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). Celiac-Artery Dissection

Akshat Agrawal, Published September 12, 2026,N Engl J Med 2026;395: e15,DOI: 10.1056/NEJMicm2605936,VOL. 395 NO. 11

Abstract

A 72-year-old man with well-controlled hypertension, hyperlipidemia, and a stable ascending aortic aneurysm presented to the emergency department with sudden-onset, severe epigastric pain after moving boxes in his house. The pain had lasted for 10 to 15 minutes before hospital arrival and was not associated with nausea, vomiting, or abdominal discomfort. The patient had no history of smoking. His blood pressure was 164/89 mm Hg. The physical examination was unremarkable. The troponin level was normal, and an electrocardiogram showed no ischemic changes. The serum lactate level was not checked during the admission. Owing to concern for aortic dissection, computed tomographic angiography (CTA) of the chest, abdomen, and pelvis was performed. These scans showed a dissection of the celiac artery with an underlying aneurysmal dilatation (Panel A, axial view; Panel B, coronal view; and Panel C, sagittal view). Aneurysmal dilatations of the infrarenal abdominal aorta and distal right common iliac artery were also seen. A diagnosis of a spontaneous, isolated celiac-artery dissection — an uncommon vascular phenomenon with a favorable prognosis that typically improves with conservative treatment — was made. A vascular surgeon evaluated the patient and recommended medical management. Treatment with clopidogrel and antihypertensive medications was prescribed, and the pain did not recur. At discharge, a 6-month follow-up CTA was scheduled to monitor for thrombosis, stenosis, or worsening of the aneurysmal dilatation.

(2). Cerebral Schistosomiasis

Mary-France G. Lebii et al, Published September 19, 2026,DOI: 10.1056/NEJMicm2609443

Abstract

A previously healthy 35-year-old female rice farmer presented to the emergency department after a 1-minute episode of arm and leg shaking on the right side. She reported no preceding headache, confusion, or weakness. Physical examination was normal. Magnetic resonance imaging of the brain was performed. Axial and coronal T1-weighted images obtained after administration of contrast material (Panels A and B, respectively) showed an area of linear enhancement (arrow) associated with a cluster of enhancing nodules and surrounding edema in the left frontal lobe.

This arborizing radiographic pattern may be seen in neuroschistosomiasis, with the nodules representing granulomatous inflammation around schistosome eggs. Owing to concern about schistosomiasis, a circumoval precipitin test for Schistosoma japonicum — which involves incubation of live S. japonicum eggs with patient serum — was performed. A tail-like precipitate (Panel C, asterisk) formed outside the eggs, a finding that indicates an antibody-mediated reaction against antigens secreted by the eggs (a positive result); a small knob (arrow), often seen on S. japonicum eggs, was also visible on eggs in the sample. A Kato–Katz stool smear was also positive for S. japonicum (190 eggs per gram of stool). A diagnosis of cerebral schistosomiasis resulting in a focal seizure was made.

Treatment with praziquantel, glucocorticoids, and levetiracetam was initiated. At a 3-month follow-up visit, the patient reported no further seizures. Repeat imaging obtained at that time showed no abnormalities.

(3).Congenital Amniotic Band Sequence

Yao Lu,  Published September 23, 2026,N Engl J Med 2026;395:1218,DOI: 10.1056/NEJMicm2607665,VOL. 395 NO. 12

Abstract

A baby girl was noted to have severe swelling and discoloration of the left arm immediately after birth by cesarean section at 38 weeks’ gestation. Prenatal ultrasonography at 28 weeks’ gestation had identified soft-tissue swelling of the left arm of undetermined cause. Her mother (gravida 2, para 0) had not undergone any prenatal intrauterine interventions. On physical examination, swelling, cyanosis, and limited movement of the left arm, shoulder, and chest were observed. Two areas of constriction were noted at the level of the wrist and proximal forearm (Panel A, arrows). Brachial and radial pulses were detectable by Doppler ultrasonography. Magnetic resonance imaging of the arm showed two fibrous bands penetrating the deep fascia (Panel B, arrows). A diagnosis of congenital amniotic band sequence was made.

Amniotic band sequence describes the cascade of events that occurs after early rupture of the amnion in which fetal body parts project into the chorionic cavity and subsequently risk deformation, constriction by amniotic bands, or amputation. In this case, no other anatomical abnormalities were identified. Surgical release of the bands was performed, and the baby went home on postoperative day 7. At the 5-month follow-up, the left arm had healed well (Panel C) and functioned normally.

(4). Serotonin Syndrome

Hiro Takefuji. Published September 26, 2026,DOI: 10.1056/NEJMicm2607537

Abstract

A 23-year-old man with depression was brought to the emergency department 1 hour after a witnessed ingestion of 2000 mg of sertraline in a suicide attempt. His depression had been treated with daily sertraline and clonazepam. Initial physical examination was notable only for slight drowsiness. Urine toxicologic screening was positive only for benzodiazepines. Six hours after the ingestion, the patient’s temperature rose to 38.0°C. On repeat assessment, he was agitated, and restraints were needed for the examination to continue. The pupils in both eyes were dilated to 6 mm. Spontaneous clonus was observed in the calves (Video 1A), and sustained, inducible clonus and patellar hyperreflexia were also noted in both legs (Video 1B; identifying information has been blurred in the video and in the still images [above] from Video 1B). No ocular clonus, diaphoresis, muscular rigidity, or tremor was noted. A diagnosis of serotonin syndrome was made. In serotonin syndrome, clonus and hyperreflexia are typically more pronounced in the legs than in other parts of the body. Treatment with intravenous diazepam was given. Over the next 24 hours, the patient’s symptoms abated. He was discharged to a psychiatric facility. At follow-up 1 month later, his depression was abating.

(5). Thyroglossal Duct Cyst

Donglai Hu et al, Published September 30, 2026,N Engl J Med 2026;395:1318,DOI: 10.1056/NEJMicm2607953,VOL. 395 NO. 13

Abstract

A 6-year-old boy was brought to the pediatric surgery clinic with a 2-year history of an asymptomatic, stable lump on his neck. Physical examination revealed a nontender, mobile, midline mass in the anterior neck (Panel A) that moved up with tongue protrusion and swallowing. Ultrasonography of the neck revealed a well-defined, thin-walled hypoechoic mass and a normal thyroid gland. A thyroglossal duct cyst was suspected. A thyroglossal duct cyst is a common congenital cervical anomaly that results from incomplete or failed obliteration of the embryonic thyroglossal duct, which leaves behind fluid-secreting epithelia that generate a cyst. Magnetic resonance imaging (MRI) of the neck was subsequently conducted to plan the operative approach (although cross-sectional imaging is not typically needed for this condition in children). Sagittal T2-weighted MRI showed a hyperintense, beaded fistulous duct (Panel B, arrow) originating from the tongue base, coursing inferiorly through the hyoid bone, and terminating in a cyst anterior to the thyroid cartilage. The cyst (Panel C, asterisk) and the central portion of the hyoid bone (Panel C, arrow) were excised. Histopathological analysis showed no evidence of infection or cancer. The patient recovered well and had no recurrence at 2 years of follow-up.

(6). Menkes Disease

Hsin-Yu Chen, Published October 3, 2026,DOI: 10.1056/NEJMicm2607595

Abstract

A 2-month-old boy who had been born late preterm was brought to the emergency department after a seizure. He had previously been hospitalized at 16 days of age for feeding difficulty, micrognathia, and hypotonia. Results of exome sequencing were pending at the time of discharge. There was no family history of genetic conditions. Physical examination during the current presentation was notable for decreased activity and shallow breathing. There was sparse, coarse, lightly pigmented hair on the scalp (Panel A). A chest radiograph showed flaring and expansion of the anterior rib ends (Panel B, arrows). Levels of serum copper and ceruloplasmin were markedly lower than normal. Magnetic resonance angiography of the brain revealed tortuosity and elongation of the intracranial and extracranial arteries (Panel C). Results of the previously ordered exome sequencing showed a hemizygous pathogenic variant in ATP7A. A diagnosis of Menkes disease was made. Menkes disease is an X-linked recessive neurodegenerative disorder of copper metabolism caused by deficiency or dysfunction of a copper-transporting ATPase. It manifests as developmental delay, seizures, kinky hair, bony abnormalities, and cerebral vessels that have a corkscrew appearance on imaging. Given the poor prognosis and lack of approved disease-specific therapy in Taiwan, the patient’s family chose to pursue palliative care. The baby died at 5 months of age.

(7). Syphilitic Chancre on the Nipple

Yangbin Wang, Published October 7, 2026,N Engl J Med 2026;395: e19,DOI: 10.1056/NEJMicm2605910,VOL. 395 NO. 14

 

Abstract

A 35-year-old woman presented to the hospital with a 20-day history of a painless nipple ulcer. On physical examination, there was ulceration, crusting, and a yellowish exudate on the right nipple (Panel A, which shows the patient’s hand identifying the site). Erosive adenomatosis was initially suspected, and a skin biopsy was planned to establish the diagnosis and rule out cancer. As part of the hospital’s routine preprocedural evaluation, testing for syphilis was performed. An assay for Treponema pallidum particle agglutination was positive, and the rapid plasma reagin titer was 1:8. The patient had no history of syphilis. Testing for human immunodeficiency virus infection was negative. Histopathological analysis of the nipple-biopsy specimen showed epidermal necrosis with an inflammatory exudate, dermal capillary proliferation, and dense perivascular lymphoplasmacytic infiltrates. Immunohistochemical analysis was positive for T. pallidum organisms (Panel B, shown at 400× magnification). A diagnosis of a syphilitic chancre of the nipple was made. Primary syphilitic chancres can occur at any site of inoculation (including extragenital erogenous locations) and should be considered in the differential diagnosis of an unexplained ulcerative lesion. Treatment with intramuscular benzathine penicillin G was given. At follow up 12 days after the initial diagnosis, the lesion had resolved (Panel C).

(8). Flushing in Carcinoid Syndrome

N. Karthik et al, Published October 10, 2026,DOI: 10.1056/NEJMicm2606144

Postgraduate Institute of Medical Education and Research, Chandigarh, India

Abstract

A 44-year-old man was admitted to a tertiary care hospital for the management of carcinoid syndrome. Four years earlier, he had received a diagnosis of carcinoid syndrome related to metastatic neuroendocrine cancer of unknown primary cause during an evaluation of episodic facial flushing, diarrhea, and dyspnea. Treatment with octreotide had been started, but the patient faced financial constraints that interfered with his ability to adhere to the therapy, and his symptoms had worsened. On physical examination at the current presentation, he had mottled, violaceous, blanchable flushing across the face (Panel A) and torso (Panel B). Flushing is the most common manifestation of carcinoid syndrome. It occurs when tumor cells (most commonly hepatic metastases) release vasoactive substances into the systemic circulation, which results in cutaneous vasodilation. Although flushing episodes typically manifest as transient discoloration of the face, neck, and upper chest, chronic episodes may lead to more-diffuse, persistent, and violaceous flushing, as well as to the development of telangiectasias. Laboratory studies showed high 24-hour urinary excretion of 5-hydroxyindoleacetic acid and high serum levels of chromogranin A. Positron-emission tomography–computed tomography with the use of gallium-68–dotatate identified numerous hepatic and skeletal metastases without a clear primary tumor. Intensified treatment of carcinoid syndrome was initiated. Four weeks later, the patient’s flushing had abated considerably (Panel C [photograph taken by the patient]).

(9). Alkaptonuria

Prasanta Padhan, Published October 14, 2026,N Engl J Med 2026;395:1529,DOI: 10.1056/NEJMicm2607077,VOL. 395 NO. 15

Abstract

A 64-year-old woman with no known medical history presented to the rheumatology outpatient clinic with a 4-year history of worsening low back pain and difficulty walking. On examination, she had patches of darkly pigmented sclera (Panel A), kyphosis, and a Trendelenburg gait. Radiographs of the lumbosacral spine showed narrowing of the intervertebral disk space, disk-space calcification, and vertebral end-plate sclerosis (Panel B, lateral view). Radiographs of the pelvis showed destruction of the femoral heads (Panel C, anterior view). On further history taking, she reported that since childhood her urine had darkened when left sitting out. A urine sample turned black after being left out overnight at room temperature (Panel D). Urine levels of homogentisic acid were elevated. Molecular genetic testing was not available. A diagnosis of alkaptonuria was made. Alkaptonuria is an autosomal recessive disorder of tyrosine metabolism that results in high levels of homogentisic acid that subsequently polymerizes to form a pigment. The condition manifests in childhood with darkening of urine after oxidization by air and in adulthood with pigmentation of connective tissues (known as ochronosis) and early-onset, severe osteoarthropathy (known as ochronotic arthropathy). Treatment with nitisinone (an enzyme inhibitor that reduces homogentisic acid production) was initiated, and bilateral total hip replacement was performed. The patient was lost to follow-up 2 months after surgery.

(10). Periorbital Purpura and Fatigue in a Man Aged 57 Years

Mehmet Rasih Sonsöz, JAMA Cardiol,Published Online: October 14, 2026,doi: 10.1001/jamacardio.2026.3614

Clinical clues of systemic light-chain amyloidosis. A, Bilateral periorbital purpura, or raccoon eyes. B, The apical 4-chamber view on transthoracic echocardiography demonstrates concentric left ventricular hypertrophy, a granular (sparkling) appearance of the left ventricular myocardium, and biatrial enlargement. The interventricular septum is 18 mm.

Abstract

A 57-year-old man presented with periorbital purpura and fatigue (Figure, A). Electrocardiography showed poor R-wave progression, and cranial imaging findings were normal. Troponin T (0.064 ng/mL; to convert to micrograms per liter, multiply by 1) and N-terminal pro–B-type natriuretic peptide (7802 pg/mL) levels were elevated. Transthoracic echocardiography disclosed biventricular hypertrophy with a granular left ventricular myocardium (Video and Figure, B). Serum free-light-chain testing showed lambda dominance. Abdominal fat aspirate was positive for amyloid, and systemic light-chain (AL) amyloidosis was diagnosed.

Periorbital purpura is uncommon but highly specific for systemic AL amyloidosis1 and likely reflects vascular fragility from amyloid infiltration.2 Early diagnosis and treatment of the disease are essential, as cardiac involvement is the major driver of the outcome.

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