Medical Images
Primary Lateral Sclerosis
A man in his mid-30s presented with gradually progressive upper and lower extremity weakness most prominent in his right leg. Clinical examination revealed an upper motor neuron pattern of weakness in the extremities, hyperreflexia, and sustained ankle clonus that had progressed over the preceding 2 years. Muscle bulk was normal with unremarkable sensory examination findings. Magnetic resonance imaging revealed marked atrophy of bilateral motor cortices and symmetric increased T2-weighted signal involving the corticospinal tracts (Figure).Collateral Vascularization in Chronic Superior Vena Cava Syndrome
A man in his mid-70s presented with distended superficial veins on the chest and abdomen (Figure A) ongoing for 3 months. Computed tomography of the chest with contrast medium revealed marked collateral vessels (Figure B) secondary to a mass in the mediastinum (Figure C) obstructing the superior vena cava (SVC) with associated thrombus (Panel C), consistent with chronic SVC syndrome. Biopsy identified lung adenocarcinoma, and subsequent imaging revealed widely metastatic disease. The patient was treated with palliative radiotherapy to the area of SVC obstruction in the mediastinum to a total dose of 30 Gy delivered in 10 fractions, followed by systemic therapy with pembrolizumab, carboplatin, and pemetrexed.Multiple Duodenal Polyps in a Young Patient With Liver Cirrhosis
A woman in her mid-20s with recently decompensated liver cirrhosis secondary to autoimmune hepatitis was evaluated for liver transplantation. Esophagogastroduodenoscopy was performed to screen for esophageal/gastric varices. The patient had nonspecific mild abdominal pain and dyspepsia without diarrhea or constipation. Laboratory findings were remarkable for iron deficiency anemia with a hemoglobin level of 9.5 g/dL and a ferritin level of 10 μg/L. Esophagogastroduodenoscopy revealed multiple pedunculated polyps with superficial ulcerations ranging in size from 8 to 20 mm throughout the second part of the duodenum (Figure 1).Acute Esophageal Necrosis Presenting as Acute Blood Loss Anemia
An elderly male with coronary artery disease as well as atrial fibrillation on rivaroxaban presented following a syncopal episode. Workup revealed acute non–ST-elevation myocardial infarction. Aspirin and clopidogrel were administered followed by coronary angiography. Twelve hours after his procedure, he developed delirium, fever, tachycardia, and hypotension. Urgent chest computed tomography revealed acute subsegmental pulmonary emboli for which heparin drip was initiated. Empiric antibiotics were also started due to concern for sepsis; ultimately, no infectious source was identified.Mounier-Kuhn With Multiple Diverticula
A male in his 60s, nonsmoker, with history of gastroesophageal reflux disease, hiatal hernia repair, and recurrent bronchitis presented to an otolaryngology subspecialty clinic with 1 month of mild dyspnea. Office bronchoscopy identified a paratracheal diverticulum and abnormal scar tissue in the mainstem bronchi bilaterally. The trachea demonstrated posterior scar bands with intermittent dilations (Figure 1). Computed tomography (CT) imaging revealed a 44×18–mm cystic, extrapulmonary lesion along the right side of the trachea, as well as tracheobronchomegaly (Figure 2).Polypoid Corditis: Reinke Edema of the Larynx
Polypoid corditis (also called Reinke edema) is a benign condition that arises in chronic smokers. The Reinke space is the loose connective tissue directly subjacent to the basement membrane of the squamous-lined true vocal fold. Devoid of glandular tissue and lymphatic channels, this area is prone to react to trauma, either due to smoke, excessive phonation, or otherwise. Given the lack of lymphatic channels, the tissue may become edematous with increased vascularization, so-called Reinke edema, and may manifest clinically as a polypoid projection into the airway.Shiitake Flagellate Dermatitis
A man in his early 70s presented with a 3-day history of intensely pruritic erythematous papules and papular vesicular eruption arranged in a flagellate pattern on his neck, trunk, (Figure 1), and extremities with no general symptoms. On questioning, he had eaten undercooked shiitake mushrooms 2 days before the onset of the cutaneous lesions. Laboratory investigation was unremarkable. A skin biopsy revealed spongiosis, marked papillary dermal edema, and a dermal perivascular inflammatory infiltrate mainly composed of lymphocytes and eosinophils.Thyroid Dermopathy and Acropachy
A 58-year-old man with a 9-year history of gradually worsening and disabling hand and feet swelling, with associated burning pain, is followed in Dermatology. He developed Graves disease 20 years ago, treated with radioactive iodine, and Graves ophthalmopathy treated with surgical decompression and tarsorrhaphy 8 years ago. He is a former smoker. Examination revealed disfiguring hypertrophic, firm, skin-colored overgrowth, and nonpitting edema of hands (Figure 1; Supplemental Figure, available online at http://www.mayoclinicproceedings.org ) and feet (Figure 2).Pustular Psoriasis
A woman in her 60s with no past dermatologic history presented with a 4-month history of a pustular eruption. Before onset she had received steroid injections for cervical radiculopathy, but there were no other new medications or illnesses. Dermatologic exam showed more than 90% body surface area involvement with erythematous patches studded with pustules and diffuse skin sloughing (Figure 1) (Supplemental Figure 1, available online at http://www.mayoclinicproceedings.org ). Skin biopsy specimens showed subcorneal neutrophilic pustules with hypogranulosis (Figure 2).Disseminated Bullous Impetigo in an Adult With Atopic Dermatitis Flare
A man in his mid-20s with a history of atopic dermatitis presented to the emergency department with a 1-week history of a worsening painful and pruritic generalized rash. Examination revealed erythematous erosions on the trunk and limbs with shallow bullae (Figure 1; Supplemental Figure 1, available online at http://www.mayoclinicproceedings.org ) and absence of Nikolsky sign.Linear IgA Bullous Dermatosis in Association With Crohn Disease
A man in his 50s with a 3-year history of Crohn disease presented with a 1-week history of pruritic blistering on the trunk and extremities. Examination revealed tense vesicles arranged in annular pattern on the nape, upper back, and extensor side of the upper arms (Figure 1). No new medications were initiated in the past 3 months, including antibiotics, angiotensin-converting enzyme (ACE) inhibitors, and nonsteroidal anti-inflammatory drugs (NSAIDs). A skin biopsy from the right upper arm showed a subepidermal blister with neutrophilic infiltrates at the basement membrane and papillary dermis.Pityriasis Amiantacea
A woman in her early 30s presented with a 2-month history of a spontaneous nonpruritic rash on her frontal scalp, which progressed to her temporal scalp. She had no history of psoriasis, seborrheic dermatitis, or eczema. Examination revealed thick adherent yellow scales on the frontal, temporal, and vertex scalp with associated nonscarring alopecia (Figures 1 and 2).Gardner Syndrome With Breast Desmoid Tumors
A young woman with familial adenomatosis polyposis presented with a history of pain and progressive enlargement of bilateral breast masses for a decade. She was diagnosed with left breast desmoid tumor via percutaneous biopsy and has since undergone multiple additional percutaneous breast biopsies and surgical excisional biopsies. She underwent multiple treatment regimens for recurrent bilateral breast desmoid tumors, including methotrexate/vinblastine, tamoxifen, doxorubicin, sunitinib, and pazopanib, with ultimate disease progression for all therapies.Breakthrough Invasive Fusarium Orbital Rhinosinusitis With Meningitis
A patient around 70 years of age with a history of relapsed acute myeloid leukemia and previously treated pulmonary aspergillosis receiving voriconazole prophylaxis was admitted for initiation of induction therapy before proceeding with allogeneic stem cell transplantation. Because of drug interactions and QTc prolongation, voriconazole was transitioned to isavuconazole prophylaxis on admission. On day 13 of chemotherapy, the patient became hypotensive and febrile to 38.5° C, and acute left eye and facial pain with sinus congestion developed.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).Eruptive Xanthomas
A 21-year-old woman with a history of poorly controlled diabetes mellitus presented with a 5-week history of an itchy rash. She reported a recent hospitalization for pancreatitis and a family history of paternal hypertriglyceridemia. Examination revealed numerous pink-to-yellow dome–shaped papules on her back, buttocks, bilateral legs, and arms, accentuated on extensor surfaces (Figures 1 and 2). Although eruptive xanthomas were favored clinically, the differential diagnosis also included multicentric reticulohistiocytosis, disseminated granuloma annulare, and sarcoidosis.Mycotic Pseudoaneurysm of Carotid Artery as a Rare Complication of Lemierre Syndrome
A 74-year-old man presented to the emergency department complaining of fever, swelling at the neck, and dysphonia. He had no significant medical history except for dental care a few days before. Computed tomography angiography showed an internal jugular vein (IJV) thrombophlebitis with a venous wall rupture (Figure 1), in continuity with a voluminous abscess (Figure 2) and surrounding a right carotid bulb pseudoaneurysm. Emergency open surgery was performed under general anesthesia, and no shunt was necessary.Papillary Urothelial Carcinoma
A 70-year-old man with a history of hypertension and asymptomatic atrial flutter presented with pyuria on urine microscopic examination. Cystoscopy revealed bladder lesions emanating from the left ureteral orifice and posterior lateral wall (Figure, A and B). Upper tract evaluation with ureteropyelograms revealed no other lesions. Transurethral resection of the bladder tumors was performed to further characterize these lesions. Histopathological examination revealed the presence of noninvasive high-grade urothelial carcinoma (Figure, C and D).Thyroid Abscess Associated With Pyriform Sinus Fistula
A 24-year-old previously healthy man presented with a 3-day history of sore throat, dysphagia, and painful neck swelling. On physical examination, his left anterior neck was swollen and tender. Contrast-enhanced computed tomography of the neck revealed a cystic lesion with enhancing walls and tracheal compression (Figure 1). A diagnosis of thyroid abscess was made. The patient received parenteral antibiotic therapy as well as incision and drainage of the abscess. Pus cultures grew Streptococcus viridans and Prevotella buccae.Vulvar Lymphangioma Circumscriptum Secondary to Crohn Disease
A 56-year-old woman presented to the dermatologist for worsening vulvar papules and edema for 3 years. She had Crohn disease in remission status post colectomy with ileostomy and vaginal fistula repair. Prior nondiagnostic biopsies performed by the gynecology service showed squamous hyperplasia, lichenoid features, acute and chronic inflammation, and dermal fibrosis. The labia were markedly edematous, with clear to hemorrhagic papules and vesicles coalescing to a papillomatous plaque (Figure 1).Rhinorbitocerebral Mucormycosis in Uncontrolled Diabetes
A 46-year-old woman with medical history of poorly controlled diabetes mellitus, including recent hospitalization for diabetic ketoacidosis, presented with left-predominant frontal headache that was not responsive to 1 month of oral antibiotics. Exploration in the operating room demonstrated black necrotic tissue in multiple areas concerning for fungal invasion (Supplemental Figures 1 and 2, available online at http://www.mayoclinicproceedings.org ). She was admitted to her local hospital for high suspicion of mucormycosis, and intravenous (IV) liposomal amphotericin was initiated.NSAID-Induced Colopathy
A 71-year-old man was hospitalized with a 2-year history of worsening diarrhea, abdominal pain, and 30-pound weight loss. He had chronic osteoarthritis for which he took diclofenac sodium daily for over 10 years for symptomatic relief. Esophago-gastroduodenoscopy showed ulcerative gastroduodenal disease. Colonoscopy revealed large, extensive, punched out, geographic ulcerations throughout the rectum and sigmoid colon (Figure 1) and given their severity, the procedure was shortened to minimize potential complications.Brachydactyly in Pseudopseudohypoparathyroidism
A 26-year-old woman was seen for a longstanding mild elevation of parathyroid hormone (PTH), with otherwise normal serum mineral levels. Repeat testing confirmed elevated PTH 75 pg/mL (15 to 65 pg/mL) with normal calcium 9.1 mg/dL (8.6 to 10.0 mg/dL), phosphorus 3.7 mg/dL (2.5 to 4.5 mg/dL), and creatinine 0.67 mg/dL (0.59 to 1.04 mg/dL). The results of 24-hour urine calcium excretion, thyroid stimulating hormone, and free thyroxine tests were normal. Total 25-hydroxy-vitamin D level was 18 ng/mL, indicating mild deficiency.Necrobiotic Xanthogranuloma
A 75-year-old woman was referred to the hematology clinic for a 2-year history of erythematous skin lesions. One year after the initial lesions erupted, physical examination showed extensive xanthomatous plaques with erythematous borders on the neck, chest, breasts, abdomen, arms, thighs, and eyelids (Figure 1A). She had no associated systemic or focal symptoms. Initial biopsy at this time was interpreted as consistent with atypical granuloma annulare. However, lesions were not responsive to topical or intralesional corticosteroids or ultraviolet B phototherapy.Heparin Skin Necrosis in Heparin-Induced Thrombocytopenia
A 66-year-old woman presented with painful abdominal skin necrosis where she had been injecting subcutaneous enoxaparin 1 week following elective knee arthroplasty (Figure). Her complete blood cell count and basic metabolic panel yielded unremarkable findings. Enoxaparin was discontinued, and a direct thrombin inhibitor was started. Heparin platelet factor 4 IgG antibody was strongly positive (2.065 OD), as was the serotonin release assay—findings consistent with the diagnosis of heparin skin necrosis and heparin-induced thrombocytopenia.Diffuse Soft-Tissue Swelling in Antinuclear Matrix Protein-2 Antibody-Associated Dermatomyositis Sine Dermatitis
A 66-year-old man presented with progressive weakness and myalgia for 3 months, followed by anasarca and dysphagia. Physical examination showed symmetric limb-girdle weakness and generalized edema without skin rashes. Creatine kinase was 1584 U/L (normal: <308). Muscle biopsy displayed inflammatory myopathy with perifascicular pathology (Figure 1). Myositis-specific antibody panel identified positive antinuclear matrix protein 2 (NXP2) autoantibody. Results of a whole-body computed tomography scan were normal except for subcutaneous and soft-tissue edema (Figure 2).Xiphoid Process Syndrome
A 59-year-old woman presented with a 30-year history of epigastric cutaneous protuberance. A mass was visible in the mid-portion of the epigastrium, particularly when in the supine position (Figure A). Sagittal computed tomography revealed an elongated and curved xiphoid process (Figure B). The measured length, width, and thickness of the xiphoid process were 63.2 mm (reference range, 40-50 mm), 21.1 mm (reference range, 15-20 mm), and 4.9 mm (reference range, 3-5 mm), respectively. The angle from the sternal body to xiphoid process was 138° (reference range, 160°-180°).Groove Sign in Eosinophilic Fasciitis
A 62-year-old woman had development of firm, indurated plaques on her legs following vigorous massage therapy. Her legs had a peau d’orange texture and exhibited a groove sign bilaterally (Figure). Investigations revealed peripheral eosinophilia, an elevated erythrocyte sedimentation rate, and skin biopsy findings compatible with eosinophilic fasciitis (EF).Multiple Renal Microaneurysms in Polyarteritis Nodosa
A 22-year-old man was admitted to our hospital with a 6-month history of fever, arthralgia, and weight loss for the examination of fever of unknown origin. He had no medical history and took no medication before the onset of symptoms. On examination, his temperature was 37.9 °C. The laboratory findings showed eosinophilia and a C-reactive protein (CRP) level of 15.0 mg/L. Myeloperoxidase-antineutrophilic cytoplasmic antibodies (MPO-ANCAs) were slightly elevated (6.1 U/mL, normal: < 3.5 U/mL). Proteinase 3 (PR3)-ANCA, rheumatoid factor (RF), antinuclear antibody, hepatitis B surface antigen, and hepatitis C virus antibody were negative.Arteriovenous Malformations in the Setting of Giant Elephantiasis Neuromatosa
A 65-year-old man presented with giant elephantiasis of the left leg, accompanied by skin pigmentation and local ulceration (Figure A), which had started to grow since he was 4. Numerous café-au-lait spots were found across the trunk. The patient had previously undergone surgery 4 times during recent 10 years and had been diagnosed with neurofibromatosis type 1 (NF-1) based on clinical symptoms and histopathological results. Magnetic resonance imaging revealed extensive inhomogeneous signal intensity masses consisting of multiple flow void vascular structures.Multiple Giant Coronary Artery Aneurysms in Kawasaki Disease
A 35-year-old man with a history of Kawasaki disease and coronary artery aneurysms (CAAs) at the age of 1 year, for which a coronary artery bypass graft surgical procedure (saphenous vein graft to the left anterior descending [LAD] artery because of the occluded left internal thoracic artery) was performed, presented with dyspnea on exertion. On arrival at our institution, his vital signs were stable, but electrocardiography revealed T-wave inversions in leads V1 through V3. Chest radiography revealed an abnormality of the contour of the left cardiac border (Supplemental Figure 1, available online at http://www.mayoclinicproceedings.org ), and chest computed tomography revealed bulky calcified masses on the left ventricle (Supplemental Figure 2, available online at http://www.mayoclinicproceedings.org ).Corneal Epitheliopathy Associated With Antibody-Drug Conjugates
This report highlights corneal epithelial changes in 3 patients receiving different antibody-drug conjugate (ADC) therapies that inhibit tubulin assembly: anetumab ravtansine for malignant pleural mesothelioma (Figure A), ado-trastuzumab emtansine for human epidermal growth factor receptor–positive ductal carcinoma of the breast (Figure B), and belantamab mafodotin for refractory myeloma (Figures C and D). The ADCs are a novel approach for treating cancer by using targeted monoclonal antibodies to direct cytotoxic payloads to malignant cells while reducing systemic toxicity.Oyster Shell-Like Skin Lesions in a Young Man
An otherwise healthy 30-year-old man presented with oyster shell-like skin lesions (Figure 1) on his scalp, face, trunk, arms, and legs of 1 month’s duration. He denied excessive alcohol ingestion or drug use. Three months ago, he had a high-risk sexual exposure. Physical examination revealed condylomata lata (Supplemental Figure 1, available online at http://www.mayoclinicproceedings.org ) in the perineal and perianal areas. Skin biopsy revealed a dense infiltrate of lymphocytes, plasma cells, and neutrophils in the dermis.Porphyria Cutanea Tarda
A 44-year-old man with human immunodeficiency virus infection, untreated hepatitis C virus infection, and active alcohol abuse presented with bilateral blistering on the dorsal hands of 2 months’ duration (Figure 1). The blisters were pruritic and photoexacerbated and resolved spontaneously with scarring. Examination revealed tense bullae limited to the dorsal hands in various stages of healing, including milia and scarring. Biopsy specimens for histopathologic evaluation and direct immunofluorescence revealed pauci-inflammatory subepidermal clefting and homogeneous deposition along the basement membrane and within walls of superficial dermal vessels with multiple conjugates, consistent with porphyria cutanea tarda (PCT; Figure 2).Nail Lichen Planus
A 56-year-old woman presented with a 1-year history of altered nail growth and fragility, causing pain and cosmetic concern. Examination revealed onychodystrophy of multiple fingernails and toenails, with onycholysis, distal nail plate splitting, pterygium, longitudinal ridging, and subungual hyperkeratosis (Figure). She had a concomitant pruritic eruption on her chest and extremities and gingival ulceration. The scalp and vulva were uninvolved.Disseminated Nocardia in an Immunocompetent Host
A 44-year-old man with no medical comorbidities presented with recurrent inferior vena cava thrombosis and several months of fever, headache, and weight loss. Positron emission tomography–computed tomography was performed, which revealed a 1.5-cm fluorodeoxyglucose avid left lung mass and hypermetabolic soft tissue masses in bilateral inguinal regions (Figure 1). He underwent computed tomography–guided biopsy of the lung and left inguinal masses. Histopathology found clumps of filamentous branching bacilli, consistent with Nocardia (Supplemental Figure, available online at http://www.mayoclinicproceedings.org ).Scalp Necrosis in Giant Cell Arteritis
A 67-year-old woman presented with a 2-month history of headache; jaw claudication, weight loss of 6 kg; right-hand ischemia; and scalp necrosis (Figure 1A and B), which developed at the same time as her other symptoms. She had no visual symptoms and ophthalmic examination results were normal, with no occult visual arterial abnormalities suggestive of subclinical ischemia. Both temporal arteries were indurated on physical examination. Her C-reactive protein (CRP) level was at 92 mg/L.A Unique Case of Chronic Cough
A 49-year-old man with a history of coronary artery disease presented to pulmonary clinic with a progressive chronic cough that started 1 year previously, associated with scant hemoptysis and recent onset dyspnea on exertion. He denied smoking, fevers, night sweats, and weight loss. Results of the physical examination were unremarkable. Chest computed tomography (Figure 1) showed a large longitudinal filling tracheal defect. Follow-up bronchoscopy revealed several large wart-like nodular lesions on the vocal cords and in the trachea (Figure 2), causing severe tracheal narrowing.Darier Disease
A 60-year-old woman presented with a generalized pruritic rash since adolescence. She reported her son had a similar rash. Physical examination revealed greasy brown and keratotic papules and plaques in a seborrheic distribution, which included her chest, back, forehead, scalp margins, and ears (Figures 1 and 2). Histopathology revealed acantholytic dyskeratosis. The clinicopathological features along with the patient’s family history were consistent with Darier disease. The patient’s skin disease markedly improved with acitretin.Diffuse Wide Inflammatory Striae as the Presenting Symptom of Cushing Disease in a Young Adult
A 19-year-old man presented to his pediatrician after developing wide inflammatory striae over his trunk and lower extremities (Figure 1A and B). No further evaluation was performed until 12 months later when he developed facial acne, ecchymoses, decreased proximal muscle strength, and polyuria, and he was diagnosed with type 2 diabetes mellitus and hypertension.High-Resolution Vessel-Wall Imaging for Analysis of Intracranial Aneurysm Daughter- Sac Vulnerability
A 58-year-old man was found incidentally to have an aneurysm of the right middle cerebral artery on a magnetic resonance imaging scan of the head, obtained for evaluation of trigeminal neuralgia. A computed tomography angiogram confirmed the presence of the aneurysm (Figure A). No treatment was recommended at that time, and he was followed with serial imaging studies. Seven years later, a new daughter sac had developed that demonstrated enhancement on high-resolution vessel-wall imaging (HR-VWI) (Figure B and C).Pruritic Skin Eruption in a Pregnant Woman
A 21-year-old gravida1para0 previously healthy pregnant woman at 37 weeks’ gestation had a pruritic skin eruption that initially involved the umbilicus and spread to affect much of the abdomen, lower back, and extremities. Her pregnancy was otherwise uncomplicated. Urticarial lesions with rare blisters were noted (Figure 1). Skin biopsy revealed spongiosis and mixed dermal inflammation with eosinophils, whereas direct immunofluorescence revealed linear deposition of C3 along the basement membrane zone (BMZ) (Figure 2).Metastatic Gastrinoma Localized on Gallium-68 DOTATATE Imaging
A 63-year-old woman presents for evaluation of chronic abdominal pain and diarrhea. Earlier evaluation was negative for Helicobacter pylori or nonsteroidal anti-inflammatory drug use. Multiple esophagogastroduodenoscopies revealed severe esophagitis and several duodenal ulcers despite a maximum dose of omeprazole 2 years before diagnosis. Computed tomography and 2 endoscopic ultrasounds revealed only duodenal inflammation and a benign hepatic cyst. Magnetic resonance imaging found similar findings in addition to a 10-mm pancreatic cyst with no worrisome features.Osseous Sarcoidosis of the Hand
A 46-year-old woman presented to the internal medicine department with a 6-month history of swelling of the phalangeal soft tissue of both hands, with painful tenderness (Figure 1). She had medical history of stage 2 sarcoidosis diagnosed two years earlier without disease progression noticed in computer tomography (CT) scan of the chest and spirometry performed during the follow up. She had no other medical history and no treatment. At the time of presentation, the patient was afebrile and had no other pulmonary or abdominal symptoms.Inguinoscrotal Bladder Hernia Causing Hydroureteronephrosis and Acute Kidney Injury
A 69-year-old man with chronic kidney disease, baseline creatinine 1.3-1.5 mg/dL, and an indwelling urinary catheter was admitted to inpatient medicine for evaluation of right scrotal pain, penile pain, decreased urine output, and hematuria 2 weeks after undergoing robotic bilateral inguinoscrotal hernia repair. Computed tomographic abdomen and pelvic imaging on admission demonstrated a large right direct inguinal hernia extending into the hemiscrotum containing cecum, small bowel, distal ureters, and distended urinary bladder with bilateral hydroureteronephrosis (Figures 1-3).Superficial Thrombophlebitis From Intravenous Pentamidine in Hematopoietic Cell Transplantation Recipient
A 47-year-old man with acute myeloid leukemia, who underwent allogeneic hematopoietic cell transplantation (HCT), remains on maintenance guadecitabine chemotherapy and tacrolimus 0.5 mg for primary prophylaxis of chronic graft-versus-host disease. Following HCT, the patient was receiving intravenous (IV) pentamidine 300 mg through a central venous catheter (CVC) every 3 weeks for prophylaxis of Pneumocystis jirovecii (PJP) for 6 months without any adverse events. After removal of the CVC, he presented to the outpatient infusion center and received pentamidine infusion through a peripheral vein for the first time.Venous Hypertension (Sore Thumb Syndrome)
A 70-year-old woman was admitted because of a sudden swelling in her left hand. She had started hemodialysis 30 years previously because of chronic glomerulonephritis, and she received maintenance dialysis 3 times per week. An arteriovenous fistula was created on her left snuffbox (black arrow). A clinical examination revealed that the skin around her left hand was shiny and swollen reddish black. Her hand was unable to grip because of mild pain and the marked edema of the hand limiting the range of motion of the fingers (Figure 1).Lancisi Sign: Giant C-V Waves in Tricuspid Regurgitation
A 78-year-old woman with rheumatic heart disease and tissue aortic valve replacement 2 years previously presented to the cardiology clinic with worsening breathlessness and weight gain. She had New York Heart Association (NYHA) class III dyspnea. Neck examination revealed large, systolic, monomorphic pulsations (Figure A; Supplemental Video 1, available online at http://www.mayoclinicproceedings.org ). A grade 3/6 holosystolic murmur was heard, loudest at the left-lower sternal edge, which was augmented by inspiration.Rare Cause of Acute Myocardial Infarction
A 32-year-old White woman with a history of intravenous drug use was admitted because of altered mental status. She was afebrile and normotensive, but tachycardic and tachypneic. The initial laboratory results were remarkable for a white blood cell count of 16,200/μL, a hemoglobin level of 3.2 g/dL, a lactic acid level of 14 mmol/L, and an elevated troponin level of 11 ng/mL. Her electrocardiogram revealed ST-segment elevation in the anterolateral leads (Figure 1A), but no immediate intervention was performed because of her profound anemia.A Red, Swollen Finger
A 75-year-old man with atrial fibrillation taking amiodarone and apixaban, heart failure with an ejection fraction of 20%, and long QT interval presented for evaluation of progressive swelling and erythema of the right fifth finger over 5 months. He had no known trauma to the hand or unusual exposures. He owned a cat and enjoyed the outdoors. On examination, he had a small nodular papule on the right fifth digit with surrounding fusiform swelling and erythema (Figure 1). The left hand was unaffected.A Rare Case of Pembrolizumab-Associated Granulomatous Panniculitis
A 59-year-old woman developed a cutaneous reaction after prolonged immunotherapy for treatment of metastatic high-grade serous and endometrioid endometrial cancer. Following her 17th cycle of pembrolizumab therapy, the patient developed 1-cm, tender, erythematous nodules on the right calf and ankle of 2 weeks' duration (Figure 1). The differential diagnosis included erythema nodosum, infection, vasculitis, and autoimmune or metastatic disease. Histopathological examination revealed a predominantly lobular panniculitis (Figure 2A) with acute and chronic focally granulomatous inflammation (Figure 2B and C), without evidence of vasculitis.Retained Products of Conception After Cesarean Section and Occult Placenta Accreta
A 30-year-old woman had a history of prior cesarean section complicated by occult placenta accreta. During her subsequent pregnancy, third trimester ultrasound identified findings concerning for recurrent accreta (Figure 1). Hysterectomy was recommended if, at delivery, there was clinical evidence of accreta and routine cesarean section if not. At 37 weeks, the patient underwent repeat cesarean section. The placenta delivered spontaneously and intact and hysterectomy was not required.Hansen Disease (Leprosy)
A 77-year-old man with psoriatic arthritis, on methotrexate, presented with asymptomatic skin lesions. He denied altered sensation within the lesions and history of international travel, but he reported previously cleaning out suspected armadillo burrows. Physical examination revealed pink, smooth, annular, and cyclic papules and plaques on the extremities and back (Figures 1 and 2). Histopathology showed clusters of acid-fast staining organisms within foamy histiocytes in the dermis (Supplemental Figure, available online at http://www.mayoclinicproceedings.org ).A 73-Year-Old With a Linear Rash
A 73-year-old man with a history of bilateral hip replacements developed a unilateral, asymptomatic skin eruption on his left buttock 3 months after a left hip revision. Over the ensuing 3 years, he noticed mild irritation with heat exposure. Hydrocortisone 1% cream provided no benefit. Skin examination revealed linear pink to brown papules with overlying scale, which did not involve his previous surgical scar site (Figure 1). The clinical differential diagnosis included linear lichen planus, lichen striatus, persistent postherpetic granulomatous skin eruption, or other linear skin entities.Acute Generalized Exanthematous Pustulosis Secondary to Oral Nystatin
A previously healthy 58-year-old woman presented to the emergency department with a 4-day history of a rapidly progressive generalized skin eruption. One week before, she was started on oral nystatin. On physical examination, she was afebrile, tachycardic, and hypotensive. She had generalized erythema with confluent pustules, pronounced in the intertriginous areas, including the axilla, creases of the elbow, inguinal folds, and medial thighs (Figure 1 A and B). Laboratory evaluation showed a leukocytosis with neutrophilia, elevated creatinine, and elevated lactate.Pachydermodactyly
An 18-year-old male presented with a 2-year history of asymptomatic proximal interphalangeal (PIP) joints swelling involving the second, third, and fourth fingers of both hands (Figure 1). No morning stiffness, rashes, or other symptoms were reported. Family history was unremarkable. Range of joint motion was normal. Blood tests including rheumatoid factor, C-reactive protein, HLA-B27, antinuclear antibody, and extractable nuclear antigen were all negative or within normal limits. X-ray of the hands showed soft tissue swelling around PIP joints, without articular narrowing or bony erosions (Figure 2).A Challenging Case of Leg Ulcers Associated With Retiform Purpura: Cutaneous Oxalosis in the Setting of Primary Type 1 Hyperoxaluria
Hyperoxaluria, a rare metabolic disorder associated with increased serum oxalate deposits in the skin, kidneys, and other organs, can be primary or secondary.1 Primary hyperoxaluria (PH) types 1 (PH-1) and 2 (PH-2) are autosomal recessive. The most common type, PH-1, results from deficiency of alanine-glyoxylate aminotransferase causing accumulation of glyoxalate and oxalate.1,2 The patient in this report had the most prevalent juvenile form of PH-1, characterized by recurrent calcium oxalate kidney stones preceding development of renal failure.Ependymal Petechial Hemorrhages in Bacterial Meningitis
A 28-year-old male patient with a history of subacute sclerosing panencephalitis, secondary to measles infection as an infant presented to our neurology department with increasing gait difficulty and poor bladder control. An Ommaya reservoir was placed in the right frontal horn for intrathecal interferon therapy at the time of subacute sclerosing panencephalitis diagnosis 19 years ago. About a month before the current complaints, the patient experienced acute onset of seizures. This reservoir was removed at that time because of a clinical suspicion of bacterial meningitis and a lumbar puncture was positive for elevated protein with a decreased cerebrospinal fluid–to-serum glucose ratio.Severe Epidermodysplasia Verruciformis
A 50-year-old man presented with a 43-year history of multiple hyperkeratotic plaques on his face, trunk, and extremities. Warty papules first appeared on his hands 43 years ago, and then gradually scattered over the whole body. The papules enlarged to form large vegetating hyperkeratotic masses (Figure 1). Hand function and life quality was severely impaired. No one else in the patient’s family was similarly affected. Skin biopsy showed hyperkeratosis, thickening of the stratum spinosum, and vacuolated cells with clear, light-blue pale cytoplasm in the upper epidermis.Bilateral Elastofibroma Dorsi Mistaken For Lipoma
A 58-year-old woman presented with bilateral tumors on her upper back that have been causing discomfort for several years. She had undergone attempted resection by an outside surgeon of the left-sided lesion, which was thought to be a superficial lipoma, but the operation was aborted and she was referred to our practice when the tumor was found to be deep to the muscle. Physical examination showed bilateral tumors on her upper back and the scar from her attempted resection. She could pop the tumors out from under her scapulae by raising and adducting her arms (Figure 1, Supplemental video).Hypertrophic Pulmonary Osteoarthropathy Revealing a Solitary Fibrous Tumor
A 63-year-old woman who was a nonsmoker was referred to our department with a 2-year history of recurrent seronegative rheumatoid arthritis. Each episode had resolved within 1 to 2 weeks after prednisone therapy (20 mg/day). Physical examination revealed painful and inflammatory joint effusion of the knees and ankles and digital clubbing of all fingers and toes (Figure 1). Further elicitation of her history revealed similar symptoms every 4 months since age 2 years. The remainder of physical examination findings were unremarkable.Epidermoid Metaplasia of the Esophagus
A 76-year-old man presented with a 1.5-year history of intermittent globus sensation and rare episodes of solid food dysphagia. He reported no heartburn or regurgitation. Two months previously, he had undergone esophagoduodenoscopy that revealed Los Angeles classification grade C esophagitis with a nonobstructing peptic stricture. Treatment with pantoprazole, 40 mg twice daily, was initiated. Repeated esophagoduodenoscopy at the current presentation revealed healing of the prior erosive esophagitis and well-demarcated, white plaques with altered texture in the distal esophagus (Figure 1).Nodular Growths on the Lingual Surface of the Mandibular Jaw
A 60-year-old African-American man presented to clinic with 1 to 2 weeks of ear itching and pain. On physical examination, he was incidentally found to have asymptomatic bilateral bony, nodular, protruding masses, with overlying pink mucosa in the lingual premolar region of the mandible (Figure).Small Bowel Pseudomelanosis
A 78-year-old woman with a history of type 2 diabetes mellitus, chronic kidney disease stage 4, hypertension, atrial fibrillation, grade 1 follicular lymphoma, gastroesophageal reflux disease, and iron deficiency anemia presented with several months of transfusion-dependent anemia. Medications included oral ferrous sulfate, insulin, spironolactone, clonidine, metoprolol, simvastatin, omeprazole, and apixaban. In the past several months, she had been receiving weekly darbepoetin alfa injections and requiring 4 blood transfusions a month.Chemical-Associated Vitiligo
An otherwise healthy man in his 40s presented with white macules and patches that appeared on his skin several years ago. Initially, he noticed asymptomatic white discoloration on the ventral aspect of wrists, with subsequent involvement of thehead and neck. He had no relevant medical, drug, or family history, except for thyroid dysfunction in his mother. He worked in a laundry facility, with frequent exposure to detergents. Examination revealed well-demarcated hypopigmented patches without erythema or scaling on the ventral forearms (Figure 1).Isolated Histoplasma Tenosynovitis in a Patient on Adalimumab
A 42-year-old woman presented with a 3-week history of left hand swelling and pain, with a “shooting” sensation up her arm. Medical history was remarkable for Crohn disease on adalimumab and azathioprine. Physical examination was notable for erythema and tenderness on the palmar aspect of the left hand (Figure 1). Magnetic resonance imaging (MRI) identified flexor tenosynovial enhancement with surrounding inflammation (Supplemental Figure 1, available online at http://www.mayoclinicproceedings.org).Common Variable Immunodeficiency Enteropathy With Chronic Giardiasis
A 61-year-old man from Georgia, with common variable immunodeficiency (CVID), presented with generalized weakness, multiple diarrheal episodes day and night, and 120-lb weight loss over 4 years in the context of chronic giardiasis refractory to multiple treatments with metronidazole. He was deficient in vitamins A, D, and K, as well as iron and zinc. Magnetic resonance imaging of his abdomen showed small-bowel thickening, dilated portal vein, and splenomegaly characteristic of CVID (Figure 1). Upper endoscopy revealed diffusely thickened duodenal folds (Supplemental Figure, available online at http://www.mayoclinicproceedings.org).Purple Fingers and Toes
A 34-year-old female patient presented with painful erythematous papules on both hands and feet. The lesions appeared in late December and were increasing in number by the time she was evaluated in early spring. She was at 19 weeks of pregnancy, with no other new symptoms or relevant medical or drug history. On dermatologic examination, multiple mildly tender violaceous papules were noted bilaterally on tips of acral surfaces (Figure 1). No ulceration or necrosis was observed.Yellow Nails
A 57-year-old man presented with a 1-year history of yellowish discoloration and increased brittleness affecting his fingernails and toenails, with spontaneous avulsion of left toenail. On review of systems, he reported a history of progressive shortness of breath, fatigue, and chronic cough of 2 years duration, with unintentional weight loss. He denied use of tobacco or other drugs. Dermatological examination revealed diffuse yellow discoloration of all fingernails and toenails (Figure 1). Nail clipping sent for Grocott-Gömöri silver (GMS) staining showed negative results for fungal hyphae, excluding onychomycosis.A Case of Nodal Anthracosis Presenting as PET-Positive Mediastinal and Hilar Lymphadenopathies
A 78-year-old Nepali female nonsmoker was referred to the pulmonary clinic for evaluation of an incidental 1.1-cm left upper-lobe lung nodule. A positron emission tomography (PET) scan of the chest showed normal metabolic activity in the left upper lobe but revealed fluorodeoxyglucose-avid bilateral hilar and mediastinal lymph nodes, concerning for malignancy (Figure 1). Subsequently, endobronchial ultrasound-guided transbronchial needle aspiration of the paratracheal lymph nodes revealed abundant anthracitic pigment on microscopic examination, consistent with the diagnosis of nodal anthracosis (Figure 2).Implications of Infection Prevention and Control Measures From a Patient With Atypical 2019 Novel Coronavirus Pneumonia
The 2019 novel coronavirus (2019-nCoV) pneumonia broke out in Wuhan, China, at the end of December 2019.1,2 A 50-year-old man presented to the hospital with a 6-day history of fever and fatigue without chills, runny nose, dyspnea, cough, and diarrhea. His temperature rose slightly to 38.3°C after admission, and a physical examination of his chest revealed coarse breath sounds in both lungs. Laboratory studies found that the white blood cell count values (5.35×109/L) and the serum concentration of procalcitonin (0.08 ng/mL; normal range, <0.15 ng/mL) were normal.Spontaneous Bronchial Casts Expectoration in Patient With Radiation Pneumonitis
We present a case of a 47-year-old woman with a history of right pleural mesothelioma status post partial pleurectomy, decortication, and intraoperative hyperthermic chemotherapy, followed by adjuvant proton radiation therapy. She also has a remote history of Hodgkin lymphoma treated with systemic chemotherapy and radiation therapy to the mediastinum. Three months post proton therapy, she presented with a progressive chronic cough and thick sputum production with spontaneous bronchial casts expectoration in the form of the bronchial tree (Figure).Branch Retinal Arterial Occlusion With Multiple Emboli
A 75-year-old man with hypertension presented to the emergency department complaining of sudden right eye visual field loss. His right visual acuity was 20/60. Fundus examination revealed multiple intravascular yellow-white plaques (Hollenhorst plaques; arrows) and pale retina (Figure A). Optical coherence tomography showed inner retinal edema in the involved area (Figure B). A diagnosis of branch retinal arterial occlusion was made. Tracking back his systemic history, he had internal carotid arterial occlusion 4 years ago.Toxoplasmosis-Associated Immune Reconstitution Inflammatory Syndrome in an Allogenic Hematopoietic Stem Cell Transplant Recipient
A 34-year-old man with chronic myelogenous leukemia status post allogeneic hematopoietic stem cell transplant (HSCT) on tacrolimus for graft-vs-host disease prophylaxis, presented with a 1-week history of fevers and severe headaches. Brain magnetic resonance imaging (MRI) demonstrated numerous small focal lesions in the left basal ganglia and left temporal lobe with a ring pattern, as well as a large lesion in the left occipital lobe with mild leptomeningeal enhancement (Figure 1). Cerebrospinal fluid (CSF) analysis revealed lymphocytic pleocytosis, and Toxoplasma gondii was detected by polymerase chain reaction (PCR).Foreign Body in the Mucosa in a Patient With Atopic Dermatitis
A 60-year-old patient, who was being followed for a diagnosis of atopic dermatitis, was admitted to our outpatient clinic with eyelid itching and redness. Itching and eye watering increased especially in the spring months. Upon dermatological examination, erythema and fine squam in the right eyelid, and especially exacerbated plaques at the folds—such as antecubital and popliteal regions—were noted (Figure 1). Topical steroids and oral antihistamine tablets were prescribed for exacerbation of atopic dermatitis.Aortic Root Thrombus Post-Left Ventricular Assist Device Placement
A 64-year-old man with a significant history of atrial fibrillation, diabetes mellitus, coronary artery disease, and refractory cardiogenic shock, requiring milrinone 0.375 μg/kg/min, dobutamine 7.5 μg/kg/min, and axillary Impella 5.0 pump (ABIOMED, Danvers, MA) for hemodynamic support, was listed as United Network for Organ Sharing Status (UNOS) 2 for orthotopic heart transplantation (OHT). During the course of his hospitalization, his cardiac hemodynamics deteriorated, requiring him to undergo placement of Heartmate 3 (Abbott Laboratories, Chicago, IL) left ventricular assist device (LVAD) as a bridge to transplant.
