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

(1). Oral Manifestations of Pemphigus Vulgaris

Joseph Katz, Published February 26, 2025,N Engl J Med 2025;392:902;DOI: 10.1056/NEJMicm2411370,,VOL. 392 NO. 9

Abstract

A 44-year-old woman presented with an 11-month history of mouth ulcers and blistered lips and a 6-month history of blisters on her arms and legs. The lips were swollen with bleeding erosions, and erosions were seen in the mouth.

(2). Laryngeal Involvement in Disseminated Cryptococcosis

Christopher C. Marino et al, Published February 22, 2025,N Engl J Med 2025;392: e25,DOI: 10.1056/NEJMicm2414062,VOL. 392 NO. 9

Abstract

A 46-year-old woman with multiple myeloma presented with a 2-month history of hoarseness and painful swallowing. Laryngoscopy showed an exophytic mass involving the laryngeal surface on the right side.

(3). Mitral Regurgitation from Ischemic Papillary-Muscle Rupture

Priyanka Bhugra et al, Published March 1, 2025, https://www.nejm.org/doi/full/10.1056/NEJMicm2410729?query=WB

A 59-year-old woman presented with a 2-day history of progressive dyspnea. Her blood pressure was 140/98 mm Hg, respiratory rate 40 breaths per minute, and oxygen saturation 90% while she was breathing 100% oxygen through a nonrebreather mask. On physical examination, there were rales in both lungs and a pansystolic murmur at the cardiac apex. An electrocardiogram showed sinus tachycardia with T-wave inversions in the anterior leads but no Q waves or ST-segment elevations. A high-sensitivity troponin assay showed a level of 1093 ng per liter (reference value, <19). A transthoracic echocardiogram showed severe mitral regurgitation with flailing of the anterior mitral-valve leaflet, and a transesophageal echocardiogram showed rupture of the anterolateral papillary muscle with prolapse into the left atrium (Panel A, arrow, and Video 1) and severe mitral regurgitation (Panel B and Video 2). A diagnosis of mitral regurgitation from ischemic papillary-muscle rupture was made. Because of its dual arterial supply, the anterolateral papillary muscle is less likely to rupture than the posteromedial papillary muscle, which is supplied by a single artery. In this case, coronary angiography revealed multivessel disease with a severe stenosis of a large obtuse marginal branch of the left circumflex artery, which was thought to be the culprit lesion. Emergency mitral-valve replacement surgery was performed, but coronary-artery bypass grafting could not be performed owing to poor distal vessel targets. The patient declined percutaneous coronary intervention but did well with medical management over 1 year of follow-up.

(4). Emphysematous Vertebral Osteomyelitis

Xingxin Hu et al, Published March 5, 2025,N Engl J Med 2025;392:1017,DOI: 10.1056/NEJMicm2412956,VOL. 392 NO. 10

Abstract

A 62-year-old man presented to the ED with a 5-day history of low back pain and a 1-day history of lethargy. Imaging of the spine showed gas within L4.

(5). Chronic granulomatous invasive fungal rhinosinusitis mimicking meningioma

Ling Aye et all, https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(24)00809-0/abstract

A 45-year-old man from Hainan, a tropical island, who was immunocompetent presented with transient limb weakness. He reported mild headaches for the past 4 months, but no additional symptoms. The patient’s medical history was notable for hepatitis B and chronic liver cirrhosis, but otherwise unremarkable. No notable ophthalmological, otolaryngological, or neurological signs were found through physical examination. Head CT revealed a lesion involving sinuses, orbits, and brain (figure A). MRI showed an extra-axial mass in the anterior skull base, with a typical dural tail sign (figures B and C). The patient was initially suspected to have meningioma, and received partial surgical resection of the lesion. Postoperative histopathological examination revealed granulomatous inflammation, with no evidence of malignancy (figure D). Grocott’s methenamine silver eosin staining showed sparse fungal hyphae (figure E), which was further identified as Aspergillus flavus by metagenomic next-generation sequencing. The diagnosis of chronic granulomatous invasive fungal rhinosinusitis was confirmed. After 3 months of intravenous voriconazole (200 mg every 12 h), his symptoms had improved and the size of the lesion had decreased substantially. The treatment was then switched to oral voriconazole (200 mg every 12 h), and the size of the lesion was found to have further decreased by the 6-month follow-up.

  • CT of the head shows a diffuse lesion in the sellar region, involving the nasal cavity, sinuses, and orbits (coronal view). T1-weighted postcontrast head MRI images show an anterior cranial base mass involving sinuses, orbits and cavernous sinus, with a typical dural tail sign (indicated by arrows; B is coronal view; C is axial view). (D) Haematoxylin–eosin staining at ×10 reveals granulomatous inflammation. (E) Grocott’s methenamine silver eosin staining images at ×20 (left) and ×60 (right) show sparse fungal hyphae (indicated by arrows)

(6). Linear IgA Bullous Dermatosis of Childhood

Arjun Pandya, Published March 12, 2025,N Engl J Med 2025;392:1120,DOI: 10.1056/NEJMicm2413814,VOL. 392 NO. 11

Abstract

A 2-year-old boy presented with a 1-week history of itchy, red spots. Tense vesicles, erosions, and inflammatory plaques were seen. Direct immunofluorescence revealed a linear band of IgA at the dermoepidermal junction.

(7). Thin Skin in Cushing’s Syndrome

Jean Regina et al, Published March 8, 2025, N Engl J Med 2025;392: e28,DOI: 10.1056/NEJMicm2414582,VOL. 392 NO. 11

Abstract

A woman with a history of metastatic small-cell lung cancer and Cushing’s syndrome was found to have reduced skin thickness, a possible result of antianabolic effects of excess cortisol

(8). Gastric Adenocarcinoma and Proximal Polyposis of the Stomach

Kosuke Tanaka et al, published March 12, 2025,N Engl J Med 2025;392: e29,DOI: 10.1056/NEJMicm2413107,VOL. 392 NO. 11

Abstract

A woman was seen for evaluation of gastric polyposis, a condition her uncle also had. On upper endoscopy, innumerable polyps in the gastric corpus and an area of pale mucosa along the greater curvature were identified

(9). Chronic granulomatous invasive fungal rhinosinusitis mimicking meningioma

Ling Aye et all, https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(24)00809-0/abstract

A 45-year-old man from Hainan, a tropical island, who was immunocompetent presented with transient limb weakness. He reported mild headaches for the past 4 months, but no additional symptoms. The patient’s medical history was notable for hepatitis B and chronic liver cirrhosis, but otherwise unremarkable. No notable ophthalmological, otolaryngological, or neurological signs were found through physical examination. Head CT revealed a lesion involving sinuses, orbits, and brain (figure A). MRI showed an extra-axial mass in the anterior skull base, with a typical dural tail sign (figures B and C). The patient was initially suspected to have meningioma, and received partial surgical resection of the lesion. Postoperative histopathological examination revealed granulomatous inflammation, with no evidence of malignancy (figure D). Grocott’s methenamine silver eosin staining showed sparse fungal hyphae (figure E), which was further identified as Aspergillus flavus by metagenomic next-generation sequencing. The diagnosis of chronic granulomatous invasive fungal rhinosinusitis was confirmed. After 3 months of intravenous voriconazole (200 mg every 12 h), his symptoms had improved and the size of the lesion had decreased substantially. The treatment was then switched to oral voriconazole (200 mg every 12 h), and the size of the lesion was found to have further decreased by the 6-month follow-up.

  1. CT of the head shows a diffuse lesion in the sellar region, involving the nasal cavity, sinuses, and orbits (coronal view). T1-weighted postcontrast head MRI images show an anterior cranial base mass involving sinuses, orbits and cavernous sinus, with a typical dural tail sign (indicated by arrows; B is coronal view; C is axial view). (D) Haematoxylin–eosin staining at ×10 reveals granulomatous inflammation. (E) Grocott’s methenamine silver eosin staining images at ×20 (left) and ×60 (right) show sparse fungal hyphae (indicated by arrows)

(10). A Man in His 30s with Ponytail Coronary Artery Anomaly

Leizhi Ku et al, JAMA Cardiol. Published online March 19, 2025. doi:10.1001/jamacardio.2025.0124

A male in his 30s presented with chest tightness. Coronary computed tomography angiography showed the proximal left anterior descending (LAD) artery splitting into many small arteries (Figure, A). Coronary angiography revealed that the LAD was divided into many small arteries mimicking a ponytail (Figure, B and Video). Coronary intravascular ultrasound revealed multiple small branches with a maximum diameter of approximately 1.5 mm. Cardiac magnetic resonance imaging showed no myocardial ischemia. The patient was treated conservatively and maintained good health at follow-up.

Coronary computed tomography angiography (CCTA) imaging. A, CCTA shows the proximal area of the left anterior descending (LAD) artery, which is split into many small arteries. B, Coronary angiography reveals that the LAD is divided into many small arteries mimicking a ponytail.

Link to the  article and video : https://jamanetwork.com/journals/jamacardiology/fullarticle/2831570?guestAccessKey=188e41f1-2493-4c0c-8c92-0878f88d1f73&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamacardiology&utm_content=olf&utm_term=031925&adv=000004305673

Ponytail coronary artery anomaly is rare and underrecognized in the previous literature; it does not fit within the traditional arterial classification system. However, ponytail coronary artery anomaly can be difficult to manage in those with coronary atherosclerosis. Furthermore, such abnormalities may lead to erroneous diagnoses during radiological interpretation and clinical management.

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