Clinical Images

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Cutaneous findings in atheromatous embolism

Typical appearance of blue toes due to multiple atheromatous emboli to the lower limbs in a patient with extensive atheromatous disease of the aorta.

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Janeway lesions

Peripheral embolization to the sole leads to a cluster of erythematous macules known as Janeway lesions.

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Splinter hemorrhages

Note the splinter hemorrhages along the distal aspect of the nail plate, due to emboli from subacute bacterial endocarditis.

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Left leg lymphedema with typical skin changes

Note that the toes are edematous and the skin is thickened in a classic peau d’orange pattern with verrucous changes.

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Contact dermatitis

Erythematous papules, vesicles, and serous weeping localized to areas of contact with the offending agent are characteristic.

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Erythema multiforme

The classic target lesion has a dull red center, pale zone, and darker outer ring (arrow).

This acute self-limited reaction may occur with infection,
antibiotic use, exposure to radiation or chemicals, or
malignancy.

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Erythema nodosum

The erythematous plaques and nodules are commonly located on pretibial areas. Lesions are painful and indurated and heal spontaneously without ulceration.

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Candidal intertrigo

Erythematous areas surrounded by satellite pustules are restricted to warm, moist intertriginous areas.

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Herpes simplex

(A) Primary infection. Grouped vesicles on an erythematous base on the patient’s lips and oral mucosa may progress to pustules before resolving.

(B) Tzanck smear. The multinucleated giant cells from vesicular fluid provide a presumptive diagnosis of HSV infection. However, the Tzanck smear cannot distinguish between HSV and VZV infection.

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Herpes simplex

(A) Primary infection. Grouped vesicles on an erythematous base on the patient’s lips and oral mucosa may progress to pustules before resolving.

(B) Tzanck smear. The multinucleated giant cells from vesicular fluid provide a presumptive diagnosis of HSV infection. However, the Tzanck smear cannot distinguish between HSV and VZV infection.

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Primary syphilis

The chancre, which appears at the site of infection, is an ulcerated papule with a smooth, clean base; raised, indurated borders; and scant discharge.

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Kaposi’s sarcoma

Manifests as red to purple nodules and surrounding pink to red macules. The latter appear most often in immunosuppressed patients.

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Pityriasis rosea

Pink plaques with an oval configuration are seen that follow the lines of cleavage.

Inset: Herald patch. The collarette of scale is more obvious on this magnification.

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Impetigo

Dried pustules with superficial golden-brown crust are most commonly found around the nose and mouth.

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Molluscum contagiosum

The dome-shaped, fleshy, umbilicated papule on the child’s eyelid is characteristic.

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Herpes zoster

The unilateral dermatomal distribution of the grouped
vesicles on an erythematous base is characteristic.

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Malar rash of systemic lupus erythematosus

The malar rash is a red to purple, continuous plaque extending across the bridge of the nose and to both cheeks.

Front 18

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Tinea corporis

Ring-shaped, erythematous, scaling macules with central clearing are characteristic.

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Psoriasis

(A) Skin changes. The classic sharply demarcated dark red plaques with silvery scales are commonly located
on extensor surfaces (e.g., elbows, knees).

(B) Nail changes. Note the pitting, onycholysis, and oil spots.

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Psoriasis

(A) Skin changes. The classic sharply demarcated dark red plaques with silvery scales are commonly located
on extensor surfaces (e.g., elbows, knees).

(B) Nail changes. Note the pitting, onycholysis, and oil spots.

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Tinea versicolor

These pinkish scaling macules com-monly appear on the chest and back. Lesions may also be lightly pigmented or hypopigmented depending on
the patient’s skin color and sun exposure.

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Actinic keratosis

The discrete patch has an erythematous base and rough white scaling. Actinic keratosis is a premalignant lesion that may progress to squamous cell carcinoma. It is most commonly found in sun-exposed
areas.

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Squamous cell carcinoma

Note the crusting and ulceration of this erythematous plaque. Most lesions are exophytic nodules with erosion or ulceration.

Front 24

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Nodular basal cell carcinoma

A smooth, pearly nodule with telangiectasias.

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Melanoma

Note the asymmetry, border irregularity, color variation, and large diameter of this plaque.

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Nonproliferative Diabetic Retinopathy

Flame hemorrhages (F), dot-blot hemorrhages (D), cotton-wool spots (C), and yellow exudate (Y) result from small vessel damage and occlusion.

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Hypertensive retinopathy

Note the tortuous retinal veins (V) and venous microaneurysms (M). Other findings include hemorrhages, retinal infarcts, detachment of the
retina, and disk edema.

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Papilledema

Look for blurred disk margins due to edema of the optic disk (arrows).

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Subretinal hemorrhage

Note the preretinal blood and overlying retinal vessels (R). Subretinal hemorrhages may be seen in any condition with abnormal vessel proliferation (e.g., diabetes, hypertension) or in trauma.

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Cholesterol emboli

Cholesterol emboli (Hollenhorst plaque; arrow) usually arise in atherosclerotic carotid arteries and often lodge at the bifurcation of retinal arteries.

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Tay–Sachs Cherry-red spot

The red spot in the macula may be seen in Tay–Sachs disease, Niemann–Pick dis-ease, central retinal artery occlusion, and methanol toxicity.

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Acute lymphoblastic leukemia

Peripheral blood smear reveals numerous large, uniform lymphoblasts, which are large cells with a high nuclear-to-cytoplasmic ratio. Some lymphoblasts have visible clefts in their nuclei.

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Chronic lymphocytic leukemia

The numerous, small, mature lymphocytes and smudge cells (S; fragile malignant lymphocytes are disrupted during blood smear preparation) are characteristic.

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Acute myelocytic leukemia

Large, uniform myeloblasts with round or kidney-shaped nuclei and prominent nucleoli are characteristic.

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Auer rod in acute myelocytic leukemia

The red rod-shaped structure (arrow) in the cytoplasm of the myelo-blast is pathognomonic.

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Hairy cell leukemia

Note the hairlike cytoplasmic projections from neoplastic lymphocytes. Villous lymphoma
can also look like this.

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Iron deficiency anemia

Note the microcytic, hypochromic RBCs (“doughnut cells”) with enlarged areas of central pallor.

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Spherocytes

These RBCs (S) lack areas of central pallor. Spherocytes are seen in autoimmune hemolysis and hereditary spherocytosis.

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Sickle cells

Sickle-shaped RBCs (S) are almost always seen on the blood smear, regardless of whether the patient is having a sickle cell crisis or not. Anisocytosis, poikilocytosis, target cells, and nucleated RBCs can also
be seen.

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Schistocytes

These fragmented RBCs may be seen in microangiopathic hemolytic anemia and mechanical
hemolysis.

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Target cells

The dense zone of hemoglobin in the RBC center is characteristic. Target cells are seen in hemoglobin C or S disease, thalassemia, severe liver disease, and
severe iron deficiency anemia as well as postsplenectomy.

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Mononucleosis

These atypical lymphocytes, with abundant blue cytoplasm, no granules, and variably shaped
nuclei, are classically seen in EBV and CMV infections.

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Basophilic stippling

The basophilic granules (arrow) within the RBCs are a nonspecific finding that may suggest megaloblastic anemia, lead poisoning, or reticulocytes.

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Eosinophilia

Eosinophils have red-staining cytoplasmic granules. Eosinophilia may be seen in atopic diseases, parasitic infections, collagen vascular diseases, medications, malignancies such as Hodgkin’s disease, and
endocrinopathies like adrenal insufficiency.

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Neutrophil (N) and band (B)

The more immature band form has a stretched, nonlobulated nucleus rather than a segmented nucleus. Bands are nonspecific markers of stress.

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Hypersegmentation

The nucleus of this hypersegmented neutrophil has six lobes (six or more nuclear lobes are required). This is a characteristic finding of megaloblastic anemia.

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Thrombotic thrombocytopenic purpura (TTP)

Note the schistocytes (S) and paucity of platelets. TTP is characterized by microangiopathic hemolytic anemia, thrombocytopenia, fever, neurologic abnormalities, and renal failure.

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Thrombocytosis

Numerous platelets are seen in myeloproliferative disorders, severe iron deficiency anemia, inflammation, and postsplenectomy states.

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Streptococcus pneumoniae

This is a sputum sample from a patient with pneumonia. Note the characteristic lancet-shaped gram-positive diplococci.

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Staphylococcus aureus

These clusters of gram-positive cocci were isolated from the sputum of a patient with pneumonia.

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Pseudomonas aeruginosa

This sputum sample from a patient with pneumonia revealed gram-negative rods. The large number of neutrophils and relative paucity of epithelial cells indicate that this sample is not contaminated with oropharyngeal flora.

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Tuberculosis (AFB smear)

Note the red color of the tubercle bacilli an acid-fast staining of a sputum sample (“red snappers”).

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Listeria

These numerous rod-shaped bacilli were isolated from the blood of a patient with Listeria meningitis.

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Aspergillosis

Note the characteristic appearance of Aspergillus spores in radiating columns.

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Cryptococcus

Note the budding yeast (arrow) and wide capsule of Cryptococcus isolated from CSF.

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Entamoeba

Entamoeba cysts have large nuclei. This is a sample from diarrheal stool.

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Giardia trophozoite in stool

The trophozoite exhibits a classic pear shape with two nuclei imparting an owl’s-eye appearance.

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Strongyloides

These filarial larvae were found in the stool of a patient with watery diarrhea.

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Clostridium wound infection

The lucency at the end of each gram-positive bacillus is the terminal spore (arrow). This sample was isolated from an infected wound site.

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KOH mount of Candida albicans

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Gardnerella vaginalis

Note the granular epithelial cells (“clue cells”) and indistinct cell margins.

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Rheumatoid arthritis

The swan-neck deformities of the digits and severe involvement of the proximal interphalangeal joints are characteristic.

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Gout

Negatively birefringent crystals.

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Pneumomediastinum

The lucency outlining the left heart border on chest x-ray suggests air in the mediastinum.

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Pneumoperitoneum

The lucency outlining small bowel on abdominal x-ray indicated the abnormal presence of air.

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Spontaneous pneumothorax on the right side

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CXR demonstrating tension pneumothorax

Clinical signs alone should be sufficient to diagnose this condition and avert the life-threatening delay involved in obtaining an x-ray.

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Acute epidural hematoma

Unenhanced CT scan shows a typical lens-shaped frontal epidural clot.

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Acute subdural hematoma

Note the substantial mass effect (displacement) of brain tissue but little edema.