Toddler’s fracture

A 23 mo M presents to urgent care with his mother for evaluation of left foot pain. The child’s father was swinging the child the previous night and the child struck his left foot against a piece of furniture. He was unwilling to move his foot or walk last night but is partially able to bear weight on it now. His mother noted some localized swelling and gave him ibuprofen; she was concerned about a left foot sprain. The patient has no other symptoms or concerns. Physical exam reveals the child disfavoring the left foot. No tenderness is noted on the 5th metatarsal head or medial aspect of the foot.
Left foot x-rays were obtained and revealed:
Dedicated left tibia/fibula x-rays were also obtained:

A toddler’s fracture, sometimes known as a CAST (childhood accidental spiral tibial) fracture, typically occurs in a young, ambulatory child (9 mo to 3 yo) who suffers low-energy trauma with rotation. The fibula is unaffected, but the tibia sustains a nondisplaced spiral/oblique fracture, usually in the distal half. Bruising, pain, and a limping gait or refusal to bear weight are common symptoms. This is a potentially occult fracture that is missed in nearly one-third of patients. As such, it may be necessary to obtain repeat films 1 week after initial presentation. Long-leg casting with repeat imaging 2 weeks later is the typical treatment protocol. Healing usually takes 3-4 weeks. Long bone fractures in non-ambulatory children, multiple fractures at different stages of healing, delays in seeking care, or inconsistent/implausible caregiver history may suggest nonaccidental trauma (NAT) instead.
In our patient, a tibial fracture was noted on left foot radiographs; tib-fib films confirmed a nondisplaced spiral fracture. No stigmata of abuse were present. The patient was placed in a splint and referred to a pediatric orthopedist for casting. Repeat radiographs 1 month later showed the fracture was healing well, and the child was permitted to return to full activity without restriction 6 weeks after his injury.

Diagnostic Enigma- Case presenting with unilateral bluish sclera

Antiphospholipid syndrome in man with severe pulmonary hypertension

A Man Coughed Up This Perfectly Shaped Blood Clot, Stunning His Doctors

If someone showed you the above picture without context, you’d probably think it was an intact blood vessel. Readers, it is not. It is a perfect cast of the branching air passages in the right lung of a man dying of heart failure, formed from coagulated blood that had been accumulating therein.

main article image

The man’s doctors were absolutely gobsmacked by the thing, which they published in the New England Journal of Medicine.

First, let’s get one thing clear. It’s not actually part of his lung, as some news headlines are claiming. It’s not possible to cough up a lung (although you can cough so hard a lung herniates through your ribs. That’s not fun, so try to avoid it).

In fact, bronchial tree clots – called casts – aren’t uncommon at all. Several blood clot casts have been reported in the last few years – coughed up by a 57-year-old-woman with lupus in 2010, a 25-year-old pregnant woman in 2005, and an 80-year-old man in 2015.

And if you head on over to medical image-sharing social network Figure 1 and search for ‘bronchial cast’, you’ll see a variety of casts, formed from coagulated blood, or from mucus that accumulates in the lungs in certain medical conditions.

What makes this particular cast so intriguing is not that it happened at all, but that it’s absolutely enormous – and the patient coughed it up in one piece, without it breaking.

“We were astonished,” the man’s doctor, Georg Wieselthaler, told The Atlantic. “It’s a curiosity you can’t imagine – I mean, this is very, very, very rare.”

The patient, an anonymous 36-year-old man, coughed up the cast while being treated for acute end-stage heart failure in the ICU, after a long history of heart failure.

His doctors connected his heart to a device to help it pump blood around his body. But because these devices can also cause blood clots, they had to give him a continuous infusion of an anticoagulant called Heparin to try and prevent this from happening.

Except coagulation is a necessary part of the body’s self-repair system, working to keep blood vessels from developing tiny tears that will result in internal bleeding – or, if they occur in the blood vessels that transport blood around the lungs, from leaking into the air passages and accumulating there.

Sadly, this is what happened with the patient. Over the course of the week after his doctors implemented the Impella device and the Heparin treatment, he started to cough up smaller blood clots, culminating in an extreme fit of coughing during which he brought up a giant mass.

When the doctors unfolded it, they saw a cast so perfect they were able to clearly identify it as the man’s right bronchial tree.

They think what held it together could have been a protein called fibrinogen, which is vital to the clotting process. Although the patient was on anticoagulants, his infection caused an elevated level of fibrinogen in his blood – this could have held the clot together while he coughed it up.

Sadly, although he felt better after the clot was out of his lungs, and coughed up no further clots, the condition of his heart was too severe. He died just over a week later from complications of heart failure.

Case of Addison’s disease mimicking anorexia nervosa

A case of Meningitis induced by amoxicillin

Severe anemia in a kidney transplant patient

24 y/o F with ESRD due to Henoch-Schönlein Purpura undergoes kidney transplant. The donor is her mother. Induced with ATG followed by Tacrolimus, Mycophenolate mofetil and prednisone.

Uneventful recovery with discharge creatinine of 0.7 mg/dL. TAC trough levels between 8-11 ng/ml . Discharge Hb of 12.1 g/dL. 2 months after surgery she notices mild fatigue and pallor, otherwise fairly asymptomatic.

On PE nothing stands out except for pallor. Lab only notable for Hb of 7.2 g/dL , normo, normo ,with normal WBC and platelet count. Anemia workup is extensive and turns up only remarkable for reticulocyte 0.29%, Haptoglobin of 89 mg/dL and a normal LDH. Subsequently, a bone marrow aspirate is done that reveals hypoplastic erythroid series and a few giant pronormoblast with nuclear inclusions as shown in fig below consistent with parvovirus B19 infection.

Blood B19 PCR comes back at 895000 copies. She is treated with 2 doses of IVIG 1 gr/kg/day on alternate days, transient discontinuation of MMF, with resolution of anemia.

Fortunately, no side effects of IVIG or other B19 manifestations occurred.

A case of Acquired Hemophilia induced by Levofloxacin

Atypical skin manifestations of dengue fever in a child

54 yo with Severe Leg Pain/Weakness

A 54-year-old otherwise healthy female presented to her primary care physician with acute severe left thigh pain, which was treated with steroid taper, pain medications, muscle relaxants without improvement. She is unable to ambulate due to pain and requires use of wheelchair due to pain and weakness. She denies any bowel or bladder changes and has no right leg symptoms and no night sweats, fevers, chills, or red flags.
She was sent for advanced imaging by PCP and referred to spine for evaluation.
Past medical and social history
The patient had a past medical history of hyperlipidemia and reflux, a bilateral total knee arthroplasty in 2017, and carpal tunnel release.
She reports no alcohol, tobacco or illicit drug use. She is engaged to be married and employed in computer work.
Physical exam
  • Well-developed, well-nourished female in a moderate-to-significant degree of discomfort
  • Found sitting in wheelchair
  • Right lower extremity strength 5/5 throughout; reflex patella and Achilles 2/4
  • Left lower extremity plantar flexion and dorsiflexion 5/5; quadriceps and hip flexors are markedly weaker on left 3+/5; Achilles reflex 2/4; patella reflex 1/4
  • Marked paresthesia over the left anterior thigh to knee.
  • Bilateral total knee arthroplasty scars noted; no warmth; full range of motion bilateral knee 0-110 flexion
  • No pain with range of motion of the hip
  • The patient had a CT of the lumbar spine disk space ordered by her primary care physician
  • The CT revealed the patient has degenerative disk disease at L5-S1, but this does not explain her dermatomal complaint or, more importantly, her physical exam as above
  • The patient believed that her knee replacement was a contraindication for MRI, which in this scenario it is not. Total joint replacement is generally completed with Titanium or Cobalt Chrome, neither of which is contraindicated for MRI imaging. Testing of these materials to 3 tesla magnets have been found to be safe.
  • She was sent for an MRI of the lumbar spine

The patient took pain medication and an oral sedative, but her discomfort precluded her from completing all sequences of the above MRI. Significant motion artifact was consequently noted, particularly on axial imaging. Her symptoms remained unexplained, necessitating further workup.
On reexamination, the patient demonstrated ongoing reflex changes, motor weakness, and dermatomal-specific complaints. After increased sedation and pain control measures, the area of concern (L3-5 nerve roots) was imaged.
Repeat MRI imaging with light oral sedation 24 hours later.
The blue arrow represents marked foraminal narrowing on the symptomatic side.
The green arrow represents a normal finding.
The green arrows demonstrate normal nerve roots at the L4-5 disk space. Notice the nice perineural fat signal (white) around the nerve root.
The blue arrow demonstrates a large foraminal herniated disk impaling the left exiting L3 nerve root (which correlates with her subjective and objective findings).
Extraforaminal disc herniations are uncommon causes of lumbar radiculopathy and occur less frequently than posterior or posterolateral disc herniation at the lumbar level. Extraforaminal disk herniation accounts for less than 10% of most lumbar disk herniations. The extraforaminal zone is generally not focused on in daily practice with spine MRI, particularly in the condition of large extrusion or protrusion causing descending nerve root compression.
The CT features of extraforaminal disc herniation are nonspecific. Recently, a detailed evaluation of disc herniation using only CT imaging was determined to be unsuitable. MR is preferred because it is noninvasive and has high soft-tissue resolution and multiplanar imaging capabilities. It may be a more favorable method for evaluating a symptomatic patient with both central and lateral spine canal pathology.
Lastly, this case study underscores the need to use the most appropriate imaging tool at our disposal and to treat the patient rather than the radiograph.