Everything Has Its Place

A 25 year old man has a soccer injury and fractures the tibial diaphysis in his right leg. However, he doesn't have health insurance so he doesn't go to the emergency department immediately. Instead, he wraps his leg and hopes it will get better. Unfortunately it doesn't. In the next few hours, the pain rapidly worsens, spreading further than just the site of the initial injury. He describes this pain as deep aching associated with numbness and tingling. He finally goes to urgent care where passive range of motion causes pain. The skin has a tense woody feel. His sensation is diminished. He goes to surgery.

Challenge: What's your diagnosis?

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As

Two patients come into the emergency department.

The first patient is a volcanist (you know, a person who explores volcanoes) who just got back from a trip inside a volcano hours ago. He presents with nausea, vomiting, abdominal pain, and severe watery diarrhea. You ask him what he's been eating, but you can tell - he has garlic on his breath. His exam shows hypotension and signs of dehydration. An EKG shows a QTc of 500; the patient takes no medications. He is admitted to the hospital with an uncertain diagnosis and a week later develops pancytopenia and hepatitis. Three weeks into the hospitalization, he starts requiring higher and higher doses of gabapentin for a painful peripheral neuropathy starting with distal paresthesias and progressing to ascending sensory loss and weakness.

The second patient is a person visiting from West Bengal (or India, or Bangladesh). He presents with the skin changes shown above. He has a history of HTN and squamous cell carcinoma. He also has a symmetric sensorimotor polyneuropathy. This began years ago as numbness and tingling in the feet, progressing to the arms. The patient can't even walk because of intense burning in his soles. He often gets cramping in his calves. On exam, there is diminished vibratory sensation and decreased deep tendon reflexes.

Challenge: What's your diagnosis?

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A

A few days after a young child gets a sore throat, he develops a diffuse blanching erythema with numerous small papules starting at the head and neck, then involving the trunk and extremities, before having the appearance shown in the first image. The rash feels like sandpaper and is easiest to see along the inguinal crease, axillary fold, and antecubital fossa.

Challenge: What's your diagnosis?

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Popcorn

 Sorry, this post was a little late.

This 30 year old woman is transferred from an outside hospital with multiple focal progressive neurologic deficits and seizures. MRI shows several lesions shown here. They do not show up on conventional brain angiography. CT shows irregular hyperdense masses.

The patient goes to surgery where the surgeon comments on a "mulberry appearance to purplish clusters."

Challenge: What's your diagnosis?

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b2-4ac

You receive this pathology specimen which is a liver biopsy in a 50 year old drinker who presented with fever, jaundice, and anorexia. Exam showed hepatomegaly, a mildly tender liver, and a bruit heard over the liver. The patient was mildly confused, had some asterixis, and had a guaiac positive stool.

Challenge: What's your most likely diagnosis?

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Manicure

These images show the friable slow-growing nails in a 40 year old woman with pleural effusions, bronchiectasis, frequent pneumonias, and swollen lower extremities.

Challenge: What's your diagnosis?

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Tut

Some people believe that the person shown above suffered from a syndrome characterized by congenital fusion of cervical vertebrae, though others dispute the claim. Below is shown an image of a patient who actually has the disease.

A variable number of vertebrae can be fused, which may result in atlantoaxial instability. There are autosomal dominant, autosomal recessive, and sporadic variants. Significant scoliosis develops in more than half of affected children. The most common sign is limitation in range of motion of the neck. Some patients also have a low hairline and short neck. Associated findings include deafness, genitourinary abnormalities, and cardiovascular abnormalities.

Challenge: What's this disease?

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Frog

Challenge: This gentleman has a smoking history where the number of pack-years is three times his age. Yikes! What's the radiologic diagnosis?

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