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Endgames Picture Quiz

Pigmentation and confusion

BMJ 2011; 342 doi: (Published 23 February 2011) Cite this as: BMJ 2011;342:c7437
  1. Wui-hang Cheung, specialist registrar in endocrinology1,
  2. Janet Dua, core medical trainee year 21,
  3. Johanna Reed, foundation year 2 trainee1,
  4. Sabina Russell, consultant endocrinologist1
  1. 1Chase Farm Hospital, London, UK
  1. Correspondence to: J Dua janetdua3000{at}

A previously well 51 year old Cypriot woman presented to the emergency department with a five day history of vomiting. She reported no diarrhoea, fever, or abdominal pain. She had no unwell contacts or recent foreign travel. Her medical history included recently diagnosed depression and a review by dermatologists two years previously for generalised darkening of her skin. Her dentist had biopsied an area of discoloration on her gums.

On examination, her pulse was 100 beats/min, temperature 37.9°C, and blood pressure 107/63 mm Hg. She was dehydrated and had mild epigastric tenderness. Initial blood tests showed a haemoglobin concentration of 118 g/L (normal range 120-152 g/L), white cell count of 2.8×109/L (4.1-10×109/L), neutrophil count of 1.2 mm3(2.5-7.5 mm3), sodium concentration of 131 mmol/L (135-145 mmol/L), potassium concentration of 4.4 mmol/L (3.5-4.5 mmol/L), corrected calcium concentration of 1.98 mmol/L (2.15-2.61 mmol/L), alanine transaminase concentration of 92 U/L (64-83 U/L), alkaline phosphatase concentration of 56 U/L (<55 U/L), bilirubin concentration of 7 µmol/L (0.2-1.3 µmol/L), and C reactive protein concentration of 45 mg/l (<1 mg/l).

The patient was admitted to a general medical ward and overnight became confused, disorientated, and agitated. Observations showed that her heart rate had changed to 110 beats/min, her blood pressure was 98/55 mm Hg, and her temperature had increased to 38°C. Her Glasgow coma scale score was 12, and she had developed brisk reflexes and bilateral extensor plantar responses. Her arterial blood gas showed a pH of 7.29, pO2 of 12.7 kPa, pCO2 of 2.8 kPa, base excess of −15 mmol/L, chloride concentration of −109 mmol/L, and bicarbonate concentration of −10 mmol/L. Her plasma glucose concentration was 1.1 mmol/L.

Figure 1 shows the patient during admission, and figure 2 is a photograph of the patient that was taken …

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