Nutritional Diseases


Virtual Patient Menu.


OBJECTIVE:

Apply your knowledge of nutrition and diet with general pathology to interpret clinical historical and laboratory findings to understand mechanisms and patterns of nutritional disease processes.


CASE 1

(Click here to go to the answers)

Clinical History:

A 22-year-old woman is in the 2nd trimester of her first pregnancy (G1 P0). An ultrasound performed at 18 weeks gestation showed a normal male fetus with no apparent abnormalities. She has felt progressively more tired and weak as the weeks have passed, however. She delivers a 2400 gm infant at 38 weeks gestation. The Apgar scores are 6 at 1 minute and 8 at 5 minutes. The baby has a pale color. Both baby and mother continue to appear pale and somewhat listless at well-baby checkups in the ensuing 3 months.

A CBC is ordered on the mother and shows:
WBC count8500/uL
Hgb9.8 g/dL
Hct26.5%
MCV70 fL
Platelet count481,000/uL

Questions:

  1. How do you interpret the CBC?

  2. What is the most likely cause for these findings?

  3. What other laboratory tests can you do to confirm the diagnosis?

  4. What are the dietary sources to alleviate this problem?

  5. What pharmacologic therapy is available to treat this condition?




CASE 2

(Click here to go to the answers)

Clinical History:

A 48-year-old man has been tired and listless for the past 9 months. He lives alone in a small, run-down apartment near the downtown section of a large city. He is visited by a friend, who notes the presence of pizza delivery boxes scattered throughout the apartment, as well as a refrigerator containing 20 cans of beer and nothing else except for a pint of soured milk, half a loaf of stale bread with green patches, and an apple with something growing on it that is fuzzy and pink. The man states that he has had a feeling of nausea for months and as a consequence has a reduced appetite. On examination he has paresthesias of his lower legs. An upper GI endoscopy shows diffuse gastric rugal atrophy.

A CBC shows the following:

WBC count6190/uL
Hgb9.1 g/dL
Hct28.3%
MCV129 fL
Platelet count331,000/uL

Questions:

  1. How do you interpret the CBC?

  2. What is the probable cause for these findings?

  3. How could you confirm your diagnosis?

  4. What are dietary sources to alleviate this problem?

  5. Is there a medication available to treat this condition?




CASE 3

(Click here to go to the answers)

Clinical History:

A 57-year-old woman has experienced episodes of chest pain recently. These episodes have occurred when she has walked only a couple of city blocks, from the courthouse where she works to the fast food place where she eats her usual lunch--a double cheeseburger with order of fries. On examination her height is 165 cm (5' 5") and weight 84 kg (185 lbs), with BMI 31. Her heart rate is 81/min and regular with no murmurs. Her blood pressure is 140/90 mm Hg.

Laboratory findings show:

Triglycerides182 mg/dL (<200 mg/dL)
Total cholesterol276 mg/dL (<200 mg/dL)
LDL cholesterol211 mg/dL (<110 mg/dL)
HDL cholesterol 29 mg/dL (>60 mg/dL)
Fasting glucose 118 mg/dL (<110 mg/dL)

Questions:

  1. How do you interpret these findings?

  2. What is the probable cause for these findings?

  3. What can be done to help?

  4. Is there a medication available to treat this condition?




CASE 4

(Click here to go to the answers)

Clinical History:

In 1909, at the age of 51, William Howard Taft became President of the U.S. He was 182 cm (just under 6') tall. He had always been a "big" man, but during the presidency, his weight reached 150 kg (330 lb) and more. He became famous for exhibiting numerous periods of somnolence throughout the day. At night he snored loudly. His wife Nellie took to calling him "sleeping beauty." His blood pressure reached 210 mm Hg systolic. He developed gout. On examination he exhibited central obesity and a short, thick neck. He had hypoventilation. His complexion was "ruddy" from plethora. A serum chemistry panel could have revealed the following:

Cr1.4 mg/dL
BUN22 mg/dL
Glucose130 mg/dL
Total protein7.3 g/dL
Albumin5.1 g/dL
Hgb A1C 7%

Further History

He served one term as President, having been defeated for re-election in part due to his poor reputation as a bumbler who was "asleep at the wheel". Upon leaving office, he began a program of weight loss directed by the Dean of Yale Medical School, Dr. George Blumer. He lost 30 kg (over 60 lbs) and kept the weight off. He was appointed Chief Justice of the Supreme Court in 1921 and in that capacity never once exhibited somnolence; serving 9 distinguished years before his death in 1930.

Questions:

  1. What is the BMI? What do the laboratory findings suggest?

  2. What condition is suggested by the somnolence and hypoventilation? Explain the plethora.

  3. What are possible health problems in such persons?

  4. What are possible lifestyle modifications to prevent these problems?

  5. What is the socioeconomic status of most persons with high BMI?




CASE 5

(Click here to go to the answers)

Clinical History:

A 22-year-old primigravida has a normal prenatal course, though there is minimal fetal movement. Her baby is born at term and weighs 3220 gm. Apgar scores are 9 and 10 at 1 and 5 minutes. Following delivery, physical examination reveals that the infant has a 5 cm mid-thoracic meningomyelocele.

Questions:

  1. How could the risk for this condition have been reduced?

  2. What diagnostic test(s) during pregnancy could have suggested the presence of this problem?

  3. What are potential outcomes for fetuses with neural tube defects?




CASE 6

(Click here to go to the answers)

Clinical History:

The summer of '86 was hot and dry on the northern plains. Fall was milder than usual. But strange events made everyone uneasy. Migrating birds began flying south much earlier than normal. Arctic snowy owls were seen for the first time anyone could remember. Animals began growing long coats of fur. Then in mid-November an arctic storm dumped large amounts of snow that drifted deep with the howling wind, the temperature dropped to -20 F. and snow continued to fall for a month. Mid-December brought a brief respite of warmer temperatures, and the snow began to melt. However, new storms came and temperatures plummeted, causing the melting snow to freeze into solid sheets of ice that prevented animals from grazing and people from traveling. A blizzard in mid-January lasted 3 days, with temperatures going as low as -60 F. After 100 days of extreme cold, a Chinook wind in February brought warming that melted the snow and ice to reveal thousands of rotting animal carcasses across the land.

Members of the Crow Nation (Apsáalooke) have been driven from the lands they occupied for thousands of years to places that newly arrived homesteaders and ranchers do not want. No native Americans have citizenship rights. The buffalo, a major traditional food source, are nearly extinct. A family of four has a meager existence even in the best of times on land near the Rosebud River. Now, with the onset of a severe winter, they are confined to a sod hut with dwindling supplies consisting of 20 kg of white flour, 20 kg of corn meal, and 5 kg of dried apples.

The infant boy had been born at 38 weeks with weight of 2400 gm (5.3 lb). Now at 12 weeks of age, the baby is only 3600 gm (8 lb) because mother can produce little milk. The baby dies a week later in early December.

Questions:

  1. What problem is suggested by these findings?

  2. How could this situation have been prevented?

Further History:

The 5-year-old girl weighs 16 kg (35 lb) and begins to develop abdominal enlargement with swollen feet. She becomes weaker with diminished muscle strength. Her normally dark hair appears lighter at the roots. She has areas of flaking skin. Representative serum chemistry values would show total protein 4.9 g/dL and albumin 2.8 g/dL. She develops a fever with productive cough. In early January she leaves the hut to search for firewood, but she cannot see well in the dark and gets lost. She is found frozen to death the next morning.

Questions:

  1. What problems are suggested by these findings?

  2. How could this situation have been prevented?

  3. What are the mechanisms by which these findings are produced?

Further History:

By late January they are boiling shoes to eat. The 30-year-old father is becoming weaker. He develops soft and inflamed gingiva with loose teeth, swollen and tender joints, myalgias, poor wound healing following even minor injuries, and purpuric areas on his skin. "Bumps" on his skin represent hyperkeratotic hair follicles with surrounding hemorrhage. Representative laboratory findings would include hemoglobin 8 g/dL, hematocrit 24.2%, MCV 84 fL, platelet count 249,000/microliter, prothrombin time 12 sec (control 12.2), and partial thromboplastin time 25 sec (control 26). He develops a high fever with shaking chills and dies in late January.

Questions:

  1. What specific nutritional deficiency is suggested by these findings?

  2. How could this situation have been prevented?

  3. What is the mechanism by which these findings are produced?

  4. What laboratory findings may be present?

  5. In the modern world, who is at risk for these problems?

  6. What are good dietary sources?

Further History:

By early February the 23-year-old mother has a BMI of 15. She has developed erythema with vesiculation and focal desquamation of her hands. She has nausea, vomiting, and diarrhea. When the thaw comes, relatives able to travel with a surviving horse arrive to find her disoriented, confused, and talking incoherently. She cannot carry out activities of daily living -- even if there were "living" at this point.

Questions:

  1. What problem is suggested by these findings?

  2. What are good dietary sources?

  3. What was the result of the Dawes Act passed by the U.S. Congress in '87?




CASE 7

(Click here to go to the answers)

Clinical History:

A 24-year-old woman has the homozygous ΔF508 mutation of the CFTR gene. She has had problems with respiratory tract infections since childhood. She has a chronic diarrhea with large amounts of foul-smelling stools. Her body mass index is 19. She is noted to have several contusions of varying ages, ranging from red to blue to purple to brown, scattered over her lower legs and arms. She has generalized muscle weakness. A neurologic examination shows absent deep tendon reflexes. She has reduced sensation to vibration and pain. MR imaging of her brain shows hyperintense areas of white matter with FLAIR mode and bright areas of spinal cord posterior columns with T2 weighting.

Laboratory findings include:

WBC count8150/microliter
Hgb13.2 g/dL
Hct40.8%
MCV94 fL
Platelets188,000/microliter
Prothrombin time24 sec (control 12.2 sec)
Partial thromboplastin time22.5 sec (control 23.1 sec)
Quantitative stool fat10 gm/day (normal <6) [note: laboratory technicians consider such specimens a form of bioterrorism]

Questions:

  1. What underlying disease does she have?

  2. What problem in the gastrointestinal tract has resulted from this disease?

  3. What nutrient deficiencies could she have?

  4. What are dietary sources?

  5. Is there a therapy for her underlying condition?




CASE 8

(Click here to go to the answers)

Clinical History:

A 65-year-old woman lives alone in a small trailer in a trailer park. She is living off of pension benefits and meager savings, but the rent takes most of her income. She eats sparingly, mostly just sandwiches with bread and cheese, and some canned soup. She doesn't go out much, mostly to Friday night bingo. She gets little exercise. She incurred a fracture to her right wrist in a fall several months ago. After an open reduction-internal fixation (ORIF) procedure, the fracture is still not completely healed. She now has medical care costs to pay, too.

Questions:

  1. What do you suspect?

  2. Is there laboratory testing that is of value?

  3. What does this dietary deficiency cause in children?

  4. What are dietary sources?




CASE 9

(Click here to go to the answers)

Clinical History:

A 15-year-old girl is brought in to you by her mother, who is concerned about her daughter's health, after several recent episodes of fainting. The mother states that the girl has become a very picky eater over the past two years and rarely wants to sit with the family at mealtimes, but rather remain in her room reading fashion magazines or exercising. She describes most of the foods her mother prepares as bad or dangerous. She will often prepare elaborate meals for the rest of the family which she does not eat herself. When asked about her eating habits, the girl states that she gets plenty to eat and is concerned about not becoming too fat. She began menstruation at age 13 with irregular periods, but menstruation stopped 8 months ago. Her body mass index is 16.5. Physical examination reveals decreased muscle mass of extremities and decreased strength. Neurologic examination reveals no deficits.

Laboratory findings include:

WBC Count9070/microliter
Hgb11.9 g/dL
Hct35.8%
MCV77 fL
Platelet count307,000/microliter
Cr0.6 mg/dL
BUN12 mg/dL
Glucose58 mg/dL
Total protein6.0 g/dL
Albumin3.2 g/dL
Bilirubin, total0.4 mg/dL
Alk Phos109 U/L
AST23 U/L
ALT20 U/L

Questions:

  1. What do you suspect in this case?

  2. What are organ-related consequences of this condition?

  3. What can be done for this condition?

  4. The girl's 16-year-old friend advises that she has her own solution, "I eat everything I want, and then force myself to vomit all of it up, or I just stop eating for a couple of days. It works for me." What is the problem here?

  5. What ethical issues are raised by this case?




CASE 10

(Click here to go to the answers)

Clinical History:

A 35-year-old man and his buddies at the biker's gathering in Sturgis, South Dakota, are extolling the virtues of the "beer diet" to which they all strongly adhere. Their physical appearance is typical: early middle-aged guys with beards whose bandanas cover balding heads and who have big guts hanging over their belts as they tool down main street. Any dietary advice to this crowd will be met with little enthusiasm.

Classic laboratory findings would include:

WBC Count6030/microliter
Hgb12.9 g/dL
Hct39.9%
MCV104 fL
Platelet count201,000/microliter
Cr1.6 mg/dL
BUN22 mg/dL
Glucose112 mg/dL
Total protein6.4 g/dL
Albumin3.5 g/dL
Bilirubin, total1.2 mg/dL
Alk Phos45 U/L
AST88 U/L
ALT56 U/L

Questions:

  1. What do the laboratory findings indicate?

  2. What is the downside to increased ethanol consumption?

  3. Is the biker better off than you? (question for self-reflection)



Virtual Patient Menu.