Cherry red epiglottis

In the neck region the airway (larynx) and the passage (esophagus) for food, drink and so on  are near each other. If food and other material accidentally go into the airway death from airway obstruction can result.

The epiglottis is a flexible flap of tissue that prevents food and other material from going into the airway during swallowing. Due to for example, bacterial infection, the epiglottis and adjacent tissues can become (inflamed) swollen and red – cherry red epiglottis.

When inflamed, the epiglottis itself can obstruct the airway with fatal consequences; consequently visualizing the cherry red epiglottis should only be done for instance in an operating theatre with airway management specialists in attendance.

Vaccination with the Haemophilus influenzae type b (Hib) vaccine helps prevent epiglottitis (inflammation of the epiglottis) and other diseases caused by the bacterium Haemophilus influenzae.

Reference

Hung TY  et al. Bedside ultrasonography as a safe and effective tool to diagnose acute epiglottitis. Am J Emerg Med, 2011, 29(3):359.e1-3. Go to reference
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Epiglottis, Cherry

Image from Wikimedia Commons

Image from Wikimedia Commons

Salt and pepper retinopathy

Salt and pepper retinopathy refers to tiny light specks (hypopigmentation) interspersed among tiny dark specks (hyperpigmentation) that may be seen in those affected by the rubella virus when the eye’s back (retina) is viewed using special equipment.

These specks resemble salt and pepper in appearance – salt and pepper retinopathy. Besides rubella virus infection, syphilis and the toxic effects of some drugs can produce salt and pepper retinopathy. Salt and pepper retinopathy normally does not affect vision.

Vaccination of both males and females against the rubella virus helps prevent harmful effects of the rubella virus on the baby such as blindness, deafness, heart defects and other dreadful manifestations of the congenital rubella syndrome.

Please see also the celery-stick sign (click here).

Reference:

Damasceno N, Damasceno E, Souza E. Acquired unilateral rubella retinopathy in adult. Clin Ophthalmol, 2011 5:3-4. Go to reference
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Salt and pepper shakers, salt and paper retinopathy

Image from Wikimedia Commons

Image from the University of Michigan Kellogg Eye Centre

Carrot-shaped nuclei

Headache, vomiting and weakness can be the initial manifestations of medulloblastoma, the most common malignant brain tumor of childhood. The nuclei of some medulloblastomas when seen under the microscope can in shape remind you of carrots – carrot-shaped nuclei.

Medulloblastomas affect the cerebellum, a part of the brain concerned with fine-tuning movements but not initiating movements. At times medulloblastoma cells may spread to other regions via the cerebrospinal fluid, which is a clear colorless fluid surrounding the brain and spinal cord.

Surgery, radiotherapy and chemotherapy are forms of treatment for medulloblastoma.

Reference:

Kroh H, Bidziński J . Glial differentiation in medulloblastoma. Case report. Neuropatol Pol, 1993 31(1-2):75-82. Go to reference
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Carrots, Medulloblastoma (white blob)

Image from Wikimedia Commons

Image from Wikimedia Commons

Peaches and cream complexion

Located in the neck’s front region is the thyroid, a gland which produces and releases thyroid hormones that regulate the body’s metabolic rate.

A deficiency of thyroid hormones (hypothyroidism) can come about because of several reasons such as iodine deficiency (iodine is a component of thyroid hormones), destruction of the thyroid gland by disease or radiation, dysfunction of the structures which control the thyroid.

Individuals with hypothyroidism can gain weight, tolerate the cold poorly, be depressed, feel fatigued, have slow speech, menstrual cycle abnormalities, dry skin and in those with fair skin a complexion likened to peaches and cream – peaches and cream complexion.

Reference:

O'Callaghan JM, Bewick J, Paice A, Ng P. Stabbing? Cause. BMJ Case Rep, 2009;2009. pii: bcr12.2008.1312. Go to reference
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Peaches and cream

Image from Wikimedia Commons

Image from Wikimedia Commons

Nutcracker syndrome

The aorta, the body’s main artery originates from the heart; in the tummy region it gives off several other arteries that supply organs with blood. The inferior vena cava (IVC) returns blood from the lower body back to the heart. In the tummy, the aorta and IVC lie side by side; the aorta lies on the IVC’s left side.

One of the aorta’s tummy branches is the superior mesenteric artery (SMA) which supplies the intestines with blood.

Blood returning from the left kidney (within the left renal vein) must cross in front of the aorta to reach the IVC because of the relationship between the aorta and IVC - the aorta lies on the IVC’s left side.

Rarely, the left renal vein can become compressed between the SMA and aorta causing it to dilate. The SMA and aorta in this situation have been likened to the handles of a nutcracker squashing a nut which in this case is the left renal vein – nut cracker phenomenon (renal vein entrapment syndrome).

When the nutcracker phenomenon causes disease such as blood in the urine, tummy pain, the situation is then known as the nutcracker syndrome.

Reference:

Navarro J, Azua-Romeo J, Tovar MT, Lopez JA. Nutcracker syndrome: a rare anatomic variant. BJUI, 2012 DOI: 10.1002/BJUIw-2011-092-web Go to reference
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Anatomy, Nutcracker

Comments  

Image from Wikimedia Commons

Image from Wikimedia Commons

Sunflower cataracts

The body needs the metal copper for some of its functions such as assisting enzymes carry out their task of facilitating biochemical reactions.

In the rare inherited disease – Wilson’s disease – named after a doctor who described it, copper accumulates abnormally mainly in the liver and brain. Because of excess copper, the lens of the eye can look like a sunflower – sunflower cataracts. A cararact is cloudiness of the eye’s lens which can result from numerous causes.

Treatment for Wilson’s disease includes avoiding foods with copper, using medications which prevent absorption of dietary copper or bind to copper within the body and liver transplantation.

Reference:

Goyal V, Tripathi M. Sunflower cataract in Wilson's disease. J Neurol Neurosurg Psychiatry, 2000 69(1): 133. Go to reference

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Sunflowers, eye 

Image from Wikimedia Commons

Image from Wikimedia Commons

Celery-stick sign

Abnormal alternating dense (sclerotic) and not so dense (lucent) bone at the ends (metaphysis) of the thigh bone (femur) and shin bone (tibia) can occur following infection of the developing baby (via an infected mother) with the rubella virus particularly during the first weeks of pregnancy.

These bands of alternating sclerotic and lucent bone are seen on radiographic - X-ray - images and they resemble celery sticks/stalks in look – celery-stick sign.

Vaccination of both females and males against the rubella virus helps prevent harmful effects of the rubella virus on the baby such as deafness, blindness, heart defects and other dreadful manifestations of the congenital rubella syndrome.
The celery-stick sign is not unique to congenital rubella.
Please also see salt and pepper retinopathy (click here).
Reference:

de Mol AC, Vrancken S, Eggink AJ, Verduyn Lunel FM, Warris A. [The first newborn with congenital rubella syndrome during the rubella epidemic in The Netherlands in 2004/'05]. Ned Tijdschr Geneeskd, 2006 150(13):741-6.

Go to reference
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Celery, rubella virus

Image from Wikimedia Commons

3D animation of rubella virus - courtesy of Martin Gardiner

Ripe cheese odor

Leucine is one of the amino acids, which are the building blocks of proteins. Leucine is an essential amino acid meaning that the body cannot make leucine from scratch; it has to be obtained from the diet.

Isovaleric acidemia is a rare inherited disease in which there is a deficiency of the enzyme responsible for the processing of dietary leucine. Failure to process leucine results in the abnormal accumulation of isovaleric acid and other compounds, resulting in an affected individual having a body odor reminiscent of ripe cheese or sweaty feet/socks.

Isovaleric acidemia is a serious disorder that usually manifests in infancy with poor feeding, vomiting, convulsions and due to abnormal accumulation of isovaleric acid and other compounds there is damage to the nervous system.

Reference:

Lee H et al. A novel duplication at the putative DNA polymerase alpha arrest site and a founder mutation in Chinese in the IVD gene underlie isovaleric acidaemia. Hong Kong Med J, 2010 16(3):219-22. Go to reference

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Socks and cheese

Image from Wikimedia Commons

Image from Wikimedia Commons

Cottage loaf sign (TAPVC)

The heart is one of the first organs to function; it begins to beat from about 5 weeks of pregnancy. Normally after birth, 4 pulmonary veins return oxygenated blood from the lungs to the heart’s left side. This blood is then pumped by the heart to the rest of the body.

During pregnancy, when the future baby’s heart is developing, abnormalities in the heart’s development can occur. One of these abnormalities is total anomalous pulmonary venous connection/drainage (TAPVC) where the 4 pulmonary veins do not drain into the heart’s left side.

Patients with TAPVC because of the abnormal internal anatomy may on chest X-ray have an appearance akin to a cottage loaf – cottage loaf sign.

Reference:

Somerville J, Grech V. The chest x-ray in congenital heart disease 1. Total anomalous pulmonary venous drainage and coarctation of the aorta. Images Paediatr Cardiol, 2009 11(1):7–9. Go to reference
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Panel A ‘Cottage loaf’, ‘snowman’ or ‘figure of 8’ heart shape due to total anomalous pulmonary venous drainage, image reproduced with kind permission of the Images in Pediatric Cardiology journal. Panel B Outline of cottage loaf. Panel C Cottage loaf (a rustic traditional English loaf of bread made with yeast and white flour) consisting of two parts, the upper part is smaller than the lower part, image from Wikimedia Commons the free media repository.

Dish-face deformity

The middle of the face around the nose area may be hypoplastic (underdeveloped) in Larsen syndrome giving the face a look resembling a dish – dish-face. Other features of this syndrome named after Larsen who described it can include a tendency for the large joints to dislocate as well as abnormalities of the hands and feet.

Larsen syndrome is rare and is typically inherited in a dominant manner; meaning only one copy of the abnormal gene is enough to cause the syndrome when inherited from a parent who has the syndrome.

Mid-face fractures can also result in one developing the dish face-deformity.

Reference:

Kaissi A, Ganger R, Klaushofer K, Grill F. The management of knee dislocation in a child with Larsen syndrome. Clinics (Sao Paulo), 2011, 66(7):1295–1299. Go to reference
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Dish, Autosomal dominant inheritance

Image from Wikimedia Commons

Image from Wikimedia Commons

Coffee bean sign

The sigmoid colon is a part of the large intestine; it can twist upon itself abnormally – sigmoid volvulus.

Sigmoid volvulus is a life threatening condition that can present with vomiting, abdominal distension, abdominal pain and inability to pass flatus and stool, which emanate from intestinal obstruction caused by the sigmoid colon twisting on itself.

Abdominal X-rays in individuals with sigmoid volvulus usually have the coffee bean sign, so named because the dilated obstructed bowel which has coiled upon itself has an appearance resembling a coffee bean.

The coffee bean sign is also known as the 'omega', 'bent inner tube' or 'inverted U’ sign. The coffee bean sign is not exclusive to sigmoid volvulus, it can also be a feature of other diseases.

Reference:

Feldman D. The coffee bean sign. Radiology, 2000 216:178-179 (also source of image). Go to reference

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Abdominal X-ray showing the coffee bean sign, coffee beans 

Image reproduced with the kind permission of the Radiological Society of North America (RSNA®) - click here for image caption 

Image from Wikimedia Commons

Spaghetti and meatball appearance

By adulthood, most people are infected with the JC virus which is named from the initials of John Cunningham a patient who was afflicted by this virus.

Usually, the JC virus causes no problems for infected persons unless their immune system is compromised by AIDS, organ transplantation, some cancers, the use of certain drugs and so on.

Oligodendrocytes, the cells which form myelin that insulates nerve cells in the brain and spinal cord thereby facilitating efficient transmission of nerve impulses are infected by the JC virus.

On electron microscopy of oligodendrocytes in progressive multifocal leukoencephalopathy (PML) a serious disease caused by the JC virus, virus particles appear as both filamentous and spherical forms resembling spaghetti and meatballs respectively.

Reference:

Smith AB, Smirniotopolous JG, Rushing EJ. From the archives of the AFIP: central nervous system infections associated with human immunodeficiency virus infection: radiologic-pathologic correlation. Radiographics. 2008, 28(7):2033-58. Go to reference

Go to spaghetti & meatball appearance of Pityriasis versicolor
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Spaghetti and meatballs

Image from Wikimedia Commons

Butter stools

The digestion and absorption of fats is a complex process that involves the stomach, liver, pancreas, intestines and other organs. Due to disease of these aforementioned organs either singly or jointly, fat digestion and absorption becomes impaired resulting in excess fat in stool (human feces).

The feces become greasy, fatty and bulky (steatorrhea) – butter stools. It is not unusual for this type of stool to be foul-smelling and to float in water.

In general, stool consists of about 75% water and 25% solid matter.

Reference:
Harper M. Congenital steatorrhoea due to defect of the pancreas. Med J Aust, 1949 1(5):137-41. Go to reference
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Butter

Image from Wikimedia Commons

Cottage cheese appearance

The vagina is an organ used for having sex, as an outlet for menstrual blood flow and for child birth. Candida albicans, a fungus, is an organism found naturally in healthy people for example on the skin, in the mouth and vagina and so on.

However, at times due to circumstances such as use of antibiotics, poorly controlled diabetes mellitus, immunosuppression, etc. or for unknown reasons, a vaginal overgrowth of Candida may occur (thrush). Besides a thin watery discharge, itching of the private parts, discomfort during sexual intercourse, etc. women with thrush can develop a thick white discharge that resembles cottage cheese in appearance.

Most women during their lifetime will have at least one episode of thrush - thrush is not transmitted by making love.

Reference:

Achkar JM, Fries BC. Candida infections of the genitourinary tract. Clin Microbiol Rev, 2010 23(2):253-73. Go to reference
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Cottage cheese, candida albicans

 

Image from Wikimedia Commons

Image from Wikimedia Commons

Tumbler test

Meningitis is potentially life threatening inflammation of the protective coverings of the brain and spinal cord – the meninges – caused for example by bacteria, viruses, parasites, fungi, drugs and so forth.

The bacterium Neisseria meningitides (meningococcus), causes meningitis as well as sepsis (infection of the blood). In meningococcemia bleeding may occur into the skin causing a rash that does not grow fainter when a transparent glass tumbler is pressed against it – tumbler test aka glass test.

The tumbler test is controversial because it is difficult to perform and interpret, it is not particularly useful in dark skinned people, the non-blanching rash may not indicate meningococcemia and appearance of the rash is a relatively late feature in the natural course of the disease.

Reference:
Mant D, Van den Bruel A. Should we promote the tumbler test? Arch Dis Child, 2011 (7):613-4. Go to reference
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Child affected by a life threatening non-blanching rash, tumbler

Image from Wikimedia Commons

Image from Wikimedia Commons

Tripe palms

Internal cancers such as of the lung and stomach can cause the palms to become thickened and velvety such that they look a lot like tripe, the thick velvety insides of cows, sheep and so forth that make delicious dishes - depending of course on one’s taste - tripe palms.

Tripe palms are not due to the presence of cancer cells in the palms but are the result of substances produced by cancer cells elsewhere in the body or the body’s response to cancerous products which result in the palms becoming thick and velvety.

Although tripe palms are rare, the majority of individuals with tripe palms will have an internal malignancy, thus recognizing tripe palms is important.

Paraneoplastic phenomena such as tripe palms are phenomena due to the presence of cancer cells within the body not directly caused by the local presence or effects of cancerous cells.

Reference:

Patel A, Teixeiria F, Redington AE. Palmoplantar keratoderma ("tripe palms") associated with primary pulmonary adenocarcinoma. Thorax, 2005 (11):976. Go to reference

Tripe

Image from Wikimedia Commons

Sausage-string appearance

Sudden (acute) hypertension (raised blood pressure) can cause small blood vessels to develop areas of alternating constriction and dilatation making the blood vessels look like sausages on a string – sausage-string appearance. Why this sausaging happens is unclear.

Nonetheless, hypertension has serious complications such as stroke, heart and kidney disease.

Most individuals with hypertension feel well despite ongoing organ damage.

In the absence of an identifiable cause, treatment for hypertension includes weight loss, exercise, a diet rich in fruits and vegetables, medication and so forth.

Reference:

Jacobsen JC, Beierholm U, Mikkelsen R, Gustafsson F, Alstrøm P, Holstein-Rathlou NH. "Sausage-string" appearance of arteries and arterioles can be caused by an instability of the blood vessel wall. Am J Physiol Regul Integr Comp Physiol, 2002 283(5):R1118-30.

Go to reference

Sausages, complications of hypertension

Image from Wikimedia Commons

Image from Wikimedia Commons

Mulberry molars

Usually the molars, which are teeth located at the mouth’s back have four cusps (eminences). At times in individuals with congenital (present at birth) syphilis molars develop multiple abnormal rudimentary cusps giving the molars a look not unlike mulberries – mulberry molars.

Congenital syphilis is transmitted from the mother to the fetus during pregnancy across the placenta (vertical transmission) or during birth.

Antibiotics such as penicillin given to the pregnant woman, her baby (and the father) help treat syphilis.

Like HIV, syphilis is a sexually transmitted infection, it is caused by the spiral-shaped bacterium Treponema pallidum.

Besides mulberry molars, congenital syphilis has many other clinical manifestations that involve the skin, blood, bones, brain, kidneys, eyes, ears and so on.

Reference:

Khetarpal S, Kempf E, Mostow E. Congenital syphilis: early- and late-stage findings of rhagades and dental anomalies. Pediatr Dermatol, 2011 28(4):401-3. Go to reference

Abnormal teeth in syphilis, electron microscope image of Treponema pallidum

Image from Wikimedia Commons

Image from Wikimedia Commons

Cream of tomato soup

Blood normally contains fats (lipids) which include triglycerides. In the body, fats are important for several reasons, for example, as an energy store and source, as components of cell membranes, insulators and so forth.

Due to genetic or environmental abnormalities or a combination of both abnormalities blood levels of triglycerides can become abnormally increased – hypertriglyceridemia.

On drawing blood from a person with severe hypertriglyceridemia it appears cloudy because of the high concentration of triglycerides; in appearance, the blood resembles cream of tomato soup.

Severe hypertriglyceridemia is associated with increased risk of having heart attack, inflammation of the pancreas (pancreatitis) and other ailments.

Reference:

Tremblay K, Méthot J, Brisson D, Gaudet D. Etiology and risk of lactescent plasma and severe hypertriglyceridemia. J Clin Lipidol, 2011 5(1):37-44. Go to reference

Tomato soup, triglyceride

Image from Wikimedia Commons

Image from Wikimedia Commons