(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient is a 62 year-old male with a history of trauma falling on an outstretched hand. He had been complaining of pain in the right clavicular region. Although a chest radiograph was inconclusive, the CT scan (Figures 1a and 1b) demonstrated permeative changes involving the right clavicle with a subacute pathologic fracture of the mid shaft of the right clavicle. There was a diffuse abnormality of all bones with generalized osteoporosis and permeative changes suggestive of myeloma, leukemia and other marrow infiltrative processes. A CT guided fine needle aspiration was performed and showed cytomorphologic and immunophenotypic evidence of a κ-restricted plasmacytoma.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 62 year-old man presented to his primary care physician with an unexplained 60 lb weight loss, slight nausea and anorexia over the course of a year. A dynamic, contrast-enhanced abdominal computed tomography scan revealed an incidental 1.8 cm enhancing mass at the lower pole of the left kidney with no other abnormalities identified. Laparoscopic partial nephrectomy of the tumor was performed and the patient made an uneventful recovery. The tumor has followed a benign course without evidence of local recurrence or metastasis during the follow-up period of 2 months.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient is a 62-year old man who was suffering from a chronic pyothorax after pneumectomy 44 years ago. In August 2002 a fenestration of the left thoracic wall was performed. Besides several serological signs of inflammation, NSE (neuron-specific enolase) was markedly elevated. Postoperatively, the patient complained of progressive ataxia and a cerebellar biopsy was performed. Despite treatment the patient died from aspergillus sepsis two month later and permission for autopsy was obtained.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 62 year old woman presents to the clinic for neurologic and psychologic examination and genetic testing. Her cousin with mild chorea was recently diagnosed with Huntington disease (HD) following testing. Her maternal uncle is reported to have similar symptoms but has never undergone genetic testing. The patient's brother recently tested positive for HD as well at the age of 65. Her mother was diagnosed as a paranoid schizophrenic but never with this specific disorder. See Figure 1.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 63-year-old male immigrant from Hong Kong presented with a 2-day history of urinary retention. On examination, he had a cauda equina syndrome. Imaging by CT and MRI revealed a large L2- L3 disc herniation and spinal stenosis. An emergency bilateral L2 laminectomy and L2-L3 discectomy resolved his pre-operative symptoms. However, the MRI scan had also identified a sclerotic lesion at the left T12 pedicle, characterised by abnormal bone marrow T1 hypointensity (Figure 1a) and T2 hyperintensity (Figure 1b), suggesting a metastasis. However, a primary site was not identified in CT scans of the chest, abdomen and pelvis, and a skeletal survey and an isotope bone scan did not reveal any other bone lesions. A fluoroscopic guided biopsy of the left T12 pediclular lesion was carried out.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

An obese and hypertensive 63-year-old Caucasian woman presented with persistent and progressively worsening exertional dyspnea, occasionally accompanied by anginal chest pain as well as dysphonia, hoarseness, dysphagia, complaints of lower extremity weakness, and documented mild chronic L5-S1 denervation. Work-up revealed moderate obstructive ventilatory defect, borderline restrictive defect, and variable extrathoracic obstruction. Weakness and progressively poor quality of sleep characterized by sleep-disordered breathing, increased daytime somnolence, fatigue upon waking and increased snoring were added to her initial complaints. A sleep study established the diagnosis of severe obstructive sleep apnea. Treatment with continuous positive airway pressure (CPAP) produced significant improvement in her energy levels, more restful sleep and less fatigue, but her dyspnea worsened. A new cycle of cardiac and respiratory evaluation was positive for mild pulmonary hypertension and negative for myocardial ischemia and pulmonary fibrosis. Shortly after these last assessments, and two to three years after onset of symptoms, the patient died suddenly in her sleep.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 63-year-old woman developed deterioration of her general condition over a three-week period, with apathy and drowsiness. Major history included rheumatoid arthritis treated by corticoids and anti-TNFα and right breast tumorectomy. Physical examination revealed tachypnea, dyspnea, Cushingoid facies, bilateral rhonchi and bilateral edema of the lower limbs. Neurologic examination revealed drowsiness. Further tests brought out atrial fibrillation, cardiac failure and inflammatory syndrome.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient is a 63 year-old retired Navy veteran with a history of diabetes mellitus type II who presented to an outside hospital with mental status changes. He suffered clinical deterioration during the first 24 hours of his stay and was referred to our hospital in consideration of possible acute stroke. Presenting symptoms included fluent aphasia, confusion, and speaking gibberish. He also related a recent history of chronic cough, sputum production, and a 15 pound weight loss. As part of his initial stroke evaluation, he underwent CT angiography of the head and neck. This study was remarkable for pulmonary findings consistent with a large apical cavitary lesion (Figure 1). A high resolution chest CT without contrast was then performed, confirming a large cavitary lesion in the right upper lobe with a relatively thin wall (Figure 2). Sputum was collected for Acid Fast Bacilli (AFB) culture. In addition, a lumbar puncture was performed to collect cerebral spinal fluid (CSF) for analysis, AFB culture, and nucleic acid amplification of M. tuberculosis via PCR. Results of both sputum and CSF specimens are listed in the Microbiology and Laboratory sections.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 63 year-old man initially presented in February 2003 with 3 episodes of syncopes accompanied by nausea, vomiting and sweating. Starting June 2003, the patient became indifferent and showed a weight loss of 15 kg over a period of the following 6 months. In July 2003, beginning ataxia, visual and cognitive decline were reported. Neurological examination in October 2003 revealed a right VI nerve palsy, ataxia, dysarthria and dementia as the main clinical features. One month later, he suffered a cardiac arrest with resuscitation, but he eventually died of a cardio-respiratory insufficiency in November 2003 showing the clinical picture of brainstem encephalitis. Final clinical report suggested a metastatic neoplasm with unknown primary.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient is a 63 year old woman with elevated calcium who, on work-up for hyperparathyroidism, was found to have a single nodule within the superior pole of the left lobe of her thyroid, measuring 0.5 cm, as well as three hypoechoic nodules of the right lobe, measuring up to 2.0 cm. The patient underwent surgical parathyroid exploration and total thyroidectomy after fine needle aspiration of the dominant right lobe nodule demonstrated a "follicular neoplasm or lesion." However, the remainder of this case will focus on a smaller right lobe nodule that was not biopsied.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient was a 63-year-old woman who was found to have probable lung cancer and multiple brain metastases, for which she received whole brain radiation and steroids treatment. Three weeks after the therapies were started, she developed gastrointestinal bleeding and underwent colectomy for acute diverticulitis with perforation. During the surgery, the ovaries appeared to be likely involved by metastatic disease, therefore bilateral oophorectomy was also performed. Computed tomography of the pelvis at the time of evaluation for source of metastatic disease did not reveal abnormalities in the ovaries.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

On admission to our hospital, the patient complained of severe abdominal tenderness, with peritoneal signs, and underwent urgent laparotomy. There were no abnormal intraoperative findings, and biopsies taken from the stomach, duodenum, and rectum were normal. Gastroscopy and colonoscopy were performed, and were unrevealing. Post-operatively, the patient was encephalopathic, and minimally responsive. MRI of the brain again demonstrated abundant T2/FLAIR hyperintense (non-enhancing) lesions in the periventricular white matter and corpus callosum (Fig 1A; axial FLAIR sequence), consistent with central nervous system (CNS) demyelination. A small focus of enhancing T2/FLAIR signal hyperintensity in the right thalamus was suggestive of chronic thalamic stroke. The dura was diffusely thickened, and uniformly enhancing, following administration of gadolinium (Fig 1B; axial T1 gadolinium sequence). The differential diagnosis of this new dural process included infectious, malignant, and autoimmune causes. Clinically, the patient continued to deteriorate, and expired three days later.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 64-year-old Caucasian male patient presented with a three-month-history of episodes with visual disturbances and tingling sensations of the left side of his body to a department of neurology. In addition, within the last three weeks preceding the admittance several episodes of irresponsiveness had occurred, in which the patient had paused with eyes open, followed by short-lived aphasia. The patient and his spouse did not report memory deficits beyond these episodes. Neurological examination did not reveal any abnormalities. Cerebral MRI showed FLAIR hyperintensity and slight swelling of the left hippocampus (Figure 1A). 18F-DOPA positron emission tomography showed increased uptake of the medial aspects of the lesion (Figure 1B). T1-weighted images prior and after administration of gadolinium showed contrast enhancement of the same region (Figure 1C/D) EEG showed left frontotemporal slowing. Cerebrospinal fluid (CSF) analysis was normal. Routine laboratory results were inconspicuous with exception of hyponatremia (127 mmol/l). The diagnosis of symptomatic temporal lobe epilepsy as result of the left temporal lesion, most possibly representing a high-grade glioma, was made, surgical resection was suggested and an anticonvulsive therapy with levetiracetam was initiated. After discharge, the patient presented to our Department of Neurosurgery asking for a second opinion. A resection of the lesion was suggested and performed three months after the first symptoms. Post surgery, the patient did not develop new neurological deficits and was sent to rehabilitation. Here, the patient developed frequent complex-partial seizures followed by right-sided hemiparesis, disorientation, long-lasting somnolence and severe memory disturbances. Six months after the initial symptoms, the patient was admitted to our Department of Neurology. Repeated cerebral MRI showed status after resection of the left hippocampus. EEG showed severe generalized slowing, while CSF again was normal.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 64 year old man with a history of hyperlipidemia and hypertension presented to neurosurgery clinic with progressive pain in the left lower limb and mid-back. Sagittal (Fig. 1a) and axial (Fig. 1b) T1-weighted MRI of the lumbar spine showed a 1.3 x 1.1 x 1.2 cm homogeneously enhancing, intradural, ovoid and slightly lobulated solid mass at the L4 vertebral level. The lesion occupied the majority of the thecal sac, with resulting splaying and compression of the nerve roots of the cauda equina. The MRI features favored a nerve root meningioma with a differential of a schwannoma, while metastatic disease was thought to be a less likely diagnostic consideration. The patient underwent elective lumbar laminectomy L3 through L5. The lesion was identified by ultrasound before opening the dura. The tumor was found to arise from a lumbosacral nerve root and had a purple-brown appearance. It was elevated out of the cauda equina and the surrounding proximal and distal nerves were separated from the mass before its complete gross removal. The patient recovered uneventfully from the procedure with no neurological deficits and remains recurrence-free one year after the diagnosis.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient is a 64 year old male with a history of lung transplant 4 years previously for chronic obstructive pulmonary disease and silicosis. The allograft lung function was good. The patient developed fevers and cough 4 weeks previous to admission. Upon admission, a chest CT was performed and showed a 9 mm left lingula nodule (Figure 1). Blood cultures, sputum culture, urine Legionella antigen, EBV and CMV viral loads were all negative. Due to suspicion of infection, he was treated with vancomycin and piperacillin/tazobactam, and discharged.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 64 year-old man presented with multiple transient cerebral ischemic attacks progressing for a week consisting of right-sided hemiparesis. The patient had a history of squamous cell cancer of the pharynx managed by chemotherapy and radiotherapy 10 years earlier. Six years ago, he had a lingual recurrence of his cancer, for which he underwent a partial glossectomy with left cervical dissection.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A previously healthy 64 years old woman was admitted to our hospital arguing generalized fatigue, sleep impairment, mild weight loss and chronic progressive headache, becoming holocranial and resistant to many drugs during last few months. The patient was alert and orientated. No papilledema but slightly neck stiffness was noted. Cranial nerve functions were intact.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 64-year-old diabetic woman presented with progressive cognitive deterioration and gait ataxia. Symptoms appeared one month before admission, without hyperthermia. Clinical examination showed temporo-spatial disorientation, loss in attention, judgment and memory capacities, a gait ataxia with a kinetic cerebellar syndrome and a left side bradykinesia. There was neither pyramidal syndrome nor cranial nerve palsy. General examination was normal. Brain MRI (T1-wi with and without gadolinium, Flair and T2-wi) found a periventricular diffuse leukoencephalopathy (Figure 1A) without gadolinium enhancement (Figure 1B). EEG showed diffused slow waves and epileptic seizures without periodic paroxystic activity. Hematological and biological serum analyses (including LDH, beta2-microglobulinemia, fibrinogen, CRP, electrophoresis and immunoelectrophoresis of the proteins, transaminases, urea, creatinine, lymphocyte immunophenotyping) were normal. All serological investigations (HIV, HSV1 and HSV2, CMV, VZV, EBV, JC virus) remained negative. The CSF presented normal cell count (2 lymphocytes / mm3) and protein level (0,3 g / L), without abnormal cells or intrathecal protein synthesis except a positivity of 14.3.3 protein. The neurological state worsened progressively with dementia, epileptic seizures, extrapyramidal and cerebellar syndromes. The patient died three months after onset of symptoms, and an autopsy restricted to the brain was performed.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

This 65 year old female who was diagnosed with a right CP angle tumor after an MRI was done to investigate facial pain in 1999. In 2006, her pain became quite severe and she developed numbness in all three divisions of the trigeminal nerve along with decreased corneal reflex and facial paresis on the right side. The lesion was partially resected at the time by right retrolabyrinthine approach with pre and post sigmoid craniectomy. The patient recovered uneventfully except for wound infection, which required debridement. In 2012, she presented with left sided weakness and gait instability. MRI with gadolinium showed a recurrent hypointense lesion with rim enhancement as well as an enhancing nodule at the tentorial incisura on the right side (Figure 1a). A subtemporal approach was undertaken with subtotal resection of tumor that encircled the right posterior cerebral artery. Postoperatively, she received stereotactic radiosurgery with Cyberknife for a total of 2500 cGy. In spite of this, her lesion progressed. She continued to worsen neurologically and an Ommaya reservoir was inserted for aspiration of the cystic portion of the lesion. She has since begun a radiation boost to the area of 54 Gy in thirty fractions.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 65-year-old gentleman, chronic smoker without any known co-morbidity presented with sudden onset right hemiplegia associated with headache and vomiting. He soon developed altered sensorium. However, there was no history of preceding trauma or hypertension. Contrast enhanced CT scan showed a left parietal hematoma with mass effect (Figs. 1A, 1B). In view of the expanding hematoma and deteriorating clinical condition, craniotomy was done to remove the hematoma and decompress the brain. A fleshy soft tissue with hematoma was excised. Postoperatively, his sensorium improved but the paresis persisted. Postoperative scans showed evacuation of the clot along with excision of lesion (Fig. 1C). A week later, he died and a whole-body scan could not be performed.