FEATURED IMAGES IN CLINICAL MEDICINE
Web-only Images in Clinical Medicine have been published monthly since August 2001 and weekly since July 2003. Click on any graphic below to view the full article. For more information, see the editorial, Internet-Only Publication.
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Gossypiboma in the Pouch of Douglas
This 63-year-old woman presented with vague pelvic and back pain. She had undergone laparascopic surgery of the fallopian tubes 27 years earlier.
Possover M.
N Engl J Med 2008;359:e9, August 21, 2008
Imaging of Thebesian Venous System
During left ventriculography in this 46-year-old man with hypertrophic cardiomyopathy, contrast material was injected into thebesian veins. Thebesian veins are small, valveless direct connections between the coronary arteries or venous system and the chambers of the heart.
Singhal S., Khoury S.
N Engl J Med 2008;359:e8, August 14, 2008
Allergic Bronchopulmonary Aspergillosis
This 26-year-old man who had a long history of poorly controlled asthma was admitted for an exacerbation. His IgE level was 21,494 IU per milliliter.
Chen T.-H., Hollingsworth H.
N Engl J Med 2008;359:e7, August 7, 2008
Horizontal Pendular Nystagmus in a Patient with Ocular Albinism
This 32-year-old woman with ocular albinism presented with a congenital horizontal pendular nystagmus. She had no cutaneous manifestations of albinism. (See video.)
Teitel A.D., Rubin J.
N Engl J Med 2008;359:e5, July 31, 2008
Dynamic Tumor Staging
In this 54-year-old man with a mass in the right lower lobe, there was concern about chest-wall invasion. A real-time echo changed the diagnosis from stage IIb to stage Ib. (See video.)
Park C.M., Goo J.M.
N Engl J Med 2008;359:e4, July 24, 2008
Vitiligo and Cutaneous Melanoma
This 58-year-old woman presented with white facial patches that had progressively increased in size (shown under Wood’s light). There was also a 2-cm gray lesion on the right leg and inguinal adenopathy.
Redondo P., Del Olmo J.
N Engl J Med 2008;359:e3, July 17, 2008
Bifid Uvula and Aortic Aneurysm
This 24-year-old man had a family history of aortic disease. The triad of craniofacial abnormalities, aortic aneurysm, and bifid uvula suggested a diagnosis of Loeys–Dietz syndrome.
Vilacosta I., Cañadas Godoy V.
N Engl J Med 2008;359:e2, July 10, 2008
Bilateral Kidney Calcifications
This 37-year-old man was given a diagnosis of renal tubular acidosis at 9 years of age but had no medical follow-up or treatment for 22 years.
Serrano A., Batlle D.
N Engl J Med 2008;359:e1, July 3, 2008
Spontaneous Thrombolysis of an Obstructed Mechanical Aortic Valve
In this 28-year-old man with heart failure and marked jugular venous distention, fluoroscopy confirmed immobilization of one aortic prosthetic valve leaflet. Repeat fluoroscopy 6 months later revealed normal bileaflet motion of the aortic-valve prosthesis. (See videos.)
Wake N., Desai A.S.
N Engl J Med 2008;358:e31, June 26, 2008
Bladder Foreign Body
This 35-year-old woman with bipolar disorder was found wandering with disorganized speech. The patient said that she had a nail in her uterus.
Corcoran W.E., Phifer N.
N Engl J Med 2008;358:e29, June 19, 2008
Severe Kyphosis
This 89-year-old woman was admitted with hypercapnic respiratory failure. She had a long history of osteoporosis and multiple vertebral compression fractures.
Blechacz B., Gajic O.
N Engl J Med 2008;358:e28, June 12, 2008
Bilateral Peritonsillar Abscesses
This 19-year-old woman presented with a 10-day history of odynophagia, voice changes, and fever. She had been treated with azithromycin and prednisone for pharyngitis.
Fiechtl J.F., Stack L.B.
N Engl J Med 2008;358:e27, June 5, 2008
Severe Constipation
This 46-year-old man with cerebral palsy presented with difficulty in breathing. He was admitted to intensive care with a diagnosis of sepsis.
Cumbo-Nacheli G.
N Engl J Med 2008;358:e26, May 29, 2008
Starr–Edwards Heart Valves
This 67-year-old woman presented with dyspnea and severe tricuspid regurgitation. The mitral and aortic valves from 38 years earlier were functioning normally (see video).
Piazza N., Gregoire J.
N Engl J Med 2008;358:e24, May 22, 2008
Giant Ovarian Cyst
This 24-year-old woman presented with a history of progressive abdominal distention accompanied by early satiety and constipation.
Young T.-H., Lee H.-S.
N Engl J Med 2008;358:e22, May 15, 2008
Fluorescence Diagnosis of Subclinical Actinic Keratoses
In this 74-year-old man, actinic keratosis was diagnosed after application of topical photosensitizers.
Sanmartin O., Guillen C.
N Engl J Med 2008;358:e21, May 8, 2008
Nevus Sebaceus of Jadassohn
This 14-year-old girl noticed that a small birthmark on her scalp had started growing rapidly. It was pruritic and caused considerable emotional distress.
Ibrahim S.F., Tu J.H.
N Engl J Med 2008;358:e20, May 1, 2008
Babesiosis
This 34-year-old man had fevers to 40°C, shaking chills, and hemolytic anemia. He had had a splenectomy and recently had traveled widely.
Noskoviak K., Broome E.
N Engl J Med 2008;358:e19, April 24, 2008
Clonorchis sinensis
This 62-year-old Korean man had fever, abdominal pain, and abnormal liver-function tests. Computed tomographic scan showed dilatation of the common bile duct. After cannulation of the common bile duct, numerous worms popped out (see video).
Park D.H., Son H.-Y.
N Engl J Med 2008;358:e18, April 17, 2008
Cerebral Embolism of Probable Aortic Origin
This 70-year-old woman was admitted with acute left hemiparesis. A CT scan revealed a new calcified object in the right middle cerebral artery.
Oppenheim R.E., Felsberg G.J.
N Engl J Med 2008;358:e17, April 10, 2008
Ascariasis
This 60-year-old woman in Korea presented with vague abdominal discomfort. Colonoscopy revealed a 20-cm worm, which moved (see video).
Jang M.K., Lee K.S.
N Engl J Med 2008;358:e16, April 3, 2008
Crystalluria from Acyclovir Use
A 60-year-old man with advanced HIV was admitted because of altered mental status, fever, and seizure-like activity. Two hours after the administration of acyclovir, his urine became cloudy and white.
Mason W.J., Nickols H.H.
N Engl J Med 2008;358:e14, March 27, 2008
Spontaneous Otogenic Pneumocephalus
This healthy 54-year-old woman presented with abnormal acoustic sensations, aphasia, and visual-field disturbances. She reported no head trauma or recent infection.
Villa R.A., Capdevila A.
N Engl J Med 2008;358:e13, March 20, 2008
Green Urine
This 76-year-old man with a kidney transplant underwent radical surgery for esophageal carcinoma. He received methylene blue through his nasogastric tube to look for a possible fistula.
Stratta P., Barbe M.C.
N Engl J Med 2008;358:e12, March 13, 2008
A Medical Mystery: Epigastric Pain
This 82-year-old woman presented with respiratory symptoms, and a chest film was obtained. Six years later, she presented with epigastric pain, nausea, and vomiting. What is the diagnosis?
Murali R., Attar B.M.
N Engl J Med 2008;358:1053, March 6, 2008
Chronic Venous Insufficiency and Dystrophic Subcutaneous Calcification
This 70-year-old woman was referred for evaluation of an ulcerative lesion on her right lower leg. She had chronic venous insufficiency.
Miedinger D., Daikeler T.
N Engl J Med 2008;358:e10, February 28, 2008
Cold-Induced Urticaria
This 43-year-old woman presented with a 10-month history of an urticarial rash induced by cold, particularly when she was swimming.
Huissoon A., Krishna M.T.
N Engl J Med 2008;358:e9, February 21, 2008
Sarcoid Arthropathy
This 43-year-old woman presented with pain and stiffness in the hands and feet, having had the symptoms for 5 years. Rheumatoid arthritis had been diagnosed. Pulmonary sarcoidosis had also been diagnosed years earlier.
Ahuja A., Seetharaman M.
N Engl J Med 2008;358:e7, February 14, 2008
Blue Hives
This 77-year-old woman underwent resection of a papillary carcinoma of the right breast. Isosulfan blue dye was used to define lymphatic drainage. Blue hives developed on upper arms and chest as a result of an allergic reaction to the dye.
O’Sullivan M.J., Morrow M.
N Engl J Med 2008;358:e6, February 7, 2008
Calcified Hematoma of the Skull
This 46-year-old man presented with a hard subcutaneous mass in the forehead. The lesion had developed rapidly after a head trauma 24 years before and subsequently hardened.
Fathi A.-R., Erni D.
N Engl J Med 2008;358:e5, January 31, 2008
Renal Failure from Vitamin C after Transplantation
In this 31-year-old woman, oliguric renal allograft failure developed from widespread deposition of calcium oxalate crystals. She had a history of self-medication with vitamin C (2 g per day) while on dialysis.
Nankivell B.J., Murali K.M.
N Engl J Med 2008;358:e4, January 24, 2008
Penetrating Orbital Trauma
This 15-year-old boy presented with an inability to open his left eye after being assaulted with a pencil. A small laceration was noted.
Reddy H.S., Chang E.
N Engl J Med 2008;358:e3, January 17, 2008
Retiform Purpura
A rapidly spreading, painful rash and confusion developed in this 46-year-old man with a history of chronic alcoholism. He was febrile and hypotensive.
Lipsker D., Kara F.
N Engl J Med 2008;358:e1, January 10, 2008
Medical Mystery: Cloud Surrounding the Optic Disks
This 42-year-old man presented for a routine eye examination. What is the most likely diagnosis?
Randhawa S., Lee A.G.
N Engl J Med 2008;358:69, January 3, 2008
Small-Bowel Intussusception
In this previously healthy 22-year-old man with a hemoglobin level of 5.1 g per deciliter, endoscopy of the gastrointestinal tract was unremarkable, despite a positive test for fecal occult blood. Six days later, he presented with abdominal pain and vomiting.
Wilson C.H., White S.A.
N Engl J Med 2007;357:e30, December 27, 2007
Chronic Budd–Chiari Syndrome and Abdominal Varices
This 44-year-old man with chronic liver disease presented with recurrent upper gastrointestinal bleeding. Computed tomography revealed a suprahepatic inferior vena caval web.
Sharma S., Kandpal H.
N Engl J Med 2007;357:e29, December 20, 2007
Dissecting Aneurysm of the Posterior Cerebral Artery
This 43-year-old man presented with hemianesthesia involving the right arm, the right leg, and the right side of the face. MRI scans revealed a dilatation of the left posterior cerebral artery, with a double lumen.
Renard D., Milhaud D.
N Engl J Med 2007;357:e27, December 13, 2007
Reversal of Laryngeal Paresis
This 51-year-old man with non–small-cell lung cancer had aphonia and left vocal cord paresis. After radiation therapy, vocal cord mobility returned, and he could speak normally. (See videos.)
Lewin J.S., Zinner R.G.
N Engl J Med 2007;357:e25, December 6, 2007
A Cobwebbing Trabecular Pattern
This 39-year-old woman with β-thalassemia major had required transfusion since she was 1 year old. She presented with pain and decreased mobility in both ankles.
Young T.-H., Lee H.-S.
N Engl J Med 2007;357:e24, November 29, 2007
Trichobezoar
This 18-year-old woman presented with pain, weight loss, and a firm epigastric mass. She had a habit of eating her hair.
Levy R.M., Komanduri S.
N Engl J Med 2007;357:e23, November 22, 2007
Harlequin’s Darker Side
This healthy woman presented with a history of flushing on the left side of her face and upper trunk after vigorous exercise.
Duddy M.E., Baker M.R.
N Engl J Med 2007;357:e22, November 15, 2007
Pulmonary Alveolar Proteinosis
A 45-year-old male farmer presented with breathlessness, dry cough, and bilateral alveolar and interstitial opacities, leading to a diagnosis of pulmonary alveolar proteinosis. Bilateral lung lavage was performed with 12 liters of saline. The lavage fluid gradually cleared.
Udwadia Z.F., Jain S.
N Engl J Med 2007;357:e21, November 8, 2007
Peripheral Artery Disease
This 69-year-old man presented with discoloration of the left foot and pain while at rest.
Kang H.-C., Chung M.-Y.
N Engl J Med 2007;357:e19, November 1, 2007
Magnetic Resonance Imaging of Retinal Detachment
This 80-year-old woman with a myopia of –19.0 diopters underwent a diagnostic workup after the visual acuity of her right eye decreased from 20/100 to the perception of light only.
Nölte I., Brockmann M.A.
N Engl J Med 2007;357:e18, October 25, 2007
Recanalized Umbilical Vein
This 72-year-old woman with compensated cirrhosis due to hepatitis C infection presented with swelling of the lower leg, splenomegaly, and visible tortuous vessels on the abdominal wall.
Young T.-H., Lee H.-S.
N Engl J Med 2007;357:e17, October 18, 2007
Aneurysmal Arteriovenous Fistula
This 50-year-old man had a 30-year history of end-stage renal disease. After a second renal transplant failed, he began to undergo dialysis. The left brachiocephalic arteriovenous fistula became severely aneurysmal over the next 6 years.
Sinnamon K., Mullan R.
N Engl J Med 2007;357:e16, October 11, 2007
Medical Mystery — An Unusual Complication of Colonoscopy
This 69-year-old man presented with left-sided lower abdominal and groin pain that began 36 hours after a colonoscopy. He had diverticular disease and had undergone polypectomy of a dysplastic adenoma of the sigmoid colon. He was hypotensive and febrile with a palpable, tender mass in the groin.
Gladman M.A., Shami S.S.
N Engl J Med 2007;357:1431, October 4, 2007
Purple Urine
This 76-year-old male nursing home resident was undergoing hemodialysis. The patient had no fever, urinary tract symptoms, or leukocytosis. The urinalysis showed a pH of 9.0.
Lee J.
N Engl J Med 2007;357:e14, September 27, 2007
Herpetic Glossitis
This 75-year-old woman with diabetes mellitus reported a 3-day history of throat discomfort and white eruptions on the tongue. She reported only minimal oral pain.
Chan C.-C., Chiu H.-C.
N Engl J Med 2007;357:e13, September 20, 2007
Ehlers–Danlos Syndrome
This 20-year-old man presented with hypermobility of the joints. Physical examination revealed hyperelasticity of the skin and also a rectal prolapse of about 15 cm in length.
Chen C.-W., Jao S.-W.
N Engl J Med 2007;357:e12, September 13, 2007
Lipemia Retinalis Associated with Secondary Hyperlipidemia
This 26-year-old man with diabetes mellitus presented with poor glycemic control. He had no problems with his vision. Total serum cholesterol level was 1086 mg per deciliter with a triglyceride level of 11,929 mg per deciliter.
Park Y.-H., Lee Y.-C.
N Engl J Med 2007;357:e11, September 6, 2007
Oral Acanthosis Nigricans
This 44-year-old woman presented with increasing oral papillomatosis, predominantly on the lips and less pronounced on the tongue and buccal mucosa. A biopsy was performed.
Schnopp C., Baumstark J.
N Engl J Med 2007;357:e10, August 30, 2007
Peutz–Jeghers Syndrome
This 12-year-old boy presented with abdominal pain, vomiting, and abdominal distention. CT scan showed proximal jejunojejunal and ileocolic intussusceptions.
Cureton E., Kim S.
N Engl J Med 2007;357:e9, August 23, 2007
Endometriosis
This 36-year-old woman presented with an abdomen that was tense and distended, with a purplish umbilical mass. She reported having dysmenorrhea, right shoulder pain at the time of menstruation, and umbilical pain.
Ferrero S., Remorgida V.
N Engl J Med 2007;357:e8, August 16, 2007
Asymptomatic Bladder Stones
In this healthy 26-year-old driver, hematuria was incidentally noted. Abdominal radiography showed large bladder stones.
Daneshbod Y.
N Engl J Med 2007;357:e7, August 9, 2007
An Intraabdominal Cyst
This 50-year-old woman presented with abdominal tenderness, fever, vaginal bleeding, and a periumbilical mass. CT showed a large intraabdominal cystic lesion.
van der Vlies C.H., Busch O.R.C.
N Engl J Med 2007;357:e6, August 2, 2007
Ascending Aortic Aneurysm in a Young Adult
This man presented with chest pain of 2 days’ duration. The pain was heavy, intermittent, and worse when he was lying flat.
Harris P.D., Cokis C.
N Engl J Med 2007;357:e5, July 26, 2007
Macular Hemorrhage from Bungee Jumping
This 25-year-old woman went bungee jumping from 150 ft (46 m). Immediately afterward, she noticed a substantial decrease in vision in her left eye.
Jain A.K., Gaynon M.
N Engl J Med 2007;357:e3, July 19, 2007
Nephrogenic Fibrosing Dermopathy
This 70-year-old man with end-stage renal disease was admitted for evaluation of thickening of his skin. Two months earlier he had had magnetic resonance angiography of the transplanted kidney with gadolinium enhancement.
Garovic V.D., Helgen K.E.
N Engl J Med 2007;357:e2, July 12, 2007
Phytophotodermatitis and Limes
This 23-year-old woman presented to the emergency department with a painful, erythematous, blistering rash on sun-exposed skin. At the beach, she had prepared cocktails of rum and limes. A burning erythema developed and later blistered.
Pomeranz M.K., Karen J.K.
N Engl J Med 2007;357:e1, July 5, 2007
Endemic Multinodular Goiter
Thirty-five years ago, this 72-year-old woman noticed a painless, slowly enlarging anterior neck mass. For the past few years, she has had a sensation of suffocating after falling asleep.
Cuevas-Ramos D., Pérez-Enríquez B.
N Engl J Med 2007;356:e27, June 28, 2007
A Medical Mystery — High Blood Pressure
This 28-year-old woman presented with a blood pressure of 200/100 mm Hg. Hypertension had been diagnosed during her first pregnancy. What is the diagnosis?
Quiros-Lopez R., Garcia-Alegria J.
N Engl J Med 2007;356:2630, June 21, 2007
Peripheral Smear with Malassezia furfur
This 53-year-old man with short-bowel syndrome that required total parenteral nutrition presented with fever and elevated liver-enzyme levels. A peripheral-blood smear showed intracellular and extracellular budding yeasts. Blood cultures grew only coagulase-negative staphylococci.
Bhargava P., Longhi L.P.
N Engl J Med 2007;356:e25, June 14, 2007
Chronic Calcific Pancreatitis
This 40-year-old alcoholic had a 4-year history of diabetes mellitus. He reported passing bulky, foul-smelling stools.
Babu V.
N Engl J Med 2007;356:e24, June 7, 2007
Putaminal Necrosis
This 51-year-old man presented with acute-onset bilateral blindness after a bout of binge drinking.
Chattopadhyay S., Chandra P.
N Engl J Med 2007;356:e23, May 31, 2007
A Complication of Central Venous Catheterization
In this 65-year-old man, a right internal jugular catheter was placed for management of congestive heart failure. There was difficulty removing the guidewire, requiring force to pull it out.
Nanda S., Strockoz-Scaff L.
N Engl J Med 2007;356:e22, May 24, 2007
Eosinophilic Esophagitis
This 51-year-old woman with a history of asthma presented with a sensation of food impaction. A biopsy was performed.
Hawari R., Pasricha P.J.
N Engl J Med 2007;356:e20, May 17, 2007
Lymphomatous Infiltration of the Eyelids
This healthy 70-year-old man had been treated with antibiotics, with no improvement. There was rubbery, painless thickening with right preauricular lymphadenopathy. A biopsy was performed.
Cooke C.A., White S.T.
N Engl J Med 2007;356:e19, May 10, 2007
Duplication of the Inferior Vena Cava
In this 68-year-old man, a CT scan showed a mass consistent with a renal-cell carcinoma in the upper pole of the left kidney and a duplication of the inferior vena cava.
Masood J., Barua J.M.
N Engl J Med 2007;356:e17, May 3, 2007
Pulmonary and Peritoneal Ossification
This 20-year-old man presented with fever and abdominal pain. He began peritoneal dialysis at the age of 4 years because of nephropathy.
Kuo P.H., Shin M.S.
N Engl J Med 2007;356:e16, April 26, 2007
Meningioma
This 83-year-old woman had staring spells and episodes of unresponsiveness.
Ahmed S.N., Scozzafava J.
N Engl J Med 2007;356:e14, April 19, 2007
Gravid Uterus in an Incisional Hernia
This 32-year-old healthy woman, gravida 6, had had two cesarean sections. The physical examination showed a gravid uterus and findings consistent with an incisional hernia.
Chanana C., Malhotra N.
N Engl J Med 2007;356:e13, April 12, 2007
A Medical Mystery — Skin Discolorations in a Bank Employee
A healthy 34-year-old bank employee presented with black discolorations on all her fingers. She was unable to remove the spots. The same symptoms had developed in some of her colleagues.
Schanz S., Metzler G.
N Engl J Med 2007;356:1455, April 5, 2007
Rapid Progression of Basal-Type Breast Cancer
This 33-year-old woman with a BRCA1 mutation had an enhancing lesion on MRI. Biopsies showed no evidence of cancer. One year later there was a large, invasive carcinoma.
Seewaldt V.L., Scott V.
N Engl J Med 2007;356:e12, March 29, 2007
Dupuytren’s Contracture
This 57-year-old man with a history of diabetes mellitus and alcohol consumption had contractures of both hands, diagnosed as Dupuytren’s contracture. He subsequently underwent bilateral fasciectomy.
Calif E., Stahl S.
N Engl J Med 2007;356:e11, March 22, 2007
Bright Green Serum
This 49-year-old woman had abdominal pain and then contrast-medium–induced renal failure. The patient was found to have bright green serum.
Bailey H., Wu A.H.B.
N Engl J Med 2007;356:e10, March 15, 2007
Calcified Left Atrial Thrombus
This 21-year-old woman with a history of rheumatic fever presented with left-sided weakness, atrial fibrillation, and a large ball-valve thrombus in a dilated left atrium.
Pappachan J.M., Bino B.C.
N Engl J Med 2007;356:e9, March 8, 2007
Erythema Ab Igne
This 69-year-old man with osteoarthritis had applied a heating pad repeatedly to his left knee to relieve discomfort.
Chan C.-C., Chiu H.-C.
N Engl J Med 2007;356:e8, March 1, 2007
Bone within Bone — Chronic Osteomyelitis
This afebrile 8-year-old Ethiopian girl presented with a limp and a small, pus-secreting wound on her left thigh.
Hevroni A., Koplewitz B.Z.
N Engl J Med 2007;356:e7, February 22, 2007
Two Hearts
This 64-year-old man with ischemic cardiomyopathy underwent cardiac transplantation. The recipient’s native heart (N) was left in place. The heterotopic donor heart (D) functions as a biologic left ventricular assist device.
Ghany R.A., de Marchena E.
N Engl J Med 2007;356:e6, February 15, 2007
Hydrofluoric Acid Burn
This 45-year-old man was exposed to a reservoir of 70% hydrofluoric acid while repairing a pipeline.
Dünser M.W., Rieder J.
N Engl J Med 2007;356:e5, February 8, 2007
A Medical Mystery: Dilated Bowel
This 70-year-old man presented with increasing abdominal distention. His abdomen was soft and nontender. What disorder does this man have?
Handwerker J., Raptopoulos V.D.
N Engl J Med 2007;356:503, February 1, 2007
Hepatosplenic Candidiasis
This 19-year-old woman underwent chemotherapy for acute myelomonocytic leukemia. Fever persisted despite empirical antibacterial therapy, and the serum alkaline phosphatase level increased to 335 U per liter.
Halkic N., Ksontini R.
N Engl J Med 2007;356:e4, January 25, 2007
Phlegmasia Cerulea Dolens
In this 85-year-old woman with lung cancer, bluish discoloration of the left great toe was noted, followed by progressive swelling and cyanosis of the leg.
Barham K., Shah T.
N Engl J Med 2007;356:e3, January 18, 2007
A retraction has been published: N Engl J Med 2007;356(10):1075.
Complication of Central Venous Catheterization
A man with Crohn’s disease underwent an uncomplicated operation involving lysis of adhesions. A central venous catheter was placed through the left subclavian vein. Six months later he presented with posterior cervical pain.
Guo H.
N Engl J Med 2007;356:e2, January 11, 2007
Papillary Fibroelastoma of the Pulmonary Artery
This 74-year-old man underwent an ultrasonographic examination as part of an evaluation for a hepatoma. A tumor in the pulmonary artery was noted.
Kondo T., Tobe S.
N Engl J Med 2007;356:e1, January 4, 2007
Adults with Osteogenesis Imperfecta
In adults with osteogenesis imperfecta, a wide spectrum of skeletal manifestations is apparent. Many mutations in the type I collagen gene are associated with this disorder.
Reeder J., Orwoll E.
N Engl J Med 2006;355:e28, December 28, 2006
Multiple Pulmonary Bacterial Abscesses
This HIV-positive woman presented with fever, chest pain, and hemoptysis. There was a history of intravenous drug use and a 3/6 pansystolic murmur along the left sternal border.
Chen J.-Y., Li Y.-H.
N Engl J Med 2006;355:e27, December 21, 2006
Abnormal Eye Movements Associated with Unilateral Loss of Vestibular Function
Acute unilateral loss of peripheral vestibular function causes spontaneous nystagmus. Initially, nystagmus is present during visual fixation (see video).
Lewis R.F., Carey J.P.
N Engl J Med 2006;355:e26, December 14, 2006
Medical Mystery — Abnormal Abdominal Radiograph
This 50-year-old woman presented with obtundation and hypotension. An immobile, firm mass was palpated to the right of the umbilicus.
Tajima K., Kurabayashi M.
N Engl J Med 2006;355:2467, December 7, 2006
Bisphosphonate-Associated Contact Stomatitis
This 68-year-old woman was referred because of erosive mucositis of the hard palate. The patient reported that she held the alendronate tablet in her mouth behind her upper denture plate before being able to swallow it.
Rubegni P., Fimiani M.
N Engl J Med 2006;355:e25, November 30, 2006
Squamous-Cell Carcinoma with Pericardial Metastases
This 78-year-old woman presented with dyspnea and a pleural effusion. She had a chronic decubitus ulcer with squamous-cell carcinoma adjacent to the ulcer.
Boukhalil P., Debek A.
N Engl J Med 2006;355:e24, November 23, 2006
Minocycline-Induced Hyperpigmentation
This 89-year-old woman presented with a nonhealing leg ulcer. She was taking minocycline twice a day as suppressive therapy after orthopedic fixation of a hip fracture 28 months earlier.
Holm A.N., Nelson W.K.
N Engl J Med 2006;355:e23, November 16, 2006
Crohn’s Disease and an Olive
This 45-year-old man presented with 3 days of colicky abdominal pain, nausea, and vomiting. He had been admitted 36 months earlier because of a similar episode. Computed tomography demonstrated a small-bowel stricture with an intraluminal radiopaque mass.
Shedda S., Frizelle F.
N Engl J Med 2006;355:e22, November 9, 2006
Necrobiosis Lipoidica Diabeticorum
This 52-year-old man with diabetes reported a 3-month history of a pretibial rash. The lesions had begun to ulcerate but were not painful.
Wake N., Fang J.C.
N Engl J Med 2006;355:e20, November 2, 2006
Cardiac Constriction Due to a Calcified Pericardium
This 66-year-old man with class IV heart failure had had pulmonary tuberculosis 60 years earlier. Fluoroscopy and echocardiography confirmed another diagnosis.
Mobius-Winkler S., Walther C.
N Engl J Med 2006;355:e19, October 26, 2006
Massive Hemoptysis
This 54-year-old man presented with hemoptysis and a remote history of tuberculosis. He then had an episode of massive hemoptysis.
van den Heuvel M.M., van Rensburg J.J.
N Engl J Med 2006;355:e17, October 19, 2006
Medical Mystery — Visual-Field Defect
This 31-year-old woman presented with a visual-field deficit in the left eye and a systolic ejection murmur. What is the diagnosis?
Mathura J.R., Jampol L.M.
N Engl J Med 2006;355:1592, October 12, 2006
Arteriovenous Fistula on CT Angiography
This 62-year-old man with diabetes and end-stage renal disease with an arteriovenous fistula presented with a possible stenosis of the fistula. Multislice CT was used to detect the lesions.
Laureys M.
N Engl J Med 2006;355:e15, October 5, 2006
Plantar Melanoma — A False Vegetant Wart
This woman had a verrucous nodule on the sole of her foot that had been treated as a plantar wart for 2 years. Histopathological examination showed an amelanotic malignant melanoma.
De Giorgi V., Massi D.
N Engl J Med 2006;355:e13, September 28, 2006
Uni-, Bi-, Tri-, and Quadricuspid Aortic Valves
A 47-year-old woman presented with left-sided chest pain and minimal dyspnea on exertion. Echocardiography showed a quadricuspid aortic valve. Tricuspid, bicuspid, and unicuspid aortic valves are also shown.
Schulze M.R., Strasser R.H.
N Engl J Med 2006;355:e11, September 21, 2006
Elevated Jugular Venous Pressure
This 43-year-old man presented in respiratory distress. Breath sounds were absent on the right side, and there was complete opacification of the right lung field.
Györik S., Menafoglio A.
N Engl J Med 2006;355:e10, September 14, 2006
Catamenial Pneumothorax
This 38-year-old female smoker was admitted because of recurrent right-sided pneumothorax. It was her second day of menstruation; the first episode had also taken place on the second day of her menstrual cycle.
Kronauer C.M.
N Engl J Med 2006;355:e9, September 7, 2006
Anomalous Origin of the Right Coronary Artery
In this 49-year-old man, exercise testing was suggestive of inferior-wall myocardial ischemia. CT coronary angiography with contrast showed anomalous origin of the right coronary artery from the left coronary cusp.
Wann S., Schuchard G.
N Engl J Med 2006;355:e8, August 31, 2006
Ocular Bleeding Due to Anticoagulation
This 83-year-old woman with glaucoma and atrial fibrillation was receiving warfarin. She woke up with pain in the right eye and what she thought was a big bruise.
Stead L.G., Judson K.A.
N Engl J Med 2006;355:e7, August 24, 2006
Loiasis
An eosinophil count was 17 percent in this 14-year-old refugee from Cameroon. Direct examination of blood revealed highly motile microfilariae. (See video.)
Weitzel T., Jelinek T.
N Engl J Med 2006;355:e6, August 17, 2006
Adie’s Pupil in the Ross Syndrome
This 34-year-old woman reported that the right side of her face was warmer than the left and had a propensity for sweating. She had a left-sided tonic pupil.
Hagemann G., Bartke T.
N Engl J Med 2006;355:e5, August 10, 2006
Lung Carcinoma with Anti-Hu Paraneoplastic Syndrome
This 54-year-old smoker presented with weight loss and a burning sensation in her hands and feet. Her pupils were asymmetric and unresponsive to light.
Gordon W.C., Leach M.T.J.
N Engl J Med 2006;355:e4, August 3, 2006
A Medical Mystery: Abnormal Chest X-Ray Film
This routine chest x-ray raised the possibility of an aortic-arch aneurysm. The pacemaker was functioning properly. What is the diagnosis?
Turkington J.R.A., McAteer E.
N Engl J Med 2006;355:393, July 27, 2006
Müller’s Sign
This woman presented with fever and rigors after hemodialysis. There was a diastolic decrescendo murmur. The video shows pulsation, or bobbing, of the uvula during systole.
Williams B.R. III, Steinberg J.P.
N Engl J Med 2006;355:e3, July 20, 2006
Acquired Leukonychia Totalis
This 72-year-old woman with diabetes mellitus reported dyspnea, orthopnea, and a progressive whitening of her fingernails.
Antonarakis E.S.
N Engl J Med 2006;355:e2, July 13, 2006
Abdominal Pseudohernia Due to Herpes Zoster
Herpes zoster in the right T11–T12 dermatomes developed in a 75-year-old man. Four weeks later, he noticed a protrusion of the right abdominal wall.
Tagg N.T., Tsao J.W.
N Engl J Med 2006;355:e1, July 6, 2006
Hypothyroid-Induced Hyporeflexia
This woman with a surgical scar on the neck and hypothermia became obtunded. The video shows delayed relaxation phase of the biceps reflex.
Sosnay P.R., Kim S.
N Engl J Med 2006;354:e27, June 29, 2006
Venous Air Embolism
This 82-year-old man had acute respiratory distress after computed tomography of the thorax.
Cuvelier A., Muir J.-F.
N Engl J Med 2006;354:e26, June 22, 2006
Tooth Aspiration
This 77-year-old man was intubated because of recurrent seizures. Pneumonia in his right lung worsened despite antibiotic treatment.
Ostrinsky Y., Cohen Z.
N Engl J Med 2006;354:e25, June 15, 2006
Zenker’s Diverticulum
This 68-year-old man could no longer eat or drink without coughing.
Hannan S.A., Alusi G.
N Engl J Med 2006;354:e24, June 8, 2006
A Medical Mystery — Arthritis
This 51-year-old woman with rheumatoid arthritis presented with swelling of the right shoulder.
Jansen T.L., Spoorenberg A.
N Engl J Med 2006;354:2375, June 1, 2006
Pneumoperitoneum Due to Spontaneously Perforated Pyometra
This 40-year-old diabetic woman presented with fever and diffuse abdominal pain.
Tsai M.-S., Wu. M.-H.
N Engl J Med 2006;354:e23, May 25, 2006
Burton’s Line
This man presented with abdominal pain of eight months’ duration. Physical examination showed a bluish discoloration of the gums. The patient had worked in a lead-smelting company for the past 30 years.
Nogué S., Culla A.
N Engl J Med 2006;354:e21, May 18, 2006
Rotator-Cuff Tear
This 72-year-old man had been using crutches for more than 50 years. A painless shoulder mass had become progressively larger.
Auethavekiat P., Michet C.J.
N Engl J Med 2006;354:e20, May 11, 2006
Scrofula
This 39-year-old Zambian man presented with a draining neck mass, weight loss, and low-grade fever.
Khalid S.K., Jassim O.
N Engl J Med 2006;354:e18, May 4, 2006
Cat Scratch Disease Lymphadenopathy
This healthy 7-year-old girl had a two-week history of a tender lymph node. No other nodes were enlarged.
Eidlitz-Markus T., Zeharia A.
N Engl J Med 2006;354:e17, April 27, 2006
Umbilical-Cord Prolapse at 29 Weeks’ Gestation
This 23-year-old woman was admitted at 29 weeks because of preterm premature rupture of the membranes. Doppler ultrasonography showed the cord prolapsing through the cervix.
Belfort M.
N Engl J Med 2006;354:e15, April 20, 2006
Pseudoclubbing
This man had obstructive nephropathy necessitating hemodialysis and transplantation. His course was complicated by severe secondary hyperparathyroidism.
Farzaneh-Far A.
N Engl J Med 2006;354:e14, April 13, 2006
A Medical Mystery — Gangrene and Cutaneous Nodules
This 61-year-old man presented with digital gangrene and mottled discolorations of the skin with palpable cutaneous nodules.
Schanz S., Ulmer A.
N Engl J Med 2006;354:1515, April 6, 2006
Enterobius vermicularis
This man presented with crampy pain in the right lower quadrant after a trip to Hungary. A colonoscopy revealed multiple mobile 1-cm worms. (See video.)
Brown M.D.
N Engl J Med 2006;354:e12, March 30, 2006
Talc Retinopathy
This 37-year-old woman presented with blurred vision. She reported intravenous use of methylphenidate tablets crushed and dissolved in water.
El-Jabali F., Cohen S.
N Engl J Med 2006;354:e11, March 23, 2006
Giant Ganglion Cyst
This 90-year-old woman presented with a rapidly enlarging cystic lesion on her left fifth finger.
Mortimer N.J., Johnston G.A.
N Engl J Med 2006;354:e10, March 16, 2006
Veiled Right Kidney Sign in a Patient with Valentino’s Syndrome
This man presented with severe abdominal pain after use of nonsteroidal antiinflammatory drugs. Radiography revealed air around the right kidney.
Wang H.-P., Su W.-C.
N Engl J Med 2006;354:e9, March 9, 2006
Nebulizer-Associated Anisocoria
This woman was transferred to the ward after intensive care for fungal pneumonia and septicemia. She received medications through a face mask and was recovering well when her right pupil became fixed and dilated. A CT scan was normal.
Iosson N.
N Engl J Med 2006;354:e8, March 2, 2006
Malignant Obstruction of the Superior Vena Cava
This man with non–small-cell carcinoma of the lung presented with progressive symptoms of cough, hoarseness, and swelling of the face and arms. The jugular veins were nonpulsatile.
Kanani R.S., Drachman D.E.
N Engl J Med 2006;354:e7, February 23, 2006
Colonic Ileus
This 77-year-old man presented with abdominal pain and distention. The serum potassium level was 2.6 mmol per liter. Mechanical obstruction was excluded.
Hazelwood S., Burton D.
N Engl J Med 2006;354:e6, February 16, 2006
Subacute Urinary Retention
This 88-year-old man had undergone resection of adenocarcinoma of the rectum. He then presented with a three-month history of swelling of the legs.
Kassem S., Friedman G.
N Engl J Med 2006;354:e5, February 9, 2006
A Medical Mystery — Concentric Calcification
This elderly man had recurrent hematuria and a serum creatinine level of 4.4 mg per deciliter.
Kim D.H.D., Yu V.L.
N Engl J Med 2006;354:508, February 2, 2006
The Importance of Early Cervical-Spine Radiography
In the emergency department after a high-speed motorbike collision, this patient’s blood pressure was 70/35 mm Hg. He did not respond to advanced resuscitation; results of an emergency laparotomy were normal. Radiography of the cervical spine was then obtained.
McMonagle M.P.
N Engl J Med 2006;354:e4, January 26, 2006
Heavy-Metal Meals of Mercury
This 28-year-old from Singapore presented with nausea, lethargy, and tremor. For 12 weeks, his mother-in-law had provided him with a traditional Indian medicine and meals containing elemental mercury.
Yoong J.K.C.
N Engl J Med 2006;354:e3, January 19, 2006
Milwaukee Shoulder
This 85-year-old woman presented with right shoulder pain and swelling and a large hematoma extending into the chest wall. Passive mobility was painful but largely unrestricted. She had had no recent trauma.
Genta M.S., Gabay C.
N Engl J Med 2006;354:e2, January 12, 2006
Pellegrini–Stieda Syndrome
This 38-year-old man had an incomplete spinal cord injury due to a diving accident some years earlier. He reported new pain in the left knee.
Altschuler E.L., Bryce T.N.
N Engl J Med 2006;354:e1, January 5, 2006
Buckshot Ingestion
This 73-year-old Inuit woman was referred after an incomplete colonoscopy. A preliminary abdominal radiograph showed something in the appendix.
Cox W.M., Pesola G.R.
N Engl J Med 2005;353:e23, December 29, 2005
Eye Worm
A healthy Nigerian man living in the United States noticed something wiggling in his right eye while he was driving.
Gupta A., Kedhar S.
N Engl J Med 2005;353:e22, December 22, 2005
Urinary Calcium Oxalate Crystals in Ethylene Glycol Intoxication
This 73-year-old man presented with a self-inflicted stab wound, plasma ethanol level of 27 mg per deciliter, and a pH of 6.91. Analysis of the urine showed calcium oxalate monohydrate crystals. Free crystals were extensive.
Morfin J., Chin A.
N Engl J Med 2005;353:e21, December 15, 2005
Deforming Gout
This 80-year-old man was referred to the rheumatology clinic. He had received colchicine and urate-lowering drugs intermittently over several years.
Pacheco G., Cavallasca J.A.
N Engl J Med 2005;353:e20, December 8, 2005
A Medical Mystery — Extensive Ecchymosis
This 71-year-old man was evaluated for severe anemia, ecchymosis of the lower limbs, and hemorrhages of the oral cavity. What is the diagnosis?
Mulleman D., Goupille P.
N Engl J Med 2005;353:2384, December 1, 2005
Caput Medusae
This 47-year-old man with a history of compensated cirrhosis due to chronic hepatitis B infection presented for routine evaluation.
Yang P.-M., Chen D.-S.
N Engl J Med 2005;353:e19, November 24, 2005
Pulmonary Sequestration
This 48-year-old man without prior pulmonary symptoms had minor thoracic pain.
Platon A., Poletti P.-A.
N Engl J Med 2005;353:e18, November 17, 2005
Cetuximab-Associated Acneiform Eruption
This 48-year-old man with metastatic colon cancer was treated with cetuximab, a monoclonal antibody to EGFR. An eruption of sterile papules and pustules with adherent crust developed on his face, chest, and back.
Moss J.E., Burtness B.
N Engl J Med 2005;353:e17, November 10, 2005
Actinomyces Hepatic Abscess with Cutaneous Fistula
This 64-year-old man with a history of colonic resection for adenocarcinoma presented with abdominal discomfort. Hypodense lesions involving the liver appeared to cross the capsule and peritoneal membrane. A specimen was obtained by fine-needle aspiration of a liver lesion.
Saad M., Moorman J.
N Engl J Med 2005;353:e16, November 3, 2005
Angioedema of the Arytenoids
This woman reported feeling as if something were stuck in her throat. She had a hoarse, raspy voice but no respiratory symptoms.
Shiber J.R.
N Engl J Med 2005;353:e15, October 27, 2005
Left Sixth Cranial Nerve Palsy with Herpes Zoster Ophthalmicus
This man reported acute left retro-orbital pain of one week’s duration. Three days later, double vision developed.
Jude E., Chakraborty A.
N Engl J Med 2005;353:e14, October 20, 2005
Bone Changes in Rheumatoid Arthritis
This 38-year-old woman with rheumatoid arthritis had complete remission after therapy with methotrexate. Radiographs were taken to assess the treatment. This radiograph was taken one year before treatment.
Ikari K., Momohara S.
N Engl J Med 2005;353:e13, October 13, 2005
Medical Mystery — One Brown Eye and One Blue Eye
A 10-year-old boy has a brown right eye and a blue left eye, as well as mild ptosis and miosis of his left eye. What is the condition he had at the age of 10 months?
Gesundheit B., Greenberg M.
N Engl J Med 2005;353:1502, October 6, 2005
Aortic Regurgitation — Bounding Carotids
This 66-year-old man presented with dyspnea and repeated angina with mild effort. The blood pressure was 164/49 mm Hg, and the carotid pulses were prominent. (See video.)
Calderón C.V., Carrera J.B.
N Engl J Med 2005;353:e12, September 29, 2005
Ebstein’s Anomaly
This 44-year-old woman with increasing dyspnea had Ebstein’s anomaly, an abnormality in the development of the tricuspid valve. She had declined heart transplantation. On echocardiography, a small left ventricle is seen next to massively dilated right heart chambers. (See video.)
O’Loughlin A.J., Hayward C.
N Engl J Med 2005;353:e11, September 22, 2005
Atherosclerotic Aortic Occlusion
This 46-year-old woman had lifestyle-limiting claudication of the legs. She had hypertension, hyperlipidemia, and a history of smoking. A computed tomographic angiogram showed aortic occlusion just below the origin of the renal arteries (red arrowhead).
Macedo T.A.
N Engl J Med 2005;353:e10, September 15, 2005
Candida albicans in a Peripheral-Blood Smear
An infant born at 26 weeks required intubation, catheterization of the umbilical artery and vein, and broad-spectrum antimicrobial agents. On the fifth postnatal day, the infant became clinically unstable.
Nadir E., Kaufshtein M.
N Engl J Med 2005;353:e9, September 8, 2005
Air-Pressure Injury of the Eye and Intracranial Structures
This 5-year-old boy activated an air-pressure pistol directly toward his right eye. Visual acuity was reduced to 20/80. Computed tomography disclosed intraorbital and extraocular air, but no fractures.
Mennel S., Peter S.
N Engl J Med 2005;353:e8, September 1, 2005
Coagulase-Negative Staphylococcus within Neutrophils in Acute Leukemia
In this 43-year-old man with a relapse of acute myelomonocytic leukemia, fever developed during salvage chemotherapy. There was no growth in 19 blood cultures. On day 35, 1-µm inclusions were observed within peripheral-blood neutrophils.
Ortuño F.J., Heras I.
N Engl J Med 2005;353:e7, August 25, 2005
Central Serous Chorioretinopathy in Pregnancy
This 32-year-old woman, who was seven months pregnant, presented with blurring and greenish discoloration of central vision in the left eye.
Mayo G.L., Tolentino M.J.
N Engl J Med 2005;353:e6, August 18, 2005
Patulous Eustachian Tube
This 26-year-old man reported an aural fullness and a flapping noise in his right ear. Otoscopy revealed inward-and-outward movements of his tympanic membrane in time with his nasal respiration (see video).
Ng S.K., van Hasselt C.A.
N Engl J Med 2005;353:e5, August 11, 2005
Medical Mystery — Abdominal Pain
This 40-year-old man presented with a four-day history of pain in the left upper quadrant, accompanied by fatigue, fever, sweating, and sore throat.
Kim K.M., Kopelman R.I.
N Engl J Med 2005;353:508, August 4, 2005
Transcatheter Treatment of Thromboembolism in the Superior Mesenteric Artery
This woman with a history of atrial fibrillation presented with an acute onset of severe abdominal pain. A scan of the abdominal area was performed after the administration of contrast material.
Nishida A., Fukui K.
N Engl J Med 2005;353:e4, July 28, 2005
Paget’s Disease of the Breast
This 70-year-old woman presented with an erythematous, scaly plaque that had replaced the areola of the left breast. No breast mass or lymphadenopathy was detected.
Fox L.P., Grossman M.E.
N Engl J Med 2005;353:e3, July 21, 2005
Pseudomonas Cellulitis
This man’s new job required that he wear boots, which caused his feet to perspire. Erythema appeared, and itching became intense. A topical steroid provided temporary relief.
Habif T.P.
N Engl J Med 2005;353:e2, July 14, 2005
Small-Bowel Prolapse through a Persistent Omphalomesenteric Duct
This 23-day-old term male infant presented to the emergency room with acute small-bowel evisceration. His parents had noted erythema and umbilical drainage before the evisceration.
Saad D.F., Gow K.W.
N Engl J Med 2005;353:e1, July 7, 2005
Calcific Arteriopathy
A 38-year-old man who had undergone renal and pancreatic transplantation five years earlier was referred because of acral gangrene of both hands. Segmental arterial pressures in the upper limbs were more than 300 mm Hg.
Joyal F., Margaroli P.
N Engl J Med 2005;352:e24, June 30, 2005
Tsunami Sinusitis
This 35-year-old man was brought to the hospital on December 26, 2004. He had inhaled seawater when he nearly drowned. He had sinus discomfort but no difficulty breathing.
Limchawalit K., Suchato C.
N Engl J Med 2005;352:e23, June 23, 2005
Recurrent Respiratory Papillomatosis with Lung Involvement
This five-year-old girl had an episode of respiratory distress with collapse of the right lung. During bronchoscopy, multiple tracheal papillomas were seen.
Glikman, D., Baroody F.M.
N Engl J Med 2005;352:e22, June 16, 2005
Myiasis Due to Dermatobia hominis (Human Botfly)
This man presented with skin lesions on his chest and arm six weeks after a vacation in Belize at the beach and in the rain forest. Physical examination revealed five nodules with surrounding erythema and a central pore (see video).
Marty F.M., Whiteside K.R.
N Engl J Med 2005;352:e21, June 9, 2005
A Medical Mystery — Bradycardia
A 49-year-old man reported fatigue, arthralgia, and headache, along with a two-day history of chest pain. Physical examination revealed a pulse of 38 beats per minute. What is the diagnosis?
Rosenberg R.
N Engl J Med 2005;352:2337, June 2, 2005
Arrowwood Contaminant in Pap Smear
This harmless contaminant was seen in a routine cervical smear of a young woman. What is it?
Farkas T.A.
N Engl J Med 2005;352:e20, May 26, 2005
Chromoblastomycosis
This 67-year-old man from Jamaica had a nodule excised from his left foot, and he was told he had a fungal infection. He did not seek medical attention until years later when he was unable to walk.
Brown M., Pasvol G.
N Engl J Med 2005;352:e19, May 19, 2005
Wernicke’s Encephalopathy
This 21-year-old woman has schizoaffective disorder and a four-month history of vomiting and weight loss. She was oriented only to person. She had ocular bobbing and an ataxic gait. The MRI shows hyperintensity of the mamillary bodies.
Kaineg B., Hudgins P.A.
N Engl J Med 2005;352:e18, May 12, 2005
Improvement in Hypertensive Retinopathy after Treatment of Hypertension
A 34-year-old woman presented with headache, blurred vision, a blood pressure of 240/150, and grade IV hypertensive retinopathy. Serial photographs demonstrate progressive improvement after treatment of the elevated blood pressure.
Strachan M.W.J., McKnight J.A.
N Engl J Med 2005;352:e17, May 5, 2005
Painless Loss of Vision after Vomiting
This 24-year-old woman was 30 weeks’ pregnant with twins. She vomited and noticed an acute onset of a large central scotoma in the right eye.
Zhang G.S., Mathura Jr., J.R.
N Engl J Med 2005;352:e16, April 28, 2005
Disseminated Gonococcal Infection
A 23-year-old woman with swelling in her right third finger was prescribed cephalexin and indomethacin for tenosynovitis. Over the next several days, a painful rash developed on the patient’s extremities.
Russ S., Wrenn K.
N Engl J Med 2005;352:e15, April 21, 2005
Airway Dilatation after Inhalation of a Beta-Agonist
A woman with a 25-year history of asthma underwent high-resolution multislice helical computed tomographic scanning. Videos before and after the inhalation of albuterol reveal an increase in the airway caliber from a segmental bronchus to an eighth-generation bronchus.
Tamura G., Suda Y.
N Engl J Med 2005;352:e14, April 14, 2005
Medical Mystery — 50 Years of Medical Progress
Between 1949 and 2002, this patient underwent four lifesaving procedures. This plain chest radiograph highlights all four of the procedures. What are they?
Ostermaier R., Taut M.
N Engl J Med 2005;352:1473, April 7, 2005
Uremic Frost
A 57-year-old woman with chronic renal insufficiency had refused dialysis for two years. She was found in respiratory distress. Diffuse deposits of tiny white crystalline material were observed on her skin. Initial laboratory studies showed a blood urea nitrogen level of 208 mg per deciliter, a bicarbonate level of 5 meq per liter, and an arterial pH of 6.74.
Walsh S.R., Parada N.A.
N Engl J Med 2005;352:e13, March 31, 2005
Severe Fecal Impaction
A 49-year-old man with a history of paraplegia was admitted to the intensive care unit because of abdominal pain and hyperkalemia (serum potassium, 7 mmol per liter).
Loubières Y., Chereau O.
N Engl J Med 2005;352:e12, March 24, 2005
Streptococcal Pharyngitis
An afebrile 26-year-old man presented with a two-day history of a sore throat. He was unable to eat solids because of pain.
Nimishikavi S., Stead L.
N Engl J Med 2005;352:e10, March 17, 2005
Marjolin’s Ulcer
This 33-year-old man had had a burn injury to his arm as a child. He presented with a rapidly growing ulcer in the burn scar.
Chong A.J., Klein M.B.
N Engl J Med 2005;352:e9, March 10, 2005
Tuberculosis Empyema Necessitatis
An 18-year-old man presented with a six-month history of an increasing mass on his back. He noticed serous drainage from a sore on the left lateral wall of his chest.
Chaiyasate K., Hramiec J.
N Engl J Med 2005;352:e8, March 3, 2005
Malposition of a Sengstaken–Blakemore Tube
An 86-year-old woman had a history of cirrhosis and esophageal variceal bleeding. She presented with hematemesis, and a Sengstaken–Blakemore tube was placed. Subsequently, the patient had pain in the left chest.
Chien J.-Y., Yu C.-J.
N Engl J Med 2005;352:e7, February 24, 2005
Tinea Circinata
A 46-year-old woman with a history of infection with the human immunodeficiency virus presented with a violaceous plaque on the pretibial surface. Interspersed within hives were numerous yellow-white pustules.
Rovansek K.A., Papadopolous A.
N Engl J Med 2005;352:e6, February 17, 2005
Finger Avulsion with Pulled-Out Flexor Tendon
A 17-year-old boy jumped over a fence and sustained an avulsion injury. The fifth finger was amputated, and the tendon of the flexor digitorum profundus muscle was completely pulled out. The finger was replanted microsurgically.
Huemer G.M., Dunst K.M.
N Engl J Med 2005;352:e5, February 10, 2005
Ascaris lumbricoides Blocking the Common Bile Duct
This 63-year-old woman with vomiting and abdominal pain had undergone a laparoscopic cholecystectomy one year earlier. Endoscopic cholangiopancreatography showed a structure measuring 10 cm at the papilla.
Esser-Köchling B.G., Hirsch F.W.
N Engl J Med 2005;352:e4, February 3, 2005
Embolization of the Tip of a Central Venous Catheter into the Pulmonary Artery
A 56-year-old man who had undergone replacement of the mitral and aortic valves then underwent aortobifemoral bypass surgery. The postoperative course was complicated by retroperitoneal bleeding. (See videos of an object in the left pulmonary artery.)
Morguet A.J., Schultheiss H.-P.
N Engl J Med 2005;352:e3, January 27, 2005
A Medical Mystery
A male infant was born at 38 weeks with a weight of 3430 g. At seven months of age his weight was 8450 g, and his blood pressure was 114/52 mm Hg. What is the diagnosis?
Hartmann H., Schumacher U.
N Engl J Med 2005;352:273, January 20, 2005
Calcified Filariasis of the Breasts
A 23-year-old woman from Cameroon had nonpainful, mobile, firm lumps in both breasts. Mammography showed multiple serpiginous calcifications.
Alkadhi H., Garzoli E.
N Engl J Med 2005;352:e2, January 13, 2005
Obstructive Lingual Thyroid
A 43-year-old woman with early breast cancer could not be intubated for the administration of anesthesia.
Barthel A., Bornstein S.R.
N Engl J Med 2005;352:e1, January 6, 2005
Fatal Free-Floating Left Atrial Thrombus
This 68-year-old woman was resuscitated after cardiac arrest. Echocardiography showed a dilated left atrium and severe mitral-valve stenosis. A free-floating thrombus caused intermittent occlusion of the mitral valve. (See video clip.)
Tornóczky T., Ajtay Z.
N Engl J Med 2004;351:e25, December 30, 2004
Laterally Spreading Colon Cancer
On colonoscopy with a magnifying videoscope, an irregularity of the colonic wall at the transverse colon was detected. Indigo carmine solution was sprayed in the area.
Tamura S., Onishi S.
N Engl J Med 2004;351:e24, December 23, 2004
“Shoulder Pad” Sign
This 66-year-old man presented with fatigue, paresthesia of the legs, weight loss, and shoulder enlargement, with limitation of movement. Periorbital ecchymoses (the “raccoon” sign) were present. What’s the diagnosis?
Guerreiro de Moura C.G., Pinto de Souza S.
N Engl J Med 2004;351:e23, December 16, 2004
Diaphragmatic Hernia
A 76-year-old man was referred because of hemoptysis. He had had pulmonary tuberculosis six years before and an abnormal chest radiograph during adolescence.
Fukamizu R., Hayashi S.
N Engl J Med 2004;351:e22, December 9, 2004
The Tale of Phineas Gage, Digitally Remastered
In 1848, Phineas Gage, a construction foreman, triggered an explosion that propelled an iron shaft through his head. He regained consciousness within minutes. For a computer reconstruction, see Video Clip 2.
Ratiu P., Talos I.-F.
N Engl J Med 2004;351:e21, December 2, 2004
Double Aortic Arch Diagnosed by Magnetic Resonance Imaging
A six-month-old boy had recurrent respiratory difficulties, then respiratory failure. Magnetic resonance imaging shows aorta, esophagus, and trachea.
Lotz J., Macchiarini P.
N Engl J Med 2004;351:e20, November 25, 2004
Left Nasal Discharge and Meningitis
This 29-year-old soldier had headache and fever. He had had intermittent, clear nasal discharge from the left nostril since a minor motor vehicle accident two years earlier.
Chang G.Y.
N Engl J Med 2004;351:e19, November 18, 2004
Peripartum Dissection of the Right Coronary Artery
This 35-year-old woman was evaluated after giving birth. Her electrocardiogram showed transient ST depressions in leads II, III, aVF, and V4 through V6. Evaluation included intravascular ultrasound imaging (Video Clip 1).
Frimerman A., Meisel S.R.
N Engl J Med 2004;351:e18, November 11, 2004
Backscatter from Lead
This 65-year-old man underwent routine chest radiography. Note the little spheres in the posterior thoracic wall.
Hassink R.J., Doevendans P.A.
N Engl J Med 2004;351:e17, November 4, 2004
Falciform-Ligament Sign of Pneumoperitoneum
An 87-year-old woman presented with fever and shock. She had had diarrhea, then constipation, then diffuse abdominal pain.
Lin J.-N.
N Engl J Med 2004;351:e16, October 28, 2004
Nontraumatic Clostridium septicum Myonecrosis
A 73-year-old man with colon cancer presented with pain in the right hip, without a history of trauma.
Arteta-Bulos R., Mustafa Karim S.
N Engl J Med 2004;351:e15, October 21, 2004
Ureteral Obstruction in Pregnancy
This 19-year-old primigravida presented with fever and right-flank pain at 22 weeks of gestation. Renal ultrasonography showed caliceal dilatation of 23 mm in the right kidney.
Grotegut C.A.
N Engl J Med 2004;351:e14, October 14, 2004
A Medical Mystery
A 16-year-old boy presented with hyperpigmentation of the skin; his sclera were unaffected. What is the diagnosis?
Wickless S.C.
N Engl J Med 2004;351:1547, October 7, 2004
Communicating Hydrocephalus
A 56-year-old surgeon presented with memory deficits and dysphoric mood unresponsive to antidepressants. Her symptoms had necessitated early retirement.
Newman J.P., Segal R.
N Engl J Med 2004;351:e1, September 30, 2004
Morgagni’s Hernia
A 64-year-old woman without symptoms underwent routine chest radiography, which revealed a well-circumscribed, low-density mass that measured 8 cm in diameter.
Schubert H., Haage P.
N Engl J Med 2004;351:e12, September 23, 2004
Endovascular Repair of a Ruptured Abdominal Aortic Aneurysm
This 62-year-old man was diaphoretic and had a markedly tender, pulsatile abdominal mass.
Lee W.A.
N Engl J Med 2004;351:e11, September 16, 2004
Marchiafava–Bignami Disease
This 45-year-old man with chronic alcoholism on examination showed disorientation, dysarthria, sensory neuropathy, and coarse rigidity of all four limbs. The mean corpuscular volume was 99 µm3.
Demaerel P., Van Paesschen W.
N Engl J Med 2004;351:e10, September 9, 2004
Bilateral Renal Arteriovenous Malformation
Echocardiography revealed left ventricular hypertrophy and an enlarged inferior vena cava.
Minetti E., Montoli A.
N Engl J Med 2004;351:e9, September 2, 2004
Inhaled Foreign Body
This woman was adjusting her head scarf while holding the pin in her mouth.
Tariq S.M., George J.
N Engl J Med 2004;351:e8, August 26, 2004
Bilateral Renal Arteriovenous Malformation
This girl had Ewing’s Sarcoma of the distal femur. She was treated with wide surgical excision of the tumor with a rotationplasty.
Dormans J.P., Garg S.
N Engl J Med 2004;351:e7, August 19, 2004
Imperforate Hymen with Hematocolpometra
Pelvic ultrasonography showed dilatation of the vagina (white arrow) and uterus (black arrow) caused by fluid.
Stone S.M., Alexander J.L.
N Engl J Med 2004;351:e6, August 12, 2004
Gastrothorax Simulating Acute Tension Pneumothorax
Three years earlier, this 27-year-old man had undergone surgery to repair a traumatic rupture of the left side of the diaphragm.
de Jager C.P.C., Trof R.J.
N Engl J Med 2004;351:e5, August 5, 2004
Electrocardiographic Changes in Extreme Hypothermia
An HIV-positive man was brought to the emergency department with altered mental status, aspiration pneumonia, and a core temperature of 27.6°C.
Saadlla H.
N Engl J Med 2004;351:e4, July 29, 2004
A Cystic Mass in the Liver
This woman presented with intermittent discomfort in the right upper abdomen and a mass filling the epigastrium.
Halkic N., Gillet M.
N Engl J Med 2004;351:e3, July 22, 2004
Massive Subcutaneous Emphysema after Tracheal Perforation
After a laminectomy and posterior spinal fusion, subcutaneous emphysema and hypoxemia developed. A chest radiograph revealed no pneumothorax. Bilateral chest tubes were placed, but the hypoxemia did not improve.
Hirose K., Visser B.C.
N Engl J Med 2004;351:e2, July 15, 2004
Swinging Heart
A man with small-cell lung carcinoma had syncope and muffled heart sounds. The EKG showed low voltage with electrical alternans. (See video.)
Akkerhuis J.M., Hersbach F.M.R.J.
N Engl J Med 2004;351:e1, July 8, 2004
A Medical Mystery — Which Twin Is the Patient?
Which of these 50-year-old identical twins is the patient, and what is the diagnosis?
Nieuwlaat W.-A., Pieters G.
N Engl J Med 2004;351:68, July 1, 2004
Homozygous Hemoglobin C Disease
A Ghanaian child on routine screening had a hemoglobin of 9.0 g per deciliter, a hematocrit of 24.3 percent, a mean corpuscular volume of 53.8 µm3, and a reticulocyte count of 1.6 percent.
Fairhurst R.M., Casella J.F.
N Engl J Med 2004;350:e24, June 24, 2004
Radiation Injury from a Fluoroscopic Procedure
This man underwent an ablative procedure for supraventricular arrhythmias. A painful ulceration developed on his right arm four months later.
Wong L., Rehm J.
N Engl J Med 2004;350:e23, June 17, 2004
Dislocation of the Lenses
A 60-year-old man presented after a fall and minor trauma to the head.
Mathur S.K., Grodinsky D.
N Engl J Med 2004;350:e22, June 10, 2004
A Calcified Pelvic Mass
In an 88-year-old woman, a painless, nonpulsating mass was palpable in the suprapubic region.
Koehler F., Kivelitz D.
N Engl J Med 2004;350:e21, June 3, 2004
Sarcoptes scabiei Infestation
A man and his fiancée had pruritus of two months’ duration. They had similar skin lesions.
Stoffle N.N., Cohen P.R.
N Engl J Med 2004;350:e20, May 27, 2004
Pericardial Cyst
What is the smoothly marginated density in the region of the right cardiophrenic angle that partially obscures the right border of the heart?
Serwer B.A., Barold H.S.
N Engl J Med 2004;350:e19, May 20, 2004
Papilledema and Spinal Cord Tumor
Computed tomographic examination showed a communicating hydrocephalus.
Amlashi S.F.A., Riffaud L.
N Engl J Med 2004;350:e18, May 13, 2004
Air Embolism after the Insertion of a Central Venous Catheter
A 17-year-old was involved in a car accident. Before she was transported to a hospital, a central venous catheter was inserted.
Teichgräber U.K.M., Benter T.
N Engl J Med 2004;350:e17, May 6, 2004
Pneumoperitoneum
A 47-year-old man had respiratory failure complicating pneumonia. Mechanical ventilation with positive end-expiratory pressure was initiated.
van Steijn J.H.M., van der Voort P.H.J.
N Engl J Med 2004;350:e16, Apr 29, 2004
Hemispheric Arteriovenous Malformation
This 23-year-old man had a history of tonic–clonic seizures.
Vermillion J.M., Harris F.S.
N Engl J Med 2004;350:e15, Apr 22, 2004
Lemierre’s Syndrome
Examination revealed pustular exudates on the right tonsil.
Lai C., Vummidi D.R.
N Engl J Med 2004;350:e14, Apr 15, 2004
Pseudomyxoma Peritonei
A 55-year-old man presented with increasing abdominal girth, a weight loss of 4.5 kg, and anorexia and na