Image of the Week

A 30-year-old male presents with a one-year history of worsening lower back pain and alternating buttock pain. He mentions his symptoms are typically worse first thing in the morning, but seem to remit later in the day with NSAIDs and exercise. Physical examination reveals swelling of the proximal interphalangeal joints of several digits, restricted lumbar movement, and tenderness of the sacroiliac joint. An X-ray demonstrates the findings seen here. Which of the following extra-articular clinical manifestations is most commonly associated with this patient’s condition?

A) Blurred vision
B) Right lower quadrant pain
C) Plaques with silver scale
D) Shortness of breath

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A 31-year-old female presents to the emergency department with deep puncture wounds on her forearm after being attacked by a pack of stray dogs. On examination, she has a loss of sensation throughout her right medial palm and fingers and she is unable to extend her fourth and fifth digits. After her wounds are irrigated, she is administered tetanus, rabies, and antibiotic prophylaxis. Based on this patient’s detected nerve damage, what other hand functions might also be impaired?

A. Finger abduction
B. Extension of wrist
C. Pinching
D. Extension of thumb

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An 80-year-old female with a history of arthritis and high blood pressure presents with recurrent lesions and erythema on the palms of her hands and the soles of her feet. On examination, hyperkeratosis, brown macules, and discrete pustules are seen on her palmoplantar surfaces. A fungal culture and serologic tests are unremarkable. Which of the following is most strongly associated with this patient’s condition?

A) Exposure to ultraviolet radiation
B) Prior HPV infection
C) History of cigarette smoking
D) Prior aspergillus exposure

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After visiting an Asian food festival, this 50-year-old male now presents with a pruritic, whiplash-striped, erythematous rash on his torso. Do you recognize the cause of this presentation?

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An initial blood test reveals renal impairment and a serum calcium level of 13 mg/dL. An X-ray of her skull demonstrates numerous lytic lesions and a bone marrow biopsy is performed. What findings would you expect to see in this patient’s bone marrow aspirate?
(Image credit: @Lucy_A.)

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A young patient presents with a rough, irregular growth on his fourth finger. Is this lesion simply an unusual presentation of a common condition or is it indicative of a rare disease?

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This patient returned from a 4-hour bike ride with a non-blanching purpuric rash on his lower legs that spared the skin compressed by his socks. He had no significant medical history and denied taking medication. Was a bike ride the cause of this eruption?

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A 17-year-old female presents with a high fever, ecchymoses on her trunk, and a five-month history of generalized fatigue. On examination, her skin is pale. A peripheral blood smear demonstrates pancytopenia and her bone marrow aspirate contains 35% blast cells. Based on this patient’s clinical presentation and bone marrow aspirate, what is the most likely diagnosis?

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A 20-year-old male is brought to the emergency room with left shoulder pain that worsens with inspiration following a motor vehicle accident. Abdominal examination reveals generalized abdominal tenderness and severe left quadrant pain. Over the course of the examination, his systolic blood pressure falls from 90 to 75 mmHg. A bedside ultrasound demonstrates fluid in the hepatorenal space. After initial resuscitation, which of the following is the best next step for this patient?

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This 17-year-old girl presented with severe pruritus affecting both feet after travelling through mud and water on her daily commute to school. The accepted diagnosis was pitted keratolysis.

The chief complaint of pruritus began 3 months prior to diagnosis and was exacerbated in the week prior to diagnosis. During the medical investigation, the patient explained that she lived 5km from the nearest school and had been walking through rivers and mud to get there.

Pitted keratolysis is usually asymptomatic. Comments on Figure 1 suggested that topical antibiotics might be too costly for this patient, so 20% aluminum chloride alone, as an antiperspirant and antibacterial, perhaps compounded, would be an inexpensive alternative.

This patient has been diagnosed with a hereditary (consanguineous) form of palmoplantar keratoderma, a condition characterized by an overproduction of keratin in the palms and soles. The disorder varies in severity and can be complicated by frequent bacterial, viral, and fungal infections. Symptoms are generally managed with the use of emollients and keratolytic agents.

The condition appeared in the entire family due to consanguinity. Consanguinity among ethnic groups is not uncommon, leading to hereditary conditions commonly seen only in those population subsets.

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A 40-year-old male presented with a painful mass on his left shoulder. He had previously undergone several courses of chemotherapy and radiation therapy for stage IV Hodgkin lymphoma that had relapsed twice. View this case to find out the cause of the mass and how it was treated.

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This 12-year-old patient has a rare genetic disorder called cherubism. Patients present with bilateral swelling of the jaw caused by the replacement of maxillary and mandibular bone with fibrous tissue and bony cysts.

Surgery can be performed, though it is recommended to delay surgical intervention until after puberty as spontaneous regression may occur.

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