A 62-year old male presents to the ED due to concern for an allergic reaction to oral vancomycin that he has been taking for about 2 months for clostridium difficile colitis.  His other medications include Viramune and Epzicom, which he has been taking for years, but did stop temporarily and then restarted about a month ago.  His T-cells are >400.  There is no fever, no chest pain, and no shortness of breath.  His only other symptom is the ongoing diarrhea, which is watery and occurs 5-10 times a day.  The rash is affecting his entire body and is uncomfortable, but not especially itchy.  (Images are shown below).

His labs are essentially normal.

What is the most likely diagnosis?  What is the treatment? 

BONUS: What other condition(s) should you consider when someone has diarrhea and rash? 

NOTE: Enter any comments at the bottom of this page

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35: Diarrhea

A 31-year old female presents with 5 days of abdominal pain and diarrhea, now with blood.  She states she has had a few similar episodes in the past, but this is worse.  She has never seen a doctor for it.  She is otherwise healthy.

On exam her vitals are normal.  She is tender in the right lower quadrant.  Rectal exam shows a small amount of stool with a little gross blood.

Her UA and pregnancy tests are negative.  Her CBC is normal except for a mild microcytic anemia with a hemoglobin of 10.1.  LFT’s and metabolic panel are normal.  A CT scan is ordered and one cut is shown below.  What does it show?  What is the significance.

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A young woman in her 20’s presents to the ED for 9 days of sore throat followed by neck stiffness. On exam the oropharynx appears normal. She has a stiff neck. What does this x-ray show? What is the differential diagnosis of meningismus?****

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A gentleman presents with shortness of breath and leg edema for 2 months that has become worse during the last 2 days.  He has a history of diarrhea & protein wasting due to prior gastric bypass surgery, but is otherwise healthy.  He denies fever, chest pain and cough.

On exam vitals are notable for tachypnea and tachycardia.  Pulse ox is 95% on room air.  The oropharynx is moist and his lungs are clear without wheezing or rales.  His legs have 1-2+ bilateral edema with a negative Homan’s sign and no erythema.
EKG: atrial fibrillation at a rate of 158 and nonspecific ST abnormalities.

CBC: white count of 11, platelet count 137,000.

Chemistry: sodium 150, chloride 128, carbon dioxide 11, anion gap 11, creatinine 1.7, magnesium  low at 1.2,  albumin 1.7.

Troponin undetectable.  BNP normal.

ABG on 2L O2: pH 7.36, pCO2 15, pO2 102.

Below is his chest x-ray.  What diagnostic findings are shown?  What is the treatment?

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