Drug misuse, intoxication and withdrawal Quiz: Ace Your Exams

A 16-year-old boy is brought to his primary care physician’s office to evaluate recurrent headaches and sneezing for six weeks. The patient’s parent says, “Initially, I thought it was a seasonal flu, but I have also noticed nose bleeds that occur spontaneously.” The patient has been spending most of his free time in his bedroom, skipping meals, and he becomes irritable when asked to participate in family activities. The patient says that he is doing well academically and socially. Past medical history is significant for asthma which is managed with albuterol. Vitals are within normal limits. A 10- lb (4.5 kg) weight loss has been noted since the patient’s last physical five months ago. Physical examination reveals the smell of gasoline on the patient’s breath and a flaky, eczematous rash surrounding the mouth and nasolabial folds. The abdomen is soft and nontender to palpation. Neurological examination reveals numbness and tingling of the hands and feet, bilateral hand tremors, and decreased deep tendon reflexes. Which of the following is the most likely etiology of this patient’s presentation?