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Massive Splenomegaly from Disseminated Mycobacterium avium–intracellulare Infection Lucas R. Massoth, Abner Louissaint, Jr. N Engl J Med 2020; 382:1041DOI: 10.1056/NEJMicm1905550 A 29-year-old man with HIV infection presented with abdominal pain and drenching nights sweats. Computed tomography of the abdomen revealed massive splenomegaly caused by disseminated Mycobacterium avium–intracellulare infection.
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IMAGES IN CLINICAL MEDICINE Skin Discoloration from Amiodarone Robert P. Murphy and Michelle Canavan N Engl J Med 2020; 382:e5DOI: 10.1056/NEJMicm1906774 An 81-year-old man with a history of atrial fibrillation and hypertension presented to the emergency department after a fall. His medications were apixaban, ramipril, bisoprolol, amlodipine, and amiodarone. Physical examination revealed blue and gray pigmentation, sometimes referred to as ceruloderma, wit...
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IMAGES IN CLINICAL MEDICINE Crazy Paving in Pulmonary Alveolar Proteinosis Brian W. Allwood and Sami Bennji N Engl J Med 2020; 382:275DOI: 10.1056/NEJMicm1908563 A 34-year-old man with a 20-pack-year smoking history presented to the emergency department with a 4-month history of progressively worsening dyspnea and nonproductive cough. The oxygen saturation was 65% while the patient was breathing ambient air. He appeared to have dyspnea at rest, his fi...
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IMAGES IN CLINICAL MEDICINE Crepitus and Subcutaneous Emphysema Yehia Saleh and Ahmad Alratroot N Engl J Med 2020; 382:e1DOI: 10.1056/NEJMicm1907386 An 86-year-old woman with a history of severe emphysema presented to the emergency department with sudden-onset shortness of breath. Two weeks earlier, she had been treated for community-acquired pneumonia that was complicated by a pneumothorax on the right side, leading to the temporary insertion of a chest t...
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IMAGES IN CLINICAL MEDICINE Multiple Renal Arteries Sahib Y. Tuteja and Bence Forgac N Engl J Med 2019; 381:862DOI: 10.1056/NEJMicm1902894
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IMAGES IN CLINICAL MEDICINE Epiglottitis Nikita Chapurin and Alexander Gelbard N Engl J Med 2019; 381:e15DOI: 10.1056/NEJMicm1816761 A previously healthy, fully immunized 48-year-old man presented to an urgent care clinic with a 3-day history of odynophagia, fever with temperatures of up to 40°C, and progressive shortness of breath. A lateral radiograph of the neck showed the “thumb sign” (Panel A, arrow), which was suggestive of an enlarged epiglottis. ...
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IMAGES IN CLINICAL MEDICINE Emphysematous Cholecystitis Sondes Mhamdi and Kais Mhamdi N Engl J Med 2019; 381:e14DOI: 10.1056/NEJMicm1814551 An 80-year-old man with a history of hypertension presented to the emergency department with a 2-day history of abdominal pain in the right upper quadrant. The patient was febrile. On physical examination, he had abdominal tenderness in the right upper quadrant, and Murphy’s sign was positive. Laboratory studies reveal...
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IMAGES IN CLINICAL MEDICINE Fish Bone Perforation Takafumi Taguchi and Hiroyuki Kitagawa N Engl J Med 2019; 381:762DOI: 10.1056/NEJMicm1900442 A 73-year-old man presented to the emergency department with the acute onset of severe lower abdominal pain. He recalled eating yellow-tail fish the day before the onset of the pain. His temperature was 38°C, blood pressure 122/69 mm Hg, and heart rate 77 beats per minute. On physical examination, he had tenderness ...
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IMAGES IN CLINICAL MEDICINE Air in the Spleen Simon De Freitas, Evan G. Wong N Engl J Med 2019; 381:566DOI: 10.1056/NEJMicm1817266 A 56-year-old woman presented to the emergency department with a 1-month history of epigastric and left-upper-quadrant abdominal pain. Her medical history included polysubstance use disorder (including cocaine and heroin use) and hepatitis C virus infection, as well as rheumatoid arthritis, for which she had been taking naproxe...
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IMAGES IN CLINICAL MEDICINE Thrombotic Thrombocytopenic Purpura Shruti Bhandari and Rohit Kumar N Engl J Med 2019; 380:e23DOI: 10.1056/NEJMicm1813768 A 35-year-old man presented to the emergency department with a 2-day history of abdominal pain, headache, and brown urine. On examination, his temperature was 37.5°C. He was alert and oriented to time, place, and self, and he had no purpura or petechiae. Laboratory evaluation revealed a hemoglobin level of 8....
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