images in clinical medicineT h e ne w e ngl a nd jou r na l o f m e dic i ne n engl j med 355;10 www.nejm.org september 7, 2006 A 38-year-old female smoker reported having had intermittent, recurrent right-sided chest pain for several months. Pelvic endometriosis had been diagnosed during laparoscopy for in vitro fertilization 6 years earlier. Six months before presentation, a small, right-sided spontaneous pneumothorax had been diagnosed for which she received no treatment; follow-up chest radiography 2 weeks later revealed no abnormalities. She was admitted because of acute dyspnea, and a recurrent right-sided pneumothorax was diagnosed (Panel A). It was her second day of menstruation, and she remembered that the first episode of pneumothorax had also taken place on the second day of her menstrual cycle. Spiral computed tomography of the thorax showed no abnormalities. Video-assisted thoracoscopy on the fifth day of menstruation showed numerous brownish oval lesions scattered on the diaphragm (Panel B), a finding diagnostic of endometrial implants. These lesions may vary in size during the menstrual cycle and may disappear altogether. During thoracoscopy a talc poudrage was applied, and treatment with a gonadotropin-releasing-hormone analogue was started. Menstruation stopped, and the chest pain disappeared. During a 6-month follow-up period, pneumothorax did not recur.

The legs of a 46-year-old man with scurvy are shown. The man had a mild mental disorder, and his diet consisted only of bread, pasta, packaged cookies, and water. Large ecchymotic areas extended over the backs of the legs (Panel A). A close-up (Panel B) shows perifollicular hemorrhages and hyperkeratotic papules in which hair is fragmented and buried. The plasma ascorbic acid concentration was 0.11 mg per deciliter (6.25 m mol per liter; normal concentration, Ͼ 0.62 mg per deciliter [35 m mol per liter]) after three days of a hospital diet. With a normal diet and vitamin C replacement therapy (500 mg orally per day), all findings disappeared within two and a half weeks.

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