Mystery Quiz

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 pleural effusions…

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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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Mystery Quiz

November 30, 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 …

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Mystery Quiz- The Answer

June 17, 2011
Mystery Quiz- The Answer

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

The answer to the mystery quiz is lymphangitic carcinomatosis (LC). The diffuse interstitial and infiltrative pattern seen on CXR is best appreciated on the CT of the chest. On Images 4, 5 and 6, interlobular septal thickening is apparent (arrow) and is due to tumor infiltration of interstitial lymphatics. Also evident on these images (arrowhead) is diffuse peribronchial thickening due to tumor infiltration of the airways. Image 6 (open arrowhead) additionally shows pleural nodules, …

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Mystery Quiz

June 16, 2011
Mystery Quiz

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

The patient is a 62 year old man presenting with increasing breathlessness for the past six weeks. The patient first noted symptoms of mild shortness of breath and cough productive of yellow sputum that he attributed to his yearly winter cold. The sputum cleared and at presentation the patient had largely unproductive cough. A construction worker until six months earlier, the patient’s unlimited exercise tolerance was now limited to minimal exertion. He denied …

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Mystery Quiz- The Answer

February 11, 2011
Mystery Quiz- The Answer

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

The answer to the mystery quiz is pulmonary artery aneurysm. The chest CT shows a very round lesion in the left lower lobe with possible surrounding ground glass opacity. This perfectly round shadow suggests a vascular origin (Image 4, arrow). The apparent vascularity is further suggested by the sequential axial cuts on the CT (Image 5) which show a tubular dilatation (Image 5b) that bifurcates distally (Image 5d & e). This impression was confirmed …

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Mystery Quiz

February 4, 2011
Mystery Quiz

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

The patient is an 84 year old man who presents with small amounts of hemoptysis for one week prior to admission. He is a life-long non-smoker who began having cough with sputum production for one year without fever, chills, nightsweats, orthopnea, weight loss, arthralgias or rash. The patient denied unusual occupational exposures, history of prior TB, travel, or owning pets. The past medical history was significant for coronary bypass surgery, hypertension, atrial fibrillation treated …

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Mystery Quiz- The Answer

November 13, 2010
Mystery Quiz- The Answer

Dana Clutter, MD

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

Faculty peer reviewed

The answer to the mystery quiz is bacillary angiomatosis (BA). BA is a disease that most frequently affects individuals infected with the human immunodeficiency virus (HIV) and typically presents with multiple cutaneous papules and nodules. Visceral manifestations also occur and can involve the bone, lungs, lymph nodes, spleen, liver (termed peliosis hepatis) and the central nervous system.(1) Since the relatively recent first description of the disease …

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Mystery Quiz

November 10, 2010
Mystery Quiz

Dana Clutter, MD

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

A 25 year old woman infected with HIV presents to an HIV/AIDS clinic in Kampala, Uganda, for evaluation of cutaneous lesions on her face, arms and back. Aside from the disfiguring nature of her lesions, she reports being in her usual state of health. She denies any constitutional symptoms and all of her vital signs are stable. Her current CD4+ T cell count is 1 cell/cmm and she has …

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