBD), specifically of Crohn disease. Fistula formation is associated with the development of sinus tracts in these patients. Common sites for fistulas connect the intestine to the bladder, skin, intestine, or vagina. Unlike ulcerative colitis, which involves only the mucosal and submucosallayers of the intestine, Crohn disease is characterized by inflammation in all layers of the intestinal wall.

TNFα seems to play a key role in the etiology of this autoimmune disease. Blocking TNFα with a monoclonal antibody causes disease remission in a large number of patients with IBD. Infliximab, adalimumab, and certolizumab pegol are monoclonal antibodies against TNFα approved for use in moderate to severe IBD. These immunomodulators are used for conditions refractory to first-line agents (eg, glucocorticoids, 5-aminosalicylates).

Chlamydia trachomatis is the most common bacterial cause of urethritis and pelvic inflammatory disease in the United States. If it produces a discharge, it is typically described as purulent. It can also be very painful. It is an intracellular organism, rather than one that covers the outside of epithelial cells.

Major takeaway
Gardnerella vaginalis is a gram-variable, pleomorphic rod bacteria that is associated with bacterial vaginosis. When this condition is suspected, microscopic viewing of a vaginal wet mount shows clue cells covering vaginal epithelial cells, giving them a stippled appearance.
Main explanation
Gardnerella vaginalis is a gram-variable, pleomorphic rod bacteria that is associated with bacterial vaginosis. When this condition is suspected, microscopic viewing of a vaginal wet mount shows clue cells covering vaginal epithelial cells, giving them a stippled appearance. The term “gram-variable” means that when a collection of the bacteria are gram stained, some of them will turn pink and others purple (gram-negative and gram-positive, respectively). Though associated with recent sexual activity, bacterial vaginosis is not considered a sexually transmitted infection. In addition to Gardnerella vaginalis, bacterial vaginosis also involves an imbalance of the normal vaginal flora including anaerobic bacterial overgrowth. Symptoms include a white or gray vaginal discharge with a fishy odorthat can be enhanced by mixing the vaginal discharge with potassium hydroxide, which is called the amine whiff test. The vaginal pH will also be greater than 4.5. It is not painful. Treatment includes metronidazole or clindamycin.

Neisseria gonorrhoeae is a gram-negative diplococci that, like Chlamydia trachomatis, can cause infection of the urinary and reproductive tracts. Its discharge is creamy and purulent. The infection is often painful, unlike the one experienced by this patient.

Trichomonas vaginalis is a that results in vaginitis with a frothy green discharge and a strawberry cervix. Microscopic viewing of a discharge sample will show characteristic motile bacterial trophozoites.

Yersinia pestis is not a sexually transmitted infection. It is the cause of the plague and is transmitted by fleas who acquire the bacteria from prairie dogs and rats. This patient is not currently exhibiting signs of the plague.

Cavernous sinus thrombosis is a septic thrombotic process secondary to infections of the orbit, nasal sinuses, or central face. Headache is the most common presenting symptom, and patients often go on to experience orbital pain, diplopia, visual disturbances, and changes in mental status and coma once the CNS becomes involved.

Major takeaway
Cluster headaches are characterized by recurrent severe, unilateral, periorbital headaches with associated ipsilateral lacrimation, nasal congestion, and Horner’s syndrome. They are most often seen in younger males and can cause significant distress and disruption to daily life.
Main explanation
Cluster headaches, unlike migrainous headaches, affect males more often than females. The average age of presentation for cluster headaches is in the mid-20s and the typical pattern is severe, daily headaches for a period of weeks to months following by headache-free period ranging from months to years. Cluster headaches characteristically occur around the same timeeach day, often in the early hours of the morning, in the periorbital region with associated ipsilateral lacrimation and conjunctival injection, Horner’s syndrome and nasal congestion are also commonly associated. Treatment involves high flow O2 and triptan therapy in the acute setting, and prophylaxis with the centrally acting calcium channel blocker, verapamil.

Migraine headaches often last for 2-24 hours, are more common in females, and present with associated symptoms of aura, nausea, vomiting, and photophobia. First line therapy involves trigger avoidance and nonsteroidal anti-inflammatory drugs. Triptans are the most commonly used abortive therapy.

Subarachnoid hemorrhage is an acute presentation that can be due to trauma, aneurysmal rupture, or AVM. Patients describe a “thunderclap” headache or worst ever headache, and symptoms do not wax and wane. There may be symptoms of raised intracranial pressure.

Tension-type headaches present as a tight, band-like pain over the head without features of migraine or cluster headaches (e.g. – photophobia, nausea, aura, etc.). They are a diagnosis of exclusion, and treatment involves stress reduction and simple analgesia.

Major takeaway
Wilson disease is an autosomal recessive disorder characterized by abnormal coppermetabolism. It is caused by a mutation of the ATP7B gene on the long arm of chromosome 13.
Main explanation
The patient most likely has Wilson disease (hepatolenticular degeneration). Wilson disease is an autosomal recessive disorder caused by a mutation in the ATP7B gene on the long arm of chromosome 13. This leads to abnormal metabolism and deposition of copper in various tissues of the body, including the brain and liver. Onset and manifestation of symptoms are variable, but typically includes hepatic, neurologic and psychiatric symptoms such as cirrhosis, copper colored corneal deposits (Kayser-Fleischer rings), tremors, dysarthria, dystonia, and cerebellar ataxia. On magnetic resonance imaging (MRI) there are hyperintensities in the basal ganglia, specifically the lentiform nuclei.A mnemonic to remember Wilson disease is Copper is Hella BAD:
Ceruloplasmin decreased, Cirrhosis, Corneal deposits (Kayser-Fleischer rings), Copperaccumulation, Carcinoma (hepatocellular)
Hemolytic anemia
Basal ganglia degeneration (parkinsonian symptoms)
Asterixis
Dementia, Dyskinesia, Dysarthria

Arylsulfatase A deficiency is the cause of metachromatic leukodystrophy. The brain radiological findings are hyperintensities but all along the lateral aspect of the lateral ventricle.

Hexosaminidase A deficiency is the cause of Tay-Sachs disease, a disorder characterized by abnormal accumulation of GM2 ganglioside in the brain.

Porphobilinogen synthase is an enzyme involved in porphyrin synthesis. Inhibition/deficiency of the enzyme is usually due to heavy metal poisoning, especially lead.

Thamine deficiency is the primary cause of Wernicke encephalopathy, a disease characterized by altered mental status, ocular dysfunction, and ataxia.

Major takeaway
Anorexia nervosa (AN) may present with low levels of FSH, LH, TSH, and prolactin. However, if bulimic episodes are also involved, these hormones may be normal. The patient’s history usually gives more direction.

Main explanation
Anorexia nervosa (AN) is a potentially life-threatening eating disorder characterized by the inability to maintain a minimally normal weight, a devastating fear of weight gain, relentless dietary habits that prevent weight gain, and a disturbance in the way in which body weightand shape are perceived. It could be associated with bulimic and non-bulimic episodes. It could lead to secondary amenorrhea in healthy females. Amenorrhea results from disorders in the hypothalamic-pituitary-ovarian axis in which levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) are low despite low levels of estrogen. Due to this, reversion to the prepubertal state occurs, and the LH response to gonadotropin-releasing hormone (GnRH) is blunted. This blunted response is insufficient to maintain menstrual integrity, and amenorrhearesults. Note that anorexia nervosa can manifest with normal FSH, TSH, prolactin, coagulationstudy, and HCG levels.

Pituitary adenoma are common neoplasms, and recognition of their presentation is critical. Persons with abnormal menstruationcaused by a pituitary adenoma tend to have elevated prolactin

Anorexia nervosa is an eating disorder that impairs kidney function. However, renal disease is not characterised by low hormonal levels. Renal diseases are also associated with elderly patients.

Androgen tumor leads to androgen excess. Androgen excess affects mainly the pilosebaceous unit (PSU) and the reproductive system. In females, it leads to virilization of reproductive organs.

Cervical stenosis is a slowly progressive condition that pinches the spinal cord in the neck. Cervical myelopathy refers to this compression of the cervical spinal cord as a result of spinal stenosis. Cervical spinal stenosis with myelopathy is more common in elderly patients