Bilateral swelling and pain of the distal interphalangeal (DIP) joints for several months brought this 65-year-old woman to her physician. She complained also of stiffness in the region of the DIP joints when she arose in the morning and after short periods (less than 15 minutes) of inactivity. A history such as this, in conjunction with the appearance of the patient's hand, is typical of Heberden nodes, which are a manifestation of osteoarthritis (OA).
This striking picture of a bifid uvula in an asymptomatic 57-year-old man was taken by Robert P. Blereau, MD of Morgan City, La.
During the last few weeks of gestation or shortly after birth, the layers of the processus vaginalis normally fuse together and obliterate the entrance to the inguinal canal in the vicinity of the internal inguinal ring. An indirect hernia results from a failure of fusion of the processus vaginalis; the bowel subsequently descends through the inguinal canal.
A 2-year-old boy was hospitalized because of acute abdominal pain. He had no other symptoms. The child's temperature was 37.3°C (99.1°F). He was irritable and had generalized abdominal tenderness. A stool test was positive for blood. Results of laboratory investigations were normal.
During investigation of a long-standing iron-deficiency anemia, a 67-year-old woman was found to have cecal colon cancer, Duke's stage B. A right hemicolectomy was performed at that time, and she had periodic follow-up examinations. Four years later, during a routine outpatient visit, her carcinoembryonic antigen (CEA) serum level was found to be 27.7 ng/mL (upper normal limit, 5 ng/mL). Four months earlier, her CEA level had been normal.
The parents of an 18-month-old girl were curious about a depressed area on their daughter's lower back, which had been present at birth. The child was otherwise healthy.
For 8 months, a 69-year-old man had dysphagia, throat irritation, and a recurrent cough. He also complained of a bulge on the left side of the neck that decreased in size when pressed.
A sudden and severe loss of central vision in her left eye sent a 51-year-old woman for medical consultation. She was very nearsighted (211.00 diopters) in both eyes. Corrected visual acuity in her unaffected right eye was 20/20; the best corrected visual acuity in her left eye was 20/400.
A 35-year-old Nigerian man presented to the emergency department with a distended, tender abdomen; fever; and weight loss. His abdomen had grown increasingly large during the past several months as his appetite diminished. The patient reported no allergies, took no medication, and denied tobacco, alcohol, and illicit drug use. His only significant medical history was jaundice during adolescence.
A 68-year-old woman was referred from an acute care clinic for evaluation of a persistent cellulitis. Ten days before, erythematous, pruritic plaques developed on her ankles; these slowly enlarged, and pustules formed. The patient denied fever or chills. Her past medical history was unremarkable, and conjugated estrogen, medroxyprogesterone acetate tablets, and multivitamins were the only medications and nutritional supplements she was taking.
This red papule developed 6 months ago at the base of a 53-year-old woman's thumb. The lesion was asymptomatic, but it bled easily when traumatized. It was treated definitively with surgical excision, and the biopsy report was consistent with the clinical diagnosis of pyogenic granuloma. This most commonly appears on the face or fingers and may result from minor trauma.
A painful skin eruption surrounding her colostomy stoma had appeared several months ago and was slowly increasing in size, complained a 64-year-old woman with Crohn's disease. The lesion consisted of several coalescent ulcers with a yellow, fibrinoid base and a violaceous, undermined border.
The left ear of a 1-month-old infant girl shows a congenital papillomatous lesion at the preauricular area. She had no other apparent abnormalities.
This contorted hand of a 49-year-old man demonstrates Dupuytren's contracture, a disorder first described by Baron Guillaume Dupuytren in 1831. Although the condition may occur as a completely independent abnormality, it is commonly associated with chronic liver disease, diabetes mellitus, epilepsy, palmar fasciitis, carpal tunnel syndrome, rheumatoid arthritis, pulmonary tuberculosis, and alcoholism. This patient had a history of alcohol abuse.
A 76-year-old woman had a 40-year history of rheumatoid arthritis (RA). She had repeatedly refused treatment with disease-modifying drugs, including methotrexate. Nodules began to develop 15 years after the initial diagnosis; they recurred after surgical removal.
The use of preserved artificial tears several times a day provided little relief to this 54-year-old woman with red and painful eyes. The patient had a history of rheumatoid arthritis and dry eye syndrome; the latter is very common in patients with rheumatoid arthritis.
A 65-year-old woman, who was confined to a wheelchair because of severe rheumatoid arthritis, was concerned about nodules that had erupted on her fingers and hands during the previous 3 weeks. Her medical history included colon cancer, chronic renal insufficiency, anemia, and hypertension. The nonpruritic nodules were painful when they began to form under the skin; however, once they erupted, the pain disappeared.
A variety of rheumatic diseases-systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and the vasculitides among them-manifest as “lumps, bumps, and holes” involving the extremities. Each of these diseases works through specific mechanisms on different structures of the skin to produce a distinctive pathology. In doing so, each provides clues to the cause, which the history and physical examination can help confirm.
This 64-year-old woman has had rheumatoid arthritis for 15 years; her hands show classic rheumatic changes. She also had a leg ulcer that had failed to heal in 8 years despite three skin grafts.
Various types of cutaneous lesions may occur in association with RA, including rheumatoid nodules, rheumatoid neutrophilic dermatitis, vasculitis, palpable purpura, and pyoderma gangrenosum. Many of these manifestations-including rheumatoid nodules-are specific for RA. The presence of these nodules is associated with seropositive disease and with a more severe, erosive clinical presentation. The nodules appear in 20% to 30% of patients with RA. Sites of predilection are those subject to shear stress, including the subcutaneous tissues over the extensor aspects of the elbow region, over the sacrum in bedridden persons, and at the pericardial and pleural surfaces.
