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

Images in Medicine

1. Cutaneous Leishmaniasis

Umber Dube et al, Published April 23, 2025, N Engl J Med 2025;392: e41, VOL. 392 NO. 16

2. Abdominal Aortic Occlusion from Left Atrial Myxoma Embolism

Chirag A. Buch et al, Published April 30, 2025, N Engl J Med 2025;392:1732, DOI: 10.1056/NEJMicm2414920, VOL. 392 NO. 17

Abstract

A 26-year-old man presented with acute leg pain and loss of function in the left leg. CTA of the abdomen showed a saddle embolus at the aortoiliac junction. A heterogeneous mass was seen in the left atrium.

3. Cholelithiasis, Cholecystitis, and Choledocholithiasis

Zhuo-Long Tu, Published April 26, 2025, N Engl J Med 2025;392: e42, DOI: 10.1056/NEJMicm2412996,VOL. 392 NO. 17

Abstract

An 80-year-old woman presented with a 3-day history of abdominal pain. Imaging revealed numerous small gallstones in the gallbladder and cystic duct, consistent with cholecystitis.

4. Challenges in Clinical Electrocardiography, May 5, 2025: An Ominous Electrocardiographic Pattern in Undefined Syncope

Guangqiang Wang etal, JAMA Intern Med. Published online May 5, 2025. doi:10.1001/jamainternmed.2025.0979

Case Presentation

Aman in his late 60s presented to the emergency department with a 3-month history of recurrent spontaneous chest tightness, palpitations, and syncope. His cardiac risk factors included hypertension and type 2 diabetes. On admission, his vital signs were normal. Cardiopulmonary and neurological examination results were normal, and the initial electrocardiogram (ECG) showed negative T waves in multiple leads. Transthoracic echocardiography revealed left ventricular hypertrophy with normal left ventricular contraction and no regional wall kinetics abnormalities. After admission, he experienced similar symptoms without loss of consciousness while at rest. The patient’s symptoms resolved within 5 minutes of onset. Holter monitoring during this episode is shown in the Figure.

 

A, Compared with lead V1, lead II showed the onset and termination of spontaneous ischemic episodes with progression and resolution of ST-segment elevation, followed by an R-on-T ventricular extrasystole, a couplet of ventricular extrasystoles, or polymorphic ventricular tachycardia during the symptomatic period. B, The 12-lead electrocardiogram (ECG) revealed a typical lambda pattern, including a prominent J wave, down-sloping ST-segment elevation, QT prolongation, and deep T-wave inversion, followed by an R-on-T ventricular extrasystole or polymorphic ventricular tachycardia in multiple leads, especially in leads V2 through V4. The arrowhead indicates the typical lambda pattern.

Questions: What is the most likely diagnosis based on ECG changes, and what should be the next step?

Interpretation

Holter monitoring recorded episodes of ST-segment elevation (STE) with frequent R-on-T ventricular extrasystoles, nonsustained polymorphic ventricular tachycardia (VT), and VT resolution consistent with the resolution of STE during the symptomatic period (Figure A). Given the Holter documentation of transient myocardial ischemia, variant angina (VA) was suspected. During the progression of STE, QRS-ST-T configurations with J waves resembling typical lambda waves were presented in leads V2 through V4 (Figure B). All lambda waves spontaneously occurred in leads I, II, aVF, aVL, and V2 through V5, indicating the territory of multivessel spasm. Malignant features of the typical lambda pattern, including a prominent J-wave, STE, QT prolongation, and increased T-wave width and depth, were evident in leads V2 through V4. Moreover, the lambda pattern was followed by a closely coupled R-on-T ventricular extrasystole or paroxysmal polymorphic VT.

The patient did not undergo the ergonovine or acetylcholine provocation test due to the malignant arrhythmia induced by coronary vasospasm. However, a successful coronary angioplasty with stenting of the proximal left anterior descending artery (LAD) was performed using intravascular ultrasonography. The coronary angioplasty revealed a 75% fixed focal stenosis in the proximal LAD. Routine medications included aspirin, clopidogrel, diltiazem, isosorbide dinitrate, and atorvastatin. During a 6-month follow-up period, the patient remained symptom free, and no episodes of life-threatening arrhythmias were documented on repeated Holter monitoring.

Discussion

VA is often overlooked and clinically underdiagnosed, particularly in cases of unexplained syncope. Therefore, Holter monitoring is crucial for detecting vasospastic attacks and lethal arrhythmias.1 VA is a clinical syndrome characterized by transient, reversible ST-segment changes on ECG, coinciding with recurrent anginal episodes at rest. Approximately 3% to 14% of patients with VA develop fatal arrhythmias, such as atrioventricular block, asystole, VT, and ventricular fibrillation (VF), leading to syncope and sudden cardiac death (SCD) during ischemic attacks.2 The primary challenge in VA diagnosis occurs when coexisting coronary artery obstructive stenosis is present. Coronary vasospasm occurs at the site of preexisting organic stenosis in 90% of patients.3 Moreover, the spasm diffusely affected multiple coronary arteries in this patient.

An ECG pattern with both an initial-QRS upsloping and end-QRS slurring concomitant with steep down-sloping STE landing on an inverted T wave in a case of Brugada syndrome was reported by Riera et al.4 The QRS-ST-T complex resembles the Greek letter λ, which was referred to as the lambda wave by Gussak et al.5 Furthermore, the lambda pattern, a monophasic curve, is observed in VA. In precordial leads, the typical lambda pattern has been shown to be associated with impending polymorphic VT or VF, occurring with severe myocardial ischemia at the maximum STE, specifically involving the LAD territory (Figure B). The typical lambda pattern is associated with a long duration of ischemic attack and has always preceded malignant arrhythmias.6

Malignant arrhythmias are closely related to the degree and duration of STE, which indicates the severity of ischemia. The most severe arrhythmias occurred during the crisis, particularly at the highest STE.7 Myocardial ischemia can increase the T-wave width and depth, and prolong the corrected QT interval. Therefore, the duration and degree of myocardial ischemia associated with vasospasm play crucial roles in the occurrence of life-threatening arrhythmias and SCD.1

Long-acting calcium channel antagonists and nitrates, with the cessation of β-blockers, are highly effective in preventing coronary vasospasms and related arrhythmias. Although outcomes following stenting in patients with VA are controversial, coronary stenting is typically indicated in patients with discrete obstructive lesions and vasospasms.2 The presence of recurrent life-threatening ventricular tachyarrhythmias should be considered for implantable cardioverter-defibrillator implantation in patients with refractory VA.8 Timely intervention can be lifesaving.

In conclusion, the appearance of a unique lambda pattern, an uncommon ECG pattern, can indicate coronary vasospasm and predict imminent malignant arrhythmias in patients with VA. Physicians should immediately identify these patterns and implement proactive intervention measures.

Take-Home Points

The transient lambda pattern is a rare and profound ECG indicator of coronary vasospasm in vasospastic angina.

As a warning sign of electrical instability, the lambda pattern serves as an independent, simple, and intuitive parameter for predicting the occurrence of impending malignant arrhythmias, a risk factor for SCD in patients with VA.

Life-threatening arrhythmias, including ventricular tachyarrhythmias and bradyarrhythmias, may be associated with the location and degree of coronary vasospasm in patients with VA.

Timely invention can play a lifesaving role in high-risk patients with VA, and Holter monitoring can provide a diagnostic tool for evaluating the efficacy of medical therapy in patients with VA and syncope.

5. Central Nervous System Tuberculomas

In-Suk Bae etal, Published May 3, 2025,N Engl J Med 2025;392:1846,DOI: 10.1056/NEJMicm2415077,VOL. 392 NO. 18

Abstract

A 57-year-old man with previously treated pulmonary tuberculosis presented with a 2-week history of neck pain, headache, and tingling in his hand. MRI of the head showed numerous small, peripherally enhancing nodules.

6. Sea Anemone Sting

Weniko Caré etal, Published May 7, 2025, N Engl J Med 2025;392: e43,DOI: 10.1056/NEJMicm2416009,VOL. 392 NO.

Abstract

A 28-year-old woman presented with a painful rash 5 days after a fall on sea rocks. On examination, fine, erythematous, linear lesions in a stellate distribution on the posterior right thigh were seen.

7. Paget’s Disease of Bone

Masashi Hasebe et al, Published May 10, 2025,DOI: 10.1056/NEJMicm2414362

Abstract

An 80-year-old woman presented with a several-year history of gradual forehead enlargement and progressive hearing loss. Radiography of the skull showed marked thickening of the calvarium, with a cotton-wool appearance.

8. Hair Tourniquet

Anton Ivan Moorees,Published May 14, 2025,N Engl J Med 2025;392: e44,DOI: 10.1056/NEJMicm2416174,VOL. 392 NO. 19

Abstract

A 6-month-old girl was brought to the ED with a 3-day history of redness and swelling of the left fourth toe. A circumferential ring was seen constricting the middle phalanx of the toe.

9. Torsion of a Mature Cystic Ovarian Teratoma

Xiaodong Zhang et al, Published May 14, 2025,N Engl J Med 2025;392: e45,DOI: 10.1056/NEJMicm2415320, VOL. 392 NO. 19

Abstract

A 59-year-old woman presented with a 1-day history of lower abdominal pain. Magnetic resonance imaging showed an adnexal mass with sack-of-marbles and whirlpool signs.

10. Acute Superior Mesenteric Vein Thrombosis and Small-Bowel Infarction et al, Published May 28, 2025,N Engl J Med 2025;392:2048,DOI: 10.1056/NEJMicm2500451,VOL. 392 NO. 20

Abstract

A 68-year-old man with cirrhosis presented with a 2-day history of severe abdominal pain. CT showed thrombosis of the superior mesenteric vein.

11. Insulin-Derived Amyloidosis

Daniel Connors and Philip Chia, Published May 28, 2025,N Engl J Med 2025;392: e50,DOI: 10.1056/NEJMicm2415719,VOL. 392 NO. 20

Abstract

A 47-year-old man with type 2 diabetes presented with several years of progressive growth of pendulous skin lesions on his lower abdominal wall where he had repeatedly injected insulin.

12. Sarah Servattalab, Published May 24, 2025,N Engl J Med 2025;392: e51,DOI: 10.1056/NEJMicm2414170,VOL. 392 NO. 20

Abstract

A full-term baby boy was evaluated at a quaternary care hospital for a large, violaceous, firm, hypertrichotic plaque on the right side of the back. Laboratory studies showed thrombocytopenia and low fibrinogen and elevated d-dimer levels.

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