Quiz week 34
Q1. A 49 year old man goes to Florida. He visits Tampa and St. Petersburg. He presents to the ER with bullous lesions on his face and arms. All that he can recall is that he went to the beach and had a couple of beers. He then went on a boat ride 3 days ago where he caught some Kingfish. The lesions started to crop up about 2 days ago. He is awake and alert. His Vitals are normal. What should you do for him now?
The answer is choice 4. One would check for porphyrins. This patient has the typical presentation of Porphyria cutanea tarda (PCT). I have faced a similar question in the boards. When the board presents a patient with Vibrio vulnificus - which is what a lot of doctors were baited into, the boards will present a patient with fever. Patient may also be hypotensive and the incubation period is short: 6-18 hours. Tetracyclines are the drugs of choice. ICU admission is required when you suspect something rapidly progressing and if this were Vibrio, I would admit to the ICU. Not in this case though because:
PCT on the other hand will have only the bullae but all else will be fine. It is treated with phlebotomy. This brings us to the answer to question 2. It is choice 2. This patient is asymptomatic as regards the hypercalcemia. This is the commonest way that primary hyperparathyroidism is discovered. Hydration is not so important in the asymptomatic individual. Phlebotomy on the other hand should not cause the same effect as dehydration would in a patient with hypercalcemia. Actually, physiologically thinking about it, one would produce alkalosis (contraction alkalosis - mediated by renin-angiotensin-aldosterone). Alkalosis would reduce the ionized calcium by promoting the binding to albumin. One should check the PTH in this patient and see where it leads us to. For a more detailed account of hypercalcemia, please click here.
Q2. You send out routine lab tests for him. His calcium comes back at 12.3. Albumin is 4.5 g/dl. What should your next step be?