An immunosuppressed man in his 60s was admitted to our hospital for hypertensive urgency

He had a past medical history significant for metastatic renal cell carcinoma, a lung transplant secondary to chronic obstructive pulmonary disease, end-stage kidney disease being treated with hemodialysis, and multiple nonmelanoma skin cancers

A dermatologist was consulted during his admission to evaluate a friable, growing lesion on his right elbow that had appeared 2 months prior

Physical exam revealed 2 closely adjacent dome-shaped erythematous nodules with edematous borders (Figure, A)

A, Two closely adjacent friable, erythematous nodules with rolled borders on the left elbow

B, Pseudoepitheliomatous hyperplasia of the epidermis with focal ulceration and multiple collections of neutrophils

C, Mixed inflammatory infiltrate containing neutrophils, plasma cells, histiocytic, and multinucleate giant cells containing refractile spore-like structures

D, Numerous spores and pseudohyphae staining positively for pigment


An elderly woman presented to the emergency department with sudden-onset upper abdominal pain and vomiting for 7 days

She underwent gastric surgery more than 25 years ago, of which no details were available

On general physical examination, her vital signs were stable

The results from initial blood tests, including hemogram, liver and kidney function tests, and serum amylase, were unremarkable

Contrast-enhanced abdominal computed tomography was performed (Figure 1)


A 49-year-old woman with no relevant medical history presented with a 2-day history of headache and facial swelling

She was found to have severely elevated blood pressure at an urgent care center, prompting her transfer to the hospital

On review of systems, she endorsed anorexia and malaise for the past several days

She was in no acute distress but appeared languid

Physical examination demonstrated periorbital and 1+ bipedal pitting edema

She had mild tenderness to percussion of both flanks

Serum studies revealed a creatinine level of 13 mg/dL (to convert to micromoles per liter, multiply by 88.4), potassium level of 6.6 mEq/L (to convert to millimoles per liter, multiply by 1.0), and bicarbonate level of 16 mEq/L (to convert to millimoles per liter, multiply by 1.0)

Her serum calcium level was 8.5 mg/dL (to convert to millimoles per liter, multiply by 0.25) and her serum phosphate level was elevated at 5 mg/dL (to convert to millimoles per liter, multiply by 0.323)

Computed tomography of the abdomen and pelvis revealed severe bilateral hydronephrosis with renal cortical thinning and obstructing calculi at both ureteropelvic junctions (Figure 1)

The patient underwent emergent dialysis followed by placement of bilateral percutaneous nephrostomy tubes

Subsequently, her blood pressure normalized, edema improved, hyperkalemia and metabolic acidosis resolved, and serum creatinine level decreased to 1.6 mg/dL

Interestingly, her serum calcium level elevated to 12 mg/dL and her serum phosphate level became low at 2.4 mg/dL

Computed tomographic scans of the abdomen and pelvis without contrast, showing obstructing calculi bilaterally at the ureteropelvic junctions (arrowheads) with resultant severe hydronephrosis and renal cortical thinning (A) and significant renal stone burden in the lower pole of the left kidney (B)


A 5-year-old boy with global developmental delay presented with a 3-day history of vomiting, diarrhea, and refusing to bear weight

His parents said that he is a “picky eater,” with a diet consisting exclusively of orange soda, meat, and chili

His mother reported that he was having difficulty grasping objects and recently started biting his fingers

A physical examination revealed a very irritable, inconsolable child with diffuse muscle tenderness

The results of an extremity examination were consistent with carpal spasm, with a fully extended first finger with hyperextended distal interphalangeal joint, thumb constantly adducted to the hand, and last 3 digits mildly flexed and adducted together

The extremity examination also revealed twitching of facial muscles in response to tapping over area of facial nerve (ie, a positive Chvestok sign1 )

Laboratory studies confirm hypocalcemia (with a calcium level of 5.5 mg/dL [to convert to millimoles per liter, multiply by 0.25]), and a diagnosis of tetany is made

Additional physical examination findings include wrists that are unusually wide with prominent styloid processes of the radius and ulna

radiographs were abnormal (Figure, A and B)

A, The patient’s wrist is unusually wide and notable for prominent styloid processes of the radius and ulna

B, Wrist radiograph shows widening of the physes of the distal radius

There is associated transverse splaying, fraying, and cupping of the adjacent metaphyses, with loss of the zone of peripheral calcification

Further investigation revealed a parathyroid hormone (PTH) level of 798 pg/mL (normal range, 15-87 pg/mL [to convert to nanograms per liter, multiply by 1.0]), a vitamin D level of 7 pg/mL (normal level, >25 pg/mL [to convert to picomoles per liter, multiply by 2.6]), and a normal phosphorous level of 4.5 mg/dL (to convert to millimoles per liter, multiply by 0.323)

Oral and intravenous supplementations of calcium were started, but the patient’s calcium levels remained refractory, even after correction of other electrolytes, including potassium and magnesium

He was placed on a continuous intravenous calcium infusion for 3 days with eventual normalization of his calcium level


A man in his early 70s walked into the emergency department with a 4-day history of fever and tingling sensation in the chest

His medical history was significant with hypertension, intracranial hemorrhage, and chronic kidney disease (CKD)

On arrival, his blood pressure was 130/64 mm Hg, heart rate was 104 beats/min, respiratory rate was 32 breaths/min, body temperature was 37.1°C, and arterial oxygen saturation was 95% on room air

There was no murmur, rub, or gallop in chest auscultation

Electrocardiographic (ECG) findings were significant for diffuse ST-segment elevation (Figure 1, A)

Laboratory examination revealed leukocytosis with normal cardiac enzyme levels and mild renal dysfunction (serum creatinine, 1.4 mg/dL [to convert to micromoles per liter, multiply 88.4])

The C-reactive protein level was also elevated

He was admitted to the hospital with the suspected diagnosis of acute pericarditis

After admission, his chest discomfort resolved in 2 days, but he was still febrile, and pericardial effusion did not decrease

Computed tomography (CT) of the chest was performed (Figure 1, B and C)


A young man without antecedent episodes of rhinosinusitis or sinus surgery presented with progressive headache and left periorbital edema and pain recalcitrant to 4 days of outpatient oral antibiotics and 2 days of intravenous vancomycin and ceftriaxone

His family history was positive for a similar presentation involving his mother

Physical examination revealed left orbital swelling and erythema with proptosis

Cranial nerve function and ocular range of motion were intact

Contrast-enhanced computed tomographic (Figure, A) and magnetic resonance imaging studies of the paranasal sinuses (Figure, B) disclosed extensive preseptal and postseptal orbital inflammation, bilateral frontal sinus opacification from a large left frontal osteoma occupying the inferior aspect of the left frontal sinus, and left epidural abscess

The patient underwent a bicoronal approach osteoplastic flap and endoscopic frontal sinusotomy for access and drainage of left frontal sinus disease and obstructive osteoma excision

In addition to frontal sinus osteoma, multiple 3- to 5-mm osteomas covering the calvarium were encountered (Figure, C)

The patient’s postoperative period progressed without incident, and he was discharged home with oral antibiotics following resolution of symptoms

Histopathologic findings of operative specimens showed dense lamellar bone (Figure, D)

Genetic analysis was positive for mutation in the APC gene at 5q21, resulting in a stop codon

A, Contrast-enhanced computed tomographic (CT) in bone windows

B, T1-weighted magnetic resonance image (MRI)

C, Reflected osteoplastic flap, frontal sinusotomy

D, Hematoxylin-eosin, original magnification ×400.


A man in his 50s was referred to the otolaryngology clinic because of a globus sensation in the throat and a 6-month history of throat pain

His medical history was significant for hypertension, dyslipidemia, and cigarette smoking

Flexible fiber-optic laryngoscopy revealed a 15-mm submucosal swelling in the right aryepiglottic fold

The vocal folds were free of lesions and had intact motion

Findings from the rest of the head and neck examination were unremarkable

A computed tomographic (CT) scan of the neck revealed a submucosal hypodense supraglottic mass on the right side that was compressing the airway

A magnetic resonance imaging study (MRI) of the neck demonstrated a soft-tissue mass measuring 27 × 17 mm and causing deviation of the right aryepiglottic fold medially and compressing the airway (Figure, A and B)

The patient underwent direct laryngoscopy, and a submucosal mass was observed in the right aryepiglottic fold (Figure, C)

The mass was dissected submucosally, excised completely, and sent for a histopathologic examination (Figure, D)

Results from the S100 protein immunostain were positive

The postoperative course was uneventful, and after 5 months, the patient had no detectable laryngeal lesions and the vocal fold movement was intact


A woman in her 40s had an 8-year history of progressive dyspnea associated with nonproductive cough

Her medical history was notable for dyspepsia, hypertension, and diabetes

She had no history of smoking, type B symptoms, angiotensin-converting enzyme-inhibitor use, or known cardiac pathologic abnormalities

Findings from a complete head and neck examination were within normal limits aside from laryngeal findings

Flexible laryngoscopy with videostroboscopy revealed right vocal fold polyp and left vocal fold desquamation, with bilateral linear bands along the vocal folds

Initial treatment with proton pump inhibitors and evaluation by the gastroenterology unit did not improve her symptoms, so further workup was undertaken

Noncontrast computed tomography (CT) revealed numerous calcified subglottic and tracheal nodules extending from the cricoid to the left mainstem bronchus (Figure, A)

She underwent direct laryngoscopy and bronchoscopy with biopsies

On induction, subglottic firm mass consistent with calcification prevented passage of an endotracheal tube, and the patient’s airway was secured with a rigid bronchoscope

Further examination revealed edema of the vocal folds with multiple submucosal masses in the subglottis and upper trachea (Figure, B-D)

The lesions were varying sizes, and not all were calcified

They affected the anterior cartilaginous trachea and the posterior membranous portion

Biopsy specimens of representative lesions revealed amorphous, eosinophilic material with calcification, metaplastic ossification, and multinucleated foreign-body giant cells

The disease was treated with debulking of scattered lesions from the glottis through to both main stem bronchi and airway dilation, which provided symptomatic relief

A, Calcified subglottic, upper tracheal, and left mainstem bronchus lesions

B, Waxy, friable deposits in the supraglottic airway

C, Nodular lesions scattered circumferentially in the trachea

D, Nodular lesions extending into bronchi and lower airways


A 72-year-old woman was treated with a total postoperative radiotherapy dose of 55.86 Gy (to convert to rad, divide by 0.01) in 21 fractions after lumpectomy of a cT1bN0M0 mammary carcinoma

Two months after the last dose of radiation she developed pruritic pustules and papules on the skin of the ipsilateral right breast

She mentioned that she had a cold sore once several years ago

Levoceterizine gave some relief of the itch

Physical examination findings showed pustules surrounding the areola on the right breast with an increasing number in the submammary fold (Figure 1)


A man in his 70s with hypertension, benign prostatic hypertrophy, and myelodysplastic syndrome (MDS) presented for a second opinion regarding treatment of MDS

Three years prior he had developed neutropenia and mild thrombocytopenia

A bone marrow biopsy sample demonstrated refractory cytopenia with multilineage dysplasia

Cytogenetic testing results were normal, and there were 5% bone marrow blasts

The patient was treated initially with cyanocobalamin 250 micrograms daily, then danazol 200 milligrams 3 times daily, then epoietin α 60,000 units weekly

Filgrastim 300 micrograms weekly was added to epoietin α to attempt to augment response after 1 year of therapy

After approximately 2 years, he developed more pronounced cytopenias and presented with a white blood cell count of 2100/μL(480 neutrophils), hemoglobin level of 8.4 g/dL, and platelet count of 92 000/μL

He noted fatigue, but otherwise felt well

Physical examination revealed an isolated, symptomatic polypoid mass involving his right upper labial mucosa (Figure)

It had been recently biopsied without definitive diagnosis, but since the biopsy, the mass had increased in size

An isolated polypoid mass affecting the right upper labial mucosa


Diffuse melanosis in metastatic melanoma

A 65-year-old woman presented with a 5-year history of gradually increasing blue discoloration of her ears

She had mild knee arthralgia that was treated with nonsteroidal anti-inflammatory drugs (NSAIDs)

She was seeing an ophthalmologist annually regarding brown spots on both eyes diagnosed as conjunctival nevi

No other family members were similarly affected

As an infant, her mother had taken her to their physician owing to dark discoloration of her diapers, but this was not investigated further

Examination revealed slate blue macular pigmentation within the antihelix and conchal bowls of both ears (Figure, A)

There were prominent dark brown deposits on the conjunctivae medial and lateral to the iris of both eyes (Figure, B)

No other pigmentary changes were noted on the skin or mucosal surfaces

A punch biopsy specimen from the pigmented area on the left ear was obtained (Figure, C)

A, Examination of the left ear revealing slate blue macular discoloration, most prominent over the antihelix

B, Examination of the left eye showing dark brown pigment deposition of the conjunctiva lateral to the iris

Similar deposits were seen medial to the iris, bilaterally in both eyes

C, Hematoxylin-eosin stain on punch biopsy specimen of pigmented area on left ear demonstrating large pigment deposit in the dermis and adjacent to the cartilage (original magnification ×150)


A male neonate born prematurely at 27 weeks’ gestational age was noted to have a erythematous eruption at birth

The neonate was the product of a dichorionic, diamniotic twin pregnancy

The other twin did not have any dermatalogic abnormalities

They were born to a previously healthy woman who had been hospitalized 12 days prior for tocolytic therapy

One day prior to delivery, the mother was noted to have yeast on urinalysis

The presence of epithelial cells in the sample suggested vaginal contamination

Despite tocolytic therapy, labor ultimately progressed the following day and cesarean delivery was performed owing to breech presentation of the unaffected twin

Physical examination of the affected twin revealed an afebrile, 1200 g preterm infant

Skin examination showed 100 to 200 pink papules, 0.05 to 0.2 cm in size, distributed on the trunk, extensor upper arms, and upper legs (Figure, A and B)

A subset of the lesions appeared vesiculopustular, but no fluid was evident after attempted unroofing

The diaper area, hands, feet, nails, and oral mucosa were unaffected

The second twin had normal cutaneous examination findings

Laboratory analysis revealed a white blood cell (WBC) count of 6000/μL, which was composed of 21% neutrophils, 38% lymphocytes, 24% monocytes, and 5% eosinophils

Gram stain of lesional scrapings did not reveal bacteria nor WBCs, though potassium hydroxide staining showed numerous yeast forms

Lesional polymerase chain reaction was negative for herpes simplex virus

Bacterial cultures from the skin and the blood were ultimately negative

The placentas from both neonates were sent for pathologic analysis (Figure, C and D)

A, Pink papules and vesicopustules were noted on the trunk, arms, and extensor thighs, but spared the diaper area

C and D, histopathologic images of umbilical cord section


A 50-year-old woman presented with a 20-year history of slowly progressive red-to-brown pruritic hyperkeratotic papules and reticulated hyperpigmentation involving her face, neck, chest, back, and upper and lower extremities (Figure, A and B)

She was previously diagnosed with Darier disease after biopsy revealed acantholytic dyskeratosis

She was treated with fluorouracil and tazarotene, 0.1%, cream with mild improvement, but she continued to develop new lesions

Social, family, and past medical history were noncontributory

Physical examination revealed reddish-brown hyperkeratotic papules on the neck, trunk, and extremities and diffuse brown macules, many in a reticulated pattern, on the face, neck, trunk, and extremities

A punch biopsy specimen was collected from both the arm and trunk and histologic examination was performed (Figure, C and D)

Photographs of clinical findings of reticulate hyperpigmentation of the (A) neck and chest and (B) lower extremities

Hematoxylin-eosin of (C) hyperorthokeratosis, epidermal acanthosis and elongated epidermal rete ridges with bud-like filiform projections and suprapapillary plate thinning (original magnification ×4) and (D) focal acantholysis without dyskeratosis (original magnification ×10)


Fibromuscular dysplasia of the carotid artery

A 45-year-old woman with no medical history presented with intermittent episodes of right hand and leg discoordination and paresthesia of increasing frequency 2 weeks prior to presentation

She denied any antecedent trauma or neck manipulation

She had no known history of renal dysfunction or poorly controlled hypertension and was a lifelong nonsmoker

She was seen in the emergency department and underwent brain magnetic resonance imaging, which demonstrated patchy enhancement in the left basal ganglia and corona radiata concerning for demyelinating lesions

She was admitted and underwent further workup

Pertinent laboratory results included C-reactive protein level of 0.01 mg/L (to convert to nanomoles per liter, multiply by 9.524), erythrocyte sedimentation rate of 6 mm/h (to convert to millimeters per hour, multiply by 1), and normal cholesterol panel

She underwent an extensive imaging workup consisting of bilateral carotid duplex, computed tomographic neck angiography (Figure 1A) and cerebral arteriogram (Figure 1B)

A, Computed tomographic arteriogram of the neck demonstrating near occlusion of the proximal left internal carotid artery (arrowhead)

B, Cerebral arteriogram demonstrating a string sign in the proximal left internal carotid artery (arrowhead)


A 13-month-old girl was hospitalized with acute exudative tonsillitis

The product of a full-term normal delivery, she had had occasional mouth ulcers and recurrent tonsillitis treated with oral antibiotics by her family physician

Her vaccinations were all up to date including the measles, mumps, and rubella vaccine given 2 days before hospitalization, the day of fever onset

Admission examination revealed severe exudative pharyngitis and oral candidiasis

Laboratory parameters included a hemoglobin level of 11.4 g/dL (to convert to grams per liter, multiply by 10), white blood cell count of 5600/μL (to convert to × 109 perliter, multiply by 0.001), absolute lymphocyte count of 5600/μL (to convert to × 109 perliter, multiply by 0.001), absolute neutrophil count of 300/μL (to convert to × 109 perliter, multiply by 0.001), platelet count of 327 × 103/μ (to convert to × 109 per liter, multiply by 1), and C-reactive protein level of 183 mg/L (normal range, <10mg/L

to convert to micromoles per liter, multiply by 9.524)

Intravenous benzylpenicillin was initiated and was followed by defervescence and improvement in her condition

Admission blood and throat culture results were negative

Two days later, at approximately 8:00 am, her mother noticed 2 purple spots in the diaper area

By 4:00 pm, the lesions were described as firm, nontender purpuric nodules

She remained afebrile and clinically stable

By 9:00 pm, the lesions had progressed, with the emergence of multiple discrete ulcers involving the labial, perineal, and gluteal areas

She rapidly deteriorated with onset of septic shock, her white blood cell count fell to 0/μL, and her C-reactive protein level increased to 404 mg/L

Following stabilization and initiation of broad-spectrum antibiotics, she was transferred to a pediatric intensive care unit where Figure 1 was obtained

Multiple ulcers with an erythematous rim and notable absence of pus


A man in his 40s presented with a 2-year history of gradual-onset, left-sided hearing loss

It was associated with a whistling tinnitus and occasional sharp otalgia lasting for a few minutes, approximately twice a week, without otorrhea

He reported labyrinthitis 2 years previously with possible reduced hearing afterward

He took no regular medications, had no allergies or clinically significant family history, and was an occasional smoker and alcohol drinker

Examination showed a smooth mass behind the left tympanic membrane

Findings from flexible nasoendoscopy were unremarkable

Pure-tone audiometry demonstrated a mixed hearing loss on the left side

Results from tympanometry of the left ear were normal

A computed tomographic scan showed an expansile ground-glass density lesion arising within the lateral aspect of the otic capsule on the left (Figure, A and B)

The lesion eroded into the lateral aspect of the basal and second turns of the cochlea as well as the tympanic portion of the facial nerve canal

Magnetic resonance imaging demonstrated a 7 × 8-mm lesion arising from the otic capsule, with mild uniform enhancement following gadolinium

A technetium bone scan showed a lesion in the temporal bone, and a focus of increased uptake in the left lateral eighth rib (no fracture was demonstrated) (Figure, C)

To obtain a diagnosis, a bony sample was obtained, which consisted of small fragments of woven bony tissue with mild osteocyte nuclei enlargement and hyperchromasia, with no sign of neoplasia

A and B, Computed tomographic (CT) images showing left otic capsule lesion

C, Single photon emission tomography/CT showing uptake of tracer in the left temporal bone and left eighth rib


Multinodular goiter with hemorrhagic cyst

Anaplastic (undifferentiated) thyroid carcinoma

A woman in her 80s with a previous diagnosis of a multinodular goiter was referred for exertional dyspnea and chest discomfort

Her medical history was significant for gastroesophageal reflux disease, hypertension, stable angina, and obstructive sleep apnea for which she was using continuous positive airway pressure therapy at night

A repeated computed tomographic (CT) scan, when compared with a study 3 years prior, indicated clinically significant growth

A positron emission tomographic/CT scan was significant for increased metabolic activity in the mass

Surgical intervention was recommended for alleviation of symptoms and definitive diagnosis

A left thyroidectomy with partial right thyroidectomy (Figure, A) and a left modified neck dissection (levels II-IV) were performed

Gross examination revealed an encapsulated, 11.0 × 8.4 × 8.2-cm, tan-orange, predominantly hemorrhagic, necrotic nodule without grossly identifiable thyroid parenchyma (Figure, B)

Extensive sampling revealed pleomorphic epithelioid cells with enlarged, hyperchromatic nuclei, irregular nuclear membranes, and increased mitotic activity (Figure, C)

There was evidence of angiogenesis and formation of nests around areas with organizing hemorrhage

Tumor cells showed strong membrane reactivity for CD31, confirming an endothelial origin of the lesion (Figure, D)

Adjacent thyroid parenchyma showed multinodular goiter and chronic lymphocytic thyroiditis

The neck dissection revealed normal lymphatic contents

C, Enlarged, hyperchromatic nuclei and mitoses

D, Neoplastic cells showing immunoreactivity to CD31.


A woman in her 90s with no significant medical history presented to the otolaryngology clinic with a chief concern of worsening hoarseness over several years

She had not experienced shortness of breath, gastric reflux, smoking, cough, dysphagia, odynophagia, fevers, or chills

Findings from a physical examination were remarkable for a rough voice

Flexible nasolaryngoscopy revealed normal abduction and adduction of the vocal folds with a white sessile lesion starting at the right midfold on the superior and medial surfaces that crossed the midline to involve the entire left vocal fold as shown in the Figure, A

Histopathologic images of the biopsied lesion are shown in the Figure, B-D

A, Gross appearance of vocal folds by flexible nasolaryngoscopy

B, Hematoxylin-eosin, original magnification ×400. C, Gram stain, original magnification ×400. D, Gomori methenamine silver stain, original magnification  × 400.


An asymptomatic 47-year-old woman underwent a radiographic screening to rule out tuberculosis prior to volunteering at her local hospital

The incidental finding of a mediastinal mass prompted a referral to her primary care physician, who elicited from the patient some complaints of mild but worsening orthopnea that was exacerbated when she would lie down

She denied any recent weight loss, muscle weakness, or diplopia

Her surgical history was significant for having undergone a cesarean section

A computed tomographic scan of the chest was obtained (Figure, A), and the patient was referred to surgery for evaluation

A, Computed tomographic scan of the chest revealing a mediastinal mass

B, Intraoperative dissection following median sternotomy

A physical examination identified a midline trachea, no significant thyromegaly in the neck, no significant lymphadenopathy, and no additional significant findings

The patient was taken to the operating room for surgery to remove the mass (with gross findings as seen in Figure, B)


A man in his 70s with a history of rheumatoid arthritis and a 50-pack-year smoking history presented with a worsening unproductive cough

Chest radiography identified a right lung nodule, with complete workup revealing a T2aN0M0 right upper lobe non–small-cell lung cancer (NSCLC) measuring 4.3 × 2.9 cm

A clinically significant cardiac history precluded the option of surgery

He was treated with a definitive accelerated hypofractionated course of radiotherapy to a total of dose 60 Gy in 8 fractions

Acute toxic effects were not observed, with the exception of minor fatigue that resolved 1 month after treatment

A surveillance computed tomographic (CT) scan obtained at 3 months demonstrated that the right upper lobe tumor had decreased by 1 cm in all dimensions, and at this time the patient denied any new symptoms, including pain

Approximately 5 months after treatment, he awakened with abrupt onset of severe right shoulder pain

The pain was sharp, constant, and localized to his right scapula and ultimately progressed to the point of radiating down the extensor surface of his arm ending at his elbow

He denied paresthesias, weakness, or any inciting events that could have led to its onset

His primary care physician obtained a CT scan, followed 2 days later by a magnetic resonance image (MRI) of his right shoulder (Figure 1)

Right shoulder diagnostic imaging 5 months after treatment


Chondrodermatitis nodularis helicis chronicus

A man in his 70s presented for evaluation of a nonhealing lesion of his left cheek

Examination of the head and neck revealed the incidental finding of bilateral auricular rigidity and immobility

Both ears appeared normal and were nontender and asymptomatic (Figure, A)

The patient recalled that his barber had noted an increase in difficulty trimming hair in the areas around his auricles owing to their inflexibility

The only other notable finding was increased rigidity of his nasal cartilage

The patient denied any decrease in auditory acuity, frostbite, or any previous trauma to his ears

His medical history included type 2 diabetes mellitus, hypertension and secondary chronic renal insufficiency, cardiovascular disease, and gout

His long-term medications included lisinopril, glipizide, terazosin, insulin glargine, labetalol, allopurinol, hydrochlorothiazide, and erythropoietin

An incisional biopsy of his left auricle was performed

Hematoxylin-eosin staining of the biopsy specimen showed regions of ossification and calcification (Figure, B)

A computed tomographic (CT) scan of the head was performed within 2 weeks of his original biopsy and showed extensive calcification in the area of the auricles (Figure, C)

The patient’s laboratory workup showed an elevated creatinine level of 1.8 mg/dL (reference range, 0.6-1.2 mg/dL), which had been his baseline level for the past 2 years

He had a hemoglobin level of 11.1 g/dL (reference range, 14-18 g/dL), which was felt to be secondary to his chronic renal failure

His serum calcium level  had been normal with the exception of an elevated value noted of 10.4 mg/dL noted 1 year ago (reference range, 8.7-10.2 mg/dL)

His phosphorus, alkaline phosphorus, electrolyte, and AM cortisol levels

and thyroid function were within normal limits


A man in his 30s had ulceration of the skin of the soles, legs, hands, elbow joints, and face of 15 days’ duration

It had started as swelling of the feet, followed by erythematous acral lesions

Numbness of the hands and feet had begun 1½ years previously, spreading gradually to the forearm and legs

He had no history of fever, joint pains, or epistaxis

Black eschar and ulceration with purulent discharge was seen over the soles and elbows

There were triangular and bizarre purpuric and necrotic lesions over the legs, thighs, and dorsum of the hands (Figure, A) with necrosis of pinnae and nasolabial folds

There was diffuse infiltration of the face and madarosis of the lateral half of the eyebrows

He also had hypoesthesia over the palms, proximal forearms, feet, and legs

Peripheral nerve examination revealed thickening of the right radial cutaneous and both ulnar nerves

Bilateral inguinal lymphadenopathy was present

Findings from the rest of the general physical and systemic examination were normal

Punch biopsy specimens were obtained (Figure, B-D)

A, Multiple bizarrely shaped purpuric and necrotic plaques on the hands and lower limbs


A woman in her 60s presented with a 6-month history of itchy eruptions that initially started on the arms and then spread to involve the lower legs

The patient admitted to occasional burning sensation of new lesions

On review of systems, the patient denied fevers, fatigue, myalgias, arthritis, shortness of breath, oral ulcers, and recent infections

Clinical examination revealed several erythematous patches and plaques on the arms and lower legs, and nontender violaceous firm nodules on the elbows, wrist, ankle, interphalangeal, and metatarsophalangeal joints (Figure 1A and B)

A punch biopsy specimen from a plaque on the right forearm was obtained (Figure 1C and D)


Primary central nervous system lymphoma–leptomeningeal variant

Carcinomatous meningitis–primary adenocarcinoma of the lung

A 69-year-old white man presented to the emergency department reporting 2 months of progressive bilateral lower extremity weakness, left facial weakness, and diplopia in the setting of a 20.4-kg weight loss over the previous 6 months and new-onset urinary incontinence

Two months prior he had undergone lumbar vertebra 3–sacra vertebra 1 lumbar laminectomies performed for symptomatic spinal stenosis

He denied headaches, fevers, cough, risk factors for immunosuppression, or travel outside of the northwestern United States

His medical history was notable for hypertension and a 50-packs-per-year smoking history

Physical examination was notable for a thin, frail-appearing man with normal vital signs and intact mentation

Cranial nerve examination revealed visual acuity of 20/400 OS, with an afferent pupillary defect and left-sided facial weakness including eye closure

He demonstrated profoundly decreased bulk and hypotonia throughout all extremities, with fasciculations apparent across his chest and lower extremities

Lower extremity muscle strength was graded 2/5 throughout with absent reflexes and intact sensation

Initial laboratories revealed a normal complete blood cell count and chest radiography

Magnetic resonance imaging of the neuroaxis revealed leptomeningeal enhancement around the cerebral convexities, cerebellum, and spinal cord including the cauda equina (Figure 1)

Cerebrospinal fluid (CSF) studies revealed a white blood cell count of 29/μL (to convert to × 109 per liter, multiply by .001) with a near-complete lymphocytic predominance, a red blood cell count of 363 × 106/μL (to convert to × 1012 per liter, multiply by 1), a protein level of 0.142 g/dL (to convert to grams per liter, multiply by 10), and glucose level of 19 mg/dL (to convert to millimoles per liter, multiply by 0.0555)

Cerebrospinal fluid cytology analysis did not identify malignant cells, with negative assay results for tuberculosis and fungal infections

Repeated flow cytometry did not identify abnormal B-cell or T-cell population

Whole-body positron emission tomography–computed tomography showed extensive leptomeningeal and nerve root hypermetabolism without evidence of a primary malignancy

Sagittal T1-weighted MRI of the lumbar spine without (A) and with (B) contrast showing leptomeningeal enhancement of the lumbar spinal cord, cauda equina, and multilevel postsurgical changes


Opiate-induced anamnestic recall of prior deficits

Focal seizures with postictal hemiparesis

Four days following resection of a scrotal lipoma, a 15-year-old boy with trisomy 21 presented to the emergency department with somnolence, pain, and paucity of speech with right hand and face weakness

The scrotal lipoma resection had been performed under general anesthesia without complications

He was somnolent immediately following the procedure, and had not spoken since the day after the procedure

He was taking acetaminophen and 10 mg of oxycodone every 4 hours

Right-sided hand and face weakness developed 2 days after the procedure

His medical history was significant for trisomy 21, with mild cognitive delay and baseline dysarthria, but no aphasia

He had been self-sufficient with daily activities

In the emergency department, his examination was significant for a temperature of 38.1°C and significant scrotal swelling and pain

The neurologic examination was remarkable for somnolence, right hemineglect, right facial droop with right hand weakness, right patellar hyperreflexia, and mutism, although he attempted to use sign language

His laboratory values showed a white blood cell count of 6.8 × 103/μL (to convert to  × 109/L, multiply by 0.001), platelet count of 248×103/µL (to convert to × 109/L, multiply by 1), hematocrit level of 30.9% (to convert to proportion of 1.0, multiply by 0.01), hemoglobin level of 10.2 g/dL (to convert to grams per liter, multiply by 1) with a normal differential, activated partial thromboplastin time of 40 seconds, fibrinogen level of 678 mg/dL (to convert to grams per liter, divide by 100), and normal urinalysis results

He received naloxone, after which his alertness improved, he could say his name, and he could follow commands well

The right face and hand weakness persisted, and he was unable to walk independently

Magnetic resonance imaging of the brain was performed (Figure 1)


A woman in her 50s presented with a 4-week history of a slowly enlarging mass on the left side of the neck

Physical examination revealed a mobile, nontender, 4-cm mass in the left side of the floor of mouth

A contrast-enhanced computed tomographic scan of the neck showed a 3.8-cm cystic neck mass in the left floor of mouth (Figure, A)

An ultrasonography (US)-guided fine-needle aspiration (FNA) biopsy showed bland-appearing cuboidal to columnar epithelial cells arranged in clusters

Repeated US-guided FNA biopsy showed a hypercellular specimen composed of numerous fragments of bland-appearing cuboidal and columnar epithelium and granular debris, which was eosinophilic in cell block sections and papillary structures with fibrovascular cores

The hypercellularity was atypical, and a low-grade neoplasm could not be ruled out

At this point, the patient elected observation of the mass and a repeated biopsy

A core biopsy showed a well-differentiated papillary neoplasm with hyalinized fibrovascular cores and some degenerative changes (Figure, B-D)

Immunophenotypically, the neoplastic cells were negative for the markers TTF-1, PAX-8, estrogen receptor, and thyroglobulin

These results, with the morphologic characteristics, were most consistent with a low-grade salivary neoplasm

She underwent excision of the cystic floor of mouth mass and a level I neck dissection

Pathologic examination revealed a cystic, 2.5-cm encapsulated mass arising from a minor salivary gland

A, Computed tomographic image of the neck showing a mass in the left floor of mouth


A 5-year-old girl with a history of autism presented to an outside emergency department with a 10-day history of otitis media and recent fevers

She was eventually transferred to our hospital after a computerized tomographic (CT) scan was performed showing potential clinically significant ear abnormalities

On evaluation, the patient had a bulging, hyperemic left tympanic membrane, along with fullness of the postauricular, upper cervical region

No focal neurologic deficits or meningeal signs were observed

A CT scan of the temporal bones with contrast was performed at our facility (Figure)

A-C, Axial computed tomographic (CT) scans with contrast


An elderly man was evaluated for long-standing discharge and hearing loss in the left ear and mild dizziness

Biopsy of the soft tissue at the external ear canal (EEC) showed granulation tissue

He was obese and had congestive heart failure and hypertension

Findings from the otolaryngologic examination were otherwise unremarkable

Advanced-stage mixed conductive and sensorineural hearing loss in the left ear were noted

Computed tomography (CT) showed a soft-tissue mass in the mastoid and middle ear cavity extending to the EEC with no significant erosion of ossicles (Figure, A)

During modified radical mastoidectomy, the mastoid cavity was found to be full of edematous, fragile soft tissue with mucoid secretions

Histopathological examination revealed a polypoid lesion showing typical papillary architecture with central fibrovascular cores and dilated glandular structures, lined by a bland-looking single layer of high columnar/cuboidal epithelial cells (Figure, B)

No mitotic activity or necrosis was detected

The richly vascularized fibrotic stroma consisted of cholesterol clefts, foamy macrophages, lymphocytes, and eosinophils, reminiscent of inflammatory granulation tissue (Figure, C)

The epithelial cells were positive for cytokeratin-7 (CK7) (Figure, D), CK19, epithelial membrane antigen, and glial fibrillary acidic protein

Ki-67 immunostain showed a proliferation index of less than 1%

A, Temporal bone at the level of external acoustic canal

original magnification ×20. C, Papillary and dilated glandular structures

original magnification ×10. D, Strong CK7 positivity


A teenaged girl was evaluated for loss of smell with a probable duration of years, but she was uncertain about exact duration

Her parents stated that at the age of 3 years she sustained minor trauma to her nose while at a playground but that she had not experienced any major head trauma

The patient had a history of frequent cough and congestion, seasonal allergies, monthly migraine headaches, and considerable nose congestion at night

She did not recall a history of recurrent sinusitis, snoring, or mouth breathing

Her family history was otherwise normal and did not include any pattern of familial anosmia or delayed puberty

She reported the ability to detect very strong odors but not subtle ones

She was even unable to smell smoke at times

Physical examination revealed a clinically significant hump on the dorsum of the nose consistent with minimal prior trauma, but no other abnormal findings

The patient failed the Penn smell tests, correctly identifying only 3 of the 11 smells

Flexible fiber-optic examination of the nose revealed no masses, polyps, or cysts

A magnetic resonance image of the anterior skull base demonstrated absent olfactory sulci (OS) and bilateral olfactory grooves containing minimal tissue (Figure, A, yellow arrowheads)

The Figure, B, depicts normal OS (pink arrowheads) and bulbs (yellow arrowheads) from a different patient for comparison

A, The anterior skull base of the study patient


A man in his early 20s presented to the otolaryngology clinic with a history of a small opening in the left lateral side of the neck that produced chronic purulent discharge

Despite several previous attempts at surgical resection, the drainage had persisted for 6 years

Initial computed tomography (CT) identified infiltration of the subcutaneous tissues in the left side of the neck anterior to the strap muscle at the level of the larynx, without discrete abscess

Computed tomography also showed a small tract that extended from the skin of the lateral side of the neck to the left strap muscles

The patient was referred to radiology, where a 22-gauge intravenous access catheter was inserted into the draining puncta

Isovue-300 was infused under conventional fluoroscopic guidance (Figure, A)

When the patient stated that he tasted contrast material, the infusion was terminated, and the patient was transferred to the CT service, where axial images of the neck were obtained and reformatted in multiple planes (Figure, B and C)

A, Conventional fluoroscopic fistulogram of the neck

B and C, Maximum-intensity projection reformatted computed tomographic (CT) images of the neck


A 39-year-old active woman presented with a progressive 6-month history of bilateral lower extremity pain after walking 1 block or ascending a flight of stairs

The pain was aching, relieved with rest, and primarily in her buttocks and thighs bilaterally

The patient denied history of prior abdominal or lower extremity surgery, trauma, or cardiovascular problems

Review of systems and family history revealed nothing remarkable

Physical examination revealed normal sinus rhythm and normal blood pressure

She had no abdominal tenderness and no palpable masses

Femoral pulses were weakly palpable and symmetric, and pedal pulses were not palpable

Laboratory findings were unremarkable except for an elevated erythrocyte sedimentation rate (ESR) (34 mm/h)

Noninvasive arterial flow studies demonstrated an ankle brachial index of 0.60 on the right and 0.62 on the left with biphasic waveforms in the femoral, popliteal, and tibial vessels

Subsequent magnetic resonance angiography (MRA) of the chest, abdomen, and pelvis showed mild stenosis of bilateral subclavian arteries and an abnormal-appearing infrarenal aorta (Figure 1)

Magnetic resonance angiography of the abdomen and pelvis


A previously healthy, African American man in his mid-60s with a history of hepatitis C cirrhosis (compensated) presented to the emergency department after collapsing at work with sudden-onset back and abdominal pain

He was hypotensive (blood pressure, 87/55 mm Hg) on arrival to the emergency department

The patient’s condition was rapidly stabilized and computed tomography with contrast demonstrated a large (12.4 × 10.2-cm) right hepatic mass with heterogeneous enhancement on arterial phase and intrahepatic and intraperitoneal hemorrhage (Figure 1A)

Emergency angiography was performed by interventional radiology, demonstrating active contrast extravasation originating from the right hepatic artery

Embolization was performed with Gelfoam and microparticles, resulting in hemodynamic stability and a quick recovery

Delayed liver resection was subsequently performed (Figure 1B)

A, Large hepatic mass seen on computed tomography, with evidence of intrahepatic and intraperitoneal hemorrhage

B, Pathologic specimen after delayed surgical treatment of the underlying mass


A woman in her 80s presented with a 1-week history of progressive, painful blisters and ulcers of the groin

This was associated with enlargement of the tongue over the past 3 months, leading to difficulty with mastication

She also reported numbness with no associated weakness of her distal lower limbs for 3 months

This restricted her mobility to the extent that she required diapers

However, she declined any further investigations for her peripheral neuropathy

She had IgG λ-type multiple myeloma complicated by anemia and lytic lesions in the calvarium, which was managed conservatively with transfusions

She was taking folic acid and intramuscular cyanocobalamin supplements owing to deficiencies attributed to a dietary cause

On examination, there were circinate purpuric patches with erosions on the natal cleft, buttocks, inguinal creases, and vulva (Figure, A)

Hemorrhagic flaccid bullae were observed on the posterior perineum

This was accompanied by macroglossia, glossitis, and a hemorrhagic erosion on the hard palate (Figure, B)

There were purpuric macules periorbitally and on the lips, inframammary folds, forearms, and thighs

Laboratory findings revealed a platelet count of 171 × 103/μL (reference range, 140-440 × 103/μL), prothrombin time of 11.7 seconds (reference range, 9.9-11.4 seconds), activated partial thromboplastin time of 36.0 seconds (reference range, 25.7- 32.9 seconds), and serum zinc levels of 34.4 μg/dL (reference range, 72.4-124.4 μg/dL)

(To convert zinc to micromoles per liter, multiply by 0.153.) Results from initial punch biopsies from a purpuric macule on the right inframammary fold and a blister at the perineum were inconclusive

A repeated biopsy from a hemorrhagic blister at the left groin was performed (Figure, C and D)

B, Clinical findings of macroglossia and glossitis with purpura of the lips

C, Punch biopsy specimen of a flaccid bulla showing the floor of a subepidermal blister lined by fibrin and a chronic inflammatory infiltrate

D, Scattered short eosinophilic amorphous bands in the dermis


A man in his early 40s with a medical history significant for verruca vulgaris, dyshidrotic eczema, and human immunodeficiency virus (HIV) diagnosed 1 year prior to presentation reported a chief complaint of dry, swollen lips

The patient reported a 1-month history of “puffy and bumpy” lips

He also described his lower lip as sometimes becoming “dry and scaly” during this time but denied any bleeding from the area

On physical examination, there were several erythematous papules at the vermillion border of the lower lip within a background of edema (Figure, A and B)

In addition, the patient had slight fissuring of the tongue, but the remainder of the oral mucosa was normal and intact

Findings of a complete review of systems were unremarkable, other than occasional headaches

The patient denied fevers, night sweats, abdominal pain, neurologic symptoms, chest pain, cough, and shortness of breath

He disclosed full compliance with his HIV highly active antiretroviral therapy (HAART), which included ritonavir, darunavir, etravirine, and raltegravir

He also reported taking sumatriptan as needed for headaches

Numerous laboratory tests were performed, including a complete blood cell count, complete metabolic panel, CD4 count, HIV viral load, and assays for C-reactive protein, erythrocyte sedimentation rate, angiotensin-converting enzyme, and rapid plasma reagin

all results were normal except for a slightly elevated angiotensin converting enzyme level (84 µg/L

His CD4 count was within normal limits (520 cells/µL) and HIV viral load was undetectable

A biopsy was performed on the right lower lip (Figure, C and D)

Clinical images (A and B) show persistent, nontender swelling of the lips in a patient with human immunodeficiency virus, showing erythematous papules at the vermillion border and edema of the lower lip

C and D, Histologic images of a biopsy specimen from a papule on the lower lip show, at low magnification (C), a nodular, nonnecrotizing granulomatous dermatitis and, at higher magnification (D), the presence of epithelioid histiocytes with admixed lymphocytes


A 41-year-old woman presented with a rapidly growing, painful nodule on her upper cutaneous lip (Figure, A) as well as several smaller papules on her face and neck, all of which had developed within the preceding 6 months

A, Centrally depressed, firm, pink 1.1-cm nodule on the upper cutaneous lip and skin-colored papule on the left medial cheek (above marker dots)

B, Cup-shaped tumor demonstrated keratinocyte atypia with a central core of keratinaceous debris

C, Sebaceous tumor with a modestly increased ratio of basaloid cells to sebocytes

The patient’s medical history included diabetes mellitus type 2, hypercholesterolemia, hypertension, and depression

Review of her family medical history revealed that her paternal grandfather died from melanoma and that her father died from colon cancer

She stated that most of the men in her family had died from some form of cancer by the fourth decade of life

On physical examination, a tender, centrally depressed, firm, pink 1.1-cm nodule was present on her upper cutaneous lip (Figure, A)

Three other skin-colored to pink papules were present on her face and neck

Shave biopsies of all 4 skin lesions were performed (Figure, B and C)


A male neonate was born at 25 weeks’ gestation by cesarean delivery because of hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome in his primigravid mother, who also had systemic lupus erythematosus managed with hydroxychloroquine, aspirin, and prednisone during pregnancy

The patient’s premature birth was complicated by acute respiratory distress that necessitated intubation and necrotizing enterocolitis that required parenteral nutrition

At birth, the patient was found to be mildly anemic (hemoglobin level, 11.0 g/dL [to convert to grams per liter, multiply by 10]) and thrombocytopenic (platelet count, 120 × 103/µL [to convert to 109/L, multiply by 1]) with concomitant intraventricular hemorrhage

Although afebrile, he was treated empirically for sepsis with vancomycin hydrochloride and cefepime hydrochloride

A cerebrospinal fluid culture result was positive for Staphylococcus epidermidis, but the results of additional blood cultures were negative for organisms

On day 8 after birth, a 0.5-cm, circular, crusted papule with a surrounding rim of erythema on the left hip was noted (Figure, A)

A punch biopsy of the lesion was performed (Figure, B and C)

A, Crusted circular papule with a surrounding rim of erythema and induration on the left hip

B, Biopsy specimen revealing epidermal necrosis with fungal elements within the superficial dermis (hematoxylin-eosin, original magnification ×20)

C, Biopsy specimen highlighting branching and septate hyphae within the superficial dermis (specimen was stained with Gomori methenamine silver, original magnification ×40)


Acute hepatitis associated with Epstein-Barr virus infection

Vanishing bile duct syndrome associated with Hodgkin lymphoma

Metastatic cholangiocarcinoma secondary to primary sclerosing cholangitis

A Hispanic man in his 20s with no known medical history presented with worsening abdominal pain over 5 days, persistent pruritus, and scleral icterus

The patient noted swelling on the right side of the neck and a 5-kg weight loss over the past 2 months

He reported a history of moderate alcohol consumption, drinking 1 beer per day during the week and approximately 5 to 8 beers over the weekend, but denied any use of nutritional supplements or illicit drugs

There was no recent travel outside the state

Human immunodeficiency virus test results on admission were negative

Physical examination revealed scleral icterus, jaundice, and a fixed right supraclavicular lymph node conglomerate measuring 6 × 3 cm

There was no cervical, left supraclavicular, axillary, or inguinal lymphadenopathy

Computed tomography of the neck, chest, abdomen, and pelvis demonstrated a large right supraclavicular lymph node, extensive mediastinal lymphadenopathy, a large extracardiac mass abutting the left atrium, hepatomegaly, and multiple splenic lesions

Laboratory evaluation demonstrated a total serum bilirubin level of 10.5 mg/dL with a direct component of 8.4 mg/dL (to convert to micromoles per liter, multiply by 17.104)

Mild leukopenia and slight thrombocytopenia in the absence of associated anemia was noted on initial complete blood cell count

A liver biopsy was performed, with results shown in Figure 1.Hepatic biopsy at time of presentation shows a portal tract containing both hepatic artery and hepatic vein branches (hematoxylin-eosin, original magnification ×40)


Type III neuroendocrine tumor of the stomach

Gastric metastasis of Merkel cell carcinoma

A woman in her 70s was referred to our tertiary care center for an asymptomatic mass of the gastric fundus

Her medical history was significant for chronic gastritis, which was being treated with esomeprazole 20 mg

a laparoscopic cholecystectomy 18 years prior

and excision of a 26-mm Merkel cell carcinoma of the left knee with negative results of the sentinel lymph node biopsy (stage II) 19 months prior

Results of the patient’s follow-up examinations were negative until a high-resolution computed tomographic scan showed a 45 × 40-mm intraluminal protruding mass with slightly enlarged lymph nodes along the lesser curvature of the gastric fundus (Figure, A)

Results of fluorine 18–labeled fluorodeoxyglucose and gallium citrate Ga 68–labeled 1,4,7,10-tetraazacyclododecane-N,N',N'',N'''-tetraacetic (DOTA)-D-Phe1-Try3-octreotide (DOTATOC) positron emission tomography confirmed the presence of a metabolically active mass in the gastric fundus (maximum standardized uptake value, 6) with intense 68Ga–DOTATOC uptake (maximum standardized uptake value, 24) as well as mild 68Ga–DOTATOC uptake in 2 lymph nodes of the lesser curvature

A, Multislice computed tomographic scan showing the 45 × 40-mm mass in the gastric fundus

B, Endoscopic image showing the endophytic lesion in the posterior wall of the gastric fundus at the esophagogastric junction

Preoperative workup was completed via esophagogastroduodenoscopy, which showed the presence of the polypoid lesion in the posterior wall of the gastric fundus at the level of the esophagogastric junction (Figure, B)

Multiple biopsies were performed at the time of the endoscopy


Main duct intraductal papillary mucinous neoplasia

We present the case of a 40-year-old man who was admitted to our hospital with acute abdominal pain on the right flank

A similar episode had occurred 1 month before admission that improved spontaneously

A physical examination did not reveal any clinical abnormities, but the patient reported dysuria and abnormally frequent urination

A computed tomographic scan of the abdomen revealed nephrolithiasis with a 4-mm kidney stone on the right side and a slightly congested right kidney

During computed tomography, we incidentally found a 10 × 10 × 8-cm mass in the tail of the pancreas (Figure 1), as well as thrombosis of the splenic vein

His medical history was uneventful, and there was no weight loss

However, the patient’s father had died of a pancreatic carcinoma the previous year at the age of 65 years

The patient’s laboratory values, including cancer antigen 19-9 and carcinoembryonic antigen levels, were normal

Computed tomographic (CT) scans of the abdomen reveal the mass in the pancreas (arrowheads)


A woman in her 50s presented for evaluation of intermittent epigastric pain, palpitations, and hot flashes for 2 months

The patient had a history of an ovarian cyst treated conservatively, and cosmetic breast augmentation

She had a 10 pack-year smoking history and denied alcohol or illicit drug use

Examination revealed distant heart sounds but otherwise had unremarkable results

An echocardiogram demonstrated a mass in the left ventricular myocardium

Cardiac magnetic resonance imaging was obtained to further assess the mass lesion

This revealed multiple intramyocardial masses involving the left ventricle, the largest of which measured 2.7 × 2.2 cm

and moderate pericardial effusion (Figure)

Computed tomographic imaging of the chest, abdomen, and pelvis with contrast failed to reveal discrete masses or lymphadenopathy elsewhere

A transcutaneous biopsy of the left ventricular mass was nondiagnostic


Hyperkeratotic spicules of multiple myeloma

A woman in her 70s with a medical history that was significant for polycythemia vera and acute myelogenous leukemia was seen for evaluation of textural skin changes on her face that had been present for 2½ years

She denied having pruritus or pain, but her skin had a rough sandpapery sensation

She reported that the involvement extended to her neck, the upper part of her chest, and her bilateral forearms

She associated the onset of the textural changes with her diagnosis of polycythemia vera

She stated that it began before her diagnosis of acute myelogenous leukemia and the initiation of treatment with hydroxyurea 4 years later

She had previously received treatment with long courses of triamcinolone acetonide cream, 0.1%, bacitracin ointment, and a combination antibiotic ointment of neomycin sulfate, polymyxin B, and bacitracin, with no improvement of her skin’s condition

Her additional daily medication regimen included donepezil hydrochloride, melatonin, and aspirin, 81 mg

Findings from the patient’s physical examination revealed background erythema with numerous rough horny spicules at the follicular ostia on her face, ears, and neck

Findings from the rest of her examination revealed a pigmented macule on her right cheek

Two punch biopsy specimens were obtained from her right cheek and right postauricular area and submitted for histopathologic examination (Figure)

Histopathologic images (hematoxylin-eosin) of the punch biopsy specimen from the right side of the lateral neck


A 12-year-old boy presented for evaluation of a 3-month history of ulcerated lesions on the dorsal aspect of his feet since returning from Pakistan, where his family was living

The patient had no history of medical problems

He was born in Spain and had received his childhood immunizations

He remembered insect bites on his feet, but the lesions later became ulcerated and painful

The patient denied experiencing fever, arthralgia, or a sore throat

Findings from the physical examination revealed 6 painful ulcerated, exudative nodules with a grayish membrane over the ulcers on the dorsal aspect of his feet (Figure 1)

No signs of lymphangitis or lymphadenopathy were detected

A 4-mm punch biopsy specimen from one lesion was obtained and stained with hematoxylin-eosin and Gram stain for histopathologic analysis

Another skin specimen was cultured for microbiologic analysis

Ulcerated and exudative nodules with grayish membrane on the dorsal aspect of the feet


A 6-month-old daughter of nonconsanguineous parents was seen with multiple polycyclic dark to less dark brown, partly livid shimmering macules, which covered large areas of the back, neck, buttocks, and lower extremities (Figure, A)

According to her mother, new lesions had appeared during the past weeks on the shoulders

Physical examination revealed coarse facial features, hepatomegaly (7 cm below the costal arch), distinctive lumbar kyphosis, and muscular hypotonia compared with her twin brother

Dermoscopy showed faint clouds of nonhomogeneously distributed light brown pigment

A, Polycyclic, brown, partly livid shimmering macules covered large areas of the back, neck, buttocks, and lower extremities

B, Fusiform and dendritic cells were found scattered in the dermis (hematoxylin-eosin, original magnification ×100)

C, Immunohistological staining of the same specimen (original magnification ×200)

S-100 protein positivity identified these cells as melanocytes

D, A triangle-shaped first lumbar vertebral body is shown


A woman in her 50s was seen by her physician with a 1-month history of gait unsteadiness and imbalance and was suspected to have neuropathy, but she then went to the emergency department reporting 2 successive transient episodes, each lasting less than 1 hour, of acute dizziness, disorientation, gait dysfunction, and confusion

Urinalysis revealed a urinary tract infection, but computed tomography (CT) of the head showed extensive mass lesions with bilateral edema

Magnetic resonance imaging (MRI) of the brain delineated expansile mass lesions of the splenium of the corpus callosum, with T2–fluid-attenuated inversion recovery hyperintensity in the bilateral parietal lobes, left thalamus, and midbrain (Figure, A)

administration of contrast revealed multiple ring-enhancing lesions (Figure, B)

The woman’s medical history was significant for type 2 diabetes mellitus (DM), hypertension, recurrent urinary tract infections, onychomycosis, end-stage renal failure, and a history of living, unrelated donor renal transplant 12 years earlier, kidney transplant rejection, and prior episodes of syncope

Medications included tacrolimus, mycophenolate mofetil hydrochloride, prednisone (1 mg/d), losartan potassium, and insulin

Family history was notable for her father having died of lung cancer and her mother had heart disease and DM

Social history did not reveal any unusual exposures

Physical examination results showed a transplant surgical scar and onychomycosis

Neurologic findings revealed reasonably preserved mental status, with bedside examination revealing normal attention, language, and orientation but mild memory deficits for short-term recall (2 of 3 words recalled at a 5-minute delay) and long-term fund of knowledge

Cranial nerve, motor, sensory, and reflex examination results were significant only for gait ataxia, with an inability to perform tandem gait

Blood test results were consistent with DM

Findings from cerebrospinal fluid (CSF) examination included a white blood cell count of 9/µL, with differential examination showing 84% lymphocytes, 13% monocytes, and 3% neutrophils

Flow cytometry revealed B and T lymphocytes but no monoclonal populations of cells

Polymerase chain reaction amplification tests on CSF revealed no evidence of cytomegalovirus or herpes simplex virus 1 or 2 genetic material

Serum and CSF serologic test results were negative for antibodies to toxoplasma

testing using polymerase chain reaction on blood for Epstein-Barr virus (EBV) revealed minimal (very low positive) viral DNA at 52 IU/mL

A CT scan of the chest, abdomen, and pelvis showed a small, subpleural nodule

Whole-body positron emission tomography revealed hypermetabolic regions in the brain

Dexamethasone sodium phosphate and levetiracetam were administered

The patient underwent a diagnostic procedure

Brain magnetic resonance imaging showing unsuspected mass lesions

A, A T2 fluid-attenuated inversion recovery (FLAIR) sequence illustrating prominent T2 hyperintensity in the right more than the left parietal white matter suggestive of edema, an expansive mass lesion on the right more than the left splenium of the corpus callosum, and an infiltrative mass lesion in the left thalamus extending into the mesencephalon

B, A T1 sequence after administration of gadolinium contrast agent

Ring-enhancing regions are visible in the right parietal lobe and splenium of the corpus callosum, and a more solidly enhancing lesion is seen in the left thalamus as well as some apparent leptomeningeal enhancement


A healthy young girl presented in June 2014 with a 4-week history of a painless, enlarging lesion on her right thumb that started as a small erythematous blister

She reported recently injuring her hand on a metal fence at home and biting her nails frequently

She lives on a farm in Ohio and has extensive direct contact with sheep and cows

family pets include a cat, a dog, and a hamster

There was no known recent travel or contact with anyone with a similar lesion

She reported mild tender lymphadenopathy of the right axilla but denied fever

Examination revealed an erythematous, 1 × 1.5-cm, well-defined eroded pustule with central crusting and an erythematous border (Figure)

There were several slightly enlarged, mildly tender lymph nodes noted in the right axilla

Eroded and crusted pustule with surrounding inflammation on the thumb

Complete blood cell count, erythrocyte sedimentation rate, and basic metabolic panel results were unremarkable

Findings on radiography revealed focal soft-tissue swelling with no evidence of foreign body, subcutaneous gas, or osseous involvement


A man in his 60s presented to the clinic with a 5-month history of sudden-onset, progressively worsening dysphonia, dry cough, and the sensation of a lump in his throat

He described a progressively worsening voice with use to the point where he was nearly aphonic by the end of his workday

He denied any heartburn, hemoptysis, pain, neck masses, or smoking history

Prior treatment with 2 rounds of oral antibiotics and 1 round of oral steroids from his primary care physician did not improve his symptoms

Objectively, the patient’s voice was rough, diplophonic, and very strained

Videostroboscopic examination in the clinic revealed a broad-based submucosal mass in the anterior two-thirds of the right true vocal fold (Figure, A) that disrupted vibration of both vocal folds owing to its size and anterior location (Figure, B and Video)

Findings from the remainder of his head and neck examination were unremarkable

The patient was taken to the operating room for microdirect laryngoscopy under general anesthesia (Figure, C)

A microflap incision along the lateral aspect of the right true vocal fold mass was performed, and a firm, submucosal, tan-colored, seemingly encapsulated, multilobulated mass was removed en bloc with narrow margins and sent for permanent section analysis (Figure, D)

The mass was deep to the epithelium of the true vocal fold and superficial to the vocal ligament

A and B, Clinical views of endoscopic appearance of the anterior right true vocal fold mass

C and D, Intraoperative endoscopic views

D, A microflap incision was performed along the lateral aspect of the lesion and a multilobulated, firm submucosal mass deep to the epithelium but superficial to the vocal ligament was resected


A woman in her 70s presented with a 4-day history of new-onset, left-sided acute epistaxis described as episodes of bright red bleeding and clotting from the left anterior nare, occurring multiple times per day, lasting minutes each time, and stopped with pressure

She denied other sinonasal symptoms, history of epistaxis, nasal trauma, or surgery

Clinical evaluation revealed a soft-tissue mass filling the left nasal cavity and based on the mucosal surface of the anterolateral nasal vestibule

Noncontrast paranasal sinus computed tomography showed a 1.2 × 0.8-cm ovoid soft-tissue mass opacifying the posterior aspect of the left nasal vestibule (Figure, A, arrowhead)

Endoscopic excision under local anesthesia was performed to remove a broad-based soft-tissue mass from the left nasal vestibule mucosa with a cuff of grossly healthy submucosa

A tissue specimen was biopsied (Figure, B-D)

The patient had an uneventful postoperative course, and her epistaxis symptoms were resolved at the 5-month follow-up

A, Noncontrast paranasal sinus computed tomographic image

B-D, Histopathologic images from the nasal cavity mass, original magnifications ×100.


A teen-aged boy with a recent history of resolved streptococcal pharyngitis presented with dizziness, vomiting, unstable gait, and headaches of 2 weeks’ duration

Laboratory evaluation revealed a sodium level of 109 mEq/L

Rapid correction to 136 mEq/L occurred, resulting in lethargy, aphasia, and ataxia

He was diagnosed as having idiopathic syndrome of inappropriate antidiuretic hormone secretion (SIADH)

Magnetic resonance imaging (MRI) demonstrated an abnormal signal within the basal ganglia and insular cortex

A 2.5 × 1.5 × 1.8-cm mass was found in the superior right maxillary sinus with extension into the infundibulum (Figure, A)

Computed tomographic (CT) scans of the sinuses without intravenous contrast demonstrated that the mass had calcifications

Owing to persistent hyponatremia (sodium level, 125-130 mEq/L) and an identifiable lesion, the patient was taken to the operating room for biopsy

He underwent a maxillary antrostomy with near-complete removal of the mass

Over the subsequent 2 weeks, the hyponatremia resolved and the patient was left with slight dysarthria and difficulties with fine-motor movements

The submucosa contained a small, round, blue-cell tumor growing in circumscribed lobules and nests separated by vascularized fibrous stroma

The neoplastic cells had uniform, small, round nuclei with scant cytoplasm

Cells were arranged in a pseudorosette pattern (Figure, B)

The nuclei demonstrated dispersed, salt and pepper nuclear chromatin and inconspicuous nucleoli

The cells were surrounded by a neurofibrillary matrix

There were prominent microcalcifications

The tumor cells were diffusely positive for immunohistochemical marker synaptophysin (Figure, C)

Results from cytokeratin staining were negative (Figure, D)

A, T1-weighted postgadolinium magnetic resonance image, coronal view

B, Hematoxylin-eosin, original magnification ×100. C, Tissue positivity for synaptophysin, original magnification ×200. D, Tissue negativity for cytokeratin, original magnification ×200.


A woman in her 60s presented to the emergency department with a 3-week history of enlarging and painful cervical masses

She reported a distant history of breast cancer and a recent history of an oral cavity lesion, which was not biopsied or followed up

She did not have any known tuberculosis exposure, recent foreign travel, exposure to unpasteurized food, history of immunodeficiency, or alcohol or tobacco use

She did not have fever, chills, cough, dysphagia, or odynophagia

Physical examination revealed a healthy-appearing woman with normal vital signs

She was found to have bilateral cervical lymphadenopathy, which included fixed and bulky nodes in level IB and IIA and nontender level IV and V nodes

An oral cavity examination revealed no evidence of masses or lesions, floor of mouth and base of tongue were soft, and the palatine tonsils had no lesions or ulcers

Flexible laryngoscopy revealed no evidence of pharyngeal or laryngeal lesions

Contrast-enhanced computed tomographic (CT) scans of the neck (Figure) revealed bilateral lymphadenopathy with central necrosis


Arteriovenous malformation of the oropharynx

A woman in her 70s was referred to our hospital for evaluation of a dry cough, foreign body sensation in the throat, and mild dysphagia of 2 months’ duration

Her medical history included hypertension, diabetes mellitus, and right-sided chronic otitis media of 4 years’ duration successfully treated surgically 1 year earlier (tympanoplasty type 1)

On oral endoscopic examination, mild bilateral hyperemia of the tonsillar area and posterior pharyngeal wall were noted

A submucosal pulsatile mass was clearly visible in the right retropharyngeal area (Figure, A and B

No other clinically significant abnormalities were noted

Part of the clinical findings were suggestive of laryngopharyngeal reflux disease, and oral esomeprazole, 40 mg/d, was prescribed

Head and neck magnetic resonance angiography was recommended (Figure, C and D)

A and B, Endoscopic examination of the oropharynx revealing a submucosal pulsatile mass in the right retropharyngeal area

Abnormal medial course of the right internal carotid artery (arrow)

Aberrant internal carotid artery in the retropharyngeal space


A 60-year-old man with advanced melanoma presented with headaches and increasing fatigue during treatment with ipilimumab

Several months earlier, he presented to the emergency department with shortness of breath

Imaging revealed pulmonary emboli and incidental groin lymphadenopathy

He then underwent inguinal lymph node dissection and was found to have 9 lymph nodes involved with melanoma (stage IIIC melanoma)

He was then treated with ipilimumab (3 mg/kg), a monoclonal antibody to cytotoxic T lymphocyte antigen-4 (CTLA-4), every 3 weeks, as part of an investigational adjuvant therapy clinical trial

When presenting for his fourth and final dose of ipilimumab, he reported central headaches, severe fatigue, poor appetite, intermittent nausea, and a mild rash

On examination, vital signs were within normal limits

Physical examination had largely unremarkable results except for a slightly red, raised rash over his chest and proximal extremities

Laboratory testing showed the following: thyrotropin, 0.02 mIU/L (reference range, 0.3-5.0 mIU/L), and free thyroxine, less than 0.25 ng/dL (reference range, 0.5-1.2 ng/dL

to convert to picomoles per liter, multiply by 12.871)

Cosyntropin stimulation test showed a cortisol peak level of 0.9 µg/dL (reference range, >20 µg/dL

to convert to nanomoles per liter, multiply by 27.588)

to convert to picomoles per liter, multiply by 0.22) and testosterone levels (<0.1 ng/mL

to convert to nanomoles per liter, multiply by 0.0347)

Magnetic resonance imaging (MRI) of the brain is shown in the Figure

Magnetic resonance imaging of the brain with contrast


A 65-year-old man was admitted to our hospital with a painful anal mass and fecal incontinence

The anal lesion appeared 1 year earlier and grew slowly to the current size

The patient reported bleeding from the rectum after defecation and denied weight loss or fever

His medical history included atopic dermatitis and pulmonary tuberculosis

There was no family history of gastrointestinal pathology

He had not undergone any previous abdominal surgery, except inguinal hernia repair

No history of sexually transmitted diseases was found

Physical examination revealed a 12 × 10-cm hard mass on the left side of the anus (Figure 1A)

It was ulcerated, covered by purulent exudate, and very painful

The scrotum was mildly tender to palpation

Digital rectal examination and rectoscopy were not performed because of the pain and fecal incontinence

Routine blood, liver, and renal function test results were normal, as were results for carcinoembryonic antigen and cancer antigen 19-9. Chest radiography showed no abnormalities

Computed tomographic scan of the pelvis showed a hypodense 12 × 7 × 3-cm mass extending to the anus, anal canal, and lower perirectal space (Figure 1B)

Abdominal computed tomography showed no pathology

Clinical photograph of the giant perianal mass in the left perianal region (A) and abdominal computed tomographic scan showing the mass in the anus (B)


A woman in her 40s was referred to our service owing to unusual findings detected on routine abdominal ultrasonography ordered by her gynecologist

The ultrasonographic scan showed a hepatic mass in the right lobe composing approximately 50% of the liver parenchyma

The patient was asymptomatic, and there were no significant findings on abdominal physical examination— the liver was not palpable

Results of whole blood analyses, including α-fetoprotein, were within the reference ranges

She had not received any medication, including contraceptive pills or hormones, for more than 10 years

Nine years before this examination, the patient underwent elective splenectomy and hepatic biopsy at another institution

However, she did not know the reason for removal of the spleen, and results of the histopathologic examination were not available

She had undergone a cesarean section at age 25 years

The patient had no history of trauma or other previous medical events

An abdominal computed tomographic scan revealed a well-defined, solid, heterogeneous mass, completely intrahepatic, with no enhancement and no liquid component, causing slight displacement of the right hepatic vein (Figure 1)

Cross-sectional computed tomographic image of the abdomen shows a large, intrahepatic, 20-cm solid mass


A woman in her mid-70s with a history of type 2 diabetes mellitus, end-stage renal disease, and coronary artery disease was admitted to the hospital for fever, lethargy, and altered mental status

On day 7 of her hospital stay, she developed severe, unremitting left ankle pain with purpuric lesions on the skin

She had previously undergone coronary artery bypass grafting with simultaneous aortic valve replacement and ileal conduit urinary diversion as a result of to recurrent upper urinary tract infections

Laboratory findings were significant for neutrophil-predominant leukocytosis (leukocyte count, 19 400/μL [to convert to ×109/L, multiply by 0.001])

Physical examination revealed multiple stellate, purpuric plaques with central flaccid bullae on the medial and lateral aspects of the left ankle (Figure, A)

The remainder of her skin examination findings were unremarkable

Punch biopsy specimens were obtained along the border of normal and lesional skin (Figure, B and C), and she underwent transesophageal echocardiography

A, Stellate purpura with overlying flaccid bulla on the medial aspect of the ankle

B, Partially necrotic epidermis with intraepidermal bulla formation with marked perivascular infiltrates in the deep dermis and subcutaneous tissue (hematoxylin-eosin, original magnification ×25)

C, A small blood vessel occluded with fibrinoid material with a perivascular lymphoneutrophilic infiltrate (hematoxylin-eosin, original magnification ×400)


A man in his 50s of Indian descent presented with a pruritic eruption on his scalp, arms, neck, and feet

The eruption began during the summer 3 months before presentation

His medical history was significant for type 2 diabetes mellitus and hypertension, which were managed with metformin, glimepiride, and atenolol

Physical examination revealed hyperpigmented annular plaques with violaceous borders on his scalp and the superior part of his forehead (Figure, A)

There were violaceous papules on the dorsal aspect of the hands (Figure, B), extensor surface of the arms, and the nape of the neck

A, Hyperpigmented annular plaques with violaceous borders on the scalp

B, Violaceous papules on the dorsal aspect of the hands

C, Histopathologic analysis of violaceous eruption on the hand

Lymphocytic infiltrate at the dermoepidermal junction (hematoxylin-eosin, original magnification ×10)

A punch biopsy specimen was obtained and sent for histopathologic evaluation (Figure, C)


A woman in her 40s with a medical history of pulmonary embolism and deep venous thrombosis presented with a 6-month history of pruritic, pink scaling plaques on her face and neck (Figure, A)

The lesions subsequently involved her chest, abdomen, and back and flared with sun exposure

A diagnosis of lupus erythematosus (LE) was favored, but the lesions failed to improve on a regimen that included hydroxychloroquine sulfate, fluocinonide ointment, 0.05%, and tacrolimus ointment, 0.1%

Biopsy samples were obtained for histopathologic evaluation

A, This case shows well-demarcated plaques with an overlying scale crust occurring in a photodistributed pattern on the central face

B, Hematoxylin-eosin, original magnification ×4. C, Hematoxylin-eosin, original magnification ×10.Laboratory findings were significant for positive antinuclear antibody titers at 1:640, lymphopenia, and normocytic anemia

Test results were negative or within normal limits for levels of antiribonucleoprotein, antihistone, antiphospholipid, anti-Smith, anti-Ro/Sjögren syndrome antigen A, and anti-La/Sjögren syndrome antigen B antibodies, C3, C4, CH50, rapid plasma reagin, and creatinine

Urinalysis results were within normal limits

A biopsy specimen was obtained (Figure, B and C)


A previously healthy 6-year-old boy presented with 6 days of fever (maximum temperature of 40°C), intermittent nonbilious emesis, and 4 days of crampy, diffuse abdominal pain

Physical examination findings were significant for ill appearance, bilateral nonexudative conjunctivitis, shotty bilateral anterior cervical lymphadenopathy, diffuse abdominal tenderness (greatest in the right upper quadrant), and associated rebound and guarding

There was also a blanching, erythematous, macular rash on his cheeks (Figure, A) and an intermittent, erythematous, reticular rash on his chest, abdomen, arms, and legs (Figure, B) that spared his palms and soles and flared with fever

The remainder of his examination findings were unremarkable

Laboratory studies were significant for an elevated aspartate transaminase level of 264 U/L (reference range, 12-47 U/L

to convert to microkatals per liter, multiply by 0.0167) and an alanine transaminase level of 251 U/L (reference range, 17-63 U/L

A complete blood cell count revealed leukopenia with a white blood cell count of 28 300/µL (to convert to ×109/L, multiply by 0.001) (neutrophils, 64%

and bands, 11%), a low-normal hemoglobin level of 11.4 g/dL (to convert to grams per liter, multiply by 10), and thrombocytopenia with a platelet count of 610 × 103/µL (to convert to ×109/L, multiply by 1)

Computed tomography of the abdomen revealed a dilated appendix (7 mm) with mucosal hyperemia and an internal appendicolith

acute appendicitis could not be excluded radiographically, so the patient was admitted for further workup because of a concern for acute abdomen

The patient lives in the southeastern United States and had no reported history of unusual exposures or insect or tick bites

A, A blanching, erythematous, macular rash present on the patient’s cheeks

B, An example of an intermittent, erythematous, reticular rash present on the patient’s left arm


A woman in her 60s was referred for a large, left-sided, progressively enlarging mandibular mass, present for approximately 7 months

She had no pain or neurosensory disturbances related to the lesion

however, she did have difficulty tolerating a regular diet owing to the bulk of the mass

She had no significant medical history, had quit smoking cigarettes 4 year prior to presentation, but had a 20 pack-year smoking history

Findings from the physical examination were notable for a 4.9-cm exophytic, nodular, slightly mobile mass of the left lower posterior alveolar ridge, involving the buccal and lingual gingiva

Previous biopsy demonstrated squamous mucosa with ulceration and chronic inflammation

Contrasted computed tomography revealed an exophytic complex mass with areas of calcification and ossification inferiorly and a necrotic, cystic irregularly enhancing portion superiorly (Figure, A-C)

An additional biopsy was performed (Figure, D)

The mass was excised, and teeth 20 to 26 were removed

The alveolar ridge was recontoured, and the incision was closed primarily

D, Histopathologic image of biopsy specimen


A woman in her 40s with no significant medical history presented with a 4-year history of intermittent left-sided throat pain, which eventually progressed to left ear pain approximately 1 year prior to her presentation

She had not experienced any dysphagia, dysphonia, dyspnea, fevers, or weight loss

She had no significant use of tobacco or alcohol in the past

Findings from an otoscopic examination was unremarkable

Nasopharyngoscopy was performed and failed to reveal any masses, ulcerations, or mucosal lesions

A magnetic resonance image (MRI) revealed an enhancing 1 × 6-mm lesion in the left side of the posterolateral tongue base (Figure, A)

A biopsy of the mass revealed an intermediate-grade infiltrating neoplasm forming solid sheets and glandular structures (Figure, B)

The tumor cells stained positive for CK7 and p63, and negative for CK20, p16, and S-100 by immunohistochemical analysis

Stain for mucicarmine was positive in glandular areas (Figure, C)

After establishing the diagnosis, the patient was taken to the operating room for a left base of tongue resection via suprahyoid approach along with a left-sided neck dissection of levels I to IV

The tumor was removed with negative margins, and no positive cervical lymph nodes were found on final pathologic analysis

A, Magnetic resonance (MRI) image of a lesion in the left side of the posterolateral tongue base

B, Intermediate-grade infiltrating neoplasm forming solid sheets and glandular structures

Hematoxylin-eosin, original magnification ×20. C, Mucicarmine stain in the glandular area, original magnification ×40.


A woman in her 70s with a 7-year history of essential thrombocythemia was diagnosed as having acute myelogenous leukemia 4 days prior to hospital admission for induction chemotherapy

She was febrile at admission and treated empirically with antifungal, antibiotic, and antiviral medications in the setting of cultures that were negative for organisms

The initial chemotherapy regimen failed, requiring a more aggressive regimen, which left her pancytopenic

During the course of the second chemotherapy treatment, she developed left-sided mandibular pain

A computed tomographic scan revealed cellulitic changes along the buccal cortex of the mandible and a small 2 × 12-mm abscess formation

At initial evaluation by the otolaryngology service on hospital day 32, she had decreased sensation at the left mandibular branch of the trigeminal nerve and ecchymoses along the mandibular buccal-gingival borders bilaterally with induration of the left floor of mouth and buccal mucosa (Figure, A)

She continued to receive broad spectrum antimicrobial and antifungal coverage

By hospital day 38, the patient had developed evidence of ischemia and necrosis along the gingival and lingual aspects of the left mandibular alveolar ridge, extending past midline to involve mucosa on the right side

Magnetic resonance imaging revealed a 7 × 10 × 35-mm abscess involving both gingival and lingual aspects of the left anterior mandible (arrowheads) (Figure, B)

Biopsy specimens of the right mandibular gingiva are shown in the Figure, C and D

C and D, Histopathologic images from biopsy specimens

C, Original magnification ×250. D, Original magnification ×500.


A man in his 20s presented with a painless, gradually increasing swelling in the right side of the neck of 6 years’ duration

There was no history of dysphagia, hoarseness of voice, dyspnea, or constitutional symptoms, such as fever, weight loss, or night sweats

Clinical examination revealed a 7 × 6-cm, well-defined, firm, nontender swelling extending from the angle of the mandible to the clavicle

Oropharyngeal examination revealed a mucosal bulge on the lateral pharyngeal wall with normal overlying mucosa

A computed tomographic (CT) scan of the neck was performed, which revealed a solid 7 × 8 × 10-cm right carotid space mass, with a few cystic areas and coarse specks of calcification within (Figure, A, yellow arrowhead)

It showed heterogeneous postcontrast enhancement, predominantly around the calcific foci

It extended from the C2 to D1 vertebral level and displaced the right common carotid artery and internal jugular vein anterolaterally (Figure, A, red arrowhead)

Fat planes around the mass were well maintained (Figure, B, arrowheads), and there was no bone destruction

A biopsy was performed from the mass (Figure, C and D)

A, Axial postcontrast computed tomographic (CT) image of the neck

B, Coronal postcontrast CT image of the neck

C, Hematoxylin-eosin, original magnification ×200. D, Hematoxylin-eosin, original magnification ×400.


A man in his 70s presented with blurred vision in his left eye

The patient had a history of myelodysplastic syndrome (refractory anemia with excess blasts–2), prostate cancer treated with prostatectomy and radiation therapy 5 years prior, and colonic adenocarcinoma treated with right hemicolectomy 6 years prior

Four months before presentation, his myelodysplastic syndrome transformed into acute myeloid leukemia (AML)

He was randomized to experimental drug CPX-351 for induction, but treatment was discontinued as a result of renal failure

However, remission was successfully induced with mitoxantrone hydrochloride and etoposide therapy, as confirmed by bone marrow biopsy, and he was prescribed continuing melphalan therapy on an outpatient basis

Three days prior to presentation, the patient on awakening noticed an acute onset of blurred vision in his left eye without any pain, photophobia, diplopia, vision loss, or floaters

He had no history of ocular surgery or trauma

Visual acuity was 20/20 in the right eye and 20/30 in the left

External examination had unremarkable results

Pupillary and motility assessments had normal results

Intraocular pressure was elevated bilaterally, measuring 29 mm Hg in the right eye and 41 mm Hg in the left

Slitlamp examination of the right eye revealed a 0.5-mm hypopyon with small hemorrhages on the iris surface (Figure 1A)

In the left eye, examination demonstrated a 1.5-mm hypopyon mixed with hemorrhage, 1+ cells in the anterior chamber, and small hemorrhages on the iris surface (Figure 1B)

Bilaterally, gonioscopy revealed open angles with few hemorrhages in the angle but no neovascularization

Dilated fundoscopic examination had unremarkable results bilaterally, with no retinal hemorrhages or optic disc swelling

Color slitlamp photographs illustrating bilateral hypopyon (black arrowheads) with iris surface hemorrhages (white arrowheads)

A, Right eye with 0.5-mm hypopyon with small hemorrhages on the iris surface and presumed infiltration

B, Left eye with 1.5-mm hypopyon mixed with hemorrhage and small iris surface hemorrhages and presumed infiltration


Gallbladder duplication with double cystic duct

Choledochal cyst and long common biliopancreatic channel

A 57-year-old woman with a medical history of recurrent biliary colic was admitted with symptoms consistent with mild gallstone pancreatitis

Routine laboratory test results showed total bilirubin of 4.74 mg/dL (to convert to millimoles per liter, multiply by 17.104) and amylase of 1.041 U/L (to convert to microkatals per liter, multiply by 0.0167)

An abdominal ultrasonography scan demonstrated gallstones and a mildly dilated common bile duct (CBD)

Magnetic resonance imaging of the abdomen confirmed these results and revealed cholelithiasis

The patient consequently underwent urgent laparoscopic cholecystectomy with intraoperative cholangiography (Figure, A)

Intraoperative cholangiography revealed an unusual anatomical variant and subsequent transcystic choledochoscopy was performed, which demonstrated a double lumen at the distal CBD (Figure, B)

Multiple gallstones were found within a dilated region of cystic duct


Infrarenal aortitis due to diverticulitis

An elderly man presented to the emergency department with a 1-month history of new-onset, persistent lower abdominal and flank pain

The pain was sharp and constant with intermittent radiation to the back and associated anorexia with a 10-kg weight loss

He did not report any previous abdominal surgery

The patient stated that he had not had any procedures with intravascular instrumentation in the past year, dental cleanings, intravenous drug use, cutaneous abscesses, or recent trauma

Physical examination revealed he was afebrile and in normal sinus rhythm

there was minimal epigastric abdominal tenderness without signs of peritonitis and no palpable masses

Femoral pulses were palpable and symmetric

Laboratory examination revealed mild anemia (hematocrit, 35% [to convert to a proportion of 1.0, multiply by 0.01]), no leukocytosis, and an elevated erythrocyte sedimentation rate (71 mm/h)

Blood and urine cultures were negative for organisms

A computed tomographic (CT) angiogram showed asymmetric attenuation surrounding the infrarenal aorta (Figure 1)

On comparison, a CT scan that was performed 6 months before presentation had identified no aneurysmal disease

Computed tomographic scan with arterial phase intravenous contrast with asymmetric attenuation surrounding the infrarenal aorta


A man in his 20s was referred to our department because of the presence of a sticky material around the underarm hair for approximately 1 year

The patient explained that he usually plays soccer and sweats abundantly

He did not apply deodorant or any other products in the underarm, and he ensured proper hygiene of the area

Physical examination revealed creamy yellow concretions along several hair shafts, in both armpits, with strong axillary odor (Figure, A)

These concretions did not disappear when cleansed with alcohol

Hair samples of the affected areas were sent for microscopy examination (Figure, B-D) and microbiologic culture

Treatment with antiseptic soap and a miconazole nitrate cream was initiated

After 2 weeks of treatment, the lesions had resolved and the patient had normal axillary hairs

Confirmation of the suspected diagnosis was made with the results of complementary tests

A, Clinical photograph of axillary hairs shows creamy yellow concretions along several axillary hairs

B, Direct microscopic examination of the hair shaft (original magnification ×40)

C, Periodic acid–Schiff stain (original magnification ×400)

D, Grocott silver stain (original magnification ×400)


A healthy teenaged boy was seen with a papular eruption on the trunk and legs of 3 months’ duration

He had initially developed lesions on his legs, which then spread to his neck, chest, and buttocks

This eruption was asymptomatic, and the patient reported no history of vesiculation

His mother noted minimal evolution of the lesions, except for recent flattening of those on the legs

Physical examination showed numerous discrete (1 to 3 mm) smooth brown papules concentrated on the neck, chest, anterior and lateral thighs, and buttocks (Figure 1)

Several lesions had a positive Darier sign (Figure 1A)

A, Multiple small brown papules of the chest

Localized erythema developed around several lesions after firm stroking

B, Scattered small brown papules of the lateral thigh

There was no family history of similar lesions

A punch biopsy of a papule on the left thigh was performed, and the specimen was submitted for pathological review


A woman in her 50s presented with diffuse blue to slate-gray patches on her entire face immediately after administration of Q-switched Nd:YAG laser toning (Figure 1A)

These pigmented lesions corresponded exactly to areas that had previously received laser treatment

Her history was remarkable for rheumatoid arthritis treated with oral gold salts 15 years ago, but the total dosage of gold salts could not be determined

Rechallenge with the original Q-switched Nd:YAG laser was administered on the right forearm, and a similar slate-gray macule developed immediately (Figure 1B)

A skin biopsy specimen of the lesion on the right side of the woman’s face was obtained, and histopathologic evaluation was conducted

A, Diffuse blue to slate-gray patches developed on the face, corresponding exactly to areas that had previously received laser treatment

B, A rechallenge test administered on the right forearm with the original Q-switched Nd:YAG laser yielded a similar slate-gray macule (arrowhead)


Ulcerated segmental infantile hemangioma

A 7-week-old full-term girl was referred to our clinic for persistent and expanding diaper dermatitis present since 1 week of age

She was initially treated at an outside hospital with intravenous clindamycin hydrochloride for presumed perianal cellulitis and was discharged with a regimen of oral clindamycin hydrochloride

When the patient was aged 4 weeks, the lesion became ulcerated and she was admitted to our hospital

She was given intravenous antibiotics and mupirocin, 2%, ointment, triamcinolone, 0.1%, ointment, clotrimazole, 1%, cream, nystatin cream, and zinc oxide paste

Results of cultures for bacteria and herpes simplex virus were negative

The patient had no systemic symptoms and was discharged and scheduled for an outpatient dermatology appointment

Physical examination showed a well-nourished, well-developed infant whose gluteal region had well-demarcated ulcers with scalloped borders on either side of the midline, superior to the anal verge

The base of the ulcers was covered with fibrinous material and the residue of topical medications

Bright red matted telangiectasias extended from the anus to the ulcers (Figure)

Two well-demarcated ulcers covered with white fibrinous material

The ulcerations are superimposed on prominent red matted telangiectasias


A woman in her 60s presented to her primary care physician with a right-sided lower motor neuron facial nerve palsy

This resolved with oral steroids and antiviral drugs consistent with a presumed diagnosis of idiopathic facial nerve (Bell) palsy

Six months later the patient developed discomfort around her right ear, prompting a referral to the local otolaryngology service

Her medical history was significant for localized invasive ductal carcinoma of the right breast treated with wide local excision 13 years previously

At presentation she was considered disease-free

Findings from the clinical examination, including otoscopy, were unremarkable

A magnetic resonance imaging (MRI) scan revealed an 8-mm lesion within the right parotid gland with a spiculated border and ill-defined surrounding enhancement extending close to the stylomastoid foramen (Figure, A)

This was of low T2 signal with no perineural spread evident

A fine-needle aspirate and core biopsy were obtained under ultrasonographic guidance

The cytologic findings showed loosely cohesive groups of atypical epithelial cells

Histologic examination of the core biopsy revealed an infiltrative lesion composed of cords and nests of medium-sized cells surrounded by a densely hyalinized stroma (Figure, B)

The cells contained hyperchromatic vesicular nuclei with moderate amounts of eosinophilic cytoplasm (Figure, C)

Immunohistochemical analysis showed the cells were diffusely positive for cytokeratin 7 (CK7), estrogen receptor (ER), progesterone receptor (PR), and androgen receptor (Figure, D)

A, Axial fast spoiled gradient echo gadolinium-enhanced magnetic resonance imaging (MRI) scan with fat suppression demonstrating lesion of the right parotid gland (arrowhead)

C, Cells with hyperchromatic vesicular nuclei and moderate amounts of eosinophilic cytoplasm

D, Immunohistochemical (IHC) analysis for estrogen receptor