Clinical Case 145: Stump the Chumps Perth

I have a special treat for you today!  One of the best things about FOAMed is the collaborations with great clinicians and teachers.  I was lucky enough to be able to get together with a few excellent minds to present this clinical case at the recent Australian Medical Students Society Conference, in Perth. WA.

If you are not aware of the IMreasoning podcast – go and check it out.  The guys run a series called Stump the Chumps, and this was a live recording of a case that happened on stage.  The MC for the case discussion was the excellent Dr Michelle Johnston ( @Eleytherius ) – worlds colliding!

You can Download the audio version of the case discussion over at IMReasoning  or the video version is below:

If you prefer the old-school written version then please read on!

Here is the case!

Ms. Gwendolyn Dartmouth-Merman is a 60-year old resident of Broome. For all of her life she has experienced good health and lives a very clean lifestyle as a vegan. She has 2 adult children and is separated from her long-term partner of 25 years. She lives alone.

Gwendoline is an avid practitioner of yoga; she meditates twice a day in Buddhist tradition and travels to India, Japan or Thailand for spiritual retreats annually.

She is an artist and makes a living selling her paintings [mostly depictions of the Buddha in flowing robes ], sculptures and hand-crafted jewellery at the local open-air markets.

Gwen enjoys gardening and grows a large vegetable and herb garden. She owns a large block on the outskirts of town. She tries to be self-sufficient and “organic”.

She spends her days working on her creations in her studio behind her house. She does grow a small amount of cannabis but only smokes it on special occasions with friends. She does not drink alcohol. She drinks water from her own well – she has concerns about fluorinated public water!

The Story:
Gwendolyn has presented for the third time in a week to the ED, GP and now the GP again with increasing pain in her lower back, hips and upper thighs.

The pain has been increasing over the course of at least 6 weeks but now has progressed to the point where she is walking in a slow waddle. She has not been able to do many of the yoga poses and exercises that were part of her daily routine until a month ago.

She has been feeling somewhat lethargic and run-down which is unusual for her. She does not think that she has had any fevers, night sweats, chills or rigors. She is sleeping OK, more than usual.

She has not had any weight loss – though she is very thin (BMI 19 as a result of her veganism – this is life long).

On systems review:
• No diarrhea or constipation, No abdominal pain
• She does report some nocturia recently but no dysuria or incontinence.
• She has no headaches
• No visual disturbance
• No respiratory sxs of cough, wheeze, dyspnoea
• No chest pain / pleurisy /
• No rashes / photosensitivity
• ENT: she reports some chronic pharyngeal irritation which she attributes to sinusitis and a “post nasal drip”.
• Gwen has noted that she seems to be “losing her smell” – the incense candles that she burns each day are difficult to smell.
• She doesn’t have any joint symptoms other than her lumbar spine and hips
• Gwen is postmenopausal by 10 years and has had no PV bleeding or climacteric sxs for 5 years

Observations: HR 75/min, SR. BP 130/70 RR=14 SpO2 97% RA Afebrile

Thin woman, with typical northern Aussie sun-damaged skin.
No pallor, jaundice or peripheral stigmata of chronic illness.

Dentition – yellowed

ENT = no LN, pharynx NAD, otherwise normal. No ulcers or evidence of recent infection

Chest clear
Heart sounds dual, no murmurs
Abdomen soft, scaphoid, no organomegaly or lymphadenopathy

Joints – all appear normal with some osteoarthritis of the fingers – not warm or tender.
Lumbar spine : painful on extremes of ROM, tender to palpate over bony prominences.
Hips: reasonable ROM but tender over trochanters

Neurological exam: CNs all normal aside from marked anosmia
Normal tone all limbs
Power – maybe slightly decreased in quads, hip extensors 4+/5
Normal reflexes, sensation intact
Bedside Tests

ECG: sinus rhythm, NAD

BSL 5.2 mmol/l

Urinalysis: protein large,
glucose +,
no leuks or red cells

VBG is normal

Reported : osteopaenia with signs of osteomalacia. Multiple stress fractures involving the pubic rami and femoral neck. Consistent with Looser zones / pseudofractures No evidence of sacro-ileitis or malignant lesions / metastases

Case courtesy of Dr Dalia Ibrahim,

Lumbar spine – old crush fracture to L4 vertebral body with 15 – 20% loss of height, no retropulsion or erosive / malignant lesions.

Renal tract USS = bilateral small kidneys, homogenous appearance, no focal scars. Normal Doppler flow. Incidental 3 mm stone in inferior pole of L kidney

FBP: Hb 101, normocytic, normochromic picture. No signs of haemolysis / schistocytes etc. Normal white counts and differentials Platelets 255

UECr: Na =141, K = 4.9, Cl = 111* Urea = 11.1, Creat = 130*

LFTS normal – with normal albumin 37 but ALP = 370*

Calcium = 2.25 mmol/L (normal)

Vit D = 79 nmol/l (normal)  Parathyroid hormone = 7.0 pmol/l [1.6-6.9 ] Phosphate = 0.75 mmol (*low)

Mg = 0.66 mmol/L

ESR = 7mm CRP = 17… its always

17 ANA = negative Uric acid = 0.52 mmol/L * (high)

HbA1c = 5.1%

Spot urine protein : creat ratio HIGH at 288 mg/mmol

Urinary glucose was detected

Quant protein analysis : relative small albuminuria BUT

B2-microglobilinuria = 25,000 mg/l (ref < 200 mg/L) – this suggests a proximal tubular dysfunction….

AND the final Diagnosis is….. what do you think can explain all of these symptoms?


Chronic CADMIUM Toxicity

Urinary cadmium levels were high and serum Cadmium levels were 2000 nmol/l [ industry reference range < 90 ] Exposure for Gwendolyn may have come from a range of possible sources:

1. She painted with imported “natural” pastels and bright yellow and orange pigments to make her artwork very warm and bright. Cadmium is present in these colours and can be ingested or the powdered pastels inhaled as part of the preparation

2. She made her own jewellery and used a soldering iron to join the pieces in a poorly ventilated studio – many solders conatin cadmium

3. She travelled to several countries with high lachground levels – particularly the Toyama Prefecture, Japan, where epidemic of itai-itai disease (translated: ouch, ouch!) occurred due to industrial pollution in the early 20th century

4. Unbeknownst to Gwen her Organic vegetable garden and well from which she sourced her water was previously the town rubbish tip and there was a large battery load buried here after World War II. Her block was sold off as reclaimed land in the 60 s and the rest is history!



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