Journal scan: A review of images in clinical medicine of immediate clinical significance, harvested from major international journals

From the desk of the Editor-in-chief

Images in Clinical Medicine

(1). Bladder Stone

Zihao Li, Published January 4, 2025

Abstract

A 72-year-old woman with a 30-year history of paraplegia was referred to the urology clinic for treatment of a bladder stone. CT of the abdomen revealed a large bladder stone with a tree ring–like appearance.

Practice Clinical updates

(2). Fever of unknown origin

William F Wright et al, BMJ 2025; 388 doi: https://doi.org/10.1136/bmj-2024-080847 (Published 06 January 2025), BMJ 2025; 388:e080847

What you need to know

Fever of unknown origin is a clinical syndrome, and updated criteria (based on international consensus) are a raised temperature on several occasions with a prolonged illness in an immunocompetent patient and uncertain diagnosis on completion of a recommended set of minimal laboratory and imaging studies

Causes can be classified as infections, non-infection inflammatory disorders, neoplasms, miscellaneous conditions, and undiagnosed illnesses, and they vary with geographic region and patient’s age

Incorporate travel history when evaluating potential causes

It is more often explained by a common disease with an atypical presentation rather than by a rare disease

Consider early referral to a specialist for patients with confirmed fever, with or without elevated inflammatory markers, who remain undiagnosed in a generalist setting

Fever of unknown origin (also known as fever of undetermined origin or pyrexia of unknown origin) is often a debilitating clinical syndrome. Patients with this syndrome present to medical practitioners across all levels of health care, including general practice, emergency department, and secondary care services, across all geographic areas. There are limited epidemiological data on this syndrome, and no data related to primary care presentations. However, in two retrospective cohort studies from Japan and Italy, prevalence of fever of unknown origin in secondary care ranged from 1.9% to 2.9% in 9830 hospitalised patients.

What is fever of unknown origin?

Fever of unknown origin is a diagnosis based on a set of clinical, laboratory, and radiographic criteria. is a syndrome characterised by a prolonged febrile illness with a set of medical signs and investigative findings

(3). Argyria

Tin Yan Lee et al, Published January 8, 2025,N Engl J Med 2025;392:185,VOL. 392 NO. 2

Abstract

An 84-year-old man was noted to have gray skin. On physical examination, diffuse gray pigmentation of the skin, nails, and sclera was seen. A skin biopsy revealed small, dark granules in sweat glands.

Argyria, also known as argyrosis, is a rare condition that causes the skin to turn blue or blue-gray due to a buildup of silver in the body:

Symptoms

The most obvious symptom of argyria is skin discoloration that’s usually most noticeable in areas exposed to the sun. The discoloration can also affect the nails and mucous membranes.

Causes

Argyria can be caused by chronic exposure to silver compounds, such as colloidal silver, silver dust, or silver-containing medications. It can also be caused by dental amalgams, acupuncture needles, or orthopedic implants.

Diagnosis

Argyriais diagnosed by taking a skin biopsy and examining the skin cells under a microscope. Blood and urine samples can also be used to determine if there has been exposure to silver recently.

Treatment

There’s no cure for argyria, but laser therapy and other measures can help improve the discoloration. Steps can be taken to limit further exposure to silver, such as: wearing sunscreen with a high sun protection factor , limiting time in the sun , wearing protective clothing and eyewear when working with silver , avoiding silver-containing medicines, supplements, and cosmetics

(4). Progressive Acro-Osteolysis of the Fingers

Kenji Yamada etal, Annals of Internal Medicine: Clinical Cases,Volume 4, Number 1,https://doi.org/10.7326/aimcc.2024.0633

Abstract

A 63-year-old woman with systemic sclerosis (SSc) exhibited progression of bone resorption in the distal phalanges (acro-osteolysis). This case underscores the importance of adequately managing Raynaud phenomenon, as it alone can drive the progression of acro-osteolysis in patients with long-standing SSc.

A 63-year-old woman with a 20-year history of systemic sclerosis (SSc) reported pain and shortening of the fingertips refractory to amlodipine, 2.5 mg, and bosentan, 62.5 mg, both once daily. She had been diagnosed with SSc based on the Raynaud phenomenon, skin thickening of the fingers on bilateral hands extending proximal to the metacarpophalangeal joints, pitting scars, abnormal nailfold capillaries, telangiectasia, puffy fingers, and a positive anti-RNA polymerase III antibody test. At the current visit, she reported no history of ulcers, gangrene, or trauma to the digits in the preceding 2 years. Physical examination revealed shortening of the fingers. No signs of calcinosis cutis or features suggestive of psoriasis existed. Blood analysis ruled out hyperparathyroidism or diabetes mellitus. Compared with the image taken 2 years earlier (Figure 1, A; arrows), the current radiograph indicated significant bone resorption of the distal phalanges in the shape of a small pyramid or a flattened ridge of the bilateral index fingers and the middle finger of her left hand (Figure 1, B; arrows). Based on these findings, the patient was diagnosed with acro-osteolysis due to SSc.

Figure 1. Radiographs of patient’s hands. A. The bilateral hands’ radiograph taken two years earlier indicated the bone resorption of the distal phalanges in the shape of a small pyramid or a flattened ridge of the bilateral index fingers and the middle finger of her left hand. B. The bilateral hands’ radiograph taken at the current visit showed the progression of bone resorption of the distal phalanges in the shape of a small pyramid or a flattened ridge of the bilateral index fingers and the middle finger of her left hand.

Acro-osteolysis, bone resorption of the distal phalanges, is a musculoskeletal involvement type in SSc associated with significant disability and functional impairment (1). Generally, this condition reportedly occurs in 20% to 40% of patients with SSc (2). Acro-osteolysis in SSc might be related to hypoxia resulting from impaired blood supply (1). This condition potentially promotes osteoclast formation in peripheral blood and is associated with increased vascular endothelial growth factor plasma levels (1). Apart from the long duration of the disease, the patient exhibited no prominent predisposing factors for acro-osteolysis, including digital ulcers, extraarticular calcification, or pulmonary hypertension (3). This case suggests that refractory Raynaud phenomenon alone could induce the progression of acro-osteolysis in patients with a long-term history of SSc.

(5). Exogenous Lipoid Pneumonia

Taichi Kaneko etal, Published January 11, 2025, https://www.nejm.org/doi/full/10.1056/NEJMicm2407298?query=WB

A 38-year-old woman with a history of disordered eating was found to have ground-glass opacities on a chest CT. Cytologic examination of bronchoalveolar-lavage fluid showed lipid-laden macrophages and droplets of oil.

(6). Vertebral Web and Embolic Stroke

Kiran Waqar etal, JAMA Neurol. 2025;82(1):104-105. doi:10.1001/jamaneurol.2024.4025

A31-year-old female individual without prior medical comorbidities was referred for further evaluation of embolic stroke of undermined source. She experienced sudden onset of headache and vertigo 5 months prior to our initial evaluation, at which point she was diagnosed with embolic acute infarcts in bilateral cerebellar hemispheres, right pons, and left thalamus. There was no history of trauma or neck pain. She started receiving acetylsalicylic acid and thereafter remained free of recurrent vascular events.

General physical examination was normal without stigmata of systemic vasculitis. Neurological examination was notable for mild left-sided appendicular ataxia. Results of extensive evaluation, including routine blood investigations, hypercoagulation and vasculitis panels, transthoracic and transesophageal echocardiography, and cardiac rhythm monitoring, were negative for an embolic source. Vascular imaging with computed tomographic and magnetic resonance angiography raised concerns for vasculitis. A high-resolution vessel wall magnetic resonance imaging scan did not reveal abnormal vessel wall thickening or contrast enhancement in the suspected vessels. Cerebrospinal fluid analysis was normal. Digital subtraction angiography demonstrated no angiographic evidence of vasculitis but revealed a focal lesion in the terminal V3 segment of the right vertebral artery (Figures 1 and 2; Video). The lesion was circumferential but predominantly posterior with a shelflike ledge, causing kinking of the vessel with moderate stenosis but without flow limitation. There was contrast stagnation in the ledge late into the venous phase.

Figure 1. Reconstructed 3-Dimensional Rotational Angiogram From Right Vertebral Injection

The reconstructed angiogram demonstrates the shelflike ledge-shaped circumferential stenotic lesion in the right vertebral artery V3 segment suggestive of an arterial web (arrowhead).

Figure 2. Digital Subtraction Angiography (DSA)

The lesion appearance was extremely suggestive of an arterial web, akin to that commonly seen in extracranial carotid arteries. While dissection is common in this location and cannot be completely ruled out, the lack of intramural hematoma on magnetic resonance imaging, absence of dissection flap or pseudoaneurysm on digital subtraction angiography, and lack of supportive clinical history argued against a dissection. Since the remainder of etiological investigation results were negative, the vertebral artery web was deemed the source of the posterior circulation strokes. Given the high rate of recurrent ischemic events in carotid webs despite medical management, vertebral artery stenting was discussed. The patient preferred to continue antithrombotic treatment alone and consider stenting only on recurrence.

Discussion

This case report describes a novel etiology for embolic stroke of undermined source. There is recent heightened awareness of web disease causing embolic stroke particularly in younger patients without traditional stroke risk factors. A web is a non-atherosclerotic, noninflammatory shelflike intraluminal membrane most commonly seen in the carotid bulb with pathogenesis linked to fibromuscular dysplasia or congenital anomaly. Alterations in laminar flow and creation of stasis above and below the web leads to thrombi formation with subsequent thromboembolism and cerebral infarction. There is a high recurrent stroke rate up to 26.8% despite medical management of carotid web, and interventional procedures to reduce thrombotic propensity by stenting or endarterectomy are now commonly employed.1 Vertebral artery webs are much more rarely reported. Few case reports suggest most common involvement in the V1 and V3 segments.2-4 Similar to carotid web, it is plausible that turbulence and stasis from the vertebral web lead to thrombosis. Stroke recurrence rate in vertebral web on medical management is unknown, and it remains to be seen if it mirrors its carotid counterpart.

(7). Livedo Racemosa

Abstract

A 66-year-old woman with a history of metastatic breast cancer presented to the dermatology clinic with a 1-month history of an asymptomatic, lacy rash on her left thigh.

(8). Vaginal Varix in Pregnancy

Sara Tameish, etal, Published January 18, 2025

Abstract

A 31-year-old woman was evaluated at 35 weeks 2 days’ gestation for a vaginal lesion. On examination, a nontender purple mass originating from the vaginal wall on the left side protruded into the introitus.

(9). Cytomegalovirus Retinitis

Nicolas Kitic etal, January 22, 2025, N Engl J Med 2025;392:382,VOL. 392 NO. 4

Abstract

A 34-year-old woman with HIV infection presented with a 3-day history of a blind spot in the right eye. Funduscopy revealed dense areas of retinal necrosis and hemorrhage in both eyes.

(10). Endobronchial Kaposi ’s sarcoma

Fredrik Eika et al, NEJM January 25, 2025, https://www.nejm.org/doi/full/10.1056/NEJMicm2407099?query=WB

Abstract

A darkened patch of endobronchial mucosa was found during bronchoscopy in a 55-year-old man with a history of orthotopic liver transplantation complicated by post-transplantation Kaposi’s sarcoma.

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Journal scan: A review of images in clinical medicine of immediate clinical significance, harvested from major international journals

Journal scan: A review of images in clinical medicine of immediate clinical significance, harvested from major international journals

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