Medical Emergencies · patient case question
The patient reports slowed mental state and low mood, and has white frost-like deposits on the face, trunk and extremities. What is the MOST likely underlying condition?
Patient case: Medically complex patient presenting with erosion and lethargy
Patient: Male, 58 years old
Chief Complaint: Sensitive upper front teeth and a persistent sour taste.
Background: Type 2 diabetes. Long-standing reflux symptoms, worse at night. Recently referred to a nephrologist.
Current Findings: Cupped, smooth erosive lesions on the palatal surfaces of the maxillary anterior teeth. He appears lethargic, describes low mood and slowed thinking, and has a fine white crystalline deposit visible on the skin of his face, trunk and limbs.
Laboratory: HbA1c 8.2%
Show answer and explanation
Correct answer: D. End-stage renal disease
- A. Addison disease causes HYPERpigmentation — bronzing of skin and diffuse oral mucosal pigmentation — together with fatigue, weight loss and hypotension. The colour change runs in the opposite direction.
- B. Hepatitis B causes jaundice, fatigue and right upper quadrant discomfort. Jaundice is a YELLOW discolouration; it is not a surface crystalline deposit.
- C. SLE presents with a malar butterfly rash, photosensitivity, arthralgia, serositis and oral ulceration — an erythematous rash, not a white crystalline deposit.
- D. CORRECT. The white crystalline deposit is URAEMIC FROST — urea crystallising on the skin as sweat evaporates, seen when blood urea is grossly elevated in advanced renal failure. It occurs alongside uraemic encephalopathy, which produces exactly the slowed cognition and depressed mood described. The recent nephrology referral fits.
Note: Dental implications of end-stage renal disease run wide: bleeding tendency from platelet dysfunction, anaemia, treat on the day AFTER dialysis (not the same day, because of heparinisation), avoid the arteriovenous fistula arm for blood pressure, avoid nephrotoxic drugs including NSAIDs, and adjust doses of renally cleared agents.
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