Intelligent Malingering in the Setting of Porphyria Variegata: A Rare Occurrence on Both Fronts

Malingering can be a difficult diagnosis to discern, especially in patients with well-crafted stories presenting with signs and symptoms that align directly with the literature. This can further become a challenge when a patient is malingering in the setting of a rare disease, where many complaints can be subjective in nature and not entirely testable by physical exam alone. Malingering is responsible for billions of dollars of healthcare waste every single year, and this report can serve as a guide of history elements, signs and symptoms to look out for with patients malingering in the setting of the porphyrias. It is important to recognize when patients are malingering, and when they are not, so that they may receive the appropriate care to help with their condition. This report can also serve as a guideline for what laboratory tests and studies to order in the setting of a suspected porphyria case, in order to confirm the diagnosis and get the patient the appropriate treatment regimen. Intelligent malingering is a growing problem, especially with the amount of access the general public has to medical information, and it is important for us to be able to identify when a patient is truly suffering from a rare disease and when they are malingering

Richter Transformation in Chronic Lymphocytic Leukemia with Hypercalcemia and Acute Kidney Injury Presenting as Altered Mental Status: A Case Report

Introduction: Richter’s transformation is a deadly complication of chronic lymphocytic leukemia (CLL) associated with high mortality. This transformation involves the development of an aggressive, diffuse large B cell lymphoma in the setting of a chronic, underlying case of CLL. Although it is rare, Richter’s transformation is important to identify in patients with a history of CLL because of its significant mortality if left untreated. In the setting of CLL, there are many ways in which patients can present if they are currently undergoing a Richter’s transformation. Case Description: Patients may present with symptoms common to CLL which include but are not limited to fatigue, easy bruising, weight loss, etc., or they may present more unusually, as in the case that will be presented here: with altered mental status, fall, hypercalcemia and acute kidney injury (AKI). Discussion: With the current state of affairs due to COVID-19, it is also important to recognize the potential complications of patients with this disease state that are positive for COVID-19, leading to further complications such as disseminated intravascular coagulation (DIC). Recognizing these patients, and directing their care appropriately is important for their disease progression and outlook

Vitamin C Deficiency in a Food Insecure Patient: A Rare Case Report

Introduction: Scurvy is rarely seen in developed countries and is characterized by deficiency of vitamin C, which can lead to symptoms including wound impairment, bleeding manifestations, and loss of teeth. Case Description: We present a case of a 53-year-old male with a right knee hemarthrosis after a fall. The patient also noted progressively enlarging spontaneous hematomas, denying any recent trauma except for the fall to the knee. He denied family history of bleeding and clotting disorders and endorsed aspirin use in the setting of a prior stroke. He actively resided at a local shelter with limited means of transportation for routine medical care. Physical exam revealed large, firm hematomas on his bilateral lower extremities, poor dentition with spontaneous gum bleeding, and scattered petechiae on his back and feet. The patient’s diet consisted entirely of fast-food meals; he denied intake of fruits or vegetables for almost a full year. Nutritional deficiencies including ascorbic acid remained higher on the differential. Vitamin C levels returned \u3c 0.01 indicating severe deficiency (\u3c 0.02 is diagnostic). A bleeding disorder was ruled out based on other labs. He was treated with vitamin C, iron, thiamine, and folate supplementation. His hematomas improved significantly during the hospitalization. He was discharged on a multivitamin regimen and recommended outpatient physical therapy. Discussion: Scurvy is rare in the adult population of developed countries, and while easily treatable with an excellent prognosis, the consequences are deadly if missed. Clinicians should maintain a broad differential and consider social determinants of health in high-risk groups