Mystery Quiz

Mystery Quiz-The Answer

December 17, 2014
Mystery Quiz-The Answer

Vivian Hayashi MD, Robert Smith MD

The answer to the mystery quiz is pleural effusions, specifically, bilateral subpulmonic effusions. The chest radiograph shows a number of findings: (1) the apparent diaphragm shadow is in fact fluid sandwiched between the undersurface of the lung and the actual diaphragm (Image 2a, arrow); (2) the density of this shadow is homogenously white (Image 2a, asterisk) and differs from a normal diaphragm which has a graded density (Image 2b, triangle) due to superimposed air that progressively decreases towards the…

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Mystery Quiz

December 2, 2014
Mystery Quiz

Vivian Hayashi MD, Robert Smith MD

The patient is an 82 year old man with frequent breathlessness. The patient had been admitted several times in the past two years for congestive heart failure. Two years earlier, the patient suffered an NSTEMI. A diagnostic cardiac catheterization revealed triple vessel coronary disease. A decision to perform CABG vs coronary stenting was delayed pending an evaluation of iron-deficiency anemia associated with a positive test for fecal occult blood. A recent echocardiogram showed normal left ventricular function but diastolic…

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Mystery Quiz- The Answer

July 10, 2014
Mystery Quiz- The Answer

Vivian Hayashi MD, Robert Smith MD

The answer to the mystery quiz is rhabdomyolysis due to legionella pneumonia (LP). The presentation of the patient, namely severe rhabdomyolysis complicated by acute kidney injury, obscured the presence of a subtle retrocardiac density that is visible on the CXR (Image 2, asterisk). The upper axial image from an abdominal CT, obtained one day after the CXR, shows the extent of the LLL infiltrate (Image 3). The infiltrate is contained by the major fissure and is characterized by air…

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Mystery Quiz

July 2, 2014
Mystery Quiz

Vivian Hayashi MD, Robert Smith MD

A 51 year old man presented to the emergency room with fever and myalgias for four days. The patient was previously in good health except for occasional asthmatic exacerbations. He noted thigh pain in the few days prior to admission, for which he took about 8 tablets of ibuprofen. Additional symptoms included anorexia, epigastric pain, emesis that was neither bloody nor bilious, and loose stools. The patient also noted that his urine was dark colored and he experienced perioral…

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Mystery Quiz-The Answer

December 20, 2013
Mystery Quiz-The Answer

Vivian Hayashi MD, Robert Smith MD

The answer to the Mystery Quiz is diaphragmatic hernia, specifically a Bochdalek hernia. The CXR shows increased density behind the heart that has a smooth superior border (Image 2, arrows). This density does not obscure the left heart border, denoting a posterior location behind the heart. Furthermore, the lateral aspect of the opacity demonstrates low attenuation (hypo-dense) suggesting the presence of fat (Image 2, asterisk). The left hemidiaphragm is not visible indicating that the abnormality is contiguous with the…

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Mystery Quiz

December 17, 2013
Mystery Quiz

Vivian Hayashi MD, Robert Smith MD

The patient is a 78 year old man who presented to the emergency room with fever, pain, swelling, and erythema of the right leg over a two day period. The patient denied abdominal symptoms, cough or breathlessness over his baseline. His past medical history included Waldenstrom’s macroglobulinemia ten years earlier that responded to treatment with chlorambucil. Other morbidities included severe chronic obstructive pulmonary disease, myocardial infarction 20 years previously, and chronic venous insufficiency resulting in lower extremity edema. The…

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Mystery Quiz-The Answer

January 10, 2013
Mystery Quiz-The Answer

Elizabeth Mulaikal MD, Vivian Hayashi MD, Robert Smith MD

The answer to the mystery quiz is pulmonary Mycobacterium kansasii infection. The patient’s clinical presentation of fevers and night sweats suggested an infectious process or B symptoms due to lymphoma. The initial chest radiograph (image 1) demonstrated a left hilar mass which was noted to be larger on a subsequent chest radiograph (images 2 and 4)) 1 month later. This increase in size over a short duration again suggested an infectious etiology. Importantly and a key…

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Mystery Quiz

December 21, 2012
Mystery Quiz

Elizabeth Mulaikal MD, Vivian Hayashi MD, Robert Smith MD

The patient is a 55 year old African American male with a 60 pack year history of tobacco use and AIDS,who presented with 1 month of intermittent fevers and weight loss. His most recent CD4 count and viral load were 2/cmm and 50,623 copies/mL, respectively. Prior opportunistic infections included pneumocystis pneumonia and thrush. He was previously homeless, but currently resides in a Single Room Occupancy Housing. Upon presentation he complained of occasional night sweats, but no…

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Mystery Quiz- The Answer

June 29, 2012

Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors

The answer to the mystery quiz is thymoma associated with myasthenia gravis. The clue to the case is the intermittent dysphagia and chewing difficulty. If one considers myasthenia in the differential, then an otherwise grossly normal appearing chest radiograph may be viewed more closely, with attention directed to the upper, anterior mediastinum. The chest radiograph shows the ascending aorta (image 3, arrow); on the lateral film, the retrosternal space, which normally contains air, appears…

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Mystery Quiz

June 19, 2012
Mystery Quiz

Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors

The patient is a 61 year old man admitted to the psychiatry service for depression. During the hospitalization the patient reported a three year history of dysphagia and occasional right sided chest pain not clearly associated with exertion. He first noted difficulty chewing and swallowing turkey on Thanksgiving Day. The symptoms were intermittent thereafter and involved solid foods but not liquids. His chewing and swallowing difficulty abated for a year but returned one year…

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Mystery Quiz- The Answer

December 14, 2011
Mystery Quiz- The Answer

Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors
The answer to the mystery quiz is Kaposi’s sarcoma. The CXR shows bilateral confluent airspaceopacities which have a wide differential diagnosis in this case. The CT narrows the differential.  Specifically, the opacities appear to emanate from the central hilar areas, cuff the airways, and fan out into the more distal airspaces (Images 3 and 4).  This appearance is very suggestive of Kaposi’s sarcoma. CT scans may also reveal mediastinal lymphadenopathy and large

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Mystery Quiz

December 9, 2011
Mystery Quiz

Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors

The patient is a 52 year old African-American man who presented with breathlessness and weight loss over one month along with watery stools during the week prior to admission. He had a history of untreated HIV infection, a CD4 cell count of 5/cmm, oral candidiasis, and peri-rectal HSV infection. The patient reported occasional cough with variable sputum production but denied fever, night sweats, hemoptysis, recent travel, or sick contacts. His risk factor for HIV…

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