Famous Patients, Famous Operations, 2003 - Part 4: The Case of the Jaundiced Musician

Albert B. Lowenfels, MD

Disclosures

August 19, 2003

Introduction

Chief Complaint: A 57-year-old white male musician presents with a chief complaint of vomiting and swelling of the legs and abdomen. The patient is short (168 cm), stocky, pale, and deeply jaundiced. He is awake, responds to questions, but is drowsy. The skin is jaundiced with petechial hemorrhages over the abdomen, and there is marked scleral icterus. He has a hearing deficit at all frequencies. On auscultation of the chest there are some basal rales. The abdomen is without scars and there is massive ascites. After abdominal paracentesis, a firm irregular liver is palpated upon deep inspiration. His spleen is palpable below the left costal margin.

Past History: His illness dates back 4 months, characterized over the past few weeks by progressive weakness, increased swelling of the abdomen, marked swelling of the legs, recurrent febrile episodes (fever and chills), and gradually increasing jaundice. He had a long history of gastrointestinal complaints beginning at age 21 years, when he had an initial attack of abdominal pain accompanied by diarrhea, followed by similar attacks every few years. Four years prior to the present illness he experienced abdominal pain, vomiting, and jaundice; the jaundice persisted for a few months. Initially, alcohol alleviated the pain, but as the attacks became more frequent, alcohol exacerbated the symptoms.

At age 17, he had an attack of what appeared to be asthma. He had experienced frequent attacks of joint pain and "gout" and occasional bouts of diarrhea. At age 53, he experienced a painful ocular condition leading to diminished visual acuity. His mother died of tuberculosis when the patient was 16 years old; his father died of complications of alcoholism. He reported being a pipe smoker and consuming alcohol regularly, sometimes as much as a liter of wine per day.

Disease Course: During the 4-month interval from the onset of current symptoms until death, the patient had recurrent attacks of abdominal pain, vomiting, and diarrhea. He also had an attack of pneumonia. His jaundice persisted and he required paracentesis on 4 occasions. About a week before his death, he developed massive edema, fever, and diminished urinary output. About 48 hours before his death, he lapsed into a progressively deepening coma. An autopsy was performed on the day following the patient's death.

Who was our mystery patient?

  1. Enrico Caruso

  2. Wolfgang Amadeus Mozart

  3. Kurt Cobain

  4. Ludwig van Beethoven

View the correct answer.

Which of the following diseases is least likely to be present?

  1. Pancreatitis

  2. Cirrhosis of the liver

  3. Stomach cancer

  4. Inflammatory bowel disease

View the correct answer.

Which of the findings is least likely to be explained by heavy drinking?

  1. Hearing deficit

  2. Jaundice

  3. Ascites

  4. Coma

View the correct answer.

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