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 clinical medicine

(1). Bronchial Casts from Inhalation of Forest-Fire Smoke

Yuling Wang etal, Published April 18, 2026,DOI: 10.1056/NEJMicm2518379

Abstract

An 87-year-old man presented with difficulty breathing after having inhaled thick smoke from a forest fire for several hours. Respiratory failure developed. On flexible bronchoscopy, black casts were seen in the airway.

(2). An otherwise healthy 30-year-old man presented to clinic for a 2-year history of skin lesions on his right foot. He worked as an agricultural laborer and had sustained injuries to his feet over the years, including a puncture lesion in between the fourth and fifth toes of his right foot. What is the most likely diagnosis?

Chromoblastomycosis

Cutaneous tuberculosis

Mycetoma ( Right answer)

Mycobacterium ulcerans

Tetanus

(3). Vibrio vulnificus Necrotizing Soft-Tissue Infection

Natalie Rosseau et al, Published April 22, 2026,N Engl J Med 2026;394: e31. DOI: 10.1056/NEJMicm2600207,VOL. 394 NO. 16

A 74-year-old man presented to the emergency department with a 3-day history of a painful laceration on his right leg that he had sustained while jumping into waters off the Gulf Coast of Florida. Two days after the injury to his leg, skin changes had appeared on his right arm. He had no known history of chronic liver disease or an immunocompromising condition. On physical examination, ecchymosis, crepitus, and desquamation of the right lower leg were observed (Panel A). The right forearm had erythema, swelling, and ecchymosis with a hemorrhagic bulla (Panel B). Urgent surgical débridement of the arm and leg was performed. Blood and tissue cultures grew Vibrio vulnificus. A diagnosis of V. vulnificus necrotizing soft-tissue infection was made. V. vulnificus is found in warm, low-salinity coastal and estuarine waters. Transmission occurs primarily through consumption of undercooked seafood or exposure of open wounds to water containing the bacteria. The abundance and geographic range of V. vulnificus is projected to increase owing to factors related to climate change, including rising water temperatures, storm surges, salinity changes, and algal blooms. This patient was ultimately treated with above-the-knee amputation and meshed autografting of the forearm, and he completed a course of ceftriaxone and doxycycline. At 6 months after autografting and amputation, the forearm (Panel C) and amputation site had healed well.

(4). Membranoproliferative Glomerulonephritis Due to Cryoglobulinemia

Noriaki Kawano, Published April 25, 2026,DOI: 10.1056/NEJMicm2513605

A 60-year-old woman with stage II follicular lymphoma, for which she was undergoing monitoring for disease progression but was not receiving active treatment, was referred to the hospital for evaluation of leg swelling and proteinuria that had persisted for 2 weeks. She also had a rash on her lower legs that was provoked by cold temperatures. Physical examination was notable for edema in both legs with overlying livedo reticularis. Laboratory studies showed a rapid rise in the urea nitrogen and creatinine levels and nephrotic-range proteinuria. An IgG kappa monoclonal protein was also detected. Blood complement levels and the results of antibody testing for hepatitis C virus were normal. The patient’s plasma was clear at 37°C but turbid at 4°C (Panel A) a sign of temperature-dependent precipitation of cryoglobulins. A semiquantitative cryocrit was 25% (normal result, undetectable). A kidney biopsy revealed endocapillary proliferative glomerulonephritis (Panel B, hematoxylin and eosin stain) with intraglomerular hyaline pseudothrombi created by cryoglobulin deposits (Panel C, periodic acid–Schiff stain). Immunofluorescence staining showed diffuse granular IgG deposits (Panel D). A diagnosis of type I (i.e., monoclonal immunoglobulin-related) cryoglobulinemia resulting in membranoproliferative glomerulonephritis was made. The patient began treatment with glucocorticoids for cryoglobulinemia-associated glomerulonephritis and rituximab-based therapy for lymphoma. Three months after initiation of treatment, the patient’s kidney function improved, and her condition remained in remission at 12 months.

(5). Barrett’s Esophagus

Rebecca C. Fitzgerald, Published April 29, 2026,N Engl J Med 2026;394:1723-1735,DOI: 10.1056/NEJMcp2506887,VOL. 394 NO. 17

Summary

Barrett’s esophagus develops as a result of chronic acid and bile reflux and carries an increased risk of esophageal adenocarcinoma. Because it has no specific symptoms, many patients do not receive a diagnosis, or they present with symptoms of gastroesophageal reflux disease and other related risk factors or complications. Diagnosis relies on endoscopic and histopathological findings, including a visible columnar-cell–lined segment measuring at least 1 cm long that contains intestinal metaplasia with goblet cells. Ongoing surveillance focuses on early detection of malignant progression, particularly high-grade dysplasia and early-stage cancer, which allows curative endoscopic treatment and avoids the adverse effects associated with chemotherapy or esophagectomy. Participation in clinical trials is encouraged to improve detection, risk stratification, and management strategies.

(6). Erythema Multiforme Inês Pereira Amaral et al, Published May 6, 2026,N Engl J Med 2026;394: e36,DOI: 10.1056/NEJMicm2517901,VOL. 394 NO. 18

A previously healthy 22-year-old man presented to the emergency department with a 5-day history of painful lesions on his hands, feet, and mouth, with accompanying fever and malaise. Two months earlier, he had had a similar episode. His temperature was 39.1°C. On physical examination, hemorrhagic crusting of the lips, an ulceration at the right commissure of the mouth, and shallow erosions on the tongue, palate, and buccal mucosa were observed (Panel A). Target lesions with central vesicles were also found on the palms (Panel B) and soles. Polymerase-chain-reaction testing of a swab sample from the lip ulceration was positive for herpes simplex virus (HSV) type 1. Testing was negative for human immunodeficiency virus and syphilis. A diagnosis of erythema multiforme associated with HSV infection was made. Erythema multiforme is an acute, immune-mediated mucocutaneous reaction that is most commonly triggered by infection. It may also be idiopathic or associated with medication. It can be accompanied by systemic symptoms in severe cases and may have a recurring course, as in this patient. Owing to discomfort associated with oral intake, the patient was treated with systemic glucocorticoids, along with therapeutic and then prophylactic antiviral therapy. Three weeks after presentation, the lesions had abated and had not recurred (Panels C and D).  –

(7). Cerebral Syphilitic Gumma

Ke Xiao, Published May 9, 2026,DOI: 10.1056/NEJMicm2518333

A 50-year-old man presented to the emergency department with a 1-month history of headache and worsening weakness of the left arm and leg. Physical examination was notable for the patient’s inability to raise his left arm against gravity or lift his left leg against resistance. Magnetic resonance imaging of the brain after the administration of contrast material showed an enhancing lesion with extensive surrounding edema adjacent to the cerebral falx in the right frontoparietal lobe (Panel A, arrow; T1-weighted, sagittal view). A serum Treponema pallidum particle agglutination (TPPA) assay was positive, and the titer was 1:16 on a toluidine red unheated serum test (TRUST). Testing for human immunodeficiency virus was negative. An analysis of the cerebrospinal fluid showed lymphocytic pleocytosis with a positive TPPA result. Histopathological analysis of a biopsy sample of the brain lesion showed abundant plasma-cell infiltration with arteriolitis (Panel B) and spirochetes on immunohistochemical staining (Panel C). A diagnosis of cerebral syphilitic gumma — a rare manifestation of long-standing syphilis — was made. Treatment with a 2-week course of intravenous penicillin was given. Seven weeks after the completion of treatment, the weakness of the left side had abated, the brain lesion had substantially decreased in size (Panel D), and the TRUST titer had decreased to 1:2.

(8). Inhalation Injury from House Fire Smoke

Juan Huang et al, Published May 13, 2026,N Engl J Med 2026;394: e39,VOL. 394 NO. 19

A 55-year-old man presented to the emergency department with cough, chest pain, and worsening dyspnea after being trapped in a burning house for 10 minutes. His heart rate was 120 beats per minute, his respiratory rate 30 breaths per minute, and his oxygen saturation 92% while he was receiving supplemental oxygen through a nasal cannula at a rate of 4 liters per minute. On physical examination, the patient was covered in soot but had no burn injuries. His sputum was carbonaceous (Panel A). Diffuse expiratory wheezing was present on auscultation. Carboxyhemoglobin testing was not available. Computed tomography of the chest revealed segmental mucus plugging. Owing to serious concern about inhalation injury, flexible bronchoscopy was performed to confirm the diagnosis and determine the severity of the injury. After copious secretions were removed from the airway with suction, carbonaceous deposits that extended from the subglottic region to the distal segmental airways were seen (Panel B and video). After therapeutic bronchoalveolar lavage was performed, erythema and edema of the airway mucosa were noted (Panel C). A diagnosis of severe inhalation injury from smoke was made. Treatment with inhaled bronchodilators and supplemental oxygen was administered. The patient was discharged 1 week later. At a follow-up visit 4 weeks after discharge, repeat bronchoscopy showed no abnormalities (Panel D).

(9). Central Retinal-Vein Occlusion

Gil Calvão Santos,  Published May 13, 2026,N Engl J Med 2026;394: e40,VOL. 394 NO. 19

A 65-year-old woman with diabetes, hypertension, and dyslipidemia presented to the ophthalmology clinic with a 14-hour history of painless, progressively worsening, blurry vision in the right eye. Physical examination was notable for a visual acuity of 20/400 in the right eye, with the patient unable to see fingers in the peripheral visual fields. There was also a relative afferent pupillary defect in the right eye. Examination of the left eye was normal. Funduscopy of the right eye showed retinal hemorrhages (Panel A, yellow arrows) and marked venous dilatation (Panel A, white arrows) in all four quadrants — findings known as a “blood and thunder” appearance. Cotton-wool spots (Panel A, red arrow) and optic-disk edema were also seen. Funduscopy of the left eye was normal (Panel B). A diagnosis of central retinal-vein occlusion was made. Central retinal-vein occlusion occurs when an acute thrombus obstructs venous outflow from a proximal retinal vein, resulting in sudden-onset, painless vision loss. Fluorescein angiography confirmed ischemic injury, and optical coherence tomography identified severe macular edema. Improved control of cardiovascular disease risk factors was initiated to prevent the occurrence of central retinal-vein occlusion in the contralateral eye. Treatment with anti–vascular endothelial growth factor injections was given. At the 3-month follow-up visit, the patient’s visual acuity in the right eye was 20/80, with persistent blind spots from residual macular scarring.

(10). Acute Esophageal Necrosis

Kai Nie, Published May 23, 2026,DOI: 10.1056/NEJMicm2600976

Abstract

A 51-year-old man presented with a 2-hour history of coffee-ground emesis and difficulty swallowing. Upper endoscopy showed black discoloration and friability of the mucosa from the midesophagus to the gastroesophageal junction.

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