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Diagnostic Dilemma
Above the Threshold Time of Coagulation: Delayed Diagnosis of Acquired Hemophilia A
A man in his 80s presented to our hospital's emergency department with left hip pain after falling while transferring from a wheelchair on a visit day. He had been taking clopidogrel for >10 years after atherothrombotic stroke and apixaban 2.5 mg twice a day for 2 years since he was diagnosed with deep vein thrombosis. The patient had no coagulation abnormalities when he started apixaban therapy and had never experienced bleeding events. His medical history included cervical spondylosis surgery, right femoral neck fracture, hypertension, and benign prostatic hypertrophy.Fever of Unknown Origin Secondary to Pulmonary Histoplasmosis in Scleroderma-Related Interstitial Lung Disease
A Caucasian male in his mid-50s presented to a community hospital in fall 2020 with a 1-month history of nonproductive cough, nausea, vomiting, chills, and nightly fevers greater than 40°C with associated diaphoresis. His past medical history included limited-cutaneous systemic sclerosis (Lc-SSc) diagnosed 5 years prior, SSc-related interstitial lung disease (SSc-ILD), dyslipidemia, osteoporosis, nephrolithiasis, and gastroesophageal reflux. His interstitial lung disease was diagnosed 2 years prior to presentation, and he was responding well to mycophenolate mofetil and oral low-dose prednisone daily.Bacteremia, Liver Injury, and Pneumonitis: Strongyloides Unleashed by a Supplement
A 51-year-old woman presented with 2 weeks of fevers and postprandial abdominal pain. The symptoms began insidiously and were accompanied by nausea, vomiting, headache, and dizziness. Review of systems was also notable for joint pain in her hands and feet for the past year. She had otherwise been well, and had no diarrhea, urinary symptoms, skin complaints, cough, dyspnea, or focal neurologic symptoms. She had hypertension and diabetes and took metformin and lisinopril. She was originally from Mexico but had lived in Houston, Texas for years without traveling.Clear and Bright: An Elusive Cause of Hypoxemia
A 54-year-old previously healthy woman was hospitalized with progressive shortness of breath and hypoxemia.It All Depends: A Case of a Position-Dependent Intracardiac Shunt
An 87-year-old woman presented to clinic for evaluation of knee pain. On arrival, vital signs showed oxygen saturation (SpO2) of 87%-88% on room air. She had no chest pain or dyspnea and had ambulated to the clinic without assistive devices or resting. Medical history included hypertension, acid reflux, and incompletely treated latent tuberculosis. Home medications included losartan and omeprazole. Her hypoxia persisted on multiple rechecks, and she was placed on supplemental oxygen (O2) and referred to the emergency department (ED).Not Your Typical Hemorrhagic Pleural Effusion
A 36-year-old white man with a 20 pack-year smoking history, childhood asthma, and previous heavy alcohol use presented with progressive dyspnea on exertion and chest tightness for the past month. He lived in the Los Angeles area, but frequently hiked in the Southern California area, including twice in the past year around Bakersfield, and after one trip about 9 months prior, noted a febrile illness that he felt may have been related to an insect bite. He was seen in our Emergency Department with a low-grade fever (T = 38.06°C [100.5°F], tachycardia to 142 beats per minute) and sharp right-sided head pain.Hyperfibrinolysis: An Uncommon Cause of Bleeding in Cirrhosis
A 57-year-old man with past medical history of alcohol use disorder and cirrhosis presented with right leg pain after a fall at home. Imaging revealed a large right thigh hematoma, and he underwent placement of a Jackson-Pratt (JP) drain by interventional radiology. The hematoma began draining about 100 mL of serosanguineous fluid per day. Laboratory studies showed a hemoglobin of 10.0 g/dL, platelets of 113 k/cm2, international normalized ratio (INR) of 1.5, total bilirubin of 3.8 mg/dL, aspartate transaminase (AST) of 79 IU/L, alanine transaminase (ALT) of 20 IU/L, and alkaline phosphatase (ALP) of 170 IU/L.Miliary Tuberculosis in an Immunocompetent Male with Central Nervous System Involvement
The patient was a 51-year-old male from Mexico with no known significant past medical history who presented with several weeks of intermittent fevers, chills, night sweats, headaches, and weight loss. The headaches, fevers, chills, and night sweats had begun 2 months prior to this admission. One week prior to this admission, he had presented to another institution with a chief complaint of persistent headaches. At the outside hospital, the patient was found to have a positive Quantiferon Gold test.A Cerebrospinal Case of Dyspnea
A 63-year-old male presented to the emergency department of our hospital with a 1-week history of new onset of dyspnea. His past medical history was remarkable only for a recently diagnosed prolactin producing pituitary macroadenoma discovered during an emergency department visit for mild coronavirus disease (COVID-19) infection. He was being followed in the ambulatory endocrinology clinic for workup and had recently been started on oral cabergoline for treatment.More Than Meets the Eye: A Patient with Hand Swelling and Newly Diagnosed Diabetes Mellitus
The patient is a 72-year-old man with known history of hypertension on amlodipine and losartan. He presented to the hospital with bilateral hand pain and swelling, as well as bilateral shoulder pain and stiffness with restricted range of motion, of 2 weeks duration. The swelling was initially asymmetric and worse over the right hand, although there was no preceding trauma or fall, and no fever or infective symptoms.Facial Swelling and Pancytopenia: First Features and Clues to the Etiology of Acute Kidney Injury.
A previously healthy 45-year-old woman presented with facial swelling, abdominal bloating, and fatigue.Intravascular Large B Cell Lymphoma as a Cause of Multifocal Cryptogenic Stroke
The patient was a 66-year-old female with a history of left-sided breast cancer with prior lumpectomy and radiation, thyroid cancer status post-thyroidectomy who presented to the emergency department for difficulty finding words. She had unremarkable findings on computed tomography (CT) brain and electroencephalogram (EEG) testing. Three months later, she developed bilateral lower extremity weakness and was admitted to a local hospital. Bilateral embolic strokes were discovered on brain magnetic resonance imaging (MRI).Troubling Tenosynovitis: When a Serious Sign Persists
A 42-year-old woman was admitted to the hospital with 5 days of diffuse joint pain and swelling associated with prolonged morning stiffness and intermittent fevers up to 38.7°C. The review of systems was negative for rashes, mouth sores, pleuritic chest pain, alopecia, dysuria, vaginal discharge, diarrhea or vomiting, cough or shortness of breath, recent travel, sick contacts, or tick exposure. Her medical history was significant for a 2-year history of an undifferentiated connective tissue disease, which presented with inflammatory arthritis, palpable skin rashes (biopsy showed immunoglobulin G and immunoglobulin M granular deposition along the basement membrane zone, suggestive of a connective tissue disease), positive antinuclear antibodies, positive SS-A and SS-B, low total complement, low C3 and C4, and positive rheumatoid factor with negative anticyclic citrullinated peptide antibodies.An Elusive Case of Recurrent Gram-Negative Sepsis
An 85-year-old man was admitted to the hospital for evaluation of recurrent fever and chills.Paraneoplastic Thrombocytopenia
A 56-year-old man with a history of lisinopril-induced liver injury status post liver transplant 12 years prior, calcineurin inhibitor nephrotoxicity status post kidney transplant 2 years prior, and chronic BK viruria presented to the Emergency Department for evaluation of isolated thrombocytopenia. He was in his usual state of health when a complete blood count 3 weeks prior to presentation revealed a platelet count of 121,000/mm3. Previous platelet counts had been within normal limits, with a platelet count of 146,000/mm3 8 weeks prior to presentation.A Case of Paraneoplastic Pemphigus with Follicular Dendritic Cell Sarcoma
A 42-year-old female presented with an 8-week history of progressive generalized rash and mucocutaneous ulcers associated with 50-pound weight loss. She had no personal or family history of autoimmune disease. No recent illness or change in medications before the onset of her rash.A 77-Year-Old Man with Multiple Myeloma and a Lytic Bone Lesion
A 77-year-old patient with multiple myeloma and on lenalidomide developed a slowly progressive right upper thigh pain with no antecedent trauma. The status of his multiple myeloma was stable, and he did not have a history of osteolytic lesions. He had not received corticosteroids as part of his multiple myeloma therapy. He was found to have a right proximal femur lytic lesion (Figure 1) and received local radiation therapy for 2 months; however, the lytic lesion increased in size, associated with worsening pain and affecting his mobility and ability to carry his daily activities.An Intelligent Diagnosis: SMART Syndrome
A 92-year-old woman presented to the Emergency Department with a 10-day history of right-sided headache, confusion, and episodic head turning to the left side that was associated with spontaneous laughter and apparent visual hallucinations. Her family also noted her to be inattentive to her left side. She had been seen in the Emergency Department 3 days prior for the same symptoms, but discharged home after a computed tomography (CT) scan of the head without contrast did not demonstrate any acute abnormalities.Gaucher Disease and Heart Failure of Unknown Origin
A 46-year-old white woman, diagnosed with Gaucher disease type 1 at age 4, presented with a 6-year history of progressive shortness of breath, exercise intolerance, dizziness, and palpitations.Investigating Liver Masses in Young Adults
A previously healthy 33-year-old man presented to the Emergency Department with acute onset epigastric pain on a background of binge drinking and recreational cocaine use approximately once per week.Diagnostic Difficulties in Treating a Typical Case of a Patient Being a Doctor
A healthy 30-year-old Japanese colleague presented to the emergency department complaining of fever for 12 hours, shivering, and abdominal pain after vomiting. Two days prior, his wife and child had vomiting and diarrhea, and both were diagnosed with infectious gastroenteritis. A day prior, he had eaten sushi.Lessons Learned From a Young Lady With a Bad Sore Throat
A 19-year-old Caucasian woman presented in mid-August 2018 to an Ohio hospital with a 10-day history of severe persistent sore throat. She had recently worked as a camp counselor at Martha's Vineyard. She had 2 prior emergency department visits in Massachusetts for acute onset of sore throat, fever, and abdominal pain. She presented with pharyngeal erythema, which progressed to pharyngeal exudates. She was treated with amoxicillin for bacterial pharyngitis. Despite completion of treatment, symptoms worsened.Progressive Dyspnea and Pleural Effusion—When the Answer Lies Buried in the History
A 65-year-old Caucasian male with past medical history of prostate cancer status post prostatectomy presented to his primary care provider's office with 1 month of progressive cough, dyspnea upon exertion, and fatigue. The patient was training for a marathon and had noticed a progressive decline in his exercise function and endurance. He is a lifetime non-smoker.A Peculiar Phenotype Hindering Early Diagnosis: Multiple Endocrine Neoplasia 2B Syndrome
A 28-year-old Chinese man presented to the Emergency Department (ED) with acute onset of abdominal distension, generalized abdominal pain, and repeated vomiting. There was no fever, diarrhea, or gastrointestinal bleeding. He reported chronic constipation requiring ED attendance 5 years prior due to abdominal distension and nausea, but his bowel habits had not changed recently.A Red, Painful, and Swollen Foot Overlying a Bone Erosion
A 67-year-old man presented with 3 days of intense pain, redness, and swelling of the left fifth toe, which had been extremely troubling (Figure 1). There was no antecedent trauma, insect bite, or change in medication. He denied fever, chills or walking barefoot. He had known hypertension and vitamin D deficiency. As a child, he was diagnosed with psoriasis; skin lesions intermittently recurred into adulthood. Both his parents had gout and a grandfather had psoriasis.Generalized Erythroderma with Fever
A 74-year-old disabled woman with multiple sclerosis, complicated by chronic lower extremity weakness precluding ambulation, presented with fever (maximal temperature was 39.3°C), hypotension, and a diffuse, erythematous rash. Her symptoms began with focal redness overlying her chest. Over the next 2-3 days, the rash spread to involve her trunk, arms, palms, buttocks and legs, sparing only her face, conjunctiva, and oral and vaginal mucosa. The skin eruption was pruritic. She reported associated chills and wheezing.Unusual Presentation of Hepatitis E with Autoimmune Hemolytic Anemia: A Case Report
Hepatitis E virus infection affects almost 20 million individuals worldwide annually and causes acute liver injury in 3.5 million, with approximately 56,000 deaths. Like other viral hepatitis infections, it is also associated with extrahepatic complications and several autoimmune phenomena (cryoglobulinemia, glomerulonephritis, systemic lupus erythematosus, and arthritis).Fisherman's Dilemma: Disseminated Mycobacterium marinum in an Immunosuppressed Patient
A 54-year-old man with a history of ankylosing spondylitis on treatment with infliximab presented with a 6-month history of progressive skin lesions. The initial lesion developed as a single nodule on the right leg following an abrasion while fishing for oysters in fresh water. Four months later, the lesions abruptly spread to involve the remainder of his trunk and extremities. Additionally, the patient reported developing intermittent fevers, night sweats, and painful swelling in his hands and wrists, as well as a dry cough.Adrenal Incidentaloma: Nothing Is Ever as It Seems
A 58-year-old female patient with cholelithiasis was referred for abdominal ultrasonography in January 2017. The ultrasonography revealed a large left adrenal tumor. The size of the lesion was 65 × 47 mm. High-resolution computed tomography (CT) was then performed. It showed a well-circumscribed left adrenal mass (RECIST: 64 mm) with fat stranding. The radiation attenuation coefficient was 27 Hounsfield units. After intravenous administration of contrast media, the tumor showed slight enhancement to 37 Hounsfield units, resulting from partition reinforcement.Beware of Perianal Pain: Fournier Gangrene
A 69-year-old Japanese man without significant comorbidities experienced anal pain 5 days before he was initially examined. Although he had been aware of a 5-mm perianal mass for a long time, he had ignored it because it had not caused any issues. Subsequently, he developed a fever of 38°C, his perianal pain worsened daily, and he was seen at our hospital's emergency department. He did not have any urinary symptoms and denied recent sexual intercourse. There was no significant family history.A Patient With Recurrent Respiratory Distress and Joint Pain
A 39-year-old male presented with 1 week of constant progressive dyspnea, associated with productive cough and anterior chest pain that worsened with breathing. The sputum was clear. He reported multiple similar episodes in the past that started during adolescence. These episodes required hospital admissions that lasted 1 or 2 weeks and improved with oxygen, a systemic steroid taper, and antibiotics. He carried the diagnosis of chronic obstructive pulmonary disease (COPD) based on symptoms and occasional tobacco use.Fibrosis, Thrombosis, and Dacrocytosis: An Unusual Case of Male Systemic Lupus Erythematosus
A 39-year-old Caucasian male with no prior history of chronic disease, with recently diagnosed Raynaud phenomenon, and a prior hospitalization for sepsis of unknown etiology presented with abdominal pain. His chief complaints included weakness, fatigue, dizziness, and left flank pain. His weakness and fatigue started 1 week prior to presentation and increased in severity. In addition, abdominal and left flank pain increased in severity over the preceding few days. On the day of presentation, he was somnolent at a social gathering and became pale when family members urged him to seek medical attention.Blue Toes at High Altitude: Peripheral Cyanosis
At altitudes >2500 m, acute mountain sickness is usually self-limiting, presenting with hypoxia and pulmonary edema.1 Chronic mountain sickness results in pulmonary hypertension and the development of congestive cardiac failure.1,2 Hypoxemia is associated with signs of peripheral cyanosis. Blue toe syndrome is a common presentation of peripheral ischemia as a result of the occlusion of small-caliber peripheral vessels. The differential diagnosis includes atheroembolism, thromboembolism, and vasospastic conditions.Utilization of Unconventional Radiography to Localize an Insulinoma
Imaging led to a definitive diagnosis for a 71-year-old female who presented to the endocrine clinic for evaluation of hypoglycemia. The patient was noted to have frequent episodes of symptomatic hypoglycemia for 2 years prior to presentation. Symptoms included weakness, diaphoresis, and perioral numbness. The symptoms would resolve after treatment with carbohydrate-rich foods or drinking juice. During this time, she had an unintentional weight gain of 40 lbs., as well as several experiences of severe hypoglycemia, which required emergency services assistance.Sporadic Abdominal Malady in a Female Mandating a Diagnosis
The patient is a 74-year-old woman with a reported lifetime history of abdominal pain that flares every couple of years. She had been admitted for severe, acute-onset abdominal pain 4 times in the past 30 years, most recently 6 years prior to her presentation to our hospital. Throughout each admission, the pain self-resolved and she was discharged without a clear diagnosis. Routine colonoscopies have been unremarkable. She also had a history of hypertension, migraines, depression, and chronic constipation attributed to the opioids she takes for her degenerative disk disease of the cervical and lumbar spine.Functional Decline in an Elderly Patient: Connecting the Dots to Reach the Diagnosis
An 80-year-old woman was admitted for an unwitnessed fall. She reported altered bowel movements with increased frequency of loose stool for 2 weeks, with a decline in function over the past month.The Fugitive Finding: Acute Infectious Aortitis in a Patient with Persistent MRSA Bacteremia
Methicillin-resistant Staphylococcus aureus (MRSA) is a leading cause of bacteremia and of metastatic infections such as endocarditis, resulting in significant morbidity and mortality.1 We present a patient with persistent MRSA bacteremia despite antibiotic therapy. Although initial transesophageal echocardiography (TEE) was unremarkable, follow-up TEE confirmed infectious aortitis, illustrating the importance of repeated examination and imaging.An Unusual Cause of Stroke: Neurosarcoidosis
A 44-year-old white woman presented to the Emergency Department with acute onset of severe vertigo, nausea, vomiting, and severe right frontal headache associated with photophobia, which had started the prior evening. Her symptoms improved slightly after a night of rest, but subsequently worsened again the following morning. She denied any focal weakness, sensory changes, or speech changes. She did endorse significant incoordination and was even involved in a minor motor vehicle collision that day.Cold Case: Mystery in the Midwest of Metastatic Tuberculous Abscesses
A 42-year-old male presented with multiple upper back masses that had been enlarging for 3 months and were associated with positional discomfort. He was also having intermittent nondrenching night sweats during this 3-month time frame, but no fever, weight loss, or respiratory symptoms.A Curious Case of Endocarditis and Liver Abscess in a Previously Healthy Man
A previously healthy 49-year-old Malaysian male presented to the emergency department for 3 weeks of shortness of breath. He had a wet cough with intermittent hemoptysis, intermittent fevers, and night sweats, and 1 month of abdominal pain, nausea, and vomiting. For his gastrointestinal symptoms, he was seen in an urgent care clinic 1 week prior to presentation and received a 5-day course of unknown antibiotics without improvement. His review of systems was otherwise negative.Glycogenic Hepatopathy Causing Elevated Lactic Acid and Liver Enzymes
A 22-year-old woman with type 1 diabetes mellitus presented with 2 weeks of persistent hyperglycemia, polydipsia, and polyuria. She had been diagnosed with diabetes 3 years prior and had poor glucose control with a hemoglobin A1c of 13%. Her current symptoms started after her wearable insulin pump device (V-Go 20, Valeritas, Inc., Bridgewater, NJ) fell off 2 weeks prior. Since that time, she had no basal insulin coverage and used only short-acting insulin lispro.Connective Tissue is the Issue: Relapsing Polychondritis
This patient sought medical care out of concern for an ear infection but was ultimately diagnosed with a rare rheumatologic condition. A 43-year-old man presented to the Emergency Department with 4 weeks of pain and tenderness in both ears. He also described several weeks of chills, redness and pain in both eyes, as well as several years of hearing loss in his left ear and intermittent aching pain in his hands, elbows, knees, and ankles. He denied fevers, night sweats, weight loss, abdominal pain, or shortness of breath.Eosinophils, Lymphocytes, and Myocytes, Oh My: HIV-Associated Myocarditis
A 51-year-old woman presented to our institution with decreased exercise tolerance and progressive dyspnea.When Statins Cause an Autoimmune Response: A Report of a Severe Case of Rhabdomyolysis
A 73-year-old gentleman presented with progressive weakness over the course of a few months, more prominent in the lower extremities. He denied myalgia, seizures, immobilization, fever, or viral-like illness. His comorbidities were significant for coronary artery disease, hypothyroidism, and hyperlipidemia. Medications included metoprolol, aspirin, thyroxine, and atorvastatin, which was started 4 years prior to presentation. Patient denied any alcohol consumption or illicit drug use.A Pregnant Woman with Anterior Chest Mass and Respiratory Failure: Blastomycosis in a Historically Nonendemic Area
A 30-year-old woman, 29 weeks pregnant (G1P0), presented with progressive right-sided pleuritic chest discomfort and dyspnea for 1 week in duration. One month prior to her presentation, the patient went kayaking in the Mohawk River Valley, upstate New York. She noticed an enlarging right anterior chest mass that developed after a wooden oar inadvertently struck her during the outing. She was seen by the primary care physician 10 days prior to admission and was given a short course of dexamethasone for presumed costochondritis.Keeping a Low Profile: Insulinoma
A young patient experienced a major lapse of memory, which led to hospitalization and the diagnosis of a rare but curable disease. An otherwise healthy 21-year-old man was brought to the emergency department by his partner after he forgot to pick her up from the airport despite several reminders. His partner and father described that he had become forgetful over the past 6 months, unreliable in his responsibilities, and increasingly impatient with a quick temper. He experienced bouts of confusion lasting minutes during which he was unable to answer questions and noticed diffuse body sweating and shaking of his arms.Mucormycosis: More Than Meets the Eye!
A 42-year-old Hispanic man presented with a 3-day history of nausea and vomiting after being treated for 2 days with amoxicillin for a dental abscess. His past medical history included methamphetamine and tobacco use, hypertension, and uncontrolled type 2 diabetes mellitus (hemoglobin A1C of 13.4%). His initial vital signs were unremarkable. Physical examination was significant for right facial swelling. Laboratory tests were notable for serum glucose >400 mg/dL without diabetic ketoacidosis, leukocytosis (12.8 × 103/uL), and an elevated C-reactive protein (11.7 mg/dL).Abnormal Chest Radiograph in Rapidly Progressive Glomerulonephritis—Not the Usual Pulmonary-Renal Syndrome
A 58-year-old car workshop worker was referred to the nephrology department for foamy urine and renal impairment. He had no significant past medical or surgical problems and was otherwise asymptomatic. Systematic review was unremarkable, and he did not have cough, hemoptysis, or dyspnea. On admission, blood pressure was 181/92 mm Hg, but physical examination was unremarkable with no rash or edema. Total urine protein was 5.01 g/24 hours, whereas urine microscopy noted 927 red blood cells, which were predominantly dysmorphic, and 18 white blood cells per high-powered field.A Paralyzing Vacation: Surfer’s Myelopathy
A 23-year-old previously healthy female (body mass index = 18.3) on vacation was learning how to surf for the first time. She was in the water for about 1 hour and noticed she had trouble standing up on the surfboard. She was able to paddle back to the shallow waters, but could not walk, and had to be carried out by her boyfriend. In the car, she developed further weakness and numbness of her bilateral lower extremities to the point of losing all sensory input and motor function. She also reported mild lower back pain.A Peculiar Case of Purpura
A 40-year old man with a history of bipolar disorder and obsessive-compulsive disorder came to the Emergency Department because of general weakness, edema, and purpura on his lower extremities. His past medical history was unremarkable: he did not take any medication, did not suffer from allergies, and, besides his psychiatric background, he mentioned only an episode of self-limited diarrhea 2 years earlier, without pathological findings on colonoscopy. At that time he decided to live on a diet of oats, canned tuna, and eggs, because he believed he was allergic to fructose.Beach Bummer: A Recurrent Pruritic Buttocks Eruption Following Travel
Obtaining a comprehensive history of illness is a fundamental aspect of our medical training. In this regard, eliciting a full social history, including recent travel, is often vital in correct diagnosis. In this case, we highlight the importance of obtaining a detailed travel history.What Lurks Beneath: A Subaortic Membrane
A 29-year-old otherwise healthy man with a history of multiple emergency department (ED) visits over the last several years for dyspnea of unknown etiology presented again to the ED with increased exertional dyspnea, fatigue, and presyncopal symptoms that had progressively worsened in recent months. The patient denied chest discomfort, vertigo, dizziness, syncope, or palpitations. He took no medications and did not use tobacco, alcohol, or illicit substances.An Ominous Facial Droop
A 61-year-old white man presented to our tertiary care hospital for evaluation of a bilateral facial droop and a 10-day history of worsening dysarthria, dysgeusia, hyperacusis, and blurred vision. He reported an unintentional weight loss of 45 pounds, without fevers or night sweats. He denied arthralgia, cough, diarrhea, or dysuria, but endorsed a 7-week history of bilateral and worsening back pain radiating down the back of the thighs.A Unilateral Facial Rash with Eye Involvement
A 67-year-old man with a history of chronic obstructive pulmonary disease came to the Emergency Department with a 2-week history of a left-sided facial rash. Two days after the rash appeared as small erythematous papules on his forehead, he was seen at an outside hospital and treated with oral cephalexin and doxycycline for presumed cellulitis. He presented to our Emergency Department due to progressive expansion of the rash despite compliance with antibiotics. His rash now extended over the left scalp and forehead, involving the upper eyelid, but did not cross the midline of the face.Giant Cell Arteritis Presenting with a Tongue Lesion
An 83-year-old woman presented to our hospital with a 2-month history of progressive weight loss, weakness, and recent odynophagia. Her daughter first noticed her tongue with white plaques about 2 weeks prior to our admission (Figure 1). She was admitted to another hospital, treated for thrush, and discharged. Her tongue surface then developed a whitish exudate over the tip (Figure 2) and became more painful. Most of the history was obtained from the daughter because the patient had severe dysarthria from the tongue lesions.Challenging to Treat: Fluctuating Abdominal and Joint Pain and Rash
A previously healthy 21-year-old woman was transferred as a result of refractory abdominal pain, rash, and joint swelling for a 1-month duration. She initially presented in her home community with acute, cramping abdominal pain that was accompanied by nausea and diarrhea, which was occasionally bloody. She also noticed intermittent fevers and was diagnosed with gastroenteritis.A Genetic Origin? Purpura Fulminans
Over days, a patient's relatively small lesion evolved into widespread tissue damage. A previously healthy 49-year-old Arab woman was admitted for a 2-cm painful red lesion on her left breast. She had been well until a few days earlier, when she developed left flank pain and was treated with ofloxacin for a presumed urinary tract infection. During the first 48 hours of her admission, the erythematous lesion over the left breast progressed, developing the appearance of a hematoma. Ultimately, it involved the entire breast (Figure 1).Behind the Curve: Late-Onset Axial Spondyloarthritis
The patient's diagnosis was more commonly associated with people in their teens and twenties. Yet, a 56-year-old woman met the criteria. Her primary care physician referred her to us after a 3-month history of neck and low back pain. The pain was sharp in nature, started from the posterior neck, and gradually involved the rest of the back. It persisted throughout the day and was worse with physical activity. She had associated morning stiffness, typically lasting 30 minutes to 1 hour. This was accompanied by generalized lethargy, poor appetite, and an unintentional weight loss of 2 kg (from 48 to 46 kg) over the same 3-month period.Without Warning: Scleroderma Renal Crisis
The patient's disease had yet to be diagnosed when a complication emerged in dramatic fashion. A 44-year-old man of Indian descent presented to an outside hospital after having suffered a seizure at work. He had no previous history of seizures. His family and coworkers denied precipitating events or a history of illicit drug use. He presented with altered mental status, and his blood pressure was 255/154 mmHg.Follow the Beads: Fibromuscular Dysplasia
Imaging provided a definitive diagnosis for a 58-year-old woman who presented to the emergency department with abdominal pain. The previous day, she had nonbloody diarrhea followed by sharp epigastric pain that migrated to her right lower quadrant and flank. The pain improved while she was lying flat and worsened with upright posture. Additionally, she had distinct, persistent pressure over the epigastrium and multiple episodes of nonbloody emesis that developed after the diarrhea.Bilateral Breast Ulcers: Granulomatosis with Polyangiitis
An investigation into the patient's unusual dermatologic symptoms identified an underlying autoimmune disease. Fourteen days after breast-reduction surgery, the patient, a 25-year-old white woman, was completely recovered. But at 20 days after surgery, she had bilateral mammary ulcerative lesions and was admitted to another hospital. The lesions were painless, and she was afebrile. Negative pressure wound therapy failed to accomplish secondary intention healing. For 6 weeks, she was treated with oral prednisolone, 1 mg/kg/day, and hyperbaric oxygen therapy, but these had limited effect.Lift Then Shift: Thyrotoxic Periodic Paralysis
A transient paralysis was precipitated by thyroid dysfunction. The patient, a 29-year-old man, woke up with diffuse muscle pain and weakness so profound that he was unable to get out of bed. His family called 911, and he was transported by ambulance to the emergency department. The night before, he was in his usual state of health and completed a strenuous workout at the gym.A Missing Link: Sarcoid-Lymphoma Syndrome
When the patient's autoimmune disorder did not respond to treatment, an additional workup uncovered a malignancy—one with an undefined connection. A 73-year-old woman presented with fatigue, left upper quadrant pain, headache, nausea, and cognitive dysfunction. An initial workup revealed hypercalcemia, a low level of parathyroid hormone, elevated levels of angiotensin-converting enzyme and alkaline phosphatase, pancytopenia, and mediastinal lymphadenopathy (Table). While magnetic resonance imaging of her brain produced unremarkable results, abdominal imaging showed trace ascites, mild splenomegaly with calcified granulomas, and borderline hepatomegaly.A Unifying Diagnosis: IgG4-Related Disease
The patient had long grappled with a disease attributed to toxin exposure after the World Trade Center attack on September 11, 2001. Years later, a biopsy specimen offered a different possible explanation for his signs and symptoms.Not All It's CrAged Up to Be: Disseminated Cryptococcosis
Phenomena known as cognitive biases, when applied to the details of a patient's medical history, evidently steered the first attempts at diagnosis in the wrong direction. A 60-year-old man presented after 6 weeks of progressively worsening fevers, weight loss, malaise, night sweats, and confusion. Originally, the fevers were intermittent and low grade at 37.7°C (99.9°F). In the 2 weeks prior to presentation, they occurred daily, with temperatures rising to 39°C (102°F). The patient also reported mild headaches, a dry cough, and palpable lymphadenopathy in his axilla and neck.Caught on Colonoscopy: Schistosomiasis Manifesting as a Single Colonic Polyp
A screening colonoscopy identified an unexpected diagnosis in a 64-year-old male patient. He was an asymptomatic landscaper who presented for a first-time screening colonoscopy based on age. His only active medical issue was psoriasis, for which he took apremilast. At the time of colonoscopy, he denied any bright red blood per rectum, melena, changes in stooling habits, abdominal pain, nausea, vomiting, changes in appetite, weight loss, or night sweats. He did not report any family history of colon cancer.Don't Move a Muscle: A Case of Diabetic Myonecrosis
Poorly controlled diabetes mellitus is associated with well-known microvascular complications, including retinopathy, neuropathy, and nephropathy. We present a case of a much less recognized complication—diabetic myonecrosis—and review the current literature with regard to diagnostic and management considerations.A Vanishing Entity: Rheumatoid Vasculitis
Although advances in the treatment of rheumatoid arthritis have made rheumatoid vasculitis less common than it once was, the complication should retain a secure place in the differential diagnosis. A 45-year-old woman presented to her physician's office with painful leg ulcers. Her medical history included long-term, double seropositive, erosive rheumatoid arthritis, treated latent tuberculosis, type 1 renal tubular acidosis, upper-extremity deep venous thrombosis, and recurrent Clostridium difficile infection.When Appearance Is Everything: Chylous Ascites
The patient had numerous bouts of ascites, but this time the fluid's color and composition heralded a new and ominous diagnosis. A 75-year-old woman with cirrhosis secondary to nonalcoholic steatohepatitis was admitted with abdominal pain. Her medical history also included coronary artery bypass grafting, congestive heart failure with a reduced ejection fraction of 40%, chronic kidney disease (stage III), type 2 diabetes, and obesity.Conduction Dysfunction and Near Expunction: Giant Cell Myocarditis
A patient who had been in relatively good health was suddenly on a cataclysmic course. The 70-year-old man presented to his primary care physician with shortness of breath. Five days prior, he experienced increasing pulmonary congestion and required additional help from his nocturnal continuous positive airway pressure device for improved sleep quality. Twenty-four hours after the onset of symptoms, he had increasing orthopnea. By the following day, he needed to stay upright in a chair to breathe comfortably.Menace Elbow: Disseminated Nocardiosis
A vivid argument can be made against presumptive diagnosis of a serious disease based on clinical and radiologic findings. Our patient's case emphasizes the importance of a confirmatory tissue sample.Serious Cover-Up: Hodgkin's Lymphoma Masked by Organizing Pneumonia
A biopsy indicated that the patient had organizing pneumonia, but after several months a second biopsy more clearly demonstrated malignancy. A 20-year-old woman was admitted with complaints of hemoptysis and chest discomfort. Her symptoms began 2 weeks before hospitalization, with a dry cough and occasional episodes of vomiting.Chamber-Made: Mural Endocarditis
The patient began to feel better 2 days into an intravenous course of antibiotics, but this was deceptive. A 25-year-old woman with a history of polysubstance abuse and recent tick exposure presented after 10 days of fever, myalgia, and shortness of breath without cough. She used intranasal cocaine 1 day before admission, and her last use of an intravenous substance occurred 6 months earlier. She had no recent travel history.A Surprising Diagnosis: Syphilitic Gastritis and Hepatitis
When patients present with gastrointestinal symptoms, sexually transmitted infection is unlikely to be at the top of the differential diagnosis. A 47-year-old homosexual man underwent evaluation for persistent fatigue, abdominal pain, and anemia with a positive fecal occult stool test, all of which raised concern for an acute gastrointestinal bleed. Approximately 6 months earlier, the patient began to have persistent loose bowel movements, for which he did not seek medical care. Two months before presentation, while on vacation in Thailand, he developed an asymptomatic maculopapular rash over his palms that improved spontaneously.The Simplest Explanation: Pancytopenia
Pancytopenia has a very broad differential diagnosis. Fortunately, for a 76-year-old woman with abnormal blood counts, the cause was easily treated. The patient presented to the Emergency Department of our hospital after 10 days of fever, malaise, and anorexia. Daily fevers had been as high as 38.9°C (102°F). She also reported an unintentional 4.5-kg (10-lb) weight loss over the preceding month. She had no sore throat, cough, dyspnea, headache, neck stiffness, abdominal pain, nausea, emesis, diarrhea, dysuria, joint pains, or rashes.Breaking Away: Superior Mesenteric Artery Embolus
The patient had 2 bouts of endocarditis in a short period, each instigated by a different organism, but the second had a most unusual herald. A 38-year-old man with fever and abdominal pain was brought to the Emergency Department from a subacute rehabilitation facility. Three months earlier, he had been admitted to the hospital and diagnosed with Granulicatella species bacteremia secondary to injection drug use and complicated by aortic valve endocarditis, splenic infarct, and a splenic artery aneurysm.Follow the Lead: Internal Jugular Vein Thrombosis
Although head and neck pain in the absence of focal neurologic deficits and other neurologic symptoms frequently have a benign source, a thorough evaluation and history sometimes uncover a life-threatening situation. A 65-year-old white woman presented to her primary care physician after 2 days of severe headache and neck pain. Her headache, mainly in the occipital region, radiated to the left retroauricular region and the back of her left neck. She denied weakness, numbness, nausea, vomiting, visual disturbances, dizziness, lightheadedness, and a history of trauma.Blood Is Thicker: Hyperviscosity Syndrome
Pain, presumably related to a previous injury, was the patient's main concern, but in fact, she had a serious complication of an as yet undiagnosed disease. A 49-year-old woman presented to the emergency department with persistent chest pain and new back pain. Three months earlier, she had a mechanical fall from standing height that resulted in fractures of her left seventh, eighth, and ninth ribs. Left-sided chest pain persisted, and she developed nontraumatic lower back pain that progressed in severity, prompting her to seek care.A Binge and a Breach: Cardiac Tamponade Caused by Haemophilus influenzae
A hefty dose of alcohol could well have been the trigger for a potentially deadly infection in a young, immunocompetent woman. After consuming 500-750 mL of hard alcohol, the 30-year-old patient had multiple bouts of forceful nonbloody emesis. She then developed severe pleuritic chest pain and palpitations, prompting a visit to the emergency department. On questioning, she acknowledged shortness of breath and a nonproductive cough. A review of systems was otherwise noncontributory. She denied fevers, chills, nasal congestion, sore throat, or sick contacts.A Congenital Culprit: Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery
A serious birth defect went unnoticed for 3 decades, and then it nearly proved fatal. The patient, a 30-year-old woman who had no history of cardiovascular disease, collapsed while jogging. Fortunately, a bystander immediately performed cardiopulmonary resuscitation. On arrival, emergency personnel noted that she was in ventricular fibrillation. They administered advanced cardiac life support with electrical and medical therapy, restoring her spontaneous circulation. Her regular medications, prescribed for anxiety, included lorazepam and paroxetine.A Measured Solution: Klinefelter Syndrome
A comprehensive physical examination was the key to diagnosis of a complex clinical syndrome in a 32-year-old man. He presented to the Emergency Department with intermittent, left-sided numbness and tingling in his fingers and toes that had begun 2 months earlier but escalated in frequency over the previous 3 days. While in the Emergency Department, he had a tonic-clonic seizure with left gaze deviation, head turning, tongue biting, and urinary incontinence. The seizure persisted for 3 minutes and terminated with a 2-mg dose of intravenous lorazepam.A Web Effect: Plummer-Vinson Syndrome
Although chest discomfort is a major complaint, it is sometimes difficult to identify the cause, especially in young patients. A 27-year-old woman presented to our walk-in clinic for chest discomfort that occurred when she swallowed. She had been seeking treatment for a year and a half, but several doctors and dentists had examined her without being able to diagnose a physical condition. The general conclusion was that her disorder might actually be psychological in nature. She had no remarkable medical history, and a recent otolaryngologic workup had been negative.When Biochemical Phenotype Predicts Genotype: Pheochromocytoma and Paraganglioma
A 45-year-old man's vague symptoms and unusual medical history spurred an investigation that culminated with an examination of his genes. The patient presented to his primary care physician with a 2-week history of progressive fatigue and 2 episodes of intermittent left upper- and lower-extremity weakness. An extensive work-up for a cause was unrevealing. Magnetic resonance imaging (MRI) of the brain demonstrated bilateral chronic infarcts resulting from multiple cryptogenic strokes in his past medical history.A Traveler's Disease Without Leaving Home: Typhoid Fever
“The art of medicine is in observation.” – Osler, AequanimitasFalls and Delirium: Platypnea-Orthodeoxia Syndrome
An 85-year-old woman's inability to remain standing was ultimately connected to an undiagnosed congenital defect. The patient was admitted to the geriatric unit of a university hospital for new frequent falls and subacute delirium, both of which began 1 month before presentation. Her medical history included ischemic stroke 10 years earlier, mild neurocognitive impairment, and Von Recklinghausen neurofibromatosis with isolated skin involvement.Cause for Pause: Obstructive Sleep Apnea
At intervals during the patient's sleep, his heart, specifically his sinoatrial node, took a brief hiatus. A 34-year-old Hispanic man presented to the Emergency Department for dyspnea, particularly on neck flexion, and dysphagia that had worsened over 4 days. He also complained of excessive daytime sleepiness. His family reported that he snored loudly and had apneic spells when he slept. He was morbidly obese, with a body mass index of 40 kg/m2, and he had a history of type 2 diabetes mellitus. He did not have angina.A Masked Marauder: Hepatitis C Neuropathy
When a 52-year-old man presented with burning pain in his feet, his type 1 diabetes, albeit well controlled, was initially thought to be the cause. In fact, a previously undiagnosed infection was to blame. The patient first presented to an outside hospital, where he reported that pain had started over his left heel and then spread to the rest of his left foot, his ankle, and his calf over the course of a few days. Two months later, his right foot was also involved. Aside from diabetes, he had a history of melanoma, for which he had been treated 4 years earlier.The Hyperlipidemia Effect: Pseudohyponatremia in Pancreatic Cancer
A patient's newly discovered malignancy was evidently accompanied by a sodium deficit. The 48-year-old man presented to the Emergency Department for evaluation of abdominal pain and weight loss. He described gradual onset of severe, burning, epigastric pain with radiation to the back. In addition, he reported a 70-lb weight loss over 2 months, yellowing of the eyes and skin, darkening of the urine, and occasional clay-colored stools. He had not experienced fevers, nausea, vomiting, or diarrhea. His abdominal discomfort had caused him to eat less in recent days than he would have previously.Difficult to Discern: Tuberculous Myositis with Poncet's Arthritis
The fundamental question in treating a 65-year-old man was whether he had 1 disease or 2 with coinciding symptoms. He originally presented with symmetric swelling of the hands and forearms, polyarticular arthralgias, and facial erythema. Born in India, the patient had been residing in the United States for several decades. He had no history of trauma, insect bites, recent travel, or use of injectable drugs. At that time, rheumatologic evaluation revealed positive antinuclear antibodies, anti-double-stranded DNA antibodies, and anti-SSA/Ro antibodies.No Neck Pain: Meningococcemia
The patient's symptoms belied the dangerous infection that had invaded his bloodstream. A 46-year-old man was referred to our Gastroenterology unit for the management of acute abdominal pain with vomiting and fever. His medical history included ophthalmic migraines, which were treated with nonsteroidal anti-inflammatory drugs. He had no allergies, did not travel abroad, and had no known contact with ill patients.Dueling Lungs: The Progression of Swyer-James Syndrome
Severe pulmonary hypertension led us to recommend surgery in the face of progressive Swyer-James syndrome.Case of Tuberculous Pericarditis Mimicking Lupus Carditis
A 48-year-old man presented to the emergency department of our hospital complaining of sharp substernal chest pain, fever, and chills for 3 days. He denied shortness of breath, cough, night sweats, nausea, vomiting, or diarrhea. He also denied dry eyes, dry mouth, oral ulcers, or photosensitivity. He was born in the Dominican Republic but has lived in the United States since childhood. He last travelled to the Dominican Republic 5 years before presentation but otherwise had no recent travel history.Slowly Growing Adrenal Mass: A 20-Year Incubation
A 68-year-old Japanese woman was referred for the evaluation of bilateral adrenal masses. These masses were incidentally discovered 20 years previously on computed tomography (CT) when they measured 2.5 cm and 2.0 cm (Figure 1A, B). At that time she had no signs or symptoms of adrenal cortical hormone excess or deficiency. The plasma corticotropin (ACTH) concentration was suppressed, and the plasma cortisol concentration was normal at 8 AM with a normal diurnal rhythm (Table). The overnight 1-mg and 8-mg dexamethasone suppression test (DST) showed an absence of cortisol suppression, which was consistent with ACTH-independent subclinical Cushing syndrome.Sole-Searing Pain: Classic Kaposi's Sarcoma
Patients frequently report lower-extremity pain, and common etiologies include cellulitis, venous thromboembolic disease, gout, and peripheral vascular disease. However, the case of a patient in terrible discomfort over a prolonged period highlights the importance of considering more atypical conditions when no improvement occurs with treatment.Demonstrating Hickam's Dictum: Metachronous Pulmonary Adenocarcinoma, Carcinoid Tumor, and Histoplasmosis
Although Occam's razor is frequently invoked in medicine, it is useful to keep Hickam's dictum in mind, as well; essentially, patients can have a number of diseases at the same time. This idea was illustrated by the case of a 76-year-old woman with an irregular stellate pulmonary nodule in her right middle lobe (Figure 1A). She had been undergoing computed tomography (CT) of the abdomen and pelvis for follow-up of a renal angiomyolipoma that had been stable for many years and for investigation of documented calcifications within her spleen (Figure 1B) when the nodule was discovered incidentally.Three Thrombi at Onset: Behçet's Disease
Diagnosis can be difficult when the classic symptoms of an uncommon illness emerge weeks after presentation. A 51-year-old African American man presented to the emergency department after 2 weeks of sharp midabdominal pain. He denied diarrhea, fevers, nausea, or vomiting. A review of systems was significant for a 10-lb unintentional weight loss over the preceding 2 months and a dull frontal headache. He was a construction worker who lived alone, had no medical history, and had no significant family history.More than a Mite Contagious: Crusted Scabies
Although an extensive skin infestation might be expected to cause serious discomfort, this is not always the case. A holiday visit sparked concern among family members when they saw that their relative, a 53-year-old woman who lived alone, was unable to perform routine daily activities. They brought her to the hospital to be evaluated for generalized weakness and poor appetite. Her medical history was significant for hypertension, chronic obstructive pulmonary disease, and vascular dementia.Smoke and Mirrors: Moyamoya Syndrome
A history of poorly controlled Graves' disease likely predisposed a 40-year-old woman to a syndrome that is more familiar in Asia. She presented to the emergency department with left-sided facial numbness and cramping, drooling, and aphasia. Similar symptoms had prompted previous visits. Two months earlier, she presented with dizziness, paresthesias, left-sided tingling, and near-syncope. At that time, exceedingly low levels of thyroid-stimulating hormone (<0.01 mIU/L) indicated significant hyperthyroidism, which, in combination with anxiety, was deemed responsible for her symptoms.It's Complicated: Parvovirus B19 in Thalassemia
An ordinarily mild infection became a serious problem for a patient with underlying disease. A 38-year-old Cantonese-speaking Chinese woman presented to the Emergency Department with transient fevers, nonbloody diarrhea, and lightheadedness. The symptoms had begun 5 days earlier. She had no nausea or vomiting and no bleeding, bruising, chest pain, cough, joint pain, rash, or shortness of breath. Through a translator, she reported a history of “Mediterranean anemia.” None of her contacts were sick, and she had not traveled recently.A History Lesson: Pulmonary Vein Stenosis
Signs and symptoms suggested infection, but the true diagnosis was rooted in the patient's recent past. A 46-year-old man who spends his winters in Arizona had been bothered by right-sided back and shoulder pain for 5 months. He sought care with his chiropractor but grew concerned after the pain worsened, and he developed new night sweats, subjective fevers, dry cough, and fatigue. The patient was a nonsmoker with a medical history of gastroesophageal reflux, hypertension, and atrial fibrillation, for which he had undergone successful radiofrequency ablation 7 months before presentation.
