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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?Granulomatous lesions of the skin: Do not fall into the trap
A 51-year-old woman was referred to investigate skin lesions present on her backside.A man with fever and aortitis
A 54-year-old man presented with a chief complaint of fever and pain around the left clavicle. He had a primary germ cell tumor of the mediastinum and had been undergoing chemotherapy for approximately six months. To prevent myelosuppression, pegfilgrastim was administered after each chemotherapy session. Pegfilgrastim was administered 4 days before the onset of fever and pain. On examination, he had a body temperature of 38.1 °C and pain in the left arm. Laboratory findings showed elevated C-reactive protein level (19.4 mg/dL).Chest pain in a Ukrainian woman living in Italy immediately after news of homeland Russian invasion.
A 54-year-old Ukrainian woman without cardiovascular risk factors presented with left-sided chest pain. The symptom appeared as soon as she got the news from her relatives in Ukraina of the beginning of the Russian bombing on February 24th, 2022. Physical examination was negative. The ECG showed sinus rhythm with slight elevation of the ST segment in the precordial leads (Figure. A). Laboratory testing revealed an elevated high-sensitivity troponin I level (4929 ng/L), with normal renal function and Nt-proBNP levels.(Figure. B)Abdominal aortic aneurysm and gas in the kidney in a diabetes patient
A 65-year-old man was admitted to our emergency department with a 12-day history of nausea and a progressive backache, and an 8-day history of dysuria with low-grade fever. He had been diagnosed with diabetes mellitus 20 years previously, and had a history of poor glycemic control.A pretibial skin lesion in a patient with type 1 diabetes mellitus
A 17-years-old woman with type 1 diabetes mellitus known since the age of 9 was admitted in the high-dependency unit for diabetic ketoacidosis. She had a history of poor glycemic control and many previous hospitalizations. Two years earlier, she reported the appearance of a red-brown, telangiectatic and hyperpigmented patch, localized in the pretibial skin of her left leg (Fig. 1). The lesion was well-circumscribed with erythema at the periphery. Two months before a spontaneous ulceration appeared in the middle of the lesion, apparently without any trauma.Palpitations in a middle-aged male… Searching a needle in a haystack
A gentleman in his 50s presented with episodes of intermittent palpitations which were self-limiting. His symptoms were not related to exertion and had short duration with sudden onset and offset. He had no prior comorbidities and denied history of syncope. Cardiovascular system examination was unremarkable. Baseline electrocardiogram is shown in Fig. 1A. The electrocardiogram during an episode of palpitations requiring urgent hospitalization is shown in Fig. 1B. He was treated with intravenous amiodarone infusion and subsequently switched to oral anti arrhythmic medications.A diagnosis at hand
A 45-year-old man was found unconscious on the sidewalk and brought to the Emergency Department. He could not provide anamnestic information, but the hospital electronic archive revealed he was homeless and had a history of excessive alcohol consumption (250–300 g daily intake). He suffered from depressive disorder and had attempted suicide 9 years before by caustic ingestion, which led to total gastrectomy and esophagojejunal anastomosis. Physical examination revealed a Glasgow Coma Scale score of 8 with no focal neurological signs.Segmental anhidrosis and heat intolerance
A 62 year-old woman with no previous medical history presented to the Dermatology department with sweating disorders for several years. She described segmental hyperhidrosis and hyperemia while running. This excessive sweating occurred in the left hemiface, the left half of the trunk, the left upper limb and the right lower limb (Fig. 1A). This was associated with heat intolerance and previous faintness during sport. She did not describe any chest pain before faintness and the cardiac auscultation was normal.Acute abdominal pain following esophagogastroduodenoscopy
A 48-year-old man developed abdominal pain and vomiting twelve hours after esophagogastroduodenoscopy. He had lost 4.4 kg while being treated for a gluteal muscle abscess two months prior, and then underwent surgery for gastric perforation one month prior to admission. His-postoperative course was uneventful and endoscopy showed a healed benign gastric ulcer. His-past medical history included schizophrenia and poorly controlled type 1 diabetes. Prescribed medications included insulin and vonoprazan.Darier's sign
A 38-year-old Caucasian male presented with a ten-year history of back pains, dyspepsia and allergic rhinitis and conjunctivitis treated with non-steroidal antirheumatic drugs and on-demand antihystamines. During this time, slowly progressive brownish freckles and patches on the trunk and the extremities began to occur. Because the patient was an entrepreneur with a busy working schedule, he did not pursue any further medical workup. However, due to increasing back pains, he underwent regular massages, and after these treatments, the skin on the back usually became swollen, itchy and red (Fig. 1A), necessitating the use of antihystamines.Autosplenectomy
A 30-year-old woman manifested fatigue and high fever. She was diagnosed with antiphospholipid antibodies positive-systemic lupus erythematosus (SLE), but she had never demonstrated any serious organ involvements including nephritis and thrombosis, and had never received immunosuppressants. Physical examination demonstrated costovertebral tenderness and pyuria, and she was treated with cefaclor for uncomplicated pyelonephritis. After ten days, she visited our emergency room with the same manifestations and was improved equally by cefaclor.An unusual cause of colitis
An 81-year-old Japanese woman presented to the author's department with acute abdominal pain and nausea. Laboratory evaluation showed a white-cell count of 13,270 cells/mm3 (Reference range, 3500–8500) and a C-reactive protein of 2.37 mg/dL (Reference range, 0.00–0.30). Non-enhanced computed tomography (CT) revealed calcification of mesenteric veins and thickening of the wall of the ascending and transverse colon (Fig. 1, Panel A). Colonoscopy showed edematous mucosa with erosions in the right hemicolon (Fig. 1, Panel B).Multiple organ nodules or polyps
A 48-year old female presented with intermittent epigastric pain for 2 months accompanied with belching, nausea, vomiting and occasionally melena. She had endometrial polypectomy and thyroidectomy in 2018. A resection of nodules in the right lung was performed in 2019. In addition, she had a history of breast cyst. The patient had no clear family history of any cancerous disease.Multiple tumors on the pleura with pleural effusion mimicking malignant mesothelioma
A 68-year-old male presented with left chest pain and was referred to our hospital due to left-sided pleural effusion on a chest X-ray (Fig. 1 A). Initial laboratory data included a white blood cell count of 5650/μL and a C-reactive protein level of 0.36 mg/dL. CT during drainage of bloody effusion showed multiple tumors on the left chest wall and diaphragm, and residual effusion on the dorsal side, without hilar or peripheral lung lesions (Fig. 1B, C). No extrathoracic tumors were detected. Although effusion cytology was positive for malignancy, the histological type could not be determined even with cell block specimens.New onset rectal bleeding
A 36-year-old male with no significant past medical history presented to the emergency department for new onset hematochezia. Prior to arrival, the patient reported having five episodes of passing bloody stool and frank blood without associated abdominal or rectal pain, nausea, vomiting, or fever. He denied rectal trauma including anal receptive intercourse. He was not on any prescription medications. On physical examination, his vital signs were normal. His abdominal examination was unremarkable, and digital rectal examination revealed an empty rectal vault.Stuck in my head as an old song
A 61-year-old piano man was admitted to the emergency department for loss of consciousness, aphasia and Glasgow coma scale of 13 points. His past medical history included hypertension, non-insulin-dependent diabetes mellitus and occasional inhalation of cocaine.“Comb and Target signs” in abdominal CT in patients with purpura
A 56-year-old woman complained of nausea, abdominal pain, and bloody diarrhea 10 days prior to the day of consult in our institution. Her abdominal pain worsened and was accompanied by joint pain for several days, prompting a consult at our hospital. Physical examination revealed strong rebound tenderness in the right lower abdomen and the presence of multiple palpable purpuras in the lower extremities (Figure C). Laboratory test results revealed a high C-reactive protein level of 1.21 mg/dL, as well as normal renal function and urinary findings.COVID-19 vaccination and a severe pain in the neck
A 40-year-old woman developed malaise and severe anterior neck pain 12 hours after the second dose of COVID-19 mRNA vaccine (Pfizer/BioNTech). The pain peaked and plateaued at the fourth post-vaccination day. Her GP prescribed ibuprofen and azithromycin for presumed bacterial pharyngitis, with no avail. She visited our endocrine clinic 26 days post-vaccination with ongoing symptoms including bony aches, exhaustion, emotional lability, palpitations and hyperhidrosis. Upon general examination she was haemodynamically stable but with significant neck tenderness (visual acuity score = 8/10).An unusual cause of heart failure
A 59 year-old lady presents to the hospital with complaints of exertional shortness of breath for the past few months. This was associated with orthopnea and lower limb swelling. On examination, she had bibasal crepitations on chest auscultation and bipedal oedema to the ankles. She had nil significant past medical history or family history of cardiac disease. Her electrocardiogram revealed normal sinus rhythm with nil ST segment changes. B-type Natriuretic Peptide was raised at 2,430pg/ml and her chest radiograph showed cardiomegaly with signs of pleural effusion.Facial hypertrichosis, hyperpigmentation, and hepatosplenomegaly
A 51-year-old woman presented for evaluation of new-onset of facial hypertrichosis, hyperpigmentation and blistering on the back of the hands with sunlight exposure, additionally she referred change of urine to reddish coloration; previously she was being studied for anaemia and neutropenia, and received multiple blood transfusions as treatment. She has no significant medical history. Physical examination demonstrated scars in sun exposed areas, evident hypertrichosis in her cheeks, hepatosplenomegaly, and pink fluorescence of the urine with Wood's lamp illumination (WLI) (Fig. 1).The truth comes out of children's mouths
A 16 year-old patient of Hawaiian ancestry was admitted for confusion in April 2018. He had no relevant past medical history except he went to the dentist few months ago for patchy darkish pigmented macules of the oral mucosa (Fig. 1A). His mother reported that he complained of pharyngitis and diarrhoea since one week. Blood pressure, body temperature and heart rates at admission were 80/50 mm Hg, 38.3°C and 163 beats per min respectively. Oxygen saturation and glycemia were estimated to 100% room air and 3.2 mmol/L using pulse oximeter and glucometer respectively.Subarachnoid hemorrhage as the key to the diagnosis
A 70-year-old woman was admitted at the emergency department due to abdominal pain progressing over the last six hours. She had been feeling sick for the last month, with nausea and persistent fever. Initial work-up revealed mild anemia, elevated inflammatory markers and an unremarkable abdominal ultrasound. While at the emergency department, she suddenly progressed to coma, with admission to the intensive care unit. Both cranial CT scan and angiography were conducted, showing a cortical artery aneurysm surrounded by a sulcal subarachnoid hemorrhage on the left parietal convexityFig. 1.Skin lesions, weakness, and axillary adenopathies in a 44-year-old woman
A 44-year-old woman was referred to the Internal Medicine clinic with a six months history of generalized, worsening myalgia, Raynaud's phenomenon and muscular weakness. These symptoms were associated with asthenia and a weight loss of 5 Kg. Physical examination revealed a stony-hard left axillary lymphadenopathy, bilateral 3/5 quadriceps strength and hyperkeratotic skin lesions depicted in Fig. 1; the remainder of the examination, including breast examination, was normal. Blood tests showed elevated creatinphosphokinase (6363 UI/L), lactate dehydrogenase (779 UI/L), aspartate aminotransferase (156 UI/L), alanine amininotransferase (183 UI/L), and aldolase (159 UI/L); the rest of the tests were anodyne.Man with pruritic rash
A 41-year-old previously healthy man presented with a 3-day history of fevers, headache, abdominal pain, and pruritic rash. The rash began on his forehead and extended to the rest of his body. He had been taking amoxicillin, which he was prescribed at an urgent care, and applying calamine lotion with no improvement in symptoms. He did not take any medications or supplements, including steroids or other immunosuppressive therapies. He did not have recent travel, sick contacts, or tick exposure. Review of systems was negative for changes in vision, sore throat, cough, dyspnea, nausea, vomiting, diarrhea, myalgias, weakness, or dysuria.Lupus pernio: Skin manifestation of systemic disease
62-year-old woman presented to our institution with the chief complaint of slowly progressive exertional dyspnea over the preceding two years in conjunction with a cough and facial rash. Physical examination was remarkable for erythematous to violaceous nodules and plaques around eyes, over eyelids and over the nose (Fig. 1A). Complete blood count, comprehensive metabolic panel, erythrocyte sedimentation rate and C-reactive protein were unremarkable. Computerized tomography(CT) of chest Innumerable groundglass nodules again identified in bilateral lungs as well as scattered areas of tree-in-bud pattern (Fig. 1B).
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