Sally H. Ebeling

Case 9-2008: A 65-year-old woman with a nonhealing ulcer of the jaw

From the Departments of Oral and Maxillofacial Surgery (T.B.D.), Oncology (N.S.R.), Radiology (P.A.C.), and Pathology (A.E.R.), Massachusetts General Hospital; the Department of Radiology, Massachusetts Eye and Ear Infirmary (P.A.C.); the Department of Oral and Maxillofacial Surgery, Harvard School of Dental Medicine (T.B.D.); and the Departments of Oncology (N.S.R.), Radiology (P.A.C.), and Pathology (A.E.R.), Harvard Medical School.

Case 23-2013: A 54-Year-Old Woman with Abdominal Pain, Vomiting, and Confusion

Dr. Sara R. Schoenfeld (Medicine): A 54-year-old woman was admitted to this hospital because of abdominal pain, vomiting, and confusion. The patient was in her usual health until approximately 3 days before admission, when she reportedly began to feel unwell, with weakness, chills, and skin that was abnormally warm to the touch. She self-administered aspirin, without improvement. During the next 2 days, her oral intake decreased. Approximately 22 hours before presentation, vomiting occurred. Nine hours before presentation, she began to travel home to Italy from the eastern United States. During the next 2 hours, increasing abdominal pain occurred, associated with vomiting and shortness of breath, and she took additional aspirin for pain. Approximately 2 hours before presentation, while the patient was in flight, abdominal pain markedly worsened, vomiting increased, and she became confused and unresponsive. The flight was diverted to Boston. On examination by emergency medical services personnel, she was nonverbal and was moaning continuously. The blood pressure was 120/70 mm Hg, the pulse 52 beats per minute, and the respiratory rate 26 breaths per minute. The capillary blood glucose level was 116 mg per deciliter (6.4 mmol per liter). She was brought to the emergency department at this hospital by ambulance. The patient’s history was obtained from her husband through an interpreter. She had non–insulin-dependent (type 2) diabetes mellitus, hypertension, nephrolithiasis, and chronic kidney disease. Medications included enalapril, metformin, glimepiride, nimesulide, imipramine, aspirin, and ibuprofen. She had no known allergies. She was married and had children. She lived in Italy and did not speak English. She had vacationed in North America for 10 days, traveling to urban areas. She did not smoke, drink alcohol, or use illicit drugs, and there was no history of unusual ingestions. On examination, the patient was incoherent and appeared agitated and uncomfortable, with frequent groaning. She was oriented to person only and opened her eyes to command. The blood pressure was 120/70 mm Hg, the pulse 52 beats per minute, the temperature 36.7°C, the respiratory rate 18 breaths per minute, and the oxygen saturation 95% while she was breathing ambient air. The pupils were 3 mm

Case 26-2008: A 26-Year-Old Woman with Headache and Behavioral Changes

Dr. Thomas J. Cummings, Jr. (Psychiatry): A 26-year-old woman was admitted to this hospital because of headache, behavioral changes, abnormal movements, and inability to communicate. The patient had been well, except for occasional migraine headaches, until 7 weeks earlier, when generalized, diffuse headache developed. It was most severe in the occipital region, with associated neck stiffness, sensitivity to sounds, intermittent blurred vision, nausea, and vomiting. There were no prodromal symptoms or visual scotoma, which had occurred routinely with her migraines, and the pain did not diminish in response to her usual migraine treatment. During the next 10 days, she was seen multiple times in the emergency departments of other hospitals. A computed tomographic (CT) scan of the brain obtained without the administration of gadolinium reportedly showed inflammatory changes in the left maxillary and ethmoid sinuses but was otherwise normal. Medications, including butalbital, oxycodone, hydrocodone, ibuprofen, sumatriptan, indomethacin, acetaminophen, and caffeine, were administered, with transient partial relief from pain. Somnolence, dysphoria, short-term memory problems, confusion, agitation, and symptoms of depersonalization developed. Five and a half weeks before admission to this hospital, increasing visual disturbances that were thought to be visual hallucinations developed, with increasing confusion. On evaluation in a local emergency department, laboratory tests revealed negative results in tests for Lyme disease and syphilis. She was admitted to an inpatient psychiatric facility. The patient had a history of migraine headaches, obesity, asthma, and seasonal allergies. She smoked cigarettes and drank up to six alcoholic beverages on weekends. Several days before the onset of symptoms, she had attended a party and taken a drug that was reported to contain cocaine, crystal methamphetamine, ecstasy, and possibly salvia. On admission to the psychiatric hospital, her speech was initially fluent and appropriate but became garbled and incoherent; abnormal movements developed, including hyperextension of the arms and movements of the mouth. Antipsychotic medications, including haloperidol, risperidone, benztropine, lorazepam, olanzapine, valproic acid, and quetiapine, were administered, without improvement. Fever developed, and the serum level of creatine kinase was reportedly elevated. On the fifth day, she was transferred to another hospital because of suspected neuroleptic malignant syndrome. Case 26-2008: A 26-Year-Old Woman with Headache and Behavioral Changes

Case 5-2009: A 47-Year-Old Woman with a Rash and Numbness and Pain in the Legs

Dr. John H. Stone: A 47-year-old woman was seen in the Rheumatology Clinic of this hospital because of numbness and pain in the legs and a rash. The patient had been well until approximately 2 years earlier, when numbness developed, first on the lateral aspect of the left leg, ankle, and foot, and then in an identical distribution on the right. Approximately 3 months later, pain developed on the medial aspect of the left foot, followed by pain in the same distribution on the right foot. During the next 9 months, the pain spread to involve both lower legs diffusely. One year before presentation, acute swelling of the distal left leg developed after an airplane trip. Ultrasonography of the legs, performed at another hospital, showed no evidence of deep venous thrombosis. The swelling subsided spontaneously during a 2-week period. Six to 8 months before this evaluation, mottled discoloration of the skin developed on the feet, ankles, and lower legs, with isolated, tender nodules up to 1.5 cm in diameter that blanched partially with pressure. Intermittent swelling of the legs and ankles occurred. Results of laboratory tests are shown in Table 1. Approximately 8 weeks before presentation, the patient saw a physician at another facility. Levels of serum electrolytes, albumin, globulin, thyrotropin, ferritin, folate, and vitamin B12 and results of renaland liver-function tests were normal. Results of other laboratory tests are shown in Table 1. The next day, a dermatologist performed a biopsy of the skin of the left temple. Pathological examination of the specimen reportedly showed perivascular and perifollicular inflammation with telangiectasias, which was thought to be consistent with rosacea-like dermatitis. One week later, pathological examination of a biopsy specimen of a cutaneous nodule on the left ankle reportedly revealed a focal lymphohistiocytic infiltrate around a small muscular artery in the subcutis, with no evidence of vasculitis or erythema nodosum. Three weeks before presentation, the patient saw a rheumatologist at another facility. The patient reported a history of dry eyes (for which she used cyclosporine eye drops) and numbness, tingling, and color changes in her fingers in conditions Case 5-2009: A 47-Year-Old Woman with a Rash and Numbness and Pain in the Legs

Case 24-2009 — A 26-Year-Old Woman with Painful Swelling of the Neck

Dr. John H. Stone: A 26-year-old woman was seen in the rheumatology clinic of this hospital because of painful swelling on both sides of the neck. She had been well until approximately 3 months earlier, when dry mouth and increased thirst developed. Two weeks later, submental swelling occurred that was associated with local tenderness, pain on swallowing (with solids more than with liquids), and decreased appetite. Approximately 4 weeks after the onset of symptoms, she saw a physician; cephalexin was prescribed, with no improvement. During the next 2 weeks, pain developed in both ears. Seven weeks before evaluation at this hospital, she went to the emergency department of the Massachusetts Eye and Ear Infirmary. On examination there, the vital signs were normal. Anterior rhinoscopy revealed a minimally deviated septum and mildly edematous turbinates. The submandibular glands were symmetrically enlarged, irregular, bosselated, and tender. There was mild discomfort in the temporomandibular joints, more on the left than on the right. The remainder of the physical examination and fiberoptic endoscopic inspection of the larynx were normal. The level of plasma sodium was 132 mmol per liter (reference range, 135 to 145); the results of other laboratory tests, including a complete blood count, levels of other electrolytes, and tests of liver and renal function, were normal. Computed tomography (CT) of the neck after the intravenous administration of contrast material showed prominently enhancing submandibular glands that were enlarged and prominently enhancing parotid glands, all of which appeared nodular. No sialoliths or sialodocholiths were observed. Periodontal disease was present in the tissue surrounding both third mandibular molars, which were partially impacted. Ibuprofen was prescribed, to be taken as needed. Ten days later, fine-needle aspiration of the left and right submandibular glands was performed. Cytologic examination revealed a paucicellular specimen with polymorphous lymphoid cells, normal salivary-gland tissue, and no malignant cells. Two weeks after the fine-needle aspiration, the patient was seen in the infectious disease clinic of this hospital. Additional history was obtained. She had been born in an urban area of Morocco and immigrated to the United States 22 months before presentation at this hospital; a chest radiograph was reportedly normal at Case 24-2009: A 26-Year-Old Woman with Painful Swelling of the Neck

Case 34-2010: A 65-Year-Old Woman with an Incorrect Operation on the Left Hand

From the Departments of Orthopedics (D.C.R., J.H.H.) and Medicine (G.S.M.) and the Massachusetts General Physicians Organization (G.S.M.), Massachusetts General Hospital; and the Departments of Orthopaedic Surgery (D.C.R., J.H.H.) and Medicine (G.S.M.), Harvard Medical School — both in Boston.

Case 35-2004: A 68-Year-Old Man with End-Stage Renal Disease and Thickening of the Skin

From the Department of Dermatology, Lahey Clinic, Burlington, Mass. (S.L.M.); the Division of Rheumatology, Department of Medicine (J.K.), the Department of Dermatology (B.T.M.), and the Division of Dermatopathology, Department of Pathology (V.L.), Massachusetts General Hospital; and the Departments of Dermatology (S.L.M., B.T.M.), Medicine (J.K.), and Pathology (V.L.), Harvard Medical School.

Case 25-2010: A 24-Year-Old Woman with Abdominal Pain and Shock

From the National Emerging Infectious Diseases Laboratories, Boston University Medical Center, and the Department of Medicine, Boston University School of Medicine (M.S.K.); the Department of Radiology (S.I.L.) and the Clinical Microbiology Laboratory, Department of Pathology (M.J.F.), Massachusetts General Hospital; and the Departments of Radiology (S.I.L.) and Pathology (M.J.F.), Harvard Medical School — all in Boston; the Department of Infectious Disease and International Health, Dartmouth–Hitchcock Medical Center, Lebanon, NH, and the Department of Medicine, Dartmouth Medical School, Hanover, NH (E.A.T.); and the Infectious Disease Pathology Branch, Centers for Disease Control and Prevention, Atlanta (S.Z.).

Case 41-2009: A 16-Year-Old Boy with Hypothermia and Frostbite

Dr. Benjamin Sandefur (Emergency Medicine): A 16-year-old boy was admitted to the hospital after being found unconscious in a snow bank at 6 a.m. on New Year’s Day. He had been well until the night before admission, when he attended a party where alcohol was consumed. He was last seen at approximately 11 p.m. Approximately 2 hours later, his friends and family noticed his absence and notified police; a search was begun. At approximately 6 a.m., he was found unconscious in a snowbank by local firefighters and police officers. The ambient temperature was −15°C (5°F), with a wind-chill factor of approximately −29°C (−20°F). He was partially undressed, with his pants down and his right boot off; his limbs were buried in the snow, and a layer of ice surrounded his right foot. In the ambulance, an intravenous catheter was placed, and 150 ml of crystalloid was infused. He was brought to the emergency department of this hospital, arriving at 6:50 a.m. On initial examination, he was drowsy and slow to respond but oriented, with spontaneous respirations and no shivering. The rectal temperature was 31.3°C (88.3°F), the blood pressure 153/62 mm Hg (20 minutes later, 112/56), the pulse 72 beats per minute (20 minutes later, 52), and the respiratory rate 20 breaths per minute; a pulse oximeter showed an oxygen saturation of 93% while he was breathing ambient air. There were abrasions on his forehead. The distal right foot was encased in ice, both hands were cold and hard to palpation, and the left foot was cold but soft. The arms, buttocks, and legs (up to the thighs) were purplish-red, and the toes and fingers were blue. There were abrasions on the dorsal surfaces of the hands, legs, and feet. Neurologic examination showed no focal abnormalities. The white-cell count was 14,600 per cubic millimeter (reference range, 4500 to 13,000), with 81% neutrophils (reference range, 40 to 62), 16% lymphocytes (reference range, 27 to 40), and 3% monocytes (reference range, 4 to 11); the level of potassium was 3.2 mmol per liter (reference range, 3.4 to 4.8), carbon dioxide 18.3 mmol per liter (reference range, 23.0 to 31.9), glucose 60 mg per deciliter (3.3 mmol per liter) (reference range, 70 to 110 mg per deciliter [3.9 to 6.1 mmol per liter]), aspartate aminotransferase 58 U per liter (reference range, 10 to 40), lipase 127 U per liter (reference range, 13 to 60), amylase 206 U per liter (reference range, 3 to 100), and creatine kinase 3815 U per liter (reference range, 60 to 400). The remainder of the complete blood Case 41-2009: A 16-Year-Old Boy with Hypothermia and Frostbite

Case 12-2009: A 46-year-old man with migraine, aphasia, and hemiparesis and similarly affected family members

From the Departments of Neurology (S.D.B.), Radiology (W.A.C.), and Pathology (M.P.F.), Massachusetts General Hospital, Boston; the Department of Neurology, Foothills Hospital, and the Department of Clinical Neurosciences, University of Calgary — both in Calgary, AB, Canada (E.E.S.); and the Departments of Neurology (S.D.B.), Cell Biology (J.F.A.-V.), Radiology (W.A.C.), and Pathology (M.P.F.), Harvard Medical School, Boston.