Clinical Images:

Clinical ImageSimultaneous hot and cold thyroid nodules: Which is malignant?Yuki Otsuka, M.D.1, Yasuhiro Nakano, M.D.1, Daisuke Omura, M.D., Ph.D.1, Takayuki Iwamoto, M.D., Ph.D.2, Ruiko Hayashi, M.D.3 and Fumio Otsuka, M.D., Ph.D.11Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan

A 70-year-old diabetic woman was admitted to our hospital with a complaint of high fever accompanying shaking chills for three days. The patient had no abdominal symptoms and no history of eating raw food. The patient’s body temperature was increased to 39 oC, and blood analysis showed elevations of leukocytes (17,400 /µL) and C-reactive protein (16.5 mg/dL). Computed tomography revealed air density spots in the aortic wall (Fig A ), and Salmonella enteritidis serotype O9 was detected by blood culture. Under a tentative diagnosis of Salmonella-induced infective aortic aneurysm, the patient underwent antibiotic treatment with ampicillin/sulbactam. On day 11, the air had disappeared and the aortic wall showed a varicose deformity, leading to a differential diagnosis of infective aortic aneurysm (Fig B ). The patient recovered completely with 8-week antibiotic therapy without any operation.Cases of infective aortic aneurysms account for only about 1% to 3% of total cases of aortic aneurysm. However, the case fatality has been reported to be as high as 18 percent in two years1, and an early diagnosis is essential. Salmonella species are known as a common pathogen of the crucial infection2, and so clinicians should pay attention to the development of the disease.

Key Clinical Message:Clinicians should recognize the importance of evaluating iron overload in those with alcoholic liver diseases. Markedly elevated serum ferritin levels are a diagnostic clue for secondary hemochromatosis, necessitating the iron depletion therapy.