A 29-year-old female patient presented initially with symptoms of stress urinary incontinence occurring several times every day, for 4 years. She also reported symptoms of urgency and urge urinary incontinence and pelvic dragging. In the past she had 2 uncomplicated spontaneous vaginal deliveries and she suffered from asthma that was well controlled by medical treatment (bronchodilators by inhalation).

Physical examination revealed a moderate cystocele with paravaginal defects, a small rectocele, and a first-degree uterine prolapse. Urodynamic investigation showed urodynamic stress incontinence. As previous conservative treatment with pelvic floor exercises and physiotherapy had failed, she underwent a Burch colposuspension. The procedure and the recovery were uneventful and the stress urinary incontinence was cured.

Ten months after surgery the patient reported increasing pelvic dragging sensation. Clinical examination revealed a moderate rectoenterocele and 1st-2nd degree of uterine prolapse with an elongated cervix and a small high cystocele. The patient underwent a Manchester procedure with repair of cystocele using a polypropylene mesh (Prolene). The uterus was also suspended by the posterior IVS (intravaginal slingplasty) technique. Pelvic organ prolapse symptoms were subsided.

However, the patient noted an offensive vaginal discharge 3 months after the second operation and she reported an episode of light vaginal bleeding. Examination revealed a large mesh erosion of the anterior vaginal wall (2×3cm) (Figure 1) and 2 small erosions of the IVS tape on the posterior vaginal wall. The uterus and the vaginal walls were well supported.

A 40-year-old man suffered from gradually worsening dyspnea and swollen ankles for six months prior to his evaluation. He underwent a chest X-ray, lung function tests, a 24-hour Holter heart rhythm monitoring, and a polysomnography study. A working diagnosis of sleep apnea syndrome was made in another institution and the patient was advised to use a continuous positive airway pressure (CPAP) mask. With the use of the mask, his symptomatology got worse: he had severe dyspnea at rest and leg edema, which was extending up to the knees. He also noticed an increased abdominal girth. The patient was assessed by a cardiologist in his hometown who perfomed a Doppler echocardiography and diagnosed a thrombus of the right ventricle and an abnormally moving intraventricular septum. These findings prompted an emergency referral to the hospital.

On physical examination the patient was hemodynamically unstable with a blood pressure of 90/65 mmHg, pulse rate 105 per minute, respiratory rate 25 per minute, and temperature 38,2 0 C. He was severely dyspneic at rest and was mildly obese (Body Mass Index of 27,75). The first and second heart sounds were normal but there was a pericardial knock. Pulsus paradoxus was present as well. There were few crackles of the lung fields up to the midzone. Abdominal examination revealed splenomegaly and signs of free peritoneal fluid. He had edema of the legs up to the level of the knees.

An initial workup revealed the presence of mild anemia (Ht: 37.6%), an increased erythrocyte sedimentation rate (ESR = 50 mm at the first hour), an elevated C-reactive protein (CRP = 16.36 mg/dl with upper normal limits: 0.5 mg/dl) and decreased serum albumin levels (2.7 gr/dl). Measurement of other routine biochemical parameters was normal. Tuberculin skin testing was negative. An electrocardiogram showed decreased voltage. Imaging included a chest X-ray which showed calcification of the pericardium and a small left pleural effusion, and an echocardiogram which showed a localized pericardial effusion causing tamponade of the right ventricle and calcification of a thickened pericardium. A CT scan of the chest is shown in Figure 1.

A 90-year-old woman presented to the emergency department complaining of a 3-month history of headache, and recent blindness of her right eye. She also reported weakness and weight loss (5 kg during the last 3 months prior to her presentation) but no fever. She had been treated symptomatically with non-steroidal anti-inflammatory drugs without noting any significant relief. There was no history of trauma or burn. Her past medical history included diabetes mellitus type II and arterial hypertension.

The physical examination on presentation was unremarkable except for a large area of scalp necrosis in the temporo-parietal region bilaterally (photos 1 and 2).

Routine laboratory testing on admission showed anemia (hematocrit = 31,1%) and elevated erythrocyte sedimentation rate (ESR = 120mm/first hour). Serological tests for varicella-zoster virus (VZV) and herpes simplex virus 1 and 2 (HSV1 and HSV2) were negative. A CT scan of the head was unremarkable.

A 44-year-old white man presented with a 12-month history of slightly pruritic, papular lesions on his face, upper and lower extremities. No other complains were mentioned. No similar skin dermatosis was reported from his family history including first-degree relatives. The patient had no history of kidney disease, diabetes mellitus or liver disease.

Physical examination was unremarkable except for the skin findings. Specifically, skin lesions were 8 in number located on the middle of the chin, on the right angle of the mouth and on the extensor surfaces of the forearms, elbows, thighs and knees. There was no mucous membrane involvement. Skin lesions were characterized by areas with diameter of 1 cm up to 8 cm consisting of multiple hyperkeratotic plaques and burrows. The large and old lesions of the extremities did not have signs of inflammation (Figure 1). In contrast, the small and new lesions on the face had clear signs of ongoing inflammation with an erythematous halo surrounding them (Figure 2). Mild tenderness and increased temperature was also evident on the face skin lesions.

Testing for anti-nuclear and anti-mitochondrial antibodies was negative, but it was weakly positive for anti-smooth muscle antibodies. There was also a slight elevation of the level of the haemolytic complement [CH50 = 556 U/ml (normal 300-510 U/l)]. The levels of the third and fourth component of complement (C3 and C4) were normal. Finally, a serologic test for syphilis [Venereal Disease Research laboratory (VDRL) slide test] was negative.