A male infant presented to the pediatric otolaryngology office for evaluation of a left postauricular mass

Initially the lesion appeared to be acutely inflamed with erythema, overlying crusting, and tenderness to palpation

The child was treated with a course of antibiotics

Four weeks after the initial evaluation, the acute inflammation had resolved, but the lesion had increased in size

The child was otherwise healthy, and the parents stated that he had no systemic symptoms such as fever or weight loss

On physical examination, a 1.5-cm superficial, ovoid firm lesion was noted in the left postauricular area (Figure, A)

While the lesion was attached to the skin, it was mobile over the mastoid bone

There were no middle ear abnormalities on physical examination

Ultrasonography of the lesion revealed a nonvascular, well-circumscribed 1.7 × 1.4 × 0.6-cm lesion in the soft tissue posterior to the left ear

It demonstrated a heterogenous echotexture but was predominantly hypoechoic without internal vascularity or distinct calcifications

Excisional biopsy under general anesthesia was performed owing to rapid enlargement and unclear etiology of the lesion

The lesion had distinct borders and separated easily from the surrounding soft-tissue attachments

It was completely excised, including the overlying skin

Pathologic examination revealed a neoplasm extending from the reticular dermis into the subcutaneous adipose tissue (Figure, B)

There were lobules of lipidized histiocytic cells with eosinophils in a background of collagen (Figure, C)

The lesion stained negatively for S-100 and CD1a (Figure, D)

A, Gross photograph of left postauricular mass

B-D, Histopathologic images (hematoxylin-eosin)

B, High-powered (original magnification ×100) view depicting some pale areas representing lipidized cells

C, High-powered (original magnification ×400) view demonstrating pale, foamy cells (xanthoma cells)

D, Neoplastic cells staining negatively for S100 (original magnification ×400)


A man in his 60s presented to the oral and maxillofacial surgery department with a 7-month history of a painless progressive swelling of the anterior mandible

He reported numbness of the lower lip and difficulty on swallowing

His medical history was significant for hypertension and coronary artery bypass surgery

On intraoral examination, the mass was hard in consistency with relatively normal overlying mucosa

Computed tomographic (CT) images with bone window showed a grossly expansile, multilocular, low-attenuation lesion of the anterior segment of the mandible (Figure, A and B)

The images demonstrated severe erosion of the facial and lingual cortices with a remarkable scalloping pattern, and multiple wispy, ill-defined intralesional septa

Soft-tissue CT images indicated a cystic and solid nature of the mass (Figure, C and D)


A woman in her 60s presented with a history of persistent globus pharyngis spanning 2 decades

She stated that she had no other symptoms, and her family medical history was not remarkable

On examination, the rigid indirect laryngoscopy revealed yellowish floppy granular proliferation affecting the bilateral arytenoids and posterior aspects of the aryepiglottic folds, with symmetrical vocal cord motion (Figure, A)

The main lesions were clearly demarcated from the surrounding normal mucosa

The patient then underwent microlaryngeal surgery with biopsy under general anesthesia

The nidus was fragile and bled copiously when traumatized

The specimens mounted on the hematoxylin-eosin slides showed eosinophilic amorphous material underlying the epithelium (Figure, B)

Staining for thioflavin T revealed yellow-green fluorescence (Figure, C)

The fibrillar component emitted a characteristic apple-green birefringence under polarized light after binding to Congo red dye

No clinical evidence of systemic involvement and/or plasma cell dyscrasia was found

A, Endoscopic examination demonstrated symmetric yellowish lesions affecting the arytenoids and posterior aspects of the aryepiglottic folds, with a patent airway and mobile vocal folds

B, Eosinophilic amorphous material underlying the epithelium (hematoxylin-eosin, original magnification ×200)

C, Thioflavin T exhibited a typical yellow-green fluorescence after binding to amyloid fibrils (original magnification ×200)


An adolescent female with a medical history significant for absent corpus callosum, polycystic ovarian syndrome, and papillary thyroid cancer status post–total thyroidectomy and I-131 ablation, presented with a 1-year history of submental swelling

On examination, she had a 6-cm nontender mass in the submentum

Her floor of mouth (FOM) was soft, and there was no cervical lymphadenopathy

Attempted open biopsy at the time of thyroidectomy revealed only adipose tissue

Ultrasonography (US) (Figure, A) revealed a well-circumscribed, avascular, homogeneous, isoechoic lesion, measuring 6.2 × 6.0 × 6.0 cm along the FOM and left submandibular regions

Magnetic resonance imaging (MRI) of the neck revealed the lesion within the FOM, above the mylohyoid muscle

The lesion involved the root of the tongue in the midline and extended to the left, causing significant thinning of the left mylohyoid muscle without extension through it

The lesion demonstrated a fluid signal with T2 hyperintensity (Figure B), T1 hypointensity (Figure, C), and peripheral rim enhancement

Mild restricted diffusion was also noted

The patient underwent transcervical excision of the mass (Figure, D)

The mass was encapsulated and positioned above the mylohyoid muscle and extended into the FOM between bilateral genioglossus muscles

The mass was removed entirely via transcervical excision

A, Sagittal midline ultrasonography shows a floor of mouth lesion with uniform low-level echoes

B, Axial T2-weighted magnetic resonance image (MRI) revealing a hyperintense lesion involving the floor of mouth

C, Coronal postcontrast MRI revealing a T1 hypointense unilocular lesion involving the floor of the mouth and root of the tongue

D, Intraoperative photograph during mass excision


A 50-year-old man with transformed marginal zone lymphoma presented with intensely painful lesions on his left foot for 2 days

He noted a childhood history of plantar warts and believed these lesions to be identical in appearance

He did not recall any injury or unusual exposure

He had received his third cycle of R-CHOP (rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate, prednisone) 2 weeks prior to presentation as well as an injection of granulocyte-colony stimulating factor

He was anticipating his fourth cycle of treatment the day of his presentation

He also complained of a pruritic rash on his left thigh that had started several days before the appearance of his plantar foot lesions

The patient was afebrile, and his vital signs were within normal limits

Physical examination revealed grouped, brown, flat-topped papules on his distal plantar left foot (Figure)

It was exquisitely tender to palpation, and the patient was visibly uncomfortable when walking

He also demonstrated erythematous papules and plaques on his posterolateral thigh

Laboratory studies revealed pancytopenia, with a white blood cell count of 2800/μL, hemoglobin level of 11.6 g/dL, and a platelet count of 81 × 103/μL

His lactate dehydrogenase level was elevated at 914 U/L, and results of his comprehensive metabolic panel were unremarkable

(To convert white blood cell count to ×109/L, multiply by 0.001

to convert hemoglobin to grams per liter, multiply by 10

to convert lactate dehydrogenase to microkatals per liter, multiply by 0.0167.)Photographs of a patient with painful lesions on the foot


A 52-year-old woman with a history of diabetes mellitus and cigarette smoking who had a prior laparoscopic cholecystectomy was referred to our institution for severe postprandial epigastric abdominal pain that had been ongoing for several months and unintentional weight loss

She had been prescribed total parenteral nutrition prior to referral

On presentation, her physical examination was remarkable for mild epigastric tenderness

The results of laboratory testing, including a complete blood cell count, chemistry values, liver function tests, and amylase and lipase levels, were unremarkable

Computed tomography demonstrated focal gastric thickening

Esophagogastroduodenoscopy with endoscopic ultrasonography was performed that confirmed a submucosal gastric mass (Figure, A)

A fine-needle aspiration biopsy revealed benign and reactive glandular cells and debris

Magnetic resonance cholangiopancreatography demonstrated a 2.4-cm hypervascular and exophytic mass in the gastric antrum and locoregional lymphadenopathy (Figure, B)

A, Endoscopic ultrasonography of the gastric antrum mass reveals an area of gastric thickening (arrowheads) corresponding to computed tomographic findings

During endoscopy, this area was visualized grossly as a bulge in the atrium along the incisura

A fine-needle aspiration biopsy was nondiagnostic, showing gastric antral-type mucosa without pathologic changes (inset)

B, The coronal image in T2 phase reveals a 1.8 × 2.4 × 1.5-cm hypotense lesion (arrowhead) in the gastric antrum

The lesion was also enhanced on T1 arterial phase sequencing


A woman in her mid-50s presented to the clinic with a 6-month history of progressive swelling and pain on the right side of her neck

The patient described a history of sleep apnea, a remote transient ischemic attack with left-sided weakness, and a prior thyroidectomy

She had increasing fatigue during the last 6 months, as well as worsening anxiety

On physical examination, the neck was supple, with no palpable masses or lymphadenopathy, and had a well-healed transverse neck incision

Magnetic resonance imaging revealed a 1.1-cm, round, partially enhancing, cystic mass near the tail of the parotid gland that appeared hypointense on T2-weighted imaging (Figure 1)

An enlarged and distended venous structure that measured up to 7 mm was also visualized in the area

Laboratory work revealed no abnormalities

Magnetic resonance images of the parotid gland

T1-weighted image (A) and T2-weighted image (B) revealing a round, partially enhancing, cystic mass near the tail of the parotid gland (white and red arrowheads)


A 72-year-old man with a medical history of atrial fibrillation, type 2 diabetes mellitus, chronic kidney disease, hypertension, and congestive heart failure presented with a 2-month history of scaly erythematous papules on both forearms (Figure, A)

The lesions were pruritic at times and the patient reported no improvement with chlorhexidine wash or hydrocortisone, 1%, cream

He was otherwise asymptomatic, and review of his systems revealed no abnormalities

His medications included amiodarone, furosemide, nifedipine, insulin glargine, and allopurinol

He denied preceding trauma, recent travel, or new medications

A, Red, scaly papules on the patient's forearm

B, Punch biopsy specimen from the center of a papule on the forearm shows pseudoepitheliomatous hyperplasia, spongiosis with vesiculation, intraepidermal neutrophilic microabscesses, focal subepidermal bulla formation, and dermal infiltrate of neutrophils, lymphocytes, and histiocytes (hematoxylin-eosin, original magnification ×4)

Physical examination revealed numerous red to violaceous scaly papules symmetrically distributed on both forearms

Laboratory tests revealed a serum creatinine level of 3.79 mg/dL (normal range, 0.70-1.40 mg/dL) and serum iodine level of 42 305 ng/mL (normal range, 40-92 ng/mL)

A punch biopsy was obtained from the center of a papule on the right forearm (Figure, B)


A woman in her 50s admitted for bacterial pneumonia was noted to have an ulcerated plaque on the forearm

The patient had been discharged approximately 2 weeks prior, after an admission for congestive heart failure

A few days after that discharge, the patient noticed a painful ulceration on the right distal forearm, at the site where a peripheral intravenous catheter had been inserted during her initial hospitalization

On physical examination, the patient had an ulcerated plaque on the right forearm with 2 tender, 1- to 2-cm red nodules in the right antecubital fossa (Figure, A)

On further questioning, the patient noted that between her hospitalizations she had gone home and cleaned her fish tank, played with her pet cat, and gardened in her indoor cactus garden

She said she had not recently traveled, and was not taking any immunosuppressive medications

A skin biopsy and culture were performed from the forearm lesion (Figure, B and C)

A, An ulcerated plaque on the right forearm

Note 2 tender, 1- to 2-cm red nodules in the right antecubital fossa

Hematoxylin-eosin, original magnification ×20. C, Organisms seen on Gram stain


A woman in her early 40s presented with a 6-month history of rash in the bilateral axillae

The areas involved were not itchy or tender but bothered her cosmetically

The patient reported using an aluminum-containing antiperspirant spray for years before the onset of the eruption but had since discontinued use of deodorants or antiperspirants without improvement in her lesions

Her medical history was significant only for epilepsy, and her daily medications included lamotrigine and cholecalciferol

Physical examination revealed multiple red-brown to purplish follicular papules and nodules in bilateral axillae with focal areas of scarring (Figure 1)

Multiple red-brown papules within the axilla bilaterally

She did not improve with multiple medications, including topical antifungals, topical corticosteroids, oral ketoconazole, topical dapsone, doxycycline (40 mg/d), minocycline (100 mg twice daily), a combination of amoxicillin and clavulanate, and intralesional triamcinolone acetonide

A 4-mm punch biopsy was performed on the right axilla for evaluation


A 9-month-old boy presented with a left-sided facial mass

His perinatal history was notable for macrosomia, macrocephaly, left-sided failure on newborn hearing screen, and a congenital hypertrichotic patch of the left scalp

During the first few months, he was observed to frequently tug at his left ear while displaying apparent discomfort and sleeping difficulties

He was treated empirically with multiple antibiotics for presumed otitis media and subsequently had bilateral myringotomy tubes placed

When the left side of his face became more swollen, magnetic resonance imaging was performed at 8 months of age and revealed a left-sided parotid mass

He was referred to our institution for further evaluation

Additional magnetic resonance imaging and magnetic resonance angiography of the brain and neck revealed an infiltrative vascular mass of the left parotid, skull base, and deeper facial structures with occlusion of the left internal jugular vein and extension into the external auditory canal

The differential diagnosis included atypical infantile hemangioma, congenital hemangioma, or venous malformation

The dermatology department was consulted to consider treatment with propranolol

On examination, the patient was afebrile, intermittently irritable, but otherwise well appearing with stable vital signs

Of note, his length was in the 76th percentile for age, whereas his weight and head circumference were both greater than the 99th percentile for age

Swelling of the left lower part of the face was noted

A nontender, faint blue patch with subtle swelling and thick, coarse overlying hair was present on the left preauricular-temporal part of the scalp (Figure1A)

Subtle scattered tan patches were present on the trunk and extremities (Figure 1B)

A, Blue patch of the left periauricular scalp

Note the difference in the textural quality of the hair overlying the affected area, which the parents trimmed regularly to maintain a more uniform appearance

B, Representative light tan patches with irregular borders on the back

A total of 15 similar lesions were noted on examination


Lymphoepithelial carcinoma of parotid gland

Undifferentiated carcinoma of parotid gland

Metastatic squamous carcinoma to parotid gland

A previously healthy man in his 20s who was of Asian heritage presented with a nontender mass in the left parotid region, which had been slowly enlarging for 18 months

He had experienced occasional blepharospasm and paresthesia in the ipsilateral eye and cheek

He had also noted an unintended 3-kg weight loss in the same duration, which he subjectively attributed to the stress of school

Physical examination demonstrated a firm, immobile, irregular mass n the left parotid and approximately 3 × 3 cm in size

Mild left-sided buccal weakness was noted

Otherwise, his cranial nerve function was intact

Fine needle aspiration demonstrated medium-size ovoid cells with minimal cytoplasm in crowded groups

T2-weighted magnet resonance imaging following the initial computed tomographic (CT) scan demonstrated a poorly marginated mass that was 4 cm in maximum diameter abutting the left superficial parotid with involvement of the masseter (Figure, A)

A parotidectomy with excision of the tumor was planned

During the initial exposure of the tumor, an intraoperative frozen section demonstrated a cellular infiltrate, and a diagnosis of lymphoma could not be excluded

Given the size and fixed nature of the tumor, the decision was made to stop resection on establishing a definitive diagnosis

Flow cytometry demonstrated phenotypically normal T-cell and B-cell populations

Permanent histologic sections demonstrated nests of nonkeratinizing undifferentiated atypical epithelial cells intimately intermingled with a dense lymphoplasmacytic infiltrate (Figure, B)

Immunohistochemical analysis for cytokeratin AE1/3 was positive in the carcinoma cells (Figure, C)

In situ hybridization for Epstein-Barr virus–encoded small RNAs (EBERs) was positive (Figure, D)

A, T2-weighted coronal magnetic resonance image of the face

B, Hematoxylin-eosin, original magnification ×20. C, Cytokeratin AE1/3 immunostain, original magnification ×20. D, Epstein-Barr virus in situ hybridization, original magnification ×20.


A 5-year-old boy presented with a 1-year history of a mass gradually growing over the helix of his left auricle

It was associated with minimal pain and intermittently fluctuated in size

Physical examination revealed a single 1.0 × 0.7-cm mass on the left mid helix that was firm, nontender, nonerythematous, and nonerosive

The resected specimen appeared cystic (Figure, A) with granulomatous reaction at the periphery (Figure, B)

The lesion was found to be superficially located in the dermis and filled with a soft white material that appeared as purple to blue crystals

A, Specimen shows purple to blue crystals with cystic components

B, Cystic structure with amorphous material and granulomatous reaction at the periphery with occasional foreign-body giant cells


An infant girl presented to the pediatric otolaryngology clinic with a 2-month history of an enlarging left preauricular mass

The parents first noticed a pea-sized nodule in front of her left ear that was now 3 cm, soft, mobile, and nontender, without overlying skin changes or facial nerve impairment

The infant was otherwise well without fevers, feeding well, and growing appropriately

Her mother had a full-term vaginal delivery without complications and a medical history that was notable only for gastroesophageal reflux disease treated with ranitidine

Ultrasonography showed a 2.2 × 3.0-cm solid nodule

The patient was then referred for magnetic resonance imaging (MRI) with contrast, which showed a 2.9 × 1.6 × 2.3-cm mass with a well-defined capsule arising from within the superficial left parotid gland

The mass was largely of fat signal intensity on both T1-weighted (Figure, A) and T2-weighted sequences with heterogeneous soft-tissue enhancement on T1 post-contrast (Figure, B)

The mass also suppressed relatively uniformly on short T1 inversion recovery (STIR) sequence (Figure, C)

The Figure, D, shows the mass in situ during surgical excision with facial nerve monitoring

Magnetic resonance images of a patient with a left preauricular mass of the superficial parotid lobe


A man in his 60s with a 20 pack-year smoking history presented with a several-month history of intermittent left otalgia, facial pain, swelling, and dysphagia

The pain was exacerbated by eating and prolonged talking

He was initially seen at an emergency department, where his symptoms were unsuccessfully treated with antibiotics

He stated that he had not experienced hoarseness, weight loss, fever, night sweats, parotid mass, or involuntary facial nerve spasms

His medical history was significant for blunt trauma to the left maxilla region approximately 10 years prior to presentation

His surgical history was noncontributory

Physical examination demonstrated a well-developed man in no distress who spoke in a normal tone

The external auditory canals and the tympanic membranes were intact and clear bilaterally

The nasal cavity and the nasopharynx were normal

The oral cavity and oropharynx revealed moist mucosa with no lesions or erythema

Fiber-optic flexible nasopharyngoscopy and laryngoscopy revealed normal pharyngeal walls and pyriform sinuses

The vocal folds were symmetric and mobile bilaterally

Computed tomography (CT) of the neck demonstrated a ossified mass (arrowheads) in the left parapharyngeal space (Figure)


A man in his 50s with a history of hypercholesterolemia and type 2 diabetes mellitus was referred for diarrhea (5-6 times per day) and a 27-kg weight loss in the preceding 5 months

The patient did not have abdominal pain, nausea, vomiting, or a history of abdominal surgical procedures and did not use alcohol or tobacco

On physical examination, the patient’s abdomen was soft, nontender, and nondistended, with no palpable masses, and he did not appear jaundiced

Results of laboratory testing demonstrated a carbohydrate antigen 19-9 level of less than 1 U/mL and a carcinoembryonic antigen level of 6.0 ng/mL (to convert to micrograms per liter, multiply by 1.0)

A duodenal mass was found using esophagogastroduodenoscopy and biopsies were taken

To further evaluate the lesion, the patient underwent a computed tomographic scan of the abdomen and pelvis with contrast dye (Figure 1)

A, Cross-sectional computed tomographic scan demonstrating a 4.7 × 2.9-cm, heterogeneous, solid mass involving the ampulla of Vater and the head of the pancreas

A heterogeneous soft-tissue nodule can be seen (arrowhead)

The common bile duct (CBD), duct of Santorini (S), and duct of Wirsung (W) can all be identified traversing the mass compressing the duodenum (D)

B, Coronal computed tomographic scan demonstrating a polypoid pedunculated ampullary tumor extending into the duodenal lumen


A man in his late 60s with a history of laryngeal cancer was transferred to our institution

The patient had undergone laryngectomy with radiation, modified radical neck dissection, and a pectoralis major flap into the right-sided neck wound in 1998. This operation was subsequently complicated by right carotid blowout requiring right-sided carotid artery ligation on November 5, 2005. The patient initially presented to our hospital with a Glasgow Coma Scale score of 3. Findings from computed tomography of the head at the referring hospital showed acute right-hemispheric stroke with left-sided hemiparesis

On examination, the patient was afebrile, with a heart rate of 108 beats/min and blood pressure of 169/91 mm Hg with 100% oxygen saturation

Pertinent findings included an improved Glasgow Coma Scale score of 12 and left arm and leg hemiparesis

The right upper arm was cool to the touch below the elbow, with cyanotic right fingers, and the right-sided radial and brachial pulses were absent

The patient also presented with a pulsatile mass in the upper chest wall on the right side

A confirmatory magnetic resonance image of the head is shown in Figure 1A, and a selective angiogram of the innominate artery is shown in Figure 1B

A, Magnetic resonance imaging of the head

B, Selective angiogram of the innominate artery


Primary human immunodeficiency virus infection

A 23-year-old white man who has sex with men (MSM) presented with a 1-month history of skin lesions on the palms and soles as well as a 2-week history of lesions in his oropharynx

He reported that a fraction of the lesions had blistered earlier in the course of his illness

The patient also described myalgias and fatigue over the preceding month

He moved to Texas from the northeast a few months prior to his illness

He denied any exposure to sexually transmitted infections or a history of genital lesions

On examination, the patient had erythematous papules on bilateral palms and soles as well as eroded vesicles on the palate (Figure, A and B)

A biopsy specimen of a papule on the left sole was obtained for immunohistochemical staining (Figure, C and D)

A serologic antibody test revealed an elevated coxsackievirus titer of 1:16 (reference range, <1:8

C, Hematoxylin-eosin–stained section of the biopsy specimen (original magnification, ×20)

D, Immunohistochemistry stain of biopsy specimen (anti–Treponema pallidum polyclonal antibody immunostain


A man in his 50s was referred to the dermatology clinic for a chronic, painful nonhealing ulcer on the right forearm following a ground-level fall 3 months previously

He reported subjective fevers, as well as increasing erythema and tenderness immediately around the right forearm lesion

He stated that he did not have a history of poor wound healing or painful skin ulcers

He had a history of type 2 diabetes and an allogenic bone marrow transplant 1 year prior for myelodysplastic syndrome complicated by pancytopenia and chronic graft-vs-host disease

Physical examination revealed an isolated slightly erythematous, edematous plaque with a prominent central eschar on the right forearm (Figure, A)

An incisional biopsy at the edge of the eschar was performed, and a specimen was sent for pathological evaluation (Figure, B-D)

A, Clinical photograph of a nonhealing ulcer with central eschar on the right forearm

B, Necrotic debris and fat necrosis with saponification (hematoxylin-eosin, original magnification ×40)

C, Saponification and needle-like clefts within necrotic adipocytes (hematoxylin-eosin, original magnification ×200)

D, Numerous nonseptate, thick-walled fungal hyphae in the dermis (hematoxylin-eosin, original magnification ×400)


Granulomatosis with polyangiitis (Wegener granulomatosis)

A man in his 70s presented with erythematous ears associated with a burning sensation

He reported that the lesions had begun 6 months previously and that they were most bothersome at the end of the day or when he was exposed to the cold and damp environment while out on his boat

He applied ice to alleviate the burning, but this worsened the condition

A heating pad provided some measure of relief, as did a brief course of systemic corticosteroids

Physical examination revealed that some papular lesions were associated with slight purpura and hemorrhagic crust (Figure, A)

Histologic findings from biopsy specimens were also obtained by routine histologic analysis (Figure, B) and direct immunofluorescence examination (Figure, C)

A, Clinically, the left ear demonstrates erythema, edema, and focal crusting

B, Biopsy specimen from the left ear reveals thrombi within engorged blood vessels but fails to reveal significant inflammation of blood vessel walls (hematoxylin-eosin, original magnification ×200)

C, Biopsy specimen from the left ear under direct immunofluorescence and stained for anti-IgM highlights thrombi within vessels (original magnification ×200)


Recurrent painful ophthalmoplegic neuropathy

A young boy presented for evaluation of “droopiness” of the eyelid

He had 3 episodes of right-sided ptosis, each of which occurred at 18 months, 3 years, and 5 years of age

None of these episodes was preceded by fever

During the last 2 episodes, he experienced severe right-sided headache lasting for 6 to 7 days before development of ptosis

There was no history of loss of consciousness, seizures, loss of vision or hearing, facial deviation, trouble swallowing, or weakness of the extremities in any of these episodes

There was history of migraine on the maternal side of the family

There was no family history of autoimmune disorders or cerebral aneurysms

At the time of the clinic visit, the patient was asymptomatic and results of the neurologic examination were normal

The family provided a photograph of the patient’s face at the time of the first episode (Figure, A)

After the first episode, with a presumed diagnosis of acute disseminated encephalomyelitis, he received intravenous pulse methylprednisolone sodium succinate, 30 mg/kg, for 3 days and recovered completely in 3 weeks

The patient received intravenous immunoglobulin, 2 g/kg, for 2 days after the subsequent 2 episodes, with a presumed diagnosis of chronic inflammatory demyelinating neuropathy, and recovered fully

Results of brain magnetic resonance imaging performed at 18 months showed thickening of the cisternal part of the right third cranial nerve in the perimesencephalic cistern (Figure, B) with no parenchymal lesions

Results of tests on cerebrospinal fluid collected via lumbar puncture were normal

A, The patient’s right-sided ptosis during the first episode at age 18 months

B, Results of brain magnetic resonance imaging showing thickening of the cisternal part of the right third cranial nerve in the perimesencephalic cistern (white arrowhead)


Melanin-pigmented oncocytic metaplasia of the nasopharynx

A man in his 60s with a history of hyperlipidemia, gout, and sleep apnea had a consultation for an incidental finding of a left torus tubarius, blackish, mucosal lesion noted during a health examination at a local clinic in July 2014. He had no nasal obstruction, nasal bleeding, or feeling of aural fullness

Fibroscopic evaluation revealed a black nevus–like lesion over the left torus tubarius, without surface necrosis or signs of bleeding when touched

Examination of the neck, nasal cavity, and larynx showed no remarkable findings

It was recommended that he receive laser excision of the lesion under endoscopy

During the surgery, the superficial lesion was found to be confined to the left torus tubarius, without invasion of the surrounding structures (Figure, A, arrowhead)

The margins were clearly identified, and laser excision was performed smoothly with only minimal bleeding

The surgical specimen was a single black, soft-tissue fragment measuring 0.4 × 0.3 × 0.2 cm

Microscopy revealed small mixed serous and mucinous glands, normal respiratory epithelia with marked oncocytic cell changes, and abundant eosinophilic granular cytoplasm arranged in a tubular and microcystic pattern (Figure, B)

Scattered brown pigments were noted in the cytoplasm of most oncocytic cells (Figure, C)

The brown pigment was negative for iron stain (Figure, D) and HMB45 stain, but positive for Fontana Masson stain

Ki-67 staining revealed low proliferative index in the lesion

Some lymphocytic infiltration of the stroma was also noted

B, Hematoxylin-eosin, original magnification ×100. C, Hematoxylin-eosin, original magnification ×200. D, Iron stain, original magnification ×100.


A woman in her 50s developed severe trismus several months after treatment of a dental abscess

Approximately 10 years after onset of symptoms, she was seen by an oral surgeon who attempted mandibular release via a cervical incision

According to the patient, the surgeon was “unable to reach” the affected area, and the operation was unsuccessful

There was no other significant medical or surgical history

On physical examination, severe trismus was present with maximal interdental distance of 1 mm

The patient was brought to the operating room for excision

A maxillofacial computed tomographic (CT) examination was performed (Figure)

A-C, Noncontrast computed tomographic images

A, Axial slice from an image of the facial bones

B, Coronal slice from an enhanced scan of the facial bones

C, Coronal image of the facial bones using a soft-tissue algorithm

Asterisk indicates left medial pterygoid artery

D, Three-dimensional reconstructed image of the facial bones


A man in his 30s presented to the emergency department with a worsening sinus infection and vision loss

His medical history was significant for previous nasal endoscopy with biopsy of nasal polyps 6 years previously, with a finding of benign nasal polyps by surgical pathology

The patient had then been lost to follow-up

He now complained of nasal drainage, severe headaches, and long-standing visual loss

There had been no acute worsening of headaches or visual loss in the previous months

Physical examination showed severe left proptosis, telecanthus, purulent nasal drainage, and nasal polypsis filling the bilateral nasal cavities

Ophthalmology consultation revealed no evidence of restriction of gaze or papilledema, and a recommendation was made for endoscopic sinus surgery to remove the source of infection

Computed tomographic imaging revealed extensive nasal polyposis, bony remodeling consistent with long-standing inflammation, and massive erosion of the bilateral skull base and orbits (Figure 1A)

The patient underwent endoscopic sinus surgery

Nasal polyps were present and had a typical appearance superficially (Figure 1B)

However, on deeper dissection, they became increasingly difficult to remove even with powered instrumentation, and an atypical, fibrotic endoscopic appearance was noted (Figure 1C)

Tissue was sent for histologic evaluation

Following this, the dissection was terminated

A, Coronal computed tomographic scan demonstrating extensive nasal polyposis and bony remodeling of bilateral skull base and orbits

B, Rigid nasal endoscopy demonstrating superficial appearance consistent with nasal polyps

C, Rigid nasal endoscopy following deeper dissection of area in question, demonstrating atypical fibrotic appearance


A woman in her 50s presented with a several-month history of symptoms that included foreign body sensation in her throat, mild odynophagia, and dyspnea

She had a history of adenoid cystic carcinoma of the right submandibular gland and had undergone wide tumor excision and postoperative radiation therapy 20 years previously (60 Gy/30 fractions in 1993)

She also had a history of hyperthyroidism, which was under medical control (with propylthiouracil, 50 mg/d)

She stated that she did not have blurred vision, headache, seizures, or trismus

She had no family history of neurofibromatosis

A physical examination revealed a bulge in the floor of mouth, limitation of tongue movement, and no palpable lymphadenopathy

She had no suspicious spots or nodules on the skin

Postgadolinium T1-weighted magnetic resonance imaging disclosed a 7.0 × 4.0 × 3.0-cm, well-defined enhancing mass in the right side of the floor of the mouth, extending posteriorly to the tongue base and medially across the midline (Figure, A)

The results of laboratory investigations were normal

Transcervical removal of the tumor was performed

The surgical specimen was a 7.2 × 5.8 × 4.3-cm encapsulated tumor composed of a homogeneous, whitish, rubbery, and glistening content (Figure, B)

Microscopic examination demonstrated oval to eel-like spindle nuclei distributed in a background of generally wavy collagenous fibers and mucinous matrix (Figure, C)

The specimen showed sparse cellularity and no cellular atypia

Neither mitotic figure nor tumor necrosis was found

The specimen was immunoreactive for S-100 (Figure, D), focally positive for CD34, but nonreactive for smooth muscle actin

A, Axial T1-weighed gadolinium-enhanced magnetic resonance image of the neck

Hematoxylin-eosin, original magnification ×200. D, Histopathologic image

S-100 protein stain, original magnification ×200.


The patient was a woman in her 30s with a history of goiter, hypertension, asthma, obstructive sleep apnea, and skin lesions in the lower extremities for which biopsy findings more a decade before suggested sarcoidosis

She presented with a 1-day history of sore throat, fever, chills, productive cough, globus sensation, dysphagia, and a change in her voice to the point it had become muffled and hoarse

Throughout the day she noticed progressive worsening of her symptoms in addition to becoming dyspneic

The patient tried using her albuterol inhaler, but this provided no relief of her symptoms

The patient was afebrile at presentation, and there were no signs of infection

On examination, there was mildly tender right cervical lymphadenopathy but no evidence of peritonsillar exudates

Laryngoscopy demonstrated diffuse swelling of the supraglottic structures, particularly the epiglottis and left aryepiglottic fold, with a pale appearance of the mucosa (Figure, A)

In addition, a neck computed tomographic (CT) scan was obtained, which showed marked swelling of the supraglottic structures with areas of patchy enhancement and narrowing of the airway, as well as enlarged right cervical lymph nodes (Figure, B-D)

Owing to airway compromise, the patient was intubated and received intravenous steroids and ceftriaxone

Subsequently, she underwent debulking surgery and carbon dioxide laser ablation of the left arytenoid

B, Axial contrast-enhanced computed tomographic (CT) image through level of the aryepiglottic folds

C, Axial contrast-enhanced CT through level of the epiglottis


A 20-year-old otherwise healthy woman presented to the emergency department after a motor vehicle crash in which computed tomographic images of the abdomen were obtained as part of the trauma evaluation

Small free fluid within the pelvis and 2 large mesenteric masses were discovered adjacent to the liver, pancreas, and stomach (Figure 1)

An endoscopic ultrasound-guided fine-needle aspiration of the abdominal mass was obtained and the diagnosis was made

The patient underwent exploratory laparotomy and en-bloc resection of the intraperitoneal tumors

During the trauma workup after a motor vehicle crash, 2 large peritoneal tumors were identified in her upper abdomen

A, An exophilic mass in segment 3 of the liver invading the distal stomach

B, A mass in the lessor sac attaching to the body of pancreas

The arrowheads indicate 2 isolated tumors close to the liver, pancreas, and stomach


A 5-year-old boy with a 1-year history of intermittent abdominal pain presented to the emergency department with 2 days of nausea, nonbilious emesis, and diffuse abdominal pain

He was afebrile and had normal vital signs

Physical examination findings were notable for mild abdominal distension and tenderness without guarding or rebound sign

Abdominal ultrasonography revealed a normal appendix

Abdominal radiography (Figure 1A) revealed multiple polygonal calcified lesions in the pelvis and a nonobstructive bowel gas pattern

Computed tomography (Figure 1B) revealed a 5.6 × 5.3 × 4.6-cm midline cystic pelvic mass adjacent to the anterior rectal wall that contained several irregularly shaped ossifications

Laboratory study results were significant for normal levels of α-fetoprotein and chorionic gonadotropin and a white blood cell count of 19 700/μL (reference range, 5500-15 500/μL

to convert to ×109/L, multiply by 0.001)

The patient was taken to the operating room for an exploratory laparotomy

A, Supine abdominal radiograph reveals multiple polygonal calcified lesions in the pelvis (black arrowhead)

B, Computed tomographic sagittal image of the abdomen reveals a midline cystic pelvic mass that contains several irregularly shaped ossifications (white arrowhead)


A newborn girl with a nodular lesion on the scalp present since birth was seen at the dermatology clinic

The parents reported occasional erosions and crusting that resolved with topical mupirocin, 2%, cream, but with no continued growth

Physical examination revealed a firm, exophytic, and flat-topped nodule, with superficial erosion and crust on the right parietal side of the scalp measuring 3 cm in diameter and 1 cm thick (Figure, A)

A 4-mm punch skin biopsy was performed, and tissue was sent for pathologic analysis (Figure, B and C)

Cerebral and abdominal ultrasonography revealed no evidence of visceral involvement

The lesion regressed without treatment over a period of 8 months

Close follow-up every 3 months was scheduled, and complete involution of the tumor was noted at 10 months of age (Figure, D)

A, Nodular lesion on the right parietal scalp at initial presentation

B, Histopathologic image of a biopsy specimen (hematoxylin-eosin, original magnification ×200)

C, Immunohistochemical image of a biopsy specimen (actin stain, original magnification ×100)

D, Complete regression of tumor at 10 months of age


A man in his 60s presented with a painless rapidly enlarging ulcer on his left leg 1 week after the onset of diverticulitis, a neutropenic fever, and severe sepsis due to multidrug-resistant Pseudomonas aeruginosa infection that necessitated admission to the intensive care unit

His medical history included a heart transplant for ischemic cardiomyopathy in his early 50s, and he was receiving long-term immunosuppressive therapy with cyclosporine, mycophenolate mofetil, and deflazacort

He had received a diagnosis of plasmablastic lymphoma 6 months earlier and was being treated with polychemotherapy (cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate, and prednisone [CHOP] regimen)

Physical examination revealed a well-demarcated 5 × 5-cm round ulcer with raised border, surrounding erythema, and a base with purulent debris (Figure 1A)

A superficial swab culture sample grew P aeruginosa

A punch biopsy specimen from the edge of the ulcer was obtained and sent for histopathologic evaluation (Figure 1B)

A, Cutaneous ulcer on the patient’s left leg with a raised erythematous border and a base with purulent debris

B, Diagnostic biopsy shows enlarged endothelial cells with intranuclear inclusions surrounded by a clear halo, and some cytoplasmic inclusions

Similar findings are detected in some macrophages (hematoxylin-eosin, original magnification ×400)


Type I cryoglobulinemia associated with multiple myeloma

A woman in her 80s with a history of nonischemic cardiomyopathy and chronic kidney disease presented with purpuric lesions on her face, elbows, knees, and feet

She was initially admitted for altered mental status in the setting of an unwitnessed fall and was noted to have “bruises” on her lower extremities

Dermatology was consulted after the development of new lesions on her nose, ear, and the extensor surfaces of her arms bilaterally

Admission laboratory test results showed hypercalcemia (calcium level, 11.5 mg/dL) and acute kidney injury (creatinine level, 5.6 mg/dL)

On physical examination, the patient’s nose, bilateral cheeks, forehead, and left ear (helical rim and antihelix [Figure, A]) were found to have dusky purpuric macules and patches

Her knees, feet, and the extensor surfaces of her arms had reticulated purpuric macules and patches

There was skin sloughing off the lesions on her elbows (Figure, B) and knees

Four-millimeter punch biopsy specimens were taken from the left ear, right arm, and forehead (Figure, C and D)

Clinical and histopathologic images from a case of acral retiform purpura

A, Dusky purpuric macules on the helical rim and antihelix of the ear

B, Reticulated purpuric patches with focal areas of necrosis on the extensor surfaces of the arms

C and D, In specimens from the forehead, multifocal intravascular fibrinoid material consisting of a mix of cryoglobulins and fibrin thrombi with relatively little vessel wall inflammation was seen (hematoxylin-eosin, original magnification ×4 [C] and ×10 [D])


An adolescent girl presented to her pediatrician reporting abdominal distention

She first became aware of her increased abdominal girth when friends at school asked whether she was pregnant

She had noticed her clothing becoming tighter over recent weeks

She had not experienced abdominal pain or other symptoms, and there was no history of trauma

Physical examination revealed a firm, distended abdomen without bowel sounds

Results of laboratory studies, including a complete blood cell count, basic metabolic panel, and liver function tests, were within normal limits

An abdominal radiograph showed a paucity of bowel gas markings (Figure 1A)

A subsequent computed tomographic scan of the abdomen and pelvis revealed a 30-cm retroperitoneal cystic structure causing significant mass effect on the abdominal viscera, displacing the right kidney superiorly under the liver causing moderate hydronephrosis (Figure 1B)

A, Abdominal radiograph showing a paucity of bowel gas markings

B, Abdominal computed tomographic scan showing a massive retroperitoneal cystic lesion with displacement of abdominal organs and right moderate hydronephrosis


Fungal ball and invasive squamous cell carcinoma

A man in his 60s had an 8-month history of right-sided nasal congestion and rhinorrhea

He had no clinically significant improvement in symptoms despite multiple courses of oral antibiotics

Over the previous 2 months, he had developed progressive right-sided facial swelling, pain, blurred vision, and a 6.8-kg weight loss

There was no history of immunocompromise or foreign travel

A computed tomographic (CT) scan at an outside hospital showed complete opacification and an invasive process centered in the right maxillary sinus

An endoscopic maxillary antrostomy and biopsy showed inflammatory changes and numerous fungal organisms consistent with Aspergillus species

The patient was started on treatment with intravenous antifungal and broad-spectrum antibiotics, and he was transferred for further evaluation and management

The patient’s examination was notable for right-sided facial and periorbital swelling, severe pain, and limitation of lateral gaze of the right eye

A repeated CT scan was completed (Figure)

A, Coronal view of the paranasal sinuses in bone windows showing near-complete opacification of the right maxillary sinus with soft-tissue thickening, a calcific focus, and associated erosion of the bony walls

B, Coronal view of the paranasal sinuses in soft-tissue windows

C, Axial view of the paranasal sinuses in bone windows


Well-differentiated liposarcoma of the larynx

A man in his 40s with a 10-year history of smoking 180 packs of cigarettes per year choked easily and had experienced a foreign body sensation in his throat for 6 months

He was a tour guide, a profession that requires speech

Because he experienced voice fatigue frequently, he visited a hospital for professional assistance

Fibroscopy showed a well-circumscribed mass of approximately 3 × 3 × 2 cm, with a smooth surface, located at the laryngeal side of the left aryepiglottic fold and covering nearby structures, such as the bilateral vocal cords and left pyriform sinus (Figure 1, A)

A biopsy was performed, and the patient visited our institution (Taipei Veterans General Hospital) for further intervention

The laryngeal mass was removed through transoral laser microsurgery

The tumor was at the submucosa with focally ulcerated overlying epithelium

It was composed of adipocytes of various sizes in a fibromyxoid background

In the fibromyxoid areas, atypical spindle cells with hyperchromatic and enlarged nuclei were present, as well as scattered lipoblasts without areas of dedifferentiation (Figure 1, B)

Immunohistochemically, the tumor exhibited substantial nuclear staining for both CDK4 and MDM2 and stains (Figure 1, C)


A teenage girl presented with new onset of bilateral upper extremity numbness and paresthesias

The rest of the clinical history and neurological examination was unremarkable

A magnetic resonance imaging (MRI) study of the brain and cervical spine obtained to evaluate for demyelinating disease demonstrated a normal brain and cervical cord, but an incidental T2 hyperintense lesion within the right pterygoid muscles was noted

On further consultation with the otolaryngology department, the patient stated that she had not experienced any sensation of a mass, and results from a focused otolaryngologic examination were also normal

A dedicated fifth cranial nerve MRI examination performed to better characterize the lesion revealed a well-defined, lobulated T2 hyperintense lesion within the right pterygoid muscles without mass effect, adjacent edema, or other invasive features (Figure, A)

There was a small focus of signal void on the T2-weighted images, suspicious for tiny calcification

On gadolinium administration, there was sequential increased enhancement on the postcontrast T1-weighted axial images (Figure, B and C)

Further imaging workup with single-proton emission computed tomography-CT (SPECT-CT) using technetium Tc 99m–labeled red blood cells (RBCs) demonstrated increased tracer pooling within the lesion (Figure, D)

A-C, Magnetic resonance imaging studies (axial views) of a teenager with an incidental masticator space lesion

D, Single-proton emission computed tomographic image (axial view) using technetium Tc 99m–labeled red blood cells demonstrating increased tracer pooling within the lesion


A woman in her 50s presented with dysphagia and frequent throat clearing

A right pyriform sinus mass was seen on fiber-optic laryngoscopy

Computed tomography (CT) and magnetic resonance imaging (MRI) confirmed the finding of a hypopharyngeal mass

The patient underwent an endoscopic laser excision

Immunohistochemical stains revealed tumor cells that were focally positive for myogenin and diffusely positive for desmin and myoglobin

An MRI scan obtained 1 month postoperatively demonstrated a persistent mass or swelling

The patient continued to experience dysphagia, globus, and a choking sensation when coughing

On fiber-optic examination, right pyriform sinus fullness was visualized

During operative laryngoscopy, no mass was identified

An interval MRI demonstrated a 2-cm soft-tissue mass in the cervical esophagus (Figure, A)

Using rigid suspension laryngoscopy, we identified a large, smooth-walled ovoid mass herniating from the cervical esophageal opening

A mucosal stalk anchored the mass to the lateral pyriform sinus wall

Endoscopic snare cautery was used to excise the mass

The tumor was well-defined, solitary, tan-red, and composed of sheets of large, round-to-polygonal cells with marked eosinophilic, granular cytoplasm (Figure, B)

Most tumor cells exhibited peripherally or centrally located vesicular nuclei with prominent nucleoli

Peripheral intracellular vacuoles indenting the cytoplasm were seen, which represent a processing artifact due to intracellular glycogen loss (Figure, C)

A, Axial contrast-enhanced spoiled gradient magnetic resonance image

B, Hematoxylin-eosin, original magnification ×20. C, Hematoxylin-eosin, original magnification ×40.


A man in his 50s presented with a facial mass growing over 1 year, with 28.5-kg weight loss due to poor oral intake

He reported a 44–pack-year smoking history and remote alcohol abuse

On physical examination he had a 10-cm right-sided facial mass extending under the auricle from the mastoid to the zygoma and inferiorly to the angle of the mandible

The mass was firm, mildly tender, but without overlying skin changes or cervical lymphadenopathy

Computed tomographic (CT) and magnetic resonance imaging (MRI) scans showed maxillary sinus compression with partial destruction of the zygomatic arch, mandible, and orbital floor (Figure, A and B)

The mass extended into the right pterygopalatine fossa, disrupting the floor of the middle cranial fossa and widening the foramen ovale

A core biopsy specimen revealed spindle cell proliferation with abundant collagen that stained focally with CD34, smooth muscle actin, and Bcl-2. The Figure, C, shows a gross pathologic image after excision of the mass

Histopathologic findings demonstrated spindle cells arranged in long fascicles with abundant interstitial collagen (Figure, D)

Tumor cells exhibited central, oval nuclei, and moderate amounts of pale-pink cytoplasm with indistinct borders

There was no increased or atypical mitosis, necrosis, or vascular invasion

Immunostaining demonstrated strong nuclear staining for β-catenin antibody and was positive for smooth muscle actin antibody, while stains for desmin, pan-keratin, S-100, CD34, and Bcl-2 antibodies were negative

A, Coronal computed tomographic scan of the mass

B, Postcontrast axial T1-weighted magnetic resonance image

D, Histopathologic image of excised tissue (hematoxylin-eosin, original magnification ×40)


A man in his 40s presented with sudden left-sided abdominal pain that was sharp, severe, and associated with emesis

He denied fevers, dizziness, or recent trauma

He had no notable medical or surgical history

He was well nourished, alert, and in no acute distress

Results of an abdominal examination revealed normoactive bowel sounds, no distention, but tenderness on the left side

Computed tomography (CT) of the abdomen and pelvis with intravenous contrast revealed a 12 × 13 × 11-cm left-sided adrenal mass (Figure 1)

Results of laboratory examination revealed plasma levels of metanephrines, normetanephrines, cortisol, renin, and aldosterone within reference limits


A man in his mid-20s with a history of alcohol abuse presented with abdominal pain after 3 days of drinking

He described the pain as a sharp, left upper-quadrant pain migrating to the epigastric region for 24 hours

The patient had a history of multiple episodes of hematemesis attributed to alcoholic gastritis

however, at this admission, he indicated he had not experienced vomiting

He admitted to early satiety over the past few months

Physical examination revealed a soft nondistended abdomen, but it was very tender in the epigastric region without rebound or guarding

Elevated results of liver function tests, as well as amylase and lipase levels consistent with alcoholic pancreatitis, were noted

Magnetic resonance imaging, computed tomographic imaging, and upper endoscopy findings are shown in Figure 1. Biopsy results of the mass were reported as normal gastric mucosa

A, Computed tomographic scan and magnetic resonance imaging (inset) demonstrating a heterogeneous mass lesion in the fundus and body of the stomach

B, Upper endoscopic image directly visualizing the mass intruding into the lumen of the stomach


A woman in her 70s with a medical history of hyperthyroidism, hypertension, and neuropathy was admitted to the hospital with a 6-day history of painful lesions involving both ears

Initially, the left ear developed very painful lesions that resembled bruises

Subsequently, her right ear became involved and developed similar lesions, but she denied any other areas being affected

She had recently been treated for a urinary tract infection with trimethoprim-sulfamethoxazole and levofloxacin

The lesions appeared while she was taking levofloxacin

however, on admission the antibiotic therapy was continued

Her other medications included propylthiouracil, amlodipine besylate, pravastatin sodium, solifenacin succinate, and gabapentin

On physical examination, the patient had localized retiform purpura on the right earlobe and bilateral helices that were tender to palpation (Figure, A)

Findings from laboratory tests, including a hypercoagulability workup, complete blood cell count, comprehensive metabolic panel, urinalysis, cryoglobulins, cytoplasmic antineutrophil cytoplasmic antibodies, and complement levels were all unremarkable

However, the test result for perinuclear antineutrophil cytoplasmic antibodies (p-ANCAs) was positive

A punch biopsy for histopathologic examination was performed (Figure, B and C)

B, Abundant red blood cell extravasation and fibrin thrombi (hematoxylin-eosin, original magnification ×10)

C, Leukocytoclastic vasculitis and fibrin thrombi (hematoxylin-eosin, original magnification ×40)


A woman in her 40s with a history of atopy presented with a 1-year history of asymptomatic red-brown patches on the distal extensor extremities

The lesions began on the bilateral lower legs and spread to the thighs, buttocks, hands, forearms, and proximal arms

Physical examination revealed numerous stellate red-brown patches without induration, scale, or ulceration (Figure, A)

Review of systems was notable for episodic muscle cramping and numbness involving the lower extremities

The patient had no notable recent medical illnesses, illicit drug use, or new medications

An incisional wedge biopsy was performed on a lesion from the lower extremity, and the specimen was stained with hematoxylin-eosin (Figure, B and C)

A, Stellate red-brown patches on the patient's right lower extremity

B, Specimen from a lower-extremity lesion (original magnification ×10)

C, Same specimen as shown in panel B but at higher magnification (×20)


A man in his 30s with no medical history of illness presented with a lesion of concern on his left scalp

The patient noted that the lesion had slowly enlarged over the preceding 5 years from when he first noticed it as a small bump

He denied a history of trauma prior to its development

The patient denied any spontaneous bleeding, crusting, or itching, and he was primarily concerned about its growth

There was no personal or family history of malignancy

On physical examination, the patient’s left frontal scalp revealed a mobile 1.2-cm mammillated, soft, brown plaque with protruding terminal hairs (Figure, A)

The remainder of the patient’s skin examination revealed no other concerning lesions

Dermoscopically, the lesion was characterized by irregular pigment globules, milialike cysts, and focal arborizing vessels (Figure, B)

A shave biopsy was performed for histopathologic examination (Figure, C and D)


A woman in her 50s was referred to a neurologist for a history of gait, balance, personality, and judgment changes over 4 years

Her family noted that her first symptoms appeared at age 55, with subtle gait dysfunction and then evident imbalance

By age 57, there was concern over progressive withdrawal from social interchange, personality changes, and impairment of judgment

By age 59, she was experiencing bouts of inappropriate out-of-context laughter and tears, inattention, daytime fatigue, and frank memory impairment

She developed visuoperceptive changes and difficulties using the television remote control device

She developed obsessive checking behaviors

She started having swallowing difficulties but nonetheless had unexpected weight gain

She developed progressively worse motoric problems, with stiffness, abnormal posturing, a left toe pointing upward, and falls

Her medical history was significant only for restless legs syndrome, hypertension, hyperlipidemia, myopia, and a deviated nasal septum

Her family history revealed that her father was alive and well at approximately age 90 years, and her mother had died at approximately age 80 years with a history of neuropsychiatric disease and gait change

There was no history of tobacco, excess alcohol, or recreational drug use

General examination findings were noncontributory

Neurological examination revealed abnormal mental status, with full orientation and good registration, concentration, digit span, and language function but with poor calculations and constructions (Figure 1A) and decreased short-term memory

Nonetheless, her Mini-Mental State Examination score was 28 of 30. Cranial nerve examination revealed some decreased upgaze and mild facial masking

Motor examination revealed rigidity and dystonic posturing in the left arm and leg, imbalance on gait, decreased arm swing, and retropulsion but no significant tremor

Sensory examination findings were normal

Reflex examination showed mild left hyperreflexia with an upgoing left toe

Blood and urine laboratory study results were within normal limits

Cerebrospinal fluid was unremarkable except for biomarkers that showed a mid-range β-amyloid 42 level of 530 pg/mL and normal total tau and phosphotau levels of 182 and 25 pg/mL, respectively

Magnetic resonance imaging of the brain was reported as unremarkable (Figure 1B)

Positron emission tomography (PET) imaging of the brain revealed right frontotemporoparietal hypometabolism with some sensorimotor sparing (Figure 1C), which was neither typical nor atypical of Alzheimer disease

Electroencephalography showed left frontotemporal sharp waves and slowing

She had continued progressive decline in cognition and motor function and died almost mute and bedridden in her early 60s after a 9-year course of illness

Constructional apraxia is seen in her copying of the top row template figures, with preserved writing in script

B, Brain magnetic resonance imaging at the time of presentation

The top panel shows selected sagittal T1-weighted images, and the bottom panel shows selected axial T1-weighted images

C, Brain positron emission tomography using fluorodeoxyglucose F 18 tracer in the axial plane

Frontal and temporal hypometabolism is seen, more marked on the right, with some apparent sensorimotor sparing bilaterally


Circumscribed juvenile pityriasis rubra pilaris

A healthy 7-year-old girl presented with a 2-month history of an itchy rash on her elbows, knees, hands, and feet

The patient was otherwise healthy with normal development and growth

She had no other medical problems and was not taking any medications

The rash started as small pink bumps on her knees and elbows, spreading to her hands and feet and progressively thickening

The patient’s history was otherwise unremarkable

she had no pets, had no recent travel outside the United States, and her vaccinations were up to date

On physical examination, the patient had well-defined, follicular, pink, scaly papules coalescing into thin plaques on her knees (Figure 1A), elbows, and dorsal hands and feet, as well as diffuse, marked orange-red hyperkeratosis and hyperlinearity of her palms with clear demarcation at the wrists (Figure 1B)

A, Well-defined follicular, pink, scaly papules coalescing into plaques on the patient’s knees

B, Marked orange-red hyperkeratosis of the patient’s palms

Initial treatment with hydrocortisone valerate cream, 0.2%, provided minimal improvement


A preteen boy presented with a 1-year history of right-sided nasal obstruction and a 4-day history of intermittent right-sided epistaxis following blunt trauma to the nose

The epistaxis occurred 3 to 4 times a day and resolved with pressure

He did not have facial pain, facial paresthesia, or visual changes

There was no family or personal history of bleeding disorders

Nasal endoscopy revealed a large, well-vascularized, polypoid mass filling the right anterior nasal cavity

A computed tomographic scan showed a right nasal cavity mass (4.5 × 1.7 cm) extending to the posterior choana with opacification and bony remodeling of the right maxillary sinus

The mass had heterogeneous intermediate signal intensity on T2-weighted magnetic resonance imaging (Figure, A)

The patient was taken to the operating room for biopsy and possible excision of the nasal mass

As the lesion was biopsied, there was brisk bleeding

However, the lesion was found to have a narrow pedicle of attachment and was resected in its entirety

The mass was based on the superior aspect of the nasal septum and cribriform plate

Hematoxylin-eosin stain showed a sheet-like proliferation of epithelioid and polygonal cells with pale eosinophilic granular cytoplasm and relatively uniform vesicular nuclei (Figure, B)

Branching, staghorn-like blood vessels were scattered throughout the tumor

The tumor cells stained positive for smooth muscle actin (Figure, C), muscle specific actin, Bcl-2, INI-1, and transcription factor E3 (Figure, D)

A, T2-weighted magnetic resonance imaging (MRI) scan of a right nasal cavity mass extending to the posterior choana with heterogeneous intermediate signal intensity

B, A sheetlike proliferation of epithelioid and polygonal cells with pale eosinophilic granular cytoplasm and relatively uniform vesicular nuclei (hematoxylin-eosin, original magnification ×40)

C, The tumor cells stained positive for smooth muscle actin (original magnification ×20)

D, The tumor cells stained positive for transcription factor E3 (original magnification ×20)


A young boy with mild developmental delay and autism presented with a 1-week history of progressive left periorbital swelling

His parents reported that he complained of left orbital pain just before they noticed the swelling, and he was treated with cold compresses with only slight improvement

He had never experienced these symptoms before

The patient had not experienced diplopia, change in visual acuity, nasal obstruction, change in oral intake, weight loss, recent upper respiratory infection, sick contacts, fevers, or chills

At the time of presentation, the patient was breathing comfortably and was afebrile

Findings from his head and neck examination were significant for a firm mass over the left zygoma and lateral infraorbital rim, 2 × 3 cm in diameter

The mass was nontender, nonerythematous, and fixed to the underlying zygoma and lateral infraorbital rim

Ophthalmology examination revealed intact extraocular movements, bilateral visual acuity of 20/50, and no evidence of afferent papillary defect

Computed tomographic (CT) images showed a round, soft-tissue mass with osseous destruction and erosion into the zygoma, infratemporal fossa, inferolateral orbit, and maxillary sinus (Figure, A and B)

Concern for orbital involvement prompted magnetic resonance imaging (MRI) of the maxillofacial region (Figure, C and D)

He was taken to the operating room the following day for open biopsy

A and B, Computed tomographic images of the maxillofacial region showing a round, soft-tissue mass

C and D, Magnetic resonance imaging (MRI) scans of the maxillofacial region

D, Postcontrast T1-weighted MRI scan, coronal view


Chondrodermatitis nodularis chronica helicis

A man in his 40s presented with a 2-year history of a few small painful nodules on both ears

The nodules were painful on touch, especially while the patient was sleeping in a lateral position

However, he used to wear a cap, which created pressure and friction on the upper part of both ears

On examination, the free border of the helix of both the ears showed a few dull red, dome-shaped, firm nodules 2 to 3 mm in size with central crusting (Figure, A)

No cervical lymphadenopathy was observed

One of the nodules on the right ear was excised

histopathologic features of the nodule are shown in the Figure, B

It showed a sharply defined, centrally depressed ulcer covered by a hyperkeratotic parakeratotic scale, occasional bacterial colonies, and plasma

The adjacent epidermis showed hyperplasia

The base of ulcer showed eosinophilic degeneration of collagen and solar elastosis

In addition, there were a few proliferating blood vessels and mild lymphomononuclear infiltrate

Underlying cartilage was not seen in the section

On serial sectioning, cartilage was seen and found to be normal

A, An ear with dull red, dome-shaped, firm nodules 2 to 3 mm in size with central crusting (arrowheads)

B, Histopathologic image (hematoxylin-eosin, original magnification ×100)


A healthy nonsmoking woman in her 30s presented with a 6-year history of a nontender mass on the right side of the inferior face, overlying the mandible

She first noticed the mass following an uncomplicated dental procedure

It grew slowly for a few years but then stabilized

She stated that it was sensitive to cold liquids but was otherwise asymptomatic

Results from routine laboratory tests and hematologic markers were normal

Examination revealed a roughly 4 × 2.5-cm, nontender, firm mass anterior to the right mandibular parasymphysis

The mass was fully mobile relative to the underlying mandible and could be seen bulging into the gingivolabial sulcus

There were no overlying skin or mucosal changes, and the skin and mucosa moved freely over the mass

Computed tomographic (CT) imaging demonstrated a well-defined, hyperdense, mildly heterogeneous mass with few focal areas of fat attenuation along the inferior aspect of the lesion (Figure, A-C)

The mass was separate from the right mandibular parasymphysis without evidence of periosteal reaction or erosion into the underlying bone

The surrounding soft tissues appeared unremarkable

The patient was taken to the operating theater, where a firm, multilobulated, yellow mass was excised through a gingivolabial incision (Figure, D)

The mass was not fixed to any adjacent structures

Axial views of soft tissue (A) and bony windows (B) demonstrating an ossified hyperdense mass within the right gingivobuccal space with well-defined margins

D, The intraoperative photograph shows the well-defined mass, just prior to removal, arising in the right gingivobuccal space, separate from the underlying mandible


Inflammatory demyelinating processes such as multiple sclerosis

Neoplasms such as multicentric glioma, glioblastoma multiforme, and metastases

Infectious causes including tuberculosis, neurosyphilis, and toxoplasmosis

A previously healthy woman in her 50s presented with complaints of increasing forgetfulness, fatigue, and depressed mood after dealing with the deaths of several close relatives

She was diagnosed with depression and began treatment with antidepressant medication

After 8 months, she had worsening complaints

At that time, a family member reported that her memory problems had progressed

She was no longer able to find misplaced objects, remember appointments, or handle financial affairs

She was often subdued, her mood depressed, and her sleeping time increased

Clinical examination at that time revealed a flattened affect and a 22 of 30 Mini-Mental State Examination score

Findings were otherwise normal, and there were no focal neurologic deficits

Basic laboratory workup results were unremarkable

She was referred to a neurologist, who ordered contrast-enhanced magnetic resonance imaging (MRI) of the brain

The MRI (Figure) revealed extensive ill-defined areas of FLAIR (fluid-attenuated inversion recovery) and T2 signal abnormalities with additional enhancing nodular foci located within deep white matter structures, the basal ganglia, the caudate, the pons, and the midbrain

Also identified was enhancement of the interpeduncular cistern and cerebral peduncles, suggestive of leptomeningeal involvement

Magnetic resonance images (MRIs) of the head obtained 8 months after patient’s first clinical visit

A, Axial T2-weighted MRI of the head at the level of the lateral ventricles demonstrates extensive ill-defined areas of increasing signal with only minimal associated mass effect involving the frontal lobe white matter, greater on the left than on the right

B, Contrast-enhanced T1-weighted MRI at the same level demonstrates abnormal patchy enhancement of the head of the left caudate nucleus and the deep anterior left frontal lobe white matter


Anterior thoracolumbar spinal cord herniation

A 36-year-old man presented with 2 weeks of episodic numbness and paresthesias in both feet, with symptom-free intervals between episodes

Episodes progressed in frequency and duration, occurring several times daily and lasting for hours

His symptoms were prominent after activity and reliably triggered by straining with urination and terminated by lying supine

The patient also reported a 1-week history of urinary retention requiring intermittent self-catheterization

Neurological examinations both during and between episodes revealed symmetric patellar and Achilles hyperreflexia with bilateral crossed adductor response, but otherwise the results were normal

A thoracic spine magnetic resonance imaging scan with fast imaging employing steady-state acquisition (FIESTA) sequences was obtained (Figure)

A dynamic computed tomographic myelogram demonstrated a lesion compressing the dorsal spinal cord at the T7 level (Video)

Magnetic resonance imaging (MRI) of the thoracic spine using fast imaging employing steady-state acquisition (FIESTA) sequences

The MRI scan with FIESTA sequences revealed a blurry spinal cord signal alteration at the T7-T8 level with deformation of the cord posteriorly (arrowhead)


A woman in her 60s presented to the emergency department with a 1-day history of abdominal pain

She reported acute onset of pain that woke her up from sleep, was crampy in nature, and was localized to the right upper quadrant

She denied any nausea or vomiting and there was no association with eating

She reported similar pain over the previous month but not to the current severity

There was no history of fevers/chills, diarrhea, melena, or hematochezia

Her medical history included hypertension and gastroesophageal reflux

Her only operations in the past were nononcologic, nongastrointestinal procedures

On examination, her heart and lungs were normal

Her abdomen was soft but tender in the right upper quadrant

Laboratory evaluation revealed a normal compete blood cell count, including a white blood cell count of 8900/µL (to convert to ×109 per liter, multiply by 0.001)

Results from a complete metabolic panel, including lipase, and from carcinoembryonic antigen and carbohydrate antigen 19-9 testing were normal

Ultrasonography revealed asymmetric thickening of the gallbladder wall without pericholecystic fluid

Computed tomographic scans of the abdomen with oral and intravenous contrast were obtained (Figure 1)

Computed tomographic scan with coronal (A) and sagittal (B) views showing a soft-tissue mass associated with the fundus of the gallbladder


An elderly woman of Bahamian heritage with Fitzpatrick VI skin type presented with a 1-week history of indolent papules all over her body

Findings from physical examination were notable for discrete skin-colored to pink papules coalescing into plaques on her face, trunk (Figure, A and B), and all 4 extremities

There was no scale or other epidermal change

A punch biopsy for hematoxylin-eosin staining was performed (Figure, C)

The patient returned 1 week later with worsening cutaneous eruptions and new complaints of fever, weakness, and malaise

Repeat physical examination revealed splenomegaly and axillary lymphadenopathy

A peripheral blood smear (Figure, D) and other diagnostic tests were performed

A, Discrete skin-colored to pink papules on the abdomen

B, Discrete papules coalescing into plaques on superior gluteal cleft

C, Punch biopsy specimen (hematoxylin-eosin)

D, Peripheral blood smear (hematoxylin-eosin, original magnification ×100)


A man in his 70s with a history of T2N2 melanoma, locally metastatic squamous cell carcinoma, and non-Hodgkin follicular lymphoma presented with weakness, a blistering erythematous eruption, and painful oral lesions of 1 month’s duration

On physical examination, the patient was in severe discomfort with limited movement owing to cutaneous pain

He was cachectic and had widespread erosions and tense and flaccid bullae with overlying crust affecting his trunk and extremities (including the palms and soles) but sparing his scalp (Figure, A)

He had severe stomatitis with localized hemorrhagic lesions, shaggy erosions on the buccal and gingival mucosa, and erythematous macules on his hard and soft palates (Figure, B)

Findings from laboratory tests, including a complete blood cell count and a comprehensive metabolic panel, were unremarkable except for mild anemia

Results from a computed tomographic scan of the chest and neck showed adenopathy suspicious for lymphoproliferative disorder or potentially metastatic disease

A punch biopsy for histopathologic examination (Figure, C) and direct immunofluorescence (DIF) was performed, and serum was tested for indirect immunofluorescence (IIF) on rodent epithelium (Figure, D)

A, Erosions, tense and flaccid bullae, and overlying crust over the dorsal side of the foot

B, Severe stomatitis and hemorrhagic crust

C, Histopathologic image of a biopsy specimen showing suprabasal acantholysis and a dermal infiltrate of lymphocytes, histiocytes, and scattered eosinophils (hematoxylin-eosin, original magnification ×20)

D, Positive indirect immunofluorescence test of rat urinary bladder epithelium


A woman in her 20s with a medical history significant for systemic lupus erythematosus (SLE) presented with tender erythematous nodules after undergoing right knee arthroscopy (Figure, A)

SLE had been diagnosed ten years previously after she presented with a positive antinuclear antibody titer (most recent titer, 1:1280), arthralgias, leukopenia, oral ulcers, and a malar erythematous eruption

There was no history of discoid or tumid lupus lesions

Initially, the lesions were thought secondary to soft-tissue infection and were treated with courses of clindamycin, vancomycin, and doxycycline

Physical examination revealed poorly demarcated erythematous plaques and nodules, tender to palpation, ranging from the distal thigh to the lower leg, adjacent to arthroscopy sites

Lesions around the suture sites appeared more violaceous

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

A, Clinical photograph of right knee demonstrating ill-defined erythematous plaques and nodules adjacent to 2 small incisional scars from previous arthroscopy

B and C, Photomicrographs of punch biopsy specimen

B, Hematoxylin-eosin, original magnification ×4. C, Hematoxylin-eosin, original magnification ×10.


A 7-year-old girl presented to the dermatology clinic with a 4-week history of progressive nail changes

Her mother reported a sudden onset of brittle nails with cracks followed by painless sloughing of nails

Initially only the fingernails had been affected, but the toenails soon showed the same pathology

The family was concerned and suspected an internal disease or vitamin deficiency

The child was otherwise well and no previous skin or nail conditions were known

On clinical examination, most fingernails showed semilunar whitish grooves in the middle of the nail plate (Figure, A)

The toenails had transverse partial cracks of the proximal nail plate with distal onycholysis but normal proximal nail growth (Figure, B)

A, Fingernails showed semilunar whitish grooves in the middle of the nail plate

B, Toenails had transverse partial cracks of the proximal nail plate with distal onycholysis


A man in his 50s presented with a 7-month history of worsening, primarily left-sided, sinus obstruction and congestion with associated hyposmia, facial pressure, and headaches

He had no history of sinus disease or surgery and had no epistaxis, weight loss, or visual symptoms

Computed tomography showed a 3.1-cm mass in the left ethmoid sinus and nasal cavity (Figure, A)

Positron emission tomographic scanning showed no evidence of metastasis

Nasal endoscopy revealed a friable, polypoid mass in the ethmoid sinus with extension into the nasal cavity and superiorly to the skull base

A biopsy specimen showed a heterogeneous tumor with small, angulated, blue cells with hyperchromatic nuclei, apoptosis, and mitosis, malignant glands lined by cuboidal cells with round nuclei, prominent nucleoli, and eosinophilic cytoplasm

The glands had luminal mucin production (Figure, B)

Focally, there were also scattered round cells with abundant eosinophilic, refractile cytoplasm, features of rhabdomyoblasts (Figure, C)

These latter cells were strongly positive for desmin (Figure, D) and myogenin

B, Blastema as indicated by the asterisk and malignant glands as indicated by the arrowhead

C, Rhabdomyoblasts as indicated by the arrowheads (hematoxylin-eosin, original magnification ×40)

D, Desmin immunohistochemistry with strong positive staining in the rhabdomyoblasts (original magnification ×20)


Respiratory epithelial adenomatoid hamartoma

A woman in her 50s presented with an 8-week history of increasing headache, hyposmia, hypogeusia, and nasal congestion

Endoscopic nasopharyngoscopy revealed a large polypoid nasal mass occupying the left nasal roof and completely obstructing the nasal passage

Contrast-enhanced T1-weighted magnetic resonance imaging (MRI) revealed a 1.7 × 3.5 × 2.6-cm soft-tissue mass within the left ethmoid cavity, eroding through the cribriform plate with adjacent dural enhancement (Figure, A)

Intraoperative pathologic examination showed polypoid spindle cell proliferation

Histopathologic findings showed respiratory epithelium with submucosal vascular proliferation with no atypia among the lining endothelial cells

The Figure, B, shows a central vessel surrounded by lobules of endothelial lined capillaries

The Figure, C, highlights the endothelial cells of the numerous capillaries and the central vessel

A, Contrast-enhanced T1-weighted magnetic resonance imaging of a soft-tissue mass within the left ethmoid cavity

B, Central vessel surrounded by lobules of endothelial-lined capillaries (hematoxylin-eosin, original magnification ×20)

C, Endothelial cells of the numerous capillaries and the central vessel on CD34 staining (original magnification ×20)


Diffuse idiopathic skeletal hyperostosis

A woman in her 60s presented with a 10-year history of oropharyngeal discomfort and recent episodes of snoring and obstructive sleep disturbance

Although she had been experiencing a gradually increasing lumpy feeling on swallowing for at least 6 months, she did not experience of dysphagia, dyspnea, or pain

Physical examination revealed a mass measuring approximately 4 × 3 cm and covered with normal mucosa on the posterior oropharyngeal wall

This tumor was firm, nontender, and firmly adherent (Figure, A)

Computed tomography (CT) showed a segmented bony lesion located at the odontoid process and the body of the C2 vertebra (Figure, B)

This mass showed high signal intensity with a hypointense rim in both T1- and T2-weighted magnetic resonance images (MRI) (Figure, C and D, respectively)

Polysomnography was performed and showed an apnea-hypopnea index of 58.7/h and a minimal oxygen saturation of 76%, which led to a diagnosis of obstructive sleep apnea

The mass was considered causative of obstructive sleep apnea

Hence, we performed total excision of the mass using a per-oral approach

B, Computed tomographic image showing a segmented bony lesion located at the odontoid process and the body of the C2 vertebra

C, T1-weighted magnetic resonance image (MRI) of an oropharyngeal mass

D, T2-weighted MRI of an oropharyngeal mass


A teenage girl presented with a 3-month history of a gradually enlarging soft palate mass associated with a change in her voice

She had no associated pain, difficulty swallowing, or difficulty breathing

She was otherwise healthy, with no medical or surgical history

Findings from her physical examination were unremarkable with the exception of a 2 × 2-cm firm, nontender, submucosal posterior soft palate mass just left of the uvula

There was no overlying ulceration or discoloration

Prior to presentation, a computed tomographic scan and biopsy had been performed at an outside hospital

Magnetic resonance imaging (MRI) of the face with contrast was also performed (Figure, A-C)

Imaging showed a well-circumscribed solid lesion with no evidence of infiltration of soft-tissue structures, the pterygopalatine fossa, or palatine nerve foramina

The lesion was resected via a transoral approach and was easily dissected from the surrounding tissue (Figure, D)


A man in his 60s presented for further evaluation of a right inguinal and scrotal lesion (Figure 1)

The rash initially started 4 years prior as a dime-sized, pink, scaly area in the right inguinal crease and was pruritic

Results of a biopsy at the time were consistent with lichen simplex chronicus, and treatment with topical steroids was initiated

Since then, the rash had failed to resolve and the affected area had increased in size to its present dimensions

The patient had a history of prostate cancer treated with prostatectomy 4 years previously without evidence of recurrence and melanoma of the posterior neck treated with wide local excision, in addition to non–insulin-dependent diabetes mellitus and hyperlipidemia controlled with oral medications

He does not smoke and has been in a monogamous marriage for more than 30 years

Examination revealed a multifocal scaly, pink-red beefy plaque in the right inguinal crease extending from the superior aspect of the scrotum to the gluteal crease measuring approximately 6 × 7 cm in total area with some areas of excoriation and superficial open wounds

An additional area of macular erythema extended superiorly along the inguinal crease toward the medial thigh

No lymphadenopathy of the inguinal region was noted


A man in his 50s who previously underwent renal transplantation for polycystic kidney disease presented with worsening chronic malaise, fatigue, dyspnea, early satiety, and abdominal distention with extreme discomfort

An abdominal magnetic resonance image is shown in Figure 1A

Given the symptoms and magnetic resonance imaging findings, the patient was eventually taken to the operating room

Laparotomy exposed a giant multinodular mass (Figure 1B)

B,Intraoperative photograph of the giant multinodular mass occupying most of the upper abdomen


A woman in her 30s  was referred for evaluation of a large splenic cyst identified on a computed tomographic (CT) scan

She had previously lived in Beijing, China

In 2011, she was evaluated in a Chinese clinic for abdominal bloating and moderate left upper quadrant pain

she was offered a splenectomy, but she declined and pursued a second opinion at a hospital in the United States in 2012. During that evaluation, the patient reported that she had run in areas with dog feces on the ground and had eaten sheep meat (notably, not organ meat)

Results of serologic tests for Echinococcus antibody IgG were negative

Results of a CT scan were remarkable for a 9.7 × 9.0 × 10.5-cm anterior cyst and a smaller posterior cyst measuring 4.6 × 4.7 × 3.8 cm, both with rim calcifications (Figure 1)

A large splenic cyst with calcified capsule is present in the anterior aspect of the spleen, with a smaller cyst in the posterior aspect of the spleen, also with calcified capsule

Arrowheads indicate the location of the cysts

Under higher resolution, debris is noted within the larger cyst


Fibrosis and ulceration caused by meperidine

A white man in his 30s with a 7-year history of severe, mechanical, low back pain and long-standing mental depression was referred to the dermatology department for evaluation of an asymptomatic cutaneous ulcer that had developed over the past year

Physical examination disclosed a large and deep, irregularly shaped, cutaneous ulcer on the dorsum of his right forearm

Necrotic tissue and muscle exposure was seen at the base of the ulcer (Figure, A)

Woody induration of skin on both forearms and on the abdominal region was also observed

Bilateral contracture of deltoid, triceps, and biceps muscles was noted

Active and passive range of motion was restricted at the shoulders and elbows

No signs of joint inflammation were seen

At the time of consultation, the patient was taking oral treatment with duloxetine hydrochloride, clonazepam, oxcarbazepine, fentanyl, sulpiride, zopiclone, omeprazole magnesium, and baclofen

He also admitted to self-administering subcutaneous injections of meperidine, 100 mg 4 times per day, for the past 3 years, at different sites, including the deltoid areas and abdomen

Growth from culture specimens taken from the ulcer was negative for bacteria, mycobacteria, and fungal organisms

His serum creatinine kinase level was raised (192 U/L

reference range, 0-174 U/L), but test results for complete blood cell count

antinuclear antibody, rheumatoid factor, aspartate aminotransferase, alanine aminotransaminase, and aldolase levels

and serum electrophoresis were all within normal limits

A wedge biopsy from the indurated skin of the abdominal region was performed (Figure, B and C)

(To convert creatinine kinase to microkatals per liter, multiply by 0.0167.)A, Clinical photograph of the large, deep, irregularly shaped, cutaneous ulcer on the dorsum of the right forearm

Three small ulcers are seen adjacent to the larger ulcer

B and C, Histologic images of a wedge biopsy specimen from the indurated skin of the abdominal region (hematoxylin-eosin)

B, Original magnification ×10. C, Original magnification ×40.


A man in his 60s presented with a slowly enlarging, painful mass on his buttock

He recalled that a small lesion had appeared approximately 8 months prior, and over the past several months he had noted significant growth and pain

A nonpruritic rash had also become apparent on his forearms and thighs

Physical examination showed a 2-cm macerated pedunculated growth on the left buttock within the intergluteal cleft (Figure, A)

An erythematous rash was noted on the forearms and thighs with fine scale present at the wrists

A, Photograph of a 2-cm macerated pedunculated growth on the left buttock

B, Histopathologic image of an exophytic growth on the buttock with marked epidermal hyperplasia (hematoxylin-eosin, original magnification ×40)

C, Histopathologic image of immunohistochemical staining for spirochetes (original magnification ×400)

A shave biopsy specimen of the exophytic growth on the buttock revealed marked epidermal hyperplasia (Figure, B) with a dense dermal infiltrate containing lymphocytes and plasma cells


A 40-year-old man, who resided in the eastern part of India, was referred to us from the department of otorhinolaryngology for evaluation of a nonhealing ulcer on the tongue present for the last 4 months

The lesion had started as a small painless mass on the right lateral aspect of the tongue, which gradually grew and subsequently ulcerated

It was asymptomatic except for causing mild difficulty in eating

The patient could not recall any history of trauma or tongue bite preceding the lesion

He denied consuming tobacco or alcohol regularly

He had type 2 diabetes mellitus for 2 years, which was well controlled with oral hypoglycemic agents

There was no history of high-risk behavior for human immunodeficiency virus (HIV) acquisition

On physical examination, there was a single well-defined ulcer measuring 2 × 2 cm on the right lateral aspect of tongue with a clean base and irregular and elevated heaped-up margins (Figure 1A)

There was no underlying induration, friability, or bleeding on manipulation

A 3-mm punch biopsy from the edge of the ulcer was taken and sent for histopathological examination (Figure 1B and C)

B, Biopsy from the ulcer showing a mixed cell infiltrate (hematoxylin-eosin, original magnification ×40)

C, Intracellular yeast forms within the histiocytes  (original magnification ×100)


Following 2 days of cough and congestion, an otherwise healthy full-term 5-week-old neonate developed difficulty breathing and apnea requiring cardiopulmonary resuscitation

He was transported to a local emergency department

Following a difficult orotracheal intubation with multiple attempts, the infant was transferred to a pediatric intensive care unit with a presumptive diagnosis of bronchiolitis

During the next 2 days, he was weaned off mechanical ventilation and received oxygen via the nasal cannula

He began feeding orally and was transferred to the general inpatient floor

At the time of transfer, the patient was noted to have choking with feeds as well as a large volume of clear oral secretions that required frequent suctioning

Based on these clinical findings, oral food and fluids were withheld from the patient and a fluoroscopic video swallowing study (FVSS) was performed (Figure 1 and Video)


A woman in her 60s presented to the hospital because she felt abdominal pain and increasing asthenia during the previous 4 months

She reported a weight loss of 40 kg during the previous 12 months concomitant with depression

The patient had a history of cardiac arrhythmia, hypertension, and sigmoidectomy for diverticulitis

Medications included lasilix, amlodipine, amiodarone, and atenolol

On examination, the patient appeared well

Her white blood cell count was 11400/μL (to convert to ×109/L, multiply by 0.001), her hemoglobin level was 11.5 g/dL (to convert to g/L, multiply by 10.0), and her platelet count was 233 ×103/μL (to convert to ×109/L, multiply by 1.0)

The C-reaction protein level was elevated to 41 mg/L (to convert to nmol/L, multiply by 9.524)

The results of renal and liver function, coagulation, blood level of electrolytes, total protein, albumin, antigen carcino embryonnaire, carbohydrate antigen 19-9, carbohydrate antigen 125, and β2 microglobulin tests were normal

The patient had a normal esophagogastroduodenoscopy and colonoscopy

Ultrasonography revealed a 10 × 8-m mass in the right hypochondrium

Abdominal computed tomography scan revealed a thickened gallbladder wall infiltrating the liver parenchyma

Magnetic resonance imaging showed a greatly enlarged gallbladder with a thickened wall without invading adjacent structures, a continuous mucosal line, and a hypoattenuated intramural nodule (Figure 1)


A 2-day-old girl (weight, 3.7 kg) developed abdominal distention and vomiting after feeding

Her Apgar scores at 1 and 5 minutes were 7 and 9, respectively

The infant’s postnatal course was remarkable for a febrile episode that was presumed to be due to chorioamnionitis in the mother and for which antibiotic treatment was initiated

Findings from the prenatal ultrasound, most recently conducted at 33 weeks’ gestation, were normal

The infant was active and well perfused, with a soft but distended abdomen and right-sided labial swelling

Findings from the remainder of her examination were unremarkable

An abdominal radiograph revealed dilated small-bowel loops (Figure 1A)

Radiography of the upper gastrointestinal tract with water-soluble contrast showed a normal pattern of rotation

Results of a suction rectal biopsy revealed ganglion cells to be present

Serial abdominal radiographic images showed retained contrast in the terminal ileum 6 days following the gastrointestinal series (Figure 1B)

A, Abdominal radiograph showing distended small-bowel loops with absent gas in the colon and rectum

B, Delayed radiography of the upper gastrointestinal tract with water-soluble contrast demonstrating retained contrast in the terminal ileum 6 days after initial radiography


A healthy 60-year-old woman presented with a painless subareolar nodule of her left nipple measuring 2 cm in diameter (Figure, A) that had been present for several months

Screening mammography (Figure, B) performed 4 weeks prior revealed a large grouping of left breast subareolar calcifications extending into the skin and nipple

Follow-up ultrasonography demonstrated no discrete abnormal mass or shadowing but did show multiple echogenic foci consistent with findings on mammography

An incisional biopsy specimen of the mass was obtained and sent for histopathologic evaluation (Figure, C)

A, Firm, irregular, subareolar nodule of left nipple measuring 2 cm in diameter

C, Biopsy specimen of the subareolar nodule (hematoxylin-eosin, original magnification ×20)


Epidermolysis bullosa simplex superficialis

A 2-year-old girl was referred to our department for skin fragility since early infancy

She had 2 older brothers, and the family had no medical history of note

Physical examination revealed mild xerosis with superficial skin erosions and erythematous residual macules from previous erosions

Some of the lesions had an unusual linear geographic contour and were predominantly located at areas of friction (Figure, A and B)

Hair, nails, and mucous membranes were normal

The mother explained that she often found the child peeling off skin with marked facility

Symptoms improved in winter and worsened in summer

Physical and mental developments were normal

Serological markers for celiac disease were negative

A, Clinical photograph of a disease outbreak

Skin fragility can be seen as superficial erosions distributed predominantly around the trunk, some with geometric shape

B, Photograph showing localized affectation of the disease

Erythemato-desquamative well-demarcated plaque with peeling borders on right foot

C, Hematoxylin-eosin staining (original magnification ×40) of healthy skin

Remarkable detachment of the entire stratum corneum and mild psoriasiform epidermis hyperplasia with no other significant findings


Acute lymphoblastic leukemia of the breast

A healthy woman in her 40s, lactating, 5 months post partum, presented with a 1-month history of enlargement and induration of both breasts (Figure, A)

A skin biopsy specimen from the breast was obtained (Figure, B)

She was initially diagnosed with mastitis and received several courses of antibiotics for 2 months without improvement

Subsequently she presented with back pain, paresthesias, shooting pain in the mandibular region, and diplopia

All of these conditions improved under treatment with oral corticosteroids, but the breast enlargement continued

Laboratory test results highlighted a hemoglobin level of 7.6 g/dL and a platelet count of 80 000/μL

(To convert hemoglobin to grams per liter, multiply by 10

to convert platelets to number of cells × 109/L, multiply by 1.0.)A, Enlargement and induration of both breasts

B, Histopathologic specimen from the breast (hematoxylin-eosin, original magnification ×40)


A previously healthy 8-year-old boy presented to the emergency department for evaluation of a large, tender scalp nodule

One month prior to presentation, the patient’s mother noticed multiple annular, scaly patches on the patient’s scalp and upper back

Both of the patient’s brothers developed similar patches

Two weeks before presentation, the area on the scalp grew in size, becoming a tender nodule with yellow suppurative discharge

Results of the physical examination were notable for a somewhat tired-appearing boy with a 6-cm tender, red nodule on the right frontal scalp (Figure 1)

The nodule had a boggy consistency and thick yellow crust and was draining yellow material

There was no hair within this area on the scalp

On the patient’s right upper back was an annular scaly patch

significant posterior auricular and cervical lymphadenopathy was noted bilaterally

View on presentation of a boggy, erythematous nodule with suppurative discharge and loss of hair