Stalking the Diagnosis

A CLINICAL PROBLEM-SOLVING article by Bindu Chamarthi from Brigham and Women's Hospital, Boston.
A 58-year-old woman presented to her primary care physician after several days of dizziness, anorexia, dry mouth, increased thirst, and frequent urination. She had also had a fever and reported that food would “get stuck” when she was swallowing. Her history was notable for cutaneous lupus, hyperlipidemia, osteoporosis, and primary hypothyroidism, which had been diagnosed a year earlier. The patient was given a prescription for ciprofloxacin for a urinary tract infection and was advised to drink plenty of fluids. On a follow-up visit 3 days later, her fever had resolved, but she reported continued weakness and dizziness despite drinking a lot of fluids. She was referred to the emergency department, where she received normal saline and supplemental potassium, and her symptoms abated. One week later, she returned to the emergency department with continued weakness, frequent urination, intermittent vomiting, dysphagia, and increased thirst and fluid intake. Her course was complicated by hypotension, dehydration and hyponatremia.
A review of symptoms revealed difficulty swallowing and occasional emesis of solid foods because of a feeling of “sandlike” dryness in her mouth; she also had an involuntary weight loss of 10 lb over the past month. Physical examination revealed a nontender left cervical lymph node, 2 cm in diameter.
An Interactive Medical Case associated with this article is available at NEJM.org. [Original Article]