A man in his 50s was referred to the department of oral and maxillofacial surgery for evaluation and treatment of an intraoral cystic lesion of the left lower lip

This lesion had developed spontaneously 3 months prior to consultation without an identifiable inciting event

He could recall no trauma and described a slow but progressive increase in the volume of this otherwise asymptomatic lesion

His medical history revealed a long-term history of substance abuse with active alcohol and tobacco consumption, chronic obstructive pulmonary disease, and epilepsy (tonic-clonic seizures, badly controlled owing to a lack of adherence to therapy)

Clinical intraoral examination of this fully edentulous patient revealed a nontender, mobile, cystic nodule, approximately 1 × 1 cm on the vestibular side of the lower left lip with outflow of a clear serous fluid on palpation (Figure, A)

The lesion was excised surgically and the specimen sent for additional histological examination

After hematoxylin-eosin staining, light microscopy revealed an endophytic growing lesion, which consisted of an acanthotic epidermoid epithelium organized in broad papillary folds, with at its periphery an infiltrating border

At the surface of these papillae, the epithelium was sometimes columnar

Mucocytes were present, individually dispersed throughout the epithelium, but also organized in small tubuloacinar structures emptying onto the surface

The epithelium was infiltrated by neutrophils

Atypia or mitotic figures were absent, and the subepithelial stroma contained normal-appearing seromucous acini (Figure, B and C)

A, Clinical presentation of the cystic lesion of the lower left lip

B and C, Histopathologic images, hematoxylin-eosin

The papillary fronds lining the interior of the lesion

The lesion is well demarcated from the subepithelial stroma, and has an infiltrating border

C, Detail at the base of one of the papillae

The cells at the surface of the epithelial folds are columnar

Mucocytes organized in acinar structures empty on the surface epithelium but are also individually dispersed between the epidermoid cells


A previously healthy young man in his late teens presented to his dentist with a 3-week history of left-sided facial pain, fullness, and trismus

He underwent a third maxillary molar extraction and attempted incision and drainage of the area with no improvement in symptoms

No purulence or clinically significant bleeding was identified

A contrast-enhanced computed tomographic (CT) scan was performed (Figure, A), and the patient was referred to the otolaryngology clinic

On presentation, he also reported decreased acuity in his left lower visual field, continued swelling with increasing pain, and worsening trismus

Physical examination revealed mild tenderness over a mass that extended inferiorly to the zygoma into the buccal cavity and posterolaterally to the left superior molars

The patient also reported hypoesthesia of the left maxillary division of the trigeminal nerve

Fiber-optic scope of the nasopharynx revealed a small lesion posterior to the left middle turbinate

Contrast-enhanced magnetic resonance imaging of his head, neck, and brain was performed (Figure, B and C)

A, Computed tomographic (CT) image shows a uniformly hyperdense mass extending into the left infratemporal fossa with slight extension of the mass through the medial aspect of the posterior wall of the maxillary sinus and widening of the sphenopalatine foramen

B, Contrast-enhanced magnetic resonance image (MRI) with fat saturation shows a mass with mild punctuate areas of hypointense signal (suggestive of vascularity) terminating in the left buccinator space with extension into the nasal cavity, maxillary sinus and inferior orbital fissure

C, A heterogenous mass in the left retromaxillary region and infratemporal fossa with hyperintense signal and mild salt-and-pepper appearance consistent with vascularity

D, Gross specimen is in similar orientation as mass seen in panel B


A 45-year-old woman initially presented for evaluation of a 6-month history of intermittent left facial swelling and pain

She noted a discretely palpable mass in the left parotid region during these episodes

However, at the time of clinic presentation, she had no palpable masses on physical examination

Ultrasonography performed on the day of initial evaluation revealed no intraparotid masses, lesions, or stones

The patient was encouraged to return if she noticed acute return of swelling so that she could be evaluated when symptomatic

The patient returned days later with acutely worsening left facial swelling, which she noticed while straining

On presentation, she was diagnosed as having malignant hypertension and had a palpable parotid lesion noted on physical examination

When asked to perform a Valsalva maneuver, she was noted to have more pronounced left facial swelling (Figure, A)

A short tau inversion recovery (STIR) image is shown in the Figure, B

Magnetic resonance angiogram was obtained (Figure, C and D)

A, The patient performed a Valsalva maneuver, with increased left parotid gland and neck swelling

B, Coronal T2-weighted short tau inversion recovery (STIR) image demonstrating a T2 hyperintense lesion measuring 3.7 × 3.4 × 7.4 cm involving the left parotid gland and extending to the left side of the neck

C and D, T1-weighted, fat-suppressed, gadolinium-enhanced angiography

C, Arterial section demonstrating no evidence of significant high flow component

D, Delayed phase demonstrating a homogenous contrast enhancing lesion


Diaphragmatic eventration with lung collapse

Pneumothorax with elevation of the left hemidiaphragm

Diaphragmatic rupture and a mediastinal hematoma

Diaphragmatic rupture and a traumatic rupture of the descending thoracic aorta

A 24-year-old man was brought to the emergency department after a high-speed motor vehicle collision

He was a restrained driver noted to be awake at the scene of the collision and had to be extracted from the vehicle

He was hemodynamically stable on route to the hospital

In the emergency department, the patient was awake but restless and combative and was subsequently intubated

He was hypotensive on arrival but responded transiently to fluid resuscitation

Multiple closed long bone fractures of the upper and lower extremities were noted

The chest radiography (Figure 1A) showed marked elevation of the left hemidiaphragm

The pelvic radiography revealed an unstable fracture involving bilateral pubic rami and the left sacroiliac joint

The pelvis was splinted in the emergency department

He remained transiently responsive to fluid resuscitation and was taken for emergent computed tomography

Computed tomography of the head and cervical spine showed no evidence of injury

A computed tomographic scan of the chest (Figure 1B) and abdomen was then performed, and the patient was taken to the operating room

B, Axial computed tomographic image of the chest


A 45-year-old woman with factor 1 deficiency presented to the general surgery clinic with a history of multiple episodes of lower gastrointestinal bleeding

These episodes started approximately 4 years prior, occur approximately every 3 to 4 months, and are associated with crampy abdominal pain

Although she has been hospitalized, she never required a transfusion

Colonoscopies were significant only for diverticulosis without a clear source of bleeding

Her previous abdominal surgery included a hysterectomy for menorrhagia

There is no family history of colon cancer

Physical examination showed no abnormalities

She had computed tomography of the abdomen and pelvis that showed eccentric and irregular masslike thickening of the sigmoid colon of approximately 7 cm with a wall thickness of 1.4 cm (Figure 1)

Repeat colonoscopy showed an exquisitely painful nodule at the rectosigmoid junction

There were no stigmata of recent bleed, and biopsy showed normal colonic mucosa

Axial (A) and coronal (B) computed tomography of the pelvis with rectal contrast

The images show thickening and narrowing of the sigmoid colon (arrowheads)


A 56-year-old woman with metastatic melanoma receiving ipilimumab and nivolumab every 3 weeks developed headaches during the course of her treatment

In the week following her first treatment, the patient reported a few mild morning headaches that improved with acetaminophen

After receiving 3 cycles of ipilimumab, 3 mg/kg, and nivolumab, 1 mg/kg, and 8 weeks after her first treatment, the patient reported experiencing daily headaches for at least the prior week and a half

The location of her headaches varied, and there was no associated eye or temple pain

At best, with taking nonsteroidal anti-inflammatory drugs, the headache decreased to pain rated 3 on a scale of 1 to 10. Also at this time, the patient reported low energy levels and difficulty reading

however, physical examination showed no gross visual field defects

Laboratory workup conducted 8 weeks after initiating treatment included adrenocorticotropic hormone (ACTH) and cortisol levels that were measured at 25 pg/mL (reference range, 10-60 pg/mL) and 16.8 μg/dL (reference range, 6-24 μg/dL), respectively

Thyroid-stimulating hormone (TSH) level was 0.82 mIU/L (reference range, 0.5-5.0 mIU/L), which was gradually decreasing compared with 1.41 mIU/L 5 weeks earlier and 1.21 mIU/L 2 weeks earlier

Her total triiodothyronine level was measured at 73 ng/dL (reference range, 80-200 ng/dL) and free thyroxine level was 1.0 ng/dL (reference range, 0.9-1.7 ng/dL)

Her serum sodium level was measured at 138 mEq/L

1 week later it was measured at 135 mEq/L (reference range, 135-145 mEq/L)

Contrast-enhanced magnetic resonance imaging (MRI) of the brain was performed for further assessment (Figure)

Magnetic resonance imaging (MRI) of the brain obtained 8 weeks after initiating ipilimumab (A-C) and nivolumab treatment and at follow-up (D)


Knee-located erythema elevatum diutinum (EED) with a calcaneal late-stage nodular component

A healthy man in his 20s presented with a several-month history of asymptomatic, slightly erythematous cutaneous nodules, measuring 1.5 to 3.0 cm, over the calcanea (Figure, A)

Physical examination revealed violaceous plaques, measuring 2 to 3 cm, on the extensor surface of the knees, bilaterally (Figure, B)

Excisional biopsy specimens were obtained (Figure, C and D)

A, Multiple asymptomatic erythematous nodules measuring 1.5 to 3.0 cm at presentation

B, Multiple violaceous plaques measuring 2 to 3 cm on the extensor surface of the knees

C, Excisional biopsy specimen of a calcaneal nodule (hematoxylin-eosin, original magnification ×20)

D, Excisional biopsy specimen of a plaque (hematoxylin-eosin, original magnification ×20)


A primigravida woman in her 30s at 35 weeks’ gestation and with a history of Darier disease was admitted with an acute, painful eruption on her face and neck

She reported no history of pregnancy-related complications

Physical examination revealed confluent erythema with keratotic papulovesicles distributed on the face and neck (Figure, A)

Honey-colored crusts were present on the left ear and preauricular area

The chest and inframammary area displayed occasional red, crusted papules

Laboratory tests revealed an elevated white blood cell count of 17.18 × 103/μL (reference range, 4.50-11.00 × 103/μL)

A shave biopsy specimen and tissue culture were obtained from the center of an umbilicated papule on the neck (Figure, B and C)

A, Confluent erythema with papulovesicles on the neck and face

B and C, Histopathological images, hematoxylin-eosin

B, Full-thickness epidermal necrosis with focal areas of suprabasal acantholysis with corp ronds, corp grains, and parakeratosis

C, Multinucleated cells with nuclear molding and margination


Arthritis associated with other connective tissue diseases

A man in his 40s presented with gradual hair loss of the eyelashes, eyebrows, beard, and scalp for 4 years, swelling and painful hand joints for 13 months, and multiple asymptomatic nodules on the upper arms for 40 days

The patient exhibited no associated fever, analgesia or hypesthesia

He reported no previous infections or family or personal medical history of autoimmune diseases or psoriasis

He was previously treated for rheumatoid arthritis, but various arthritis treatments showed no improvements over 1 year

A physical examination showed diffuse infiltration of the face with loss of skin creases and diminished facial hair

all joints of both hands were swollen (Figure, A)

multiple asymptomatic nodules without ulceration were present on his upper arms (Figure, B)

decreased sensation to pain, temperature and/or touch and neuropathic changes were not found

Laboratory test results showed a slightly elevated erythrocyte sedimentation rate (27 mm/h) and significantly elevated rheumatoid factor (70.1 IU/mL)

Additional immunology indicators, including C-reactive protein, anticyclic citrullinated peptide, antinuclear antibodies, and globulin levels were normal

X-ray and joint ultrasound results suggested osteoarthritis, synovitis, flexor tendon tenosynovitis, and bone erosions

Ultrasound results also indicated enlarged axillary, cervical, and inguinal lymph nodes and an enlarged spleen

Fundus fluorescein angiography showed uveitis

B, Multiple asymptomatic nodules on the upper arms

C, Skin biopsy from the patient’s upper arm nodule demonstrating diffuse infiltrate of foamy histiocytes in the dermis (hematoxylin-eosin stain, original magnification ×100)

D, Numerous acid-fast bacilli (acid-fast stain, original magnification ×400)


Postural orthostatic tachycardia syndrome

Primary adrenal insufficiency (Addison disease)

A white, nonobese, 15-year-old girl presented with 1 month of frontal and occipital throbbing headaches, tinnitus, and “whooshing” in the ears

She had 1 week of nonbilious, nonbloody emesis, and “graying out” of her vision only when standing up or sitting down

Examination noted normal visual acuities and swelling of both optic discs (Figure, A)

Magnetic resonance imaging and magnetic resonance venography of the head showed no intracranial mass or venous sinus thrombosis

Lumbar puncture showed an opening pressure of 550 mm of water and normal cerebrospinal fluid (CSF) composition

A diagnosis of idiopathic intracranial hypertension was made, and she was treated with acetazolamide

Headaches initially improved but worsened during the following weeks

Three months after initial presentation, she reported a 9.07-kg weight loss (height 1.57 m

body mass index dropped from 21.3 to 16.8 [calculated as weight in kilograms divided by height in meters squared]), postural lightheadedness, worsening fatigue, muscle weakness, salt cravings, loss of axillary hair, and missed periods for 2 months

Physical examination was remarkable for ill appearance, blood pressure of 85/42 mm Hg, and hyperpigmentation of the knuckles, distal fingers, and tongue (Figure, B and C)

Repeated ophthalmic examination showed normal visual acuities and worsening optic disc swelling

The patient presented with papilledema bilaterally (A, right eye shown) patchy tongue darkening (B), and darkening of knuckles and distal fingers (C)


A man in his late 40s with a 30-pack-year history of smoking and a history of heavy drinking presented following 7 months of right-sided neck tenderness

He also reported progressive dysphagia to solids but no dyspnea, otalgia, or weight loss

Examination revealed very tender right-sided neck fullness of 6 cm

Laryngoscopic findings were unremarkable

Computed tomography (CT) with contrast demonstrated a 4.4 × 3.6 × 4.5-cm heterogeneously enhancing mass in the right side of the neck, splaying and completely surrounding both the internal and external carotid arteries (Figure, A)

Scattered lymph nodes were also observed

On magnetic resonance imaging (MRI), the mass was hyperintense on T2 (Figure, B)

A second 0.9-cm enhancing mass was visualized at the inferior right jugular foramen

Chest radiography demonstrated no suspicious pulmonary or mediastinal lesions

He underwent excision of the mass with right-sided neck dissection

Cranial nerves XI, X, and XII were identified and preserved

During subadventitial dissection of tumor off the carotid bifurcation, a laceration of the internal carotid artery was noted

Vascular surgery was performed to make an intraoperative repair, and an intraoperative angiogram demonstrated no dissections or thrombi

The lesion was suspected to be benign, and the procedure was aborted

The patient experienced no neurologic sequelae postoperatively

A specimen was taken of the right-sided neck mass (Figure, C and D)

B, Postcontrast T1 magnetic resonance image (MRI)


Solid pseudopapillary neoplasia of the pancreas

Atypical mucinous cystic neoplasia of the pancreas

A primigravid woman in her 20s who had been pregnant for 16 weeks presented with significant abdominal pain

A noncontrast computed tomographic (CT) scan revealed a 15 × 13 × 11-cm heterogeneous cystic mass that appeared to originate from the body of the pancreas and protrude into the gastric wall (Figure 1, A)

Results of CT scan also revealed a 3-cm hypodense lesion on the left lobe of the liver, ascites, and splenomegaly

Further evaluation with endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography revealed extrinsic compression of the gastric wall from a large mixed solid/cystic lesion with septations and well-defined margins with no clear involvement of the gastric wall

A thin, reddish-brown fluid (700 mL) was aspirated from the cystic component

Analysis of the aspirate showed no tumor cells or mucinous material, and normal carcinoembryonic antigen, CA19-9, and amylase

Fine-needle aspiration was performed on the solid component of the cystic tumor (Figure 1, B-E)

A, Coronal view CT scan showing a 15 × 13 × 11-cm complex heterogeneous mass originating from the body of the pancreas (white arrowhead) and protruding into the gastric wall

A hypodense lesion in segment 3 of the liver is observed (black arrowhead) and also moderate ascites (yellow arrowhead)

B, Hematoxylin-eosin stain (original magnification ×20)

C, α-smooth muscle actin immunostain (original magnification ×40)

D, CD117 immunostain (original magnification ×40)

and D, CD34 immunostain (original magnification ×40)


A man in his 60s presented with new-onset bullae and erosions over sun-exposed areas and bony prominences

His medical history was relevant for acute myeloid leukemia, for which he had received an allogeneic stem cell transplant that was complicated by biopsy-proven grade 3 cutaneous and grade 2 gastrointestinal graft-vs-host disease

As part of his posttransplant infectious prophylaxis, the patient had been prescribed valacyclovir hydrochloride, voriconazole, and trimethoprim/sulfamethoxazole

He was also taking tacrolimus hydrate and prednisone for treatment of his graft-vs-host disease

The patient reported fishing outdoors on a sunny day a few days prior to the onset of these skin lesions

On physical examination, the patient’s skin was diffusely tan and there were flaccid bullae and erosions on the bilateral dorsal hands, elbows, and knees (Figure, A)

A punch biopsy specimen from a bulla from the upper extremity was obtained (Figure, B)

A, Flaccid bulla and erosions on the left dorsal hand at presentation


An African American male in his 50s with a longstanding history of atopic dermatitis presented with a 20- to 30-year medical history of occasionally pruritic erythematous papules involving the trunk and extremities

He denied associated fevers, chills, night sweats, weight loss, joint pain, cough, difficulty breathing, or chest pain

Findings from the physical examination revealed red-brown monomorphic papules coalescing into plaques on the face, trunk, and extremities (Figure, A and B)

There were thin erythematous plaques with overlying scale on bilateral extensor upper and lower extremities

A 4-mm punch biopsy specimen from his right upper extremity was obtained and stained with hematoxylin-eosin for histopathologic analysis

Periodic acid–Schiff and acid-fast bacilli stains were also performed

A, Distribution of papules over the chest, abdomen, and upper extremities

B, Diffuse distribution of papules over the back with some papules coalescing into plaques

C, Hematoxylin-eosin stain (original magnification, ×10)


A man in his 50s with diagnoses of human immunodeficiency virus (HIV) infection, hepatitis B, and latent tuberculosis presented with a slow-growing nodule on the left foot

The lesion started 1 year prior as a tender red nodule on the medial aspect of his first metatarsophalangeal joint, which would enlarge and become painful approximately once a month (Figure, A)

The patient reported that with manipulation, a clear-to-yellow material drained from the lesion

The patient denied any purulent drainage, additional skin lesions, fever, chills, or other systemic symptoms

His medications included efavirenz–emtricitabine–tenofovir disoproxil fumarate for his HIV, with the most recent absolute CD4-positive cell count of 341 cells/mm3 (reference range, 263-2045 cells/mm3), and recent completion of an 8-month course of isoniazid treatment after being exposed to tuberculosis

Physical examination demonstrated an erythematous papulonodule without warmth or drainage on the dorsal left great toe

A punch biopsy was performed (Figure, B, C, and D) to help establish the diagnosis

A, Clinical photograph of slow-growing red papulonodule on the left toe dorsal foot

B, Biopsy with hematoxylin-eosin (H&E) staining demonstrating acral skin with acute and chronic inflammation within the deep dermis

C, Higher magnification highlights eosinophilic material surrounding small cocci

D, Gram staining of the biopsy supported the diagnosis


A 13-year-old girl presented to an emergency department with bilateral hip pain for several months and acute worsening with left-sided limp following a school field trip to a large museum

She stated that her pain worsened with walking and was minimally relieved with salicylic acid

Her parents tried to schedule an outpatient appointment for evaluation of her hip pain but had difficulty owing to a lack of a primary care physician

Review of systems was significant for heavy periods since menarche 6 months ago

It was negative for easy bruising or bleeding

The patient described normal stooling and voiding habits

The patient was described as a shy eighth grader who earns A’s and B’s in school

On physical examination, the patient was noted to be short for her age (1.3 m [4.4 ft]

height in <third percentile), weight (62.5 kg

87th percentile), and body mass index (35 [calculated as weight in kilograms divided by height in meters squared]

She had a relatively short, thick neck with acanthosis nigricans, dry skin, Tanner stage II breasts, and nonpitting edema of her hands (Figure 1A)

Her family history was significant for hypothyroidism and coronary artery disease in the father, type 2 diabetes mellitus in the maternal great grandmother, and hypothyroidism in the maternal grandmother

Radiography of the hips was performed (Figure 1B), showing bilateral slipped capital femoral epiphysis (SCFE)

Prior to undertaking definitive surgical correction of the hips, it is important to consider the potential underlying condition

A, Plain film of the hips revealing bilateral slipped capital femoral epiphysis

B, Photograph of the patient’s hand, which demonstrates nonpitting edema at time of presentation


A young man in his late teens presented to a pediatric otolaryngologist for evaluation of enlarged tonsils and recurrent tonsillitis

The patient reported 2 episodes of streptococcal tonsillitis and infectious mononucleosis over the past 8 months, as well as frequent throat soreness and associated difficulty swallowing throughout the past year

Results from a review of systems were negative for weight loss, fevers, and malaise

On physical examination, he appeared well and had 2+ cryptic tonsils

A lobular mass was noted to be extending from the inferior pole of the right tonsil

The patient was scheduled for tonsillectomy for recurrent tonsillitis and tonsillar asymmetry

His surgery was delayed for several months to accommodate his college schedule

In the operating room, the tonsils were noted to be 3+ bilaterally

The right tonsil had a smooth, pedunculated, flesh-colored mass extending inferiorly

The mass had enlarged since the prior examination

Both tonsils were removed without complication

The right tonsil with the attached mass was submitted to the pathology service fresh to allow evaluation by flow cytometry

Flow cytometry revealed no lymphoid abnormality

Grossly, the polypoid oval mass measured 2 × 1 × 1 cm, weighed 8.7 g, and had a narrow 0.4-cm-long stalk connecting it to the tonsil (Figure, A)

Histologic sections revealed a polypoid structure composed of a fibrovascular core covered by stratified squamous epithelium (Figure, B)

A subepithelial band of lymphoid tissue was noted (Figure, C) as well as lymphatic channels accentuated by D2-40 antibody (Figure, D)


A man in his 50s presented with a 5-year history of a slow-growing mass on the posterior surface of the left auricle

He denied any history of trauma or surgery around the ear, and reported only a cosmetic problem without pain or discharge

His medical history was positive for hypertension, impaired glucose tolerance, dyslipidemia, and hyperthyroidism, and negative for unusual skin pigmentation or cardiac problems

A laboratory examination revealed only slightly elevated thyroid-stimulating hormone levels (4.80 µU/mL)

A physical examination showed a solitary, 1-cm, dome-shaped, glistening, flesh-colored mass adherent to the posterior groove of the concha ridge (Figure, A and B)

There were no abnormal pigmented skin lesions on the rest of his body, including the face, trunk, and extremities

Neither a palpable thyroid nodule nor enlargement of hands and feet was identified

Gross total extirpation of the mass from the surrounding tissues was enabled by meticulous dissection

Intraoperatively, the 1-cm mass was noted to be gelatinous and glossy with well-demarcated and smooth border

It was attached to the posterior surface of the concha cartilage but easily separated using blunt dissection

Unexpectedly, low-viscosity mucoid fluid had smeared on the surface

The histopathological examination revealed the tumor to be overall hypocellular and composed of bland spindle cells with no mitotic activity in a slightly basophilic myxoid matrix (Figure, C)

The surgical wound uneventfully healed, and no recurrence was noted during the 6-month follow-up period

A, Photograph of a protruding mass on the posterior surface of the auricle

B, A preoperative close-up of the solitary lesion

C, Histopathological image showing overall hypocellular stroma with scattered bland spindle cells in slightly basophilic myxoid matrix without mitotic activity

Numerous blood vessels with collapsed lumina (arrowheads) are also visible


A well-developed man in his 20s presented to our hospital with a clinically significant elevation in serum calcium level to (14.1 mg/dL [reference range, 8.6-10.2 mg/dL]) found on routine laboratory tests

He was highly functional and denied abdominal pain, dysuria, anxiety, lethargy, and constipation

Findings from his physical examination were within normal limits

He did not have any palpable thyroid nodules or cervical lymphadenopathy

Given his elevated calcium level, parathyroid hormone (PTH) was drawn, and results returned significantly elevated at 1377 pg/mL (reference range, 10-65 pg/mL)

Because of the extremely elevated PTH level, a technetium Tc 99m sestamibi single-photon emission computed tomographic/computed tomographic (SPECT/CT) scan was obtained, which identified a lesion in the location of the right inferior parathyroid gland, measured at 2.2 cm (Figure, A)

In addition, CT showed associated lytic bone lesions of the left mandibular ramus, left scapula, and C5 vertebra (Figure, B)

A, A technetium Tc 99m sestamibi single-photon emission computed tomographic (SPECT)/computed tomographic (CT) scan


A young boy referred by his local otolaryngologist presented with dysphonia and abnormal laryngeal examination results

His voice quality had always been husky, with recent mild exacerbation

No stridor or shortness of breath was reported, but he admittedly “hated to run” and was relatively sedentary

His parents noted intermittent stertor while he was sleeping but no apnea

He had no dysphagia or aspiration manifestations

He was overweight (body mass index, calculated as weight in kilograms divided by height in meters squared, 27.2)

Findings from an otolaryngologic examination were normal other than those from flexible laryngoscopy, which demonstrated 2 laryngeal lesions, 1 in the postcricoid interarytenoid region and 1 at the anterior commissure, the latter of which compromised vocal fold approximation

Vocal fold mobility otherwise appeared normal

Operative laryngoscopy confirmed a midline, firm, posterior cricoid mass (Figure, A), and a midline, firm, anterior subglottic mass extending into the anterior commissure (Figure, A)

Tracheobronchoscopy revealed a distal tracheal submucosal mass partially obstructing the left mainstem bronchus (Figure, B)

Excisional biopsy of the postcricoid and subglottic masses with the carbon dioxide laser was performed (Figure, C)

Histopathologic examination demonstrated mucosal infiltration by a monotonous population of cells with round nuclei and abundant granular cytoplasm (Figure, D), positive for S-100 and lightly positive for CD68, with occasional interspersed more darkly staining cells, consistent with histiocytes and giant cells

Sections stained negative for epithelial, muscle, endothelial, and glial cell immunohistologic markers

C, Direct laryngoscopy of the larynx following endoscopic carbon dioxide laser ablation of the lesions

D, Histopathologic image (hematoxylin-eosin, original magnification ×200)


Congenital cystic adenomatoid malformation

A full-term 2719-g female infant was transferred to a neonatal intensive care unit (NICU) on day 1 of life after developing respiratory distress requiring endotracheal intubation

Gestation was complicated by polyhydramnios and gestational diabetes

In the NICU, choking and desaturation were noted with oral feeding

Videofluoroscopic swallow study demonstrated aspiration with all consistencies

Microlaryngoscopy and bronchoscopy were conducted, and the patient was diagnosed as having a type II laryngeal cleft

At 2 weeks of age, she decompensated secondary to Klebsiella pneumoniae sepsis and was intubated for persistent left lung collapse

At that time, computed tomographic (CT) imaging was performed, revealing the etiology of her respiratory decompensation (Figure 1)

Coronal computed tomographic image of the chest with contrast


Gastrointestinal stromal tumor of the small bowel

A 43-year-old man with generally good health presented to the emergency department with sudden onset of cramps and abdominal pain

For the past year, the patient had been investigated for hypochromic microcytic anemia

As part of the investigation, he underwent an esophagogastroduodenoscopy and a colonoscopy, which revealed a normal-looking bowel with no obvious source of bleeding visualized

Further investigation involved capsule endoscopy, which was ingested 3 days prior to his emergency department admission

The patient claimed not to have passed a bowel movement containing the capsule

Physical examination results were normal except for a nontender distended and tympanic abdomen

Results of routine laboratory testing were essentially normal except for a low level of hemoglobin (8.1 g/dL [to convert to grams per liter, multiply by 10]), with no leukocytosis noted

Contrast-enhanced abdominopelvic computed tomography demonstrated a small-bowel obstruction, with a transition zone located at the mid-jejunum

An intraluminal hypodense mass was demonstrated in this area and appeared to be the cause of the obstruction

Adjacent to this area, the capsule was clearly demonstrated in a dilated proximal loop of the small bowel (Figure 1)

Computed tomographic scan showing an intraluminal hypodense mass (pink arrowhead) causing a small-bowel obstruction

Adjacent to this area, the endoscopic capsule (asterisk) is demonstrated in a proximal dilated loop of the small bowel


A white man in his early 30s presented to the emergency department with a 48-hour history of exacerbating right lower quadrant and epigastric abdominal pain

Although previously healthy, he reported some hospitalizations for nonspecific abdominal pain during his infancy

Colicky abdominal pain started after eating cornflakes in the morning, then regressed spontaneously during the day

A relapse of the symptoms occurred the morning after and worsened during the day, with the onset of nausea as well

For this reason, the patient autonomously took 2 tablets of hyoscine butyl bromide without any benefit

His bowel was initially open to gas and normal stools but, afterward, only to gas

A physical examination revealed a soft and nondistended abdomen, with localized tenderness and guarding in the epigastric region and in the right lower quadrant

The results of a digital rectal examination were normal

His vital signs were as follows: an axillary temperature of 37.3°C, a pulse rate of 71 beats per minute, and blood pressure of 120/80 mm Hg

The results of a urinalysis were negative

blood test results were within the normal limits, except for an elevated white blood cell count of 13 000/μL (to convert to ×109 per liter, multiply by 0.001), an unconjugated bilirubin level of 1.2 mg/dL (to convert to micromoles per liter, multiply by 17.104), an increased aspartate aminotransferase level of 52 U/L (to convert to microkatals per liter, multiply by 0.0167), and an alanine aminotransferase level of 136 U/L (to convert to microkatals per liter, multiply by 0.0167)

His C-reactive protein level was 10 mg/L (to convert to nanomoles per liter, multiply by 9.524)

A plain radiograph of his abdomen was negative for air-fluid levels and for signs of perforation

Further evaluation of his abdomen using ultrasonography revealed hepatic steatosis and, in the right lower quadrant, thickening of the cecal wall and a hypoechoic area 33 mm in diameter with blurred margins (Figure 1)

Ultrasonographic images of the right iliac fossa (A) and the right lower quadrant of the abdomen (B) with thickened cecal wall (a) and hypoechoic area 33 mm in diameter with blurred margins (b)


A woman in her 80s presented to the emergency room (ER) with a 2-week history of enlarging left parietal scalp mass

She initially was seen by her primary care practitioner, where neurological examination was nonfocal

The mass continued to enlarge and she developed progressive generalized weakness, slowed speech, and focal right-handed weakness

Acute onset of headache and decline in mental status prompted presentation to the ER

On examination an 8-cm left parietal mass was tender to palpation

Treatment with 4 mg of dexamethasone was initiated intravenously

All biochemical laboratory results were normal

Brain magnetic resonance imaging showed a large enhancing left frontal-parietal mass extending both extracranially and intracranially into the superior sagittal sinus (Figure)

There was left frontal, parietal, and temporal bone involvement, and left dural thickening

Intracranially, there was adjacent vasogenic edema and associated mass effect

Computed tomographic (CT) scans of the chest, abdomen, and pelvis revealed a ground-glass sclerotic lesion of the right sacrum

Owing to involvement of the superior sagittal sinus and progressive growth, an ultrasound-guided core needle biopsy was performed

Large extracranial and intracranial mass extending into the superior sagittal sinus, brain, soft tissue, and bone, with left dural thickening as visualized on T1 postcontrast imaging coronal (A) and sagittal (B) views

Axial view of brain edema as seen on T1-weighted (C) and T2-weighted imaging without contrast (D)


A young black woman with a history of Graves disease presented with painful lesions on both legs

She reported chills, bilateral lower extremity swelling, and several small, painful, “pimple-like bumps” appearing on her bilateral lower legs, which ulcerated several days later

The ulcers progressed despite a recent course of trimethoprim-sulfamethoxazole for cultures growing methicillin-sensitive Staphylococcus aureus

The patient’s medications included methimazole and atenolol, which she had been taking since her diagnosis of Graves disease 1 year prior

She had not taken other over-the-counter medications or supplements

Physical examination of her bilateral lower extremities revealed pitting edema and multiple discrete, round, dry ulcers, most with central eschars, dusky gray borders, and collarettes of scale (Figure, A)

Results from the initial laboratory workup revealed elevated levels of C-reactive protein and increased erythrocyte sedimentation rate

A punch biopsy specimen of an ulcer edge demonstrated a mid- and deep dermal marked lymphohistiocytic infiltrate with neutrophils and focal abscess, suggesting a nonspecific infection

The patient was initially treated with cephalexin, mupirocin, and conservative wound care, but the eruption later worsened, with new lesions appearing on her right leg

During follow-up, an intact 4-mm papular lesion was identified on her lower right leg (Figure, B)

No pathergy at the previous punch biopsy site was observed

A biopsy of the new intact papule was performed (Figure, C and D)

A, Discrete, round, dry ulcers with central eschar and raised borders on left lateral lower leg

B, A new, 4-mm intact papule on right medial lower leg

C and D, Histopathological images from punch biopsy specimen of the papule, hematoxylin-eosin


A man in his 60s presented with a 7-year history of a progressive pruritic eruption involving the nose and dorsal hands

He had no improvement following treatment with class 1 topical corticosteroids and keratolytic emollients

On review of systems, he endorsed photosensitivity during childhood only

He denied any history of blistering, angioedema, dysphagia, hoarseness, dyspnea, or weight loss

Physical examination revealed multiple skin-colored, waxy, smooth and variably verrucous papules and plaques on the dorsum of the nose and hands (Figure, A and B)

A, Skin-colored, waxy, smooth papules on the dorsum of the nose

B, Waxy papules coalescing into verrucous-appearing plaques on the dorsal surface of the hand

C, Nodular deposits (hematoxylin-eosin, original magnification ×20)

D, Dermal deposits (periodic acid–Schiff–diastase staining, original magnification ×4)

Initial laboratory evaluation, including complete blood cell count, blood chemistry panel, liver function tests, serum/urine protein electrophoresis, and urine porphyrins, had unremarkable results

A punch biopsy specimen was obtained from the left dorsal hand for further evaluation (Figure, C and D)


A man in his 70s with a history of chronic lymphocytic leukemia (CLL) and prescribed cyclosporine, 100 mg twice daily, for pure red cell aplasia was admitted for spreading painful blisters on the hands and feet

He had initially developed rhinorrhea, cough, and low-grade fever 2 weeks prior

The patient was treated with azithromycin and subsequently developed few small, pruritic blisters on the hands and feet

He went to an urgent care facility and was diagnosed as having bronchitis and prescribed doxycycline and diphenhydramine

Over the next several days, he developed worsening fever, chills, and blisters and bullae on the arms, legs, and face

He was admitted to the hospital, and the dermatology service was consulted

Physical examination revealed numerous pink to violaceous macules, papules, and patches on the palms, dorsal hands, forearms, elbows, feet, and distal lower extremities (Figure, A and B)

Fewer, scattered macules were on the face, neck, trunk, upper legs, upper arms, and scrotum

Dusky bullae were seen on the bilateral dorsal aspect of the hands, fingers, toes, and heels

In the oral cavity, there was 1 violaceous macule on the right buccal mucosa and a few linear, horizontal, white lines on the left buccal mucosa

Laboratory findings revealed a white blood cell count of 25 600/μL (reference range, 3700-10 500/μL) and a platelet count of 12 400/μL (reference range, 15 000-40 000/μL)

Results from a Tzanck smear from the initial lesion on the right dorsal aspects of the third finger were negative for multinucleated giant cells

A punch biopsy was performed on the anterior side of the thigh (Figure, C and D)


Adult-onset cerebellar ataxia, areflexia, pes cavus, optic atrophy, and sensorineural hearing loss syndrome

A 51-year-old man presented with progressive difficulty walking that developed over 1 month shortly after he ran a marathon

He frequently fell and had difficulty climbing the stairs

He stated he had hearing problems, but with further questioning, it was discovered he actually had difficulty deciphering speech

He did not have dizziness on standing nor bowel or bladder incontinence

He did not take medications, and he drank socially

He had no family history of imbalance problems

His neurological examination showed mild cerebellar ataxia without myoclonus or parkinsonism

His Montreal Cognitive Assessment score was 28 of 30 points (2 points deducted from “delayed recall”)

Pure tone audiometry showed no conductive or sensorineural hearing loss

Brain magnetic resonance imaging (MRI) revealed no abnormal signal, including from the pons and cerebellum

A computed tomography scan of the chest, abdomen, and pelvis showed no malignancy

Results from cerebrospinal fluid (CSF) testing were normal without oligoclonal bands and a normal level of protein 14-3-3. He had no paraneoplastic antibodies in his serum or CSF

Results from electroencephalogram (EEG) were normal

One month later, his condition progressed

he required a wheelchair, declined cognitively, and developed personality changes

Neurological examination showed slurred speech, worsened cerebellar ataxia, and impaired postural reflex without myoclonus/asterixis

He developed seizures and was admitted to a hospital

His mental status continued to progressively decline, and he became completely mute

he could only open his eyes and follow commands to protrude his tongue but was unable to move his eyes or any limbs

Electroencephalogram showed diffuse slowing

Repeated MRI was unremarkable (Figure 1)

Magnetic resonance imaging of the brain demonstrates (A) no pontine or cerebellar atrophy and no cortical ribbon sign, ie, high signal intensity of the cerebral cortex, on (B) fluid-attenuated inversion recovery, or (C) diffusion-weighted imaging sequence


Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy

Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes

Hereditary diffuse leukoencephalopathy with axonal spheroids

A 21-year-old woman presented with a 3-year history of progressive depression, bradyphrenia, dyscalculia, and fatigue, necessitating withdrawal from college

She had an ovarian cyst, but her medical history was otherwise unremarkable

There was no history of recreational drug use, tobacco or alcohol consumption, or sexually transmitted diseases

Her mother had died at 32 years of age, after having a chronic neuropsychiatric illness, culminating in a rapidly progressive dementia

A postmortem brain examination reported the presence of multitudinous corpora amylacea, but no specific neuropathological diagnosis was made

Neurologic examination of the patient during the initial consultation revealed a Mini-Mental State Examination score of 24 of 30 (points were missed on attention, calculation, and abstraction), and the patient was abulic, but it was otherwise unremarkable

Magnetic resonance imaging (MRI) of the brain showed scattered small foci of T2 hyperintensity in the white matter affecting the corpus callosum, bifrontal, and biparietal regions, associated with bifrontal and bitemporal atrophy (Figure1A)

No lesions were identified in the cerebellum or brainstem

Laboratory investigations including complete blood cell count with differential

liver, renal, and thyroid function tests

syphilis and human immunodeficiency virus serologies

and erythrocyte sedimentation rate were unrevealing

Cerebrospinal fluid analysis showed a slight protein elevation, but no pleocytosis, oligoclonal bands, or elevated immunoglobulin G synthesis rate

A, Axial T2 sequence showing bifrontal cerebral convexity sulcal enlargement greater than expected for patient's age, punctate bifrontal subcortical fluid-attenuated inversion recovery (FLAIR) hyperintense foci (right greater than left) are noted

B, Brain magnetic resonance imaging axial and coronal T2 FLAIR sequence showing more pronounced global cerebral atrophy, progression of the subcortical FLAIR hyperintense lesions in the frontal predominant distribution, and also affecting the periventricular and deep white matter into the subcortical areas


A 15-month-old boy with congenital heart disease, seizures, and developmental delay was admitted to the hospital for a methicillin-resistant Staphylococcus aureus retropharyngeal abscess and methicillin-resistant Staphylococcus aureus bacteremia treated with vancomycin and clindamycin

The dermatology department was consulted for a diffuse truncal rash concerning for a drug rash given the initiation of several antibiotics during his hospital stay

On admission, he was noted to have several scattered 2-mm pink papules on his trunk and extremities and a high density of blue-gray macules on his trunk

The duration of his skin lesions was unknown

He was up-to-date on all of his immunizations

He lived with his parents, aunt, uncle, and 3-year-old cousin

His cousin received a diagnosis of chicken pox 6 months prior, but had persistent skin lesions and pruritus

His mother had several pruritic pink papules on her bilateral forearms, which she suspected were from sand fleas

A skin examination revealed a Fitzpatrick skin phototype I and numerous ill-defined 0.5- to 1-cm nonblanching blue-gray macules on his trunk, a few of which contained a central 2-mm dome-shaped pink papule (Figure)

There were also several similar pink 2-mm papules and hemorrhagic punctae scattered on his trunk, extremities, and scalp

Multiple ill-defined 1-cm blue-gray macules, a few of which contain a central 2-mm dome-shaped pink papule (black arrowhead) on the chest and abdomen


A toddler presented with recent onset of nasal congestion, constant rhinorrhea, and difficulty hearing

Previous treatment with montelukast provided symptomatic relief

however, this was discontinued owing to behavioral changes

His medical history was significant for an unusual gait with anterior displacement of the pelvis and hips since he began walking at 10 months of age

Since then he had experienced intermittent episodes of limping accompanied by pain in both femurs

Radiographs revealed no active fractures but did show extensive bony changes in the long bones and the skull

On examination, mild asymmetry of the head was noted on palpation with prominence of the right temporal and parietal area

On limited endoscopic examination, mucosal edema and mucopurulent discharge were observed in the left more than the right naris

An endoscope could not be advanced posteriorly owing to patient discomfort and right-sided sinonasal obstruction

Multiple macules with irregular borders were observed on the lower back, upper buttock, upper chest, upper neck, and right postauricular area

There was also a varus deformity of the lower extremities with mild discrepancy in leg length

An audiogram showed bilateral conductive hearing loss with a flat tympanogram

A computed tomographic (CT) scan of the head and neck revealed heterogenous opacification of the right ethmoid and maxillary sinuses with fluid accumulation within the bilateral mastoid bones and middle ears

His thyroid-stimulating hormone level was 0.19 mIU/mL (reference range, 0.5-2.4 mIU/mL), free thyroxine level was 1.3 ng/dL (0.9-1.6 ng/dL), and free triiodothyronine levelwas 4.6 pg/mL (3.4-5.1 pg/mL) (Figure)

A, High axial image showing right ethmoid ground glass bony changes

B, Low axial image showing right maxillary fibro-osseous changes (white arrowhead) and osseous changes in the posterior maxilla (yellow arrowhead)


An infant girl who was initially seen in the neurosurgical clinic at 7 weeks of age for a left parietal scalp cyst was referred to our clinic after the neurosurgeon discovered a new nasal midline mass  on follow-up examination

Her perinatal and medical histories were otherwise unremarkable

On examination, a 1-cm mobile, well-defined, nontender mass over the nasal dorsum was noted

Findings from the rest of the otolaryngologic examination were normal

Given the superficial nature of the nasal cyst on examination and in an effort to minimize radiation and anesthetic exposure for the patient, computed tomographic and magnetic resonance imaging were deferred

The preoperative plan was to excise the nasal dermal lesion and carefully inspect for any tracts extending intracranially, which would then warrant imaging and a revised intracranial approach

Intraoperatively, an incision was made above the mass and carried through the subcutaneous tissue to expose a mass with a white wall and pink tissue within

The 0.8 × 0.5 × 0.3-cm mass was freed from the surrounding tissue and excised down to the nasal bone

Careful inspection and palpation after excision revealed no bone involvement or intracranial extension

The neurosurgical team removed the superficial scalp cyst, which was found to be an epidermoid cyst

Histopathologic images of the excised nasal mass are shown in the Figure

Histopathologic images (hematoxylin-eosin) from the nasal mass, showing a disordered admixture of mature skeletal muscle, mature adipose tissue, and skin adnexal structures


A man in his 60s was admitted to the hospital for a myocardial infarction

Several days into his stay, he complained of having a hoarse voice for the past year

He denied dyspnea, dysphagia, and reported no weight loss

His medical history was notable for congestive heart failure, coronary artery disease, and gout

He noted a 10-pack-year smoking history and Agent Orange exposure

On examination, he had no palpable neck masses

He underwent a flexible laryngoscopy, which showed an exophytic yellow-white mid-membranous subepithelial lesion on the bilateral true vocal folds (Figure, A)

On stroboscopy, there was decreased vibratory amplitude bilaterally and moderate phase asymmetry

Several weeks later, he underwent an indirect laryngoscopy and vocal fold biopsy in the office

Grossly, pathologic findings showed a chalky white lesion

Histopathologic review showed submucosal amorphous eosinophilic material (Figure, B)

The amorphous material was negative for Congo red (Figure, C)

Examination of an unstained slide showed needle-shaped birefringent crystals (Figure, D)

With this nonspecific but benign diagnosis, and an inability for the patient to go to the operating room secondary to his comorbidities, he agreed to undergo office potassium titanyl phosphate laser photoangiolysis of the lesions to improve vocal fold contour and vibration

More of the chalky material was expressed as the overlying mucosa ablated with very little energy delivered

On follow-up, the lesions persisted but were less bulky

A, Indirect laryngoscopy showing exophytic yellow-white mid-membranous subepithelial lesion on the bilateral true vocal folds

D, Unstained slide showing needle-shaped birefringent crystals


A man in his 50s presented to the emergency department with a 10-day history of swelling in the sublingual area

The swelling had been progressively increasing over the first 3 days but had remained stable over the past week

He denied any history of similar symptoms, pain, fever, odynophagia, or difficulty breathing

He complained of some difficulty swallowing owing to the swelling

He had a history of hypertension and had been prescribed a blood pressure medication (the name of which he could not remember), but he had not been taking it for weeks

He had no other pertinent medical history

Physical examination revealed significant, soft, nontender swelling of the floor of mouth bilaterally causing elevation of the tongue (Figure, A)

There was no edema of the tongue or lips

The neck was soft, nontender to palpation, and without palpable lymphadenopathy

Computed tomographic (CT) imaging of the soft tissues of the neck with intravenous contrast showed a 6.3-cm anteroposterior × 6.9-cm cranial caudal × 4.8-cm transverse cystic nonenhancing mass centered in the root of the tongue, with elevation of the oral aspect of the tongue and some downward displacement of the floor of mouth (Figure, B and C)

The sublingual glands were compressed but otherwise appeared normal, and the sublingual spaces were effaced

Surgical excision via an intraoral approach yielded a smooth, well-circumscribed mass

Histologic examination showed keratinizing squamous epithelium


A 52-year-old previously healthy man presented to the emergency department with gradual onset of severe right lower quadrant abdominal pain over the course of 24 hours

The patient did not have a fever and he was hemodynamically normal

Laboratory workup revealed leukocytosis with a white blood cell count of 11 600/μL (to convert to ×109/L, multiply by 0.001)

Physical examination revealed tenderness in the right lower quadrant without overt signs of peritonitis

The patient reported undergoing an appendectomy when he was 10 years old

Abdominal computed tomography was obtained (Figure 1)

Coronal computed tomography scan showing calcification in the terminal ileum with surrounding enteritis (arrowhead)


A healthy 43-year-old woman presented with weight loss, heartburn, and progressively worsening dysphagia to solid food

Intriguingly, the heartburn was most severe while she was sitting up but lying supine relieved the symptoms

Paradoxically, dysphagia was worse while she was reclining and partially resolved in the upright position

The physical examination was normal while laboratory workup revealed mild anemia

She was administered a trial of acid-suppression therapy for 6 weeks, which transiently alleviated heartburn but the dysphagia persisted

Subsequently, further workup with an esophagram revealed a 2.7-cm filling defect at the gastroesophageal junction, suggestive of extrinsic compression

Computed tomography demonstrated a 2.5-cm low-attenuation ovoid lesion at the gastroesophageal junction (Figure 1A)

Considering a diagnosis of gastric tumor, she then underwent upper endoscopy that showed a mobile smooth-surfaced polypoid subepithelial lesion at the posterolateral wall of the gastroesophageal junction

The mass flopped back and forth into the gastroesophageal junction

Mucosal biopsies were performed, which were consistent with normal squamous mucosal epithelium

Following this, endoscopic ultrasonography was performed, which demonstrated an anechoic, loculated, subepithelial lesion located within the submucosa of the distal esophagus (Figure 1B)

The endosonographic borders were well defined without invasion into the nearby structures

Manometry and 24-hour pH testing revealed preserved motility but abnormal acid exposure of the distal esophagus

Ultrasonography of the liver, gallbladder, and pancreas revealed no abnormalities

A, Contrast computed tomogram (CT) revealing a mass at the gastroesophageal junction protruding into the cardia of the stomach

B, Endoscopic ultrasonography demonstrated a cystic lesion originating and localized to the wall of the esophagus but not invading local structures


A woman in her 70s with a history of sarcoidosis presented with progressive supraclavicular, facial, and mandibular swelling of 3 months’ duration

She reported pain with chewing, which led to a 5-kg weight loss, but denied trismus

On examination, there was craniofacial deformity with left facial preauricular swelling

The left parotid was firm and a fixed mass was felt throughout the left preauricular space, expanding into the temporomandibular joint area and zygoma

Soft-mobile lymphadenopathy was palpable in the left neck, and a firm, adherent, immobile right supraclavicular mass extended under the clavicle

Cranial nerve examination findings were normal

Magnetic resonance imaging and computed tomography of the neck showed a 3.2 × 4.4 × 2.8-cm lobulated enhancing paramandibular mass extending into the left masticator space and infratemporal fossa, with frank erosion of the left mandibular condyle (Figure)

Computed tomography of the chest showed a 4.6 × 3.2 × 3.5-cm supraclavicular mass with infiltration of the surrounding fat and scalene muscle and extension into the chest wall and axilla

Positron emission tomography showed a large metabolically active left masticator space mass (standardized uptake value for body weight at maximum counts per pixel [SUVmax], 18.2) and previously mentioned pathologic nodes

The right supraclavicular mass was also metabolically active (SUVmax, 19.4), and metabolically active right axillary, left mediastinal, and intra-abdominal lymphadenopathy was also noted

A, Axial computed tomography of the head and neck showing a lobulated paramandibular mass (arrowhead)

B, Magnetic resonance imaging of the brain showing a lobulated paramandibular mass (arrowhead)

C, Coronal computed tomography of the chest demonstrating a paramandibular mass (arrowhead)

D, Coronal computed tomography of the chest demonstrating a supraclavicular mass (arrowhead)


Palisaded neutrophilic and granulomatous dermatitis

A healthy woman in her 20s presented with a 5-month history of a painful erythematous eruption over her bilateral thighs

She reported that the eruption was worsening during the winter months

She had not experienced any fevers, chills, joint pains, recent weight loss, or any other constitutional symptoms

She was a nonsmoker and took no medications

A review of her social history revealed that she was working at a horse stable and rode for many hours a day

On physical examination, distributed over the bilateral posterior lateral thighs, there were several arcuate to circinate erythematous to violaceous plaques

There were also several focal areas of ulceration with overlying scale-crust (Figure, A and B)

A biopsy was performed during this initial visit (Figure, C and D)


A man in his 50s presented with a 2-month medical history of painful, gradually expanding ulcers on the left lower leg

The lesions started spontaneously as erythematous tender papules with white purulent discharge

He recently failed a course of amoxicillin and trimethoprim-sulfamethaxazole initiated by his primary care physician

He reported a medical history of rheumatoid arthritis (RA), chronic obstructive pulmonary disease, chronic kidney disease, and heavy tobacco use

The patient denied any recent changes to his medications or recent travel

No other household members were affected

Physical examination of the left lower extremity revealed a 2.5-cm keratotic plaque with central ulceration that expressed a straw-colored fluid

The limb was dusky with scattered hyperpigmented patches and surrounding erythema (Figure, A and B)

Both lower limbs exhibited pitting edema of 1+ severity, and negative Homans sign bilaterally for deep vein thrombosis

Fungal and bacterial culture samples were negative

Rheumatoid factor was elevated at 198 IU/mL, and other laboratory data were noncontributory

A punch biopsy specimen was obtained from the edge of the lesion (Figure, C and D)

C, Periodic acid–Schiff stain (original magnification ×4)

D, Hematoxylin-eosin stain (original magnification ×20)


A man in his 60s with diabetes underwent biopsy for an asymptomatic shiny indurated plaque on the right plantar foot, which had been slowly growing for the past year

The patient was then referred to a dermatology specialist for further treatment

The patient reported no fevers, chills, weight loss, or night sweats

He had long-standing, intermittent dyspnea on exertion, but no baseline shortness of breath, orthopnea, or bilateral lower extremity edema

The patient had occasional numbness in both legs in stocking distribution, attributed to diabetic neuropathy

Physical examination revealed a 4.5 cm waxy, nontender, smooth-surfaced, cobblestoned plaque located in the sulcus between the second and fourth toes (Figure, A)

A biopsy specimen obtained by the patient’s podiatrist was sent to the dermatopathology laboratory for review

A, Clinical presentation revealed smooth-surfaced cobblestoned plaque that was asymptomatic

B, Hemotoxylin-eosin stain (original magnification ×100) results show a diffuse infiltrate of pale eosinophilic material with prominent clefts

C, Congo red stain (original magnification ×200)


A 16-year-old boy with autism presented with 4 weeks of progressive bilateral lower extremity edema, ecchymosis, and arthralgias severe enough to prevent ambulation

Associated symptoms included fatigue, decreased appetite, abdominal discomfort, and intermittent scleral icterus noted by his mother

One week prior, a dentist diagnosed acute necrotizing gingivostomatitis based on gum inflammation and bleeding, prompting treatment with metronidazole and penicillin

There was no history of trauma, fevers, hematuria, or hematochezia or family history of coagulation disorders

His medical history was significant for seizures and behavioral disturbances managed with stable doses of lamotrigine and chlorpromazine

On physical examination, he was nonverbal but in no visible distress

There was hemorrhagic gingivitis (Figure, A) without cervical lymphadenopathy, and the bilateral lower extremities had marked asymmetric pitting edema, large ecchymoses on the thighs, ankles, and feet (Figure, B), and scattered petechiae (Figure, C)

His lower extremities were tender to palpation and he resisted passive ranging of his joints

A, Markedly edematous and friable gingiva

C, On the lower leg, perifollicular hemorrhage and corkscrew hairs (arrowhead) are present

Initial laboratory workup revealed microcytic anemia with hematocrit level of 22.8% (to convert to proportion of 1.0, multiply by 0.01), mean corpuscular volume of 75.9 µm3 (to convert to femtoliters, multiply by 1), white blood cell count of 5.9/µL (to convert to ×109 per liter, multiply by 0.001), platelet count of 248 ×103/µL (to convert to ×109 per liter, multiply by 1), elevated erythrocyte sedimentation rate of 52 mm/h (to convert to millimeters per hour, multiply by 1), and C-reactive protein level of 5.5 mg/L (to convert to nanomoles per liter, multiply by 9.524), with hypoalbuminemia of 3.4 g/dL (to convert albumin to grams per liter, multiply by 10), but normal creatine kinase level of 83 U/L (to convert to microkatals per liter, multiply by 0.0167), and unremarkable activated partial thromboplastin time and international normalized ratio

Ultrasonography of the lower extremities showed soft tissue swelling without thrombosis

Lower extremity magnetic resonance imaging/magnetic resonance angiography showed diffuse round mildly enhancing bone marrow lesions without vascular changes


Gastrointestinal obstruction due to adhesion band

Gastrointestinal obstruction due to internal hernia

A man in his 40s was referred from jail with abdominal pain for 5 days

The pain was constant in the hypogastric region, with no radiation

He did not have bowel movements for 5 days but passed gas normally

He did not complain of nausea or vomiting

The abdomen was soft with hypogastric tenderness

There was no abdominal distension, guarding, or rebound tenderness

Neither hernia nor surgical scars were seen on examination, and vital signs and results from laboratory tests were normal

An axial contrast computed tomography (CT) scan of the abdomen was performed (Figure 1)

A, A computed tomography scan of the abdomen did not show abnormal intestinal air-fluid levels nor free peritoneal air

B, A computed tomography scan revealed that the rectum was not empty


A previously healthy, fair-skinned professional golfer aged 69 years with a history of frequent outdoor sun exposure presented to the surgery clinic with a mass on his left upper back, which he first noted 1 year ago as a small nodule on his back

It grew rapidly throughout the past year, becoming increasingly painful and bleeding easily with light contact

Clinical examination revealed an 8 × 6 × 4-cm multilobulated, purplish lesion that was fungating and friable (Figure 1)

He also had a palpable, hard mass in the left axilla

He had no other lesions elsewhere on his body

A punch biopsy of the back mass revealed immunohistochemistry strongly positive for S-100, MART-1, and HMB-45. Computed tomographic and positron emission tomographic scans demonstrated a fludeoxyglucose-avid lesion on the back extending into the subcutaneous fat and fludeoxyglucose-avid uptake in the left axilla

An 8 × 6 × 4-cm multilobulated, purplish lesion on the back that was fungating and friable


A man in his 30s presented to the emergency department with sudden voice change, odynophagia, and left-sided neck pain following a single sneeze

He experienced a popping sensation during the sneeze followed by neck stiffness 15 minutes later

He did not have associated shortness of breath, hemoptysis, or other pertinent medical history

He had no history of trauma, surgery, or intubation

On physical examination, his vital signs were stable with normal oxygen saturation on room air

Anterior neck examination revealed tenderness over the thyroid notch and left side of the laryngotracheal complex

Flexible laryngoscopy was performed, which showed hematoma of the left true vocal fold and laryngeal surface of the epiglottis with normal vocal fold movement and complete glottic closure (Figure, A)

Hematoma of the left true vocal fold and laryngeal surface of the epiglottis


A man in his 30s presented with a 1-year history of recurrent episodes of unilateral high-pitched “clicking” in his right ear followed by vertigo that lasted 3 to 4 seconds

He reported no perceived association between these episodes and breathing and head position, and denied precipitation of symptoms with exposure to loud sound or pressure change

He had not experienced hearing loss, aural fullness, autophony, or headache

On physical examination, objective, intermittent, clicking tinnitus at a frequency of 1 click per second was noted on placement of a stethoscope in close proximity to the right ear

The tinnitus coincided temporally with the patient’s complaints but was nonsynchronous with pulse

Results from prior imaging including a computed tomographic (CT) scan of the head with multiplanar reconstruction (Figure, A, C, and D), were normal

Steady state tympanometry showed mildly decreased compliance of the tympanic membrane when the patient reported hearing the clicking sensation

The patient was tentatively diagnosed as having tensor tympani and stapedius myoclonus and after discussion of treatment options, he decided to undergo middle ear exploration for muscle sectioning

The incidental findings observed during middle ear exploration are shown in the Figure, B

A, Computed tomographic (CT) image of the head using bone window

B, Intraoperative photograph of incidental surgical findings

C, Multiplanar oblique coronal reconstruction of computed tomographic image

The inset shows the plane of reconstruction in an oblique coronal view longitudinal with the petrous pyramid

D, Computed tomographic image of the head using bone window


A woman in her 70s presented with a cervical tracheal mass measuring 1.6 × 1.3 cm found incidentally on magnetic resonance imaging for cervical spine pain

She had not experienced dyspnea, hoarseness, dysphagia, hemoptysis, or chest pain

Flexible fiber-optic nasolaryngoscopy demonstrated a smooth hypervascular mass arising from the posterior membranous trachea (Figure, A)

The patient underwent tracheostomy and complete excision via a transtracheal approach

The patient was decannulated on postoperative day 5. Histopathologic images are shown in the Figure, B-D


A man in his 70s with long-standing diabetes, coronary artery disease, and chronic renal failure presented with edema of the right lower leg and suspected venous thrombosis (which was not confirmed by subsequent Doppler ultrasonography)

Blood tests revealed serious iron deficiency anemia (hemoglobin level, 8.6 g/d [86 g/L]) and a positive result for a fecal occult blood test

and no dysphagia, stomach pain, or stool irregularity was reported

Initially, we performed an upper endoscopy that revealed normal esophageal mucosa with folding of the posterior esophageal wall through the entire length of the esophagus

Distal ending of the folding was not clearly seen in forward viewing, but in retroflexion, a necrotic polypoid lesion was observed protruding from the esophagogastric junction

A computed tomographic scan of the chest with oral contrast revealed an esophageal intraluminal tubular mass of soft-tissue density, about 15 mm in diameter originating just below the pyriform recessus and extending through the esophagus in the stomach lumen for about 20 mm (Figure 1)

The patient was referred to an ear, nose, and throat specialist who performed esophagoscopy of the hypopharynx with the patient under endotracheal anesthesia

Intraluminal tubular mass extending through the entire esophagus


A woman in her 70s presented with a new 4-cm left upper lobe lung mass with hilar lymphadenopathy

Biopsy results demonstrated a squamous cell carcinoma (SCC) of the lung, and chemoradiotherapy with carboplatin and paclitaxel for stage 3A disease was initiated

An allergic reaction prompted a change to cisplatin-etoposide, which continued as adjuvant chemotherapy after the radiation was complete

At first restaging, a recurrence of disease in the lung was detected, which was treated with cisplatin and gemcitabine for 4 months before she enrolled in a clinical trial (NCT02009449) in which she received combination therapy with pembrolizumab, 2 mg/kg intravenously for 21 days, and an investigational agent, AM0010 (pegylated recombinant human interleukin-10), 10 μg/kg subcutaneously on days 1 through 14 of the 21-day cycle

Three months into treatment, she developed multiple thick, mildly pruritic, yellow hyperkeratotic plaques on her lower extremities (Figure, A)

A referral to a dermatology expert was initiated

A, Clinical image showing representative plaque on left leg of patient on initial presentation

B, Shave biopsy of skin (hematoxylin-eosin

C, Deeper biopsy demonstrating bandlike lymphocytic infiltration (hematoxylin-eosin


A woman in her 30s presented with multiple discrete and clustered blue papules on her face and extremities

The lesions had been present since childhood, but the size of the lesions and the intensity of pain associated with them had recently increased with even light touch causing paroxysms of pain

The pain associated with these papules worsened as the day progressed, and she could not tolerate elastic compression due to excessive pain on compression

Her medical and family histories were unremarkable

Physical examination revealed multiple discrete and agminated blue papules on the face, arms, hands, and thighs with a cobblestoned appearance (Figure 1)

On palpation, the papules were exquisitely tender and partially compressible

The patient underwent duplex ultrasonography of representative papules on the thigh, and a skin biopsy specimen of a papule on the thigh was obtained for histopathologic evaluation

Clinically, multiple discrete and agminated blue papules are apparent, nodular, blue cutaneous lesions cobblestone-like in appearance, on the thigh (A) and hand and thigh (B)


Hereditary progressive mucinous histiocytosis

A woman in her 20s presented to our department for treatment of multiple facial papules

The lesions were present since childhood, progressively increasing in number

They involved primarily her face, and, less so, her extremities and trunk

There was no medical history of spontaneous regression

She had a young brother, who had the same papular lesions that had followed the same natural history, displaying a similar bodily distribution although fewer in number

Previous studies and imaging of the 2 siblings had failed to reveal any systemic findings

Physical examination revealed multiple smooth skin-colored and erythematous papules of various size, some with telangiectasia, with a medial but asymmetrical distribution on the face (Figure, A)

Identical, less numerous lesions were also present on her hands and back

Three biopsy samples were taken and showed similar findings (Figure, B-D)

A, Multiple skin-colored to erythematous asymptomatic facial papules in a woman in her 20s

The papules were present in childhood and were increasing in number

B, Hematoxylin-eosin stain (original magnification ×20)

C, Hematoxylin-eosin stain (original magnification ×40)

D, Alcian blue stain (original magnification ×10)


A man in his 60s who was a former smoker with a medical history of chronic obstructive pulmonary disease, type 2 diabetes, chronic kidney disease, anemia, and cervical myelopathy experienced low-grade fevers, unintentional 80-pound weight loss, productive cough, and development of cutaneous ulcers over a 6-month period after cervical spine fusion

Two ulcers developed at the surgical site, and 2 similar ulcers developed on his back shortly after cyst excision

He had been recently diagnosed with lung cancer based on computed tomographic (CT) and positron emission tomographic imaging showing an enhancing, hypermetabolic, 7-cm cavitary right upper lobe mass with mediastinal adenopathy

A chest x-ray 6 months prior revealed negative results

A few days after establishing care, he presented to the emergency department with extreme weakness and intolerable pain related to his ulcers

Physical examination revealed an ill-appearing man

In the right upper lobe, there were decreased breath sounds with clear auscultation in the remaining chest

On the right anterior neck were two, 3- to 4-cm tender ulcers extending to the deep subcutaneous fat with erythematous, friable borders (Figure)

On his back were 2 similar 2- to 2.5-cm ulcers

Inflammatory markers were notably elevated

A complete autoimmune panel, indirect immunofluorescence assays, enzyme immunoassays for antineutrophil cytoplasmic antibodies (c-ANCA)/proteinase 3, antineutrophil cytoplasmic antibody/myeloperoxidase, a quantiferon gold test, cultures of blood, broncheoalveolar washings, and tissue analysis were performed

Only c-ANCA testing revealed positive results

A CT scan of the sinus showed multiple bony defects and acute and chronic sinusitis

A transbronchial biopsy of the lung and excisional biopsy of the skin bridge between back ulcers were performed

A, Two deep ulcers of the right mid-lower back with erythematous borders

B, Hematoxylin and eosin stain (original magnification × 5)

C, Hematoxylin and eosin stain (original magnification × 200)

D, Hematoxylin and eosin stain (original magnification × 200)


A man in his 50s presented with weakness in the distal right hand and leg and paresthesias of the right hand

Four days before presentation, he experienced sudden, severe neck pain that swiftly progressed to neck stiffness and bilateral shoulder pain

The next day, he noticed weakness in the right arm and leg

The day before hospitalization, the weakness progressed, and he lost the ability to ambulate

Until 18 months ago, he had worked as a clerk, but he retired because of a history of hypertension and diabetes

His family history revealed no neurological disorders, except for a brother who had a brain lesion excised

On examination, he was afebrile, and his vital signs were normal

He was fully alert but had weakness in the right distal arm (medical research council [MRC] grade 3/5) and the right leg (MRC grade 4/5) with sensory impairment to pinprick and temperature in the left leg

Laboratory values revealed an elevated γ-glutamyltransferase level of 615 U/L (reference range, 10-71 U/L)

Analysis of the cerebrospinal fluid indicated xanthochromia

normal white blood cell count, 1 cell/µL

increased glucose level at 133 mg/dL (reference range, 40-80 mg/dL)

increased total protein level at 0.10 g/dL (reference range, 0.03-0.05 mg/dL)

and increased lactate level at 28.8 mg/dL (reference range, 9.9-21.6 mg/dL)

Magnetic resonance imaging (MRI) of the brain and the entire spinal cord revealed patency of the intracranial vessels and multiple abnormal signals throughout the brain on T1-, T2-, and susceptibility-weighted sequences (SWIs) and 1 lesion at the level of the fifth cervical vertebra (Figure)

A, Susceptibility-weighted magnetic resonance image (MRI) showing numerous intraparenchymal hypointensities (red arrowheads)

B, T1-weighted MRI at the level of the fifth cervical vertebra showing hyperintensity in the right ventral portion of the spinal cord (red arrowhead)

C, T2-weighted MRI showing central hypointensity of the spinal cord between the levels of the fifth cervical and seventh thoracic vertebrae (not shown) (red arrowheads)

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy


An 18-month-old boy presented to the emergency department with a rash on the left lower extremity

He was fully vaccinated, with routine vaccines at 12 months of age administered in the left thigh

The influenza vaccine was administered 1 week prior to presentation in the left buttock, after which his parents noted a red patch near the site of vaccination

The patch became raised and spread down the left thigh over the course of several days

The rash did not bleed, ulcerate, weep, or appear itchy or painful, though the patient did seem uncomfortable when getting dressed

He had no known sick contacts at day care, exposure to  herpes simplex virus, or exposure to new topical products or clothing

His pediatrician prescribed cephalexin and mupirocin for a presumed cutaneous bacterial infection

The eruption continued to spread down his left thigh over the next 2 days, at which point the pediatrician advised the family to go to the emergency department

On examination, the boy was afebrile and well-appearing

There were multiple discrete clusters of monomorphic pink to violaceous papulovesicles with surrounding erythema scattered across the left buttock, thigh, and upper calf, some with central punctate hemorrhagic crust (Figure)

Discrete clusters of monomorphic pink to violaceous papulovesicles with surrounding erythema


A man in his 30s presented to his primary care clinician after 2 years of worsening abdominal discomfort and an increasingly large recurrent umbilical hernia

He described early satiety but had no nausea or vomiting

He reported night sweats and a 9.1-kg weight loss over the prior 6 months

His social history was notable for a 15-pack-year smoking history and consumption of 6 to 8 beers per night

He had no family history of malignant disease

On examination he had no fever, a reducible umbilical hernia, a palpable left-sided abdominal mass, and significant bilateral lower extremity edema

Laboratory evaluation revealed anemia for which the patient received several blood transfusions, leukocytosis (white blood cell count, 57 000/μL), and hyponatremia (sodium level, 128 mEq/L)

He was first referred to the hematology service, and a blood smear showed 74% neutrophils

A bone marrow biopsy specimen showed a hypercellular marrow with a myeloid left shift but no increase in blasts or dyspoiesis

Tests for BCR/ABL and peripheral blood JAK2 mutation were negative

Computed tomography revealed splenomegaly, hydronephrosis, and a 25-cm left-sided retroperitoneal mass (Figure)

A, A large retroperitoneal mass extending from the upper abdomen into the pelvis


A woman in her 60s presented with acute-onset, diffuse abdominal pain for 24 hours accompanied by nausea and retching

She had no significant medical history and no prior abdominal surgery

In the emergency department, she was afebrile with stable vital signs

Results of her abdominal examination revealed a slight distension and diffuse tenderness to palpation, particularly in the epigastrium and right upper quadrant, but no peritoneal signs

Results of laboratory tests were unremarkable except for mild leukocytosis

Abdominopelvic computed tomography revealed a distended cecum in the left upper quadrant (Figure 1)

Computed tomographic images of a dilated cecum in the left upper quadrant (arrowhead)


A woman in her 60s returned for a 6-month follow-up after undergoing a substernal total thyroidectomy for a T3N0M0 right-sided undifferentiated insular carcinoma that caused dysphagia, dysphonia, and tracheal deviation (Figure, A and B)

The procedure was uneventful and well tolerated

Her history of end-stage renal disease precluded postoperative radioactive iodine treatment

Ultrasonography performed at her 3-month follow-up showed no evidence of disease recurrence or local metastasis

Her compressive symptoms had also resolved

Ultrasonography revealed a 1.3 × 1.1 × 1.0-cm hypoechoic mass in the right central compartment and a suspicious lymph node in the right carotid sheath

Fine-needle aspiration confirmed recurrence of a malignant neoplasm in the central compartment

however, the lymph node was not amenable to sampling based on its anatomic location

The patient decided to undergo a right central (level VI) lymph node dissection

Intraoperatively, insular carcinoma was dissected away from the cricothyroid membrane and recurrent laryngeal nerve

In the right central compartment several prelaryngeal and pretracheal nodes were identified and excised

After removal of the most distal of these nodes, a separate pale tan mass 2 cm in diameter was visualized at the level of the thoracic inlet

The mass demonstrated respiratory expansion and retraction

Histopathologic analysis revealed a cystic mass composed primarily of mucosal cells and sparse fibroconnective tissue (Figure, C and D)

A, A large heterogeneously enhancing mass with central necrosis arising from the right thyroid fossa with leftward displacement of the trachea (t)

Large air-filled cavity (yellow arrowhead) measuring 20 × 18 × 15 mm and communicating with the right posterolateral aspect of the trachea

Incidental small esophageal diverticulae noted (e)

B, Large air-filled cavity (red arrowhead) measuring 20 × 18 × 15 mm and communicating with the right posterolateral aspect of the trachea (t)

C and D, Histopathologic images of resected tissue specimen, hematoxylin-eosin

Respiratory mucosa with absence of thyroid, lung, smooth muscle, and cartilaginous tissues


An infant girl presented to the outpatient clinic with a history of recent-onset hoarseness in her cry

Her parents also reported loud snoring and some retractions during sleep

There was no clinically significant medical or family history

Her birth had been uncomplicated after a term pregnancy

Physical examination revealed mild inspiratory stridor and several light-brown macules approximately 1 cm in size on the patient’s skin

On flexible fiberoptic laryngoscopy (Figure), a supraglottic mass could be seen, but visualization of the full extent of the larynx or the mass was difficult owing to lack of cooperation by this very young patient

The decision was made to obtain a better view under direct laryngoscopy in the operating room

A submucosal lesion of the left aryepiglottic fold extending inferiorly to the level of the arytenoid, and displacing the epiglottis medially, was found

An incision was made through the mucosa, where a firm, whitish mass that bled minimally was noted, and a biopsy specimen was sent for permanent pathologic analysis

A magnetic resonance image was then obtained to assess the full extent of the mass and whether surrounding tissues were involved

A, View of lesion at the level of the epiglottis on direct laryngoscopy

B, View of the vocal folds on direct laryngoscopy

C, T1-weighted sagittal magnetic resonance image (MRI) showing laryngeal lesion

D, Bundles of spindle cells with angulated nuclei in a stroma of variable coarse collagen and loose myxoid matrix (hematoxylin-eosin, original magnification ×4)


A woman in her 50s presented with a 5-month history of right submandibular swelling and pain, associated with eating and relieved by gland massage

Computed tomography (CT) and ultrasonography showed normal-appearing submandibular glands and neck soft tissues

A sialogram showed high-grade stricture approximately 3 to 4 cm into the right submandibular duct orifice

Complete stricture prevented evaluation of the proximal duct and intraglandular portions

Sialendoscopy showed a widely patent right submandibular duct proximally with a segmental takeoff, consistent with the Bartholin duct draining into the Wharton duct distal to a blind pouch identified 2.5 cm from the intraoral duct orifice (Figure, A)

Despite a Wharton ductoplasty to improve sublingual gland drainage through the Bartholin duct, the degree of scarring at the hilum and inability to further dilate warranted submandibular gland (SMG) excision

Four months after SMG excision, she developed a right floor of mouth lesion after “burning her mouth” with high-temperature food

Magnetic resonance imaging demonstrated a cystic lesion in the right sublingual space following the Wharton duct (Figure, B)

Recurrent floor of mouth swelling (Figure, C) was addressed by repeated marsupialization and eventual sublingual gland excision

Pathologic analysis identified fragments of squamous mucosa with inflammation, cystic space, and compressed granulation tissues consistent with mucous extravasation (Figure, D)


A woman in her 20s presented to the emergency department with a 2-week history of progressive sore throat, dysphagia, and fever (38.2°C) that developed into dyspnea, dysphonia, and neck pain on the day of presentation

Initially, she had been treated with oral amoxicillin–clavulanic acid with no improvement

Her medical history included ulcerative colitis (UC) controlled by oral azathioprine for 2 years

Initial clinical evaluation revealed respiratory distress with respiratory rate of 21 breaths per minute, with oxygen saturation 95% on room air

Her heart rate was 95 beats per minute, her blood pressure was 135/91 mm Hg, and she was pyretic

Further examination with flexible fiberoptic laryngoscopy (Figure, A) showed considerable erythema and edema of the epiglottitis with patchy necrosis partially obstructing the glottis and saliva pooling in the supraglottis

Findings from the remainder of the otolaryngology examination and chest auscultation were normal

Subsequently, oxygen saturation improved to 100% with 3 L per minute of oxygen via nasal prongs

Her initial laboratory findings revealed a white blood cell count of 12 000/μL, absolute neutrophil count of 46%, hemoglobin count of 12.8 g/dL, and a platelet count of 175 000/μL

Her C-reactive protein level was 5 mg/dL (normal level, <0.5 mg/dL)

Results from liver function tests and chest radiograph were normal


Methicillin-resistant Staphylococcus aureus skin infection

A 69-year-old man with a history of relapsed acute myeloid leukemia (AML) monocytic type presented with intermittent fever and fatigue 2 months after allogeneic stem cell transplantation (SCT)

Post-SCT bone marrow biopsy specimen analysis at day 30 showed no evidence of leukemic cells and 99.5% donor cells

His home medications included acyclovir, fluconazole, and cyclosporine

Temperature on admission was 103.1° F, and other vital signs were unremarkable

Vancomycin and cefepime were started for possible infection

Complete blood cell counts with differential counts showed no evidence of peripheral blasts

Laboratory and imaging work-up—including chest radiographs, blood culture, fungal culture, urinalysis, sputum culture, respiratory viral panel, fungitell and galactomannan assay, coccidioidomycosis serology, and cytomegalovirus and human herpesvirus 6 polymerase chain reaction assays—were all negative

The patient was discharged with oral antibiotics after being afebrile for 72 hours

Thereafter, he had 2 more emergency department visits and was readmitted for recurrent fever

A thorough physical examination revealed 2 nonpruritic skin bumps on the right forearm and left calf that both measured 1.0 cm × 1.5 cm

Both bumps were soft without pigmentation or ulceration

Pathologic sampling of the respective lesions revealed a diffuse infiltration of large mononuclear cells with high nuclear-to-cytoplasmic ratio (Figure, A and B)

Immunohistochemistry staining was positive for CD4 cells and myeloperoxidase (Figure, C and D)A and B, Histologic evaluation of the skin biopsy specimens


A man in his 70s presented to the clinic with a split in the right fifth fingernail for the past 10 years

He reported paroxysmal, intermittent pain that was exacerbated by cold weather

He fractured the digit more than 30 years earlier

Physical examination revealed distal nail plate splitting with accompanying longitudinal erythronychia (Figure, A) and tenderness on palpation of the nail unit

Magnetic resonance imaging revealed a nail matrix lesion (Figure, B), which was excised using a transungual approach with partial nail avulsion

The specimen was analyzed by histopathology (Figure, C and D)


An African American woman in her 30s with no medical history presented with a 4-year history of diffuse progressive proliferation of dark papules

The patient noted that the lesions initially began on her thighs and rapidly multiplied throughout her skin

Some of the lesions were pruritic and when scratched could be removed, leaving behind a hyperpigmented macule

The patient described a sunburn several weeks prior to the initial eruption

She was taking no medications and these lesions were unchanged throughout an uncomplicated pregnancy

There was no personal or family history of melanoma or eruptive nevi

On physical examination, she had hundreds of 1- to 2-mm dark brown-black monomorphic papules throughout her trunk, extremities, palms, face, tongue, and sclera (Figure, A)

Findings from laboratory tests, including a complete blood cell count, comprehensive metabolic panel, and computed tomography of the chest, were unremarkable

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

A, Photograph of left thigh shows diffuse 1- to 2-mm dark brown-black macules and papules

B and C, Punch biopsy of right arm shows a circumscribed proliferation of pigmented epithelioid melanocytic nests, located primarily at tips of rete ridges

Superficial papillary dermis shows prominent pigment incontinence

D, Melan-A immunostain shows low pagetoid migration of melanocytes with a lack of melanocytic confluence at the dermal-epidermal junction


A man in his 20s presented with a large, verrucous plaque on his right calf (Figure, A)

The lesion initially appeared as a small, bluish plaque at a young age and had gradually increased in size with subsequent development of wartlike features

Aside from minor local pain and pruritus, the patient reported history of recurrent infections as well as oozing and bleeding after minimal trauma

Physical examination revealed soft, compressible nodules overlying a friable verrucous plaque in a linear distribution involving the length of the right calf with minimal tenderness on palpation

A deep punch biopsy specimen was obtained and sent for histopathological examination (Figure, B and C)

A, Clinical photograph of extensive verrucous plaque on the right calf

B, Biopsy specimen demonstrating epidermal verrucous hyperplasia, acanthosis, papillomatosis, and hyperkeratosis overlying dilated vessels in the dermis (hematoxylin-eosin, original magnification ×4)

C, Deeper section showing similarly dilated vessels in the deep dermis to the base of the specimen, indicating the probability of deeper extension (hematoxylin-eosin, original magnification ×4)


An 11-year-old boy with a history of asthma and constipation presented with 6 weeks of intermittent, worsening lower back pain

His pain was mild to moderate, woke him from sleep, and limited his physical activity

He had previously been referred to orthopedics by his pediatrician owing to multiple presentations for the same complaint

The patient denied recent trauma, fevers, weight loss, cough, rash, or sick contacts

He was born in the United States with no recent travel

According to outpatient records, his height had been unchanged for the last 2 years

A physical examination showed a well-appearing young boy with unremarkable heart, lung, and abdominal findings

There was mild tenderness to palpation of the lumbar spine, and mild pain elicited with flexion and extension of his back

His strength was 4/5 in bilateral lower extremities, with otherwise normal neurological examination findings

He had a white blood cell count of 6.2 × 103/µL (to convert to ×109 per liter, multiply by 0.001), a hemoglobin level of 10.9 g/dL (to convert to grams per liter, multiply by 10.0), and a platelet count of 611 × 103/µL (to convert to ×109 per liter, multiply by 1.0), with a normal peripheral smear result

The results of a complete metabolic panel were unremarkable, and so were his lactate dehydrogenase and uric acid levels

He had an erythrocyte sedimentation rate of 80 mm/h and a C-reactive protein level of 20 mg/L (to convert to nanomoles per liter, multiply by 9.524)

In the emergency department, a radiograph of his chest (Figure, A) revealed a right paravertebral mass, destruction of left seventh rib, a compression fracture of T8, and bony erosion of L1 vertebra

A computed tomographic (CT) scan (Figure, B) revealed paravertebral abscesses with T8 compression and destruction

Mediastinal and hilar lymphadenopathy was noted on imaging but are not shown

A, Radiograph of the chest reveals a right paravertebral mass (left arrowhead), destruction of the left seventh rib (top right arrowhead), a compression fracture of T8 (middle right arrowhead), and bony erosion of L1 vertebra (bottom right arrowhead)

B, Computed tomographic scan reveals paravertebral abscesses (left arrowhead) with T8 compression and destruction (right arrowhead)


A man in his 40s training for weight-lifting presented with new-onset progressive dizziness, lightheadedness, and shortness of breath

His medical and family history as well as review of other systems were unremarkable

Physical examination revealed a positive Kussmaul sign and pulsus paradoxus but no cardiac murmurs

There was no pedal edema, clubbing, or cyanosis

An electrocardiogram demonstrated sinus tachycardia

Results of a complete blood cell count and biochemical panel were within reference ranges

A chest radiograph revealed convexity on the right heart border suggestive of cardiomegaly (Figure 1A)

Echocardiography demonstrated normal cardiac chambers and valves

However, an echogenicity was noted compressing the superior vena cava and right ventricle

The patient subsequently underwent computed tomographic imaging of the chest that revealed a large, 16.2 × 6.8 × 5.6-cm anterior mediastinal mass compressing the right cardiac structures, particularly the superior vena cava

The mass consisted mostly of fat attenuation, but was interspersed with nodular densities (Figure 1B)

Tumor marker levels, including α-fetoprotein, lactate dehydrogenase, and β-human chorionic gonadotropin, were within reference ranges

A, Radiograph showed a convexity on the right heart border and cardiomegaly

B, Tomographic examination revealed a large, anterior mediastinal mass with fat attenuation interspersed with nodular soft tissue elements (asterisk)


Prolonged ileus secondary to retained intraluminal old blood

A 67-year-old man was evaluated for lower gastrointestinal tract bleeding

He had been transferred from an outside institution with rectal bleeding requiring blood transfusion

The result of an upper gastrointestinal endoscopy performed at the referring institution was normal

A colonoscopy had been performed at the referring institution, but visualization was poor, with fresh blood and clots noted in the ascending colon

Endoscopic treatment of a right colon arteriovenous malformation with active bleeding was attempted

This was unsuccessful and bleeding persisted

The patient underwent urgent angiography and embolization of a right colic artery branch (Figure 1B)

At angiography, no blush or bleeding vessel was evident

The decision to embolize the right colic branch was based on the endoscopic findings and the presence of pooling contrast in the cecum noted on a computed tomographic angiogram (Figure 1A) performed at the referring institution

Twenty hours after the procedure, he reported abdominal pain

Findings from computed tomographic scan of the abdomen and pelvis obtained at this time were unremarkable

He was treated with antibiotics and observed

He progressed to develop abdominal distension, vomiting, and significant right lower quadrant tenderness during the next 2 days

A, Computed tomographic angiogram showing pooling of contrast in right colon (yellow arrowhead), B, Selective embolization of right colic artery with a gel foam slurry