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 ...

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...

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....

IMAGES IN CLINICAL MEDICINE Pneumatosis Cystoides Intestinalis with Pneumoperitoneum Francesco Pata, and Salomone Di Saverio N Engl J Med 2019; 380:e17DOI: 10.1056/NEJMicm1808960 A 61-year-old woman presented to the emergency department with acute onset of diffuse abdominal pain and a 1-week history of diarrhea and vomiting. Her medical history included chronic obstructive pulmonary disease, which was being treated with an inhaled glucocorticoid and a long...

Intensive Care Medicine Nasogastric tube ending in the right pleura of an intubated patient Paparoupa, M., Yan, Y., Möller, M. et al. Intensive Care Med (2018). https://doi.org/10.1007/s00134-018-5460-x An 89-year-old woman was treated in our intensive care unit with Escherichia coli urosepsis. The patient developed multiple organ failure and became intubated and mechanically ventilated. On the third intensive care day, a new 16Fr. type “Levin” nasogastric tube was ...

IMAGES IN CLINICAL MEDICINE Portal Venous Gas Ming Cui, and Xin Lu N Engl J Med 2018; 379:e37 DOI: 10.1056/NEJMicm1806082 A 72-year-old man presented to the emergency department with an 11-hour history of periumbilical abdominal pain and inability to pass flatus. His medical history included chronic lymphocytic leukemia (for which he had been taking ibrutinib), type 2 diabetes, and chronic hepatitis B virus infection. The pulse was 155 beats per minute, and the blood press...

Re-expansion pulmonary oedema Alice Petiot, Sammy Tawk, Benoît Ghaye Lancet 2018; 392: 507 A 46-year-old man presented to the emergency department with moderate dyspnoea and a 4-day history of cough. His medical history also included alcoholic cirrhosis with portal hypertension and ascites. On admission, a chest x-ray showed complete white-out of the right hemithorax with contralateral mediastinal deviation compatible with a large pleural effusion—presumed to be hepatic hy...

IMAGES IN CLINICAL MEDICINE Corrigan’s Pulse and Quincke’s Pulse Hector I. Michelena, and Maurice Enriquez-Sarano N Engl J Med 2018; 379:e9 DOI: 10.1056/NEJMicm1715353 A 58-year-old man was referred to the cardiology clinic for evaluation of exertional dyspnea. Twelve years before presentation, he had undergone a bioprosthetic aortic-valve replacement for treatment of severe bicuspid aortic stenosis and for repair of an ascending aortic aneurysm. On physical examination, h...

IMAGES IN CLINICAL MEDICINE Vibrio vulnificus Infection Jin Park, and Chang-Seop Lee N Engl J Med 2018; 379:375 DOI: 10.1056/NEJMicm1716464 A 71-year-old man presented to the emergency department with a 2-day history of fever and excruciating pain in his left hand that had developed 12 hours after eating raw seafood. He had a history of type 2 diabetes mellitus and hypertension and was undergoing hemodialysis for end-stage renal disease. At the time of presentation, hemor...

IMAGES IN CLINICAL MEDICINE Cryptococcus neoformans Meningoencephalitis Raul Recio, and Ana Perez-Ayala N Engl J Med 2018; 379:281 DOI: 10.1056/NEJMicm1801051 A 36-year-old man presented to the emergency department with a 2-week history of fever, headache, drowsiness, and photophobia. He was previously healthy and was sexually active with men. The physical examination was notable for a temperature of 38.3°C and neck stiffness. Computed tomography of the head was normal. T...