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CLINICAL PATHOLOGICAL CONFERENCE
Baylor College of Medicine
Room M-112 DeBakey Building
March 13, 2003
12:15 - 1:15 P.M.

Clinical Discussant: Andrea Duchini, M.D.
Pathologist: Rhonda L. Shannon, M.D.
Case Preparation: David E. Greenberg, M.D.

History of the Present Illness: The patient is a 34-year-old white female who was in her usual state of good health until October 2000 when she developed neck pain and a headache. She began taking ibuprofen 800 mg four times a day. She had taken ibuprofen in the past intermittently for aches and pains. Over the next few days, she continued to have neck pain in addition to feeling fatigued. She visited her primary care physician who gave her an unknown "antibiotic" of which she took only a single dose. The following day she awoke with a rash over her back, shoulders and chest. Her lips began to ulcerate and bleed. This was the first time she had such a rash. She went back to her PCP and was found to have abnormal liver function tests. She was admitted to St. Luke's Hospital, but when her rash worsened she was transferred to the Hermann Hospital burn unit. At that time, she was diagnosed with a severe case of Stevens-Johnson syndrome. After a five week hospitalization she was discharged from Hermann Hospital. Her skin lesions had improved but her liver function tests remained abnormal. The patient continued to be followed at St. Luke's Hospital. She denied pruritus or abdominal pain. She continued to complain of fatigue and anorexia. Since the time her first symptoms began she lost approximately thirty pounds. She denied subjective fevers, chills or night sweats. She had no change in her bowel or bladder habits. She has never had prior episodes of rash. She denies history of liver or blood disorders.

Past Medical History: Endometriosis diagnosed

Past Surgical History:
1. Appendectomy
2. Right knee surgery

Allergies: "Codeine" and "Aspirin"

Medications: Ursodiol 200mg b.i.d
Lansoprazole 30mg qd
Benzonatate once qd
Diazepam 1mg b.i.d

Social History: The patient designs computer software. She denies tobacco, alcohol or IVDA. She is married and has no children. She has no recent travel and has lived in Houston for years.

Family History: No history of liver disease

Physical Exam:

BP 110/70 HR 90/min. T 98.7°F RR 14/min.
General: Icteric but in no acute distress
HEENT: Pupils are equal, round and reactive to light. Sclera are icteric. Extraocular movements are intact. Oropharynx is clear.
Neck: Supple. No lymphadenopathy. No increased jugular venous pressure.
Chest: Clear to auscultation bilaterally.
CV: Regular, rate and rhythm. No murmurs, gallops or rubs.
Abdomen: Soft. Non-tender and non-distended. Liver span was 12cm to percussion in the midclavicular line. The edge was palpable and smooth. There was no splenomegaly. There was no clinical evidence of ascites.
Extremities: There was no clubbing, cyanosis or edema. There was no palmar erythema or spider angiomas.
Skin: There were partial-thickness wounds over the precordial region with scar tissue present.
Gyn: Not performed
Neurologic: Exam non-focal

Imaging:

10/20/2000 CT Abdomen and Pelvis:
Subsegmental atelectasis is seen in both lung bases. Minimal pleural effusion is seen on the right. The liver and spleen are normal in size without focal abnormality. The gallbladder is contracted. Peripheral calcified gallstones are noted measuring approximately 3 cm in diameter. No biliary dilatation. The pancreas and adrenals are unremarkable. A small amount of fluid is noted in the pericholecystic space. The opacified small and large bowel demonstrate no focal lesion. A small amount of fluid is noted in the right lateral colon fascia. The transverse colon is distended. The descending colon is collapsed. The uterus is normal in size. The ovaries are not well seen.

10/28/2000 Right upper quadrant ultrasound and doppler:
The liver appears normal in size, measuring 16.7 cm in length. The echotexture of the liver is homogeneous and no masses are identified. The portal and hepatic veins are demonstrated to be patent with flow in the appropriate direction. No thrombosis was identified in the portal or hepatic veins. The spleen is at the upper limits of normal in size measuring 13 cm in length. The echotexture of the spleen is homogeneous with no evidence of focal mass lesion. Flow in the splenic vein was in the appropriate direction with no evidence of thrombosis. The gallbladder is significantly contracted which limits evaluation. Echoes within the gallbladder probably represent sludge. No definite gallstones or gallbladder wall thickening is identified. No abnormal biliary dilatation is seen with the common duct measuring 4 mm. No pericholecystic fluid collections are identified. The pancreas is well seen and is unremarkable. The right kidney appears normal in size with a length of 12.9 cm. There is no evidence of hydronephrosis or renal masses. No ascites was seen.

Laboratory Data: Please see laboratory flow sheet

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Contact: Donna Herrick (dherrick@bcm.tmc.edu)
URL: http://public.bcm.tmc.edu/medicine/CPC/0303_text.html
(Modified: 24-Feb-2003 /km)