Clinical Pathological Conference (9/6/02)

Chief complaint – Diarrhea for 2 weeks

HPI – This 38 y.o. African American male presents with 4-5 watery BMs/day, intermittent abdominal bloating, nausea without vomiting, and orthostatic lightheadedness. He denies overt gastrointestinal bleeding, abdominal pain, or weight loss. He also reported a four-week history of bilateral lower-extremity edema.
PMH – ‘seizure disorder’, last occurring twenty years ago; on no medications currently.
SH – ten cigars/week, occasional beer, occasional marijuana, none since being incarcerated approximately two months prior to admission
FH – sister with unspecified cancer

ROS - NEURO: history of unsteadiness on his feet and difficulty with vision, especially at night, of unspecified duration.
Exam – WD/WN man in NAD. Alert and oriented x 3.
Vitals – T 37.0, P 70, BP 110/70, R 20, 98% O2 saturation on room air.
HEENT/neck – no abnormalities.
Chest – clear bilaterally.
CV – unremarkable.
Abd – soft; mildly tender to deep palpation diffusely, tympanitic, with normal bowel sounds. Liver span of 10 cm; spleen not palpable. No ascites.
Rectal – fecal occult blood test (+).
Extremities – no clubbing or cyanosis; +2 pitting edema of ankles and pretibial area.
Neuro – decreased two-point discrimination and vibration sensation in all 4 extremities. Poor performance with rapid alternating movements (dysdiadochokinesia). Dysmetria on finger-to-nose and heel-to-shin tests. Wide-based, ataxic gait.

Labs – WBC 4.5 [79P/15L/5M/1E]. Hgb 13.3 g/dl [MCV 66/RDW 23]. Platelets WNL.
Na 138/ K 3.4/ Cl 108/ CO2 25/ BUN 4/ Cr 0.7/ glucose 99. Lipase WNL.
ALT 32/ AST 43/ AP 153/ GGTP 30/ bilirubin 1.4/ albumin 2.3/ total protein 5.5.
INR 2.1/ PTT 41.4
Serum iron 10/ TIBC 281/Ferritin 9
Peripheral blood smear – many acanthocytes and a few schistocytes.
Serum haptoglobin normal. Sickle prep negative.
Serum 1,25(OH)2 vitamin D - undetectable
Beta carotene – undetectable
Anti-HIV, HbsAg, anti-HCV all negative.
Plain abdominal films – non-specific bowel-gas pattern
Stool studies - no O&P (x 3) or WBCs; culture: normal flora; Sudan stain positive for fat globules.
Colonoscopy – normal, including random biopsies.
Additional tests were performed and a diagnosis was made.