#Image_Challenge#NEJM – QPreTest Medical

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A previously healthy, full-term, 2-month-old boy was brought to the dermatology clinic with a 2-week history of annular plaques with edematous borders and central crusting on the face, scalp, and trunk. Results of a complete blood count and comprehensive metabolic panel were normal. Examination of a skin-biopsy sample obtained from the baby’s right forehead showed vacuolar interface dermatitis and perivascular and periadnexal lymphocytic infiltrates. Which of the following is the most likely underlying cause of this baby’s findings?

Cutaneous Langerhans cell histiocytosis

Impetigo

Milia

Neonatal lupus erythematosus

Tinea corporis

None

A full-term baby boy was transferred to the neonatal intensive care unit (NICU) at 30 hours of age owing to abdominal distention and failure to pass meconium. Before the transfer, the baby had fed poorly and regurgitated colostrum. A nasogastric tube had drained yellow fluid. An abdominal radiograph had shown dilated loops of small intestine. At the NICU, a bedside abdominal ultrasonogram showed possible reversal of the superior mesenteric vessels, and an urgent laparotomy was performed. Considerable distention of the small bowel by thick meconium was identified. Which of the following is the most likely underlying cause of this patient’s symptoms?

Congenital chloride diarrhea

Cystic fibrosis

Hirschsprung’s disease

Hypothyroidism

Intestinal atresia

None

Share on A 40-year-old man in the intensive care unit (ICU) was noted to have red urine. Eight hours earlier, he had been found unconscious in a fume-filled car. Cardiopulmonary resuscitation had been initiated for asystole, which resulted in the return of spontaneous circulation. Endotracheal intubation was performed and he received treatment for inhalation of car fumes. Which of the following is the most likely cause of this patient’s red urine?

Hematuria

Hydroxocobalamin-induced discoloration

Myoglobinuria

Porphyria

Rifampin-induced discoloration

None

A 22-year-old man presented to the dermatology clinic with a 1-year history of a red, scaly rash on his face and body. On physical examination, widespread erythroderma with overlying erosions, scaling, and crusting was observed. The oral mucosa was spared. A skin biopsy from the back showed superficial acantholysis (the loss of adhesion between keratinocytes). Direct immunofluorescence of the biopsy specimen showed intercellular IgG antibodies against desmoglein-1 in the superficial layers of the epidermis. What is the most likely diagnosis?

Bullous pemphigoid

Dermatitis herpetiformis

IgA pemphigus

Pemphigus foliaceus

Pemphigus vulgaris

None

A previously healthy 2-year-old boy was brought to clinic with a 1-week history of itchy, red spots. Three days before the onset of the rash, the child had had an upper respiratory infection for which he had been given ibuprofen. On physical examination, tense vesicles and edematous pink plaques with central erosions and crust were seen on the patient’s legs, arms, and back. Dense clustering of skin lesions was observed in the axillae and inguinal folds. No mucosal involvement was noted. Histopathological analysis of a skin-biopsy sample obtained from the right lower back showed a subepidermal blister with robust neutrophilic infiltration. Direct immunofluorescence revealed a linear band of IgA along the dermoepidermal junction. What is the most likely diagnosis?

Acute febrile neutrophilic dermatosis

Dermatitis herpetiformis

Erythema multiforme

Henoch-Schonlein purpura

Linear IgA bullous dermatosis of childhood

None

Behcet’s disease

Bullous pemphigoid

Linear IgA bullous dermatosis

Pemphigus foliaceus

Pemphigus vulgaris

None

A 62-year-old man presented with a 5-day history of low back pain and a 1-day history of lethargy. Physical examination was notable for tenderness over the lumbar spine and a normal neurologic examination. Radiographs of the lumbar spine showed gas within L4. Computed tomography of the lumbar spine confirmed the presence of intramedullary gas within L4, and also showed that the gas extended into the surrounding soft tissue, epidural space, and psoas muscles. What is the most likely etiology of this skeletal finding?

Air embolism

Calcium oxalate crystal deposition

Emphysematous osteomyelitis

Iatrogenic

Osteonecrosis

None

A 19-year-old man presented with a 3-week history of an asymptomatic rash on his neck. He worked as a beach lifeguard in southern California and reported no recent international travel. On physical examination, two erythematous, raised, serpiginous eruptions were seen on the neck — one on the posterior surface and another on the right lateral surface. A punch biopsy showed nonspecific inflammation. A potassium hydroxide scraping was negative for fungal elements. What is the diagnosis?

Cutaneous larva migrans

Larva currens

Loiasis

Tinea corporis

Scabies

None

An 84-year-old man with a history of melanoma of the right forehead complicated by in-transit metastases to the scalp presented to the dermatology clinic. Seven months prior, treatment with two immunotherapy agents had been started, which had resulted in shrinking of the metastatic scalp nodules. On physical examination, there were multiple blue-gray macules on the scalp, as well as an unhealed ulcer from trauma. Dermoscopy-guided biopsy of four macules revealed scattered melanin-laden macrophages within the superficial and middle dermis without any evidence of residual melanoma. Immunohistochemical staining of a biopsy sample for markers of melanoma was also negative. What is the most likely diagnosis?

Lentigo maligna

Metastatic melanoma

Post inflammatory hyperpigmentation

Solar lentigo

Tumoral melanosis

None

A 29-year-old man with well-controlled human immunodeficiency virus infection presented with a 1-week history of a painful, whitish discoloration on his tongue. He also reported a 4-week history of painful ulcers on the scrotum. Physical examination showed smooth, pink, guttate macules on the tongue that were within a white coating that did not wipe off. No rash, ulcer, or lymphadenopathy was seen on genital examination; the reported lesions were presumed to have already resolved. Which of the following is the most likely cause of this patient’s tongue changes?

Geographic tongue

Lichen Planus

Oral leukoplakia

Secondary syphilis

Squamous Cell Carcinoma

None

A previously healthy 10-month-old girl was referred to the pediatric dermatology clinic with a 6-month history of an intermittently itchy and swollen skin lesion on her neck that had gradually increased in size. On physical examination, a thin, well-demarcated, tan plaque was seen on the neck. The lesion was rubbed firmly with a tongue depressor for 5 seconds, and within a few minutes it became edematous with a flare of surrounding erythema — a finding known as Darier’s sign. What is the most likely diagnosis?

Dermatofibroma

Juvenile Xanthogranuloma (JXG)

Langerhans Cell Histiocytosis (LCH)

Solitary Mastocytoma

Spitz Nevus

None

A 34-year-old woman with human immunodeficiency virus (HIV) infection presented with a 3-day history of a blind spot in her right eye. One week before the current presentation, the HIV viral load was 57 copies per milliliter (reference value,

Cytomegalovirus retinitis

Herpes simplex retinitis

HIV retinopathy

Retinal vasculitis from ocular syphilis

Toxoplasma retinitis

None

A 66-year-old woman with a history of metastatic breast cancer presented with a 1-month history of an asymptomatic, lacy rash on her left thigh. The rash did not vary with changes in environmental temperature. Her breast cancer treatment had been interrupted 3 months before presentation by the coronavirus disease 2019 pandemic. Physical examination was notable for an irregular, broken, netlike pattern of mottling on the left thigh that extended to the knee and lower leg. Testing for autoimmune conditions, thrombophilia, and coagulation disorders was negative. A skin-biopsy sample obtained from the left thigh showed atypical large cells within the vasculature of the reticular dermis that were positive for cytokeratin 7 and GATA-binding protein 3 on immunohistochemical staining. What is the diagnosis?

Cutis marmorata

Erythema ab igne

Intravascular lymphoma

Livedo racemosa

Livedo reticularis

None

A previously healthy 4-year-old girl presented to the emergency department with a 3-day history of dry cough and fever. On physical examination, intercostal retractions and decreased breath sounds over the left lung were observed. A chest radiograph is shown. What is the most likely diagnosis?

Bronchogenic cyst

Pulmonary abscess

Pulmonary infarct

Pulmonary metastasis

Round Pneumonia

None

A previously healthy 3-year-old boy was brought to the emergency department with a 6-week history of painless bumps and ulcers on his left leg. He initially had itchy insect bites on his foot and then bumps and ulcers had developed slowly on his leg. The boy had recently immigrated from Venezuela after a months-long journey by land with his family. On physical examination, ulcerated plaques with rolled borders and satellite papules were observed on the left lower leg, buttocks, and back. Three biopsy samples were obtained from one of the lesions. Histopathological analysis was notable for severe lymphohistiocytic infiltration with no organisms identified by routine microbiologic stains. What is the most likely diagnosis?

Brown recluse spider bites

Cutaneous Leishmaniasis

Leprosy

Phaeohyphomycosis

Pyoderma gangrenosum

None

An 84-year-old man with benign prostatic hyperplasia who had been admitted to the hospital with acute kidney injury due to obstructive uropathy was noted to have gray skin. The skin changes had been present for 5 years. On physical examination, diffuse slate-gray pigmentation of the skin, particularly on the face, hands and nails, and sclera, was seen. A skin biopsy revealed small, dark granules in the basement membrane of sweat glands and in pilosebaceous units, blood vessels, and elastic fibers in the dermis. What is the diagnosis?

Amiodarone-induced hyperpigmentation

Argyria

Hemochromatosis

Minocycline-induced hyperpigmentation

Wilson’s disease

None

A 26-year-old man presented with sudden onset of severe pain in the legs and inability to move the left leg. On physical examination, he had complete loss of motor function in the left leg. Bedside ultrasonographic examination with color Doppler showed no blood flow in the distal aorta. Computed tomographic angiography of the abdomen revealed a saddle embolus at the aortoiliac junction (left). Emergency aortoiliac embolectomy was performed, and a gelatinous mass was removed. A subsequent transthoracic echocardiogram identified a heterogeneous mass in the left atrium (middle). On hospital day 2, cardiothoracic surgery was performed to remove the left atrial mass, and a villous, friable lesion was excised (right). Histopathology of the cardiac mass showed abundant mucopolysaccharide matrix with scattered nests of lepidic cells. What is the diagnosis?

Cardiac myxoma

Cardiac sarcoma

Intracardiac thrombus

Marantic endocarditis

Papillary fibroelastoma

None

A newborn boy was admitted to the neonatal intensive care unit for management of a congenital abnormality, which had first been identified on an antenatal ultrasound image at 20 weeks’ gestation. A physical examination was notable for the presence of a red, fluid-filled sac, measuring 7.7 cm by 7.1 cm by 5.3 cm, that protruded through a lumbosacral defect. Subsequent magnetic resonance imaging of the spine confirmed the finding. What is the most likely diagnosis?

Dandy-Walker syndrome

Hemangioma

Meningocele

Presacral neurenteric cyst

Spina bifida occulta

None

A 63-year-old man with a history of coronary-artery bypass grafting presented with a 2-month history of angina that occurred during exertion of the left arm. Five years before presentation, he had undergone grafting of the left internal thoracic artery (LITA) to the left anterior descending (LAD) coronary artery. The blood pressure was 128/84 mm Hg in the right arm and unmeasurable in the left arm. On physical examination, the brachial and radial pulses on the left side were feeble. A computed tomographic angiogram of the aorta and neck vessels showed total occlusion of the subclavian artery on the left side, proximal to the origin of the LITA. Which of the following is the most likely diagnosis?

Aortic Arch Syndrome

Congenital Atretic Subclavian Artery

Coronary-Artery Bypass Graft Failure

Coronary-Subclavian Steal Syndrome

Thoracic Outlet Syndrome

None

A previously healthy 10-year-old boy was brought to the pediatric emergency department with a 4-day history of progressively worsening bruising around the eyelids. Four weeks prior, he developed a dry cough, which had intensified over the previous week. The patient was up to date on routine vaccinations and had no history of trauma or bleeding disorders. On physical examination, ecchymosis was noted on the eyelids, along with subconjunctival hemorrhages in both eyes. A complete ophthalmologic examination was otherwise normal. Which of the following is the most likely etiology of the patient’s symptoms and findings?

Acute lymphoblastic leukemia

Influenza

Inhaled foreign body

Leptospirosis

Pertussis

None

A 28-year-old woman presented with a painful rash on her right thigh. Five days before presentation, she had been walking on sea rocks on an island in the Cyclades region of Greece when she fell, landing on her buttocks. She immediately felt a severe pain in her right thigh, and an itchy, red lesion developed. On physical examination at the current presentation, innumerable fine, erythematous, linear lesions in a stellate distribution, with central clearing, on the posterior right thigh were seen. By what marine animal did the patient most likely get stung?

Coral

Jellyfish

Sea anemone

Sea urchin

Stingray

None

A previously healthy 32-year-old woman presented with a 2-hour history of severe chest pain at rest. An electrocardiogram showed ST-segment elevations in leads II, III, and aVF with reciprocal ST-segment depressions in leads I and aVL. An initial troponin I level was normal. Owing to concern for acute coronary syndrome, emergency coronary angiography was performed, which showed an abrupt caliber change extending from the proximal to the distal right coronary artery. What is the most likely etiology of arterial injury?

Atherosclerotic plaque rupture and distal occlusion

Atherosclerotic stenosis

Coronary arteritis

Dissection

Vasospasm

None

A 40-year-old man presented with a 2-day history of a burning rash on both hands. Physical examination was notable for a confluent region of erythema extending from the dorsal aspect of the thumbs to the medial aspect of the second finger. Scattered patches of erythema were observed on the knuckles and other fingers, and a small blister was noted on the base of the left thumb. What is the most likely diagnosis?

Atopic dermatitis

Hand, foot, and mouth disease

Irritant contact dermatitis

Phytophotodermatitis

Porphyria cutanea tarda

None

A 62-year-old man reported acute left retro-orbital pain of one week's duration. Physical examination revealed no abnormalities. Three days later, double vision developed, and the next day a rash appeared on the forehead. On repeated examination, it was noted that the patient had swelling of the left upper eyelid, conjunctival congestion, restricted abduction of the left eye, What is the diagnosis?

Left facial palsy

Cavernous sinus thrombosis

Orbital lymphoma

Herpes zoster ophthalmicus

Orbtial fracture

None

A 24-year-old man with thalassemia major was seen for joint pain without swelling in both ankles and hands. He had received a total of 37 transfusions. He had a fetal hemoglobin value of 94 percent and an A2 hemoglobin value of 1 percent; his father had a high percentage of A2 hemoglobin, and his mother a high percentage of fetal hemoglobin and a normal A2 hemoglobin value. What process is illustrated in the radiograph?

Paget's disease

Osteopetrosis

Hyperparathyroidism

Bone marrow hyperplasia

Acromegaly

None

A 6-month-old girl was brought to the emergency department with a 3-day history of redness and swelling of a toe. A physical examination is shown. Which of the following is the most likely underlying cause of the findings?

Allergic reaction

Cellulitis

Hair tourniquet

Non-accidental trauma

Insect bite

None

A 68-year-old man with cirrhosis presented to the emergency department with a 2-day history of severe abdominal pain. On physical examination, hypoactive bowel sounds, pain with palpation, and rebound tenderness throughout the abdomen were noted. Computed tomography of the abdomen with administration of contrast material showed thrombosis of the superior mesenteric vein (left, arrows). What complication of superior mesenteric vein thrombosis was also seen on imaging?

Ascites

Ischemic Colitis

Portal hypertension

Small-Bowel Perforation

Small-Bowel Infarction

None

A 90-year-old man with atrial fibrillation and dementia presented to the hospital with sudden onset of dyspnea that had begun 1 hour earlier. Before admission, he had not been taking anticoagulation therapy on the basis of discussions of his preferences with his primary care physician. Physical examination was notable for tachypnea and tachycardia. On chest radiography, the pulmonary vasculature was not visible in the right lung fields. In addition, the right descending pulmonary artery was enlarged. What diagnosis is suggested by these chest radiograph appearances?

Ascending Aortic Aneurysm

Atrial septal defect

Bullous emphysema

Pulmonary embolism

Pulmonary arterial hypertension

None

Atopic dermatitis

Hand, foot, and mouth disease

Irritant contact dermatitis

Phytophotodermatitis

Porphyria cutanea tard

None

A previously healthy 18-month-old girl was brought to the emergency department with sudden-onset abdominal distention that had been preceded by 3 days of diarrhea and 1 day of vomiting. On physical examination, the patient appeared lethargic and dehydrated. The abdomen was markedly distended with decreased bowel sounds, but there was no tenderness or guarding. An abdominal radiograph, obtained with the patient in the supine position, showed three circular radiopaque objects in the intestines, along with dilated loops of bowel. What is the most appropriate next step in this case?

Colonoscopy retrieval

Emergency exploratory laparotomy

Laxatives

Observation and monitoring

Serial imaging

None

A 30-year-old man presented with a 6-month history of depressed skin lesions on his back. On physical examination, numerous well-defined, erythematous, atrophic plaques were noted across the back. A fluorescence staining preparation of skin scrapings showed thick fungal hyphae and yeast cells with a “spaghetti and meatballs” pattern. What is the most likely causative organism for this skin infection?

Candida species

Epidermophyton species

Malassezia species

Microsporum species

Trichophyton species

None

A 3-year-old boy was brought to the endocrinology department with an 18-month history of bowing of the left leg that had resulted in regression of his ability to walk. On physical examination, there was lateral bowing of the left femur and anterior bowing of the left tibia, as well as testicular enlargement. Café au lait spots were also noted on the lower back, cheek, and neck. Radiographs of the wrist, femur, and tibia on the left side showed fibrous dysplasia (arrows) and rickets. What is the most likely diagnosis in this case?

Carney complex

Fanconi anemia

McCune–Albright syndrome

Neurofibromatosis type 1 (NF1)

Osteofibrous dysplasia

None

121210

None

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