Medical Images
Impressive Vascular Compression of the Trigeminal Nerve
A 65-year-old woman experienced episodic, severe, excruciating, lightning-sharp pain in her face when she drank hot or cold drinks or brushed her teeth. The pain affected the maxillary and mandibular divisions of the trigeminal nerve. The patient had no remarkable medical history but admitted to feeling depressed. Results of a neurologic examination were normal. Because carbamazepine provided no relief, magnetic resonance imaging was performed and confirmed neurovascular compression of the trigeminal nerve, in the absence of any mass or lesion or suggestion of multiple sclerosis.Primary Antiphospholipid Antibody Syndrome and Libmann-Sachs Endocarditis
Primary antiphospholipid antibody syndrome is defined by the presence of anticardiolipin antibodies in the absence of systemic lupus erythematosus. Thrombotic phenomena, stroke, and rarely chorea are components of this syndrome. Libmann-Sachs endocarditis is present in 35% to 50% of these patients, with a potential for systemic embolization.Clinical, Dermatoscopic, and Microscopic Findings of Infestation With Sarcoptes scabiei var hominis
Infestation of the epidermis with the mite Sarcoptes scabiei var hominis causes human scabies. This condition affects humans worldwide without respect to age, sex, race, or socioeconomic status. Epidemics are known to occur in overcrowded situations and in long-term care facilities. Transmission of the mite is by direct contact or via fomites. The primary symptom of infestation is intense pruritus with nocturnal exacerbation. This is due to type IV immune response to antigens deposited within the epidermis; therefore, the initial manifestations may not be noted until several weeks later.Cervical Spinal Cord Tumor Causing Complex Regional Pain Syndrome
A 63-year-old man with a 6-month history of pain and swelling of his right hand was referred to a rheumatology clinic by his primary care physician. The metacarpophalangeal and proximal interphalangeal joints on his right hand were tender, and the dorsum of his right wrist and hand was swollen substantially, with flexion deformities of the metacarpophalangeal joints. Rheumatoid factor, anti-cyclic citrullinated peptide antibodies, and acute phase reactants were normal. The initial provisional diagnosis of atypical inflammatory arthritis vs crystal deposition disease was quickly revised because of a lack of response to 3 weeks of oral corticosteroid therapy.Venous Thromboembolism in Progress
A 67-year-old man with a history of inferior infarction was admitted to our hospital because of a near-syncopal episode, sudden dyspnea, and right-sided pleuritic chest pain. On physical examination, the patient appeared in distress with a blood pressure of 79/58 mm Hg and a heart rate of 123 beats/min. The initial electrocardiogram revealed sinus tachycardia; right bundle-branch block; S wave in lead I; Q wave in leads II, III, and aVF; and T-wave inversion in leads V1 to V4 (Figure, A). The patient's left lower extremity was swollen, tender, and slightly warm; Doppler ultrasonography showed a large floating thrombus in the left femoral vein, resembling a turtle (Figure, B and Video 1, in Supporting Online Material, a link to which is provided at the end of this article).A Hemorrhoid by Any Other Name
A 92-year-old man with dementia presented with perianal discomfort and fecal incontinence of 1 week duration. He denied pain, pruritus, bleeding, or sensation of a mass. Physical examination was notable for a raised verrucous mass (0.75 cm) extending from the dentate line distally for 7 cm, circumferentially covering 75% of the anal margin. Punch biopsy specimens were obtained for diagnosis. Histology revealed intraepithelial cells with prominent nucleoli and abundant clear cytoplasm. Surgical options were explained to the patient, but given his decline in function and overall poor life expectancy, radiation therapy was offered.Cutaneous Papules, Hypercalcemia, and Osteolytic Bone Lesions
A 61-year-old Japanese American woman was hospitalized with recalcitrant hypercalcemia of 3 months' duration. Physical examination showed generalized cutaneous papules. The patient also had osteolytic bone lesions that caused fractures. On admission, the calcium level was 17.5 mg/dL (to convert to mmol/L, multiply by 0.25), and the parathyroid hormone level was suppressed. Peripheral blood smear showed a slight absolute lymphocytosis with occasional atypical lymphocytes. A skin biopsy specimen revealed a dense dermal infiltrate of atypical T lymphocytes with strong CD25 expression, characteristic of human T-cell lymphotropic virus type 1 (HTLV-1)–associated adult T-cell leukemia/lymphoma (ATCLL).The Calcareous Lung
An 84-year-old woman, who was a nonsmoker, was admitted for aortic valve replacement. Chest radiography and preoperative computed tomography (CT) of the lungs revealed diffuse interstitial lung disease with calcification seen on the pleural lining and throughout the lungs. Two of the patient's sisters had the same lung findings and died at an early age due to pulmonary diseases.Coma Bullae: Associations Beyond Medications
A 49-year-old man with a history of anterior scleritis who was receiving maintenance azathioprine therapy presented with ecchymoses and bullous lesions that had developed 2 weeks previously on the bilateral lower extremities. The patient reported that the lesions were intially small blisters that had progressed to large painful hemorrhagic bullae. He had no history of intravenous drug use, high-risk sexual behavior, or tobacco abuse. Findings on physical examination were notable for anterior scleritis, cyanotic fingers, and bilateral 2+ lower extremity edema with numerous well-demarcated bullous lesions that had a hemorrhagic fluid-filled appearance.Constrictive Pericarditis Due to Graft-vs-Host Disease
A 29-year-old man experienced a diffuse lichenoid rash that extended to his palms (panel A) and soles, peripheral blood eosinophilia, blurry vision, and recalcitrant generalized edema 2 weeks after donor lymphocyte infusion (DLI) for relapsed T-cell acute lymphoblastic leukemia. Skin biopsy revealed vacuolar interface inflammation consistent with graft-vs-host disease (GVHD). The rash improved with topical corticosteroids; however, the edema gradually worsened during the ensuing weeks, and the patient gained 23 kg.Amyopathic Dermatomyositis
A 48-year-old man presented with rash, cough, shortness of breath, and arthritis. He had experienced fatigue, fevers, and weight loss of more than 6 months' duration. Examination revealed an increased respiratory rate and hypoxia; fine crackles were audible in both lung bases. Multiple joints were arthritic, but muscle weakness was not clinically evident. This patient had classic findings of dermatomyositis, including a heliotrope rash (Figure 1), Gottron sign (Figure 2), “mechanic's hands” (Figure 3), and the V-sign (Figure 4).Ocular Sarcoidosis
A 13-year-old adolescent was admitted to our clinic with a history of otalgia, odinophagia, and subconjunctival hemorrhage (red eye). After the patient had used ophthalmic tobramycin/dexamethasone and oral amoxicillin for 3 days, prescribed when she was seen in an emergency service, the conjunctival lesion had not improved. On admission, examination of the patient revealed unilateral temporal nodular episcleritis (Table) of her left eye (arrow), arthritis of her left ankle, symmetric erythema nodosum on her legs, and a fever (temperature, 38°C).Bone Tenderness
A 46-year-old woman who was taking antipsychotic drugs for schizophrenia presented to our hospital because of worsening generalized body pain that had persisted for 1 year. Physical examination revealed bone tenderness over her entire body, especially over her upper arms, ribs, and pelvis. Initially, the only apparent laboratory abnormality was a serum alkaline phosphatase level of 830 IU/L. Bone radiography showed bone thinning; multiple symmetrical “hot spots” were detected on bone scintigraphy with technetium Tc 99m hydroxymethylene diphosphonate.Fluorodeoxyglucose-PET/CT for Diagnosis of Intravascular Large B-Cell Lymphoma
A 39-year-old woman was referred to our hospital with a 1-month history of recurrent fever. On physical examination, her spleen was palpable in the absence of peripheral lymphadenopathy and skin lesions. Laboratory studies yielded elevated values of serum lactate dehydrogenase at 1051 U/L, soluble interleukin 2 receptor at 24,500 pg/mL, and ferritin at 1019 μg/L. Blood cell counts showed a bicytopenia with a hemoglobin level of 7.0 g/dL and a platelet count of 3.7 × 109/L. Although the patient had no subjective symptoms such as dyspnea, her percutaneous oxygen saturation was low at 90%, suggesting hypoxemia.A Painful Pause
An 83-year-old man had lancinating throat pain, triggered by swallowing, coughing, and even speaking. He would pass out with excruciating pain. Magnetic resonance imaging showed an abnormal posterior inferior cerebellar artery loop (PICA) (left, arrow) exiting the brainstem (left, arrowhead), near the left glossopharyngeal and vagus nerves. Arterial compression from the posterior inferior cerebellar artery on the cranial nerves could produce demyelination, resulting in abnormal cross-conduction.Miliary Pattern on Chest Radiography: TB or not TB?
A 37-year-old nonsmoking Ecuadorian mason presented with a 3-month history of productive cough, fever, night sweats, shortness of breath, and weight loss. His symptoms were becoming progressively worse, with substantial decline in functional ability. He had blood-tinged sputum. Physical examination revealed tachypnea, and chest radiography on admission revealed scattered crackles throughout the right lung fields. Results were positive for the purified protein derivative (tuberculin) test and negative for the acid-fast bacillus smear and cultures.Pancreatic Adenocarcinoma?
A 48-year-old man with cirrhosis secondary to chronic hepatitis C and alcoholic liver disease presented with abdominal pain, hematemesis, and melena. Physical examination showed that the patient had jaundice with epigastric tenderness. Laboratory results yielded the following values: total bilirubin, 11 mg/dL; direct bilirubin, 8.5 mg/dL; alkaline phosphatase, 164 U/L; aspartate aminotransferase, 99 U/L; alanine aminotransferase, 72 U/L; and carbohydrate antigen 19-9, 86 U/mL. Computed tomography of the abdomen showed a large mass involving the head of the pancreas.Proliferative Diabetic Retinopathy
A 23-year-old man with a long-standing history of insulin-dependent diabetes mellitus presented for ophthalmic examination. Ophthalmic history was remarkable for total retinal detachment of his right eye and laser photocoagulation of his left eye due to diabetic retinopathy and diabetic macular edema. On examination, the patient's best-corrected visual acuity was light perception in the right eye and 20/20 in the left eye. Pupillary examination revealed a relative afferent pupillary defect in the right eye.Giant Hydronephrosis
A 45-year-old man was hospitalized because of an 8-month history of progressive abdominal distension and intermittent attacks of nausea. Physical examination revealed a grossly distended abdomen with a palpable mass in the right flank region. Radiography of the kidneys, ureter, and bladder showed a radiopaque nodule over the left paraspinal region, suggestive of a ureteral stone (Figure, A). Computed tomography of the abdomen revealed a huge cystic lobulated mass in the right kidney that almost filled the entire abdominal cavity.Large Intrathoracic Meningocele Associated With Neurofibromatosis Type 1
A 43-year-old man with neurofibromatosis type 1 (NF1), who presented for a routine physical examination, was found to have unilateral diminished breath sounds. He had kyphoscoliosis, for which he had undergone thoracic spinal fusion and instrumentation 32 years previously. Chest radiography revealed an extrathoracic “soft tissue mass” (9.5 × 8.5 cm). Computed tomography identified an extrapleural lesion (9 × 8 × 7 cm) suspicious for a spinal neurofibroma with cord invasion, as well as bony erosion of thoracic vertebrae and neural foramina.Male Gynecomastia
A 62-year-old man with known coronary artery disease and ischemic left ventricular dysfunction presented with chest discomfort. His history was remarkable for New York Heart Association (NYHA) class IV congestive heart failure with depressed left ventricular ejection fraction. Physical examination revealed severe gynecomastia. The patient had been taking spironolactone (25 mg) daily for 8 years as part of his medication regimen for congestive heart failure. Spironolactone had been prescribed on the basis of RALES (Randomized Aldactone Evaluation Study), which reported spironolactone's benefits in reducing morbidity and mortality in patients with NYHA class III or IV heart failure.Gardner-Diamond Syndrome: Bruising Feeling
A 53-year-old woman was admitted to the hospital with an atraumatic shoulder ecchymosis that was causing intense pain. Stressors included her significant other's recent diagnosis of cancer and conflict with an adult daughter she described as belittling and demanding. Rather than depressed, the patient seemed dramatic and impressionistic in her style. Her shoulder lesion was ascribed to Gardner-Diamond Syndrome (GDS), a rare blood dyscrasia associated with psychosocial stress, first diagnosed in this patient 10 years earlier.Mushroom-Like Gastric Tumor
A 64-year-old man was referred to our surgical department because of gastrointestinal tract bleeding. One week earlier, he had undergone coronary stenting for symptomatic stenosis of the anterior interventricular artery. He was discharged home and was instructed to take clopidogrel and aspirin. Four days later, he presented to the emergency department with lower gastrointestinal tract bleeding and syncope. His hemoglobin concentration was 8.0 mg/dL (to convert to g/L, multiply by 10).Rash and Testicular Swelling
An 86-year-old man presented with rash of 1-week duration and recently noted left testicular heaviness. Physical examination revealed an erythematous maculopapular rash involving the upper abdomen; firm, nontender left testicular swelling; a swollen left spermatic cord; and an ill-defined mass (6 × 2 cm) in the left iliac fossa. Laboratory tests yielded the following results (reference ranges shown parenthetically): total calcium, 13.92 mg/dL (8.9-10.1 mg/dL [to convert to mmol/L, multiple by 0.25]); parathyroid hormone, 6.65 pg/mL (11-55 pg/mL [to convert to ng/L, multiply by 0.1053]); and lactate dehydrogenase, 1690 U/L (122-222 U/L [to convert to μkat/L, multiply by 0.0167]).Prominent J Wave in Accidental Hypothermia
An 81-year-old man with a history of schizophrenia was found unconscious and was admitted to our hospital. On admission, his temperature was lower than 33°C. Electrocardiography showed regular bradycardia (heart rate, 46 beats/min) and prolonged QT interval of 560 ms. Prominent J wave (arrows) and ST-segment elevation were observed in almost all leads. Warming was initiated immediately after admission. Within 1 hour, the patient's temperature had increased to 33.4°C, and the amplitude of the J wave had decreased.
