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Old 09-28-2012
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Arrow Gyrus Daily Questions; Internal Medicine #32

A 28-year-old man is admitted to the hospital with a large perianal abscess. He is taken to the operating room for incision and drainage, which he tolerates well, and he is discharged home with a 2-week course of antibiotics. He returns to the hospital 2 months later for a rash on his shins. On examination, he has discrete red swollen nodules on both of his shins without fluctuance. They measure ~2 cm in diameter. He has no respiratory complaints, and the rest of his skin examination is normal. Laboratory data show a white blood cell count of 12,000 with a normal dif-ferential. Erythrocyte sedimentation rate is 64 mm/h. A chest radiograph is normal. Thyroid-stimulating hormone is 3.27 mU/L, and a glycosylated hemoglobin is 5.3%.
Which of the following conditions is he also likely to have?

A. Giant cell arteritis
B. Pneumocystis jirovecii pneumonia
C. Sarcoidosis
D. Type 1 diabetes
E. Uveitis
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E. uveitis
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uveitis he is hlab27 positive--most likely having crohn's
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E, uveitis
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The answer is E. Uveitis


Anorectal abscess is more prevalent in immunocompro-mised patients such as those with diabetes, inflammatory bowel disease (IBD), or hema-tologic disorders and in persons who are HIV-positive. They are more common in men than women and typically occur in young patients. The greatly elevated erythrocyte sedi-mentation rate (ESR) (corrected for age) suggests an inflammatory state, and the skin nodules would suggest erythema nodosum. IBD often presents with perianal abscesses and is associated with an elevated ESR, erythema nodosum, and uveitis, among other ex-traintestinal manifestations. Giant cell arteritis would be uncommon in a patient this young. A normal glycosylated hemoglobin makes type 1 diabetes less likely. Acute sarcoi-dosis may present with erythema nodosum (Lofgrens syndrome), but there is typically mediastinal adenopathy. There is no association between sarcoidosis and perianal ab-scess. While patients with HIV infection commonly develop anorectal abscess, Pneumo-cystis pneumonia would typically present with respiratory complaints and an abnormal radiograph, not erythema nodosum.
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