P2 Case A Answers

A 35 y/o nonsmoking African American woman presents to your family medicine clinic due to her recent visit to the ER. She said she felt a tightness in her chest and that she was having a lot more trouble breathing. She was afraid that it might have been signs of a heart attack, though she notes that she does have trouble breathing normally. However, this time, it felt worse. In addition, she has felt like her body has experienced some changes and she points out to you the following location on her body:

Lupus Pernio

You've also noticed her recent diagnosis of diabetes, enlarged salivary/lacrimal glands, and that painful nodules have also appeared on her lower extremities over time. She tells you, "Dr., my eyes have been weird. Is it normal for my age for things to get blurry? I've used glasses my whole life, but recently, it feels like everything is much more of a blur even with my glasses. But even that isn't as big of a deal as my trouble with breathing that's worsened." 

1. So far, you gather her history and you already know that her disease process localized where?

Sort of a trick question. It seems like her entire body is being affected. A systemic process would be better explanation. A picture of chronic, rather than acute is also painted. 

You read through her discharge summary from her recent hospitalization and you find that she had a radiologic study done of the chest and a biopsy of the lesion they found. You read the pathology report for the following image:

2. In your own words, describe what you see? 

"A granuloma showing pink-staining epithelioid cells and foreign body type of mutinucleated giant cells." -Goljan

3. Her chest radiograph is below. Before you read the radiology report, included below, you notice...?????

"Posteroanterior chest radiograph shows mediastinal and hilar lymphadenopathy and large parenchymal nodules in both lung fields. Cavitary nodule is observed in right upper zone." -AJR

4. Though this is a diagnosis of exclusion(esp infectious etiologies), you are beginning to think of this disease process:

Sarcoidosis. (A type of interstitial granulomatous pneumonitis)

5. Your patient is actually a Ph.D. in biology. She asks you to explain her disease process. In one sentence, describe the pathogenesis.

An inflammatory systemic disorder where CD4Th cells react with an unknown antigen and, in response, release cytokines that cause a formation of noncaseating granulomas. (-goljan)

6. What type of hypersensitivity is this?

Type 4

7. Name two important lab findings, if measured, that you may find in this patient that would help in your diagnosis of Sarcoidosis. 

-Hypercalcemia due to hypervitaminosis D

-Increased ACE