Funtabulously Frivolous Friday Five 334

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia FFFF, introducing the Funtabulously Frivolous Friday Five 334

Question 1

What common condition can this bug treat?

Photo Credit: Muhammad Mahdi Karim

Reveal the funtabulous answer

Warts and molluscum contagiosum.

The picture is of a blister beetle. These insects secrete Cantharides from their exoskeleton when threatened resulting in burning and blistering of the skin.

Cantharidin is extremely hazardous and needs to be used carefully. While its blistering effects has a use, it is highly toxic with an LD50 of 0.5mg/kg causing GI and renal bleeding when ingested. Cantharidin is also aphrodisiac and can cause priapism as a side effect. According to Tacitus a roman historian, the empress to Augustus Caesar would use it to entice members of imperial families to commit sexual indiscretions that she could later bribe them with. The french surgeon Ambroise Paré described severe cases of men with “violent priapism” or satyriasis (nymphomania) and even a priest who swallowed a dose who later died from haematuria.

References


Question 2

A 7 year old girl presents with insidious neck pain following a case of tonsillitis the week before. Her ENT exam is unremarkable apart from a head tilt to the left side and chin deviation to the right. Your colleagues saw her 3 weeks ago and diagnosed torticollis but she has returned after using NSAIDs with no improvement. Her CT is shown below.

What is the diagnosis?

Reveal the funtabulous answer

Grisel Syndrome or altlantoaxial rotation

Spontaneous, nontraumatic rotatory subluxation of the atlantoaxial joint following peripharyngeal inflammation or otorhino-laryngologic surgical procedures (e.g. tonsillectomy, adenoidectomy). Occurs most commonly in the pediatric population.

Pathogenesis of Grisel syndrome is still not quite clear, but it is probably a ‘double hit’ phenomenon. Firstly those with a susceptibility for having a lax C1/C2 joint i.e. children or those with ligament disorder or Down syndrome. These people then get a ‘second hit’ from spasms caused by inflammatory mediators carried to cervical muscles by the pharyngeovertebral venous plexus.

In 1830, Sir Charles Bell reported a case of death from atlanto-axial subluxation which resulted in spinal cord compression in a patient with probable syphilitic ulceration of the pharynx.

A patient, who had a deep ulcer in the back part of the throat, was seized with symptoms like those of apoplexy. These symptoms continued for two hours. At this time the patient’s head fell suddenly forward, and he instantly expired. On dissection, it was found that the ulcer had destroyed the transverse ligament, which holds the process of the dentata in its place. In consequence of the failure of this support, the process was thrown back, so as to compress the spinal marrow. The parts are preserved in my collection.

Bell, Case LXIV 1830

Grisel syndrome (La maladie de Grisel) was named after Pierre Grisel (1874–1959), a French surgeon who described the syndrome characterized by dislocation of the C1–C2 joint in patients with pharyngitis and torticollis in 1930

Other differentials for torticollis to keep you awake at night include: spondylodiscitis, osteomyelitis, juvenile idiopathic arthritis, bone tumours, posterior fossa tumours, cervical cord tumours, dystonia, pseudo-tumour cerebri, trochlear nerve palsy, nystagmus, retropharyngeal abscess, Sandifer syndrome, Lemierre syndrome and even upper lobe pneumonia.

References


Question 3

Who said?

There is no body cavity that cannot be reached with a number fourteen gauge needle and a good strong arm

Reveal the funtabulous answer

Samuel Shem from the book ‘House of God

Laws of the House of God:

  1. GOMERS don’t die.
  2. GOMERS go to ground.
  3. At a cardiac arrest, the first procedure is to take your own pulse.
  4. The patient is the one with the disease.
  5. Placement comes first.
  6. There is no body cavity that cannot be reached with a #14G needle and a good strong arm.
  7. Age + BUN = Lasix dose.
  8. They can always hurt you more.
  9. The only good admission is a dead admission.
  10. If you don’t take a temperature, you can’t find a fever.
  11. Show me a BMS (Best Medical Student, a student at The Best Medical School) who only triples my work and I will kiss his feet.
  12. If the radiology resident and the medical student both see a lesion on the chest x-ray, there can be no lesion there.
  13. The delivery of good medical care is to do as much nothing as possible.

Shem added four more “Laws” in his reflection of The House of God 34 years later.

  1. Connection comes first.
  2. Learn empathy.
  3. Speak up.
  4. Learn your trade, in the world.


Question 4

At JFKs autopsy, which gland(s) did the three pathologists confirm he was missing ?

Reveal the funtabulous answer

His adrenals

JFK had Addison’s, although he denied having a chronic disease through his presidential campaign and beyond. The official autopsy report made no mention of his adrenal glands but later one of the residents made comment that there was barely any adrenal tissue left and certainly no signs of tuberculosis, confirming he had idiopathic Addison’s disease.

Addison disease Creative med doses
Addison disease – visual map by Creativemeddoses.com

Reference:


Question 5

Name the droids and the diagnosis?

Reveal the funtabulous answer

The droids are K-2SO, BB8, R2D2 and C3PO (left to right)

The disease is RS3PE

Remitting Seronegative Symmetrical Synovitis with Pitting Edema (RS3PE), first described in 1985 by McCarty et al, is a rare syndrome that is a subset of the seronegative symmetrical polyarthritis of older people.

The main characteristics of RS3PE syndrome are:

  • Acute onset 
  • Raised acute phase reactants
  • Bilateral diffuse, symmetrical swelling 
  • Rheumatoid factor negative
  • Hand and wrist involvement  
  • Human Leukocyte Antigen (HLA) B7 Positive
  • Dorsal pitting oedema of hands             
  • Positive response to low dose corticosteroids
  • Symmetrical synovitis               
  • X-rays show soft tissue swelling in the absence of erosions.

Olive et al also proposed the following diagnostic criteria for this syndrome:

  • Bilateral pitting oedema of both hands
  • Sudden onset of polyarthritis
  • Age more than 50 years
  • Seronegative for rheumatoid factor.

Reference:


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Funtabulously Frivolous Friday Five

Dr Neil Long BMBS FACEM FRCEM FRCPC. Emergency Physician at Burnaby Hospital in Vancouver. Loves the misery of alpine climbing and working in austere environments. Supporter of FOAMed, toxicology, tropical medicine, sim and ultrasound

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