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Endocarditis with disseminated thromboembolisms and hypercoagulable state
Ten months after radical cystectomy and adjuvant chemotherapy for an anaplastic giant cell bladder cancer (pT2N2M0), a 41-year-old woman presented with a 4-week history of intermittent claudication, lower right back pain, transient monocular vision loss, and fever.Woman in a coma
A 49-year-old woman of unremarkable past health was found comatose in her car. Blood pressure was 130/70 mmHg, pulse 80 beats per minute. There was no circumstantial evidence of drug overdose. Urine toxicology tested negative. Electrocardiography (ECG) showed anterolateral ST-segment elevation (Fig. A). Head computed tomography (CT) of demonstrated no intracranial pathology. Non-sustained ventricular tachycardia developed shortly. Echocardiography revealed left ventricular dysfunction with akinesia of mid-ventricular walls but sparing basal and apical segments (Fig. B, video).Blurred vision: Hitting the bull's eye
An 18-year-old female presented with progressive blurred vision in both eyes. On evaluation, her uncorrected visual acuity was 20/400 in both eyes. Slit lamp examination revealed bilateral supero-temporal dislocated lens splitting the pupillary axis with visible stretched zonules (Fig. 1). Intraocular pressure and posterior segment evaluation were normal. Systemic examination revealed a late systolic murmur at the apex.Acute necrosis of the corpus callosum
A 58-year-old man with a history of alcohol use disorder was admitted for apathy, confusion and aphasia of abrupt onset. In addition, clinical examination revealed a tetrapyramidal syndrome. Blood analyses showed macrocytosis, mildly elevated liver transaminase levels and hypoalbuminemia. Toxicological screening for ethanol, opiates, cannabinoids, amphetamines, cocaine, and methadone were negative. A brain magnetic resonance imaging (MRI) was performed and showed bilateral cytotoxic lesions involving the splenium of the corpus callosum depicted by T2/fluid attenuated inversion recovery (FLAIR)-weighted hyperintensities (panel A) with restricted diffusion (hypersignal on b1000 diffusion-weighted sequences and hyposignal on apparent diffusion coefficient map, panels B and C respectively) (Fig. 1).A woman with purple-brown skin lesions after immunosuppressive therapy
An 80-year-old Greek woman presented to our clinic with fatigue and new-onset skin lesions around her neck, enlarging and multiplying over the previous 6 weeks. The lesions were asymptomatic but had been causing the patient considerable embarrassment. She had no fever, chills, night sweats or weight loss. Six months earlier, she had required treatment with corticosteroids and rituximab (375 mg/m2 of body-surface area per week for 4 weeks) for severe thrombocytopenia associated with autoimmune hemolytic anemia (Evans’ syndrome).A « tipical » but rare cause of neck pain
A 34-year-old man with medical history of familial deafness presented to the emergency department for an acute left cervicalgia and painful jaw for one week. He reported a context of recent physical effort because of house moving. He had already performed a cervical echography, which showed a thickening of the wall of the left common carotid artery (panel A) without disturbance of the vascular flow on Doppler (panel B). At presentation, vital parameters were normal with symmetrical blood pressure measurement, and no fever.Not always “straight ahead” – A surprising cause of acute kidney injury
A 16-year-old girl presented with a complaint of vomiting and abdominal pain, which appreared immediately following hair straightening treatment. Her medical history was remarkable for untreated cutaneous psoriasis. She denied any use of over-the-counter medications, herbal products or illicit drugs.A red herring electrocardiogram
A gentleman in his 50s presented with atypical chest pain for the last 3 months. He had no prior comorbidities. Cardiovascular system examination was unremarkable. Baseline electrocardiogram is shown in Fig. 1A. The primary care physician labelled the electrocardiogram as ST-segment elevation myocardial infarction and advised immediate coronary angiography and intervention. The electrocardiogram was reviewed by the cardiology team, and a repeat electrocardiogram was advised, shown in Fig. 1B.Dorsal pigmentation of tongue
A 56-year-old male patient with diabetes presented with black discolouration of the tongue 7 days after extraction of two mandibular molars (Fig. 1). Prophylactic oral amoxicillin 750 mg was started a day before the extraction and was continued for 4 days after extraction. Post-extraction, because of severe pain in the socket, he did not eat properly or maintain good oral hygiene. We collected a sample from the tongue lesion and performed a cytological analysis. Fragments of filiform papillae with markedly enhanced keratinisation were observed on microscopic examination of the scraped specimen.“Milking” the way to diagnosis
A 43-year-old non-smoker man presented to the emergency department with exertional dyspnoea and left pleuritic pain lasting for 3 days. He denied fever and cough and described a history of pulmonary embolism, deep venous thrombosis and multiple opportunistic infections, namely angio-invasive pulmonary aspergillosis and pulmonary and brain Nocardia sp. Infections, the brain abscess requiring surgical excision and causing squeal epilepsy. He was chronically medicated with rivaroxaban 20 mg id, Levetiracetam 500 mg bid and co-trimoxazole 960 mg bid 3 times a week.Generalized erythematous scaly rash after glucocorticoids
A 65-years-old woman with a medical history of idiopathic thrombocytopenic purpura and psoriasis in treatment with topical glucocorticoids presented with a three-month history of burning, generalized erythematous, scaly rash, and chills. A few weeks before the rash, the patient presented petechiae on her thighs due to a low platelet count (28.000 platelets per microliter), for which she started treatment with prednisone 25 mg/week. The rash was initially treated with topical ointments including clobetasol, urea, salicylic acid, ammonium lactate, and propylene glycol without improvement.Interstitial pneumonia with subpleural sparing and weight loss
A 36-years-old man from West Africa was admitted to our ED with respiratory failure and a 15 days history of fatigue and peevish cough. He reported watery diarrhea and a 30 kg weight loss in the last three months. In his clinical history, he did not make any recent trips abroad, nor did he reported any chronic disease, any contact with domestic or wild animals or any drug abuse. He received a complete vaccination course for SARS-CoV-2. On the physical examination we observed low-grade fever, bilateral diffused crackles on chest auscultation, latero-cervical and supra-clavicular lymphadenopathies and a maculopapular rash spread on the upper limbs and trunk.Malar rash with pancytopenia
A 35-year-old Japanese man presented with a four-month history of persistent flushing and persistent high fever (≥38 °C) for the past several weeks.A diabetic patient with finger gangrene
A 72-year-old male with type 2 diabetes and end-stage renal disease (ESRD) receiving hemodialysis (HD) for 10 months presented to hospital with one week of worsening pain, swelling, and bluish-black discoloration in the second and fourth right, and third left fingers. Preceding trauma to the digits had not occurred. Physical examination revealed dry gangrene in the digits (Fig. A), but no necrotic lesions in the lower limbs. An arteriovenous fistula (AVF) was created in his left forearm. Laboratory examinations showed fairly controlled diabetes (HbA1c 7.3%, post-prandial blood glucose 175 mg/dL), leukocytosis, and elevated C-reactive protein.Necrotic ulcers in an immunocompromised patient
A 68-year-old man presented to dermatology clinic with extensive ulcers for one-week duration. Patient had underlying uncontrolled Type II Diabetes Mellitus and pemphigus foliaceous. His medications were metformin 1 g twice daily, prednisolone 30 mg daily and azathioprine 50 mg daily. He denied fever, prior trauma or insect bites.An unusual cause of severe watery diarrhea
A 75-year-old man presented to the gastroenterology department with a 4-week history of severe watery diarrhea (at least 20 times a day) and appetite loss. He had been taking amlodipine 5 mg once daily for 12 years and olmesartan 20 mg once daily for 11 years because of hypertension. His vital signs were stable, and the abdominal examination was normal. He was neither anemic nor icteric. His body weight decreased by 5 kg during the last 1 month. Laboratory evaluation showed that serum creatinine level and serum uric acid level were elevated at 1.46 mg/dL (range 0.6–1.1) and 12.1 mg/dL (range 3.6–7.0), respectively.Heart failure: An autopsy case
A 78-year-old man with a history of bilateral carpal tunnel syndrome was admitted to our hospital with congestive heart failure. On physical examination a systolic ejection murmur was documented. B-type natriuretic peptide and Troponin I were elevated (8342 pg/ml and 0,2 ng/dl respectively).Persistent fever, bloody diarrhea, and skin necrosis in a young female
A 28-year-old Caucasian female presented with a two-month history of low-grade fevers, abdominal cramps, occasional bloody stools, weight loss, high C-reactive protein (234 mg/L), and with a newly-onset painful bullous skin change on the right hand (Fig. 1A). Her prior medical history included inflammatory bowel disease (IBD) successfully managed with peroral mesalazine. At the current admission, broad spectrum antibiotics (meropenem and vancomycine) were empirically started; however, the fever persisted, the blood and stool cultures were repeatedly negative, as was the skin swab.A HIV-positive subject with dermatomal and generalized vesicular skin lesions
A 58-year old man with HIV infection diagnosed in 2018 presented in July 2021 with a 7-day history of vesicular skin lesions localized to the right side of abdomen and diffuse vesicular lesions on the face, trunk, abdomen and both arms (Fig. 1A e 1B).Skin rash following amoxicillin treatment
A 26-year-old woman presented with a chief complaint of nausea for 2 days. On the previous day, she had been diagnosed with tonsilitis by her previous doctor because of fever and sore throat, and had started treatment with amoxicillin. On examination, bilateral enlarged tonsils with white spots were observed. Blood tests showed elevation of hepatic transaminase and lactate dehydrogenase levels. We suspected acute hepatitis because of her recent consumption of undercooked beef and elevation of hepatitis type A antibody.Diffuse pulmonary ill-defined centrilobular opacities: Not only bronchiolitis
metastatic pulmonary calcificationHemolytic anemia in a patient with cirrhosis: Hiding in the smear!
A 41-year-old female with alcoholic liver cirrhosis presented to the emergency department with worsening abdominal pain and progressively worsening shortness of breath for two weeks. Laboratory studies revealed a hemoglobin of 4.2 g/dL (reference range 12.0–15.5 g/dL), hematocrit 14.1% (reference range 36–44%), red cell distribution width 21.8% (reference range 12.2–16.1 g/dL), total bilirubin 6.2 mg/dL (reference range 0.1–1.0 mg/dL), indirect bilirubin 3.5 mg/dL (reference range 0.2–0.8 mg/dL).Chilblain-like acral lesions
A 70-year-old Asian female presented to the rheumatology clinic with a 5-year history of tender papules on fingers and toes aggravated under cold exposure. She also reported polyarthralgia and Raynaud phenomenon for 3 years. On examination, red painful papules were present on index fingers, middle fingers, thumbs, and toes, with central crust and ulceration (Fig. 1A-D). The toenail plates were partially or completely destroyed with hyperkeratosis of the nail bed (Fig. 1D). The extremities were cool to the touch.Vanishing tumor of the stomach
A previously healthy Japanese 36-year-old man presented to the gastroenterology department with a 2-day history of acute-onset severe epigastric pain after eating flounder sashimi. His vital signs were normal. Emergency endoscopy showed a submucosal tumor-like lesion with mild erosions in the upper body of the stomach (Fig. 1, Panel A). Further observation revealed a whitish linear worm penetrating the mucosa at the edge of the lesion (Fig. 1, Panels B and C). What is the diagnosis?
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