21- A 19 year-old female is referred following a visit to the dentist where marked erosion of her teeth was noted. She was entirely asymptomatic and her only medication was the oral contraceptive pill. On examination her blood pressure was 110/70 mmHg and her body mass index was 21.5 kg/m2 (18 - 25). Investigations sodium 135 mmol/l potassium 2.1 mmol/l bicarbonate 42 mmol/l urea 2.6 mol/L corrected calcium 2.08 mmol/ alkaline phosphatase 201 iu/l (50-110) What is the most likely diagnosis?
1) Bulimia nervosa
2) Conn's syndrome
3) Laxative abuse
4) Pregnancy
5) Primary hypoparathyroidism
Answers-5
This patient has tooth erosion associated with hypokalaemic metabolic alkalosis and hypocalcaemia. This suggests a diagnosis of hypoparathyroidism. Conn's is
unlikely in this age group, is not associated with tooth erosion and hypertension would be expected. Bulimia like laxative abuse would be associated with
hypokalaemia but the hypocalcaemia with raised alkaline phosphatase would not be expected. Early pregnancy would not fit this picture.
22- Which of the following may be responsible for a hypokalaemic hypertension
1) Non-classical congenital adrenal hyperplasia
2) Barter's syndrome
3) Diabetic nephropathy
4) Liddle's syndrome
5) Type IV renal tubular acidosis
Answers-4
Liddle's syndrome is typically asscoiated with hypokalaemic hypertension and low renin and aldosterone concentrations - the so called pseudo-hyperaldosteronism.
Barter's syndrome is associated with hypokalaemia though hypertension is not a feature. In type IV RTA, there is a hyporeninaemic hypoaldosteronism, which may
also be produced with diabetic nephropathy. Hence hyperkalaemia is more typical.
23- A 35 year old male presents with weakness and tiredness. He is noted to be hyertensive. Electrolytes show a hypokalaemia and a hypomagnesaemia. What investigation would you select for this patient?
1) Colonoscopy
2) Plasma renin toaldosterone ratio
3) Serum amylase
4) Serum calcium
5) Oral glucose tolerance test
Answers-2
The hypokalaemic hypertension with hypomagnesaemia suggests primary hyperaldosteronism. The most reliable assessment for this would be renin to aldosterone ratio.
24- A 60-year-old man was diagnosed last year with adenocarcinoma of the lung, and a 4 cm mass lesion was treated with a right lower lobectomy. He now has an abdominal CT scan that reveals scattered hepatic mass lesions and hilar lymphadenopathy. For several weeks, he has had increasing malaise. A urinalysis reveals marked proteinuria, and a 24 hour urine protein collection is 2.7 g/24hr. His serum urea is 30 mmol/L (2.5 - 7.5) with creatinine of 450 µmol/L (60 - 110). A renal biopsy is performed, and there is focal deposition of IgG and C3 with a granular pattern. He is most likely to have which of the following conditions?
1) Goodpasture's syndrome
2) Membranous glomerulonephritis
3) Minimal change glomerulonephritis
4) Nodular glomerulosclerosis
5) Rapidly progressive glomerulonephritis
Answers-2
Most cases of membranous GN are idiopathic, but in some patients there is a history of an infection or a malignancy (usually lung) with antigenemia.
25- Which one of the following is true of IgE?
1) Is present in plasma in the same concentration as IgG
2) Is increased acutely in an asthmatic attack
3) Crosses the normal placenta
4) Is increased in the serum of atopic individuals
5) Is involved in type 2 hypersensitivity
Answers-4
IgG is the predominant form of immunoglobulin in plasma at a concentration around 10,000 times that of IgE. IgG crosses the placenta to confer immunity to
the fetus but IgE does not. IgE is involved in arming mast cells and basophils. IgE causes mast cells to release vasoactive amines, such as histamine, producing an
inflammatory response which can result in a type I hypersensitivity reaction. IgE is responsible for allergen-mediated diseases such as anaphylaxis, asthma and atopy.
Total serum IgE is frequently increased in those with atopy but serum IgE does not rise acutely during an asthmatic attack.
1) Bulimia nervosa
2) Conn's syndrome
3) Laxative abuse
4) Pregnancy
5) Primary hypoparathyroidism
Answers-5
This patient has tooth erosion associated with hypokalaemic metabolic alkalosis and hypocalcaemia. This suggests a diagnosis of hypoparathyroidism. Conn's is
unlikely in this age group, is not associated with tooth erosion and hypertension would be expected. Bulimia like laxative abuse would be associated with
hypokalaemia but the hypocalcaemia with raised alkaline phosphatase would not be expected. Early pregnancy would not fit this picture.
22- Which of the following may be responsible for a hypokalaemic hypertension
1) Non-classical congenital adrenal hyperplasia
2) Barter's syndrome
3) Diabetic nephropathy
4) Liddle's syndrome
5) Type IV renal tubular acidosis
Answers-4
Liddle's syndrome is typically asscoiated with hypokalaemic hypertension and low renin and aldosterone concentrations - the so called pseudo-hyperaldosteronism.
Barter's syndrome is associated with hypokalaemia though hypertension is not a feature. In type IV RTA, there is a hyporeninaemic hypoaldosteronism, which may
also be produced with diabetic nephropathy. Hence hyperkalaemia is more typical.
23- A 35 year old male presents with weakness and tiredness. He is noted to be hyertensive. Electrolytes show a hypokalaemia and a hypomagnesaemia. What investigation would you select for this patient?
1) Colonoscopy
2) Plasma renin toaldosterone ratio
3) Serum amylase
4) Serum calcium
5) Oral glucose tolerance test
Answers-2
The hypokalaemic hypertension with hypomagnesaemia suggests primary hyperaldosteronism. The most reliable assessment for this would be renin to aldosterone ratio.
24- A 60-year-old man was diagnosed last year with adenocarcinoma of the lung, and a 4 cm mass lesion was treated with a right lower lobectomy. He now has an abdominal CT scan that reveals scattered hepatic mass lesions and hilar lymphadenopathy. For several weeks, he has had increasing malaise. A urinalysis reveals marked proteinuria, and a 24 hour urine protein collection is 2.7 g/24hr. His serum urea is 30 mmol/L (2.5 - 7.5) with creatinine of 450 µmol/L (60 - 110). A renal biopsy is performed, and there is focal deposition of IgG and C3 with a granular pattern. He is most likely to have which of the following conditions?
1) Goodpasture's syndrome
2) Membranous glomerulonephritis
3) Minimal change glomerulonephritis
4) Nodular glomerulosclerosis
5) Rapidly progressive glomerulonephritis
Answers-2
Most cases of membranous GN are idiopathic, but in some patients there is a history of an infection or a malignancy (usually lung) with antigenemia.
25- Which one of the following is true of IgE?
1) Is present in plasma in the same concentration as IgG
2) Is increased acutely in an asthmatic attack
3) Crosses the normal placenta
4) Is increased in the serum of atopic individuals
5) Is involved in type 2 hypersensitivity
Answers-4
IgG is the predominant form of immunoglobulin in plasma at a concentration around 10,000 times that of IgE. IgG crosses the placenta to confer immunity to
the fetus but IgE does not. IgE is involved in arming mast cells and basophils. IgE causes mast cells to release vasoactive amines, such as histamine, producing an
inflammatory response which can result in a type I hypersensitivity reaction. IgE is responsible for allergen-mediated diseases such as anaphylaxis, asthma and atopy.
Total serum IgE is frequently increased in those with atopy but serum IgE does not rise acutely during an asthmatic attack.
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