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#Case 2
During the winter months, a 65-year-old man
presents with livedo reticularis and purple fingertips. Other symptoms include arthralgia
and weakness. Renal impairment is present on
laboratory testing. Which of the following is
the most likely diagnosis?
#Case 2
. A 1-week-old infant is brought to the hospital because of vomiting. An upper gastrointestinal (GI) series reveals duodenal obstruction. On laparotomy, annular pancreas is found. Which of the following statements about annular pancreas is TRUE?
#Case 1
A 3-year-old girl is brought to the emergency room because of a 5-day history of high fever and fatigue. During this time she has been crying more than usual and eating less. Her mother says that the child has also complained about pain in her arms and legs for the past 3 days. She was born at term and has been otherwise healthy. She appears ill. Her temperature is 39.5°C (103.1°F), pulse is 128/min, and blood pressure is 96/52 mm Hg. The lungs are clear to auscultation. A grade 3/6 systolic murmur is heard at the apex. There is mild tenderness to palpation of the left upper quadrant with no guarding or rebound. The spleen is palpated 3 cm below the left costal margin. There is no redness or swelling of the joints. Laboratory studies show:
Hemoglobin11.8 g/dL
Leukocyte count16,300/mm3
Platelet count 220,000/mm3
Erythrocyte sedimentation rate50 mm/h
SerumGlucose96 mg/dL
Creatinine1.7 mg/dL
Total bilirubin0.4 mg/dL
AST18 U/L
ALT20 U/L
Urine
Protein 2+
RBC casts rare
RBC. 10/hpf
WBC1–2/hpf
Which of the following is the most appropriate next step in management?
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Explanation
The symptoms are typical of cryoglobulinemia. Cryoglobulins are antibodies that precipitate under cold conditions and are associated with several diseases. There are three main types of cryoglobulin syndromes based on the immunoglobulin composition of the precipitating antibody. Most cryoglobulinemic vasculitis is Type II or mixed and seen secondary to hepatitis C virus infection. Cold agglutinin disease would present with hemolytic anemia.The other syndromes would not generally be temperature sensitive. (Lichtman, pp. 1857–1858)
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Explanation case 2
Annular pancreas is a congenital anomaly; a band of pancreatic tissue encircles the second part of the duodenum. Annular pancreas is associated with Down syndrome as well as duodenal stenosis or atresia. Duodenojejunostomy and
gastrojejunostomy are acceptable treatments. Resection is not an acceptable choice due to the high incidence of fistula In adults, annular pancreas usually presents with abdominal pain,
nausea, and vomiting
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