Case Summary:

A 60-year-old male with a 10-year history of type 2 diabetes mellitus, hypertension, and stage 3 chronic kidney disease (CKD) presents with fatigue, bone pain, and pruritus. He also complains of difficulty concentrating and recent muscle cramps. On examination, he has dry, itchy skin and signs of osteodystrophy, including bone tenderness and deformities in his hands.

Key Investigations:

·         Serum calcium: 8.0 mg/dL (low)

·         Phosphate: 6.2 mg/dL (high)

·         Parathyroid hormone (PTH): 1200 pg/mL (high)

·         eGFR: 25 mL/min/1.73m²

Questions:

1.       What is the most likely diagnosis in this patient, and how do the laboratory findings support it?

2.       Explain the pathophysiology of secondary hyperparathyroidism in CKD and its impact on calcium and phosphate metabolism.

3.       What are the potential complications of uncontrolled secondary hyperparathyroidism, and how do they affect bone health?

4.       Discuss the management strategies for this patient's secondary hyperparathyroidism and CKD, including dietary modifications, medications, and potential surgical interventions.

5.       What is the role of calcium and phosphate binders in the management of this patient’s condition?

References:

·         KDIGO 2020 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease.

·         Block, G.A., et al. (2004). "The Role of Parathyroid Hormone in CKD." Nephrology Dialysis Transplantation.

Case Summary:

A 20-year-old male college student presents to the emergency department with a 2-day history of fever, headache, vomiting, and photophobia. He is alert but appears ill. On examination, he has a temperature of 39.2°C, a pulse of 110 bpm, and a blood pressure of 90/60 mmHg. He has neck stiffness and a positive Brudzinski sign. A petechial rash is noted on his lower limbs. His mental status is somewhat altered, but he can respond to questions.

Key Investigations:

·         CSF analysis: WBC 1200 cells/µL (90% neutrophils), protein 250 mg/dL, glucose 30 mg/dL

·         Blood cultures: Neisseria meningitidis, serogroup B

·         CT Head: No evidence of mass effect or abscess

·         Nasopharyngeal swab: Negative for influenza

Questions:

1.       What is the most likely causative agent in this patient, and how does the CSF analysis support this diagnosis?

2.       How does Neisseria meningitidis cause meningitis, and what are the typical risk factors for infection?

3.       Discuss the management of this patient, including initial antibiotic therapy and adjunctive treatments.

4.       What are the key components of secondary prevention in close contacts of this patient?

5.       What are the potential complications of untreated or delayed treatment of meningococcal meningitis?

References:

·         Brouwer, M. C., et al. (2010). "Meningococcal Meningitis: A Review of Clinical Presentation and Management." Lancet Infectious Diseases.

·         World Health Organization (WHO) Guidelines for the Management of Meningitis, 2022.

Case Summary:

A 46-year-old female presents with unexplained weight loss (10 kg over 2 months), palpitations, heat intolerance, and tremors. She reports having a 3-month history of increased anxiety, irregular menstruation, and bulging eyes. Her thyroid gland is diffusely enlarged on examination, and she has a resting tremor.

Key Investigations:

·         Thyroid function tests: TSH < 0.01 µU/mL, Free T4 3.2 ng/dL (normal range 0.9-2.3 ng/dL), Free T3 7.8 ng/dL (normal range 2.3-4.2 ng/dL)

·         Thyroid Ultrasound: Diffuse enlargement, no nodules

·         Radioactive Iodine Uptake Scan: Increased uptake diffusely

Questions:

1.      What is the most likely diagnosis based on the patient's clinical presentation and lab results?

2.      Discuss the pathophysiology of hyperthyroidism in this patient, and how it leads to her clinical symptoms.

3.      What are the treatment options for this patient, and how would you manage her thyroid hormone levels?

4.      What are the potential complications of untreated hyperthyroidism, especially in relation to her cardiovascular system?

5.      Explain the role of radioactive iodine therapy and antithyroid medications in the management of hyperthyroidism.

References:

·         American Thyroid Association (ATA) Guidelines, 2023.

·         Ross, D.S., et al. (2021). "Thyroid Disease: Diagnosis and Management." New England Journal of Medicine.