(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 80-year-old man was transferred to our institution with worsening heart failure. His past medical history was significant for Type-2 diabetes mellitus, hypertension, coronary artery disease, chronic obstructive pulmonary disease, emphysema, chronic renal insufficiency and recurrent exacerbations of congestive heart failure. In addition, approximately 5 weeks prior to this admission, he presented at another institution with acute onset of left hemiplegia. Radiographic imaging at the time revealed a right thalamic lesion interpreted to represent acute ischemic changes. He received thrombolytic therapy but showed little improvement in neurological symptoms. He was transferred to a rehabilitation program but there also showed no improvement in neurological symptoms. While in rehabilitation, recurrent heart failure required hospitalization and transfer to this institution. His cardiopulmonary function improved with treatment, but his neurologic status remained unchanged until hospital day ten when he exhibited progressive mental status deterioration. Magnetic resonance imaging (MRI) of the brain showed a ring-enhancing lesion similar to that seen six weeks earlier but now observed to extend into the right basal ganglia and medial temporal lobe with right cerebral hemispheric edema, right-to-left midline shift and asymmetric ventricles (Figure 1, The image has been inverted vertically to correlate with the gross pathologic specimen). These changes were interpreted to be characteristic of a cerebral abscess, but because of the lack of systemic findings, a high-grade intracerebral neoplasm was also considered. Because of his poor clinical status, the patient's family declined a brain biopsy. He died on the eleventh hospital day.

(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 80-year old male with a past medical history of dyslipidemia, hypertension, gout and prostate cancer was evaluated for peripheral blood lymphocytosis.

(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 80 year old man presented with right-sided hip pain and a palpable groin mass. Imaging showed a right acetabular fracture associated with a radiolucent soft tissue mass (Fig. 1). FNA of the mass was consistent with chondrosarcoma. Total hemipelvectomy was performed and the surgical specimen was received in five parts.

(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 an 80-year-old man who presented with the chief complaint of right hemi-scrotal swelling following a history of prostatic adenocarcinoma diagnosed 8 years earlier. The prostate cancer was treated by a combination of radiation therapy and androgen deprivation therapy. Biochemical recurrence of prostatic adenocarcinoma had recently been documented prior to the onset of the swelling. Physical examination revealed a paratesticular mass that was clinically felt to be a benign hydrocele.

(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 81 year-old male with a clinical history of hypertension and hyperlipidemia presented with weakness, confusion, aphasia, and short-term amnesia. Five months prior to presentation he had sustained a stroke involving the left middle cerebral artery. Current imaging by CT scan reveals worsening edema in the vascular territorial distribution of the left middle cerebral artery accompanied an ovoid, mass-like lesion in the left temporal-parietal region. Follow-up MRI revealed, in the anterior aspect of the left temporal lobe and extending into the insula and basal ganglia, a 5.0 x 4.6 x 3.2 cm mass with serpiginous border enhancement. Foci devoid of enhancement were also observed, suggestive of necrosis. The patient subsequently underwent a craniotomy with attempt at gross total resection, yielding an approximate 20 mL aggregate of tissue.

(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 81-year-old man with a previous history of lymphoma and a gastric mass presented with multiple liver masses. Ultrasound-Guided FNA of a liver mass was performed with on-site cytopathology evaluation (Figures 1-4).

(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 81 year-old female presented to the emergency department with complaints of blood in her urine and stool for 1 day and new onset of weakness. She has a history of congestive heart failure, type 2 diabetes, and nonalcoholic steatohepatitis. She had a cough one week ago. At presentation she appeared jaundiced. The patient had no recent blood transfusions. Relevant laboratory values (Table 1) and blood bank test results (Table 2) are reported below.

(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 82 year old female with a medical history of mitral regurgitation and prolapse and moderate coronary artery disease presented to the emergency department with increased dyspnea on exertion. She underwent coronary artery bypass graft and mitral valve repair surgery. A post-operative CBC demonstrated a mildly elevated white blood cell count, normocytic anemia with occasional ovalocytes and acanthocytes and thrombocytopenia. A peripheral blood smear was sent for pathology review.

(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 an 82-year-old man with a history of hypothyroidism and chronic prostatitis, diagnosed with moderate thrombocytopenia on routine complete blood counts. No hepatosplenomegaly or lymphadenopathy were observed. Three months later, thrombocytopenia persisted and a bone marrow biopsy was performed to evaluate for a primary marrow etiology. The following results were reported:

(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 83-year old man with a past medical history significant for meningioma and chronic myelomonocytic leukemia was admitted with fever, speech difficulties, and bruises. Laboratory data showed hyperleukocytosis and his urine culture was positive for Enterococcus faecalis. The patient received antibiotics with partial improvement. On hospital day 3, the patient developed dysarthria and severe right-sided weakness. A CT identified a left frontal meningioma (Figure 1a), surrounded by a subdural collection (Figure 1b). Gadolinium contrast MRI revealed a marked uniform enhancement in the left frontal region (Figure 1c). The collection was evacuated. Cultures collected showed no growth. On postoperative day 2, a CT showed new hyperintense lesions in the temporal and parietal regions. The family did not allow more invasive interventions. The patient passed peacefully on hospital day 8.

(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 83 year old female with a history of non-small cell lung cancer status post left upper lobectomy and adjuvant chemotherapy, deep vein thrombosis and pulmonary embolism on coumadin, chronic obstructive pulmonary disease, and extensive sigmoid diverticulosis presented to an outside hospital with a lower GI bleed and found to have an ulcerated cecal mass, as well as, a polyp concerning for a villous adenoma during colonoscopy. She was stabilized, coumadin was held, and she was scheduled for outpatient follow up. Two weeks later, the patient presented again to the outside hospital emergency department with bright red blood per rectum and was subsequently transferred to UPMC Presbyterian for further management. The patient underwent a right hemicolectomy due to extensive blood loss and multiple peritoneal implants were noted during surgery.

(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 an 83-year old male with a past medical history of hypertension. He presented with an enlarging right supraorbital mass. Physical examination revealed a right supraorbital mass causing proptosis.

(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.)

Physical examination revealed a firm, palpable area in the sacrococcygeal region. The skin overlying this mass was intact, with some erythema and bluish discoloration. A computed tomography scan showed a 10 x 9 x 8 cm soft tissue mass in the sacrococcygeal region.

(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 an 87-year-old male who had a pathology hip fracture in April 2008, admitted with failure of the open reduction and internal fixation, requiring resection of the proximal femur with reconstruction and total hip arthroplasty and the tumor was resected mostly as a palliative measure.

(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 88-year-old woman had been followed for several decades in our Movement Disorders Clinic for very long lasting Parkinsonism. In November 1918, while she was still nursing at age 3 months-old, she and her mother were infected by epidemic encephalitis. Before the age of 10, dystonic postures of the lower limb occurred and progressively worsened, leading to orthopedic deformities. When she was 19, after her first pregnancy, a resting tremor appeared in the left hand. Akinesia and mild hypertonia occurred several years later, with partial improvement during the pregnancies. Her Parkinsonism worsened very slowly and after World War II she was confined to wheelchair. Her Parkinsonism improved with the introduction of levodopa, but severe adverse effects including choreic peak-dose dyskinesia and dystonic movements occurred 3 years later. Mild psychiatric disorders appeared in the long term, along with obsessive compulsive disorders. In 1994, 70 years after the onset of extrapyramidal signs, global cognitive function assessed by the Mattis Dementia Rating Scale was normal for age: 138/144. Brain MRI was normal. 18Fluro-Dopa PET demonstrated a severe bilateral and symmetrical reduction in fluoro-dopa uptake which was more marked in the putamen than in the caudate. Fluctuant cognitive decline significantly occurred at the age of 87, with hallucinations. She finally died at the age of 88 years old.

(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 eight-year-old female patient, who was previously healthy, presented with episodes of a headache followed by recurrent bilateral eyelid movements described as a "heartbeat" that lasts few seconds following by spontaneous remission without loss of consciousness. These symptoms were experienced periodically for about 30 days. On physical examination, the patient showed no motor, sensory, or cognitive deficits. A CT brain scan revealed a left thalamic mass lesion without contrast enhancement. MRI revealed an extensive left thalamic tumor that was hypointense/isointense on T1-weighted MRI, hyperintense on T2-weighted MRI. The sagittal (Figure 1a) and coronal (Figure 1b) views of a T1- weighted MRI after gadolinium injection evidenced no-enhancement of a large anterodorsal left thalamic tumor compressing the third ventricle. While the axial view of a FLAIR MRI showed the hyperintensity of a large tumor in the left thalamus (Figure 1c). A transcranial EEG showed no abnormalities.

(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 was referred to our hospital for the first time in 2004 as an 8-year-old girl with headaches, nausea, and occasional vomiting. A marginally contrast enhancing mass, completely filling out the fourth ventricle, was detected on brain MRI. Gross total resection was achieved and based on the neuropathological diagnosis the patient underwent radiation and chemotherapy. One year later, progredient contrast enhancement was observed in the right cerebellar hemisphere at the bottom of the fourth ventricle, compatible with progredient residual tumor. These parts were again resected. Further cycles of chemotherapy followed, and the patient recovered well. However, 13 years after the first tumor presentation, the patient started to suffer from headaches and eye movement difficulties. On cranial MRI, a new contrast enhancing mass was found in the posterior fossa. Again, the tumor was resected and referred to histological examination. Shortly thereafter, a myelon-compressing intradural T8-T9 mass was detected and irradiation of the posterior fossa and the thoracic spine was started, when the patient presented with an acute transverse spinal cord syndrome. Resection of this spinal tumor was subsequently performed on an emergency basis. However, based on the rapidly progressive, especially meningeal tumor spread observed on MRI, supportive and palliative care was finally initiated.

(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 8-year-old, previously healthy girl presented with a 3-month history of intermittent, progressive night-time and early morning headaches and vomiting, and a three week history of left-sided facial weakness and mild left hemiparesis. Magnetic resonance imaging showed a 5.6 x 4.3 x 4.5 cm T1 hypointense, T2/FLAIR hyperintense mass containing several scattered foci of contrast enhancement centered within the right basal ganglia and medial temporal lobe (Fig. 1A). The mass demonstrated restricted diffusion, and contained no hemorrhage, necrosis, calcification, or surrounding vasogenic edema. The presence of restricted diffusion and heterogenous enhancement on imaging suggested a highly cellular tumor. Given the young age of this patient, the radiological differential considerations included primitive neuroectodermal tumor (PNET) and anaplastic ependymoma especially because of the lack of surrounding vasogenic edema. A stereotactic needle biopsy was performed. The patient was treated with conformal radiation therapy and concurrent chemotherapy with temozolomide, followed by temozolomide and lomustine according to the Children's Oncology Group ACNS0423 protocol. She had clinical and radiographic response to treatment until 7 months following diagnosis, when her hemiparesis returned and she developed vision loss. MRI revealed marked interval progression of her disease with extension into her right optic tract, optic chiasm, and brainstem. She was then treated with bevacizumab and irinotecan. Two months later, she developed further progression with new subependymal spread and extension into the left cerebrum and brainstem. Her therapy was discontinued and she expired 12 months from the date of her initial diagnosis.

(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 8-year-old child presented with symptoms of raised intracranial pressure starting a few days before clinical presentation. Past medical history was significant for Diabetes insipidus centralis, which was diagnosed in February 2001 and treated with Minirin®. Neurological examination was normal.

(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.)

Her initial physical exam in the emergency department revealed a distended, non-tender lower abdomen with a large palpable midline mass. The remainder of her physical exam was unremarkable. Initial laboratory workup was unremarkable, including normal levels AFP, hCG, LDH, CEA-125, and estriol. She underwent ultrasound of the abdomen and CT scan of the chest, abdomen, and pelvis (Figure 1). The CT scan revealed a solid, enhancing, 19 x 12 x 10 cm multilobulated mass arising from the left aspect of the uterus. This mass distorted the endometrial cavity and exerted significant mass effect on the iliac veins, iliac arteries, and distal ureters. The remainder of the abdominal and thoracic CT was unremarkable. The initial interpretation was worrisome for uterine malignancy, such as leiomyosarcoma or other uterine sarcomas. There was also some concern, based on the combined interpretation of the CT and ultrasound, that the mass could be arising from one or both ovaries. After discussion with the patient and her family of the above findings, and because the patient was clinically stable, she was discharged to home with short interval follow-up. A subsequent MRI of the abdomen and pelvis two days later as an outpatient showed normal appearing ovaries and re-demonstrated the large uterine mass (Figure 2).