A 64-year old female presented with fever, diffuse muscle pains and extensive areas of erythema and edema over her thighs and arms. She reported that these skin lesions developed over a few days. In addition the patient noticed generalized edema.

On examination, she looked acutely ill. She could barely walk with the support of two of her family members. Generalized edema was evident. The patient weighed 100 kg (her usual weight was 75 kg). Her blood pressure was normal but she was tachycardic (104 beats per minute) and tachypneic (20 respirations per minute) with oxygen saturation level on air of 95%. Her temperature was 390C. Areas of erythema were noted over her right and left thigh (Figure) and her arms extending to the anterior chest wall and breasts. These painful skin lesions were accompanied by warmth and tenderness. An area of fluctuance could be felt in her right thigh. On auscultation of the chest there were decreased breath sounds bilaterally. The rest of the physical examination was normal.

A hematocrit of 23.7% (hemoglobin 7.6gr/dl) accompanied by leukocytosis (19650/mm3 with 87.4% neutrophils with a shift to left) and mild thrombocytosis (501000/mm3) were present. C-reactive protein levels were increased at 26.71 mg/dl (normal up to 0.5) and erythrocyte sedimentation rate was 130 mm/1st hour (normal 0-20). There was a striking increase in creatine phosphokinase with serum levels of 6763 IU/l [upper limit of normal (ULN)=215 IU/l] accompanied by an increase in lactic dehydrogenase serum levels (LDH: 302 IU/l, ULN=190) and serum transaminases levels [AST: 230 IU/l (ULN=37) and ALT: 129 IU/l (ULN=65)]. Urine dipstick was positive for hemoglobin (++). A significant hypoalbuminemia was present [1.7 gr/dl (normal >3.5]. On urine microscopy there were 4-5 leukocytes per high power optical field, while there were no erythrocytes. Her electrocardiogram was normal. Chest X-rays revealed moderate bilateral pleural effusions.

What is the diagnosis?

A female patient from Greece, born in 1955, visited our office in January 1998 for evaluation of recurrent right pleural effusion (Figure). The patient was treated for Hodgkin's disease (supra-clavicular and mediastinal lymph node enlargement) with radiation and chemotherapy in February 1974. The treatment consisted of a series of MOPP (nitrogen mustard, vincristine, procarbazine and, prednisone) and Co60 radiation over the mediastinum and lymph nodes above the diaphragm. Details about the radiation, including dosage, were not available. She also had a splenectomy at that time. The treatment of Hodgkin's disease was successful and led to disappearance of the enlarged lymph nodes. The patient felt well and was able to receive a degree from a graduate school and subsequently to work full-time without any problem.

The patient initially felt progressively short of breath during November 1997. She did not have any fever. A chest x-ray at that time showed bilateral pleural effusion and enlargement of the shadow of the heart. An echocardiogram revealed a significant amount of pericardial fluid. The patient was subsequently admitted to a hospital for treatment.

A 59-year-old female presented with superficial hypogastric pain and low grade fever of one week duration. The patient had a history of ovarian cancer for which she underwent two abdominal operations as well as chemotherapy two years earlier. Six months prior to her visit she had been operated for hypogastric abdominal hernia with abdominal wall reconstruction using mesh support. Physical examination on admission showed erythema in the hypogastric area extending around the middle line (Figure). Routine laboratory testing, including erythrocyte sedimentation rate (ESR) did not show abnormal findings.

A 68-year-old male was admitted to our hospital due to fever and abdominal pain in the left lower quadrant that started 2 days prior to admission.

His past medical history was significant for coronary artery by-pass surgery 15 years earlier, perforation of the stomach 20 years earlier, and atrial fibrillation. His medication included acenocoumarol, isosorbide mononitrate, ramipril, furosemide, and carvedilol. The patient had dental work done 7 days prior to admission. He reported that he had stopped taking some of his medications, including acenocoumarol, prior to the visit to the dentist. However, two days prior to his admission he re-started taking acenocoumarol.

His temperature was 37.8 degrees Celsius. His blood pressure was 130/80 mmHg and his pulse rate was 120/min. Physical examination showed left lower quadrant abdominal tenderness and decreased bowel sounds. Routine laboratory testing showed: ALP 223 U/L, SGOT 41 U/L, ã-GT 239 U/L, total bilirubin 2.3 mg/dL, INR 2.33, prothrombin time 28.4 sec, partial thromboplastin time 49.2 sec, white blood cell count 15.70 K/ìl, neutrophills 83.5%, red blood cell count 3.77 M/ìl, hematocrit 39.3%, C- reactive protein 26.57 mg/dL (normal values up to 0.5 mg/dL), urea 34 mg/dL, creatinine 1.2 mg/dL.

A CT scan of the abdomen showed an area of hypodensity of the spleen with a size of 9.5×3 cm (Figure). Ascites was also noted.