Medical Images
Historical Treatment of Cavitary Tuberculosis
Two patients in their 80s were undergoing evaluation for valvular heart disease. They endorsed remote history of cavitary tuberculosis that was treated in their 20s. Both patients remained free of reactivation tuberculosis since. The first patient’s chest radiograph showed left upper lobe collapse created by multiple polyethylene balls (each <1 inch in diameter) tightly packed in the extrapleural space of the left upper hemithorax (Figure A). The second patient’s radiograph showed a large, densely calcified opacity in the right upper hemithorax with complete collapse of the right upper lobe caused by extrapleural injection of paraffin oil (Figure B).Morphologic and Clinical Features of Acute on Chronic Valproate Toxicity
An individual with Lennox-Gastaut syndrome developed pancytopenia. Peripheral smear showed red cell macrocytosis with stomatocytes and well-granulated pseudo Pelger-Huet neutrophils (Figure A).Patent Ductus Arteriosus Can Coexist With Pulmonary Sequestration in Adults, Conditioning Pulmonary Hypertension
A woman in her early 40s attended the hospital for dyspnea. Her chest radiograph revealed cardiomegaly, prominence of the cone of the pulmonary artery, and hyperflow (Figure A). The electrocardiogram revealed growth of the atrium and right ventricle. The chest computed tomography angiogram depicted right intralobar pulmonary sequestration (PS) with a patent ductus arteriosus (Figure B); the blood supply of the sequestrum originated from the abdominal aorta with venous drainage toward the pulmonary vein and the left atrium (Figure C and D).Left Ventricular Pseudoaneurysm: A Rare Cause of Chest Pain to Keep in Mind
A man in his 80s presented with sharp central chest pain, diaphoresis, and dyspnea. He had a remote history of coronary artery bypass graft. Results of the physical examination were unremarkable, and initial vital signs were stable. Electrocardiogram was unrevealing. Troponins were elevated and flat. He was initiated on intravenous nitroglycerin, after which his symptoms resolved. However, his blood pressure decreased to a minimal systolic of 76 and diastolic of 50 mm Hg. Because of the resolution of his symptoms, immediate angiography was deferred, and the patient was admitted to the cardiac intensive care unit.Follicular Thyroid Cancer With Ocular Metastasis in a Patient With a Pathogenic Germline Variant in the Checkpoint Kinase 2 (CHEK2) Gene
A very young child in the first few years of life presented with an asymptomatic right neck mass. Neck ultrasound showed heterogeneous enlargement of the right thyroid lobe, and fine-needle aspiration biopsy diagnosed the mass as benign; the patient was biochemically euthyroid. She underwent right hemithyroidectomy, and the pathology was reported as multinodular goiter with lymphocytic thyroiditis (Figure A-C). Two years later, she was found to have significant left-eye visual loss with photophobia.Middle-Aged Male With Melorheostosis
A middle-aged male presented with gross enlargement of his lower right extremity (Figure 1). There was past medical history of Histiocytosis X, Parkes-Weber syndrome, and Klippel-Trenaunay syndrome. Radiographs show extensive periosteal and endosteal thickening involving multiple bones of the right lower extremity (Figure 2). Below knee amputation was performed and gross photographs reveal dense cortical bone overgrowth, entirely obliterating the intramedullary cavity (Supplemental Figure 1, available online at http://www.mayoclinicproceedings.org ).Rumpel Leede Sign
A man between 60 and 70 years of age with a history of HIV, hepatitis C, and intravenous drug use acutely developed a petechial rash on the second day of his hospitalization for complex visual hallucinations. Examination revealed a sharply well-demarcated area of confluent, nonblanchable petechiae on his right, mid-upper arm extending distally to his fingertips (Figure and Supplementary Figure 1, available online at http://www.mayoclinicproceedings.org ).Thinking Beyond the Marrow: Deceptive Presentation of a Rare Malignant Neoplasm
A middle-aged man presented with vague abdominal and chest pain. Laboratory results suggested anemia. Computed tomography of the chest and abdomen revealed mediastinal lymphadenopathy, sclerotic bone lesions, hypointense liver masses, and pancreatic body/tail mass. Left iliac bone biopsy revealed patchy bone marrow involvement by cords of atypical cells with eccentrically placed nuclei and plump eosinophilic cytoplasm (Figure A and B), associated with extensive “stromal injury” and residual trilineage hematopoiesis.Bullous Tinea Pedis
A woman in her 70s presented with a skin eruption on the left dorsal foot that had developed spontaneously 2 weeks before. The rash initially appeared with pruritic papules that evolved to fluid-filled blisters and persisted despite self-treatment with topical hydrocortisone 1% cream and antibiotic ointment. Examination revealed an erythematous plaque with tense and denuded bullae (Figure 1). She received oral cephalexin for presumed bullous impetigo. Bacterial culture and herpes simplex virus and varicella zoster virus polymerase chain reaction (PCR) swab results were negative.Vertebrobasilar Dolichoectasia Resulting in Displacement of the Cervicomedullary Junction
A man in his 60s presented with a 6-month history of progressive gait instability, changes in speech, and dysequilibrium. Neurologic examination revealed an ataxic dysarthria, reduced palate elevation on the right, and marked truncal ataxia with postural instability. Magnetic resonance imaging of the brain revealed a dolichoectatic right-dominant vertebrobasilar system with mass effect resulting in flattening of the ventral medulla and displacement of the cervicomedullary junction (Figure). Extensive evaluation to explore genetic, infectious, inflammatory, metabolic, and neurodegenerative causes of progressive ataxia was unrevealing.Rectal Condyloma Acuminatum
A woman between 70 and 80 years of age with a history of cervical cancer presented with changes in bowel habit. The patient took prednisolone for cardiac sarcoidosis. Colonoscopy revealed a 20-mm flat, whitish lesion with diffuse reddish speckles in the lower rectum (Figure 1). Based on the medical history and endoscopic findings, we suspected rectal condyloma acuminatum. However, biopsy results could not provide a definitive diagnosis; thus, we performed endoscopic submucosal dissection for excisional biopsy.Primary Follicular Lymphoma in the Small Intestine: A Rare Cause of Bowel Obstruction
A woman between 60 and 70 years of age experienced nausea, vomiting, and epigastric pain radiating throughout the abdomen for several days. Physical examination revealed abdominal tenderness with epigastric prominence, without peritoneal irritation. Dynamic computed tomography (CT) showed dilatation of the small intestine and two points of bowel obstruction due to intestinal wall thickening (Figure 1A, arrow), increased mesenteric fatty tissue (Figure 1B), and enlarged mesenteric lymph nodes (Figure 1B, arrowhead).Half-and-Half Toenails
A man in the later decades of life was referred for uncontrolled type 2 diabetes that had persisted for 37 years. The patient had a medical history of stage 4 chronic kidney disease, hypertension, and dyslipidemia. Laboratory tests showed high levels of urea nitrogen (37.3 mg/dL [reference range, 8 to 24 mg/dL]; to convert to mmol/L, multiply by 0.357), creatinine (3.18 mg/dL [0.74 to 1.35 mg/dL]; to convert to μmol/L, multiply by 88.4), and hemoglobin A1c (8.8% [4.0% to 5.6%]) and deteriorated estimated glomerular filtration rate (16.0 mL/min per 1.73 m2).Pulmonary Cystic Echinococcosis
A male in his seventh decade of life with prostate cancer in remission and no smoking history presented with 3 months of nonproductive cough. Chest imaging showed a lobulated left lower lobe pulmonary nodule measuring 2.8 cm in greatest dimension (Supplemental Figure, available online at http://www.mayoclinicproceedings.org ). Given concern for malignancy, the patient was referred for surgical resection. In the operating room, a spherical cystic lesion was visualized in the lung parenchyma and carefully excised.Isolated Hypoglossal Neuropathy due to Cervical Spondylosis Mimicking Lingual Angioedema
A woman in her 80s presented to the emergency department with a 4-month history of “tongue swelling,” mild drooling, difficulty in swallowing, and slurred speech that worsened during 1 day. Asymmetric lingual angioedema predominantly of the right side of the tongue secondary to lisinopril was suspected. The patient was treated with diphenhydramine, dexamethasone, famotidine, and tranexamic acid, then admitted to the hospital for observation. Lisinopril was discontinued after 4 years of treatment.Pellagra Gloves
A 36-year-old homeless man presented with a 3-week history of bilateral, symmetrical, scaly, and painful dermatitis in both hands up to the rim of the sleeves (Figure) and watery bloody diarrhea. Anxiety, headaches, and tremors were also present. He had been consuming 6 to 8 liters of wine every day for the past 11 years. He used to wear a hooded sweatshirt, not having other photoexposed areas. The skin biopsy demonstrated hyperkeratosis with focal parakeratosis and dilatation of the superficial dermis capillary (Supplemental Figure, available online at http://www.mayoclinicproceedings.org ).An Extreme Case of Bioprosthetic Valve Thrombosis in a Patient With Systemic Lupus Erythematosus and Antiphospholipid Antibody Syndrome
A young woman presented with increasing fatigue, dyspnea, lightheadedness, and intermittent chest pain. She had a history of systemic lupus erythematosus, antiphospholipid antibody syndrome, and Libman-Sacks endocarditis, resulting in a bioprosthetic aortic valve replacement 6 months before presentation. A bioprosthetic valve was chosen at that time over a mechanical valve because of inability to consistently maintain therapeutic anticoagulation levels with warfarin. Transthoracic echocardiography was performed and showed severe aortic valve prosthetic stenosis with a mean gradient of 69 mm Hg and thickened leaflets (Figure A) with reduced mobility, consistent with bioprosthetic valve thrombosis (BPVT).Biliary Obstruction Due to IgG4-Related Disease
A man in his sixth decade of life with a history of myasthenia gravis and antiphospholipid syndrome complicated by embolic strokes presented for evaluation of progressive jaundice and pruritus. Laboratory evaluation revealed marked hyperbilirubinemia and elevated lipase. Computed tomography imaging revealed a pancreatic head masslike lesion with a peripancreatic low-attenuation rim and dilation of the pancreatic and biliary ducts (Figure 1) as well as multifocal hypoenhancing lesions in the bilateral kidneys (Figure 2).Lichen Planopilaris
A 46-year-old woman presented with a 1-year history of gradual asymptomatic hair loss in the anterior hairline. Examination revealed perifollicular erythema and scaling along the frontal scalp, with scarring of follicular ostia and rare lone hairs (Figure).Nonhealing Ulcer at a Surgical Site
A man in his 80s was evaluated for a 4.5 cm necrotic ulcer with a violaceous border at a previous surgical site (Figure 1). The nonhealing ulcer despite treatment was concerning for squamous cell carcinoma (Marjolin ulcer). Punch biopsy from the ulcer border revealed epidermal hyperplasia with intraepidermal acantholysis, dermal hemorrhage, and lymphoplasmacytic inflammation (Figure 2). Tissue cultures, Grocott methenamine silver, Gram, and acid-fast bacillus stains and immunohistochemistry for herpes simplex virus were unremarkable.Spinal Aneurysmal Bone Cyst Causing Spinal Cord Compression
A previously well female teenager presented with acute paraparesis. She reported a 2-month history of atraumatic back pain. Four days before admission, she progressed from walking independently to inability to mobilize. She had fecal incontinence and micturition difficulty. On examination, she had T8 sensory level with pinprick (including perineum) with reduced power (mostly 2-3/5, worse on the right) and lower limb hyperreflexia.Bladder Endometrioma
A 33-year-old woman presented for evaluation after recurrent episodes of gross hematuria. She denied any clinically significant voiding symptoms or history of urinary tract infection. She had no personal or family history of genitourinary malignant tumors. Medications included a multivitamin and oral contraceptive therapy. She noted that the hematuria occurred primarily during menstruation. A computed tomography scan revealed a 3 cm mass in the bladder (Figure A). Cystoscopy confirmed a round lesion along the posterior base of the bladder with focal areas of hemorrhage and blue discoloration (Figure B).Keto Rash: Ketoacidosis-Induced Prurigo Pigmentosa
A 37-year-old male patient has suffered from pruritic eruptions for 2 weeks and had a weight loss of 20 kg in 3 months. Associated symptoms included drowsiness, generalized weakness, nausea, nocturia, polydipsia, and polyphagia. On examination, pruritic erythematous papuloplaques mixed with brownish reticular hyperpigmentation were noted mainly on the back (Figure 1). Laboratory data revealed a serum glucose level of 805 mg/dL (44.68 mmol/L), high glycohemoglobin level (17.5%; reference range:<5.7 %), high serum level (7.2 mmol/L; reference range, <0.6 mmol/L), and high urinary ketone level (4+; reference range, negative).“Hot Cross Bun” Sign in a Patient With Kelch-like Protein 11 Rhombencephalitis
A 36-year-old man had progressive gait ataxia, diplopia, and hearing loss over 3 years. On examination, he had upper extremity ataxia, truncal ataxia, bradykinesia, and lower extremity spasticity. Brain magnetic resonance imaging revealed a “hot cross bun” sign (Figure). Kelch-like protein 11 (KLHL11) IgG was detected in serum and cerebrospinal fluid.1 Positron emission tomography revealed a hypermetabolic mediastinal mass. Subsequent biopsy revealed seminoma. The hot cross bun sign has been described in patients with multiple system atrophy as well as in a patient with KLHL11 encephalitis.Superior Mesenteric Artery Syndrome
The patient was a 22-year-old woman with a 10-year history of anorexia nervosa restricting subtype who had been diagnosed with superior mesenteric artery (SMA) syndrome (Figure 1). She reported diffuse abdominal pain and nonvolitional vomiting shortly after food consumption, which was contributing to further weight loss. With nutritional rehabilitation, which initially included increased amounts of liquid supplements and eventual tolerance of a regular oral diet, she achieved a body mass index of 20.08 kg/m2, with near resolution of her gastrointestinal (GI) symptoms and computed tomography findings no longer meeting criteria for SMA syndrome (Figure 2).
