Mechanism of hypercalcemia in sarcoidosis:
Sarcoidosis mainly causes hypercalcaemia through forming increased concentrations of calcitriol, the active component of vitamin D. This is as a result of increased activity of 1α hydroxylase produced by the sarcoid macrophages.
A 66-year-old female patient presented with transient bilateral loss of vision lasting a few seconds. A few days later she developed a right-sided hemiparesis. There was no history of head injury or headaches. She had a four-year history of hypertension. The patient had smoked for40 years.
Physical examination revealed a right-sided hemiparesis but no other abnormality. The heart rate was80 beats/min and regular. The blood pressure measured 160/100 mmHg. The following test results were obtained:
12-lead ECG Normal
2-D echocardiogram Normal with colour flow
CT scan brain Left middle cerebral artery infarction
What is the investigation of choice to ascertain the cause of her presentation?
a. Carotid Doppler studies.
b. Transoesophageal echocardiograph.
c. Carotid angiography.
d. MRI scan brain.
e. Thrombophilia screen
A 35 years old female factory worker presents with chronic headache severe in morning and with phonophobia.
She also complaints with right sided weakness sudden onset. She has fever for several days which is related with headache.
On examination no sign of meningism but there is midline swelling on throat.
CT scan of brain shows normal.
What are differential diagnosis?
You have been asked to review a 52-year-old woman in the emergency department with dyspnoea accompanied by nausea and vomiting. She tells you that she initially attributed this to a flu-like illness but as she found herself becoming increasingly short of breath she was taken to hospital by her concerned husband. Her past medical history is significant for type 2 diabetes mellitus, hypertension and obesity. Her current medications include metformin 1gram bd, canagliflozin 100mg od, ramipril 10mg od and amlodipine 5mg od. On examination she has a respiratory rate of 25 breaths/min, blood pressure 130/67 mmHg, pulse 105 bpm and oxygen saturation of 98% on room air. The only finding you elicit on physical examination is mild tenderness in the epigastric area. Her ECG shows a sinus tachycardia. Routine blood results are shown below:
Hb 167 g/l Na+ 132 mmol/l Bilirubin 22 µmol/l pH 7.14
Platelets 410 * 109/l K+ 5.5 mmol/l ALP 100 u/l PaO2 12 KPa
WBC 11.2 * 109/l Urea 10.4 mmol/l ALT 55 u/l PaCO2 1.9 KPa
Neuts 10.0 * 109/l Creatinine 111 µmol/l γGT 23 u/l HCO3- 11µmol/l
Lymphs 1.1 * 109/l Amylase 321 U/l Albumin 33 g/l Lactate 3.0 mmol/l
Eosin 0.1 * 109/l Cl- 101 mmol/l Urine Ketones 3+ Base Excess -12
What is the most likely diagnosis?
Small bowel obstruction
Metformin induced lactic acidosis
Starvation ketosis
Euglycaemic diabetic ketoacidosis
Pancreatitis