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Ans. Case 8-2007

 投稿者:March 15, 2007  投稿日:2007年 3月24日(土)15時52分14秒
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  Anatomical Diagnosis

Helicobacter cinaedi myopericarditis.

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Figure 2. T1-Weighted Conventional SpinEcho Magnetic Resonance Images Acquired in the Transverse View at a Midventricular Level before (Panel A) and Immediately after (Panel B) the Intravenous Administration of Gadolinium.
In Panels A and B, the signal intensity of the left ventricular myocardium (1) and of chest-wall skeletal muscle (2) are measured in the regions of interest (outlined) to calculate the ratio of early enhancement of global myocardial signal to that of skeletal muscle. The ratio was 3.8 in this case, indicating hyperenhancement of the myocardium, a finding consistent with myocarditis. Gadolinium was administered at a dose of 0.1 mmol per kilogram of body weight.
 
 

No.2 Case 8-2007

 投稿者:March 15, 2007  投稿日:2007年 3月24日(土)15時50分47秒
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  Twelve hours after presentation, the chest pain increased in severity. The electrocardiogram was unchanged. Results of laboratory tests performed at this time are shown in Table 1. Morphine, at a dose of 2 mg, was administered intravenously, and the pain resolved.

Approximately an hour later, in the early morning of the first hospital day, the cardiac monitor showed ventricular tachycardia at 260 beats per minute, and the patient was found pulseless and unresponsive. A biphasic shock at 150 J resulted in asystole for several seconds, followed by sinus bradycardia at 35 beats per minute without a pulse. Magnesium, at a dose of 2 mg, and atropine, at a dose of 1 mg, were given intravenously, and sinus tachycardia developed, with palpable distal pulses and a systolic blood pressure of 160 mm Hg. He awoke almost immediately and was alert and oriented. A central venous catheter was placed; during the procedure he became agitated, and lorazepam was given for sedation. Shortly thereafter, his blood pressure fell to 60/40 mm Hg, and he again became unresponsive. Norepinephrine by intravenous infusion was initiated, and the trachea was intubated for airway protection; amiodarone, as a 150-mg bolus followed by infusion of 1 mg per minute, was administered intravenously, and he was transferred to the coronary care unit.

Two more specimens of blood were obtained for culture. The norepinephrine was quickly tapered, then discontinued, and the patient was extubated. He remained hemodynamically stable and alert, without chest pain; he had normal vital signs. Amiodarone was discontinued. Results of laboratory tests performed at this time are shown in Table 1. Later that day, cardiac catheterization showed left ventricular apical hypokinesis and normal coronary arteries. That evening, the temperature rose to 38.4°C, and two more samples of blood were obtained for culture. A nasal-swab specimen was negative for influenza A and influenza B, parainfluenza, respiratory syncytial virus, and adenovirus, and a culture of urine yielded no growth.

On the second hospital day, the patient felt well. The temperature was 37.5°C; no pericardial rub was heard, and the remainder of the physical examination was normal. The cardiac monitor detected no ectopy or arrhythmias. Treatment was initiated with metoprolol, at a dose of 25 mg orally twice a day. On the third hospital day, an electrocardiogram showed nearly complete resolution of the ST-segment elevation. On the fourth hospital day, the temperature was 37.6°C. A diagnostic test result was received.

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Table 1. Results of Laboratory Tests.
 

Case 8-2007 A 48-Year-Old Man with Chest Pain Followed by

 投稿者:March 15, 2007  投稿日:2007年 3月24日(土)15時47分25秒
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  A 48-year-old man was admitted to this hospital in the early spring because of a 20-hour history of chest pain. The pain was substernal and was exacerbated when the patient was supine and inhaled deeply; it did not radiate and was not associated with shortness of breath, palpitations, nausea, or vomiting. The patient initially assumed that the pain was caused by heartburn, but it worsened overnight, and he visited his primary care physician in the morning. An electrocardiogram showed diffuse ST-segment elevation (2 to 4 mm) and PR-segment depression, and the patient was taken to the emergency department of this hospital.

He had hyperlipidemia but no history of angina, and he had previously been in good health, except for a 36-hour episode of nonbloody diarrhea 6 weeks earlier after he had eaten a chicken-salad sandwich purchased from a delicatessen. He worked in an office, was unmarried, did not smoke, and drank little alcohol. He had no recent history of travel or exposure to sick persons, pets, or other animals. He took no medications. He described the pain as 6 on a scale of 1 to 10, with higher numbers indicating worse pain.

On examination, the temperature was 37.1, the blood pressure 108/51 mm Hg, and the pulse 110 beats per minute. No cardiac murmur or pericardial rub was detected on auscultation, and the lungs were clear. The abdomen was nontender, without organomegaly. Repeated electrocardiographic examination showed the presence of diffuse ST-segment elevation and PR-segment depression (Figure 1). Aspirin, a single intravenous dose of 2.5 mg of metoprolol, and sublingual nitroglycerin were administered, and the pain decreased to 3 on the scale of 1 to 10. Results of laboratory tests are shown in Table 1. A transthoracic echocardiogram showed no pericardial effusion, left ventricular hypertrophy, or left ventricular segmental wall-motion abnormalities. The ejection fraction was normal. Treatment with ibuprofen, at a dose of 800 mg every 8 hours, was initiated, and the patient was admitted to the medical floor for observation and cardiac monitoring. Shortly after the patient arrived on the floor, specimens of blood were obtained and sent for culture.

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Figure 1. Electrocardiogram Obtained at Presentation.
Widespread ST-segment elevations across the precordial and limb leads are concave upward, with PR-segment depression.
 

Ans. Case 7-2007

 投稿者:March 8, 2007  投稿日:2007年 3月 9日(金)00時44分5秒
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  Clinical Diagnosis

Ischemic ulcer of the heel due to atherosclerotic vascular disease.
Decubitus ulcers of the hip and thigh.

Anatomical Diagnosis

Calciphylaxis, extensive, involving the right leg.
Atherosclerotic vascular disease with ischemic ulcer on the heel and osteomyelitis.

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Figure 2. Calciphylaxis in Another Patient, Showing Irregular Areas of Dusky, Purplish Discoloration on the Skin of the Flank.

http://content.nejm.org/cgi/content/full/356/10/1049

 

Case 7-2007 A 59-Year-Old Woman with Diabetic Renal Diseas

 投稿者:March 8, 2007  投稿日:2007年 3月 9日(金)00時42分13秒
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  A 59-year-old woman was admitted to the hospital because of a nonhealing ulcer on the right heel and painful ulcers on the right thigh and hip.

The patient had been morbidly obese since early childhood; she had had type 2 diabetes mellitus and hypertension for 30 years and chronic renal insufficiency for 6. Painless ulcers had developed on the plantar surfaces of both heels 6 years earlier; those on the left side had healed with wound care and decreased weight bearing, but those on the right recurred when she resumed weight bearing. Four years before admission, she became unable to walk because of the ulcers, and moved to a long-term care facility. The chronic renal insufficiency progressed, and hemodialysis was begun 8 months before admission.

Three months before admission, a large area of purple discoloration and tenderness appeared along the back of her right lower thigh. This area subsequently ulcerated. Two months before admission, an ulcer developed over the greater trochanter of the right hip. Computed tomographic (CT) scanning of the thigh performed 3 months before admission was interpreted as showing cellulitis. Ultrasound imaging of the right leg was negative for deep venous thrombosis.

At approximately the same time, an ulcer on the right heel that had been present for about 2 years enlarged despite local care and attempts at primary closure. Approximately 2 months before admission, cultures of this ulcer yielded growth of Pseudomonas aeruginosa that was susceptible to ciprofloxacin and gentamicin, and intravenous therapy with these agents was started. Approximately 1 month before admission, a limited bone scan suggested the presence of osteomyelitis of the right calcaneus. Noninvasive vascular studies revealed an anklebrachial index of 0.83 on the right and 0.90 on the left (normal, >0.96). Right calcaneal resection and placement of a vacuum-assisted closure dressing were performed 3 weeks before admission. Cultures of the resected bone grew the same species of P. aeruginosa, as well as Escherichia coli. Ciprofloxacin and gentamicin were continued.

On follow-up examinations, the heel ulcer did not improve; it became painful, with a purulent discharge, and an area of redness and swelling developed around it. The ulcers on the right hip and thigh increased in size. She was referred to the vascular-surgery clinic of this hospital 10 days before admission. At that time, there was an ulcer, 3 cm deep, on the right hip; a black, necrotic area, 15 cm by 15 cm, on the right posterior thigh; and a decubitus ulcer, 5 cm by 5 cm, on the right heel with exposed bone. None of the ulcers were purulent. Noninvasive vascular study of both legs was recommended. During the next 10 days, her physicians became increasingly concerned about sepsis from the foot ulcer, and she was sent to the emergency department of this hospital.

On examination, her vital signs were normal and the right lower leg was painful on any movement; the ulcers were unchanged. Examination by vascular ultrasound imaging was limited because of pain but revealed right distal popliteal-artery and tibial-artery disease with poor perfusion of the right foot. She was admitted to the hospital for a below-the-knee amputation of the right leg.

She did not have fever, chills, or sweats. She had diabetic retinopathy, neuropathy, and carotid and coronary atherosclerosis; carotid endarterectomy had been performed in the past because of transient ischemic attacks. She had had episodes of congestive heart failure with pulmonary edema but had no history of venous or arterial thromboses. She had no known allergies. She was unmarried, had a 16-year-old daughter, and had worked as a teacher until becoming disabled because of the ulcers. She had a 5-pack-year history of cigarette smoking, but had stopped smoking 5 years before admission. She did not drink alcohol or use illicit drugs. Her medications, in addition to the antibiotics, included simvastatin, furosemide, lisinopril, metoprolol, insulin, calcium carbonate, sevelamer, famotidine, gabapentin, narcotics for the pain from her ulcers, and laxatives.

On examination, the patient was an obese woman who was lethargic but arousable and oriented. She was in moderate discomfort from pain in her right leg. The axillary temperature was 37.4, the blood pressure 137/58 mm Hg, and the pulse regular at 72 beats per minute. Auscultation of the lungs and heart were normal; the abdomen was obese, with no tenderness or organomegaly. The carotid and radial pulses were normal. The left dorsalis pedis pulse was diminished, and the right was not palpable. An ulcer, 5 cm by 5 cm, overlying the trochanter of the right hip exposed the subcutaneous tissue without purulence or erythema. On the right posteromedial thigh, an exquisitely tender and violaceous indurated area, 15 cm by 15 cm, with black, dry ulcerations and surrounding tender erythema, extended from the popliteal fossa two thirds of the way up the thigh. An ulcer, 5 cm by 5 cm, on the right heel had cyanotic margins and a foul-smelling purulent base that exposed bone. An area of erythema that was tender to palpation spread from the heel about two thirds of the way up the lower leg. Laboratory test results are shown in Table 1.

During the evening, a repeated examination disclosed that the area of erythema on the lower leg now extended to the knee. The patient continued to have severe pain of the calf and posterior aspect of the thigh. A procedure was performed early the next morning.

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Table 1. Results of Laboratory Tests on Admission.
 

Ans. Case 6-2007

 投稿者:February 22, 2007  投稿日:2007年 2月22日(木)10時39分8秒
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  Anatomical Diagnosis

Mixed germ-cell tumor (embryonal carcinoma, teratoma, and scant yolk-sac tumor).

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Figure 2. Gross and Microscopical Features of the Testicular Tumor.
The sectioned surface of the testicular tumor shows mostly solid, yellow-to-white tissue, with focal hemorrhage and a few cysts (Panel A). The tumor has the typical papillary (Panel B, hematoxylin and eosin) and glandular pattern of embryonal carcinoma. A high-power view (Panel C, hematoxylin and eosin) shows the pleomorphic nuclei and dusky cytoplasm that are characteristic of embryonal carcinoma. A teratomatous component (Panel D, hematoxylin and eosin) has squamous epithelium with keratin production (left) and teratomatous glands (right).

http://content.nejm.org/cgi/content/full/356/8/842

 

Case 6-2007 A 28-Year-Old Man with a Mass in the Testis

 投稿者:February 22, 2007  投稿日:2007年 2月22日(木)10時37分47秒
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  A 28-year-old man was referred to this hospital for consultation on the management of an enlarging testicular mass.

One year earlier, he had noticed a small, nontender mass in the posterior aspect of the right testicle, which a physician, who was a relative of the patient, ascribed to epididymitis; the mass seemed to disappear, or at least the patient did not notice it again. One month before the consultation, the results of a routine annual physical examination were normal; no abnormalities were noted in the testicles. Ten days before the consultation, the right testicle became tender and began to enlarge rapidly. The patient did not have fever or constitutional symptoms. His primary care physician began treatment with levofloxacin. The results of laboratory studies  including urinalysis, complete blood count, platelet count, erythrocyte sedimentation rate, and liver-, renal-, and thyroid-function tests  were normal.

The testicular tenderness decreased, but the swelling persisted. One week later, an ultrasound examination performed at another hospital showed a complex testicular mass that was considered highly suggestive of cancer. The patient's physician recommended an immediate biopsy of the testis, but the patient decided to come to this hospital for a second opinion.

He felt well and had no constitutional, gastrointestinal, or urinary symptoms. He had been in excellent health, had no allergies, and took no medications. He had never had a urinary tract infection or epididymitis, and there was no history of inguinal hernia or sexually transmitted disease. He had never smoked; he occasionally drank alcohol. He had married 4 months earlier and had no children. A grandfather had died of pancreatic cancer, and a grandmother had cancer, but the patient did not know the primary site. There was no family history of testicular or other genitourinary cancer.

On physical examination, the patient appeared well, although anxious. His vital signs and the results of the general physical examination were normal; there was no tenderness of the breasts or gynecomastia. The left testis was normal; the right testis contained a firm, nontender mass, 4 cm in diameter. The epididymis was normal. A specimen of blood was drawn to test for tumor markers.

Later that day, a diagnostic procedure was performed.

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Figure 1. Ultrasonographic Images of the Right Testis.
A transverse image through the right testicle (Panel A) shows a complex intratesticular mass with a cystic component (arrowhead) and a solid component (arrow). Normal testicular tissue is seen along the anterior aspect of the mass. A Doppler image (Panel B) reveals minimal vascularity in the solid component (arrow).
 

Ans. Case 5-2007

 投稿者:February 15, 2007  投稿日:2007年 2月15日(木)12時24分5秒
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  Anatomical Diagnosis

C. burnetii (Q fever) endocarditis.

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Figure 2. Transesophageal Echocardiograms.
A midesophageal view of the aorta in the long axis (Panel A) shows a partial dehiscence of the mechanical valve (arrow). A short-axis view of the aorta (Panel B) shows partial detachment of the mechanical valve and sutures (arrows) through half its circumference. A Doppler image (Panel C) shows a large paravalvular leak (arrows). Ao denotes aorta, LA left atrium, LV left ventricle, and RA right atrium.

http://content.nejm.org/cgi/content/full/356/7/715

 

Case 5-2007 A 53-Year-Old Man with a Prosthetic Aortic Val

 投稿者:February 15, 2007  投稿日:2007年 2月15日(木)12時22分16秒
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  A 53-year-old man with a prosthetic aortic valve was admitted to this hospital because of the recent onset of fatigue, dyspnea, weight loss, and sweats.

Approximately 4 years earlier, severe aortic insufficiency had developed. Echocardiography revealed a calcified, bicuspid aortic valve. Aortic-valve replacement was performed elsewhere, with a Medtronic Hall tilting-disk valve. Three months later, aortic insufficiency recurred, and the aortic valve was replaced with another Medtronic Hall valve at the same hospital. During the second operation, there was partial dehiscence of the prosthesis along a portion of the annulus, and although there was no abscess, inflammatory tissue was present at the surgical site. Pathological examination of the excised tissue disclosed a foreign-body giant-cell reaction; no organisms were identified.

Approximately 4 months before admission, the patient began to have anorexia, fatigue, and dyspnea on exertion, which gradually worsened, causing him to avoid climbing stairs. He reported profuse sweating during the day but no night sweats, fevers, or chills. He saw his primary care physician, who prescribed escitalopram for depression.

During the next 2 months, his symptoms continued, and he lost more than 22.7 kg in weight. He noticed that his mechanical heart sounds were less crisp than usual. One month before admission, he again saw his primary care physician. The results of laboratory tests are shown in Table 1. Orally administered iron supplementation was begun.

Two weeks before admission, the patient saw his cardiologist for a regularly scheduled visit and transthoracic echocardiography. The echocardiogram showed severe aortic insufficiency, with a poorly seated valve and a moderately enlarged aortic root. The ejection fraction was 40%, and there was diffuse hypokinesis. Two specimens of blood were sent for culture the next day; there was no bacterial growth after 5 days, at which time the cultures were discarded. A transesophageal echocardiogram, obtained at another hospital 3 days later, showed an echolucent area near the left coronary cusp that raised concern about the possibility of an annular abscess. The aortic root was dilated, at 48 mm, with a normal left atrium. Additional laboratory test results are shown in Table 1.

The patient declined immediate admission to the hospital because of business issues; instead, for 1 week vancomycin (1.5 g) was administered intravenously every 12 hours, and gentamicin (500 mg) and ceftriaxone (2 g) were given intravenously every day through a peripherally inserted central catheter. One day before admission, he was admitted briefly to another hospital, and on the next day he was transferred to this hospital.

The patient had a history of obstructive sleep apnea and used continuous positive airway pressure by face mask nightly. He had not had dental work in the past year. He was allergic to acetaminophenpropoxyphene and codeine. He had no family history of valvular heart disease or rheumatologic disease. His mother was alive and well; his father had died of complications from alcohol-induced liver disease at the age of 56 years.

The patient lived in Maine, was married, and had 8 children and 13 grandchildren. The family owned three cats but had no other pets; the patient had hunted in the past, but not for many years. He owned and operated a junkyard and tow-truck service. He had not traveled outside the country and had had no contact with ill persons. He had used alcohol and tobacco in the past, but had ceased using both approximately 30 years earlier. He did not use illicit drugs. Medications taken on a daily basis included warfarin, escitalopram, furosemide (20 mg, administered intravenously), folic acid, cobalamin, aspirin, and ferrous sulfate; he took hydroxyzine occasionally for allergy symptoms.

On examination, the temperature was 37.2, the pulse 99 beats per minute, and the blood pressure 115/57 mm Hg; the respirations were 18 per minute. The oxygen saturation was 95% while the patient was breathing ambient air. He appeared well. He was obese, with a protuberant abdomen. He had a ruddy facial complexion, and he was perspiring. Dentition was poor, with no abscesses or gingival tenderness. The conjunctivas were pale. There was no cervical lymphadenopathy. A well-healed sternotomy scar was noted. Auscultation of the chest revealed bibasilar rales. There was a mechanical second heart sound, a grade 2/6 systolic murmur, heard best at the apex, and a grade 2/4 diastolic murmur, heard best at the base. The point of maximal impulse was not displaced. The jugular venous pressure was 8 cm H2O. There were no Osler's nodes, Janeway's lesions, splinter hemorrhages, or peripheral edema. No erythema or drainage was evident at the catheter site.

The antibiotics were continued, and anticoagulation therapy with heparin was begun. A urine specimen was positive for proteinuria (1+) and blood (2+) but negative for nitrite. The sediment contained 10 to 20 red cells and 5 to 10 white cells per high-power field, many bacteria, and a few squamous cells. A culture of the urine showed no growth. Specimens of blood were sent for cultures for bacteria, mycobacteria, and fungi; the results were pending. Serum protein electrophoresis showed a moderate, diffuse increase in gamma globulin. No Bence Jones protein was detected, but trace amounts of albumin, alpha and beta globulin, and intact immunoglobulin were present. Serum levels of electrolytes, calcium, phosphorus, and bilirubin were normal, and renal function was also normal. The differential white-cell count was normal. An electrocardiogram showed normal sinus rhythm without prolongation of the PR interval but with ST-segment depressions in leads V3 through V6.

On the second hospital day, a chest radiograph showed evidence of a previous sternotomy and a slightly unusual position of the aortic valve, without other abnormalities. Computed tomographic (CT) scanning of the abdomen showed an enlarged spleen with focal abnormalities that were suggestive of tiny septic emboli and multiple small, low-density lesions in both kidneys. There were sigmoid diverticula and prominent retroperitoneal lymph nodes up to 1.6 by 1.0 cm in diameter, with minimal retroperitoneal stranding. CT scanning of the chest showed emphysema and paratracheal, prevascular, and subcarinal lymphadenopathy; the largest node in the right paratracheal region was 2 cm in diameter. The aortic valve appeared malpositioned, and there were several small pockets of contrast material adjacent to the aortic-valve annulus, between the aortic root and the pulmonary artery. Examination of a specimen from a bone marrow biopsy showed hypercellular bone marrow with trilineage hematopoiesis, erythroid predominance, and a reactive plasmacytosis.

Cardiac catheterization on the third day revealed a right-dominant system with normal coronary arteries. An aortogram showed preserved left ventricular function but severe aortic insufficiency. The prosthesis was noted to be rocking, tethered only on the left. The presence of an aortic-root abscess could not be ruled out. The two sets of blood culture specimens obtained on admission still exhibited no growth.

Carotid Doppler studies showed no stenosis. CT angiography of the chest on the fourth hospital day revealed an enlarged aortic root but a normal-size distal ascending aorta and aortic arch. Results of laboratory tests are shown in Table 1. A panoramic dental film obtained on the fifth day showed no evidence of periapical abscess, although many teeth were absent. A dental consultant noted the presence of a fractured tooth and two teeth containing caries.

On the sixth hospital day, transesophageal echocardiography showed that the mechanical aortic valve rocked excessively and moved into the left ventricular outflow tract during diastole. The valve was partly detached from the annulus; the detachment involved more than half the circumference of the valve. There was a large paravalvular leak, with severe aortic insufficiency. Although the left coronary sinus was dilated, there was no continuous flow into the left ventricular outflow tract. The left ventricle was dilated, with a normal ejection fraction.

A procedure was performed.

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Table 1. Results of Laboratory Tests.
 

Ans. Case 4-2007

 投稿者:February 8, 2007  投稿日:2007年 2月 8日(木)08時11分1秒
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  Anatomical Diagnosis

Paraneoplastic cerebellar degeneration due to anti-Yo antibodies.

Metastatic poorly differentiated carcinoma, involving a right axillary lymph node, consistent with metastasis from a primary cancer in the breast (estrogen receptor negative and progesterone receptor negative, with overexpression of HER2/neu).

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Figure 1. Imaging Studies.
A sagittal T1-weighted MRI scan obtained on the patient's admission to this hospital (Panel A) shows shrinkage of the cerebellar vermis (arrow). A PET scan obtained after the administration of 18F-fluorodeoxyglucose (Panel B) shows a small focus of uptake in the left axilla and a slightly larger one in the right axilla (arrows). A follow-up PET scan obtained 4 months later (Panel C) shows extensive abnormal uptake of tracer in the region of the right axilla and chest wall (arrow).

http://content.nejm.org/cgi/content/full/356/6/612

 

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