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Unilateral agenesis of the hemidiaphragm is a very rare congenital anomaly. We present the case of an adult who was evaluated for persistent cough. Unilateral agenesis of the diaphragm was an unexpected finding on a chest radiograph.

Case In Point: Unilateral agenesis of the diaphragm


These 2 patients presented with a swollen hand and rapidly proximally progressive edema secondary to a bite.

These 2 patients presented with a swollen hand and rapidly proximally progressive edema secondary to a bite. What creature did the biting?

Swollen Hands-What’s Biting?

A 5-year-old boy with a history of atopic dermatitis since 6 weeks of age, presents with a rash around his mouth that has been present for approximately 1 year. The patient’s mother reports that desonide topical cream was applied to the affected area for about 5 days, which initially resulted in improvement, however the rash returned after this medication was discontinued. The rash also recently improved after the patient took amoxicillin for an infection. She also notes that the patient has been licking his lips more frequently.

On examination there is an erythematous papulopustular eruption restricted to the perioral region, with sparing of the vermillion border. Mild hyperpigmentation is noted on the patient’s neck. There is no active involvement of other areas of the body.

The eruption has been present for 1 year and is restricted to the perioral region. What is included in your differential? 

Clinical Topics

Rash Around the Mouth of a 5-year-old Child

A 64-year-old woman with a history of basal cell carcinoma presents to the dermatologist for skin cancer surveillance. She is incidentally noted to have bruising on her upper eyelids (above). On questioning, she reports experiencing recurrent intermittent eyelid bruising for several years. She denies a history of trauma to her face, pain, or other associated symptoms.

Her medical history is significant for hyperlipidemia, hepatitis C (diagnosed >30 years earlier), osteoporosis, celiac disease, and idiopathic proteinuria for several years. Her surgical history includes appendectomy and carpal tunnel repair.

Pertinent family history includes her mother dying of multiple myeloma and her father of complications of diabetes.

Review of systems is significant for vague symptoms of gastrointestinal discomfort. On more directed questioning, she reports the eyelid purpura is temporally related to the Valsalva maneuver/ strained bowel movements. Her medications include atorvastatin, risedronate sodium, a daily multivitamin, calcium, vitamin D, and aspirin.

Her examination reveals no bruising elsewhere and no findings of interest on skin or mucous membranes.

B. Allergic contact dermatitis, purpuric type

Eyelid bruising was observed on a 64-year-old woman during routine skin cancer follow-up. She denied trauma or pain. What does this look like to you? 

Image IQ

Image IQ: Recurrent Eyelid Purpura 

A 67-year-old woman seen in clinic for unrelated concerns is incidentally noted to have a “rash” on her flank. She says it appeared in adulthood and has been stable for some years. On the right lower back, there is an asymptomatic reticulated erythema without scale or ulceration

. The patient admits to regular heating pad use on her lower back for pain. The remainder of the skin examination is within normal limits.

The patient says the incidental finding appeared in adulthood and has been stable for years. Can you identify this reticulated erythema?

An Asymptomatic Rash on the Low Back of an Older Woman 

A 9-year-old boy presented with a 1-week history of pruritus and rash on his elbows, knees, back, and legs. Several areas of excoriation were noted. He had recently run through a field of tall grass but denied any other exposure history.

A 9-year-old boy presented with a 1-week history of pruritus and rash on his elbows, knees, back, and legs. He had recently run through a field of tall grass but denied any other exposure history. Your Dx?

What Cause of This Itchy Rash?

This full-term male infant is the product of an unremarkable pregnancy and a normal spontaneous vaginal delivery. His physical exam is otherwise normal. The right-sided groin swelling shown below is soft and compressible. It is unclear whether the testicle is contained within the affected hemiscrotum.

A compressible groin swelling is the only abnormal feature after full-term gestation and unremarkable delivery. Your Dx?

Hemiscrotal Bulge in an Otherwise Normal Neonate 

Aydin Uzunpinar, MD

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