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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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