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Old 11-10-2012
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Urine Sample Abdominal Pain and Red Urine!

A 33-year-old woman complains of lower abdominal pain which she has had for the past day. She left her job as a nurse's aide because the pain was so bad. She says the pain began after she had fallen off a stepstool while getting a bedpan off a top shelf. No one saw her fall, but she convinced her supervisor that she had an industrial accident and needed medical attention because of blood in her urine. To prove it, she brings in a urine specimen.

Macroscopic Urinalysis:
Color Red
Appearance Clear
Leukocyte Esterase Neg
Nitrite Neg
pH 7.0
Protein Neg
Blood Neg
Specific Gravity 1.015
Ketones Neg
Glucose Neg
Bilirubin Neg
Microscopic Urinalysis:
Characteristic Result
WBC/hpf <2/hpf
RBC/hpf None
Casts Occasional hyaline casts
Other Few squamous epithelial cells

A week later she faints on the job and is taken to the emergency department. No external signs of trauma are noted. Laboratory studies show negative drugs of abuse screen, normal electrolytes, but serum glucose of only 24 mg/dL. The ER physician orders a plasma C-peptide, which is low. She is given an intravenous solution containing glucose and she is fine within an hour.

A week later she comes to the emergency department complaining of severe abdominal pain for the past 3 days. She also reports weakness beginning in her hands and feet and moving toward her torso. On examination she has tachycardia and hypertension. She then experiences a tonic-clonic seizure. Laboratory studies show negative drugs of abuse screen. Her serum glucose is 65 mg/dL. Her urine has a reddish color, but it glowed while passing under an ultraviolet light.

A CBC shows Hgb 13.3 g/dL, Hct 40%, MCV 85 fL, platelet count 244,400/microliter, and WBC count 9070/microliter with differential count of 65 segs, 3 bands, 22 lymphs, 9 monos, and 1 baso. Serum chemistries show sodium 143 mmol/L, potassium 4.3 mmol/L, chloride 107 mmol/L, CO2 27 mmol/L, creatinine 1.0 mg/dL, and glucose 110 mg/dL. The HBsAg test is negative. She is rubella immune. CMV IgG titer is increased, but CMV IgM is not increased.

What is the most likely diagnosis?

A. Nephrolithiasis
B. Chronic Pancreatitis
C. Acute intermittent porphyria
D. Delta-aminolevulinate dehydratase deficiency porphyria
E. Hereditary coproporphyria
F .Factitious Disorder
G. Abdominal Angina
H. Fibromyalgia
I. Highlighter sniffing
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Old 11-11-2012
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C. Acute intermittent porphyria
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Quote:
Originally Posted by smanthrav View Post
C. Acute intermittent porphyria
nice one , had it not been for the glow in the urine ........ i would have gone for the factitious disorder .........
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Default F .Factitious Disorder

F. Factitious Disorder
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The Urine glow with woods lamp OR that turns bluish to purple on standing are characteristic...

AIP most common Ddx is Factitous disorder, it is caused by a deficiency in Porphobilogen Deaminase
These patients lack a rash
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Why not Factitious Disorder ?

She has already been to ER twice with factitious problems--Fall (which no one saw) & exogenous Insulin.
If you drink tonic water ( which contains quinine) can make your urine glow under UV light.

What Materials Glow Under a Black or Ultraviolet Light?
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Last edited by Novobiocin; 11-11-2012 at 03:14 PM.
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Originally Posted by Novobiocin View Post
Why not Factitious Disorder ?

She has already been to ER twice with factitious problems--Fall (which no one saw) & exogenous Insulin.
If you drink tonic water ( which contains quinine) can make your urine glow under UV light.

What Materials Glow Under a Black or Ultraviolet Light?
LoL thats a nice comeback, well the glowing of the urine was the differential clue of Acute intermittent porphyria and Factitous disorder.. and yes eventho she is related to medical profession and all that the glowing of the urine was the tip-off that made me think AIP, on a second thought the fall could also be a distractor that you posted sir.. AIP also has normal lab test.

Both of them can be the dx the differentiating feature would be to measure the enzyme level... but if you say its factitious disorder ill believe you
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Answer is indeed Acute intermittent porphyria and the clues are there in the History & Examination along with the glowing urine.
My point was that you have to select an answer based on a combination of factors NOT one thing.

Quote:
They include abdominal pain which is severe and poorly localized (most common, 95% of patients experience), Urinary symptoms (Dysuria, urinary retention/incontinence or dark urine), peripheral neuropathy (patchy numbness and paresthesias), Proximal motor weakness (usually starting in upper extremities which can progress to include respiratory impairment and death), autonomic nervous system involvement (circulating catecholamine levels are increased, may see tachycardia, hypertension, sweating, restlessness and tremor), neuropsychiatric symptoms (anxiety, agitation, hallucination, hysteria, delirium, depression), Electrolyte abnormalities (Hyponatremia may be due to hypothalamic involvement leading to SIADH that may lead to seizures). [6] Unlike other porphyrias, rash is not typically seen in AIP.
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Originally Posted by Novobiocin View Post
Answer is indeed Acute intermittent porphyria and the clues are there in the History & Examination along with the glowing urine.
My point was that you have to select an answer based on a combination of factors NOT one thing.
Yup thats why I chose AIP, she had abdominal pain, and neurological+psychiatric presentation which most of the time is linked with AIP, however with someone in the medical area those things can be caused by an insulin injection or god knows.. so until I saw the glowing urine then that helped me avoid more mental torture and just click and move!
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