You have recieved your COVID19 immunizations but nonetheless are still practicing
telemedicine.
You are shown a picture of the feet of a 33-year-old man who was admitted to
the hospital 2 days ago with a chief complaint of fever, chills, arthralgias, malaise,
anorexia, and a nonpruitic rash of 2 weeks duration. He has had "blurry" vision in
his right eye of several days duration. You are given no other information about his
history.
His physical examination on admission revealed a temperature of 38.2°C, a blood
pressure of 120/75 mm Hg, a regular pulse of 92 beats/minute, and a respiratory rate
of 12 breaths/minute. He has a macular rash involving his face, trunk and extremities
(see Panel A below). Ophthalmic examination of his right eye is abdormal (Panel B
below). His cervical, axillary and inguinal nodes are moderately enlarged and nontender
and his abdominal examination reveals hepatosplenomegaly. His joint and neurologic
examinations are normal.
The patient's complete blood count (CBC) shows a mild lymphocytosis with a relative
increase in T helper (Th) type17 and Th22 cells. The CBC is otherwise normal. Liver
studies reveal an alanine aminotransferase (ALT) of 359 U/L, an aspartate aminotransferase
(AST) of 161 U/L, an alkaline phosphatase (ALP) of 580 U/L, and a gamma-glutamyl transpeptidase
(GGT) of 883 U/L. His bilirubin levels are normal. Other laboratory studies, including
a chest x-ray and urinalysis, are normal.
What is your diagnosis, what test(s) would you order to confirm your suspicions,
and what treatment, if any, do you advise?
Panel A. Picture of the patient's rash.
Panel B. A picture of the posterior chamber of the patient's right eye.
Bonus Question: Why is this patient complaining of difficulty articulating and swallowing?
In order to receive credit please email your answers to smithj@etsu.edu.