It saddens me to present the last full edition of the Historical Grand Rounds. We've had a good run, but thankfully the labors of coursework are behind us and there is less of a need for distraction. However, to keep myself occupied I will still post a case now and then during third year, perhaps one per month, so I encourage you to check the website once in a while. As those around us embrace the doldrums and despondency of board examinations, I hope you friends of mine maintain the spirit for learning that sets you apart.
-Michael
Pulmonology
1. Named after the Greek word meaning "unextinguishable," this material has been wreaking havoc on the lungs of mediterranean people for over 4000 years. Its first documented use was making fire-proof tablecloths (The Emperor Charlemagne used his to amaze party guests), and in the mid 1800s it was incorporated into a whole host of other industrial products. One notable epidemic was that of Greek women who would mix the material with white paint for their houses, making them resistant to fire and giving them a nice clean look. Unfortunately, many of these women started getting specific types of pulmonary malignancies in the 1960s and 70s. What histological finding would you expect to see in the most common tumor-type associated with this material?
a. psammoma bodies wrong, mesothelioma less common
b. atypical epithelial cells within the bronchial mucosa correct, bronchogenic carcinoma
c. keratin pearls and intracellular bridges
d. pleomorphic giant cells
e. nests of neuroendocrine cells
(The correct answer will have "correct" written in white font next to it. Highlight to see.)
2. George Orwell's life was a chronicle of pulmonic misfortunes. Born in India in 1903, he spent his early years suffering from numerous bouts of bronchitis and non-descript lung infections. After later episodes of dengue fever, tuberculosis, and years of heavy smoking, he finally retired to Northern Scotland where he would write his greatest work. Some say the torture scenes in 1984 were even inspired by a procedure he went through to collapse the cavitary lesions from his TB. Soon after completing the book, he died of a condition characterized by copious amounts of purulent sputum, hemoptysis, dilated airways, and recurrent infections. What was the most likely causative factor in his final illness?
a. chronic allergies
b. defective ion transport wrong, no GI symptoms
c. lung scarring and fibrosis
d. poor ciliary motility correct, bronchiectasis as a consequence of smoking
e. viral URI
Eric Arthur Blair (aka George Orwell), 1903-1950
3. Baruch Spinoza was a Portuguese Jew who became one of the greatest philosophical minds of the 17th century. After being excommunicated from the Jewish community for his rationalist thinking, he lived a simple life as a lens grinder, spending hours each day inhaling fine glass dust. He died at the age of 44, allegedly of a serious lung illness purported to be tuberculosis. Which of the following describes the condition that made him more susceptible to this infection?
a. calcification of the hilar lymph nodes correct, silicosis
b. macrophages laden with carbon
c. calcified pleural plaques
d. pneumoconiosis affecting primarily the lower lobes
e. noncaseating granulomas
4. The now famous King George VI, father to Queen Elizabeth II, had a lifelong stammer that he dealt with by smoking (with some additional help from his Australian speech therapist). Somewhat ironically, he later developed lung cancer and was forced to undergo a pneumonectomy of his left lung, leaving him unable to speak more than a couple sentences at a time. His last few broadcast speeches had to be recorded in sections and edited together. What is the best physiological description of his lung function after the surgery?
a. increase V/Q ratio
b. decreased FEV1/FVC ratio
c. decreased FiO2
d. increased FEV1/FCV ratio
e. decreased V/Q ratio correct, same air volume, twice the blood flow
Albert Windsor (George VI), 1895-1952
5. The story of Patrick Bouvier Kennedy is not well known, since his death was overshadowed a few months later by his father's assassination. Born at 29 weeks gestation to First Lady Jacqueline Kennedy in 1963, he developed infant respiratory distress syndrome soon after birth, and died two days later following treatment in a hyperbaric chamber. At that time no other treatments were in place, but his death sparked a push in research on prematurity that lead to several important innovations. What modern day treatment would have been most likely to help Patrick?
a. inhaled glucocorticoids
b. i.v. glucocorticoids
c. maternal steroids before birth correct
d. albuterol
e. bosentan
Nephrology
Not the most fruitful topic when it comes to Historical cases... However, one clever case appears in the work of Charles Dickens. Tiny Tim, the son of Ebenezer Scrooge's clerk Mr. Cratchit, suffered from a short stature, asymmetric crippling, and episodes of weakness that would have lead to his death had Scrooge not dreamt of his tombstone and decided to pay for his medical treatment. The most plausible explanation for his symptoms is renal tubular acidosis type I, which, left untreated, leads to osteomalacia, paralysis, and death by renal failure. What treatment would have been most effective for Tiny Tim?
a. spironolactone
b. acetazolamide
c. ammonium nitrate plus calcium
d. vitamin supplements
e. sodium bicarbonate plus calcitriol correct, to neutralize the acid in his blood
