This was his third hospitalization for these symptoms; the previous admissions were 2 and 4 months earlier, with no symptoms in the intervals.

However, within 24 hours after admission, our patient developed left chemosis with eyelid edema and erythema.

Extraocular movements were limited in all directions in both eyes, with a larger deficit in the right eye.Adolescent boy with eyelid swelling, redness, and pain.

During the prior admissions, treatment included antibiotics for orbital cellulitis and corticosteroids for suspected antibiotic allergies.Physical examination was notable for right upper and lower eyelid edema and erythema, conjunctival hyperemia, chemosis, and proptosis (Figure, A).

His vision and pupillary responses were normal.

Fundus examination revealed mild blurring of the disc margins only on the right side.

Slitlamp examination identified numerous cells in the right anterior chamber.

A, Swelling of the right orbital (white arrowhead) and periorbital (black arrowhead) tissues and proptosis, with mild swelling of the left upper eyelid (blue arrowhead).

B, Maxillofacial computed tomography with intravenous contrast showed severe right proptosis with stretching of the right optic nerve (white arrowhead) and thickening of the rectus muscles and soft tissues (black arrowhead).

Mild enlargement of the lacrimal gland on the left side can also be seen (blue arrowhead).

C, Maxillofacial magnetic resonance imaging with intravenous contrast.

Coronal (left) and axial (right) views showed inflammation involving the intraconal fat and perineural soft tissues (white arrowhead), as well as the inferior and lateral extraocular muscles, on the right side.

The left eye appeared normal at admission.

The black arrowheads indicate the muscles in the coronal and axial views.Computed tomography (Figure, B) and magnetic resonance imaging (MRI) (Figure, C) of the orbit were performed.


Her medical history was unremarkable; in particular, she had no history of endometriosis.

She had visited the emergency department of another hospital 2 weeks before with the same symptoms and had received conservative treatment.

A mass was palpable in the lower right abdominal quadrant.

On physical examination in the present visit, she had lower abdominal tenderness but no sign of peritoneal irritation.

The results of routine blood investigations, including white blood cell count, hemoglobin concentration, and C-reactive protein level, were within normal limits, as they had been in the previous hospital.

Abdominal ultrasonographic examination was performed, followed by abdominal computed tomography; the results were suggestive of an ileal intussusception (Figure, A).

A colonoscopy revealed the presence of a bulge in the cecal lumen (Figure, B).A, Abdominal computed tomography suggesting the presence of an ileal intussusception.


Of note, the patient’s son has a history of neurofibromatosis 1.

He denied having pelvic pain, urinary symptoms, or bowel symptoms.

However, on surveillance computed tomography, he was noted to have a new pelvic mass that was concerning for a recurrent malignant neoplasm.

His prostate-specific antigen level was undetectable.

Subsequent magnetic resonance imaging revealed a heterogeneously enhancing mass within the prostatic bed, which had central necrosis (Figure).

The mass measured 4.8 × 5.5 × 5.0 cm and was contiguous with the right obturator internus.

No appreciable lymphadenopathy was noted.

Computed tomography–guided biopsy revealed spindle cells with a low mitotic index.

The result of immunohistochemical staining was diffusely positive for desmin and smooth muscle actin, as well as focally positive for pan-keratin and S100.

The staining result was negative for CD34 and CDK4.

Fluorescence in situ hybridization failed to demonstrate MDM2 (OMIM 164785) gene amplification.Magnetic resonance imaging of the pelvis reveals a large heterogeneously enhancing mass within the prostatic bed.

Axial (A and B) and sagittal (C and D) views reveal that the mass has T1 isointensity to hypointensity and T2 hyperintensity, suggesting internal areas of necrosis.

A marked mass effect is seen on the anterior-inferior bladder, which displaces the bladder superiorly.

The mass is contiguous with the right anterior aspect of the obturator internus and with the inner cortex of the midline superior pubic rami, which demonstrate erosion of the midline but no appreciable enhancing marrow signal.


His medical history included hypertension and diabetes mellitus; he had no recent travel.

The mass was associated with increasing pain as it grew rapidly, starting from the size of a dime and increasing to extend 15 cm.

The patient reported spontaneous drainage of pus from the mass and an unexplained weight loss.

Physical examination revealed a large palpable mass with central fluctuance and surrounding erythema.

The mass extended from the subcostal region to the anterior superior iliac spine on palpation and was tender to touch.

No active drainage was noted; however, multiple pustules were present (Figure 1A).

Computed tomography of the chest, abdomen, and pelvis showed a large (10 × 15 cm) soft-tissue mass in the right lateral abdominal wall, extending from the level of the diaphragm to the iliac crest (Figure 1B and C).

The mass appeared to directly invade the liver and extend through intercostal spaces with multiple small areas of calcification.

The patient was then taken to the operating room where an excisional biopsy was performed.A, Right flank mass on initial presentation.

Core needle biopsy showed inconclusive results, and a recommendation was made for a fresh tissue biopsy.


She denies fever, cough, orthopnea, weight loss, and appetite change.

Physical examination reveals tenderness at the location of the left fifth rib and reduced left chest expansion.

Chest radiography (Figure 1) shows left lower lobe opacification obscuring the left hemidiaphragm and blunting of the left costophrenic angle.Left, Anteroposterior chest radiograph.

She has been treated with analgesia and physiotherapy.


The lesion appeared as a small reddish-brown macule 3 years ago and has gradually increased in size.

During the past several months, the lesion has become indented and increasingly tender.

The patient denies systemic symptoms, including fevers and chills, and is primarily concerned about the changing appearance of the lesion and the new-onset tenderness.

Cutaneous examination reveals a 3-cm sclerotic reddish brown patch with central yellow deposits (Figure 1).

Laboratory evaluation includes a random blood glucose level of 217 mg/dL (12 mmol/L).


Three years earlier, red cell scintigraphy documented a splenic hemangioma, which remained stable on periodic computed tomography (CT) scans.There is no history of abdominal trauma, melena, or hematochezia.

The patient had lost 6.75 kg (15 lb) and experienced increasing fatigue during a period of 1 month.

On physical examination, vital signs are normal.

The spleen edge is palpable 6 cm below the left costal margin (increased from 1 month prior).

There is no hepatomegaly or lymphadenopathy.

On rectal examination there is no gross blood, and no stool to perform a guaiac test.

Laboratory studies show a hemoglobin level of 6.8 g/dL (from 12 g/dL 2 months earlier and 8 g/dL 1 week earlier), white blood cell (WBC) count of 15.76 × 109/L, and platelet count of 266 × 109/L.

A CT scan of the abdomen was performed (Figure 1).Computed tomography scan of the abdomen.


He had a distant history of contact lens wear but terminated use owing to recurrent corneal abrasions.

The patient was unemployed and denied cigarette smoking, alcohol use, or drug use.

Current medications included insulin, nasal spray, and aspirin.

The patient reported redness in his eye for 2 days.

He denied pain, itchiness, or recent ocular trauma.

Review of systems was positive for stiff joints of the hands and back pain.

On examination, uncorrected visual acuity was 20/40 in the right eye and 20/100 in the left eye.

Findings from Schirmer testing without anesthesia for 2 minutes were 20 mm OD and 15 mm OS.

Corneal sensation was bilaterally decreased to a level of 2/4.

There were inferior corneal epithelial defects, with significant corneal thinning bilaterally, and an inferonasal Descemetocele of the right eye.

The anterior chambers possessed 3 to 4+ cells, with bilateral hypopyons (Figure).

Serology was sent owing to concern regarding the patient’s joint pain, need for a Crohn disease workup, and presence of bilateral corneal thinning with anterior uveitis.

Significant results included an elevated rheumatoid factor of 27 IU/mL (normal, 0-14 IU/mL), while all other laboratory results were within normal limits.

Results from corneal cultures were positive for pansensitive coagulase-negative Staphylococcus, which was likely a contaminant from the eyelids.A, Slitlamp photograph of the right eye demonstrating a paracentral neurotrophic ulcer with anterior uveitis and a hypopyon.

His medical history was significant for uncontrolled type 2 diabetes mellitus, leading to bilateral below-the-knee amputations, and osteomyelitis.

The patient reported that results from a workup for Crohn disease were negative.


An ophthalmologic examination revealed visual acuity without correction of 20/20 in both eyes, and slitlamp examination findings of the right eye identified a unique lesion that was oval in shape, measured 2 mm in thickness by 2 mm in diameter, was translucent and brown, and changed its location with head posture.During gonioscopy, we observed a nonpigmented wide angle without other findings that suggested adhesions between the lesion and the structures of the camerular angle.

The patient had a clear cornea without pathologic findings, and the intraocular pressure with Goldman tonometer was 10 mm Hg in both eyes.


She has a known allergy to infliximab and had not been exposed to this drug recently.

She lives in a heavily wooded area with 2 dogs and 3 cats, although she did not recall a tick bite.Photograph of the left buttock depicting one of the annular pink-violaceous patches.

The patient noticed the rash 1 day prior to presentation.

The rash was asymptomatic with no pain or pruritus.

Since that time, the patient reported low-grade fever and 1 week of headache for which she had been taking ibuprofen.

She denied any preceding upper respiratory tract symptoms.Physical examination revealed a well-nourished girl in no acute distress with approximately 10 pink-violaceous nummular and annular patches ranging from 1 to 4 cm in diameter (Figure).

These patches were located on the trunk, buttocks, and thighs bilaterally.

Fourteen days prior to presentation, the patient was seen in the emergency department for a temperature greater than 102°F.


He had no prior chronic medical conditions.

His family history was positive for a brother with kidney stones.

He was a former smoker but denied current drug or alcohol use.

The pain was associated with morning nausea and was worsened by food and alcohol.

Review of systems was positive for dry throat, gastroesophageal reflux, and frequent headaches.

Physical examination was notable for a faintly palpable midabdominal mass slightly to the left and above the umbilicus with localized discomfort to palpation.

Ultrasonography of the abdomen showed a hypoechoic, hypervascular, solid mass left of the midline (Figure, A).

A subsequent computed tomography scan of the abdomen and pelvis demonstrated a left adrenal myelolipoma and a 4.4 × 3.7-cm hypervascular soft tissue mass just left of the midline within the mesentery in close approximation with the small bowel, centered at the level of the L3-L4 intervertebral disc (Figure, B).

He was given trials of proton pump inhibitors and dicyclomine with no relief.

A laparotomy was performed and a round, well-circumscribed soft tissue mass located approximately 90 cm distal to the ligament of Treitz at the base of the mesentery was removed intact without the need for bowel resection (Figure, C).

Pathologic photomicrograph of the specimen is shown (Figure, D).Preoperative imaging of the mesenteric mass and gross surgical specimen and histopathologic analysis.

A, Preoperative ultrasonography showing a hypoechoic, solid mass.

B, Preoperative computed tomography scan showing a hypervascular soft tissue mass.

D, Histopathologic analysis of the mesenteric mass (hematoxylin-eosin).


Her medical history was significant only for asthma.Computed tomography revealed a large amount of free fluid throughout the abdomen and pelvis with an area of focal density consistent with a hematoma in the left midabdomen that measured 7.3 × 6.1 × 7.5 cm (Figure 1).

The patient had diffuse lower abdominal pain with nausea and one episode of emesis.

Her vital signs were notable for a blood pressure of 108/69 mm Hg and a heart rate of 124 beats/min.

Physical examination findings revealed tachycardia and a distended, diffusely tender abdomen without evidence of a seatbelt sign or peritonitis.

Her laboratory findings were unremarkable except for a hemoglobin level of 10.5 g/dL (to convert to grams per liter, multiply by 10) and a white blood cell count of 21 300/μL (to convert to ×109/L, multiply by 0.001).

There was also an area of free fluid in the right lower quadrant with irregularity of the right gonadal vein and a heterogeneous and bulky uterus.Computed tomographic image (sagittal view).

Image shows a large amount of free fluid throughout the abdomen and pelvis with an area of focal density consistent with hematoma in the left midabdomen that measured 7.3 × 6.1 × 7.5 cm.


Digital rectal examination revealed no stool in the vault and gross blood and pelvic examination were negative.Surgical history was notable only for a previous cesarean delivery.

Medical history was significant for 2 years of waxing and waning generalized abdominal pain and a hospital admission for small-bowel obstruction 11 months prior that was managed conservatively.

Physical examination demonstrated a soft, nontender, and nondistended abdomen without peritoneal signs or palpable masses.

Endoscopic evaluation revealed multiple polyps in the colon, stomach, and duodenum consistent with a diagnosis of juvenile polyposis syndrome.Admission laboratories demonstrated a lactate level of 18 mg/dL (to convert to millimoles per liter, multiply by 0.111), white blood cell count of 6000/μL (to convert to ×109/L, multiply by 0.001), and hemoglobin level of 13.3 g/dL (to convert to grams per liter, multiply by 10).

Amylase and lipase levels and chemistry findings were normal.

Computed tomography with oral and intravenous contrast was obtained and is shown with imaging from her initial presentation 11 months prior (Figure 1).Axial and coronal views of computed tomography imaging on initial presentation (A) and 1 year later (B).


He had been seen by his mother 1 hour earlier and was previously fit and well and up to date with immunizations.An ambulance was called and paramedics noted a reduced Glasgow Coma Scale score of 3, trismus with normal respiratory effort, and a scalp hematoma on the left forehead.

His Glasgow Coma Scale score had improved to 14, but he had no recollection of events.

His left leg was flexed, and he cried whenever this limb was examined.

On closer inspection, his left foot was warm, with generalized mild erythema and swelling.

There were bullae on the dorsum of the first and second toes and a cluster of painless, dry, black punctate lesions laterally (Figure, left).

On arrival in the emergency department he was afebrile, normotensive with a heart rate of 120 beats/min, and had a respiratory rate of 20 breaths/min.

Similar, paler lesions were clustered symmetrically on the left (Figure, right) and right forearms.Venous blood gas analysis revealed severe lactic acidosis (pH, 6.9; Pco2, 4.9 kPa; Po2, 11.8 kPa; bicarbonate, 7.1 mEq/L; base excess, −26 mEq/L; and lactate, 171.17 mg/dL [19 mmol/L]).

Values for serum glucose and ketones were 342.3 mg/dL (19 mmol/L) and 0 mmol/L, respectively.

Other laboratory investigations were unremarkable apart from a creatinine kinase level of 3000 U/L (50.1 μkat/L) and a white blood cell count of 20 × 109 cells/L with lymphocytosis.


The patient developed paroxysmal tachycardia on the third postoperative day.

He had no chest pain or mental status alteration.

On physical examination, his pulse was 130/min and irregularly irregular, blood pressure was 126/59 mm Hg, and breath sounds were diminished in bibasilar lung fields.

A bedside 12-lead electrocardiogram showed atrial fibrillation with rapid ventricular response and no ST-segment elevation.

Portable chest x-ray showed pulmonary edema.

He was scheduled for a laparoscopic right hemicolectomy.

Immediately before surgery, sequential compression devices were placed on his legs to reduce the risk for venous thromboembolic disease.

Following his uncomplicated operation, pulse oximetry showed oxygen desaturation requiring supplemental oxygen.

Upon evaluation, guaiac-positive stools were found and follow-up colonoscopy revealed an invasive adenocarcinoma of the cecum.


He has no other medical history or symptoms.

This surgery was performed in Nigeria, and he does not know why or what was done.

He is a construction project manager and does not smoke, drink alcohol, or use illicit drugs.

In the past month, the mass significantly enlarged and became more red and painful, and he can no longer close his eye.

His best-corrected visual acuity was 20/20 in the right eye and 20/25 in the left.

His pupils were round and reactive with no afferent pupillary defect.

His intraocular pressure was 12 mm Hg in the right eye and 13 mm Hg in the left.

Extraocular movements were normal in both eyes.

Slit lamp examination of the anterior segment of the right eye was unrevealing.

The anterior chamber, iris, and lens of the left eye were normal.

He underwent ocular surface surgery, presumably for a pterygium, on the left eye 1 year ago.

He does not take any medications.
Figure 1 shows the left eye.


The parents had noted a white pupillary reflection in the left eye for the past 2 months.

On ophthalmologic examination, the visual acuity of the right eye was 6/7.5 (equivalent to 20/25) and the left eye did not follow an object.

The remainder of the physical examination was unremarkable.


His medical history included squamous cell carcinoma of the lung diagnosed 1 year prior, which was resected.

C, Fundus photograph of the left eye with retinitis, serous retinal detachment, and disc hyperemia.The patient returned with loss of vision in his right eye.

One week later, he had vision loss in both eyes.

On examination, his visual acuity was 20/30 OD and 20/25 OS and he had  mutton fat keratic precipitates and 1+ cells in both eyes.

The vitreous and retina revealed no signs of inflammation.

The result revealed mild to moderate diffuse lymphadenopathy in the neck, axillae, mediastinal, and inguinal regions.

The symmetric pattern favored a diagnosis of sarcoidosis; metastatic disease was less likely.

A lymph-node biopsy showed lymphoid follicular hyperplasia and nonnecrotizing granulomatous inflammation, consistent with sarcoidosis.

The results of special stains were negative for bartonella, fungal organisms, and mycobacterial infection (Figure 1A).A, Hematoxylin-eosin stain of the lymph-node biopsy, low (top) and high (bottom) power (original magnification ×2).

B, Fundus photograph of the right eye with 3+ vitreous haze and retinitis.

On examination, his visual acuity was counting fingers OD and 20/30 OS.

He was treated with prednisone, 60 mg daily, for sarcoid panuveitis.

His visual acuity was hand motions OD and counting fingers OS.

The patient started treatment with prednisolone acetate, 1%, 4 times daily in both eyes.

He had 2+ cells in the anterior chamber and 3+ vitreous haze (Figure 1B).

Because the scan was consistent with a diagnosis of sarcoidosis in this patient with granulomatous anterior iritis, no further laboratory testing was pursued.

The day before, he had undergone a positron emission tomography scan to look for evidence of metastatic lung cancer.


He did not take any medications, had never been hospitalized, and had never had any major surgical procedures.

It had evolved from a flat discoloration since the age of 3 years, which continued to slowly enlarge and thicken.

The patient denied spontaneous bleeding or ulceration, and he had full range of motion and use of his extremity.

On inspection, there was a 4.5 cm × 3.5 cm, verrucous plaque with underlying fullness on the right medial thigh.

There were also punctate vessels evident on the hyperkeratotic surface.Close-up of lesion at presentation.

Neither he nor his family members reported a history of similar lesions on their body.

His upper and lower extremities were otherwise normal.

A verrucous, vascular plaque with underlying fullness on the right medial thigh.


He had a history of simultaneous pancreas-kidney transplantation 15 years ago and both grafts had been functioning well.

On examination, he was in no distress, had a temperature of 37° C, and blood pressure of 91/44 mm Hg.

Two days after presentation, a computed tomographic scan of the abdomen and pelvis was obtained (Figure).

It showed an air-containing abscess and a stent in the common iliac artery.A stent can be seen in the right common iliac artery (A and C, arrowheads).

A gas-containing phlegmon was also evident (B and C, asterisks).

Two days prior to presentation, he had a peripheral angiogram done to evaluate a nonhealing left foot ulcer by an interventional cardiologist, at which time a stent graft was deployed to the right common iliac artery for a pseudoaneurysm that was incidentally discovered.


The pain was initially transient and colicky, but had increased in intensity and became constant.

She denied having fevers, chills, or change in bowel habits.

On postoperative day 11 she returned with symptoms of fever and increasing right lower quadrant pain.

Weeks later, she presented to an outside facility with spotting and cramping.

During examination, the patient had significant focal tenderness to palpation, but displayed no peritoneal signs.

Her laboratory results were unremarkable, without any findings for leukocytosis or bandemia.Computed tomograpy (CT) scan and ultrasonography were inconclusive and revealed only mild haziness in the right lower quadrant and an abnormal-appearing cecum.

Magnetic resonance imaging of the abdomen was then performed to further investigate the area surrounding the cecum (Figure, A).

Arrowhead points at the suspicious structure within the cecum.

B, Histologic slide of the resected appendix shows positive progesterone receptor immunostaining (original magnification x400).The patient recovered well and was discharged home.

Imaging revealed an abscess near the ileocolic anastomosis, which was successfully treated with percutaneous drain placement.

Given these symptoms and findings, the decision was made to explore this patient laparoscopically.

After careful intraoperative evaluation, it became evident that she would require an ileocecectomy.

The removed specimen was sent to pathology for analysis.

The patient recovered and was discharged.

The histologic analysis is presented in Figure, B.A, Abdominal magnetic resonance imaging.

Intrauterine fetal demise was noted and the patient underwent an emergency dilation and curettage.


He does not wear dentures and denies trauma, use of tobacco products, poor nutrition, and risky sexual practices.

He denies pain and discomfort but is concerned because the mass has increased in size during the past year.

Physical examination reveals a healthy appearing male with a nontender, symmetric, nodular bony protuberance on the midline of the hard palate.

Two prominent protuberances are also noted at the bilateral maxillary tuberosities (Figure).


Past medical history and family history are unrevealing.Distal left middle finger.

She first noticed a black streak down the middle of her nail 10 years prior to presentation.

Subsequently, the pigmented band on the nail plate widened and darkened, with pigment spreading to the proximal nail fold and distal acral hyponychial skin.

She has no associated symptoms, including nail splitting, bleeding, or pain, and no history of acute or recurrent trauma.

The nail examination is illustrated in the Figure.

Examination of all other nails is unremarkable.

Several years previously, she was reassured that her nail pigmentation was benign.

D, Distal dermoscopic view.Reassure patient that this is benign nail pigmentationRecommend punch biopsy of the nail bed through intact nail plateRecommend removal of the entire nail plate with representative biopsy of all areas of pigmentSend clippings of the free edge of the nail plate for histopathology and culture.


Her home medication regimen consisted of ribavirin, rifaximin, lactulose, furosemide, spironolactone, peginterferon alfa-2a, and levothyroxine sodium.

Corrected visual acuity was recorded as 20/40 OU.

Her pupils, intraocular pressure, motility, and confrontational visual fields were normal in each eye.

Anterior slitlamp examination demonstrated mild nuclear sclerotic cataracts in both eyes.

Dilated fundus examination (Figure 1) demonstrated multiple peripapillary and macular cotton-wool spots in both eyes, dot hemorrhages in both eyes, peripapillary flame hemorrhage in the right eye, and a disc hemorrhage in the left eye.Fundus photograph of the patient’s right eye at presentation.


The rash was asymptomatic and started as red bumps that then evolved into pustules and blisters.

All other family members had significant improvement with the treatment; however, our patient’s lesions continued to worsen during the subsequent 2 weeks.

On physical examination, the patient had numerous erythematous macules, papules, and pustules on her back.

Many of the lesions had superimposed hemorrhagic crust and surrounding scale.

In addition, several grouped papules were noted, including some in a linear array (Figure 1A and B).

The rest of her cutaneous examination results were unremarkable except for a few fading pink papules noted on her left abdomen (Figure 1C).Numerous erythematous papules and pustules on the back, many with overlying hemorrhagic crust and surrounding scale (A) and (B), and few erythematous papules on the left lower abdomen (C).

Shortly after the onset of the outbreak, the patient and all family members were treated with 2 once-weekly doses of permethrin, 5%, cream.

On further questioning, it was discovered that the patient’s father worked in a nursing home that had experienced a recent outbreak of scabies.


Abdominal ultrasonography showed a well-defined hypoechoic lesion abutting the pancreas.

Further imaging by contrast-enhanced computed tomography (CT) and 3-dimensional reconstruction revealed a well-circumscribed, 3-cm lesion surrounding the common hepatic artery (Figure, A and B).

The lesion demonstrated patchy arterial enhancement, and a small irregularity of the common hepatic artery was present within the lesion.

Endoscopic ultrasonography demonstrated a hypoechoic, well-defined mass; fine-needle aspiration showed no abnormal cells within the paucicellular specimen.

Surgical exploration revealed a firm, ovoid lesion surrounding the hepatic artery at the origin of the gastroduodenal artery (Figure, C).

Following resection, the lesion was bisected to reveal a smooth white arterial lumen surrounded by grayish fibrotic tissue with punctate hemorrhagic foci.

Histologic sections of the specimen demonstrated small, singly dispersed vessels embedded in a background of fascicles of spindled cells with monotonous, fusiform nuclei and abundant eosinophilic cytoplasm.

Focally, areas of myxoid degeneration were present.

Despite extensive sampling, no mitotic activity, cytologic atypia, or areas of necrosis were identified.

There was strong, diffuse cytoplasmic staining for desmin (Figure, D), and staining results for S100 were negative.

Furthermore, CD34 stained strongly positive in vessels but failed to highlight the intervening stroma.A, Computed tomography of an enhancing mass (dotted circle) surrounding the common hepatic artery with emanating gastroduodenal artery, right hepatic artery, and left hepatic artery (arrowheads).

B, 3-Dimensional reconstruction of the location of the lesion (dotted circle) with relation to the involved vessels and surrounding structures.

C, Intraoperative view of a 3-cm mass surrounding the common hepatic artery just prior to the trifurcation of the gastroduodenal artery, right hepatic artery, and left hepatic artery.

D, The tumor cells showed strong cytoplasmic expression of the smooth-muscle marker desmin.


She had a history of hypertension and depression and was receiving omeprazole and paroxetine.

The mass had appeared 2 days before presentation and was associated with vomiting.

Additionally, the patient had not passed stools or had intestinal gas for 2 days.

On physical examination, the mass was exteriorized through the anal canal.

It was covered by hypoxemic rectal mucosa, but no digestive lumen could be identified inside the mass (Figure 1).

Furthermore, the patient had a distended abdomen, absent bowel sounds, and no tenderness to palpation.

No abdominal scar was visible, and no groin hernia was palpable.

Her blood pressure was 160/80 mm Hg and her temperature was 37.8°C.

Results of complete blood cell count, coagulation tests, and basic chemistry panel were all within normal limits.

An abdominal radiograph showed several air-fluid levels without pneumoperitoneum, confirming an intestinal occlusion.View of the mass exteriorized through the anus.


She does not take any prescribed or over-the-counter medications.

Review of systems is noncontributory, and she denies fevers, chills, shortness of breath, cough, and genital lesions.

Vital signs are normal, and physical examination reveals shallow erosions with hemorrhagic crusts on the lips and widespread targetoid macules with dusky centers on the palms (Figure).

The remainder of the examination is unremarkable.A, Shallow erosions with hemorrhagic crusts on the lips of a 22-year-old woman.


He was not aware of any lower leg injury but did note that the shin rash had started as a “bump” that developed a central scab.

One week before admission, he noticed tender skin eruptions adjacent to the anus and on the left shin.

The patient reported no fevers or chills.

He had no history of eczema and had not used any special wipes or cleansing agents in the perianal area.

He did not recall having skin lesions of this type previously.On physical examination an erythematous, indurated plaque with a central black hemorrhagic crust surrounded by yellow pustulovesicles was seen on the left shin.

Adjacent to and surrounding the anus there was an area of erythema with irregular margins and superficial exfoliation (Figure).Obtain a skin biopsy of the affected area on the left shin and apply a topical antibiotic to both the perianal area and the shin area until the pathology result is available.Obtain bacterial culture from both areas and start a systemic antibiotic.Obtain both bacterial culture and fungal culture of the affected areas and administer both a systemic antibiotic and a systemic antifungal agent.Obtain fungal culture from both affected areas and initiate systemic antifungal therapy.

He received high-dose intravenous methylprednisolone when he entered the hospital.

His physician had prescribed a combination cream of betamethasone diproprionate and clotrimazole for these lesions.


She had no significant medical history or prior ocular problems.

Best-corrected visual acuity was 20/20 OD and 20/25 OS, with eccentric fixation and trace exophoria in the left eye.

Anterior segment examination revealed an enlarged right corneal nerve.

The left macula had a fibrotic-appearing epiretinal membrane (Figure 1A).

There were 2 small, flat, pigmented lesions along the arcades of the right fundus (Figure 1B), likely atypical congenital hypertrophy of the retinal pigment epithelium (CHRPE) lesions, or pigmented ocular fundus lesions (POFLs).

B-scan ultrasonography and biometric A-scan showed bilaterally clear vitreous without retinal detachment.

Fluorescein angiography showed hyperfluorescence around the macula lesion without leakage, consistent with staining (Figure 1E), in the left eye.

On follow-up, optical coherence tomography showed focal macular thickening in the left eye, most likely a retinal hamartoma (Figure 1C), and intraretinal abnormalities between the retinal pigment epithelium (RPE) and photoreceptor layer in the right eye, consistent with POFLs and likely representing combined retina-RPE hamartomas (Figure 1D).


Her medical history includes asthma and acne.

Her medications included minocycline hydrochloride (for 25 months for acne), ranitidine hydrochloride, contraceptive pills, and iron supplements.An initial physical examination revealed mild synovitis in both ankles and an erythematous, raised papule overlying the distal aspect of the right anterior tibia.

The lesion first appeared as a skin-colored papule and, within a week, developed an erythematous halo.

Seven weeks later, the original skin lesion evolved into an ulcer with erythematous, raised borders (Figure 1).

The case patient had new eruptions of nonindurated, violaceous, nontender, reticulated patches overlying the skin on the bilateral anterior tibias, consistent with livedo reticularis.

Treatment with prednisone acetate (10 mg daily) was initiated.

She denies any previous episodes, and the results of a review of mitigating factors were negative.Ulcer with raised border and erythematous halo in distal right shin.A laboratory workup revealed a positive antinuclear antibody 1:640 nucleolar pattern, an elevated erythrocyte sedimentation rate, and elevated C-reactive protein and serum IgG levels.

The results of the following laboratory studies were negative or normal: complete blood cell count, urinalysis, liver profile, Lyme disease, parvovirus B19, Monospot test, uric acid, rheumatoid factor, antistrepolysin antibody, anti-Scl70, antihepatitis C virus, hepatitis B surface antigen, hepatitis B core antibody, cytomegalovirus antibody, and human T-lymphotropic viruses 1 and 2 antibody.

Culture results of the skin lesion were negative.

The results from chest radiography were normal.

To our knowledge, there is no family history of this condition.


Routine laboratory values were within normal limits.

The patient underwent ultrasonography of the abdomen, and 2 cystic lesions were discovered in the liver.

Magnetic resonance imaging of the abdomen revealed 2 multiloculated cystic lesions in segments IV and V of the liver (Figure, A).

Additional laboratory values included normal carcinoembryonic antigen and cancer antigen 19-9 levels.

Percutaneous aspiration with a biopsy of one of the cystic lesions was performed that revealed atypical cells suspicious for malignancy.

The patient was then referred for management to our institution, where she underwent an exploratory laparotomy and enucleation of these 2 complex multiloculated cystic lesions (Figure, B).A, Axial image from abdominal magnetic resonance imaging.


Her medical history was significant for hypertension and left breast invasive ductal carcinoma in 2007 treated with lumpectomy and adjuvant radiation as well as synchronous rectal cancer after neoadjuvant chemoradiation and abdominoperineal resection.

As part of her treatment course, the patient received a total dose of 50.5 Gy pelvic irradiation and 60 Gy irradiation to the left breast and axillary basin.

On physical examination, she had a hard, well-circumscribed, fixed mass in the upper, outer quadrant of her left breast.

The lesion was not tender to palpation nor was there any associated axillary or supraclavicular lymphadenopathy.

Examination of the nipple as well as the contralateral breast and axilla was unremarkable.

Computed tomography of the thorax revealed a 6.7 × 4 cm mass arising from the left chest wall distinct from the left breast with extent to the pleural surface of the left thorax (Figure, A).

Positron emission tomography revealed metabolic activity within the mass but did not reveal any distant disease.

Core needle biopsy confirmed the diagnosis and the patient was offered resection with reconstruction.A, Computed tomographic axial section of the thorax illustrating a left chest wall mass measuring 6.7 × 4 cm apparently distinct from the left breast parenchyma with possible pleural invasion.

Lung parenchyma adjacent to the chest wall reveals stippling and fibrosis consistent with previous irradiation.The patient underwent a left radical mastectomy including resection of the pectoralis major and minor and resection of the adjacent chest wall resulting in a chest wall defect spanning ribs 2 through 4 (Figure, B).

The patient underwent immediate reconstruction of the chest wall with 2-mm-thick expanded polytetrafluoroethylene and latissimus dorsi pedicle flap reconstruction of the soft tissue defect and breast mound.B.

B, Postresection wound including chest wall.

The patient denied any antecedent trauma or infection.

The patient was followed up with yearly computed tomography of the abdomen and pelvis in addition to yearly digital mammography.

Her last mammogram, 5 months prior to presentation, was unremarkable.


He has a history of hepatitis B, hepatocellular carcinoma, and idiopathic pancreatitis.

The lesions are initially very painful and slow to resolve.

New lesions tend to appear with, or immediately after, episodes of acute pancreatitis.

Laboratory evaluation reveals elevated levels of serum lipase (2700 IU/L) and amylase (3400 IU/L).

Examination of the skin reveals erythematous subcutaneous nodules symmetrically distributed on the bilateral lower and upper extremities, primarily on the lower legs and feet.

One of the largest nodules has a small amount of yellow, oily discharge.

Previous treatments have included incision and drainage of a nodule on the right foot as well as oral and intravenous administration of antistaphylococcal antibiotics for presumed cellulitis.


Treatment with desonide, 0.05%, ointment twice daily proved to be ineffective.

The patient’s rash also failed to clear with a therapeutic trial with griseofulvin liquid (125 mg/5 mL), 5 mL daily, and econazole, 1%, cream twice daily for 2 weeks and later ciclopirox, 0.77%, cream twice daily for 2 weeks, although the patient reported some improvement.

Three weeks later, the patient presented with 2 slowly expanding, hyperpigmented, ringlike lesions with a tendency toward central clearing and peripheral scaling and erythema on the right cheek (Figure 1).A 4-year-old girl presenting with two 5-cm-diameter annular patches (arrowheads) slowly increasing in size over 3 weeks on the right cheek.

Test results for antinuclear antibody and rheumatoid factor were negative.

The presence of persistent acneiform papules on the cheeks with postinflammatory hyperpigmentation led to a therapeutic trial of erythromycin, 400 mg/5 mL, 1.3 mL orally twice a day, with food.


He has been unemployed and bedridden for the last 3 years owing to his skin disease.

He has a history of ischemic heart disease, familial Mediterranean fever, and arthropathy.

On presentation, he noted anorexia and reported a 10-kg weight loss during the last 8 months.

On physical examination, he appeared cachectic.

His abdomen was soft with no palpable mass.

A macular rash with multiple infected ulcerated areas and diffuse lower limb edema was noticed (Figure 1).

The remainder of his physical examination results were unremarkable.

He was treated with nonsteroidal anti-inflammatory drugs for pain relief and steroids for the skin disease.

Except for the skin rash, he was newly diagnosed as having diabetes mellitus.


He had undergone hemodialysis for the past year and had a brachiocephalic fistula in his left arm.

His medical history was also significant for peripheral vascular disease, hypertension, and antiphospholipid antibody syndrome for which he was receiving warfarin sodium since 2010.

His other medications were epoetin alpha, ferrous gluconate, cinacalcet hydrochloride, paricalcitol, sevelamer carbonate, amlodipine besylate, labetalol hydrochloride, lisinopril, simvastatin, pentoxifylline, and Humalog and Lantus insulin.

He did not smoke.The patient had a temperature of 37.6°C and a grade II/VI systolic ejection murmur.

He had necrosis and eschar formation involving his fingers (Figure 1A), toes (Figure 1B and C), and left posterior medial calf (Figure 1D).

He had violaceous skin with central eschar on the posterior medial aspect of his right leg (Figure 1E) that was exquisitely tender with gangrenous change.

He had normal femoral pulses with no distal pulses palpable.

Both feet were warm with good Doppler signals in the dorsalis pedis and posterior tibial arteries.

He had a palpable pulse and thrill in the brachiocephalic fistula in his left upper arm.

There was also a weak distal radial pulse.

He had good Doppler signals over the radial, ulnar, and palmar arch arteries bilaterally.Photographs of necrosis and eschar formation involving fingers (A), right (B) and left (C) toes, left posterior medial calf (D), and violaceous skin with central eschar on the posterior medial aspect of the right leg (E).Laboratory studies revealed a white blood cell count of 13 900/μL (to convert to ×109 per liter, multiply by 0.001), a hemoglobin level of 7.7 g/dL (to convert to grams per liter, multiply by 10.0), a platelet count of 309 × 103/μL (to convert to ×109 per liter, multiply by 1.0), an international normalized ratio of 2.4, a blood urea nitrogen level of 88 mg/dL (to convert to millimoles per liter, multiply by 0.357), a creatinine level of 9.9 mg/dL (to convert to micromoles per liter, multiply by 88.4), a calcium level of 7.5 mg/dL (to convert to millimoles per liter, multiply by 0.25), an albumin level of 2.4 g/dL (to convert to grams per liter, multiply by 10), and an intact parathyroid hormone level of 349.7 pg/mL (to convert to nanograms per liter, multiply by 1.0).

A skin biopsy specimen of the calf showed epidermal necrosis, dermal hemorrhage, focal dermal intravascular thrombi, and subcutaneous intravascular and extravascular calcifications.


Previously she was able to run 5 to 6 miles per day.

She has no other cardiovascular risk factors.

Her blood pressure is 124/76 mm Hg bilaterally.

There is a high-pitched systolic bruit over the right subcostal region and the umbilicus.

Exercise tolerance has worsened over the past year and is now limited to several blocks.

The ankle brachial index (ABI) at rest is borderline normal (0.91) on the right and normal (1.03) on the left.

The remainder of the examination is normal.After physical therapy and nonsteroidal anti-inflammatory agents failed to improve symptoms, a computed tomography angiogram (CTA) is performed, revealing a “beaded appearance” in the right renal artery and a long-segment stenosis of the right external iliac artery.

A catheter-based angiogram confirms the CTA findings (Figure).Perform angioplasty and stenting of the right renal and external iliac arteries.Manage medically with antihypertensive agents and a walking program.Perform angioplasty of the right renal artery and angioplasty with stenting of the right external iliac artery.Administer cilostazol for claudication and continue lisinopril for hypertension.


Thirteen days before delivery, she visited the emergency department with flulike symptoms.

The infant was born at 40 weeks’ gestation by forceps delivery.

During admission, the infant developed violaceous skin lesions with edema in inguinal and axillary regions (Figure).

Lesions became ulcerated within 3 to 4 days, with infarcted necrotic areas.

Blood tests showed leukopenia (white blood cell count, 2460/μL) with neutropenia (neutrophil count, 220/μL) (to convert both to ×109 per liter, multiply by 0.001).

Intravenous floxacillin was started, followed by surgical debridement due to progression of the major lesions.Axillary inflammatory nodule (A) and inguinal inflammatory plaques with violaceous hue (B).His mother was addicted to drugs, she had a known hepatitis C virus infection, and the pregnancy was unsupervised.

Routine infectious screening revealed negative serology for syphilis, hepatitis B virus, and human immunodeficiency virus (HIV) types 1 and 2 by enzyme-linked immunosorbent assay (ELISA).


In addition, the patient had worsening lower back and lower extremity pain, treated as sciatica on an outpatient basis, for 3 months.

The patient had constipation, urinary incontinence, and generalized weakness but no fever, nausea or vomiting, or change in bowel movements.

Physical examination revealed a firm, nonpulsatile, slightly tender mass in the left lower quadrant and significant perineal ecchymosis.

Laboratory test results were remarkable for white blood cell count (13 800/μL [to convert to ×109 per liter, multiply by 0.001]), blood urea nitrogen level (72 mg/dL [to convert to millimoles per liter, multiply by 0.357]), creatinine level (4.2 mg/dL [to convert to micromoles per liter, multiply by 88.4]), hemoglobin level (9.8 g/dL [to convert to grams per liter, multiply by 10.0]), and international normalized ratio (2.7).

Computed tomography of the abdomen and pelvis was performed (Figure).Computed tomographic images of the abdomen and pelvis.

A, Axial imaging shows that the bladder (black arrow) is displaced to the right, and a Foley catheter is located anteriorly.

The rectum (white arrow) is compressed posteriorly.

B, Coronal imaging shows that the bladder (arrow) is severely displaced, and a Foley catheter is located medially.


He had a 50-year history of cigarette smoking and had stopped smoking 5 months prior to being seen.When the symptom of hemoptysis occurred 5 months earlier, chest radiography and computed tomography (CT) revealed a ground-glass opacity in the left upper lobe.

However, about 1 month later, hemoptysis reoccurred and increased volume and frequency over the following 4 months.After treatment with an antifibrinolytic agent, a ball-like mass with an air crescent sign in the left upper lobe was noted.On physical examination, sonorous rhonchi were audible in the bilateral lungs.

Chest CT revealed a cavitary lesion with a central contrast-enhanced ball-like mass at the site of the prior ground-glass lesion.

Sputum examinations for acid-fast bacilli smear and culture, fungal culture, and cytology showed negative results.

Fiberoptic bronchoscopy revealed blood clots over the orifice of the left upper lobe bronchus, but no endobronchial lesion was detected.The chest CT finding, characteristic of a fungus ball-like shadow with an air crescent sign, highly suggested a pulmonary aspergilloma.

However, the contrast enhancement was present within the mass, and lung malignancy could not be excluded.

The patient was treated with an antifibrinolytic agent (tranexamic acid), and the hemoptysis gradually improved and follow-up chest radiography showed resolution of the lesion (Figure 1).

A whitish, firm nodule about 2 cm was noted in a cavity in the left upper lung.


In the weeks before her hospital admission, she developed subacute cognitive deterioration and progressive headaches.

On presentation she has difficulties initiating speech (nonfluent aphasia) and responds slowly and inconsistently to questions.

Otherwise, her physical examination is unremarkable.

Laboratory studies reveal an elevated erythrocyte sedimentation rate (ESR) (135 mm/h), anemia (hemoglobin level, 9.5 g/dL), and high serum levels of soluble interleukin 2 receptor (sIL2R) (36 551 pg/mL), lactate dehydrogenase (LDH) (448 U/L), and β2-microglobulin (3.1 mg/L), with normal renal function, liver enzyme levels, and serum immunological and microbiological findings.

Analysis of the cerebrospinal fluid (CSF) demonstrates a mildly increased leukocyte count (11 × 106/L) and total protein concentration (0.10 g/dL).

Magnetic resonance imaging of the brain shows multiple infarctions, and digital subtraction angiography of the intracranial vessels demonstrates abnormalities suggestive of vasculitis (Figure 1).

An electrocardiogram, computed tomography scans of the chest and abdomen, 18-fluorodeoxyglucose positron emission tomography, transesophageal echocardiography, inspection of the skin, and ophthalmologic evaluation are unremarkable.A, Axial MRI using fluid-attenuated inversion recovery (left) demonstrating hyperintense multifocal lesions involving mainly the subcortical white matter; axial diffusion-weighted MRI (right) showing hyperintense lesions consistent with recent infarctions.

B, Digital subtraction angiography of the intracranial vessels showing widespread areas of vessel wall irregularity, which consist of zones of focal stenosis and luminal tapering in many third-order and fourth-order branches.Initiate secondary preventive treatment for multiple infarctions with antiplatelet agents.Postpone treatment; obtain a brain biopsy including the leptomeninges.Postpone treatment; obtain random skin biopsies and a bone marrow biopsy.


He denies any travel or illicit drug use.

He has received appropriate immunizations, has no relevant family history, and has never experienced similar episodes.

The eruption began in his scalp and subsequently spread over 9 days’ time to his neck, back, and chest.

The patient otherwise feels well, without fever, chills, or systemic symptoms.

The physical examination is notable for numerous grouped vesicles and relatively monomorphic tense bullae, coalescing into markedly annular plaques, superimposed on erythematous bases with central clearing and scale.

The eruption is generalized and symmetric but predominates on his posterior neck, back, chest and upper arms (Figure 1), and inner thighs.

He is otherwise afebrile and appears well.A, Grouped vesicles and tense bullae in a generalized distribution on the trunk and extremities of patient.

He had been seen in the emergency department and prescribed oral cephalexin for the eruption, with no improvement.

He denies any other use of medication (including prescription or over-the-counter medications, herbal supplements, and vitamins) in the days, weeks, or months prior to onset.


On examination, visual acuity measured 20/50 OD.

Three months later, at the Illinois Eye and Ear Infirmary, she reported an improvement in her vision but noted negative images of dots when her right eye was closed.

Her local ophthalmologist considered a white dot syndrome and recommended a systemic workup.

Results of a complete blood cell count, comprehensive metabolic panel, antinuclear antibodies (including DNA and ribosomal SSA/Ro), positron emission tomography and magnetic resonance imaging (MRI) of the brain, mammography, and chest radiography were normal.

Dermatologic examination revealed a nevus on the left arm, a nevus on her left shoulder, and seborrheic keratosis on her left shoulder.

Visual acuities measured 20/30 OD and 20/20 OS.

Slitlamp examination findings were normal; there were no anterior chamber or vitreous cells.

Funduscopic examination revealed yellow-white, multisized, subretinal, creamy lesions clumped in various portions of her retina, including the periphery (Figure 1).

The lesions were smaller in the posterior pole and larger in the periphery.

Subretinal serous fluid was present overlying some of the prominent lesions inferiorly, without associated exudate or hemorrhage.Fundus photograph shows yellow-white, multisized, subretinal, creamy lesions in the right eye.


The patient otherwise had no significant medical history and was in good health.

At puberty, the lesion expanded in size, became irritated, and developed a papillated, rough texture.

On physical examination, there was a 3.6-cm × 1.5-cm verrucous skin-colored to light-brown plaque on the right nasal sidewall (Figure).Clinical photograph of a 3.6-cm × 1.5-cm verrucous skin-colored to light-brown plaque on the right nasal sidewall.


She had no comorbidities, such as diabetes mellitus or hypertension, and no previous admission to the hospital.

She is married and has 4 children; her last child was born 40 days prior to her presentation to the hospital.

The pain was usually generalized but sometimes radiated to the right iliac fossa.

The pain got worse with meals and was associated with nausea but no vomiting.

In the last 2 days, the pain was associated with loose stools, but there was no mucus or blood.

On examination, her vital signs were normal (temperature, 37.1°C; pulse, 86 beats/min; and blood pressure, 121/86 mm Hg).

There was mild tenderness in the right iliac fossa, but no lump or lumps were felt.

Her white blood cell count was 8500/μL (to convert to ×109 per liter, multiply by 0.001), her hemoglobin level was 1.3 g/dL (to convert to grams per liter, multiply by 10.0), and her platelet count was 361 × 103/μL (to convert to ×109 per liter, multiply by 1.0).

The results of renal and liver function tests were normal.Abdominal ultrasonography revealed a 4.2 × 4.2-cm mass in the midabdominal region lateral to the gall bladder fossa.

The mass has the “donut sign” with central echogenicity (Figure 1A).

An abdominal computed tomographic scan (Figure 1B) showed a 8.2 × 4 × 2.6-cm tubular thin-walled filling defect in the cecum and lower part of ascending colon.

The oral contrast agent can be seen around, proximal, and distal to the defect, with no obstruction noted.Abdominal ultrasonographic image revealing a 4.2 × 4.2-cm mass with central echogenicity, the “donut sign” (A).


The patient denied any previous medical or surgical history.

On examination, the patient had mild right upper quadrant tenderness to palpation without signs of peritonitis.

Her imaging results from the outside hospital included abdominal magnetic resonance cholangiopancreatography revealing a cystic abnormality in the region of the porta hepatis (Figure 1A).

Routine laboratory values were within normal limits, except for a mildly elevated amylase level.

A computed tomographic scan was obtained to further delineate the abnormality (Figure 1B).Magnetic resonance cholangiopancreatography (A) and abdominal computed tomography (B) revealing a cystic lesion in the region of the porta hepatis (arrowheads).

F indicates feet; H, head; L, left; and R, right.


She had received the bisphosphonate zoledronate for treatment of metastatic renal carcinoma for several months before the lesion appeared.

The patient reports no trauma or acute process around the area.

On examination, the teeth are mobile, and an area of exposed bone tissue in the mandible is detected (Figure).

There is no tenderness on palpation or profound gingival bleeding.


She is currently working and lives at home with her male partner and her pets.

She is a nonsmoker and drinks alcohol socially.

She describes it as a black lace over her field of vision that she first noticed after waking 8 days prior to presentation.

Owing to worsening vision, she was referred to us for further evaluation.

Her best-corrected visual acuity is 20/200 in the right eye and 20/20 in the left eye, with a right relative afferent pupil defect.

The results of a slitlamp examination of the intraocular pressure, motility, and anterior segment in both eyes are unremarkable.

Dilated examination findings of the left eye are normal.

She has no systemic symptoms and no past ocular or systemic health problems.


There was no history of teratogenic exposure, no family history of congenital defects, and no history of consanguinity.

There was mucus discharge from the opening.

There was no other craniofacial anomaly and bilateral nasal cavities were normal.

The trunk was 2.5 cm in length connected with a thin pedicle.

Computed tomography (CT) scan and magnetic resonance imaging (MRI) showed no other associated craniofacial abnormality.Full-term, 10-day-old girl with a trunklike projection from the medial canthus of the left eye.


Her only significant medical history was a routine cesarean section 4 years earlier.

Physical examination findings revealed a firm, mobile, nontender, midline abdominal mass.

A computed tomographic (CT) scan was performed, which showed a well-circumscribed, 10-cm mass (Figure 1).

A large, well-circumscribed mass (white arrow) is shown on the cross-sectional image.

The patient was scheduled for elective exploratory laparotomy and resection.Scout (A) and cross-sectional (B) images from a computed tomographic scan of the abdomen.

Several different physicians had evaluated the patient previously without a definitive diagnosis or treatment.


The patient had been experiencing early satiety and heat intolerance.

Physical examination was significant for orthostatic hypotension and an immobile, nontender abdominal mass.

An abdominal computed tomographic scan was obtained (Figure, A).

Based on these findings, the patient underwent surgical resection (Figure, B).Coronal imaging illustrating a large heterogeneous mass in the left abdomen (A).


The lesion began 4 years ago as a crusted papule following a puncture wound, caused by the tip of a wooden stick, that resulted in some mild bleeding.

The lesion then gradually increased in size and was slightly pruritic on occasion.

The patient reports experiencing no fevers or chills since the development of the rash.

On physical examination, a dark red plaque measuring 3.0 × 4.0 cm is observed on the right upper quadrant of the back.

The plaque is irregularly shaped with a defined border and includes several black or brown dot-like petechiae.

The plaque appears elevated and infiltrative, with a rough surface covered in waxy white crusts.

He was initially diagnosed with eczema in a local clinic and has been treated with intermittent topical application of 2.5% hydrocortisone cream over the last 3 months, with no improvement.

The physical examination is otherwise negative.


She presented for evaluation because new lesions of similar appearance appeared on the upper limbs, trunk, vulva, and perineum despite antibiotic therapy.

Also the vulva and perineum had an intense erythematous rash.

Physical examination revealed many large, tense bullae filled with clear fluid, rounded with an erythematous base and “rosette-like” blisters (Figure).

She was apyretic and vital parameters were normal.

Laboratory tests showed a normal white blood cell count and lymphocyte subpopulations, erythrocyte sedimentation rate, and C-reactive protein level.

Test results for anti-transglutaminase and antiendomysial antibodies were negative.

She had been treated with topical mupirocin and oral amoxicillin–clavulanate potassium for a suspected superficial skin infection.


His symptoms followed a 1-day discharge from a recent hospital admission for a viral illness.

He denied any history of trauma, and the remaining medical history was unremarkable.

At the time of evaluation, he reported associated left shoulder pain and was in noticeable distress.

Physical examination revealed a distended abdomen with associated diffused peritoneal signs.

He was afebrile, with a heart rate of 77 beats/min, blood pressure of 96/46 mm Hg, oxygen saturation of 100% in room air, and a respiratory rate of 16 breaths/min.

Abdominal ultrasonography was performed (Figure 1).Ultrasonography image of the right (A) and left (B) upper quadrants of the abdomen.


On examination, he tested positive for the Blumberg sign.

Blood analysis showed leucocytosis, neutrophilia, and an increased level of C-reactive protein.

Ultrasonographic (Figure, A) and computed tomographic images (Figure, B) showed a thickened wall outpouching arising from a discreetly thickened appendix and inflamed surrounding fat.

Right-sided colonic diverticulosis was also seen.

The patient underwent an appendectomy with gross findings as shown in Figure, C.Ultrasonographic image of the right lower quadrant (A) and sagittal reformatted computed tomographic image (B), both showing a thickened wall outpouching (arrow) arising from the vermiform appendix (arrowheads) with inflammatory changes in the surrounding mesenteric fat (asterisk).

C, Gross findings of excised appendix (arrowheads) reveal an inflamed wall outpouching (arrow) and mesenteric fat (asterisk).


She denies use of alcohol or illicit substances.

She denies fevers, chills, and other systemic symptoms.

Physical examination reveals necrotic black eschars and scattered stellate purpuric patches on the lower extremities (Figure, A and B).

All areas are exquisitely tender to palpation.

The remainder of the examination is unremarkable.A, Necrotic black eschars on the lower extremities.

B, Stellate purpuric patches on the lower extremity.Laboratory investigation demonstrates a creatinine level of 1.9 mg/dL (168.0 μmol/L), elevated from her baseline level of 1.2 mg/dL (106.1 μmol/L) 1 month ago.

Lupus anticoagulant level (60.9 seconds [normal value, <43.1 seconds]), prothrombin time (14.2 seconds [normal range, 11-13.2 seconds]), and partial thromboplastin time (35.4 seconds [normal range, 21-33 seconds]) are slightly elevated.

Her cancer was diagnosed 6 months ago, and she was treated with primary surgical debulking, with partial omentectomy, loop ileostomy, and 4 cycles of chemotherapy with paclitaxel + carboplatin and panitumumab + gemcitabine.


The cancer was well controlled for 31 months, when his tumor recurred and he was switched to erlotinib (150 mg/d).

One month later, he developed a few erythematous follicular papules with focal scaling on the scalp, which intermittently improved and worsened and were reasonably well controlled with topical corticosteroids.

Subsequently, the number of scalp lesions increased, accompanied by pustules and hair loss.

Paronychia, pruritus, and dry skin were also present, but the pustular eruption was limited to the scalp.

Numerous pustules with an erythematous base were observed on the scalp vertex (Figure 1).

Neither pustules nor hair loss was noted.

Neither fever nor other constitutional symptoms were noted.


The mother was 22 years old, gravida 3, para 3, without significant comorbid conditions.

She received prenatal care during the pregnancy and was negative for hepatitis B surface antigen, human immunodeficiency virus, and reactive rapid plasma reagin.

She denied a history of sexually transmitted infections, cold sores, or genital lesions.

Multiple 7- to 8-mm vesicles with erythematous bases, some with hemorrhagic crusting and others filled with clear fluid, were scattered over the chest, back, and extremities (Figure 1).

Physical examination of the neonate demonstrated a preterm, nondistressed, healthy-appearing patient, with normal vital signs.

Oropharyngeal lesions and neurologic deficits were not present.

During prenatal care she tested positive for group B streptococcus and received appropriate treatment.


She reported a normal eye examination by an optometrist 6 months prior and no history of corrective lens wear.

Her visual acuity without correction in each eye was count fingers at 5 ft with pinhole improvement to 20/200.

On slitlamp examination, the anterior chambers were shallow and the angles on gonioscopy were closed in each eye (Figure).

The undilated fundus examination revealed normal-appearing optic nerves with cup-to-disc ratios of 0.2.

Intraocular pressures were 48 mm Hg OD and 49 mm Hg OS.

When given a −6.50 D sphere trial lens, her visual acuity improved to 20/20 OD and 20/25 OS.


He had been undergoing a maintenance chemotherapy regimen consisting of vincristine sulfate, 6-mercaptopurine, methotrexate, and high-dose prednisone.

He did not undergo bone marrow or stem cell transplant as part of his treatment.

A and B, Multiple tiny, spiny, follicular hyperkeratotic papules on the face.

Alopecia was also noted involving the eyebrows and the eyelashes, but the scalp was spared.

Multiple topical medications including keratolytics were applied to the affected areas without effect.Skin examination and microscopy analysis of punch biopsy specimen.

C and D, Microscopy showed abnormal maturation of anagen hair follicles with excessive inner root sheath differentiation (original magnification ×4 [C] and ×40 [D]).Skin examination revealed multiple 1- to 3-mm, spiny, follicular, flesh-colored to erythematous hyperkeratotic papules predominantly on the face and to a lesser extent on the trunk, and extremities, with fine hairlike spicules emanating from most of them (Figure, A and B).

A punch biopsy specimen was taken (Figure, C and D).


The pain was localized to her right abdomen, both upper and lower quadrants, with acute tenderness to palpation.

Ultrasonographic findings gave concern for acute cholecystitis.

A computed tomographic scan was ordered by her primary care physician after admission to the hospital (Figure).


One day after the onset of pain, he presented to the emergency department.

The patient described his pain intensity as 8 on a scale of 1 to 10.

He also described having some nausea but no anorexia, and he experienced a single episode of emesis in the emergency department.

He was afebrile, and his heart rate was 86 beats/min; blood pressure, 128/86 mm Hg; and body mass index, 28 (calculated as weight in kilograms divided by height in meters squared).

Bilateral lower abdominal and supraumbilical tenderness was present, as was lower abdominal voluntary guarding to palpation.

Deep palpation of the left lower quadrant did not elicit pain over the right lower quadrant (ie, negative Rovsing sign).

Internal and external rotation of the flexed right leg did not elicit pain (ie, negative obturator sign).

Dorsiflexion of the right thigh against the examiner’s hand resulted in right lower quadrant pain (ie, positive psoas sign).

Levels of liver function enzymes, amylase, and bilirubin were normal, as was a complete blood cell count, except for leukocytosis of 14 000 cells/mm3.

A computed tomography (CT) scan was obtained (Figure 1).Computed tomography scan in the case patient.

A, Axial view.
B, Coronal view.
C, Sagittal view.


The patient’s medical history was notable for a 30-year history of hypertension and diabetes.

The bulge was more prominent on standing, coughing, and straining.

Physical examination revealed a reducible protrusion in the left flank, with several red to light brown macules on the overlying skin (Figure).

Computed tomography (CT) of the abdomen showed convexity of the left lower abdominal wall compared with the right and did not reveal any mass, hernia, or accumulation of fluid in the abdominal cavity.A, Lateral view showing hyperpigmented macules on the overlying skin of the left flank bulge.

Antiviral agents were not administered when he first developed zoster because the diagnosis was established more than 72 hours after first presentation of the disease.


On primary and secondary survey, he had a patent airway, was hemodynamically stable, and had a single entrance wound over the right mandible.

The appearance of his oropharynx was unremarkable.

The trachea was in midline, and breath sounds were clear and equal in all lung fields.

Radiography of the chest showed a foreign body in the right side of the chest (Figure, A).

After this initial imaging, the patient was log-rolled onto his left side, and a computed tomography (CT) scan of the chest was obtained (Figure, B).A, Anteroposterior chest radiograph taken in the trauma bay on arrival.


She has no ophthalmic or medical history and denies recent travel or abnormal exposures.

She denies ocular discomfort or systemic symptoms.

Her uncorrected acuity is 20/60 OD without improvement with pinhole and 20/20 OS.

Her pupils, intraocular pressure, motility, and confrontational visual fields are normal in each eye.

Results of the external examination and slitlamp examination of the anterior segment of both eyes are unremarkable.

Dilated examination findings of the left eye are normal.


He had no history of perinatal infections, sick contacts, recent travel, or pets.

The family lives in an apartment in New York City.On physical examination, the patient had fewer than 20 pink papulovesicles, some with hemorrhagic crust, scattered on the upper chest, abdomen, lower back, and extremities (Figure, A and B).

His parents reported several pink papules that first appeared on his trunk and spread to his extremities within 24 hours.

His increasing irritability and poor oral intake led to his admission for further evaluation.

His palms, soles, and oropharynx were otherwise unremarkable.Clinical and histologic images of papulovesicles.

The clinical images show scattered pink papulovesicles, some with overlying hemorrhagic crust (A and B).

C, A histologic section (hematoxylin and eosin, original magnification ×10) of a papule shows a focally eroded epidermis (asterisk) with a relatively dense and diffuse perivascular and interstitial dermal infiltrate (arrow) of predominantly mononuclear cells and a few neutrophils, with changes indicative of a mild vasculitis.Laboratory test results were notable for a mild leukopenia with a white blood cell count of 4.6 × 109/L (normal, 6.0-18.0 × 109/L) with 18% monocytes.

C-reactive protein was slightly elevated at 3.38 mg/L (normal, <2.9 mg/L).

Blood, urine, and wound cultures were taken, and a skin punch biopsy was performed (Figure, C).

The patient’s vaccinations were up to date.

He was started treatment with intravenous ceftriaxone and intravenous acyclovir.


She had a complicated medical history that was significant for non-Hodgkin lymphoma, chronic diarrhea, myelodysplastic syndrome treated with chemotherapy, and Behçet syndrome treated with prednisone acetate (6 mg daily).

Her surgical history was significant for a previous right-sided hemicolectomy due to recurrent right-sided diverticulitis.

The patient had some accompanying cough, nausea, and arthralgias but denied having dyspnea, emesis, and chest or abdominal pain.

On examination, she was alert and awake with appropriate mental status.

Her vital signs were as follows: blood pressure of 150/59 mm Hg, heart rate of 127 beats per minute, respiratory rate of 20 breaths per minute, temperature of 38.5°C (101.3°F) (oral), and an oxygen saturation as measured by pulse oximetry of 99% in room air.

The physical examination was unremarkable.

Significant laboratory data included a white blood cell count of 2700/μL (reference range, 4800-10 800/μL; to convert to ×109 per liter, multiply by 0.001), a lactic acid level of 19.8 mg/dL (to convert to millimoles per liter, multiply by 0.111), and a platelet count of 72×103/μL (to convert to ×109 per liter, multiply by 1.0).

Urinalysis showed trace blood, positive nitrite, +1 leukocyte esterase, and a white blood cell count of 2000/μL to 5000/μL.

A urine culture came back positive for Klebsiella pneumonia, and a blood culture came back positive for Enterobacter sakazakii (now know as Cronobacter sakazakii).

There was concern about the source of the bacteremia, so an infectious disease consult was ordered, and a computed tomographic scan of the abdomen/pelvis with contrast was performed.

The patient was scheduled for surgery, and the findings are shown in Figure 2.

Figure 1 shows a coronal, reformatted image of the scan.


She denied any history of hematemesis or hematochezia.

On abdominal examination, an irregular mass measuring 20 × 10 cm without tenderness was found, and no bruit was heard on auscultation.

No other vascular anomalies were detected on systemic examination.

All laboratory test results were within normal limits.

Upper gastrointestinal endoscopy showed normal gastric mucosa.

Nonenhanced computed tomography of the abdomen showed a partially well-circumscribed, mixed cystic and solitary mass that partially enveloped the stomach and compressed adjacent organs, likely arising from the stomach (Figure 1).Axial nonenhanced computed tomographic image showing a mixed cystic and solitary mass that partially enveloped the stomach.


His history included lumbar spine surgery and chronic back pain leading to continued requirement for opiate analgesia.

Endoscopy revealed food stasis throughout the esophagus, large diverticula in the lower esophagus, no resistance at the lower esophageal sphincter, and extensive candidiasis.

A barium swallow was diagnostic (Figure 1).

Esophageal manometry demonstrated 100% hypertensive propagated pressure waves in the distal esophagus, with a mean esophageal pressure of 335 mm Hg, a maximum pressure of 701 mm Hg, and normal relaxation of the lower esophageal sphincter.

The patient was treated with antifungal therapy and received a 1-month course of calcium channel antagonists, but symptoms were unchanged and weight loss progressed.


He has no relevant medical history and does not take any
medications.

Apart from the lesions, the physical
examination is unremarkable.

Skin examination reveals disseminated sharply demarcated, dome-shaped,
red-brown papules and nodules with a shiny, waxy surface.

These 0.1- to 0.8-cm lesions are on his
face, scalp, ears, neck, trunk, shoulder (Figure 1A),
upper extremities (Figure 1B), lower extremities
including the palms and soles, and scrotum.

The mucous membranes and periorbital area are spared.

A
shave biopsy reveals a yellow appearance of the base of the papule.

Hematoxylin-eosin stains reveal
a diffuse inflammatory infiltration of the upper and middle dermis with lymphocytes, plasma cells,
numerous foamy histiocytoid cells, and a large number of multinucleated cells.

Emperipolesis
(engulfed lymphocytes) is present within the histiocyte cytoplasm.

Electron microscopy shows indented nuclei and emperipolesis in histiocytes.

No family members have similar symptoms.


His medical history was significant for pharyngitis associated with scarlet fever that he had a month before; the pharyngitis was treated by his general practitioner with clarithromycin (500 mg twice daily for a week).

No throat culture or rapid antigen test for group A streptococci was performed at that time.

He complained of nausea, vomiting, and asthenia as well.

On physical examination, he presented with mild right upper abdominal quadrant tenderness.

He met all the criteria for systemic inflammatory response syndrome, and his blood tests showed a marked increase in inflammatory markers.

Blood and urine cultures were obtained, and the results were negative.

An abdominal ultrasonographic examination revealed a 6-cm, solid, inhomogeneous mass in liver segment 6.

A contrast-enhanced computed tomographic scan of the abdomen (Figure 1) showed that the lesion was hypodense with numerous septa without contrast enhancement.

Magnetic resonance imaging (Figure 2) evidenced a mixed solid-liquid lesion, with some septa delimiting large areas of necrosis.

The results of a serological detection test for echinococcosis were negative.

His carcinoembryonic antigen, carbohydrate antigen 19-9, and α1-fetoprotein blood levels were normal.

Serological markers for hepatitis B virus, hepatitis C virus, and human immunodeficiency virus were negative.

A study of leukocyte populations and immunoglobulin electrophoresis did not reveal any disorder of the immune system.Computed tomographic scan showing a large, hypodense, multiloculated lesion in liver segment 6.Magnetic resonance imaging scan showing an heterogeneous, capsulated lesion, with numerous septa delimiting large areas of necrosis.

Empirical antibiotic therapy with ampicillin sodium/sulbactam sodium was started.


Medical and family histories were unremarkable and no abnormalities were found on physical examination.

A radiograph of the right knee showed osteolytic lesions in the distal femur and the head of the tibia.On magnetic resonance imaging, the epiphyseal lesions were visualized as cystic and nonsclerotic and extended to the articular surface of the distal femur and proximal tibia (Figure 1).

Soft tissue extension was suspected from the tibia.

Laboratory test results showed normal blood cell count, renal function, and concentration of C-reactive protein.Aneurysmatic bone cysts were suspected and a biopsy was performed.

Histopathological examination detected spindle cell infiltrates with hemorrhages, fragmented trabecular bone, and numerous osteoclastic giant cells proliferating at a rate of 10% suggesting an aggressive giant cell lesion.Since it was still not determined whether the lesions were malignant, flourodeoxyglucose F 18 positron emission tomography/computed tomography was performed and found additional lesions in the left distal femur and the left mandible.

Biopsy of the mandible showed the same type of tissue as seen in the right femur and tibia.