(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A fifty-four year old female with past medical history of pulmonary hypertension, fibromyalgia, chronic obstructive pulmonary disease, coronary artery disease and hypertension presented to the emergency department with complaints of increased dyspnea, lower extremity edema, weight gain, orthopnea, fevers, chills, night sweats over the past few months. She denied any cough or sputum production. The patient was on trepostinil (remodulin) infusion since 3 years. She had a history of line infection two years ago which was successfully treated with antibiotics. Patient had a right subclavian port placed about ten months ago. Her other medications included estrogen, escitalopram, warfarin and gabapentin. The patient did have a remote history of smoking although she had quit smoking eight years prior. She denied any drug allergies, alcohol or intravenous drug abuse.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

This is a 54-year-old white male with a history of polymyositis, type 1 diabetes mellitus, and hypothyroidism who has been on immunosuppression with methotrexate and prednisone. He presented with an episode of vomiting, headache, memory loss, cognitive decline, and right lower extremity weakness and numbness that lasted for about four hours, three days prior to admission. The symptoms were resolved spontaneously after sleep.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 54 year-old man with past medical history significant for hypertension and gastro-esophageal reflux (GERD) presented with several months of sinus complaints (headaches, nasal drainage, sinus pain) requiring several courses of antibiotics and a right-sided tympanostomy tube placement. Over the last 2-3 months he developed bilateral eye pain with progressive vision loss, to the point of becoming blind in both eyes. He also had an unintentional weight loss of nearly 100 pounds. On physical examination no other motor, sensory, or cranial nerve deficits were seen. A CT scan of the brain showed a right frontoparietal subdural fluid collection, consistent with a hematoma, measuring up to 1 cm in thickness. This was associated with minimal midline shift and compression of the right lateral ventricle. A bilateral temporal artery biopsy and a turbinate biopsy showed no evidence of vasculitis. He underwent drainage of the hematoma without significant improvement of his symptoms. A brain MRI was performed. The T1 image revealed bilateral subdural collections, with associated diffuse meningeal thickening, (Figs 1, 2). There was a 1.5 cm lesion with restricted diffusion in the right parietal lobe and associated contrast enhancement, morphologically suspicious for a lymphoma. A FLAIR sequence showed no discrete mass corresponding to the area of restricted diffusion. In addition there was patchy mass-like effect, and mild herniation of the right parietal lobe into the burr hole.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 54-year-old woman with no significant medical history complained about nausea and vomiting. Her family reported personality changes over the past few weeks. Neurological investigation revealed paresis of the abducens and hypoglossal nerves on the left side, a right sided reduction of the visual field, as well as dysarthria and ataxia. Cranial MRI demonstrated an extensive circular meningeal lesion (2 cm x 3 cm) of the foramen magnum with contrast enhancement (Figures 1 and 2, arrows). The process compressed the medulla oblongata and ensheathed the spinal cord. Hydrocephalus of all ventricles was noted. The thoracic X-ray and a thyroid scintigraphy were normal. Ophthalmologic investigation revealed an edema of the left papilla. Serological tests for p- and c-ANCA, ANA, DNA, ENA and tumor markers were negative. The CSF showed signs of a chronic lymphocytic meningitis and was negative for Borrelia or mycobacteria. Because of circular growth, the tumor was resected only partially.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient is a previously healthy 54-year-old woman with a 12 year history of anemia and recent (3 months) onset of pancytopenia of unknown etiology (leukocytes 2.5 x 109 /L, hemoglobin 7.8 gm/dL, platelets 30 x 109 /L). Her past medical history was unremarkable. The physical examination revealed moderate splenomegaly and was otherwise unremarkable. An abdominal computed tomography scan revealed splenomegaly. Additional laboratory examinations revealed a negative Coombs test, slightly elevated lactate dehydrogenase, and slightly increased haptoglobin. The spleen was removed and her pancytopenia resolved.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 55-year-old male presented to our institution in October, 2016 with a 4-week history of intermittent slight fever and 3-week headache, accompanied by dizziness as well as fatigue, nausea, tinnitus, vision rotation, standing instability and blurred vision. Physical examination revealed no focal neurological deficit. MRI showed a flaky and nodular lesion involving the right cerebellar hemisphere and cerebellar vermis. The lesion was isointense on T2 weighted images, high signal intensity on T1 weighted images with nodular gadolinium enhancement (Figures 1a, 1b). Laboratory investigations revealed a white-cell count of 9780 per mm3 (reference range, 3500 to 9500), and an absolute eosinophil count of 1660 per mm3 (reference range, 20 to 500). A biopsy of the lesion was performed. .

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 55-year-old male presented to the outpatient clinic with a combination of neurological symptoms for one month, including movement, speech and behavioral symptoms. MRI revealed in the axial T2 sequence a right frontal lobe mass, with surrounding white matter edema and local mass effect, compressing the right lateral ventricle, with a midline shift to the left (Fig. 1a). Furthermore, in the axial and coronal post gadolinium T1 sequences the mass demonstrated ring enhancement (Figs. 1b and 1c). A wide local excision was performed.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 55-year-old woman presented with headaches and dizziness for one and a half years. An initial lumbar puncture and MRI showed no relevant results. In the meantime, she experienced intermittent nausea and vomiting with significant weight loss. Shortly before she was referred to our institution she had for the first time a generalized seizure. A MRI scan now showed FLAIR-signal intense arachnoidea and partial diffuse contrast enhancement in the left central sulcus and sylvian fissures bilaterally as well as cerebral and spinal leptomeningeal enhancement (Figs. 1 and 2). There were no parenchymal lesions. A biopsy of one of the contrast enhancing parts of arachnoidea was planned. Unexpectedly, after opening the dura mater, it was noted that the cerebral surface was covered by densely pigmented black tissue. Three cortical biopsies were taken.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 55-year-old male patient presented with a half-month history of intermittent headache; no nausea, weakness, convulsion, fever, or any other symptoms were accompanied. His physical examination was normal. The neurologic examination did not reveal any abnormalities. Laboratory findings were unremarkable. The results of chest radiograph and abdominal ultrasonography were normal. Axial T1-weighted MRI of brain showed heterogeneous enhancement signal in the deep sites of left temporal and insula lobe (Figure 1A). FLAIR sequence showed the lesion was slightly hyperintensity signal surrounded by obvious edema (Figure 1B). Then, a glioma was highly suspected and an operation of subtotal resection was performed under neuronavigation.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 55-year-old male patient had a medical history of nephrotic syndrome and was followed up at a local hospital for many years. He had felt general fatigue for 2 years which became exacerbated 2 months ago. He visited our hospital where a series of laboratory tests showed hyponatremia and hypokalemia accompanied with low cortisol level. Other endocrinologic tests were within normal limits. After transsphenoidal adenomectomy, the patient developed panhypopituitarism, which has been managed by hormone substitution. No adjuvant therapy was administered. The patient made an uneventful recovery and has been receiving regular follow-up at our neurosurgery department without clinical or radiological evidence of a recurrent tumor for 7 years.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 55-year-old Brazilian man, with previous history of bariatric surgery developed acute weakness of his lower limbs that started six weeks prior to his admission. He started with paresthesias in lower limbs followed by ascending and asymmetrical paraparesis. He was unable to walk weeks later. He had no pain, no upper limbs weakness and no loss of bowel or bladder control. Physical examination revealed paraparetic gait, and flaccid asymmetric paraparesis (left > right). Deep tendon reflexes were absent in the legs, with indifferent plantar response. Electroneuromyography was consistent with an acute inflammatory demyelinating polyradiculoneuropathy (Guillain-Barré syndrome). MRI of neuroaxis showed diffuse nodular abnormalities of the leptomeninges, more pronounced in dural sac where formed intra-rachidian mass (Fig 1) and hemorrhagic extra-axial nodular lesions in posterior fossa, basal cisterns and subarachnoid space of cerebral hemispheres (Figs 2 and 3). A second MRI showed larger lesions and more of them (Figs 4 and 5) as well as a new cerebral hemorrhage (Fig 6). An extensive search for the primary site was negative (chest and abdominal CT, cervical and testicular ultrasonography). Cisternal puncture didn't reveal any neoplastic cells and immunophenotyping demonstrated normal lymphocytes. A biopsy of the lesion (dural sac) was performed.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 55-year-old female presented with low back pain radiating to her left leg. The pain started several years ago, and recently getting worse. The pain was intermittent, shooting quality that usually worsened after lying supine for a long time. She denied any bowel or bladder symptoms. Her past medical history and family history was unremarkable. Her physical exam was normal except for left lower extremity was 4+/5 for knee and ankle extension/flexion. She also had mild decreased light-touch sensation in the left L4 and L5 distribution with 2-beat clonus in her left leg. Her big toe was equivocal on the left and downgoing on the right.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

An otherwise healthy 55-year-old male presents to the emergency department following a firecracker exploding in his right hand. He was found to have a large open fracture and a laceration extending to the wrist with exposed bone and partial amputation of the thumb. Later, he developed pulsatile bleeding of the radial artery controlled with direct pressure. He was urgently taken to the OR for debridement and reconstruction. Skin, subcutaneous tissue, muscle, and tendon specimens were sent to the microbiology department for culture.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

This 55 year-old white male had chronic obstructive pulmonary disease, cor pulmonale and left heart failure with a left ventricular ejection fraction of 30%. He had a 48 pack-year smoking history and a remote history of IV cocaine abuse. Prior to his death the patient suffered from recurrent spontaneous pneumothoraces.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

This 55 year-old gentleman is status-post laryngectomy for squamous cell carcinoma of the larynx diagnosed in 2010, complicated by a tracheostomy occlusion, leading to cardiopulmonary arrest and subsequent hypoxic brain injury. He was admitted with new-onset altered mental status, after weakness for approximately 6 months. On admission he was found to be severely malnourished.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 55-year-old man presented for a routine preoperative chest x-ray in preparation for a knee replacement. Imaging revealed an extrapleural paraspinal mass in the region of T8. Fine needle aspiration of the mass was interpreted as melanoma. Neurologic examination was unremarkable. Total body skin examination failed to reveal any suspicious pigmented lesions. The mass was in close connection with the exiting T8 nerve root and somewhat adherent to the sympathetic chain. The mass was removed within an intact capsule. Immunohistochemical staining and electron microscopy of the resected specimen revealed a malignant melanotic schwannoma. The features of melanotic schwannoma, both benign and malignant variants, and their distinction from melanoma are discussed.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient is a 55-year-old man who presented to the ED with gradual worsening of weakness. The patient reports that he had been fatigued for one month, having to rest constantly after work, and feeling exhausted with minimal exertion. He also reported feeling lightheaded with rising, as well as having epigastric abdominal pain, which was not associated with food. Four days prior to the presentation, the patient began to have black, tarry stools. He was evaluated in his primary care physician's office the day prior, and was found to have hemoglobin of 6.5 g/dL. His prior baseline from two weeks ago was 15.3 g/dL. He was subsequently referred to the ED.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 55-year-old African American man with an eight month history of poorly controlled seizures and longstanding history of cirrhosis, diabetes and hypertension was brought to the emergency department for progressively worsening confusion, memory loss and increasing frequency of seizures. On the day of presentation, the patient had a prolonged generalized tonic-clonic seizure. The patient was being treated for a hepatic encephalopathy with lactulose. Within the last eight months he had had a transjugular intrahepatic portal system shunt for management of his end stage liver disease and was awaiting a liver transplant. A non-contrast CT of the head revealed no acute intracranial process. An MRI was subsequently obtained. After admission, the patient's mental status continued to decline and ultimately progressed to multisystem organ failure. He suffered a cardiopulmonary arrest and expired.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 56-year old man with past medical history of surgery for congenital pulmonary valve disease, transient ischemic attack without sequelae, meningitis with brain abscess, hyperuricaemia and atrial fibrillation presented with recently increased tiredness, loss of strength and headache. Physical examination revealed dysarthria, and paresthesia in the left hand. No lymphadenopathies, fever, or weight loss were detected. CT-scan of the chest, abdomen and pelvis revealed no abnormalities, and HIV test was negative. On MRI, two intra-axial masses, hyperintense on T1, with contrast ring enhancement in right thalamo-capsular area, and frontal convexity, were visualized (Fig 1). A stereotactic biopsy of the thalamic lesion was performed. Three weeks later, a grayish, soft mass was resected from the frontal lesion through a right fronto-parietal craniotomy.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient is a 56-year-old woman with history of poorly differentiated squamous cell carcinoma of the esophagus, treated with neoadjuvant chemoradiation and esophagectomy. Approximately three years later, she presented with pancytopenia and was diagnosed with therapy-related myelodysplasia, consistent with refractory anemia with excess blasts-1 (RAEB-1). She was treated with induction (daunorubicin, cytarabine, and cladribine) and consolidation (daunorubicin and cytarabine) chemotherapy. She then received reduced intensity conditioning (fludarabine, cyclophosphamide, and total body irradiation) prior to undergoing double umbilical cord stem cell transplant. On day 35 post-transplant, she developed progressive bilateral loss of vision.