IMAGES IN CLINICAL MEDICINE Green UrineVCAD510 JN0-643 Maja Boshkovska Spaseski, and Dejan Spaseski N Engl J Med 2020; 383:e128DOI: 10.1056/NEJMicm2017137 A 62-year-old man with chronic obstructive pulmonary disease presented to the emergency department with a 2-day history of dyspnea and was found to have hypercapnic respiratory failure. Intubation was performed, mechanical ventilation and a continuous infusion of propofol were initiated, and the patient ...

Capnocytophaga canimorsus Infection Robert D.H. Markewitz and Tobias Graf N Engl J Med 2020; 383:1167DOI: 10.1056/NEJMicm1916407 A 62-year-old man presented to the emergency department with a 1-day history of fever and a 3-day history of chest pain. His medical history was notable for coronary heart disease and for a splenectomy that he had undergone after a car accident. Four days before presentation, he had been bitten on the left hand by his dog and h...

Miliary Tuberculosis Jerald Pelayo and Kathleen Ruddiman N Engl J Med 2020; 383:e78DOI: 10.1056/NEJMicm2001934 A 56-year-old man presented to the emergency department with a 2-month history of fatigue, weight loss of 10 kg, night sweats, and fever. He had a cough producing sputum that was occasionally bloodtinged. He had immigrated to the United States from Haiti 10 years earlier. On examination, his temperature was 36.2°C. He was breathing comfortably but ap...

CLINICAL PICTURE| VOLUME 395, ISSUE 10235, P1516, MAY 09, 2020 Myocarditis in a patient with COVID-19: a cause of raised troponin and ECG changes Denis Doyen, Pamela Moceri, Dorothée Ducreux, et al Lancet 2020; 395: 1516 A 69-year old man, from Lombardy, Italy, was admitted to our unit because of acute respiratory distress syndrome that required mechanical ventilation; he was in Nice, France, on holiday. He had previously been fit and well; he had a history of...

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.

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...

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

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. ...