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...

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...

IMAGES IN CLINICAL MEDICINE Multiple Renal Arteries Sahib Y. Tuteja and Bence Forgac N Engl J Med 2019; 381:862DOI: 10.1056/NEJMicm1902894

ICU Management & Practice, Volume 18 - Issue 1, 2018 Understanding LVAD & artificial hearts Regarding the growing number of patients with long-term mechanical assist devices, intensivists need to understand the physiology of the devices, their functioning, potential complications and their management. Long-term mechanical circulatory support (MCS) is being used increasingly for patients at risk of dying from heart failure and cardiogenic shock (Ponik...

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. ...

ICU Management & Practice, Volume 19 - Issue 2, 2019 A structural approach for diagnosing weaning failure A case from a specialised weaning centre Using a case of a former patient we describe the structured approach of analysis of the cause of weaning failure with corresponding specific therapies used in our Centre for Expertise. Previously, we suggested a structural approach for diagnosing the cause of weaning failure (Heunks and van der Hoeven 2010;...

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...

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...

JAMA Diagnostic Test Interpretation June 14, 2019 Adenosine Deaminase Diagnostic Testing in Pericardial Fluid Edward Chau, Minoo Sarkarati,Brad Spellberg JAMA. 2019;322(2):163-164. doi:10.1001/jama.2019.7535 Case A 65-year-old Vietnamese man with hypertension, type 2 diabetes mellitus, and chronic hepatitis B with cirrhosis presented with a 2-week history of shortness of breath at rest, orthopnea, and lower extremity edema. He ...