Posts filed under ‘Images in Clinical Medicine’

Gas Gangrene of a Prosthetic Hip

N Engl J of Med Nov. 2014


John C. Kurylo, M.D., and Andrew H. Schmidt, M.D.

Hennepin County Medical Center, Minneapolis, MN

An 82-year-old man with diabetes mellitus who had undergone a total hip replacement 10 years earlier presented to the emergency department with the acute onset of pain in the left hip and groin and a fever (temperature, 39.2°C).

On presentation, the blood pressure was 96/57 mm Hg, and the white-cell count was 12,400 per cubic milliliter.

A radiograph and subsequent computed tomographic scan of the hip (Panels A and B, respectively) showed free air extending lateral to the greater trochanter and superior to the acetabular component.

Broad-spectrum antibiotic therapy was initiated, and the patient underwent emergency surgical débridement with removal of the acetabular component; intra-articular cultures grew Clostridium septicum….




November 13, 2014 at 8:53 am

Syphilitic Gumma

N Engl J of Medic Aug.14, 2014 V.371 P.667-667



  1. Cherniak and M. Silverman

A 45-year-old woman presented to an outreach clinic in rural Uganda with a 1-year history of a progressively enlarging ulcerated mass on the hard palate (Panel A). The mass had initially been painless but more recently had become painful and was causing difficulty in speaking and swallowing. She had received a diagnosis of cancer and was attempting to sell her home to pay for surgical resection. She had no history of syphilitic symptoms or treatment. The results on Treponema pallidum hemagglutination assay were positive for syphilis; nontreponemal testing was not locally available. Serologic analysis for human immunodeficiency virus was negative. Tertiary syphilis with an oral gumma was diagnosed. The patient was treated with three intramuscular injections of 2.4 million units of penicillin G benzathine at 1-week intervals. At follow-up 2 months after the end of treatment, there was resolution of the mass and symptoms (Panel B). In the oral cavity, gummas may occur as masses on the hard palate or tongue that frequently ulcerate….


August 15, 2014 at 10:08 pm

Roth Spots in Infective Endocarditis

N Engl J Med 2014 V.370 e38


Omar A. Mahroo, Ph.D., and Elizabeth M. Graham, F.R.C.Ophth.

St. Thomas’ Hospital, London, United Kingdom

A 34-year-old man presented to the eye emergency department with reduced vision in the right eye that had developed that morning. He was well, apart from episodes of dizziness and dyspnea after exercise during the previous 4 months.

These episodes had started 1 week after the patient had undergone a dental treatment. Previous extensive investigations had been inconclusive. His retinal appearance and symptoms prompted referral to the cardiology team, which admitted him that day.

He was afebrile but had a pansystolic murmur and a solitary splinter hemorrhage on the right thumb. Echocardiography revealed moderate-to-severe mitral-valve regurgitation, with thickening and signs of vegetations.

The ejection fraction was 65%. The other values were normal. Four sets of blood cultures yielded Streptococcus viridans, and intravenous antibiotics were started immediately. His symptoms improved, and his visual acuity gradually improved from 20/200 at presentation to 20/20 8 months after presentation. His right fundal appearance is shown, at presentation (Panel A), 3 days later (Panel B), and 3 months later (Panel C).

The presence of white-centered hemorrhages (Roth spots) should prompt the consideration of possible infective endocarditis. A comparison of Panel A and Panel B (3 days apart) shows how quickly such spots can change. Monitoring of the patient’s mitral-valve regurgitation, which was started after complete resolution of the endocarditis, is ongoing….


July 13, 2014 at 7:01 pm

Chorioretinal Toxoplasmosis

N Engl J of Medic January 23, 2014 V.370 P.361

Images in Clinical Medicine

A 30-year-old man was incidentally found on funduscopic examination to have pigmented and sharply demarcated choroidal lesions involving the macular region. The lesions measured 5 mm in the right eye and less than 1 mm in the left eye …


January 22, 2014 at 9:27 pm

Lesions in the Oral Cavity

N Engl J of Medic Feb.21, 2013 V.368


Jose Narciso Rosa Assunção, D.D.S., Ms.C., and Gustavo Davi Rabelo, D.D.S., Ph.D.

University of São Paulo, São Paulo, Brazil

A 59-year-old man presented with multiple painful ulcers in the oral cavity that had developed over the course of a week. He also noted difficulty swallowing and speaking. Physical examination revealed …





February 22, 2013 at 8:42 am

Pott’s Disease of the Thoracic Spine

N Engl J of Medic Feb.21, 2013 V.368 P.756


Soraya Jodra, M.D., and Carlos Alvarez, M.D.

University Hospital 12 de Octubre, Madrid, Spain

A 20-year-old man who was originally from Bangladesh presented to our clinic with a 6-month history of anorexia and weight loss. The physical examination was remarkable for a temperature of 39°C. Chest radiography showed a mass that appeared to be located in the posterior mediastinum (Panel A, white arrows). Computed tomography (CT) of the chest showed a paravertebral mass of soft tissue surrounding the vertebra (Panel B, white arrows), with destruction of vertebral bodies (black arrow). The mass extended from ..



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February 22, 2013 at 8:40 am

Papulonodular Syphilis

N Engl J of Medicine Feb.7, 2013 V.368 P.561


Birgit Ziegler, M.D., and Nina Booken, M.D.- University Hospital of Mannheim, Mannheim, Germany

A 52-year-old woman presented with a 3-week history of asymptomatic erythematous papules and nodules. The lesions initially appeared on the face and tongue (Panels A and B) and subsequently spread to the trunk and lower legs. The patient had no other systemic symptoms. Two weeks earlier, she had been treated with oral penicillin G for a sore throat but had stopped taking the antibiotic after a few days because of angioedema. A biopsy of a facial lesion revealed an inflammatory infiltrate with multiple mature plasma cells suggestive of secondary syphilis. The diagnosis was made on the basis of a titer of 1:160,000 (normal range, 0 to 640) on a Treponema pallidum particle agglutination assay, a value of 5770 U per milliliter (normal range, 0 to 24) on an enzyme-linked immunosorbent assay for T. pallidum IgG, and a positive assay for T. pallidum IgM. The differential diagnosis included leukemia cutis and cutaneous sarcoidosis. The patient received the diagnosis of papulonodular secondary syphilis with mucous plaques and most likely a syphilitic pharyngitis. Because of previous penicillin intolerance, the patient was treated with intravenous ceftriaxone (2 g daily) for 3 weeks. The rash cleared within 4 weeks after the initiation of treatment.


February 7, 2013 at 9:36 am

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