It is a superficial bacterial skin infection, which commonly involves palms and soles. The skin becomes whitish in colour with an appearance of punched-out pits. Multiple bacteria like cornybacteria, actinomyces and streptomyces can cause this condition. It is commonly found in farmers, military personnel and athletes. Clinically this situation may be asymptomatic but sometimes is associated with itching and soreness. However, malodour is the major concern for the patients. Diagnosis is usually based upon clinical examination but skin scraping can be done to exclude the fungal infections. Treatment is topical antibiotics and antiseptics.

Cotard's delusion is a rare neuropsychiatric disorder characterized by having extreme delusions like denial of one's existence, considering oneself dying or dead. Patients may believe that their body parts do not exist or they have lost their internal organs and may progress to the extent of having delusions of immortality. Cotard's delusion is considered a symptom of an underlying disease rather than being a disease on its own. This has been found associated with severe depression and it can be a symptom of other conditions which affect the brain like brain damage or other mental illnesses like schizophrenia etc. Patients suffer from self starvation because of self negation and catatonia due to denial of their capability to move or speak. This condition is usually a diagnosis of exclusion and can be corrected by treating the underlying disease. Medications may include anti-depressants, anti-anxiety or antipsychotics. Therapies may include cognitive behavioral therapy (CBT). Electroconvulsive therapy (ECT) might be used as a last resort. This condition is extremely rare and only about 200 cases have been reported world wide. Image via: https://images.app.goo.gl/tEGz4eRDFxPVXNtz5

When the median nerve is injured in the elbow region, flexion of the proximal and distal interphalangeal joints of 1st-3rd digits is lost due to paralysis of flexor digitorum superficialis and lateral half of flexor digitorum profundus respectively. Flexion of distal interphalangeal joints of digits 3 and 4 is still possible because the medial part of flexor digitorum profundus is supplied by ulnar nerve. Flexion at metacarpophalangeal joints of 2nd and 3rd digits is also lost due to paralysis of 1st and 2nd lumbricals which are supplied by digital branches of median nerve. When such a person attempts to make a fist, 2nd and 3rd fingers remain partially extended and a hand of benediction is formed. Image via: https://images.app.goo.gl/6vFhiAHgrtffQhw36

Dupuytren’s contracture, a fibroproliferative disease of aponeurosis of palm, presents as thickening of palmer skin along with formation of nodules adherent to deep fascia and skin. It arises secondary to proliferation of myofibroblasts; these increased myofibroblasts subsequently replace collage type I to collagen type III. Individuals with Dupuytren’s contracture are typically males, age ranging from 40 to 80 years, along with history of alcoholism, epilepsy, manual labor, trauma, and diabetes. There is a genetic etiology of Dupuytren’s contracture, which causes more aggressive, early presentation. All the digits can be affected, however, most common are ring and middle fingers. Typically involved joint are metacarpophalangeal and proximal interphalangeal joints. Diagnosis is based on clinical examination along with key findings in history indicating presence of risk factors such as chronic alcoholism or smoking etcetera. Hueston’s table to test, if positive, is indicative of treatment. The angle of contracture at metacarpophalangeal greater than 30 degrees also indicates need for treatment. The aim of management of Dupuytren’s contracture is to eliminate deformity and to prevent associated neurovascular injury. Treatment may be operative and non-operative, depending on severity and patient’s condition. Non-operative options include physiotherapy, pharmacological therapy such as hyperbaric oxygen, vitamin E and steroids, radiotherapy, and collagenase derived from Clostridium histolyticum. Operative management may include techniques like needle fasciotomy, limited fasciotomy, and dermofasciectomy. Unfortunately, these is no definitive treatment of Dupuytren’s contracture, hence, there is always a chance of recurrence. Source Dupuytren’s Contracture – Current Concepts https://www.sciencedirect.com/science/article/abs/pii/S0976566220301107 Image via https://www.londonupperlimbsurgery.co.uk/dupuytrens-disease/

In this operative video, we demonstrate the approach to a 10-mm distal left vertebral artery and proximal basilar artery blister aneurysm in a 62-year-old male presenting with subarachnoid hemorrhage. He initially underwent clipping of the ruptured ACoA aneurysm and two incidental right MCA aneurysms. Ten days later, the posterior circulation aneurysms were clipped through an extended retrosigmoid approach, working between cranial nerves 9--11 inferiorly and 7--8 superiorly. The vertebral artery was accessible from its dural entry site to the vertebrobasilar junction with the rostral limit of the exposure at the level of the tentorium. He underwent uneventful clipping of all aneurysms without postoperative morbidity.

Caloric testing involves instilling hot and cold water into the ear respectively in order to stimulate the semicircular canals. The results of this test can hint at various pathologies of the inner ear and vestibular system. The video beautifully explains the mechanism behind this interesting yet confusing phenomenon.

Nutritional deficiency affects all systems of a growing child. A curable problem which should have been eradicated by the 21st century, still predominates in large areas of the world. The above image highlights the key differences between Kwashiorkor and Marasmus, the two major nutritional deficiency disorders affecting children. Courtesy: Medicos' Anectode https://twitter.com/AnecdoteMedicos/status/1305408480359059456

Giant Cell Arteritis (GCA) is a type of vasculitis which commonly involves medium and large sized vessels. Headache, jaw claudication, amaurosis fugax and vision loss are the most common symptoms seen in this condition but tongue necrosis is relatively rare, due to its rich vascular supply. Below is a case of 85 year old, hypertensive male, who presented in Emergency Department with a severe fronto-temporal headache along with jaw pain. The patient had been suffering from mild to moderate headache and jaw pain for the past 30 days. However, the headache increased in severity for the last 7 days along with jaw pain which involved floor of the mouth as well as the chin. Past medical history revealed cataracts and osteoporosis. The patient was suspected for GCA, on the second day of admission the patient suffered severe pain in the tongue and was not able to eat anything. On inspection, lingual volume was increased along with edema and white plaques. A lingual swab was taken which later revealed oral candidiasis. The patient was put on fluconazole therapy. Within 24 hours the color of tongue changed from white to grey, indicating lingual ischemia. Temporal pulses were absent and bilateral amaurosis was seen. Complete Blood count showed highly raised ESR and CRP as well as mild leukocytosis and anemia, indicating an acute inflammatory crisis. A doppler ultrasound and biopsy was taken which confirmed the diagnosis of Giant Cell Arteritis. The patient was put on 1mg/kg/day Prednisone followed by methotrexate 10mg/ week. After 14 days the necrotic area of the tongue detached itself on its own from the healthy tissue. Late, the Prednisone dose was tapered off to 20mg/kg gradually and the patient was discharged.

Club foot or talipes equinovarus is a congenital condition of the foot which mostly involves the subtalar joint. It is the most common musculoskeletal deformation and it occurs twice as frequently in males. In this condition, the foot is inverted, the ankle is plantarflexed and the forefoot is adducted (turned towards midline). The patients must bear weight on the lateral surface of the foot rather than the soul. Ponseti method is used for the correction of club foot. This method involves serial manipulation and casting which corrects the deformity in a step wise manner. Image via: https://images.app.goo.gl/V8r1EmDVzccoG6iR6

Alzheimer's is a neurodegenerative disease of the brain. It affects memory, thinking, and behavior, and is irreversible. 1 in 10 people over the age of 65 in the US have Alzheimer's disease, making it the 6th most common cause of death in the United States and 5th leading cause of death for those above the age of 65¹. Generally, Alzheimer's disease is diagnosed based on the signs and symptoms of dementia and ruling out other possible causes of dementia. Tests are conducted to test memory impairment, changes in behavior, and thinking skills. MRI and CT might be done to rule out other causes of Alzheimer's. Though the only way to accurately diagnose it is a brain biopsy after death. IBM and Pfizer used data from the Framingham heart study to train an AI to look for changes in speech patterns over time to check for degenerative changes. Previous attempts at predicting Alzheimers were through biomarkers in the blood and brain but these speech patterns arrive even earlier than them. The Framingham heart study followed 5000 people and their families since 1948 for changes in health and the data recorded. Using this data, the AI can predict who will get Alzheimer's disease 7 years before diagnosis with 70% accuracy. Early diagnosis can help doctors to start therapy early on. This will also help observe the progress of the disease over time which might lead to the development of a cure since when Alzheimer's is diagnosed, it has usually reached the stage where nothing can be done. References:- 1.https://alz-journals.onlinelibrary.wiley.com/doi/full/10.1002/alz.12068 2.https://www.cnet.com/health/researchers-are-using-ai-to-predict-alzheimers-disease-seven-years-before-clinical-diagnosis/ 3.image credit:- https://pixabay.com/illustrations/mental-health-mental-health-head-3337026/

Conjoined or Siamese twins are identical twins which result from incomplete separation of the embryonic disc. These twins can be joined at chest (thoracopagus), cranium (craniopagus), dorsal surface (pygopagus- fused at saccrococcygeal and perineal region). The survival and separation rate of conjoined twins is usually low however, many conjoined twins have been reported to survive including Chang and Eng Bunker, the most famous, Siamese- American conjoined twin brothers who were joined at the abdomen. They traveled on exhibitions and fathered 21 children with their 2 wives with Chang having 10 and Eng having 11 children. The photo shows Chang and Eng Bunker twins with their wives and children. Image via: https://images.app.goo.gl/sQU4zzjTAZ4Jrnut9

Central venous catheter (CVC) is an indwelling device placed either in internal jugular vein, femoral vein, or subclavian vein. CVC are employed for administration of fluids and medications. Blood can also be drawn from central line to run laboratory investigations. Central vein catheters are superior to peripheral IV lines with respect to large amount of fluid and medication administration. It can be left in body for longer time periods as compared to peripheral lines. Typical immediate complications of placing a central venous catheter are injury to structures adjacent to the catheter, hemorrhage, hemothorax, arrhythmias, and phlebitis. Infection and thrombosis could arise as long-term complications. A journal reported a case of 46 years old gentleman, who presented to ER in with picture of septic shock. Patient was a known alcoholic, a type II diabetic, and had a liver injury from prior laparotomy. Patient also had history of ICU admission 28 years back. On examination, patient was febrile, tachycardiac and hypotensive with deteriorating oxygen saturation. Patient was not responsive to fluid resuscitation hence epinephrine was administered. Broad-spectrum antibiotics were initiated. Laboratory investigations revealed severe metabolic acidosis and acute kidney injury and subsequent anuria. Inflammatory markers were also raised. Total body CT scan was conducted to determine the source of infection. A foreign body was identified in pulmonary arteries . this foreign body was thought to be the remnant of central venous catheter inserted 28 years back. Any surgical intervention was not possible due to hemodynamic instability. The patient, despite of aggressive resuscitation and treatment, could not survive and died within 18 hours of admission. Autopsy revealed presence of foreign body in pulmonary arteries, attached with arterial wall by multiple adhesions. This foreign was the remnant of the catheter that was placed 28 years back. Numerous bacterial colonies were seen on catheter. Enterococcus faecium was cultured from the remnant of CVC, hence, was the source of sepsis. This case report encouraged proper removal of CVC, and vigilant examination of the CVC to look for any missing parts. Source An Unexpected Case of Late Fatal Central Venous Catheter Sepsis: A Case Report https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0040-1713415 Image on right side shows presence of remnant of CVC taken from https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0040-1713415 https://www.youtube.com/watch?v=ubwWEXji79U

A Bochdalek hernia is one of the types of congenital diaphragmatic hernias. Diaphragm develops from 4 components including septum transversum ( central tendon), dorsal mesentery of esophagus (crura of diaphragm), pleuroperitoneal membranes and muscular ingrowth from lateral body walls. Bochdalek hernia is an opening in the posterolateral region of diaphragm due to defective formation and/or fusion of the pleuroperitoneal membranes with the other three parts of the diaphragm. This results in continuity between the pleural and peritoneal cavities. This condition is more common on the left side. If the normal fusion of pleuroperitoneal membranes is impaired during the period when intestines return to the abdomen from the umbilical cord i.e in 10th week of gestation, some viscera may pass into the thorax. This abdominal viscera compresses the heart and lungs. Mortality in these cases results not from the hernia or viscera but due to the hypoplastic lungs which were compressed during their period of development. Such cases are associated with pulmonary hypertension due to decreased vascular cross sectional area. Hypoxia can further cause pulmonary vasoconstriction which may be reversed by inhalation of nitric oxide. Lungs can achieve their normal size after repositioning the abdominal viscera and reparing the diaphragmatic defect. The axial CT of the lung bases shows herniation of abdominal fat contents into the lower posterior left hemithorax through the left hemidiaphragm (arrows). Image via: https://images.app.goo.gl/cm4uH57FK9qNUHi27 https://radiologypics.com/2013/02/05/bochdalek-hernia/amp/

A 41-year-old man presented with progressive loss of vision in both eyes that was worse in the right eye than in the left. There was no history of trauma. His uncorrected visual acuity was 6/200 in the right eye and 20/100 in the left eye. Slit-lamp examination revealed ectopia lentis in both eyes, including near-complete inferior dislocation of the lens in the right eye (shown above) in addition to visible stretched zonules (the suspensory strands of the lens) and inferotemporal subluxation of the lens in the left eye. The patient’s mother has Marfan’s syndrome, and the patient has the elongated digits and pectus excavatum that are characteristic of the disease. He underwent pars plana vitrectomy and implantation of a scleral-sutured intraocular lens in the right eye. At final follow-up, the best corrected visual acuity in the right eye was 20/20, with correction of myopia. Marfan’s syndrome is associated with ectopia lentis in both eyes, a characteristic that may be subclinical. Indications for surgery include correction of an otherwise unmanageable difference in refractive power between the two eyes (anisometropia), excessive induced astigmatism, and complications of lens subluxation, including glaucoma, uveitis, and retinal detachment.

A 31-year-old woman who was receiving long-term total parenteral nutrition after having undergone Roux-en-Y gastric bypass that was complicated by small-bowel resection presented to the pulmonology clinic with exertional dyspnea that had progressed over the course of 1 year. She had normal oxygen saturation while breathing ambient air and was not in respiratory distress. Breath sounds were normal in all lung fields, with no wheezing, ronchi, or crackles. Computed tomography of the chest revealed diffuse, innumerable centrilobular nodules in both lungs (Panel A). A lung-biopsy sample obtained by video-assisted thoracoscopic wedge resection revealed perivascular aggregates of histiocytes and foreign-body giant cells with abundant basophilic foreign material in coral-like structures (Panel B). The material was confirmed by mucicarmine staining to be crospovidone, an inactive ingredient present in many oral medications. The patient received a diagnosis of pulmonary foreign-body granulomatosis, which can occur after injection or nasal inhalation of pulverized tablets, often opioids or stimulants, that contain inert fillers such as crospovidone, talc, or cellulose. She reported that she had been using the vascular access for her total parenteral nutrition to inject oral opiates that had been previously prescribed for her after abdominal surgery. Although the best available treatment for pulmonary foreign-body granulomatosis has not been established, treatment of the underlying opioid-use disorder is critical. At follow-up 6 months after the patient’s initial presentation (3 months after diagnosis), her dyspnea remained unchanged and was not limiting her daily functioning.

Porphyrias are rare, inherited or sometimes aquired, disorders which result from a defect in the heme synthesis pathway due to an enzyme deficiency. This defeciency leads to the accumulation and increased excretion of porphyrins or their precursors. Whenever there is an enzyme defect leading to accumulation of tertrapyrrole rings, patients present with photosensitivity. Porphyria cutanea tarda, the most common porphyria, belongs to the group of chronic hepatitic porphyrias. There is a deficiency of enzyme uroporphyrinogen decarboxylase. Factors like exposure to sunlight, hepatic iron overload, estrogen therapy, infections like hepatitis B or C and HIV and alchohol ingestion can exacerbate the expression of disease. Patients usually present during their 4th or 5th decade with photosensitivity, skin lesions like slowly healing skin eruptions and blisters, crusting and scarring of skin, hyperpigmentation, increased hair growth, especially facial. Urine is red to brown in natural light and pink or red in fluorescent light. Treatment may include phlebotomy, use of iron chelators or low doses of anti-malarial drugs like chloroquine or hyrdroxychloroquine. PCT is a risk factor for developing liver cirrhosis hence, life style changes should be adapted like avoiding alcohol and smoking, avoiding sunlight and application of sunscreen. Intake of estrogen should also be discontinued. Image via: https://images.app.goo.gl/66wCBZ1VQFzERHKW9 https://images.app.goo.gl/zWPzUSXUkwdGZpLy7 https://images.app.goo.gl/3pVoW1XruWaqF9hXA

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