Zebras: Clinical Surprises

Ventriculography revealed global LV depression and an ejection fraction of 45% in this patient with Takotsubo cardiomyopathy that developed after he sustained a gunshot wound.

Takotsubo Cardiomyopathy
The authors of this case describe an unusual presentation of Takotsubo cardiomyopathy, in which the major stressor was a gunshot wound. Consider Takotsubo cardiomyopathy in the differential diagnosis of acute MI-especially in the context of significant emotional and physical stress and vascular instability.

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AP film shows a minimally displaced femoral neck fracture in a woman with a completed hip fracture that she sustained while running in a marathon.
 

Unsuspected Stress Fracture
A completed stress fracture rarely occurs in a runner competing in a marathon. But here’s a case that disproves this general rule. The authors of this case stress the importance of being aware of any unusual presentation of a stress fracture, especially in long-distance runners who report pain in a weight-bearing bone.

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Extensive perihepatic adhesions of Fitz-Hugh-Curtis syndrome are visible between the liver (inferiorly) and the peritoneal cavity and diaphragm (superior and left).

Fitz-Hugh-Curtis Syndrome
Fitz-Hugh-Curtis syndrome is not well known, but it is classified as an emergent condition. The typical presentation includes right upper quadrant pain that may be pleuritic in young, sexually active women. Up to 75% of cases are caused by Chlamydia trachomatis infection, whereas only 10% result from N gonorrhoeae infection. In the patient described in this case, perihepatitis developed from a gonococcal infection. Instead of the more typical delayed presentation with right upper quadrant pain, her clinical history was consistent with appendicitis. Furthermore, a contrast-enhanced CT scan of the abdomen revealed no abnormalities in the right upper quadrant region. Thus, the absence of either ultrasonographic or CT findings does not rule out Fitz-Hugh-Curtis syndrome.

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A radiograph of the spine showed a large calcified mass in the abdomen. A CT scan of the abdomen and pelvis with intravenous contrast subsequently revealed an 8 cm infrarenal abdominal aortic aneurysm with a right-sided retroperitoneal hematoma.

Ruptured Abdominal Aortic Aneurysm
Ruptured abdominal aortic aneurysm is a true vascular emergency. Mortality is directly related to the timeliness of diagnosis and surgery; most delays are caused by a misleading, atypical presentation. The authors of this case note that classic presenting symptoms -abdominal pain, back pain, and a palpable aortic mass-occur in fewer than half of cases. Thus, diagnosis requires a high index of suspicion in all patients with risk factors, including male sex; old age; and a history of hypertension, smoking, or dyslipidemia (specifically a low serum high-density lipoprotein cholesterol level).

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Intertrigo? Candidiasis? Tinea cruris? Erythrasma?

Asymptomatic Linear Rash
This asymptomatic linear rash in the inguinal area of this 72-year-old man proved to be an atypical presentation of contact dermatitis. According to the author of this case, because the history did not support a diagnosis of contact dermatitis, a biopsy was warranted.
 

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Why are lesions of Necrobiosis Lipoidica (NL) distinctive?
 
 

Necrobiosis Lipoidica
Although the characteristic lesions of NL are distinctive, atypical presentations may mimic other conditions...including superficial annular lesions that resemble granuloma annulare and yellow annular lesions that resemble xanthomas. The lesions of sarcoidosis may also be confused with those of NL.

According to the authors of this case, the presence or progression of these lesions is unrelated to the management of a patient's diabetes.