Malignant transformation of an enterogenous cyst

Primary neoplasm arising from the kidney

A 57-year-old woman with non–insulin-dependent diabetes mellitus and no other medical history had worsening left-sided back pain over 4 months and no other symptoms

Physical examination findings were significant for mild left flank pain, but there was no costovertebral angle tenderness

Laboratory results were within normal limits

Axial imaging demonstrated an exophytic, retroperitoneal mass with solid and cystic components involving the left kidney, posterior abdominal wall, and mesocolon (Figure 1)

The mass measured 20 cm in its greatest dimension

Findings on colonoscopy and mammography were negative

Positron emission tomography–computed tomography did not reveal any other abnormality

Coronal computed tomographic image showing a retroperitoneal mass with a cystic component and involvement of adjacent kidney and mesocolon

Red arrowhead indicates descending colon

blue arrowhead, left kidney invaded by mass

and yellow arrowhead, retroperitoneal mass with cystic component


A 73-year-old woman presented to the emergency department with 2 days of crampy abdominal pain and obstipation and 2 months of fecaluria and pneumaturia

Physical examination revealed hepatomegaly and left lower abdominal tenderness

She had normal liver function test results and a carcinoembryonic antigen level of 23.8 ng/mL (to convert to micrograms per liter, multiply by 1)

Computed tomography of the abdomen and pelvis revealed a 9-cm, obstructed sigmoid colon mass with fistulous extensions to the bladder and small bowel and numerous metastases to the liver, peritoneum, and omentum

Pathologic analysis of an endoscopic biopsy specimen revealed a moderately differentiated colon adenocarcinoma

The patient was referred to a gastroenterologist for stent placement (Figure 1A)

The night after the procedure, the patient developed generalized peritonitis, and computed tomography revealed abundant free air (Figure 1B)

B, Computed tomogram depicting perforation

The patient went to the operating room for an emergency laparotomy


A man in his 60s was admitted to the hospital for an 8-day history of abdominal pain, bloating, vomiting, diarrhea, subjective fever, weight loss, and fatigue

He also complained of multiple tender red lesions on his bilateral ankles and legs that appeared 2 days prior to admission

Findings from a review of systems were negative for cough, sore throat, history of hepatitis, tuberculosis, sarcoidosis, inflammatory bowel disease, or sulfonamide use

Physical examination revealed several ill-defined, exquisitely tender erythematous subcutaneous nodules on his bilateral shins, medial feet, ankles, and right lower thigh without overlying ulceration, necrosis, or drainage (Figure, A and B)

A punch biopsy was performed, demonstrating pathognomonic histopathologic findings (Figure, C and D)


A man in his 60s presented to the emergency department for left flank pain of 1 week’s duration

His medical history included severe peripheral arterial disease and a remote history of ruptured abdominal aortic aneurysm

Three months before presentation, he underwent percutaneous endovascular stenting of a left popliteal artery aneurysm

Physical examination of the left flank showed a well-defined 5 × 12-cm purpuric patch with a darker stellate patch within it (Figure, A)

Two punch biopsy specimens were obtained (Figure, B and C)

A, Photograph of a purpuric patch on the left flank

B, Biopsy specimen 1 (hematoxylin-eosin, original magnification ×40) showing needle-shaped clefts within the lumen of a blood vessel with minimal perivascular inflammation

C, Biopsy specimen 2 (hematoxylin-eosin, original magnification ×40)

Eccrine ducts show cellular dyshesion and necrosis


A man in his 70s presented with a 2-week history of a bullous eruption localized to the hands and feet

He denied having pruritus or spontaneous bleeding but reported discomfort from the pressure of intact bullae

His medical history was notable for diabetes mellitus and hypertension, which was well controlled with a stable regimen of lisinopril and atenolol for several years

He denied using any new medications or supplements or making recent dose adjustments in existing medications

There was no history of a prior bullous eruption

Physical examination revealed numerous small intact bullae and large erosions on the lateral feet, soles, and toes (Figure, A)

The extent of the bullae led to difficulty with ambulation

There were also intact vesicles on the lateral palms along with erosions demonstrating evidence of previous bullae formation

There were no vesicular or bullous lesions on the trunk, arms, legs, or mucosal surfaces

Hematoxylin-eosin staining of a biopsy specimen obtained from a bulla on the foot was performed (Figure, B)

A, Numerous small bullae in various stages of healing and large erosions on the feet with areas of denuded pink dermis on clinical presentation

B, Biopsy specimen obtained from a bulla on the foot (hematoxylin-eosin, original magnification ×600)


A 24-day-old African American boy born at full term via an uncomplicated spontaneous vaginal delivery presented with a 7-day history of annular plaques on the upper forehead and scalp (Figure)

The plaques emerged on day 17 of life and did not change in appearance or increase in number

He had normal growth and development and no illnesses or fevers prior to presentation

He had no contact with sick persons or with household members with similar skin lesions, and there was no history of recent sun exposure

There was no family history of autoimmune disease, and the mother denied symptoms of dry eyes, dry mouth, cavities, or photosensitivity

A physical examination revealed a well-appearing afebrile male neonate with 5 annular plaques located on the frontal and posterior scalp

The thin red border had fine scaling and several pinpoint pustules

In addition, there were faintly pink patches with scaling on the medial eyebrows and mesolabial folds

There was no cervical or postauricular lymphadenopathy


A woman in her early 60s with a history of hypertension and hyperlipidemia was transferred to our hospital after multiple transient ischemic attacks and left internal carotid artery (ICA) stenosis during the past several months

Her most recent presentation was 1 week prior for a minor stroke with amaurosis fugax, slurred speech, right-sided weakness, and facial droop lasting longer than 24 hours

Magnetic resonance imaging of the brain demonstrated subacute infarctions involving the left frontal and parietal hemispheres

She was a current smoker and was taking aspirin and statin medication at the time of presentation

Workup at another facility prior to transfer included computed tomographic angiography of the neck, which showed chronic occlusion of the right ICA and 95% stenosis of the left ICA

On examination, the patient was afebrile with a heart rate of 69 beats/min and blood pressure of 134/69 mm Hg

Pertinent findings included no carotid bruit, a regular cardiac rhythm, and equally palpable upper extremity pulses bilaterally

The patient was neurologically intact, save for 4/5 motor strength in her right upper extremity

Computed tomographic angiography of the head and neck was performed (Figure 1)

Sagittal view demonstrates the left internal carotid stenosis (A indicates anterior

P, posterior) (A) and the distal extent of the findings (arrowhead) (B)


A man in his 50s with type 1 diabetes mellitus presented with a 3-month eruption of small reddish brown spots affecting most of his fingers

The lesions were persistent, asymptomatic, and without aggravating or alleviating factors

The patient used standard finger sticks to test his blood glucose levels daily

However, he had pricked his fingers for decades without incident

A review of symptoms was positive only for intermittent bloating and diarrhea

Physical examination revealed multiple petechiae in a linear arrangement extending from the volar and lateral aspects of the fingers to the finger pads (Figure, A)

Results from initial laboratory tests, including a complete blood cell count, comprehensive metabolic panel, antinuclear antibody, erythrocyte sedimentation rate, rheumatoid factor, and cardiolipin antibody, were unremarkable

Results from a urinalysis and transthoracic echocardiogram were also unremarkable

Punch biopsies for histopathologic examination (Figure, B) and direct immunofluorescence (Figure, C) were performed

B, Histopathologic image showing subtle collections of neutrophils within the dermal papillae (hematoxylin-eosin, original magnification ×200)

C, Direct Immunofluorescence revealing granular IgA deposition within the dermal papillae and at the dermoepidermal junction (original magnification ×400)


A man in his 60s presented with a 1-year history of dystrophic nails, doughy palms, and redundant skin on each side of the gluteal cleft

He also reported easy bruising with minor trauma

Physical examination showed trachyonychia (rough accentuated linear ridges) on 8 fingernails (Figure, A), thin and brittle toenails, diffuse nonscarring alopecia, and multiple purpuric patches on the forehead, scalp, chest, and arms

He had substantial laxity of the skin on finger pads (Figure, A), and both sides of the gluteal cleft revealed soft, nontender, rugated, skin-colored linear kissing plaques with no vesicles, bullae, ulcers, or erosions present

A, Nail and cutaneous findings including trachyonychia of the fingernails and cutaneous laxity of the fingerpads

B, Histopathologic specimen of the nail bed showing orange, amorphous and extracellular material deposited in the subungual dermis of the nail bed (Congo red special stain, original magnification ×10)

C, Same specimen under polarized light microscopy revealed intense apple-green birefringence of the amorphous material in the subungual dermis (lower half of the photomicrograph) (Congo red special stain, polarized light microscopy, original magnification ×10)


A man in his 20s sustained a 92% total body surface area (TBSA), full-thickness burn after being doused in gasoline and set on fire

On arrival to the emergency department, the patient was intubated and resuscitated

He underwent emergent chest, bilateral upper and lower extremity escharotomies, and a decompressive laparotomy for abdominal compartment syndrome

Thirteen days after admission, he required a left upper extremity amputation at the level of the proximal humerus owing to development of nonviable muscle tissue that demonstrated black plaques and white nodules (Figure, A and B)

Once the patient was hemodynamically stable he was taken to the operating room and underwent 4 operations for debridement and grafting, with the initial operation taking place 10 days after admission

His hospital course was complicated by recurrent polymicrobial aspiration pneumonia, caused by methicillin-sensitive Staphylococcus aureus, Pseudomonas aeruginosa, and Enterococcus

All were successfully treated with antibiotics

A, Newly excised burn wound with stitches at the amputation site and a large white nodule

B, Close-up view of a burn wound newly excised to the subcutaneous tissue with black, plaque-shaped growth

C and D, Histopathologic images, original magnification ×50. C, Hematoxylin-eosin


A 16-year-old girl presented with fever, rash, and diffuse pain for 5 days

She reported a pruritic, painful rash on her hands and feet and multiple painful joints

Animal exposures included 3 new puppies and rodent infestation in the home and neighborhood cats

She did not report recent travel or arthropod bites

On examination, her right elbow and left knee were swollen and warm

She reported pain with passive movement of the right shoulder and left wrist

Petechial and pustular lesions were present on both hands and palms (Figure, A)

Her feet, including the soles, had many petechial lesions and a few purpuric lesions (Figure, B)

A, Numerous scattered erythematous papules and petechiae with a few pustules on the palm and fingers of the left hand

B, Many petechiae on the dorsum of the feet

Results of laboratory testing were significant for a white blood cell count of 5050/μL (to convert to ×109/L, multiply by 0.001) and a platelet count of 55×103 (to convert to ×109/L, multiply by 1)

Results of urinalysis and comprehensive metabolic panel were unremarkable


Gastrointestinal stromal tumor with central necrosis

A 54-year-old woman presented with a 6-month history of watery diarrhea and severe halitosis

She also lost more than 30 kg of weight during this period

Physical examination revealed acute cachexia with conjunctival pallor and an immobile nontender mass in the left upper abdomen

Her laboratory test results revealed a microcytic anemia and hypoalbuminemia

Abdominal computed tomography was performed (Figure 1)

The patient was scheduled for exploratory laparotomy and resection

A large central necrotic mass is shown in this computed tomography image of the abdomen


A 28-year-old white man presented to the gastrointestinal (GI) medicine clinic for persistent nausea and vomiting

He had a long-standing history of gastroesophageal reflux disease that was only partially controlled with proton pump inhibitor therapy

The symptoms were exacerbated by cessation of proton pump inhibitor medication, and he reported an associated 9-kg weight loss

Results of laboratory testing were significant for iron deficiency anemia (hematocrit, 31% [to convert to proportion of 1.0, multiply by 0.01]) and hemeoccult-positive stool

Upper and lower endoscopy, computed tomography enterography, PillCam capsule endoscopy, and a Meckel scan failed to identify a source of GI bleeding

The patient received a retrograde double-balloon enteroscopy that showed an outpouching in the distal ileum (Figure, A) with an accompanying ulceration of the adjacent mucosa (Figure, B)

Exploratory laparotomy with small-bowel resection was performed, and the gross specimen is shown in Figure, C

B, Ulceration adjacent to the outpouching of the distal ileum

C, Resected distal ileum revealing an ulceration of the mucosa


Abscess of the lesser sac (omental bursa)

Perforated ulcer of the posterior stomach wall

Lesser sac (omental bursa) internal hernia through the epiploic foramen

Large diverticle of the transverse colon

A woman in her 50s presented to our emergency department with a 3-hour history of sudden epigastric and right upper quadrant pain

She did not report any previous abdominal surgery

The colicky pain did not migrate during that period and occurred in paroxysms at 9- to 10-minute intervals

The patient was afebrile and had no nausea or vomiting

Physical examination revealed mild tachycardia (96/min) and moderate abdominal distension without signs of peritonism

Careful examination ruled out incarcerated hernias in the groin, femoral triangle, and obturator foramen

Blood analysis results showed mild leukocytosis (total white blood cell count, 10.5 × 103/μL [to convert to ×109 per liter, multiply by 0.001]) without elevation of the C-reactive protein level (<3 mg/L [to convert to nanomoles per liter, multiply by 9.524])

Serum electrolyte levels were within the normal range

Computed tomography of the abdomen was conducted (Figure)

Computed tomographic images of the abdomen

Arrowheads indicate the border of the epiploic foramen

asterisk, the air-filled cecum in the lesser sac


A white woman in her 50s presented for evaluation of recurrent gingival ulcers of 8 years’ duration

She reported that at the time of initial onset, multiple painful ulcers had appeared on the anterior maxillary gingiva

She stated that the lesions had resolved spontaneously without treatment but recurred 8 years later as swelling and ulceration of the maxillary and mandibular gingiva

She denied involvement of cutaneous surfaces and reported a history of ligneous conjunctivitis since childhood (Figure, A)

Her medical history was significant for hypothyroidism, seizures, and functional heart murmur

Medications included levothyroxine sodium, mometasone furoate, levocetirizine, and benzonatate

Review of systems was significant for easy bruising and prolonged bleeding

Intraoral examination revealed generalized mild edema with rolled margins of the maxillary and mandibular gingiva accompanied by nodular ulceration of the left maxillary gingiva (Figure, B)

Biopsy specimens were obtained from the gingival ulcer (Figure, C and D) and buccal mucosa for routine histological and direct immunofluorescence analysis, respectively

Also obtained were a complete blood cell count with differential and comprehensive metabolic panel

A, Pseudomembranous masses affecting conjunctival mucosa of the left eye consistent with ligneous conjunctivitis

B, Edema with rolled margins and nodular ulceration of the left maxillary gingiva

C and D, Punch biopsy specimen from the maxillary gingiva showing aggregates of relatively amorphous, eosinophilic material beneath the epithelium and around blood vessels (C, hematoxylin-eosin, original magnification ×100

D, hematoxylin-eosin, original magnification ×200)


Epidermolysis bullosa, Dowling-Meara type

A newborn male infant was transferred to the neonatal intensive care unit for widespread vesicles and erosions evident at birth, following a spontaneous vaginal delivery complicated by fetal meconium exposure

The mother, initially unavailable for examination because she remained at the facility where she had given birth, reported via telephone that she was healthy except for a urinary tract infection for which she had taken a 7-day course of nitrofurantoin monohydrate approximately 3 to 4 weeks before delivery

She denied a history of herpesvirus infection, blistering disorder, or autoimmune disease

On physical examination, the neonate exhibited extensive erosions rimmed by purulent vesicles involving the groin, neck, scalp, fingers, and left side of the upper chest (Figure, A and B)

Biopsy specimens were obtained, with results as shown in the Figure, C and D

A, Erosions rimmed with flaccid turbid vesicles involving the groin, thighs, and abdomen

B, Large erosion with a rim of flaccid purulent vesicles and crusting on the left side of the chest

C, Histopathologic analysis of truncal skin sample demonstrating suprabasilar acantholysis with an eosinophil-rich infiltrate (hematoxylin-eosin, original magnification ×40)

D, Direct immunofluorescence of perilesional skin from the right side of the chest demonstrates IgG in an intracellular “chicken wire” pattern involving the lower spinous layer (original magnification ×40)


Erythema annulare centrifugum, deep variant

A young man in his 20s with no significant medical history presented with an annular eruption on the face and upper torso of 2 weeks’ duration

The eruption began on his upper back, at which time he felt well

He then received significant sun exposure while on a 7-day trip to Miami, Florida

After returning from his trip, he noted that the eruption had become more prominent on his back and had spread to his face

In addition, he began to have a febrile illness with joint pain and swollen nodes, which subsequently resolved without treatment

The lesions continued to rapidly enlarge without scaling, and his plaques were not associated with itching or pain

The patient was not taking any medications at the time and denied any recent international travel

Physical examination revealed multiple annular plaques with raised erythematous-violaceous borders on the face, distributed mainly along the forehead and temporal region (Figure, A)

There were similar coalescing lesions found on back (Figure, B)

No other mucocutaneous findings were noted, and the rest of examination was unremarkable

A punch biopsy specimen was obtained from a plaque on the right upper back and submitted for pathologic review (Figure, C and D)

A, Multiple annular plaques with raised erythematous-violaceous borders are distributed mainly along the frontal and temporal region of the head

B, Similar findings are seen on the patient’s face with more central clearing and attenuated coloring

C, This pathologic specimen from a lesion on the upper back depicts distended sebaceous lobules with associated follicular dilatation and a mild chronic perivascular and perifollicular lymphomononuclear infiltrate

D, This pathologic specimen from the upper back exhibits sebaceous lobules with sebocyte necrosis and an associated neutrophilic infiltrate that also includes scattered lymphomononuclear cells


Erythema ab igne with superimposed chemotherapy effect

A man in his 60s presented in consultation from his oncologist for a 3-week history of a pruritic eruption on his back in the setting of stage IV, progressive, neuroendocrine pancreatic cancer

He had undergone numerous chemotherapeutic regimens over the past 3 years, all of which had failed

For the past 4 months he had been receiving oral etoposide (daily for the first 3 weeks of each 4-week cycle), daily pancrelipase, and monthly octreotide acetate intramuscular injections

He denied the use of heating pads but admitted to sitting on the hearth, directly in front of his fireplace, for long periods because of the cold weather and chills presumably from his underlying malignant neoplasm

He acknowledged a mild, untreated seasonal rhinitis but otherwise had enjoyed good health prior to his cancer diagnosis

Physical examination revealed a large, reticulated, erythematous plaque with micaceous and silvery scale localized to the mid-back (Figure, A)

A punch biopsy was performed (Figure, B-D)

A, Large, reticulated, erythematous plaque with silvery scale localized to the mid-back

B, Mild hyperkeratosis overlying an epidermis with dysmaturation and apoptotic cells, increased small blood vessels, pigment incontinence, and perivascular inflammation with lymphocytes and eosinophils (hematoxylin-eosin, original magnification ×20)

C, Keratinocyte dysmaturation demonstrated by large keratinocytes with hyperchromatic nuclei and prominent nucleoli, and increased mitoses with starburst cells (arrowheads) (hematoxylin-eosin, original magnification ×60)

D, Squamous metaplasia and apoptosis of the eccrine ducts (hematoxylin-eosin, original magnification ×60)


A newborn presented on the first day of life with a chest mass found on initial examination in the nursery (Figure 1)

She was born at 38.3 weeks via spontaneous vaginal delivery after an uncomplicated pregnancy to a 35-year-old, G3, now P2 mother with no significant medical history

Results of maternal prenatal laboratory tests were all unremarkable

She received regular prenatal care, and routine ultrasonography revealed no anomalies

The Apgar scores were 9 at 1 minute and 9 at 5 minutes

No resuscitation was required in the delivery room

The newborn was already breastfeeding well, voiding, and stooling by the time of the initial examination

Physical examination revealed a 3.5 × 4-cm mobile mass on the right lateral trunk at the midaxillary line at levels approximately T4 to T6. The mass was firm and round, although when palpated it was not homogeneous or smooth

There was no discoloration of the overlying skin

Results of the remainder of the physical examination were normal


An 85-year-old man with a history of occupational exposure to asbestos presented with 1 week of nausea and vomiting without any bowel function

The patient denied any history of abdominal surgery

On examination, he was mildly distended and tender focally on the right side

In the emergency department, a nasogastric tube was placed, yielding a moderate amount of dark, foul-smelling output

Laboratory results were significant for a white blood cell count of 13 300/μL (to convert to ×109 per liter, multiply by 0.001) (bands 20%)

A contrast-enhanced computed tomographic scan of the abdomen and pelvis  demonstrated dilated small intestine (measuring up to 4.7 cm), with air-fluid levels extending to the terminal ileum (Figure 1A and B)

There were several loops of normal-caliber bowel proximal to the area of concern

The decision was made to take him to the operating room for exploration given the lack of any previous abdominal surgical procedures and no other explanation for his symptoms

Intraoperatively, a large portion of the small intestine was involved in dense adhesions

After performing careful lysis on the distal involved bowel, a tightly coiled and twisted segment was encountered (Figure 1C)

At this point, further attempts to separate loops of small intestine would have been difficult, and the decision was made to resect this segment (approximately 110 cm) and perform a primary anastomosis

Cross-sectional computed tomographic scan of the abdomen

Dilated small intestine with air-fluid levels extending to the terminal ileum (A and B)

C, Intraoperative image of involved small intestine

Tightly coiled and twisted small bowel with adhesive bands


A 72-year-old man presented to the hospital after sustaining a fall, with prior generalized weakness and fatigue

He had been having recurrent gastrointestinal bleeding and melena during the past year

He reported a 6.75-kg weight loss during the past few months but did not have abdominal pain, nausea, vomiting, fevers, or chills

His surgical history was notable for a coronary artery bypass graft 9 months earlier and γ-knife resection of an acoustic neuroma 10 years ago

Physical examination revealed a soft, nontender abdomen without obvious palpable masses

Inspection of the patient’s skin demonstrated multiple fleshy, soft cutaneous nodules (Figure 1A)

The patient’s laboratory testing was only notable for anemia with a hemoglobin level of 10.4 g/dL (reference range, 12-16 g/dL)

A prior extensive examination, including upper and lower endoscopy, upper gastrointestinal series with small-bowel follow-through, and capsule endoscopy did not reveal a diagnosis

A computed tomography image of the abdomen and pelvis is shown in Figure 1B

A, Multiple cutaneous nodules and pigmented spots are evident on physical examination

B, Cross-sectional imaging reveals a large, complex, septated, right-upper-quadrant abdominal mass


Cutaneous anaplastic large cell lymphoma

Extranodal NK/T-cell lymphoma, nasal type

Subcutaneous panniculitis-like T-cell lymphoma

A white man in his 60s was referred to our dermatology clinic for rapidly enlarging lesions on his calf, thigh, and cheek

Three months prior, he had noticed a small nodule on his calf, with no overlying skin changes or tenderness

This progressed to a tender, nodular plaque while other lesions appeared

The patient denied other signs or symptoms

His medical history included Parkinson disease, for which he took no medication

Laboratory findings showed an elevated lactate dehydrogenase (LDH) level at 439 U/L (reference range, 118-242 U/L) (to convert LDH to microkatals per liter, multiply by 0.0167)

Results from serum chemical analyses, complete blood cell count, and tests of liver functions were normal

Physical examination revealed a healthy-appearing man with a 4.0 × 4.0-cm pink, firm, tender nodular plaque on his left calf (Figure, A), a 5.0-cm firm, subcutaneous mass on his right thigh, and a 0.5 × 0.5-cm subcutaneous nodule on his left cheek

There was no cervical, axillary, or inguinal lymphadenopathy

A punch biopsy specimen was obtained from each lesion (Figure, B and C)

A, Clinical photograph of the nodular plaque on the left lateral calf

B and C, Histopathologic images from the punch biopsy specimen demonstrating angiocentrism

B, The large atypical lymphoid cells can be seen infiltrating a vessel (outlined by arrowheads) (hematoxylin-eosin, original magnification ×400)

C, Histopathologic image from the punch biopsy specimen showing positive EBER in situ hybridization

The atypical lymphocytic infiltrate is strongly positive for EBV, as shown by EBV-encoded RNA in situ hybridization (original magnification ×600)


A woman in her 50s presented with “speckled” red lesions on her bilateral arms, lower legs, and feet

They had first appeared on her lower legs 15 years ago and were slowly increasing in number and spreading to involve her feet and bilateral upper extremities

The patient denied tenderness, pruritus, and edema

She reported no family history of this problem and denied any personal history of anemia, epistaxis, hematemesis, melena, hematochezia, or hemoptysis

She had a medical history of hypertension, hyperlipidemia, and tobacco abuse, requiring treatment with losartan and atorvastatin

Physical examination revealed punctate, blanchable telangiectasias coalescing to form large, retiform patches on her bilateral lower extremities, feet, and upper extremities (Figure, A)

There was no conjunctival or mucosal involvement

The patient reported no dermatographism or purpura

Histologic findings from a biopsy specimen are shown in the Figure, B

A, Multiple telangiectasias coalescing to form large, retiform patches on the bilateral lower extremities

B, Dilated, ectatic vessels in the superficial dermis with no associated inflammation or fibrinoid necrosis (hematoxylin-eosin, original magnification ×200)


A woman in her late 30s presented for evaluation and management of tender, reddish brown, slightly pruritic papules and plaques on the scalp, in the inframammary region, and in the perineum that had been present for approximately 1 year

Previous treatment with multiple courses of topical and systemic antifungals, topical and systemic corticosteroids, and oral antibiotics had failed

She reported pain, pruritus, and serous discharge associated with the plaques but denied any systemic symptoms

Her medical history was unremarkable, and she was not taking any medications at the time of presentation

Results of a physical examination revealed well-demarcated, moist, erythematous plaques and erosions in the bilateral inframammary regions (Figure 1A) and the intertriginous regions of the groin and scattered excoriated papules on the scalp

A punch biopsy specimen of the plaque along the left inframammary region was sent for pathologic evaluation (Figure 1B-D)

A, Well-demarcated erosive plaques on the bilateral inframammary region

B, Abundant atypical cells within the epidermis and papillary dermis (hematoxylin-eosin, original magnification ×10)

C, Abundant atypical cells with reniform nuclei within the epidermis and papillary dermis (hematoxylin-eosin, original magnification ×40)

D, Immunohistochemical analysis (original magnification ×10)


An 8-year-old girl presented to the dermatology clinic for further evaluation of a lesion over the right posterior thigh (Figure, A)

Her mother reported the lesion appeared at age 3 months, was previously diagnosed as a hemangioma, and was treated with observation

She also reported the lesion originated as a “cystlike papule” that had continuously expanded

In addition to causing cosmetic concerns, the lesion seemed to be irritated by clothing and would occasionally bleed and swell

The patient denied pain or itching associated with the lesion

Since its appearance at 3 months of age, several abscesses formed underneath the region of concern requiring incision and drainage

Medical history revealed no other medical problems

On physical examination, at the proximal posterior thigh, there was an 11 × 10-cm cobblestoned, gray plaque composed of numerous purplish, vesicular papules with surrounding satellite papules

A 4-mm punch biopsy was performed (Figure, B and C)

Translucent papules and histologic examination in a child

A, Clinical examination shows numerous grouped translucent papules

B and C, Dilated thin-walled vascular spaces containing valvelike papillary projections in the superficial dermis

The overlying epidermis shows acanthosis and hyperkeratosis (hematoxylin-eosin, original magnification ×20 [B] and ×400 [C])


A previously healthy 75-year-old woman was referred to our tertiary care center when a workup for abdominal pain and jaundice revealed a duodenal mass

High-resolution computed tomography revealed a 3 × 4-cm circumferential lesion in the second and third portions of the duodenum involving the pancreatic head (Figure 1)

Multiple nodules were noted along the peritoneal reflection of the right paracolic gutter

The results of a biochemical analysis were remarkable with a total bilirubin level of 6.8 mg/dL (to convert to micromoles per liter, multiply by 17.104), an aspartate aminotransferase level of 394 U/L, an alanine transaminase level of 746 U/L, and an alkaline phosphatase level of 1146 U/L (to convert the last 3 analytes to microkatals per liter, multiply by 0.0167)

Her medical history was significant for hypertension and a previous laparoscopic cholecystectomy approximately 6 years ago

Coronal computed tomographic (CT) image of abdominal mass (arrowhead) (A) and axial CT image of peritoneal implant (arrowhead) (B)


A woman in her mid-30s pregnant with twins at 13 weeks’ gestation presented with a tender right-flank mass, which she noticed after falling and sustaining trauma to the area 1 week previously

Medical history was significant for a total thyroidectomy for papillary thyroid cancer 7 years before as well as a strong family history of malignant breast cancer on the maternal side and colon and liver cancer on the paternal side

Physical examination revealed an 8 × 8-cm, tender, firm posterior right-flank mass that was mobile but fixed to the abdominal wall musculature

Laboratory examination revealed no abnormalities

Ultrasonography demonstrated a hypoechoic lesion measuring 3.3 × 3.6 cm with internal echoes and no significant flow (Figure 1A)

A noncontrast magnetic resonance image (MRI) revealed this to be a well-circumscribed T2 hyperintense lesion with diffuse surrounding soft tissue edema within the adjacent muscular and subcutaneous tissues abutting the posterior margin of the right chest wall and external oblique muscle at the level of the T11 to T12 intercostal space (Figure 1B and C)

A, Ultrasonography demonstrating a hypoechoic mass in the musculature of the right flank

B and C, T1- and T2-weighted images demonstrating an enhancing right-flank mass within the right-flank musculature

Because of the concern of malignancy, an ultrasonography-guided core biopsy was performed and demonstrated a myofibroblastic proliferation with immunostains positive for actin and negative for S100 and desmin

Her case was presented at the soft tissue tumor board, and given that the patient was asymptomatic and pregnant, the decision was made to closely watch the progression of this lesion with serial imaging with a planned resection after delivery

Unfortunately, she developed premature rupture of membranes and lost the pregnancy

Follow-up computed tomography was not able to identify the lesion but MRI showed that it was still present but decreased in size (2.4 × 1 cm) with interval resolution of surrounding inflammatory changes

She subsequently underwent wide local resection of the lesion


A woman in her 50s with a medical history of asthma and seasonal allergies presented with numerous asymptomatic flesh-colored to translucent papules on her palms and palmar and lateral aspects of her fingers (Figure, A and B)

Many of the papules were depressed centrally

There was no extension onto the dorsal aspect of the hands

There were similar translucent papules over the margins of her feet, particularly her great toes, and hyperkeratotic yellow plaques with scattered pits over her bilateral soles, concentrated in areas of pressure

The lesions on her hands first developed in her 40s and were exacerbated by alcohol-based hand sanitizer at work

They became more prominent with exposure to water but remained asymptomatic

Occasional application of urea cream to her feet did not lead to significant improvement

She also had fine-textured hair, present since childhood with thinning noted in the past 7 years

At the time, she denied a family history of similar skin findings but recently reported similar hand and foot findings in her mother

Two punch biopsies were performed from the left thenar eminence (Figure, C)

A, Clinical photograph of the palm showing dozens of flesh-colored to translucent palmar papules

B, Closer clinical view of the palmar papules over the thenar eminence, some with central depression

C, Histologic image from a skin biopsy specimen from the thenar eminence (hematoxylin-eosin, original magnification ×40)


Deep fungal or atypical mycobacterial infection

Perivulvar neutrophilic eccrine hidradenitis

A woman in her 60s developed fever, rigors, periorbital swelling, and a painful perivulvar eruption, 7 days after her first cycle of cytarabine and daunorubicin hydrochloride for newly diagnosed acute myeloid leukemia (AML)

She had a history of type 2 diabetes mellitus, hypothyroidism, and hypercholesterolemia

Her regular medications included metformin, insulin, rosuvastatin calcium, levothyroxine sodium, and aspirin

Examination revealed edematous labia and multiple perivulvar tender nodules on violaceous and indurated plaques sparing the vaginal mucosa and inguinal creases (Figure, A)

She also had bilateral injected conjunctivae with periorbital swelling

A punch biopsy of the perivulvar lesions was performed for histopathologic analysis (Figure, B and C) and tissue culture

A, Perivulvar plaques and nodules that developed after chemotherapy for acute myeloid leukemia

Edematous labia with perivulvar violaceous plaques and nodules

B and C, Skin histologic images from perivulvar plaques and nodules

B, Spongiosis and hyperplasia of the epidermis with neutrophilic infiltrate within the dermis (hematoxylin-eosin, original magnification ×10)

C, Necrotic collagen and eccrine gland destruction (hematoxylin-eosin, original magnification ×10)


A man in his 50s was referred for evaluation of pruritic lesions in the perianal area and buttocks of 2 years’ duration

He reported no history of cutaneous diseases

He had undergone heterologous bone marrow transplantation for chronic myeloid leukemia 18 years before and had hypertension controlled with lisinopril and hydrochlorothiazide and type 2 diabetes mellitus controlled by diet

Physical examination revealed multiple hyperkeratotic purplish brown papules and plaques, more confluent in the perianal area, with well-demarcated keratotic prominent margins (Figure, A and B)

Dermoscopy showed structureless brownish pigmentation and erythema in the center, demarcated by a white-yellow hyperkeratotic scale at the periphery

Because of suspicion of lichen planus annularis, the patient was treated intermittently with intramuscular triamcinolone acetonide depot and topical treatments such as corticosteroids, antifungal agents, pimecrolimus, and retinoic acid, resulting in subjective pruritus relief

however, the lesions did not show satisfactory improvement in 2 years’ follow-up

Therefore, 2 skin biopsies were performed (Figure, C)

A, Multiple hyperkeratotic purplish brown papules and plaques on both buttocks, more confluent in the perianal area, with well-demarcated slightly elevated keratotic margins

C, Biopsy specimen (hematoxylin-eosin, original magnification ×400)


Confluent and reticulated papillomatosis

A previously healthy man in his late teens and of Japanese ancestry presented with a 4-month history of a pruritic eruption that started on his neck, upper back, and buttocks (Figure 1A)

He felt well otherwise, denying fever, gastrointestinal upset, or any antecedent illness or exposure

He denied any family history of similar eruptions and was not taking any medications aside from whey protein supplementation

The cutaneous eruption had continued to spread despite topical and oral corticosteroid therapy, and diphenhydramine provided no relief from the pruritus

A, Initial clinical presentation of bullae on an erythematous base in a reticular pattern on the back

B, Biopsy specimen from the mid-abdomen showing dense infiltration of the epidermis by numerous eosinophils (hematoxylin-eosin)

C, Biopsy specimen from the back showing abrupt necrosis of the epidermis and an intraepidermal blister filled with neutrophils and eosinophils

The blister correlates with the bulla seen clinically

The upper dermis showed a mixed infiltrate of lymphocytes, eosinophils, and neutrophils (hematoxylin-eosin)

A complete blood cell count and comprehensive metabolic panel revealed only a minor lymphopenia (lymphocyte percentage, 16.8%

lymphocyte count, 1000/μL [normal, 1300-3600/μL]), a high monocyte percentage (13.6%

normal, 4.0%), but a normal absolute monocyte count

(To convert lymphocyte count to ×109/L, multiply by 0.001.) No evidence of ketosis was noted

Results from assays for herpes simplex virus IgG, antinuclear antibodies, glucagon, and zinc were all within normal limits

On clinical examination, vesicles and bullae were found coalescing into large reticulated plaques with background erythema on the upper neck, inframammary areas, groin, mid back, and extending down onto the upper buttocks

The bullae were eroded in some areas with hemorrhagic crust (Figure 1A)

Punch biopsy specimens from characteristic lesions were obtained and sent for hematoxylin-eosin (H&E) examination (Figure 1B and C)

Punch biopsy specimens of lesional and perilesional skin were also sent for direct immunofluorescence (DIF) study


A 6-day-old male infant presented to the emergency department with a linear band of skin-colored papules on his left upper extremity

These papules had been present at birth and were persistent at the time of the patient’s initial hospital discharge

Because no resolution had been noted over the next few days, the patient was taken to his primary care physician for evaluation and then sent to the emergency department for further workup

The patient’s mother noted that both the pregnancy and the delivery were uncomplicated

She denied ever having a miscarriage and had another healthy male child at home without any similar lesions

The mother had a history of varicella as a child

she did not have a history of herpes simplex virus and had no oral or genital lesions at the time of delivery

On examination, the patient was noted to have 2- to 3-mm vesicles on the left upper extremity in a linear, bandlike distribution (Figure, A), and similar 2- to 3-mm deep-seated vesicles on his left medial thigh in a whorled configuration, approximately 4 × 3 cm in total size (Figure, B)

In addition, the patient had a 1-mm vesicle on his abdomen

A, Vesicles (2-3 mm in diameter) on the left forearm are in a linear, bandlike distribution

B, Deep-seated vesicles on left medial thigh are in a whorled configuration


A 90-year-old woman presented with vomiting and acute abdominal pain that started 24 hours earlier

Her medical history included a partial oophorectomy of a right ovarian cyst, hypertension, and vomiting and abdominal pain once a year that started 10 years earlier

She had always been diagnosed as having adhesive ileus, and her symptoms always improved within a day after hospital admission

A physical examination at admission revealed that her abdomen was slightly distended and tender to palpation on the right side of the paraumbilical point without muscle guarding

The hematologic findings revealed slight anemia and amylasemia

her hemoglobin level was 9.3 g/dL (to convert to grams per liter, multiply by 10.0), and her amylase level was 168 U/L (to convert to microkatals per liter, multiply by 0.0167)

Abdominal computed tomography (CT) with intravenous contrast agent revealed a mass on the right side of the paraumbilical point (Figure 1)

Contrast-enhanced computed tomographic scan through the abdomen showing a mass on the right side of the paraumbilical point


A woman in her 30s with a history of chronic hepatitis B was found on computed tomography to have a 13-cm retroperitoneal mass on her left side with a significant mass effect

The patient was symptomatic with intermittent left upper quadrant abdominal pain that was associated with nausea and constipation

She reported no other gastrointestinal, genitourinary, or overall symptoms

In addition to chronic hepatitis B, her medical history was notable for hypertension and her surgical history was significant for a recent liver biopsy

Physical examination revealed a soft, nontender, minimally distended abdomen with no palpable masses and no costovertebral angle tenderness

Laboratory test results at presentation revealed complete blood cell count, comprehensive metabolic panel, and amylase values within the reference ranges and a hepatitis B virus quantification level of 1590 IU/mL

A computed tomographic scan of the abdomen and pelvis using intravenous contrast was obtained (Figure 1)

Coronal computed tomographic imaging on initial presentation


An 18-year-old Hispanic man residing in Los Angeles, California, presented with bilateral masses at the base of his neck, which he had for 2 months

The left-sided mass had been spontaneously draining straw-colored fluid for 5 days

Three months prior to presentation, he had received a diagnosis of pneumonia

his condition improved after a course of azithromycin

He denied ever having a fever, weight loss, contact with any sick persons, or sexual activity

or traveling outside of southern California

Examination revealed mildly tender, fluctuant masses at the base of his neck, each measuring 4 cm in diameter (Figure, A)

Laboratory values included a white blood cell count of 13/μL (to convert to ×109 per liter, multiply by 0.001) (69% neutrophils, 21% lymphocytes, and 2.3% eosinophils [to convert to proportion of 1.0, multiply by 0.01]), a hemoglobin level of 12.3 g/dL (to convert to grams per liter, multiply by 10.0), and a platelet count of 337 × 103/μL (to convert to ×109 per liter, multiply by 1.0)

The results of a screening antibody test for human immunodeficiency virus and of a Mantoux tuberculin skin test were negative

A chest radiograph revealed bilateral hilar adenopathy (Figure, B)

An excisional lymph node biopsy of the left-sided mass was performed (Figure, C)

A, Bilateral level IV (low jugular) cervical adenopathy

B, Chest radiograph showing bilateral hilar adenopathy

C, Histological examination of the excised lymph node showing multiple spherules containing endospores (arrowheads) (hematoxylin-eosin, original magnification ×200)


An otherwise healthy woman in her early 20s was referred to our general surgery clinic for massive splenomegaly after developing a migratory, urticaric maculopapular rash over her body earlier in the year

On physical examination, the inferior tip of the spleen extended well below the costal margin into her left lower quadrant

In addition to the rash and splenomegaly, the patient also described several months of fatigue, early satiety, and back pain

However, she denied other constitutional symptoms such as fevers, night sweats, chills, arthralgias, or weight loss

She did not have any personal history of mononucleosis, Lyme disease, arthritis, or bleeding disorders

In addition, there was no family history of hematologic diseases or lymphoma

Findings from a hematologic workup were unremarkable

Cross-sectional imaging was performed (Figure 1)


Catheterization of left pericardiacophrenic vein

Catheterization of left internal thoracic vein

Catheterization of left anomalous pulmonary vein

Catheterization of left superior intercostal vein

A man in his mid-50s presented to the hospital with malaise, fevers, hypotension, and altered mental status

Three months prior, he had an episode of native aortic valve endocarditis, necessitating aortic valve replacement with a pericardial bioprosthesis

He developed postoperative acute renal failure, which progressed to chronic renal failure requiring dialysis via tunneled catheter

On this admission, he was found to have methicillin-resistant Staphylococcus aureus (MRSA) bacteremia

Transesophageal echocardiography demonstrated a vegetation on his prosthetic aortic valve

He was diagnosed as having MRSA prosthetic valve endocarditis and admitted to the cardiovascular surgical intensive care unit prior to surgical intervention

In the setting of MRSA bacteremia, his tunneled dialysis catheter had been removed

Owing to his dialysis needs, a temporary dialysis catheter was placed in the right internal jugular vein

As intravenous access was required for vasoactive medications and intravenous antibiotics, a triple-lumen central catheter was placed in the left internal jugular vein under ultrasonographic guidance

The catheter went in easily without resistance, was drop tested to confirm venous placement, and flushed and drew easily, and venous waveforms and pressures were transduced

However, on postprocedure radiography, the tip of the triple-lumen catheter was not in the expected location (Figure 1)

The catheter was removed, and a new-stick insertion of a new catheter was attempted under ultrasonographic guidance

Chest radiograph showing left internal jugular catheter placement (arrowhead)


Rhabdomyosarcoma of the extraocular muscles

Idiopathic orbital inflammatory syndrome

An adolescent boy presented to our hospital with a 5-day history of right eyelid swelling and redness accompanied by blurred vision and pain with ocular movement

This was his third hospitalization for these symptoms

the previous admissions were 2 and 4 months earlier, with no symptoms in the intervals

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)

The left eye appeared normal at admission

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

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

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

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 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

The results of these examinations, in conjunction with the patient’s history, prompted biopsy


A woman in her 40s presented to our department with lower abdominal pain, lasting for a few weeks, with nausea and vomiting but no diarrhea or fever

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

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

A mass was palpable in the lower right abdominal quadrant

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

B, Colonoscopy revealing the presence of a bulge in the cecal lumen


A 66-year-old man was doing well 6 months after robotic radical prostatectomy for prostatic carcinoma and synchronous left radical nephrectomy for renal cell carcinoma

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

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

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

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


A man in his 60s presented to the emergency department with a right flank mass that had been present for 4 weeks

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

His medical history included hypertension and diabetes mellitus

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

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

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

The patient was then taken to the operating room where an excisional biopsy was performed

A, Right flank mass on initial presentation

B, Coronal view of a computed tomography (CT) scan showing a right flank mass invading the liver

C, Axial view of the CT scan showing the flank mass extending from the diaphragm to the iliac crest


A 13-year-old girl with a history of Crohn disease presented to the pediatric dermatology clinic for evaluation of a rash on her buttocks and back

The patient noticed the rash 1 day prior to presentation

The rash was asymptomatic with no pain or pruritus

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

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

The patient’s medical history is significant for a diagnosis of Crohn disease for which she receives several long-term immunomodulatory medications with no recent changes

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


A 28-year-old man presented with several months of constant, burning upper abdominal pain centered on the epigastrium

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

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

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

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)

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)


A 33-year-old woman presented to the emergency department as a restrained driver in a motor vehicle collision with air bag deployment

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)

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)

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


A 34-year-old female Jehovah’s Witness presented to the emergency department with a 3-day history of colicky lower abdominal pain, nausea without vomiting, and constipation after passing a single small bloody bowel movement

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

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

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)


Iatrogenic pancreas transplant thrombosis

A 52-year-old man presented with a 2-day history of nausea and low-grade fever to a local hospital

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

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

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)


A 26-year-old woman in the 11th week of gestation with a history of nephrolithiasis was admitted to our medical center reporting of right lower quadrant pain, loss of appetite, nausea, and vomiting occurring over 5 days

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

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)

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 histologic analysis is presented in Figure, B

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

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

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

The patient recovered and was discharged

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

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


A 9-week-old girl had a rash on her back that had been present for 7 weeks

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

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

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

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)


A previously healthy, 37-year-old man presented for a routine physical examination during which a pulsatile mass in his midepigastrium was palpated

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


A woman in her 50s was hospitalized for a painful anal mass

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


Minocycline-induced cutaneous polyarteritis nodosa

An 18-year-old woman presented with a 4-week history of a solitary painful bullous skin lesion over the lower right anterior tibia accompanied by generalized myalgia, polyarthalgia, joint stiffness, paraesthesia, and episodic ankle swelling

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

Her medical history includes asthma and acne

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

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

Treatment with prednisone acetate (10 mg daily) was initiated

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

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


Amebic liver abscess secondary to Entamoeba histolytica infection

A 74-year-old woman was seen by her primary care physician for dull epigastric and right upper quadrant abdominal pain of 1-year duration

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

B, Intraoperative view of enucleated lesions in hepatic segments IV and V


B. Spindle cell sarcoma of the chest wall

A 55-year-old woman presented to the clinic with a mass in her left breast that had been enlarging over the previous 3 months

The patient denied any antecedent trauma or infection

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

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

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

B, Postresection wound including chest wall

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


A 4-year-old, 15-kg girl presented with a 3-month history of a pruritic rash bilaterally on the cheeks, initially thought to be related to mosquito bites

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

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

Test results for antinuclear antibody and rheumatoid factor were negative

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


A 66-year-old man presented with a skin rash on his lower limb

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

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

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


A 52-year-old man with type 2 diabetes mellitus and end-stage renal disease presented with painful and progressive cutaneous necrosis of his fingers, toes, and calves and generalized muscle weakness with difficulty getting out of bed and walking

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

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


A 25-day-old newborn was admitted to our hospital with a diagnosis of bronchiolitis

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)

The lesions were biopsied and samples were sent for cultures and histopathological analysis

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

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

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)

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


D. Primary lymphoma of the urinary bladder

An 88-year-old man with a history of hypertension, atrial fibrillation while receiving warfarin sodium, congestive heart failure, extended right hemicolectomy for colon cancer, and abdominal aortic aneurysm repair visited the hospital with epigastric pain of 3 days’ duration

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


A 62-year-old man was admitted to our hospital with a concern of productive cough, profuse hemoptysis, and intermittent breathlessness for about 5 months

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

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)

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

Because of persistent massive hemoptysis, the patient underwent left exploratory thoracotomy

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


Inflammatory linear verrucous epidermal nevus

A 15-year-old male presented to the dermatology clinic with a lesion that had been present on his right nasal sidewall since birth

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

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

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


A 32-year-old woman presented to the hospital complaining about having colicky abdominal pain for the last 2 weeks

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

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

her last child was born 40 days prior to her presentation to the hospital

On examination, her vital signs were normal (temperature, 37.1°C

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)

Abdominal computed tomographic scan with oral contrast agent revealing a 8.2 × 4 × 2.6-cm tubular thin-walled filling defect in the cecum and lower part of ascending colon (B)

The contrast is seen around, proximal, and distal to the defect, with no obstruction noted


A 30-year-old female immigrant from Laos was referred to our institution after admission to an outside hospital for right upper quadrant abdominal pain with associated nausea and vomiting

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)

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

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)


A 10-day-old, full-term girl presented with a trunklike projection from the medial canthus of the left eye (Figure)

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

There was mucus discharge from the opening

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

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


A 28-year-old woman presented with a complaint of a painless abdominal mass that had been increasing in size during the past few years

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

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)

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

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


A white woman in her late 40s presented to her primary care physician for her routine annual checkup and was noted to have abdominal distention

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)


A 5-year-old girl presented with a 2-week history of pruritic, bullous skin lesions that had started on her lower limbs

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

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

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

Also the vulva and perineum had an intense erythematous rash

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


Non-Hodgkin lymphoma with associated hepatosplenomegaly

A 23-year-old otherwise healthy man presented to the emergency department after a 3-hour flight with complaints of headache and severe abdominal pain

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


Acute appendicitis with colon diverticula

A 50-year-old man presented to the emergency department with a 4-day history of right lower quadrant pain that did not migrate during that period of time

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)


A 5-year-old boy, known to have acute lymphoblastic leukemia since the age of 3 years, presented with a 3-week history of asymptomatic skin lesions primarily affecting the face and to a lesser extent the trunk and extremities (Figure, A and B)

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

Multiple topical medications including keratolytics were applied to the affected areas without effect

Skin examination and microscopy analysis of punch biopsy specimen

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

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)

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

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


An 89-year-old woman presented to her geriatrician with abdominal pain for 2 days

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)


A previously well 7-month-old male infant presented to our emergency department with 1 week of loose stools, 4 days of fever up to 39.2°C, and 2 days of skin rash

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

The patient’s vaccinations were up to date

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 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)

He was started treatment with intravenous ceftriaxone and intravenous acyclovir

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


A 64-year-old woman presented to the emergency department with a 1-day temperature of 38.9°C (102°F)

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

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

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

Figure 1 shows a coronal, reformatted image of the scan

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


Exophytic solitary giant cavernous hemangioma of stomach

A 23-year-old woman had a progressively enlarging mass associated with abdominal distention and a dragging type of discomfort for 1 week

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


A 26-year-old man was admitted to our institution for a fever (temperature, 39°C) and abdominal pain on the right side of his hypochondrium

He complained of nausea, vomiting, and asthenia as well

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

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

Empirical antibiotic therapy with ampicillin sodium/sulbactam sodium was started

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