7. Strep PharyngitisStrep Pharyngitis
►Streptococcal pharyngitis is caused byStreptococcal pharyngitis is caused by
group A -hemolytic streptococci and mostgroup A -hemolytic streptococci and most
often affects persons situated in closeoften affects persons situated in close
quarters. Common symptoms include sorequarters. Common symptoms include sore
throat, pain on swallowing, and fever. Thethroat, pain on swallowing, and fever. The
classic finding on physical examination isclassic finding on physical examination is
the presence of white exudates on swollenthe presence of white exudates on swollen
tonsils, as seen in the image. It is importanttonsils, as seen in the image. It is important
to treat this self-limited illness in order toto treat this self-limited illness in order to
prevent rheumatic fever.prevent rheumatic fever.
8. CaseCase
►A 33-year-old man who had sustained aA 33-year-old man who had sustained a
burn injury to his left upper arm as a childburn injury to his left upper arm as a child
presented with a rapidly growing, fungatingpresented with a rapidly growing, fungating
ulcer in the burn scar.ulcer in the burn scar.
9.
10. Marjolin’s UlcerMarjolin’s Ulcer
► A biopsy of the mass revealed invasiveA biopsy of the mass revealed invasive
squamous-cell carcinoma consistent withsquamous-cell carcinoma consistent with
Marjolin's ulcer. The patient underwent wide localMarjolin's ulcer. The patient underwent wide local
excision and placement of a split-thickness skinexcision and placement of a split-thickness skin
graft. No evidence of tumor was identified in thegraft. No evidence of tumor was identified in the
sentinel lymph nodes. Dr. Jean Nicolas Marjolinsentinel lymph nodes. Dr. Jean Nicolas Marjolin
first described the occurrence of ulcerating lesionsfirst described the occurrence of ulcerating lesions
within scar tissue in 1828. Marjolin's ulcer is thewithin scar tissue in 1828. Marjolin's ulcer is the
term given to these aggressive epidermoid tumorsterm given to these aggressive epidermoid tumors
that arise from areas of chronic injury, with burnthat arise from areas of chronic injury, with burn
wounds being a common site.wounds being a common site.
11. CaseCase
►A 32-year-old woman presented with aA 32-year-old woman presented with a
three-day history of tenderness and swellingthree-day history of tenderness and swelling
of the left breast. Physical examinationof the left breast. Physical examination
revealed a subcutaneous fibrous lesion thatrevealed a subcutaneous fibrous lesion that
was linear and cordlike.was linear and cordlike.
12.
13. Mondor’s DiseaseMondor’s Disease
► The patient was given nonsteroidalThe patient was given nonsteroidal
antiinflammatory drugs. The lesion and pain bothantiinflammatory drugs. The lesion and pain both
disappeared within six weeks, and the patient hasdisappeared within six weeks, and the patient has
subsequently been well.subsequently been well.
► Mondor's disease is characterized byMondor's disease is characterized by
thrombophlebitis of the subcutaneous veins of thethrombophlebitis of the subcutaneous veins of the
anterolateral thoracoabdominal wall. The conditionanterolateral thoracoabdominal wall. The condition
is three times as frequent in women as in men andis three times as frequent in women as in men and
is usually benign and self-limited, although it hasis usually benign and self-limited, although it has
been associated with breast cancer.been associated with breast cancer.
14. CaseCase
►A 51-year-old woman presented with weightA 51-year-old woman presented with weight
loss (despite good appetite), palpitations,loss (despite good appetite), palpitations,
tremor, and heat intolerance.tremor, and heat intolerance.
15.
16. Dermopathy of GravesDermopathy of Graves
► On examination, she had typical features ofOn examination, she had typical features of
Graves' disease, including a diffusely enlargedGraves' disease, including a diffusely enlarged
thyroid, periorbital edema, and proptosis, as wellthyroid, periorbital edema, and proptosis, as well
as mild thickening of the skin in the pretibial area.as mild thickening of the skin in the pretibial area.
The dermopathy extended bilaterally from justThe dermopathy extended bilaterally from just
below the knees to the feet (Panels A and B). Thebelow the knees to the feet (Panels A and B). The
skin was leathery in texture, with hyperkeratosis,skin was leathery in texture, with hyperkeratosis,
fissuring, formation of verrucous nodules, and afissuring, formation of verrucous nodules, and a
change in pigment. A trial of therapy with topicalchange in pigment. A trial of therapy with topical
steroids and compressive dressings was initiatedsteroids and compressive dressings was initiated
without any noticeable improvement after onewithout any noticeable improvement after one
year.year.
17. CaseCase
► An 86-year-old woman had a history of cirrhosisAn 86-year-old woman had a history of cirrhosis
associated with chronic hepatitis B infection lastingassociated with chronic hepatitis B infection lasting
more than 16 years; she had had five episodes ofmore than 16 years; she had had five episodes of
esophageal variceal bleeding that had requiredesophageal variceal bleeding that had required
placement of a Sengstaken–Blakemore tube forplacement of a Sengstaken–Blakemore tube for
tamponade and had undergone subsequenttamponade and had undergone subsequent
sclerotherapy. The patient presented to thesclerotherapy. The patient presented to the
emergency department with a new episode ofemergency department with a new episode of
hematemesis, and a Sengstaken–Blakemore tubehematemesis, and a Sengstaken–Blakemore tube
was placed.was placed.
18.
19. Complication of SB tubeComplication of SB tube
►Subsequently, the patient had pain in theSubsequently, the patient had pain in the
left chest area, and chest radiographyleft chest area, and chest radiography
showed a malpositioned gastric balloonshowed a malpositioned gastric balloon
(Panel A). Computed tomography of the(Panel A). Computed tomography of the
chest showed that the tube had penetratedchest showed that the tube had penetrated
the esophageal wall (arrow, Panel B), withthe esophageal wall (arrow, Panel B), with
the gastric balloon visible in the left pleuralthe gastric balloon visible in the left pleural
cavity.cavity.
20. CaseCase
►An 81-year-old man was admitted to theAn 81-year-old man was admitted to the
hospital because of a six-month history ofhospital because of a six-month history of
intermittent dysphagia, regurgitation, andintermittent dysphagia, regurgitation, and
vomiting during meals.vomiting during meals.
21.
22. Corkscrew esophagusCorkscrew esophagus
► Upper gastrointestinal endoscopy revealed anUpper gastrointestinal endoscopy revealed an
abnormal appearance of the esophagealabnormal appearance of the esophageal
peristalsis; it resembled the features of a windingperistalsis; it resembled the features of a winding
staircase (Panel A). Radiographs of thestaircase (Panel A). Radiographs of the
esophagus that were performed with the use ofesophagus that were performed with the use of
barium contrast material showed a spiral formationbarium contrast material showed a spiral formation
of the barium column up to the cervical esophagusof the barium column up to the cervical esophagus
(Panel B). Manometry confirmed an alternative(Panel B). Manometry confirmed an alternative
form of normal peristalsis and an absence ofform of normal peristalsis and an absence of
peristalsis in the esophageal body.peristalsis in the esophageal body.
23. CaseCase
►A 46-year-old woman with a history ofA 46-year-old woman with a history of
infection with the human immunodeficiencyinfection with the human immunodeficiency
virus (HIV) presented to the emergencyvirus (HIV) presented to the emergency
department for evaluation of a painful rash.department for evaluation of a painful rash.
The CD4 cell count was 365 per cubicThe CD4 cell count was 365 per cubic
millimeter, the HIV load was undetectable,millimeter, the HIV load was undetectable,
and the patient had not receivedand the patient had not received
antiretroviral therapy.antiretroviral therapy.
24.
25. Tinea CircinataTinea Circinata
►A skin-scraping specimen prepared withA skin-scraping specimen prepared with
potassium hydroxide was evaluatedpotassium hydroxide was evaluated
microscopically and found to containmicroscopically and found to contain
multiple hyphae. A diagnosis of tineamultiple hyphae. A diagnosis of tinea
circinata was made. Tinea circinata, ancircinata was made. Tinea circinata, an
uncommon morphologic variant of tineauncommon morphologic variant of tinea
corporis, is caused by the dermatophytecorporis, is caused by the dermatophyte
Trichophyton tonsuransTrichophyton tonsurans..
26.
27. Finger avulsionFinger avulsion
► A 17-year-old boy jumped over a fence and sustained an avulsionA 17-year-old boy jumped over a fence and sustained an avulsion
injury to the fifth finger of his right hand when the ring he was wearinginjury to the fifth finger of his right hand when the ring he was wearing
caught on the fence. The finger was amputated through the distalcaught on the fence. The finger was amputated through the distal
interphalangeal joint, and the tendon of the flexor digitorum profundusinterphalangeal joint, and the tendon of the flexor digitorum profundus
muscle was completely pulled out (Panel A). The insertion of themuscle was completely pulled out (Panel A). The insertion of the
superficial flexor tendon remained intact, and the patient was able tosuperficial flexor tendon remained intact, and the patient was able to
flex the remaining stump of the finger. The torn-out tendon wasflex the remaining stump of the finger. The torn-out tendon was
resected, and the amputated part of the finger replantedresected, and the amputated part of the finger replanted
microsurgically. Postoperative anticoagulant therapy consisted ofmicrosurgically. Postoperative anticoagulant therapy consisted of
aspirin and intravenous heparin given for seven days. Healing wasaspirin and intravenous heparin given for seven days. Healing was
uneventful, and the patient was discharged after 15 days. The finaluneventful, and the patient was discharged after 15 days. The final
result is shown in Panel B. At seven weeks' follow-up, the patient wasresult is shown in Panel B. At seven weeks' follow-up, the patient was
able to flex the finger actively; the range of motion was 50 degrees inable to flex the finger actively; the range of motion was 50 degrees in
the proximal interphalangeal joint and 30 degrees in the distalthe proximal interphalangeal joint and 30 degrees in the distal
interphalangeal joint.interphalangeal joint.
28. CaseCase
► A 63-year-old woman was admitted to the hospitalA 63-year-old woman was admitted to the hospital
with vomiting and abdominal pain. Approximatelywith vomiting and abdominal pain. Approximately
one year earlier, she had undergone a papillotomyone year earlier, she had undergone a papillotomy
and laparoscopic cholecystectomy for biliary colic.and laparoscopic cholecystectomy for biliary colic.
Laboratory examination revealed elevated liverLaboratory examination revealed elevated liver
enzyme levels (alkaline phosphatase, 560 U perenzyme levels (alkaline phosphatase, 560 U per
liter; glutamyltransferase, 230 U per liter; lactateliter; glutamyltransferase, 230 U per liter; lactate
dehydrogenase, 399 U per liter; and bilirubin, 1.2dehydrogenase, 399 U per liter; and bilirubin, 1.2
mg per deciliter [20.5 µmol per liter]). Onmg per deciliter [20.5 µmol per liter]). On
ultrasonography, the intrahepatic bile ducts wereultrasonography, the intrahepatic bile ducts were
not substantially widened; however, the lumen wasnot substantially widened; however, the lumen was
filled with sludge-like material.filled with sludge-like material.
29.
30. ► Endoscopic retrograde cholangiopancreatographyEndoscopic retrograde cholangiopancreatography
showed a worm-like structure measuring 10 cm inshowed a worm-like structure measuring 10 cm in
length at the papilla (Panel A); the worm waslength at the papilla (Panel A); the worm was
extracted endoscopically (Panel B). The patientextracted endoscopically (Panel B). The patient
was discharged from the hospital three days later.was discharged from the hospital three days later.
The abdominal symptoms had resolved, and theThe abdominal symptoms had resolved, and the
liver-enzyme elevation had markedly improved.liver-enzyme elevation had markedly improved.
Currently, the patient is well, without signs ofCurrently, the patient is well, without signs of
cholangitis. Biliary obstruction is an importantcholangitis. Biliary obstruction is an important
complication ofcomplication of Ascaris lumbricoidesAscaris lumbricoides infestation.infestation.
31. CaseCase
►A 64-year-old woman presented to our clinicA 64-year-old woman presented to our clinic
with a 20-year history of a slowly growingwith a 20-year history of a slowly growing
plaque on her left foot. This lesion had beenplaque on her left foot. This lesion had been
pared and a biopsy reportedly performed inpared and a biopsy reportedly performed in
the past, but the patient's concomitantthe past, but the patient's concomitant
mental illness had made her very reluctantmental illness had made her very reluctant
to undergo treatment. She ultimately soughtto undergo treatment. She ultimately sought
treatment because of increasing pain andtreatment because of increasing pain and
difficulty walking, as well as drainage anddifficulty walking, as well as drainage and
odor.odor.
32.
33. Verrucous carcinomaVerrucous carcinoma
► On examination, a large, hyperkeratotic plaque withOn examination, a large, hyperkeratotic plaque with
multiple horny projections was found. The central portionmultiple horny projections was found. The central portion
was friable, and after some débridement, an underlyingwas friable, and after some débridement, an underlying
abscess was discovered. An excisional biopsy revealedabscess was discovered. An excisional biopsy revealed
verrucous carcinoma. A radiograph revealed no underlyingverrucous carcinoma. A radiograph revealed no underlying
involvement of bone.involvement of bone.
► Verrucous carcinoma is a slow-growing variant ofVerrucous carcinoma is a slow-growing variant of
squamous-cell carcinoma. It may resemble a wart and,squamous-cell carcinoma. It may resemble a wart and,
when found on the plantar surface of the foot, may bewhen found on the plantar surface of the foot, may be
called carcinoma cuniculatum. These tumors rarelycalled carcinoma cuniculatum. These tumors rarely
metastasize, and surgical excision is recommended.metastasize, and surgical excision is recommended.
34. CaseCase
►A 56-year-old man who had recentlyA 56-year-old man who had recently
undergone coronary-artery bypass graftingundergone coronary-artery bypass grafting
and replacement of the mitral and aorticand replacement of the mitral and aortic
valves underwent aortobifemoral bypassvalves underwent aortobifemoral bypass
surgery for Fontaine stage IIb arterialsurgery for Fontaine stage IIb arterial
occlusive disease. The postoperativeocclusive disease. The postoperative
course was complicated by retroperitonealcourse was complicated by retroperitoneal
bleeding. On day 10 after surgery, a routinebleeding. On day 10 after surgery, a routine
chest radiograph in the intensive care unitchest radiograph in the intensive care unit
revealed-revealed-
35.
36. Central line complicationCentral line complication
► The foreign body was caught with the use of a 5-FrenchThe foreign body was caught with the use of a 5-French
angled snare catheter and a venous transfemoral approachangled snare catheter and a venous transfemoral approach
(Panel D [fluoroscopic anteroposterior view], arrow, and(Panel D [fluoroscopic anteroposterior view], arrow, and
video clip 2) and was withdrawn through the right heartvideo clip 2) and was withdrawn through the right heart
without complications. The 91-mm clipped tip of a triluminalwithout complications. The 91-mm clipped tip of a triluminal
central venous catheter was removed (Panel E). Accidentalcentral venous catheter was removed (Panel E). Accidental
embolization of a fragment of a temporary central venousembolization of a fragment of a temporary central venous
catheter or port catheter is a rare but potentially seriouscatheter or port catheter is a rare but potentially serious
complication. Endovascular retrieval should be consideredcomplication. Endovascular retrieval should be considered
37. CaseCase
►A 51-year-old man who was positive for theA 51-year-old man who was positive for the
human immunodeficiency virus (HIV) andhuman immunodeficiency virus (HIV) and
had been treated with a conventionalhad been treated with a conventional
protease-inhibitor–based antiretroviralprotease-inhibitor–based antiretroviral
regimen for four years had wasting of the fatregimen for four years had wasting of the fat
of the extremities and face (especially ofof the extremities and face (especially of
Bichat's fat pad), abnormal deposition of fatBichat's fat pad), abnormal deposition of fat
in the neck and trunk ("bull neck"; Panels Ain the neck and trunk ("bull neck"; Panels A
and B), insulin resistance, andand B), insulin resistance, and
hypertriglyceridemia.hypertriglyceridemia.
38.
39. LipodystrophyLipodystrophy
► The complete blood count, the hepatic profile, andThe complete blood count, the hepatic profile, and
the levels of thyroid-stimulating hormone, follicle-the levels of thyroid-stimulating hormone, follicle-
stimulating hormone, luteinizing hormone, andstimulating hormone, luteinizing hormone, and
prolactin were normal. The results of aprolactin were normal. The results of a
dexamethasone suppression test and the 24-hourdexamethasone suppression test and the 24-hour
urinary cortisol level were also normal.urinary cortisol level were also normal.
► In a substantial proportion of HIV-infected patientsIn a substantial proportion of HIV-infected patients
who receive protease inhibitors, changes in lipidwho receive protease inhibitors, changes in lipid
metabolism and body-fat distribution can developmetabolism and body-fat distribution can develop
after an average of 10 to 12 months of therapyafter an average of 10 to 12 months of therapy
40. CaseCase
► A previously healthy 54-year-old woman presented with aA previously healthy 54-year-old woman presented with a
two-week history of pelvic pain. On physical examination,two-week history of pelvic pain. On physical examination,
she had limited movement, without tenderness in theshe had limited movement, without tenderness in the
bones. An initial radiographic survey of skeletal bonebones. An initial radiographic survey of skeletal bone
showed multiple lytic lesions in the axial skeleton (Panel A,showed multiple lytic lesions in the axial skeleton (Panel A,
arrow), the ribs, the skull (Panel B, arrow), bilaterally in thearrow), the ribs, the skull (Panel B, arrow), bilaterally in the
pelvis, both femurs (Panel C, arrow), and both humeripelvis, both femurs (Panel C, arrow), and both humeri
(Panel D, arrow). Blood tests showed normocytic(Panel D, arrow). Blood tests showed normocytic
normochromic anemia with a hematocrit of 24.9 percent,normochromic anemia with a hematocrit of 24.9 percent,
along with a sedimentation rate of 140 mm per hour.along with a sedimentation rate of 140 mm per hour.
Calcium levels and the results of kidney-function and liver-Calcium levels and the results of kidney-function and liver-
function tests were normal. The patient was admitted with afunction tests were normal. The patient was admitted with a
provisional diagnosis of multiple myeloma, but no evidenceprovisional diagnosis of multiple myeloma, but no evidence
of paraprotein was detected in the blood or urine.of paraprotein was detected in the blood or urine.
41.
42. Breast cancer lytic lesionsBreast cancer lytic lesions
► Bone marrow biopsy revealed carcinoma cells thatBone marrow biopsy revealed carcinoma cells that
were positive for CA 15-3, estrogen receptor (+1),were positive for CA 15-3, estrogen receptor (+1),
and HER-2 (+2); the serum CA 15-3 level wasand HER-2 (+2); the serum CA 15-3 level was
elevated, at 106 U per milliliter (normal range, 0.3elevated, at 106 U per milliliter (normal range, 0.3
to 28.0). These findings are consistent withto 28.0). These findings are consistent with
metastatic breast disease. Subsequentmetastatic breast disease. Subsequent
mammography and needle biopsy showed onlymammography and needle biopsy showed only
fibrocystic breast disease. The patient has had afibrocystic breast disease. The patient has had a
response to chemotherapy with doxorubicin andresponse to chemotherapy with doxorubicin and
cyclophosphamide, together with analgesics andcyclophosphamide, together with analgesics and
bisphosphonatesbisphosphonates
43. CaseCase
►A 66-year-old man presented with a two-A 66-year-old man presented with a two-
year history of fatigue, paresthesia of theyear history of fatigue, paresthesia of the
legs and feet, weight loss, and shoulderlegs and feet, weight loss, and shoulder
enlargement, with limitation of movement.enlargement, with limitation of movement.
On physical examination, periorbitalOn physical examination, periorbital
ecchymoses (the "raccoon" sign) andecchymoses (the "raccoon" sign) and
infiltration of the periarticular tissues of theinfiltration of the periarticular tissues of the
shoulders were found.shoulders were found.
44.
45. AmyloidosisAmyloidosis
► A biopsy specimen of abdominal fat that was stained withA biopsy specimen of abdominal fat that was stained with
Congo red was positive for amyloid, and serum monoclonalCongo red was positive for amyloid, and serum monoclonal
paraprotein (lambda light chain) was detected byparaprotein (lambda light chain) was detected by
immunoelectrophoresis. A bone marrow biopsy specimenimmunoelectrophoresis. A bone marrow biopsy specimen
contained 30 percent plasma cells. The patient wascontained 30 percent plasma cells. The patient was
enrolled in a chemotherapy protocol but died two monthsenrolled in a chemotherapy protocol but died two months
later. Although amyloid infiltration around articularlater. Although amyloid infiltration around articular
structures is rare, the "shoulder pad" sign that results fromstructures is rare, the "shoulder pad" sign that results from
amyloid deposition in periarticular soft tissue isamyloid deposition in periarticular soft tissue is
pathognomonic for immunoglobulin amyloidosis. It haspathognomonic for immunoglobulin amyloidosis. It has
been suggested that kappa III variable light-chain amyloidbeen suggested that kappa III variable light-chain amyloid
proteins have an increased predilection for soft-tissueproteins have an increased predilection for soft-tissue
depositiondeposition
46. CaseCase
►A 76-year-old man was referred to ourA 76-year-old man was referred to our
hospital because of hemoptysis. He hadhospital because of hemoptysis. He had
had pulmonary tuberculosis six years beforehad pulmonary tuberculosis six years before
his current admission, and he had had anhis current admission, and he had had an
abnormal chest radiograph duringabnormal chest radiograph during
adolescence. A chest radiograph showedadolescence. A chest radiograph showed
an opacity in the right hemithorax that wasan opacity in the right hemithorax that was
accompanied by numerous masses, eachaccompanied by numerous masses, each
surrounded by an air crescent (Panel A).surrounded by an air crescent (Panel A).
47.
48. Congenital diaphragmatic herniaCongenital diaphragmatic hernia
► Bowel sounds were heard over the right chest, and aBowel sounds were heard over the right chest, and a
barium enema showed that the colon filled the rightbarium enema showed that the colon filled the right
hemithorax (Panel B). Computed tomography suggestedhemithorax (Panel B). Computed tomography suggested
hypoplasia of the right lung and herniation of the bowelhypoplasia of the right lung and herniation of the bowel
through the posterior diaphragm (Panel C). Bronchoscopicthrough the posterior diaphragm (Panel C). Bronchoscopic
examination showed no bleeding in any of the bronchialexamination showed no bleeding in any of the bronchial
lumina or orifices. Examination of the sputum yielded nolumina or orifices. Examination of the sputum yielded no
specific pathogens or malignant cells, and the hemoptysisspecific pathogens or malignant cells, and the hemoptysis
ceased spontaneously. Follow-up on an outpatient basisceased spontaneously. Follow-up on an outpatient basis
without specific therapy was planned. Since the patient'swithout specific therapy was planned. Since the patient's
history did not include a traumatic accident, thehistory did not include a traumatic accident, the
radiographic findings were compatible with a diagnosis ofradiographic findings were compatible with a diagnosis of
congenital diaphragmatic herniacongenital diaphragmatic hernia
49. CaseCase
►A previously healthy 34-year-old womanA previously healthy 34-year-old woman
who had back pain was referred forwho had back pain was referred for
radiography of the lumbar spine. Theradiography of the lumbar spine. The
patient's laboratory data were normal.patient's laboratory data were normal.
50.
51. CholelithiasisCholelithiasis
►The radiograph showed multiple facetedThe radiograph showed multiple faceted
stones outlining the contours of thestones outlining the contours of the
gallbladder. Ultrasonography of the uppergallbladder. Ultrasonography of the upper
abdomen showed multiple gallstones withabdomen showed multiple gallstones with
acoustic shadowing throughout theacoustic shadowing throughout the
gallbladder, which did not contain visiblegallbladder, which did not contain visible
bile. The patient underwent laparoscopicbile. The patient underwent laparoscopic
surgery to remove the gallbladder;surgery to remove the gallbladder;
numerous calculi were found to be filling thenumerous calculi were found to be filling the
lumen. She had an uneventful recovery.lumen. She had an uneventful recovery.
52. CaseCase
► A 29-year-old soldier had a two-day history ofA 29-year-old soldier had a two-day history of
headache and fever. He reported having had anheadache and fever. He reported having had an
intermittent, clear nasal discharge from the leftintermittent, clear nasal discharge from the left
nostril since his involvement in a minor motornostril since his involvement in a minor motor
vehicle accident two years earlier. Lumbarvehicle accident two years earlier. Lumbar
puncture revealed a white-cell count of 4100 perpuncture revealed a white-cell count of 4100 per
cubic millimeter, with 98 percent neutrophils — acubic millimeter, with 98 percent neutrophils — a
finding indicative of bacterial meningitis, evenfinding indicative of bacterial meningitis, even
though the microbiologic culture grew nothough the microbiologic culture grew no
organisms.organisms.
53.
54. Focal brain herniationFocal brain herniation
► Coronal computed tomography showed absence of the leftCoronal computed tomography showed absence of the left
ethmoidal plate and a focal brain herniation (Panel A,ethmoidal plate and a focal brain herniation (Panel A,
arrow). Incidental maxillary-sinus retention cysts were seenarrow). Incidental maxillary-sinus retention cysts were seen
bilaterally. Endoscopic rhinoscopy revealed a small,bilaterally. Endoscopic rhinoscopy revealed a small,
pulsating mass consistent with the presence of anpulsating mass consistent with the presence of an
encephalocele (Panel B, arrow). The asterisks indicate theencephalocele (Panel B, arrow). The asterisks indicate the
mid-septum. A fistulous defect in the nasal cavity resultedmid-septum. A fistulous defect in the nasal cavity resulted
in the leakage of cerebrospinal fluid and subsequentin the leakage of cerebrospinal fluid and subsequent
meningitis. Corrective surgery consisted of resection of themeningitis. Corrective surgery consisted of resection of the
encephalocele, followed by closure of the bony defect. Atencephalocele, followed by closure of the bony defect. At
two years, the patient was doing well, with no furthertwo years, the patient was doing well, with no further
episodes of meningitis.episodes of meningitis.
55. CaseCase
►A 72-year-old woman with a history ofA 72-year-old woman with a history of
hematuria presented with a three-monthhematuria presented with a three-month
history of weight loss and anorexia.history of weight loss and anorexia.
Computed tomography (Panel A) andComputed tomography (Panel A) and
ultrasonography showed a solid massultrasonography showed a solid mass
infiltrating the renal pelvis of theinfiltrating the renal pelvis of the
nonfunctioning right kidney.nonfunctioning right kidney.
56.
57. Staghorn Renal Cell CAStaghorn Renal Cell CA
► Subsequent radical nephrectomy confirmed theSubsequent radical nephrectomy confirmed the
presence of the mass at the upper pole and alsopresence of the mass at the upper pole and also
revealed a complete staghorn pyelocaliceal andrevealed a complete staghorn pyelocaliceal and
ureteral mass (Panel B). Histologic analysisureteral mass (Panel B). Histologic analysis
showed that the lesion was a poorly differentiatedshowed that the lesion was a poorly differentiated
renal-cell carcinoma (stage pT3aN0M0 accordingrenal-cell carcinoma (stage pT3aN0M0 according
to the tumor–node–metastasis classificationto the tumor–node–metastasis classification
system). Lung metastases developed three yearssystem). Lung metastases developed three years
after surgery. The patient was treated withafter surgery. The patient was treated with
systemic administration of interferon but died ofsystemic administration of interferon but died of
progressive disease 18 months later.progressive disease 18 months later.
58. ►A 32-year-old man reported having hadA 32-year-old man reported having had
back and abdominal pain, nausea, andback and abdominal pain, nausea, and
constipation for several weeks. The resultsconstipation for several weeks. The results
of laboratory studies were notable forof laboratory studies were notable for
normocytic anemia, a hemoglobin level ofnormocytic anemia, a hemoglobin level of
7.9 g per deciliter, a mean corpuscular7.9 g per deciliter, a mean corpuscular
volume of 82 µm3, and basophilic stipplingvolume of 82 µm3, and basophilic stippling
of erythrocytes. The man had sustained aof erythrocytes. The man had sustained a
gunshot wound to the right elbow six yearsgunshot wound to the right elbow six years
earlier.earlier.
59.
60. Lead poisoningLead poisoning
► The serum lead level was elevated, at 143.5 µg perThe serum lead level was elevated, at 143.5 µg per
deciliter (6.9 µmol per liter; normal, less than 10.0 µg perdeciliter (6.9 µmol per liter; normal, less than 10.0 µg per
deciliter [0.5 µmol per liter]). The joint space was opened,deciliter [0.5 µmol per liter]). The joint space was opened,
and fragments of the bullet were seen to be invading theand fragments of the bullet were seen to be invading the
synovium. Treatment with EDTA and dimercaprol wassynovium. Treatment with EDTA and dimercaprol was
initiated immediately. The lead level decreased to 30 µginitiated immediately. The lead level decreased to 30 µg
per deciliter (1.4 µmol per liter), and the patient's symptomsper deciliter (1.4 µmol per liter), and the patient's symptoms
resolved. He was lost to follow-up but presented again fiveresolved. He was lost to follow-up but presented again five
months later with recrudescent symptoms and a serummonths later with recrudescent symptoms and a serum
lead level of 116 µg per deciliter (5.6 µmol per liter). Hislead level of 116 µg per deciliter (5.6 µmol per liter). His
symptoms again resolved with chelation therapy.symptoms again resolved with chelation therapy.
Treatment with succimer and surgical exploration wereTreatment with succimer and surgical exploration were
recommended on an outpatient basis. The patient was lostrecommended on an outpatient basis. The patient was lost
again to follow-up.again to follow-up.
61. CaseCase
►An 87-year-old woman with iatrogenicAn 87-year-old woman with iatrogenic
Cushing's syndrome presented with feverCushing's syndrome presented with fever
and shock. She had had diarrhea forand shock. She had had diarrhea for
several days, but after the use ofseveral days, but after the use of
antidiarrheal agents, she had becomeantidiarrheal agents, she had become
constipated. On the day before admission,constipated. On the day before admission,
she had begun having diffuse abdominalshe had begun having diffuse abdominal
pain. A plain-film radiograph (Panel A)pain. A plain-film radiograph (Panel A)
62.
63. Ruptured diverticulitisRuptured diverticulitis
► X-ray showed the falciform-ligament sign, which was visibleX-ray showed the falciform-ligament sign, which was visible
as a linear density (arrow); a nasogastric tube was alsoas a linear density (arrow); a nasogastric tube was also
visible. The radiograph also showed the Rigler sign (alsovisible. The radiograph also showed the Rigler sign (also
known as the double-wall sign), indicating the presence ofknown as the double-wall sign), indicating the presence of
gas on both sides of the bowel wall (arrowheads). Agas on both sides of the bowel wall (arrowheads). A
computed tomographic scan of the abdomen showed thecomputed tomographic scan of the abdomen showed the
falciform ligament (Panel B, arrow), outlined byfalciform ligament (Panel B, arrow), outlined by
intraperitoneal free air. Pneumoperitoneum was diagnosed.intraperitoneal free air. Pneumoperitoneum was diagnosed.
Laparotomy was performed, and diverticulitis withLaparotomy was performed, and diverticulitis with
perforation of the sigmoid colon was found. Despiteperforation of the sigmoid colon was found. Despite
resection of the lesion and colostomy, the patient died fromresection of the lesion and colostomy, the patient died from
multiple-organ failure 10 days after admissionmultiple-organ failure 10 days after admission
64. CaseCase
► A 76-year-old woman was admitted with an exacerbation ofA 76-year-old woman was admitted with an exacerbation of
chronic obstructive pulmonary disease. Her conditionchronic obstructive pulmonary disease. Her condition
improved with bronchodilators, prednisolone, an antibiotic,improved with bronchodilators, prednisolone, an antibiotic,
oxygen, and supportive measures. Two years previously,oxygen, and supportive measures. Two years previously,
she had presented with vertebral compression fractures,she had presented with vertebral compression fractures,
Bence Jones proteinuria, and IgG paraproteinemia. TheBence Jones proteinuria, and IgG paraproteinemia. The
diagnosis of multiple myeloma had been confirmed bydiagnosis of multiple myeloma had been confirmed by
examination of the bone marrow, which showed 36 percentexamination of the bone marrow, which showed 36 percent
atypical plasma cells. The patient had toleratedatypical plasma cells. The patient had tolerated
chemotherapy poorly and was treated only with opiateschemotherapy poorly and was treated only with opiates
and sodium clodronate. Three days after the presentand sodium clodronate. Three days after the present
admission, pain and swelling developed in her right armadmission, pain and swelling developed in her right arm
without previous trauma.without previous trauma.
65.
66. Pathologic fracturePathologic fracture
►Radiographs of the arm showed a displacedRadiographs of the arm showed a displaced
fracture of the right humerus and multiplefracture of the right humerus and multiple
lytic lesions (Panels A and B), which arelytic lesions (Panels A and B), which are
typical of myeloma. The serum calcium leveltypical of myeloma. The serum calcium level
was normal, but the alkaline phosphatasewas normal, but the alkaline phosphatase
level was raised, at 390 U per liter (normallevel was raised, at 390 U per liter (normal
range, 70–300). The patient underwentrange, 70–300). The patient underwent
intramedullary pinning of the fracture. Sheintramedullary pinning of the fracture. She
died on the fifth postoperative day afterdied on the fifth postoperative day after
cardiac arrest.cardiac arrest.
67. CaseCase
► A 73-year-old man with a history of colon cancerA 73-year-old man with a history of colon cancer
presented to the emergency department with apresented to the emergency department with a
three-day history of pain in the right hip, without athree-day history of pain in the right hip, without a
history of trauma. He was admitted to the coronaryhistory of trauma. He was admitted to the coronary
care unit for management of a third-degreecare unit for management of a third-degree
atrioventricular block. He was febrile, withatrioventricular block. He was febrile, with
leukocytosis; blood cultures were ordered, andleukocytosis; blood cultures were ordered, and
antibiotic therapy was begun. Seven hours afterantibiotic therapy was begun. Seven hours after
admission, swelling of the right leg was noticed,admission, swelling of the right leg was noticed,
along with blisters and soft-tissue crepitus.along with blisters and soft-tissue crepitus.
68.
69. Clostridium septicum sepsisClostridium septicum sepsis
►A computed tomographic scan showed gasA computed tomographic scan showed gas
and extensive myonecrosis in the right legand extensive myonecrosis in the right leg
(Panel A) and pelvis (Panel B). According to(Panel A) and pelvis (Panel B). According to
the patient's advance directive, emergencythe patient's advance directive, emergency
amputation was not pursued. The patientamputation was not pursued. The patient
died three hours later. The blood culturesdied three hours later. The blood cultures
later grewlater grew Clostridium septicumClostridium septicum..
70. CaseCase
►A 62-year-old woman received six cycles ofA 62-year-old woman received six cycles of
docetaxel chemotherapy during a six-monthdocetaxel chemotherapy during a six-month
period for recurrent metastatic breastperiod for recurrent metastatic breast
cancer. She had completed treatment fourcancer. She had completed treatment four
weeks before this photograph was taken.weeks before this photograph was taken.
Six evenly spaced, transverse lines wereSix evenly spaced, transverse lines were
noted on all her fingernails.noted on all her fingernails.
71.
72. Beau’s linesBeau’s lines
►Beau's lines are transverse depressions inBeau's lines are transverse depressions in
the nail plate caused by temporarythe nail plate caused by temporary
cessation of cell division in the proximal nailcessation of cell division in the proximal nail
matrix. The condition may be caused bymatrix. The condition may be caused by
local disease of the nail fold or a systemiclocal disease of the nail fold or a systemic
insult, such as an illness or theinsult, such as an illness or the
administration of a drug.administration of a drug.
73. CaseCase
►A 16-year-old boy presented with a two-yearA 16-year-old boy presented with a two-year
history of hyperpigmentation of the skin; hishistory of hyperpigmentation of the skin; his
sclera were unaffected. He is shown withsclera were unaffected. He is shown with
his mother for comparison. What is thehis mother for comparison. What is the
diagnosis?diagnosis?
74.
75. ArgyriaArgyria
► The medical mystery in the October 7 issue1 involved a 16-The medical mystery in the October 7 issue1 involved a 16-
year-old white boy who presented with generalized argyriayear-old white boy who presented with generalized argyria
after ingesting a silver-containing dietary supplement forafter ingesting a silver-containing dietary supplement for
approximately two years. The supplement was packagedapproximately two years. The supplement was packaged
so that it was identical to bottled water and was touted as aso that it was identical to bottled water and was touted as a
preventive for everyday infections. Pigmentary changespreventive for everyday infections. Pigmentary changes
began on the boy's cheeks and progressed to involve hisbegan on the boy's cheeks and progressed to involve his
entire body within one year. Because of his grayingentire body within one year. Because of his graying
complexion, a workup was performed for Addison's diseasecomplexion, a workup was performed for Addison's disease
and cyanosis. All the results were negative or normal.and cyanosis. All the results were negative or normal.
There was no evidence of neuropathy or seizures.There was no evidence of neuropathy or seizures.
► The serum silver level was markedly elevated, at 209 ngThe serum silver level was markedly elevated, at 209 ng
per millimeter (normal range, 0 to 14). These findings areper millimeter (normal range, 0 to 14). These findings are
consistent with the diagnosis of generalized argyria.consistent with the diagnosis of generalized argyria.
