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

(1).Neurocysticercosis

Rolter Lorenz M., Published July 18, 2026,N Engl J Med 2026;395:388,DOI: 10.1056/NEJMicm2603020,VOL. 395 NO. 4

Abstract

A previously healthy 52-year-old woman presented to the emergency department with a 4-month history of headaches and visual hallucinations and a 1-month history of incoherent speech. On physical examination, the patient was awake and alert but unable to follow simple commands. Her speech was fluent but nonsensical, with paraphasic errors and impairment in naming and repetition. Computed tomography of the head revealed several hypodense lesions with internal hyperdensities scattered throughout the brain. Electroencephalography showed posterior temporal interictal epileptiform discharges from the left side. Results of an analysis of cerebrospinal fluid were normal. Magnetic resonance imaging of the brain revealed cystic lesions (arrows) in the temporal and occipital lobes on the left side (Panel A, fluid-attenuated inversion recovery [FLAIR] image), in the cerebellar hemispheres (Panel B, FLAIR image) and frontal lobes on both sides, and in the parietal lobe on the right side. The cysts contained bright, eccentric nodules (arrowheads) representing the scolices (anterior end) of tapeworms, a finding known as the “dot-in-hole” sign that is pathognomonic for neurocysticercosis. A diagnosis of parenchymal neurocysticercosis was made. Treatment with praziquantel, albendazole, and adjunctive glucocorticoids was given, along with levetiracetam for suspected seizures. At follow-up 1 month after starting treatment, her symptoms had abated, and repeat imaging showed smaller cysts without scolices.

(2). Koebner Phenomenon from Wet Cupping

Yusuf Demir, Published July 22, 2026,N Engl J Med 2026;395: e5,DOI: 10.1056/NEJMicm2603647,VOL. 395 NO. 4

Abstract

A 35-year-old man with a history of moderate-to-severe plaque psoriasis presented to the dermatology clinic with new skin lesions. His psoriasis had been in remission for the previous 18 months while he was receiving treatment with risankizumab. Two weeks before presentation, the patient had undergone wet cupping for the first time to treat low back pain. During the treatment, clusters of small incisions had been made at different sites across his back, after which glass cups had been applied with negative pressure to draw out small amounts of blood. On physical examination, well-demarcated, erythematous, scaly papules and plaques were present at the sites of the incisions on his shoulders and middle and lower back (Panel A; Panel B, middle of the back). A diagnosis of Koebner phenomenon from wet cupping was made. The Koebner phenomenon — also known as the isomorphic response — is the appearance of new skin lesions associated with a preexisting dermatosis (e.g., psoriasis, vitiligo, or lichen planus) at sites of previously uninvolved skin and result from cutaneous trauma. The phenomenon may occur even in patients with good control of their skin condition. The patient ceased wet cupping and continued to receive the same dose of risankizumab. At a 3-month follow-up visit, the skin lesions had abated.

(3). Pulsatile Liver in Severe Tricuspid Regurgitation

André Vaz et al, Published July 25, 2026

Abstract

A 51-year-old woman with right heart failure of unknown cause that was complicated by cardiac cirrhosis presented to the cardiology clinic with several years of worsening abdominal distention and leg swelling. The patient had faced socioeconomic barriers to accessing regular health care. Physical examination was notable for ascites, severe leg edema, giant venous pulsations in the neck, and a grade 4/6 holosystolic murmur at the lower left sternal border that augmented with inspiration. The liver was enlarged and pulsatile (Video 1A) — a late finding in chronic, severe tricuspid regurgitation. Transthoracic echocardiography revealed right cardiac-chamber enlargement, right ventricular hypokinesis, and massive tricuspid regurgitation with normal left ventricular size and function. Subsequent cardiac magnetic resonance imaging revealed marked dilatation of the right atrium and ventricle and severe tricuspid regurgitation. The liver was pulsatile owing to anterograde flow into the right atrium during diastole and retrograde flow into the inferior vena cava and hepatic veins during systole (Video 1B, coronal view, acquired during breath hold). A circumferential pericardial effusion and probable thrombus in the right atrial appendage were also present. Appropriate medical therapy was initiated, and the patient was listed for heart transplantation. Two years after starting treatment, she died of advanced heart failure and sepsis.

(4). Milwaukee Shoulder Syndrome

John Woller, Published July 29, 2026,N Engl J Med 2026;395:492,DOI: 10.1056/NEJMicm2601847,VOL. 395 NO. 5

Abstract

A 45-year-old man presented to the emergency department with a 2-month history of worsening pain and swelling in his right shoulder. He worked in construction and had chronic intermittent pain in the joint. Physical examination was notable for swelling of the right shoulder (Panel A) and decreased active range of motion. Radiography of the right shoulder showed destruction of the humeral head with a free-floating humeral diaphysis (Panel B, asterisk). Magnetic resonance imaging showed destructive arthropathy of the glenohumeral joint associated with a large effusion and free-floating calcific fragments. Full-thickness tears were seen in the supraspinatus, infraspinatus, and subscapularis tendons. Analysis of the synovial fluid revealed hemorrhagic, noninflammatory fluid with negative cultures and no visible crystals. A diagnosis of Milwaukee shoulder syndrome was made. This destructive arthropathy is characterized by the deposition of hydroxyapatite crystals (which are not visible on light microscopy), humeral head destruction, and severe rotator-cuff damage. Although this condition is most commonly seen in women over the age of 65 years, the patient was thought to be at increased risk because of his repetitive use of the shoulder in his work and a possible preexisting rotator-cuff injury. Treatment with celecoxib and acetaminophen was provided, and he was referred for evaluation for shoulder replacement.

(5). Obstructive Hypertrophic Cardiomyopathy

Julian-Kai Nishizono, Published August 1, 2026,DOI: 10.1056/NEJMicm2603868

Abstract

A 31-year-old man was referred to the cardiology clinic for evaluation of an abnormal electrocardiogram. At 15 years of age, he had received a diagnosis of nonobstructive apical hypertrophic cardiomyopathy but had not received follow-up care since that time. He reported presyncopal symptoms during emotional distress but no syncope or family history of sudden cardiac death. Physical examination was notable for a grade 3/6 systolic murmur at the left midsternal border. Transthoracic echocardiography revealed marked hypertrophy of the midventricular septum and posterior wall with a maximal wall thickness of 26 mm (reference value, ≤10), a systolic intraventricular gradient of 30 mm Hg at rest (reference value, <5), and a left ventricular ejection fraction (LVEF) of 40%. Beta-blocker therapy was initiated; after 5 months, the LVEF had improved, but the midventricular gradient had increased, which indicated worsening obstruction. Subsequent left ventriculography (Panel A and Video 1A) and cardiac magnetic resonance imaging (Panel B and Video 1B) revealed near-complete apposition of the ventricular walls during systole, which resulted in the development of a teardrop-shaped apical pouch. Simultaneous pressure recordings from the left ventricular apex and aorta showed a peak-to-peak gradient of 145 mm Hg, which confirmed a diagnosis of hypertrophic cardiomyopathy with severe obstruction. Myomectomy was performed. Complete heart block developed postoperatively, and a dual-chamber implantable cardioverter–defibrillator was placed. At a 5-month follow-up visit, the patient was asymptomatic.

(6). Type 1 Autoimmune Pancreatitis

Atsuto Kayashima et al, ,publ,shed August 5, 2026, N Engl J Med 2026;395:592,DOI: 10.1056/NEJMicm2604806, VOL. 395 NO. 6

Abstract

A 60-year-old man presented to the gastroenterology and hepatology clinic with a 1-month history of postprandial epigastric pain. The physical examination was normal, with no jaundice or abdominal tenderness observed. Laboratory testing showed mild elevations in levels of alanine aminotransferase, aspartate aminotransferase, and alkaline phosphatase. Computed tomography of the abdomen with the administration of intravenous contrast material showed a diffusely enlarged, “sausage-like” pancreas with a capsule-like rim of low attenuation (Panel A, asterisk; portal venous phase). The serum IgG4 level was 600 mg per deciliter (reference range, 11 to 121). Endoscopic retrograde cholangiopancreatography identified an intrapancreatic distal bile-duct stricture (Panel B, arrow). Histopathological analysis of a fine-needle aspiration biopsy specimen from the pancreas was limited by crush artifact but showed lymphoplasmacytic infiltration, fibrosis, chronic inflammation, and no cancer. On the basis of the typical imaging findings and an elevated serum IgG4 level, a diagnosis of type 1 autoimmune pancreatitis was made. Type 1 autoimmune pancreatitis is the pancreatic manifestation of IgG4-related disease. It can occur as an isolated disorder (as was the case in this patient) or with the involvement of multiple organs. Treatment with a tapering dose of prednisolone was initiated. At the 2-month follow-up, the pancreatic enlargement and intrapancreatic bile-duct stricture had resolved, as had the patient’s postprandial epigastric pain, and the levels of hepatobiliary enzymes had normalized.

(7). Warthin Tumors

Xiaoling Pan et al, Published August 8, 2026,DOI: 10.1056/NEJMicm260448

Abstract

A 55-year-old man with a smoking history of 10 pack-years presented to the surgery clinic with a 2-year history of an enlarging, painless lump below his right ear. Physical examination showed a well-circumscribed, nontender mass below the right ear, as well as a smaller mass at the inferior pole of the left parotid gland, which the patient had not noticed (Panel A). No cervical lymphadenopathy or cranial nerve VII deficit was seen. Axial T2-weighted, fat-suppressed magnetic resonance imaging of the neck showed a lesion in the right parotid gland, with hyperintense areas representing cystic contents (Panel B, asterisks) and mural nodules in the outermost cyst (arrow), as well as a solid nodule in the left parotid gland (arrowhead). Biopsies, which are typically performed to evaluate salivary-gland masses, were not performed in this case. The masses were resected. When sectioned longitudinally, the mass from the right side (4.0 cm in the greatest dimension) had a multicystic architecture (Panel C), and the mass from the left side had solid morphologic features with focal microcysts (Panel D). Histopathological analysis of both tumors showed bilayered oncocytic epithelium with lymphoid stroma. A diagnosis of Warthin tumors — benign, slow-growing salivary-gland tumors that are strongly associated with smoking and that often occur on both sides — was made. The patient did well postoperatively. Smoking cessation was advised.

(8). Disseminated Fusariosis

Hanna Osawa,Published August 12, 2026,N Engl J Med 2026;395: e8,DOI: 10.1056/NEJMicm2603271,VOL. 395 NO. 7

Abstract

A 61-year-old man with prolonged neutropenia as a result of salvage chemotherapy for acute myeloid leukemia was evaluated on hospital day 37 for persistent fever despite treatment with broad-spectrum antimicrobial agents. Physical examination was notable for a macule with central necrosis on the chest (Panel A), as well as a nodule on the left palm. A serum 1,3-β-d-glucan level was elevated, and a test for galactomannan was negative. Computed tomography of the chest, abdomen, and pelvis that was performed after the administration of contrast material showed multiple pulmonary nodules (Panel B, coronal view) and hypoattenuating lesions in the liver, spleen (Panel C, axial view), and kidneys. Gram’s staining of a blood culture revealed septate, hyaline hyphae (Panel D), which were subsequently identified as Fusarium keratoplasticum with the use of molecular sequencing. A diagnosis of disseminated fusariosis was made. In contrast to other invasive mold infections, fusarium species frequently cause fungemia in immunocompromised hosts. Treatment with voriconazole and liposomal amphotericin B was initiated, but the patient died of respiratory failure on hospital day 67. At autopsy, the leukemia was found to have been in morphologic remission. Gross examination of the liver (Panel E) and spleen (Panel F) showed multiple well-circumscribed yellow foci that were confirmed on histopathological analysis to be abscesses from disseminated fusariosis.

(9). Osteosarcoma

Hsueh-Min Kuo,Published June 10, 2026,N Engl J Med 2026;394:2255,DOI: 10.1056/NEJMicm2600191,VOL. 394 NO. 22

Abstract

An 11-year-old girl presented to the orthopedic clinic with a 1-month history of right thigh pain that worsened at night. She had no systemic symptoms. Physical examination was notable for soft-tissue swelling over the distal thigh and limited range of motion of the knee on the right side. Radiographs of the knee showed a metaphyseal osteoblastic lesion with ill-defined margins and cortical destruction in the distal femur (Panel A, anteroposterior view; Panel B, lateral view). The mass had a sunburst appearance, a finding that is seen in aggressive bone lesions and that results from the formation of divergent bone spicules as the periosteal reaction to the rapid growth of the tumor. On the basis of subsequent magnetic resonance imaging of the knee and a bone biopsy, a diagnosis of high-grade osteosarcoma was made. Osteosarcoma is the most common primary malignant bone tumor in children. It typically manifests in the second decade of life owing to the rapid bone growth during that stage of development. No distant sites of metastasis were identified on further imaging. Treatment with neoadjuvant chemotherapy, wide excision, reconstruction, and adjuvant chemotherapy was given. After more than 10 years of follow-up, the patient remained cancer-free with independent ambulation.

(10). Chromoblastomycosis

Eva R. Parker,Published June 17, 2026,N Engl J Med 2026;394: e54,DOI: 10.1056/NEJMicm2600078,VOL. 394 NO. 23

Abstract

A 38-year-old pregnant woman at 30 weeks’ gestation was referred to the dermatology clinic for evaluation of a long-standing, itchy lesion on her abdomen. The lesion had first appeared 9 years earlier after the patient had emigrated from Honduras, where she had worked in agriculture. The lesion had subsequently slowly expanded. On physical examination, a 15-cm erythematous, scaly plaque with a raised border and atrophic center was visible on the left upper abdomen (Panel A). Histopathological analysis of a skin-biopsy sample showed pseudoepitheliomatous hyperplasia with dermal granulomatous infiltrates. Thick-walled, brown, septate spores called muriform cells (Panel B, arrows) were also seen. The presence of such cells (also known as Medlar bodies, sclerotic bodies, or copper pennies) is pathognomonic for chromoblastomycosis. Fungal culture grew a pigmented mold, which showed septate hyphae with loosely branched clavate conidia and prominent denticles on microscopy (Panel C). The causative organism was identified as a fonsecaea species. A diagnosis of chromoblastomycosis with cicatricial morphologic features was confirmed. Chromoblastomycosis is a chronic, progressive implantation mycosis caused by dematiaceous fungi in soil and plant matter. It is typically diagnosed in agricultural workers in tropical or subtropical regions. Postpartum treatment with itraconazole was planned, but the patient was lost to follow-up.

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