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Hepatobiliary diseases
A 60-year-old woman had been diagnosed with Gallstone five years previously. The patient's symptoms were relieved following anti-inflammatory therapy for one week. She was now admitted to hepatobiliary surgical with recurrent right upper quadrant pain and itching all over her body for one month.Zosteriform erythematous rash
A 70-years-old male presented with unilateral rash below the right axilla of one-month duration. The patient gave history of cough with shortness of breath for the last two years and pain in the right axilla radiating to the right shoulder for five months. General examination revealed mild pallor, grade 1 clubbing and multiple hard, fixed, non-tender right cervical and supra-clavicular lymph nodes. On cutaneous examination, the lesions were in the form of multiple pseudo vesicular and papulonodular lesions studded over an erythematous, hard, indurated plaque present in a dermatomal fashion along T2 and T3 dermatome below the right axilla (Fig. 1).Peculiar form of rapidly progressive pneumonia in healthy man
A healthy 53–years-old male presented to ED with fever and arthralgia for two days. On admission the patient was alert, oriented, febrile; thoracic exam revealed crackles in left basal area. Blood exams showed lymphocytopenia (490/mmc), thrombocytopenia, increased C-reactive protein (263 mg/l) with procalcitonin 0.37 ng/ml; chest CT scan revealed multifocal pneumonia (Fig.1a). Blood cultures and urinary antigen test for Legionella were performed, the last was negative. Empiric therapy with piperacillin-tazobactam and levofloxacin was started.A plaque on the right retropharyngeal wall
A 25-year-old unmarried man was referred because of 1-week history of mildly sore throat, without association of systemic symptoms. He had an oral sex with a man 3 weeks before his presentation. His-past medical histories were unremarkable. Examination showed a well-delimited plaque with central ulceration on the right retropharyngeal wall, covered with white pseudomembranes and surrounded by erythema (Figure 1). No other rashes were detected elsewhere. Laboratory tests for complete blood cell count, erythrocyte sedimentation rate, biochemistry profiles, C-reactive protein, anti-nuclear antibodies, auto-antibodies and HIV were either within normal limits or negative.Itchy papules on the back and neck of a young woman
A 19-year-old female, healthy by nature, developed viral gastroenteritis, which cleared within a few days. A month later, she developed symptoms such as thirst, polydipsia, polyuria, and weight loss. Simultaneously, itchy papules appeared on her back and shoulders. A dermatologist prescribed antihistamines as her symptoms worsened, but no improvement was observed.Dyspnea with chylothorax: Importance of examining the nails
A previously healthy 53-year-old man presented to our department with 2 months of dyspnea. Lung examination revealed a left-sided pleural effusion confirmed on the chest radiograph (Fig. 1A) and CT scan. Physical examination was remarkable for dystrophic fingernails and toenails appeared 3 years ago, with yellowish discoloration, thickening of the nail plates, enhanced transverse curvature of some nails and the absence of lunula and cuticle (Fig. 1B,1C). No lymphedema was present. The pleural fluid appeared milky white with triglycerides > 110 mg/dL and the presence of chylomicrons, consistent with a chylothorax.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.
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