Th e new england journal o f medicine This article was updated on June 12, 2014, at NEJM.org. -A 59-year-old man was seen in an outpatient clinic at this hospital because of fatigue, abdominal pain, anemia, arthralgias, and abnormal liver function. -The patient had been in his usual state of health until approximately 3 days before presentation, when epigastric distress and ankle edema occurred. -He also reported increased personal stress, difficulty sleeping, dysgeusia, and nausea -he reported epigastric pain that he rated at 6 on a scale of 0 to 10 (with 10 indicating the most severe pain) and no weight loss. -He had a history of asthma, pain and effusion of the right knee associated with a Bakers cyst, occasional swelling of the right ankle, and varicose veins. -He had had normal results on colonoscopy 3 years earlier. -His medications were pirbuterol by inhalation as needed for asthma and sucralfate as needed for stomach discomfort -He lived with his partner and worked in an office. -He consumed two or three glasses of wine per night and did not smoke or use illicit drugs. On examination:, T=37.3C, BP=110/68 mm Hg, the weight= 81.8 kg, and BMI= There was pitting edema of the ankles and superficial varicosities of both legs; -the remainder of the examination was normal. -The MCV and the MCH concentration were normal, as were results of renal-function tests and blood levels of calcium, total protein, albumin, amylase, and alkaline phosphatase. -Other test results revealed a new anemia as compared with test results from 4 months earlier, which included a hematocrit of 42% and a MCV of 88 m3. -A diagnosis of gastroenteritis was made, with possible PUD and a bleeding ulcer. -Omeprazole and sucralfate were administered, -tests for blood in the stool and for antibodies to Helicobacter pylori in the blood were ordered, -an upper endoscopy was scheduled, and a bland diet was recommended. -The patient was instructed to follow up in 3 days, or sooner if his condition worsened. -The next day, the patient called his doctors office to report pain in both legs and increasing dysgeusia. -He reported that his stools were looser than usual, without hematochezia or melena. -He reported increased abdominal pain, pain in the right knee and both shoulders, and fatigue that had lasted for at least 1 week. On examination: T=37.2C, BP=131/89 mm Hg, PR=89 beats per minute, the height= cm,the weight= 80.3 kg, and the BMI The abdomen was normal, and the right knee was tender on palpation, with a mild effusion and no erythema; -the remainder of the examination was normal. -Stool obtained during a rectal examination was negative for occult blood. -The patient scheduled a follow-up visit and returned home. -That night, the patient presented to the emergency department at this hospital because of diffuse abdominal pain that was worse with eating and radiated to the left side of the chest,neck, shoulder, and back. -Pain that was initially intermittent had become constant, and he had had constipation for 2 days. -On examination: BP=187/90 mm Hg; other vital signs, the oxygen saturation, and the remainder of the examination were normal. -The blood level of lactic acid and results of coagulation tests were normal, and testing for antibodies to H. pylori in the blood and for blood in the stool was negative; -Urinalysis revealed trace ketones and was otherwise normal. -Abdominal ultrasonography was normal. -Oxycodone and ondansetron were administered. -The patient was advised to avoid acetaminophen and alcohol, and he went home in the early morning hours. -Later that morning, the patient returned to the hospital for an outpatient visit and rated the pain at 4 out of 10. -He had hypoactive bowel sounds and periumbilical fullness, with no epigastric pain on palpation. -The blood level of CRP was normal, and testing for antibodies to HCV, antibodies to the HIV, and HIV antigen was negative; -The next day, upper endoscopic examination revealed a hiatal hernia, a nonobstructing Schatzkis ring at the gastroesophageal junction, and nodularity in the duodenal bulb. -That evening, the abdominal pain markedly increased. -The next day, 5 days after the patients initial presentation, he returned to the outpatient clinic. -He reported pain in the lower abdomen (rated at 8 out of 10), constipation that had lasted for 4 days, nausea with dry heaves, shortness of breath, and insomnia due to pain. -On examination,he was tearful and writhing in discomfort. -T=37.5C, BP=129/80 mm Hg, PR=103 beats per minute, -O2Sat=100%. -The bowel sounds were hypoactive, and there was diffuse tenderness in both lower quadrants. -The remainder of the examination was unchanged. -The patient was transported to the emergency department at this hospital. On examination: -he appeared anxious and uncomfortable. -The abdomen was soft and nondistended, and he had discomfort on palpation in the lower quadrants. -The blood levels of calcium, total protein, albumin, amylase, lipase, and lactic acid were normal, and routine toxicologic screening of the blood was negative; -Radiography of the abdomen revealed a dilated colon, with findings suggestive of stool in the right and transverse colon to a transition point in the proximal descending colon. -Computed tomography (CT) of the abdomen and pelvis, performed after the administration of contrast material, revealed a large amount of stool in the cecum and no evidence of obstruction. -He was admitted to this hospital. -A diagnostic test result was received. Differential Diagnosis? A-Life-threatening intraabdominal catastrophes: -Gastrointestinal perforation, -intestinal infarction -ruptured abdominal aortic aneurysm, B-Mesenteric ischemia without infarction B-ischemic colitis D-Colonic obstruction E-Common causes of acute abdominal pain -appendicitis, -diverticulitis, -cholecystitis, -pancreatitis, -renal colic F-Inflammatory bowel disease G-Bleeding peptic ulcer H-Gastroenteritis I-hepatitis J-visceral larva migrans K-alcoholic hepatitis L-Wilsons disease and other metabolic disorders, such as hereditary tyrosinemia M-Nonalcoholic fatty liver disease and the Budd Chiari syndrome The elevated aminotransferase levels may be a nonspecific component of a systemic process -The constellation of features suggests that an extraabdominal cause of acute abdominal pain is most likely A-Acute porphyria characteristic dark urine was not present. colicky abdominal pain, often in the lower abdomen first attack of porphyria at this age would be unusual dysgeusia and basophilic stippling are not known features of porphyria Dysgeusia and basophilic stippling were distinct and prominent features in this case Common causes of dysgeusia: -Chemotherapeutic agents -other drugs -exposure to pesticides and other toxins, such as lead poisoning, -zinc deficiency and xerostomia -Dysgeusia is a known side effect of pirbuterol. Basophilic stippling: -Sideroblastic anemia and of lead poisoning -arsenic poisoning -some thalassemias -deficiency of erythrocyte pyrimidine 5'- nucleotidase -thrombotic thrombocytopenic purpura Arsenic poisoning : -causes a garlicky odor in the breath instead of true dysgeusia, - it is characteristically associated with severe diarrhea and cardiovascular symptoms, -findings that were not seen in this case. :Lead Poisoning I believe the most likely diagnosis in this case is lead poisoning, which explains all the clinical, laboratory, and imaging features, including : abdominal pain (lead colic), nausea, dysgeusia,constipation, colonic pseudo- obstruction, joint and muscle pain, behavioral and cognitive changes,acute anemia, basophilic stippling, SIADH, and decline in the blood level of phosphorus (which may be due to renal phosphate wasting). Lead poisoning PBS: microcytic anemia, with coarse basophilic stippling, polychromasia, and occasional nucleated red cells -The polychromasia and circulating nucleated red cells are suggestive of hemolysis -reticulocyte count = 4.2%(corrected for the degree of anemia) -Testing for hereditary hemochromatosis was negative -Hemoglobin electrophoresis showed no evidenceof a structural hemoglobinopathy or a -thalassemia trait -The blood lead level was markedly elevated, at 91 g /dL(reference range, 0 to 9), and the zinc protoporphyrin level was also elevated, at 425 mol /mol of hemoglobin (reference range,