Visual Practice

A visual practice article consists a brief history of the patient, the main physical examination/ laboratory findings, two multiple choice questions, one single most concern aspect about the case, and a high-quality visual content of the case (see the author’s guide for requirements).

  • The history of the patient should be concise, containing the most important and related positive and negative history notes, physical examination findings, and laboratory values.
  • The questions should be designed as multiple choices questions with only one correct answer. The preferred question topics are about the most/ least probable differential diagnosis, the most common associated signs, symptoms, or syndromes, and the gold standard diagnostic tests; but any other interesting subjects are also appreciated.
  • The single most concern aspect of the case might be a notable and critical point about the diagnosis, screening work ups, prognosis, management, and follow-up plan of the patient with maximum number of 5 references. see the author’s guide for formatting the references.
  • The visual content might be a photo of the patient, an imaging result, or a short video of a diagnostic procedure. The patient’s privacy should be fully maintained, and all patients’ names or personal information should be removed from the contents. The required quality characteristics are noted in the author’s guide.
Several foreign bodies throughout the torso following a shotgun injury

Zhale Nahavandi, AmirHossein Aghdaee, Seyyed Mojtaba Nekooghadam

A 50 year old man with a history of posterior bullet shot with a shotgun was presented to the hospital 18 hours after the accident complaining of abdominal and gluteal pain. He had stable vital signs, no respiratory distress, and no active bleeding. Physical examination revealed abdominal tenderness and generalized abdominal guarding.
After a primary survey, a complete abdominopelvic ultrasonography and whole body computed tomography (CT) scan were performed (Figure 1) and revealing several bullet fragments (confirmed with Hounsfield scale) in paraspinal and abdominal wall, mesenteric fossa, pererectal and prenephric area, intestinal surroundings and illiac fossa (Figure 2 and 3).
One of the bullet fragments was observed in left inferior renal calyx (Figure 4). Moreover another fragment was touching aortic arch (Figure 5).
Afterwards, the patient underwent explorative laparatomy. About two liters of blood clot was observed in pelvic fossa. Also evidences of spleen injury and pancreas head and rectum hematoma with no active bleeding was observed. All four quadrants were packed, drainage was applied for pancreas. Since there was no fragment in aortic intima, no intervention was needed.
After post-operative antibiotic therapy and other follow-ups such as urologic assessments, the patient was discharged.
After two weeks, the patient was again referred to the hospital with pain in the site of drainage tubes. In laboratory tests amylase levels was 162 (U/L) and lipase levels was 83 (U/L). Plural effusion and atelectasis were observed in left lung CT scan (Figure 6) which did not need invasive intervention. Accumulation of spleen subcapsular fluid was observed in abdominopelvic CT scan. Loculated fluid collection was observed in pancreaticosplenic and paracolic areas (Figure 7) which led to diagnosis of pancreas drainage infection. The patient was treated with wide spectrum antibiotics and the symptoms were resolved. Also, there was the possibility for lead poisoning with lead bullet fragments, therefore serum levels of lead were examined after two months. The results showed a high level of lead concentration in serum (29 µg/dL). The patient was treated with antioxidant and vitamin C and asked to refer to the hospital every 2 months to check the lead level and have it under control. Administrating chelating agents such as dimercaptosuccinic acid and calcium disodium EDTA should be considered if the serum lead level is increased in the follow-up. Moreover, with the possibility for secondary adverse effects due to retained fragments, such as fistula formation, visceral adhesion, recurrent infection, et Cetra, the patient was advised to do frequent imaging checkups. According to similar cases and new studies, the presence of the lead in the bullet fragments won’t be causing any contraindications for magnetic resonance imaging but may cause some artifacts thus the alternative imaging tests such as CT or X-ray graphy are suggested. There’s also no evidence for the pellets movements and visceral organs injury after MRI in shotgun injury cases.

Right to Left Shunt in Agitated Saline Test

AmirHossein Aghdaee, Zhale Nahavandi, Mehrdad Jafari Fesharaki

An 11-year-old girl was presented to the cardiology clinic with a history of atypical chest pain and nonspecific shortness of breath. The patient underwent echocardiography that revealed interatrial septum redundancy with signs of shunt flow in the color-doppler study (Video 1). The differential diagnosis included atrial septal aneurysm (ASA) associated with patent foramen oval (PFO) and atrial septal defect (ASD). Agitated saline test was performed via left cubital vein (Video 3) and significant leakage of contrast through interatrial septum was confirmed (Video 2). For further evaluation, the patient underwent the transesophageal echocardiography (TEE) to rule out the ASD. No left to right shunt was seen in TEE and the color-doppler study showed right to left shunt, hence the diagnosis of ASD was ruled out (Video 4). The final diagnosis was PFO. PFO is a congenital cardiac abnormality as a fetal blood communication tunnel between two atria (right to left) is remained open after one year of age. It has a high prevalence of about 25% in the general population. No intervention and follow up is needed; except for those who have large-sized PFO with significant right to left shunt and a history of neurological event especially in younger ages without other risk factors for atherosclerosis.


A 16-year- old girl with history of hypertension was referred to the surgery department due to multiple hypertrophied lesions in both lips and on the lateral sides of the tongue. The lesions have been appeared gradually within the last year and only issued as a cosmetic concern.

Which one could not be considered as the differential diagnosis of the patient?

  1. neurofibroma

  2. neurilemoma

  3. Leukoplakia

  4. Neuroma

Correct answer:

  • This figure demonstrates enlarged lip and hypertrophied tongue lesions which can be seen in neurofibroma, traumatic neuroma, neurilemoma, granular cell tumor, and neuroma; the net diagnosis is made by microscopic examination of a tissue biopsy. Leucoplakia as it is understood by its name is a white plaque with wide range of differential diagnosis; trauma, lichen planus, systemic lupus erythematous (SLE), leukoedema, and malignancy.

On retrograde history taking, the patient had a total thyroidectomy due to medullary thyroid carcinoma (MTC) two years ago and right adrenalectomy due to pheochromocytoma last year.

What would be the most probable diagnosis?

  1. Neurofibromatosis type 1

  2. MEN 2A syndrome

  3. MEN 2B syndrome

  4. MEN 1 syndrome

Correct answer:

  • The classic combination of the mucosal neuroma, MTC, and pheochromocytoma together define the multiple endocrine neoplasia type 2B (MEN 2B). Patients with MEN 2B syndrome also might have marfanoid features. In Neurofibromatosis type 1, neurofibromas, multiple café- au- lait spots, iris hamartomas, skeletal abnormalities, glioma, and cognitive disorders are expected. MEN 2A is identical with MEN 2B but instead of marfanoid features and neuromas, parathyroid hyperplasia is seen. MEN 1 syndrome is characterized by pituitary adenoma, parathyroid hyperplasia, and pancreatic tumor.

Due to the high fatality of MTC, early detection of MEN 2B cases and prophylactic thyroidectomy is of great importance and clinical suspicion to MEN 2B by non- endocrinologic features is critical in patients [1]. Currently, growing evidence is affecting our mindset about the clinical picture of MEN 2B syndrome. While MEN 2B patients are classically considered to be tall with marfanoid features, current studies report pediatric patients with proportionate short stature. It is also highlightable that intestinal ganglioneuromatosis associated with MEN 2B, should be considered in the differential diagnosis of Hirschsprung’s disease in children with constipation during early infancy.

A seven-month-old female infant was referred to the dermatology clinic due to several erosive cutaneous lesions. The lesions were crusted and super-infected (impetiginized), widespread on her face, trunk and, extremities. Multiple atrophic and ice-pick scars were also remarkable, especially on her face, which was attributable to previous lesions. The lesions have been appeared since one- month of age, and have been resolved on their own with atrophic scars. Hoarseness was another notable finding in her physical examination and the physical examination was otherwise normal. The hoarseness had existed since her birth. Lipoid proteinosis or Urbach- Weithe syndrome is a rare autosomal recessive disorder due to mutation in extracellular matrix protein 1  (ECM 1) characterized by the deposition of hyaline in cutaneous tissue and mucus membrane of aerodigestive tract (2). Mucocutaneous lesions including palpebral and lingual yellowish nodules, laryngeal complications such as hoarseness and obstruction, and neuro-cognitive disorders including learning difficulties, aggression, loss of fear, memory impairment, and seizures are expected in lipoid proteinosis (3-7).