Picture roundsPicture rounds

Lancet/NEJM clinical imagesLancet/NEJM clinical images

87 y/o man with N/V87 y/o man with N/V

Massive cerebral air Massive cerebral air embolismembolism

►After SBO from cholecystectomyAfter SBO from cholecystectomy►Pt. died.Pt. died.

Drawn by 6 Drawn by 6 y/o y/o

granddaughter granddaughter of patient who of patient who was admitted was admitted for Parkinson’sfor Parkinson’s

Progressive supranuclear Progressive supranuclear palsypalsy

►Parkinson’s plus syndromeParkinson’s plus syndrome►Lack up upward gazeLack up upward gaze

Strep PharyngitisStrep Pharyngitis

►Streptococcal pharyngitis is caused by Streptococcal pharyngitis is caused by group A -hemolytic streptococci and group A -hemolytic streptococci and most often affects persons situated in most often affects persons situated in close quarters. Common symptoms close quarters. Common symptoms include sore throat, pain on swallowing, include sore throat, pain on swallowing, and fever. The classic finding on physical and fever. The classic finding on physical examination is the presence of white examination is the presence of white exudates on swollen tonsils, as seen in exudates on swollen tonsils, as seen in the image. It is important to treat this the image. It is important to treat this self-limited illness in order to prevent self-limited illness in order to prevent rheumatic fever.rheumatic fever.

CaseCase

►A 33-year-old man who had sustained A 33-year-old man who had sustained a burn injury to his left upper arm as a a burn injury to his left upper arm as a child presented with a rapidly growing, child presented with a rapidly growing, fungating ulcer in the burn scar.fungating ulcer in the burn scar.

Marjolin’s UlcerMarjolin’s Ulcer

► A biopsy of the mass revealed invasive A biopsy of the mass revealed invasive squamous-cell carcinoma consistent with squamous-cell carcinoma consistent with Marjolin's ulcer. The patient underwent wide Marjolin's ulcer. The patient underwent wide local excision and placement of a split-local excision and placement of a split-thickness skin graft. No evidence of tumor was thickness skin graft. No evidence of tumor was identified in the sentinel lymph nodes. Dr. Jean identified in the sentinel lymph nodes. Dr. Jean Nicolas Marjolin first described the occurrence Nicolas Marjolin first described the occurrence of ulcerating lesions within scar tissue in 1828. of ulcerating lesions within scar tissue in 1828. Marjolin's ulcer is the term given to these Marjolin's ulcer is the term given to these aggressive epidermoid tumors that arise from aggressive epidermoid tumors that arise from areas of chronic injury, with burn wounds areas of chronic injury, with burn wounds being a common site. being a common site.

CaseCase

►A 32-year-old woman presented with a A 32-year-old woman presented with a three-day history of tenderness and three-day history of tenderness and swelling of the left breast. Physical swelling of the left breast. Physical examination revealed a subcutaneous examination revealed a subcutaneous fibrous lesion that was linear and fibrous lesion that was linear and cordlike.cordlike.

Mondor’s DiseaseMondor’s Disease

► The patient was given nonsteroidal The patient was given nonsteroidal antiinflammatory drugs. The lesion and pain antiinflammatory drugs. The lesion and pain both disappeared within six weeks, and the both disappeared within six weeks, and the patient has subsequently been well. patient has subsequently been well.

► Mondor's disease is characterized by Mondor's disease is characterized by thrombophlebitis of the subcutaneous veins of thrombophlebitis of the subcutaneous veins of the anterolateral thoracoabdominal wall. The the anterolateral thoracoabdominal wall. The condition is three times as frequent in women condition is three times as frequent in women as in men and is usually benign and self-as in men and is usually benign and self-limited, although it has been associated with limited, although it has been associated with breast cancer.breast cancer.

CaseCase

►A 51-year-old woman presented with A 51-year-old woman presented with weight loss (despite good appetite), weight loss (despite good appetite), palpitations, tremor, and heat palpitations, tremor, and heat intolerance.intolerance.

Dermopathy of GravesDermopathy of Graves

►On examination, she had typical features of On examination, she had typical features of Graves' disease, including a diffusely Graves' disease, including a diffusely enlarged thyroid, periorbital edema, and enlarged thyroid, periorbital edema, and proptosis, as well as mild thickening of the proptosis, as well as mild thickening of the skin in the pretibial area. The dermopathy skin in the pretibial area. The dermopathy extended bilaterally from just below the extended bilaterally from just below the knees to the feet (Panels A and B). The skin knees to the feet (Panels A and B). The skin was leathery in texture, with hyperkeratosis, was leathery in texture, with hyperkeratosis, fissuring, formation of verrucous nodules, fissuring, formation of verrucous nodules, and a change in pigment. A trial of therapy and a change in pigment. A trial of therapy with topical steroids and compressive with topical steroids and compressive dressings was initiated without any dressings was initiated without any noticeable improvement after one year. noticeable improvement after one year.

CaseCase

► An 86-year-old woman had a history of An 86-year-old woman had a history of cirrhosis associated with chronic hepatitis B cirrhosis associated with chronic hepatitis B infection lasting more than 16 years; she had infection lasting more than 16 years; she had had five episodes of esophageal variceal had five episodes of esophageal variceal bleeding that had required placement of a bleeding that had required placement of a Sengstaken–Blakemore tube for tamponade Sengstaken–Blakemore tube for tamponade and had undergone subsequent and had undergone subsequent sclerotherapy. The patient presented to the sclerotherapy. The patient presented to the emergency department with a new episode of emergency department with a new episode of hematemesis, and a Sengstaken–Blakemore hematemesis, and a Sengstaken–Blakemore tube was placed.tube was placed.

Complication of SB tubeComplication of SB tube

►Subsequently, the patient had pain in Subsequently, the patient had pain in the left chest area, and chest the left chest area, and chest radiography showed a malpositioned radiography showed a malpositioned gastric balloon (Panel A). Computed gastric balloon (Panel A). Computed tomography of the chest showed that tomography of the chest showed that the tube had penetrated the the tube had penetrated the esophageal wall (arrow, Panel B), with esophageal wall (arrow, Panel B), with the gastric balloon visible in the left the gastric balloon visible in the left pleural cavity. pleural cavity.

CaseCase

►An 81-year-old man was admitted to An 81-year-old man was admitted to the hospital because of a six-month the hospital because of a six-month history of intermittent dysphagia, history of intermittent dysphagia, regurgitation, and vomiting during regurgitation, and vomiting during meals.meals.

Corkscrew esophagusCorkscrew esophagus

► Upper gastrointestinal endoscopy revealed an Upper gastrointestinal endoscopy revealed an abnormal appearance of the esophageal abnormal appearance of the esophageal peristalsis; it resembled the features of a peristalsis; it resembled the features of a winding staircase (Panel A). Radiographs of winding staircase (Panel A). Radiographs of the esophagus that were performed with the the esophagus that were performed with the use of barium contrast material showed a use of barium contrast material showed a spiral formation of the barium column up to spiral formation of the barium column up to the cervical esophagus (Panel B). Manometry the cervical esophagus (Panel B). Manometry confirmed an alternative form of normal confirmed an alternative form of normal peristalsis and an absence of peristalsis in the peristalsis and an absence of peristalsis in the esophageal body. esophageal body.

CaseCase

►A 46-year-old woman with a history of A 46-year-old woman with a history of infection with the human infection with the human immunodeficiency virus (HIV) immunodeficiency virus (HIV) presented to the emergency presented to the emergency department for evaluation of a painful department for evaluation of a painful rash. The CD4 cell count was 365 per rash. The CD4 cell count was 365 per cubic millimeter, the HIV load was cubic millimeter, the HIV load was undetectable, and the patient had not undetectable, and the patient had not received antiretroviral therapy.received antiretroviral therapy.

Tinea CircinataTinea Circinata

►A skin-scraping specimen prepared A skin-scraping specimen prepared with potassium hydroxide was with potassium hydroxide was evaluated microscopically and found evaluated microscopically and found to contain multiple hyphae. A to contain multiple hyphae. A diagnosis of tinea circinata was made. diagnosis of tinea circinata was made. Tinea circinata, an uncommon Tinea circinata, an uncommon morphologic variant of tinea corporis, morphologic variant of tinea corporis, is caused by the dermatophyte is caused by the dermatophyte Trichophyton tonsuransTrichophyton tonsurans. .

Finger avulsionFinger avulsion► A 17-year-old boy jumped over a fence and sustained an A 17-year-old boy jumped over a fence and sustained an

avulsion injury to the fifth finger of his right hand when the avulsion injury to the fifth finger of his right hand when the ring he was wearing caught on the fence. The finger was ring he was wearing caught on the fence. The finger was amputated through the distal interphalangeal joint, and the amputated through the distal interphalangeal joint, and the tendon of the flexor digitorum profundus muscle was tendon of the flexor digitorum profundus muscle was completely pulled out (Panel A). The insertion of the completely pulled out (Panel A). The insertion of the superficial flexor tendon remained intact, and the patient was superficial flexor tendon remained intact, and the patient was able to flex the remaining stump of the finger. The torn-out able to flex the remaining stump of the finger. The torn-out tendon was resected, and the amputated part of the finger tendon was resected, and the amputated part of the finger replanted microsurgically. Postoperative anticoagulant replanted microsurgically. Postoperative anticoagulant therapy consisted of aspirin and intravenous heparin given for therapy consisted of aspirin and intravenous heparin given for seven days. Healing was uneventful, and the patient was seven days. Healing was uneventful, and the patient was discharged after 15 days. The final result is shown in Panel B. discharged after 15 days. The final result is shown in Panel B. At seven weeks' follow-up, the patient was able to flex the At seven weeks' follow-up, the patient was able to flex the finger actively; the range of motion was 50 degrees in the finger actively; the range of motion was 50 degrees in the proximal interphalangeal joint and 30 degrees in the distal proximal interphalangeal joint and 30 degrees in the distal interphalangeal joint. interphalangeal joint.

CaseCase

► A 63-year-old woman was admitted to the A 63-year-old woman was admitted to the hospital with vomiting and abdominal pain. hospital with vomiting and abdominal pain. Approximately one year earlier, she had Approximately one year earlier, she had undergone a papillotomy and laparoscopic undergone a papillotomy and laparoscopic cholecystectomy for biliary colic. Laboratory cholecystectomy for biliary colic. Laboratory examination revealed elevated liver enzyme examination revealed elevated liver enzyme levels (alkaline phosphatase, 560 U per liter; levels (alkaline phosphatase, 560 U per liter; glutamyltransferase, 230 U per liter; lactate glutamyltransferase, 230 U per liter; lactate dehydrogenase, 399 U per liter; and bilirubin, dehydrogenase, 399 U per liter; and bilirubin, 1.2 mg per deciliter [20.5 µmol per liter]). On 1.2 mg per deciliter [20.5 µmol per liter]). On ultrasonography, the intrahepatic bile ducts ultrasonography, the intrahepatic bile ducts were not substantially widened; however, the were not substantially widened; however, the lumen was filled with sludge-like material. lumen was filled with sludge-like material.

► Endoscopic retrograde Endoscopic retrograde cholangiopancreatography showed a worm-like cholangiopancreatography showed a worm-like structure measuring 10 cm in length at the structure measuring 10 cm in length at the papilla (Panel A); the worm was extracted papilla (Panel A); the worm was extracted endoscopically (Panel B). The patient was endoscopically (Panel B). The patient was discharged from the hospital three days later. discharged from the hospital three days later. The abdominal symptoms had resolved, and the The 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 of Currently, the patient is well, without signs of cholangitis. Biliary obstruction is an important cholangitis. Biliary obstruction is an important complication of complication of Ascaris lumbricoidesAscaris lumbricoides infestation. infestation.

CaseCase

►A 64-year-old woman presented to our A 64-year-old woman presented to our clinic with a 20-year history of a slowly clinic with a 20-year history of a slowly growing plaque on her left foot. This growing plaque on her left foot. This lesion had been pared and a biopsy lesion had been pared and a biopsy reportedly performed in the past, but the reportedly performed in the past, but the patient's concomitant mental illness had patient's concomitant mental illness had made her very reluctant to undergo made her very reluctant to undergo treatment. She ultimately sought treatment. She ultimately sought treatment because of increasing pain and treatment because of increasing pain and difficulty walking, as well as drainage and difficulty walking, as well as drainage and odor.odor.

Verrucous carcinomaVerrucous carcinoma

► On examination, a large, hyperkeratotic plaque with On examination, a large, hyperkeratotic plaque with multiple horny projections was found. The central multiple horny projections was found. The central portion was friable, and after some débridement, an portion was friable, and after some débridement, an underlying abscess was discovered. An excisional underlying abscess was discovered. An excisional biopsy revealed verrucous carcinoma. A radiograph biopsy revealed verrucous carcinoma. A radiograph revealed no underlying involvement of bone. revealed no underlying involvement of bone.

► Verrucous carcinoma is a slow-growing variant of Verrucous carcinoma is a slow-growing variant of squamous-cell carcinoma. It may resemble a wart squamous-cell carcinoma. It may resemble a wart and, when found on the plantar surface of the foot, and, when found on the plantar surface of the foot, may be called carcinoma cuniculatum. These may be called carcinoma cuniculatum. These tumors rarely metastasize, and surgical excision is tumors rarely metastasize, and surgical excision is recommended.recommended.

CaseCase

►A 56-year-old man who had recently A 56-year-old man who had recently undergone coronary-artery bypass undergone coronary-artery bypass grafting and replacement of the mitral grafting and replacement of the mitral and aortic valves underwent and aortic valves underwent aortobifemoral bypass surgery for aortobifemoral bypass surgery for Fontaine stage IIb arterial occlusive Fontaine stage IIb arterial occlusive disease. The postoperative course was disease. The postoperative course was complicated by retroperitoneal bleeding. complicated by retroperitoneal bleeding. On day 10 after surgery, a routine chest On day 10 after surgery, a routine chest radiograph in the intensive care unit radiograph in the intensive care unit revealed-revealed-

Central line complicationCentral line complication► The foreign body was caught with the use of a 5-French The foreign body was caught with the use of a 5-French

angled snare catheter and a venous transfemoral angled snare catheter and a venous transfemoral approach (Panel D [fluoroscopic anteroposterior view], approach (Panel D [fluoroscopic anteroposterior view], arrow, and arrow, and video clip 2video clip 2) and was withdrawn through the ) and was withdrawn through the right heart without complications. The 91-mm clipped right heart without complications. The 91-mm clipped tip of a triluminal central venous catheter was removed tip of a triluminal central venous catheter was removed (Panel E). Accidental embolization of a fragment of a (Panel E). Accidental embolization of a fragment of a temporary central venous catheter or port catheter is a temporary central venous catheter or port catheter is a rare but potentially serious complication. Endovascular rare but potentially serious complication. Endovascular retrieval should be considered retrieval should be considered

CaseCase

►A 51-year-old man who was positive for A 51-year-old man who was positive for the human immunodeficiency virus (HIV) the human immunodeficiency virus (HIV) and had been treated with a conventional and had been treated with a conventional protease-inhibitor–based antiretroviral protease-inhibitor–based antiretroviral regimen for four years had wasting of the regimen for four years had wasting of the fat of the extremities and face (especially fat of the extremities and face (especially of Bichat's fat pad), abnormal deposition of Bichat's fat pad), abnormal deposition of fat in the neck and trunk ("bull neck"; of fat in the neck and trunk ("bull neck"; Panels A and B), insulin resistance, and Panels A and B), insulin resistance, and hypertriglyceridemia. hypertriglyceridemia.

LipodystrophyLipodystrophy

► The complete blood count, the hepatic profile, The complete blood count, the hepatic profile, and the levels of thyroid-stimulating and the levels of thyroid-stimulating hormone, follicle-stimulating hormone, hormone, follicle-stimulating hormone, luteinizing hormone, and prolactin were luteinizing hormone, and prolactin were normal. The results of a dexamethasone normal. The results of a dexamethasone suppression test and the 24-hour urinary suppression test and the 24-hour urinary cortisol level were also normal. cortisol level were also normal.

► In a substantial proportion of HIV-infected In a substantial proportion of HIV-infected patients who receive protease inhibitors, patients who receive protease inhibitors, changes in lipid metabolism and body-fat changes in lipid metabolism and body-fat distribution can develop after an average of distribution can develop after an average of 10 to 12 months of therapy10 to 12 months of therapy

CaseCase► A previously healthy 54-year-old woman presented A previously healthy 54-year-old woman presented

with a two-week history of pelvic pain. On physical with a two-week history of pelvic pain. On physical examination, she had limited movement, without examination, she had limited movement, without tenderness in the bones. An initial radiographic survey tenderness in the bones. An initial radiographic survey of skeletal bone showed multiple lytic lesions in the of skeletal bone showed multiple lytic lesions in the axial skeleton (Panel A, arrow), the ribs, the skull axial skeleton (Panel A, arrow), the ribs, the skull (Panel B, arrow), bilaterally in the pelvis, both femurs (Panel B, arrow), bilaterally in the pelvis, both femurs (Panel C, arrow), and both humeri (Panel D, arrow). (Panel C, arrow), and both humeri (Panel D, arrow). Blood tests showed normocytic normochromic anemia Blood tests showed normocytic normochromic anemia with a hematocrit of 24.9 percent, along with a with a hematocrit of 24.9 percent, along with a sedimentation rate of 140 mm per hour. Calcium levels sedimentation rate of 140 mm per hour. Calcium levels and the results of kidney-function and liver-function and the results of kidney-function and liver-function tests were normal. The patient was admitted with a tests were normal. The patient was admitted with a provisional diagnosis of multiple myeloma, but no provisional diagnosis of multiple myeloma, but no evidence of paraprotein was detected in the blood or evidence of paraprotein was detected in the blood or urine. urine.

Breast cancer lytic lesionsBreast cancer lytic lesions

► Bone marrow biopsy revealed carcinoma Bone marrow biopsy revealed carcinoma cells that were positive for CA 15-3, estrogen cells that were positive for CA 15-3, estrogen receptor (+1), and HER-2 (+2); the serum CA receptor (+1), and HER-2 (+2); the serum CA 15-3 level was elevated, at 106 U per 15-3 level was elevated, at 106 U per milliliter (normal range, 0.3 to 28.0). These milliliter (normal range, 0.3 to 28.0). These findings are consistent with metastatic findings are consistent with metastatic breast disease. Subsequent mammography breast disease. Subsequent mammography and needle biopsy showed only fibrocystic and needle biopsy showed only fibrocystic breast disease. The patient has had a breast disease. The patient has had a response to chemotherapy with doxorubicin response to chemotherapy with doxorubicin and cyclophosphamide, together with and cyclophosphamide, together with analgesics and bisphosphonates analgesics and bisphosphonates

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 year history of fatigue, paresthesia of the legs and feet, weight loss, and the legs and feet, weight loss, and shoulder enlargement, with limitation of shoulder enlargement, with limitation of movement. On physical examination, movement. On physical examination, periorbital ecchymoses (the "raccoon" periorbital ecchymoses (the "raccoon" sign) and infiltration of the periarticular sign) and infiltration of the periarticular tissues of the shoulders were found. tissues of the shoulders were found.

AmyloidosisAmyloidosis

► A biopsy specimen of abdominal fat that was stained A biopsy specimen of abdominal fat that was stained with Congo red was positive for amyloid, and serum with Congo red was positive for amyloid, and serum monoclonal paraprotein (lambda light chain) was monoclonal paraprotein (lambda light chain) was detected by immunoelectrophoresis. A bone marrow detected by immunoelectrophoresis. A bone marrow biopsy specimen contained 30 percent plasma cells. biopsy specimen contained 30 percent plasma cells. The patient was enrolled in a chemotherapy protocol The patient was enrolled in a chemotherapy protocol but died two months later. Although amyloid but died two months later. Although amyloid infiltration around articular structures is rare, the infiltration around articular structures is rare, the "shoulder pad" sign that results from amyloid "shoulder pad" sign that results from amyloid deposition in periarticular soft tissue is deposition in periarticular soft tissue is pathognomonic for immunoglobulin amyloidosis. It pathognomonic for immunoglobulin amyloidosis. It has been suggested that kappa III variable light-has been suggested that kappa III variable light-chain amyloid proteins have an increased chain amyloid proteins have an increased predilection for soft-tissue deposition predilection for soft-tissue deposition

CaseCase

►A 76-year-old man was referred to our A 76-year-old man was referred to our hospital because of hemoptysis. He had hospital because of hemoptysis. He had had pulmonary tuberculosis six years had pulmonary tuberculosis six years before his current admission, and he had before his current admission, and he had had an abnormal chest radiograph during had an abnormal chest radiograph during adolescence. A chest radiograph showed adolescence. A chest radiograph showed an opacity in the right hemithorax that an opacity in the right hemithorax that was accompanied by numerous masses, was accompanied by numerous masses, each surrounded by an air crescent (Panel each surrounded by an air crescent (Panel A). A).

Congenital diaphragmatic Congenital diaphragmatic herniahernia

► Bowel sounds were heard over the right chest, and a Bowel sounds were heard over the right chest, and a barium enema showed that the colon filled the right barium enema showed that the colon filled the right hemithorax (Panel B). Computed tomography hemithorax (Panel B). Computed tomography suggested hypoplasia of the right lung and herniation suggested hypoplasia of the right lung and herniation of the bowel through the posterior diaphragm (Panel of the bowel through the posterior diaphragm (Panel C). Bronchoscopic examination showed no bleeding in C). Bronchoscopic examination showed no bleeding in any of the bronchial lumina or orifices. Examination of any of the bronchial lumina or orifices. Examination of the sputum yielded no specific pathogens or the sputum yielded no specific pathogens or malignant cells, and the hemoptysis ceased malignant cells, and the hemoptysis ceased spontaneously. Follow-up on an outpatient basis spontaneously. Follow-up on an outpatient basis without specific therapy was planned. Since the without specific therapy was planned. Since the patient's history did not include a traumatic accident, patient's history did not include a traumatic accident, the radiographic findings were compatible with a the radiographic findings were compatible with a diagnosis of congenital diaphragmatic hernia diagnosis of congenital diaphragmatic hernia

CaseCase

►A previously healthy 34-year-old A previously healthy 34-year-old woman who had back pain was woman who had back pain was referred for radiography of the lumbar referred for radiography of the lumbar spine. The patient's laboratory data spine. The patient's laboratory data were normal. were normal.

CholelithiasisCholelithiasis

►The radiograph showed multiple faceted The radiograph showed multiple faceted stones outlining the contours of the stones outlining the contours of the gallbladder. Ultrasonography of the upper gallbladder. Ultrasonography of the upper abdomen showed multiple gallstones with abdomen showed multiple gallstones with acoustic shadowing throughout the acoustic shadowing throughout the gallbladder, which did not contain visible gallbladder, which did not contain visible bile. The patient underwent laparoscopic bile. The patient underwent laparoscopic surgery to remove the gallbladder; surgery to remove the gallbladder; numerous calculi were found to be filling numerous calculi were found to be filling the lumen. She had an uneventful the lumen. She had an uneventful recovery. recovery.

CaseCase

► A 29-year-old soldier had a two-day history of A 29-year-old soldier had a two-day history of headache and fever. He reported having had headache and fever. He reported having had an intermittent, clear nasal discharge from an intermittent, clear nasal discharge from the left nostril since his involvement in a the left nostril since his involvement in a minor motor vehicle accident two years minor motor vehicle accident two years earlier. Lumbar puncture revealed a white-cell earlier. Lumbar puncture revealed a white-cell count of 4100 per cubic millimeter, with 98 count of 4100 per cubic millimeter, with 98 percent neutrophils — a finding indicative of percent neutrophils — a finding indicative of bacterial meningitis, even though the bacterial meningitis, even though the microbiologic culture grew no organisms. microbiologic culture grew no organisms.

Focal brain herniationFocal brain herniation

► Coronal computed tomography showed absence of Coronal computed tomography showed absence of the left ethmoidal plate and a focal brain herniation the left ethmoidal plate and a focal brain herniation (Panel A, arrow). Incidental maxillary-sinus retention (Panel A, arrow). Incidental maxillary-sinus retention cysts were seen bilaterally. Endoscopic rhinoscopy cysts were seen bilaterally. Endoscopic rhinoscopy revealed a small, pulsating mass consistent with the revealed a small, pulsating mass consistent with the presence of an encephalocele (Panel B, arrow). The presence of an encephalocele (Panel B, arrow). The asterisks indicate the mid-septum. A fistulous defect asterisks indicate the mid-septum. A fistulous defect in the nasal cavity resulted in the leakage of in the nasal cavity resulted in the leakage of cerebrospinal fluid and subsequent meningitis. cerebrospinal fluid and subsequent meningitis. Corrective surgery consisted of resection of the Corrective surgery consisted of resection of the encephalocele, followed by closure of the bony encephalocele, followed by closure of the bony defect. At two years, the patient was doing well, with defect. At two years, the patient was doing well, with no further episodes of meningitis. no further episodes of meningitis.

CaseCase

►A 72-year-old woman with a history of A 72-year-old woman with a history of hematuria presented with a three-hematuria presented with a three-month history of weight loss and month history of weight loss and anorexia. Computed tomography anorexia. Computed tomography (Panel A) and ultrasonography showed (Panel A) and ultrasonography showed a solid mass infiltrating the renal a solid mass infiltrating the renal pelvis of the nonfunctioning right pelvis of the nonfunctioning right kidney. kidney.

Staghorn Renal Cell CAStaghorn Renal Cell CA

► Subsequent radical nephrectomy confirmed Subsequent radical nephrectomy confirmed the presence of the mass at the upper pole the presence of the mass at the upper pole and also revealed a complete staghorn and also revealed a complete staghorn pyelocaliceal and ureteral mass (Panel B). pyelocaliceal and ureteral mass (Panel B). Histologic analysis showed that the lesion was Histologic analysis showed that the lesion was a poorly differentiated renal-cell carcinoma a poorly differentiated renal-cell carcinoma (stage pT3aN0M0 according to the tumor–(stage pT3aN0M0 according to the tumor–node–metastasis classification system). Lung node–metastasis classification system). Lung metastases developed three years after metastases developed three years after surgery. The patient was treated with surgery. The patient was treated with systemic administration of interferon but died systemic administration of interferon but died of progressive disease 18 months later. of progressive disease 18 months later.

►A 32-year-old man reported having had A 32-year-old man reported having had back and abdominal pain, nausea, and back and abdominal pain, nausea, and constipation for several weeks. The constipation for several weeks. The results of laboratory studies were notable results of laboratory studies were notable for normocytic anemia, a hemoglobin for normocytic anemia, a hemoglobin level of 7.9 g per deciliter, a mean level of 7.9 g per deciliter, a mean corpuscular volume of 82 µm3, and corpuscular volume of 82 µm3, and basophilic stippling of erythrocytes. The basophilic stippling of erythrocytes. The man had sustained a gunshot wound to man had sustained a gunshot wound to the right elbow six years earlier. the right elbow six years earlier.

Lead poisoningLead poisoning

► The serum lead level was elevated, at 143.5 µg per The serum lead level was elevated, at 143.5 µg per deciliter (6.9 µmol per liter; normal, less than 10.0 deciliter (6.9 µmol per liter; normal, less than 10.0 µg per deciliter [0.5 µmol per liter]). The joint space µg per deciliter [0.5 µmol per liter]). The joint space was opened, and fragments of the bullet were seen was opened, and fragments of the bullet were seen to be invading the synovium. Treatment with EDTA to be invading the synovium. Treatment with EDTA and dimercaprol was initiated immediately. The lead and dimercaprol was initiated immediately. The lead level decreased to 30 µg per deciliter (1.4 µmol per level decreased to 30 µg per deciliter (1.4 µmol per liter), and the patient's symptoms resolved. He was liter), and the patient's symptoms resolved. He was lost to follow-up but presented again five months lost to follow-up but presented again five months later with recrudescent symptoms and a serum lead later with recrudescent symptoms and a serum lead level of 116 µg per deciliter (5.6 µmol per liter). His 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 Treatment with succimer and surgical exploration were recommended on an outpatient basis. The were recommended on an outpatient basis. The patient was lost again to follow-up. patient was lost again to follow-up.

CaseCase

►An 87-year-old woman with iatrogenic An 87-year-old woman with iatrogenic Cushing's syndrome presented with Cushing's syndrome presented with fever and shock. She had had diarrhea fever and shock. She had had diarrhea for several days, but after the use of for several days, but after the use of antidiarrheal agents, she had become antidiarrheal agents, she had become constipated. On the day before constipated. On the day before admission, she had begun having admission, she had begun having diffuse abdominal pain. A plain-film diffuse abdominal pain. A plain-film radiograph (Panel A)radiograph (Panel A)

Ruptured diverticulitisRuptured diverticulitis

► X-ray showed the falciform-ligament sign, which was X-ray showed the falciform-ligament sign, which was visible as a linear density (arrow); a nasogastric tube visible as a linear density (arrow); a nasogastric tube was also visible. The radiograph also showed the was also visible. The radiograph also showed the Rigler sign (also known as the double-wall sign), Rigler sign (also known as the double-wall sign), indicating the presence of gas on both sides of the indicating the presence of gas on both sides of the bowel wall (arrowheads). A computed tomographic bowel wall (arrowheads). A computed tomographic scan of the abdomen showed the falciform ligament scan of the abdomen showed the falciform ligament (Panel B, arrow), outlined by intraperitoneal free air. (Panel B, arrow), outlined by intraperitoneal free air. Pneumoperitoneum was diagnosed. Laparotomy was Pneumoperitoneum was diagnosed. Laparotomy was performed, and diverticulitis with perforation of the performed, and diverticulitis with perforation of the sigmoid colon was found. Despite resection of the sigmoid colon was found. Despite resection of the lesion and colostomy, the patient died from multiple-lesion and colostomy, the patient died from multiple-organ failure 10 days after admission organ failure 10 days after admission

CaseCase

► A 76-year-old woman was admitted with an A 76-year-old woman was admitted with an exacerbation of chronic obstructive pulmonary exacerbation of chronic obstructive pulmonary disease. Her condition improved with bronchodilators, disease. Her condition improved with bronchodilators, prednisolone, an antibiotic, oxygen, and supportive prednisolone, an antibiotic, oxygen, and supportive measures. Two years previously, she had presented measures. Two years previously, she had presented with vertebral compression fractures, Bence Jones with vertebral compression fractures, Bence Jones proteinuria, and IgG paraproteinemia. The diagnosis of proteinuria, and IgG paraproteinemia. The diagnosis of multiple myeloma had been confirmed by examination multiple myeloma had been confirmed by examination of the bone marrow, which showed 36 percent of the bone marrow, which showed 36 percent atypical plasma cells. The patient had tolerated atypical plasma cells. The patient had tolerated chemotherapy poorly and was treated only with chemotherapy poorly and was treated only with opiates and sodium clodronate. Three days after the opiates and sodium clodronate. Three days after the present admission, pain and swelling developed in her present admission, pain and swelling developed in her right arm without previous trauma. right arm without previous trauma.

Pathologic fracturePathologic fracture

►Radiographs of the arm showed a Radiographs of the arm showed a displaced fracture of the right humerus displaced fracture of the right humerus and multiple lytic lesions (Panels A and and multiple lytic lesions (Panels A and B), which are typical of myeloma. The B), which are typical of myeloma. The serum calcium level was normal, but the serum calcium level was normal, but the alkaline phosphatase level was raised, at alkaline phosphatase level was raised, at 390 U per liter (normal range, 70–300). 390 U per liter (normal range, 70–300). The patient underwent intramedullary The patient underwent intramedullary pinning of the fracture. She died on the pinning of the fracture. She died on the fifth postoperative day after cardiac fifth postoperative day after cardiac arrest. arrest.

CaseCase

► A 73-year-old man with a history of colon A 73-year-old man with a history of colon cancer presented to the emergency cancer presented to the emergency department with a three-day history of pain in department with a three-day history of pain in the right hip, without a history of trauma. He the right hip, without a history of trauma. He was admitted to the coronary care unit for was admitted to the coronary care unit for management of a third-degree atrioventricular management of a third-degree atrioventricular block. He was febrile, with leukocytosis; blood block. He was febrile, with leukocytosis; blood cultures were ordered, and antibiotic therapy cultures were ordered, and antibiotic therapy was begun. Seven hours after admission, was begun. Seven hours after admission, swelling of the right leg was noticed, along with swelling of the right leg was noticed, along with blisters and soft-tissue crepitus. blisters and soft-tissue crepitus.

Clostridium septicum sepsisClostridium septicum sepsis

►A computed tomographic scan showed A computed tomographic scan showed gas and extensive myonecrosis in the gas and extensive myonecrosis in the right leg (Panel A) and pelvis (Panel B). right leg (Panel A) and pelvis (Panel B). According to the patient's advance According to the patient's advance directive, emergency amputation was directive, emergency amputation was not pursued. The patient died three not pursued. The patient died three hours later. The blood cultures later hours later. The blood cultures later grew grew Clostridium septicumClostridium septicum. .

CaseCase

►A 62-year-old woman received six A 62-year-old woman received six cycles of docetaxel chemotherapy cycles of docetaxel chemotherapy during a six-month period for recurrent during a six-month period for recurrent metastatic breast cancer. She had metastatic breast cancer. She had completed treatment four weeks completed treatment four weeks before this photograph was taken. Six before this photograph was taken. Six evenly spaced, transverse lines were evenly spaced, transverse lines were noted on all her fingernails. noted on all her fingernails.

Beau’s linesBeau’s lines

►Beau's lines are transverse Beau's lines are transverse depressions in the nail plate caused by depressions in the nail plate caused by temporary cessation of cell division in temporary cessation of cell division in the proximal nail matrix. The condition the proximal nail matrix. The condition may be caused by local disease of the may be caused by local disease of the nail fold or a systemic insult, such as nail fold or a systemic insult, such as an illness or the administration of a an illness or the administration of a drug. drug.

CaseCase

►A 16-year-old boy presented with a A 16-year-old boy presented with a two-year history of hyperpigmentation two-year history of hyperpigmentation of the skin; his sclera were unaffected. of the skin; his sclera were unaffected. He is shown with his mother for He is shown with his mother for comparison. What is the diagnosis? comparison. What is the diagnosis?

ArgyriaArgyria► The medical mystery in the October 7 issueThe medical mystery in the October 7 issue11 involved a involved a

16-year-old white boy who presented with generalized 16-year-old white boy who presented with generalized argyria after ingesting a silver-containing dietary argyria after ingesting a silver-containing dietary supplement for approximately two years. The supplement for approximately two years. The supplement was packaged so that it was identical to supplement was packaged so that it was identical to bottled water and was touted as a preventive for bottled water and was touted as a preventive for everyday infections. Pigmentary changes began on the everyday infections. Pigmentary changes began on the boy's cheeks and progressed to involve his entire body boy's cheeks and progressed to involve his entire body within one year. Because of his graying complexion, a within one year. Because of his graying complexion, a workup was performed for Addison's disease and workup was performed for Addison's disease and cyanosis. All the results were negative or normal. There cyanosis. All the results were negative or normal. There was no evidence of neuropathy or seizures. was no evidence of neuropathy or seizures.

► The serum silver level was markedly elevated, at 209 The serum silver level was markedly elevated, at 209 ng per millimeter (normal range, 0 to 14). These ng per millimeter (normal range, 0 to 14). These findings are consistent with the diagnosis of findings are consistent with the diagnosis of generalized argyria. generalized argyria.