A 56-year-old female patient seeked medical advice because of mild fever and a face lesion of two-week duration. Her past medical history was significant for diabetes mellitus (managed with insulin), mild chronic renal insufficiency and breast cancer for which she underwent total right mastectomy 10 years ago. The patient also received radiation and chemotherapy at that time. She recently received again chemotherapy due to hepatic and bone metastases (the last chemotherapy regimen was one month ago). Physical examination showed a temperature of 37 degrees Celsius and a large, vegetating lesion on the nose with areas of honey-coloured and black areas (Figure 1). Routine laboratory testing showed: hematocrit 39.6%, hemoglobin 13 g/dL, white blood cell count 6.91 K per cubic mm, neutrophills 93.6%, glucose 622 mg/dL, creatinine 1.9 mg/dL, blood urea 96 mg/dL, and total bilirubin 1.36 mg/dL. What is the diagnosis?

A 47-year-old female patient presented with haematochezia and fatigue. She reported that she had 4 bowel motions, which were dark red in colour without mucus. 3 weeks prior to presentation she noticed a rash that begun on the lower limbs (including the soles) and was ascending in nature and eventually involved the trunk, buttocks and upper limbs as well as the palms. Arthralgias, dysuria and frequency accompanied the skin manifestations. A skin biopsy performed elsewhere, showed leukocytoclastic vasculitis but immunofluorescence was not performed. The patient was not taking any medication prior to the development of the rash. She was on a tapering dose of methylprednisolone since and was generally well, except for continuing dysuria and frequency.

On examination, her blood pressure was normal but she was tachycardic (114 bpm) and tachypneic (20 respirations per minute) with oxygen saturation levels on air of 95%. Her temperature was 37,3 0C. A generalized purple skin rash was evident in the aforementioned areas (Figures 1 and 2). Her abdomen was exquisitely tender in all quadrants with a degree of rebound tenderness. On rectal examination dark red blood was present. The rest of the physical examination was normal.

Significant leukocytosis (34000/mm3) was present, as were mildly elevated urea levels (56 mg/dl). Urine dipstick was positive for blood (++) and leukocytes (++) and albumin (+). On urine microscopy there were 70 leukocytes and 5 erythrocytes per high power optical field, but there were no casts. Her electrocardiogram was normal but her chest X-ray revealed moderate bilateral pleural effusions. What is the diagnosis?

A 55-year-old female patient presented to us with a 10-day history of malaise, lethargy, and fever up to 39.50 C accompanied by rigors. She also complained of diffuse myalgias, arthralgias, and bilateral facial edema. Her past medical history was significant for a modified mastectomy for invasive breast cancer in 2000 but she is free of disease 6 years later. There was no history of trauma. She admitted that she had botulinum toxin injections in the forehead 4 years ago but there was no prosthesis in the periorbital area (neither silicone nor fat).

On examination, her blood pressure was 130/70 mm Hg and she was feverish (390 C). Pulse rate was 90 bpm regular and respirations were 18/ minute. There was marked edema of the face, especially in the periorbital and malar areas (Figure 1), and this was accompanied by erythema and sensitivity. There was no associated feeling of pruritus of the aforementioned area. A scar from the previous surgical operation in the breast area was evident.

Laboratory examinations showed leucocytosis (12480 /mm3 with a left shift), normal eosinophil count, increased C-reactive protein [11.4 mg/dl (normal values 0-0.5)], and increased erythrocyte sedimentation rate [70 mm/1st hour (normal 0-20)]. Creatinophosphokinase levels were increased [1453 IU/lt (normal 21-215)]. Immunoglobulin levels were increased for IgA [550 (normal 55-377) mg/dl] and IgE [(696 IU/lt (normal 0-200)], Serum protein electrophoresis was normal. C1 esterase inhibitor levels were normal [339 mg/lt (normal 210-390)]. Antinuclear autoantibodies, anti-dsDNA and anti-Sm were all negative. Serology testing was negative for Trichinella spirallis and C. trachomatis. Magnetic resonance angiography of the brain vessels was normal. MRI imaging confirmed the presence of edema in the periorbital area. Electromyography of the muscles of the upper and lower limbs was normal. What is the diagnosis?

A 53-year old woman presented to us because of pain and swelling of the right knee joint for the previous 2 days before admission. She took non-steroidal anti-inflammatory medication but experienced only minimal and temporary relief for a few hours. The pain and swelling got gradually worse. She checked her temperature and it was 400 C. The day before admission while the symptoms of the knee joint persisted, edema and pain appeared in the upper half of the calf musculature. The past medical history was significant for partial resection of the larynx due to idiopathic paralysis and a thyroidectomy for goitre.

Physical examination on admission showed a temperature of 38,50 C, blood pressure was 140/80 mmHg, respirations 14 per minute and pulse: 90 per minute regular. A tracheostomy was evident. The right knee had signs of inflammation: pain, redness, and edema. There was accompanying edema and pain of the calf musculature. The rest of the physical examination was normal.

Laboratory tests showed a leukocytosis with a shift to the left (15.250 leukocytes/mm3 with 80,9% neutrophils) and a markedly increased C-reactive protein (28,84mg/dl (normal: 0-0.5 mg/dl) and erythrocyte sedimentation rate (120 mm/1st hour (normal:0-20 mm/1st hour). Magnetic resonance imaging (MRI) of the right knee and the right calf (figure 1) disclosed extensive synovitis of the right knee with the concomitant presence of increased arthritic fluid. There was accompanying inflammation of the muscle groups of the calf and especially the gastrocnemius muscle and compression of the popliteal vein in the popliteal fossa.

What was the cause of fever, knee pain, and calf swelling? What is the diagnosis?