A 36-year-old woman was admitted to the hospital because of fever and abdominal pain of one-week duration. Fever was up to 39 degrees Celsius and was accompanied by chills. The pain was located in the right lower quadrant of the abdomen. She did not complain for other symptoms.

The patient was married to a shipman and had five healthy children, three of whom were delivered by cesarean section. Her past medical history included recurrent cellulitis-like episodes after a glass related injury, which was located in her left forearm.

Physical examination showed elevated temperature (38,8 degrees Celsius). The pulse rate was 90/min and the blood pressure 120/70 mmHg. There were three areas (2X2 cm), on her left forearm, with atrophy and hyperpigmentation. Inflammation was obvious on the right lower quadrant of the abdominal wall, where swelling, tenderness, heat and redness were found in an area of 25X15 cm. Liver, spleen and peripheral lymph nodes were not palpable. The rest of the physical examination did not show any abnormal findings.

Laboratory work-up revealed: Ht=36%, Hb=12,9 g/dl, WBC=9980/mm3 (neutrophils=75%, lymphocytes=18%, monocytes=6%, eosinophils=1%), platelets=210,000/mm3, erythrocyte sedimentation rate (ESR) = 57mm/first hour. The level of C-reactive protein was normal. The biochemical (glucose, renal and liver function, electrolytes, lipid profile, uric acid, amylase, lactate dehydrogenase, creatine kinase, and proteins) and immunological tests of the serum (rheumatoid factor test, antinuclear antibodies, antimitochondrial antibodies, anti-smooth muscle antibodies, cytoplasmic and perinuclear anti-neutrophil cytoplasmic antibodies, serum angioconverting enzyme and complement), were normal, except of the slight elevation of IgM, slight reduction of IgA and low value of C4. Urinalysis did not show abnormal findings. Chest X-rays, ECG, U/S of the abdomen and C/T of the thorax, upper and lower abdomen were normal.

A 56-year-old female from Greece with a history of Takayasu's disease (diagnosed in 1992) was admitted in late November 2002 to our unit because of fever, which started in April 2002. She was diagnosed at another hospital to have aortofemoral graft infection in June 2002. Only one of several blood cultures, performed at the previous hospital, grew a strain of Staphylococcus epidermidis. She received prolonged courses of antibiotics including vancomycin, linezolid, and rifampin. In addition, â-lactam antibiotics with coverage against Gram negative organisms had been given, because of the possibility that the isolated microorganism (Staphylococcus epidermidis) was a contaminant. Her fever relapsed and she was admitted to our unit for management.

Her past medical and surgical history was rich: rheumatic fever (1959), premature labour and eclampsia (1970), extrauterine pregnancy (1972), caesarean section (1982), small intestine ileus due to adhesions (1982), bilateral aortocarotid bypass and aortofemoral bypass (1992), which were both attributed to Takayasu's arteritis . Also, erythema nodosum (1992), appendectomy (1992), jaundice due to hepatitis B virus infection (seronegative at time of presentation), operations for femoral artery aneurysms (1994, 1995, 1997, 2001), cholecystectomy (1995), and coronary main stem bypass using the internal mammary artery (1999).

Physical examination on admission showed temperature 37.5 degrees Celsius. There were scars from previous operations. A bruit was audible over the left carotid and her femoral arteries. Right radial artery was not palpable. Laboratory testing on admission showed erythrocyte sedimentation rate (ESR) 60 mm/ 1st hour (normal<10) and C-reactive protein (CRP) 3mg/dl (normal<0.5). An electrocardiogram showed T wave inversion in leads V1 and V2. A magnetic resonance imaging (MRI) of the area of the aortofemoral graft was suggestive of active inflammation of the graft and of the surrounding area as well as adhesions of the third (retroperitoneal) part of the duodenum with the abdominal aorta.

She was treated with iv trimethoprim/sulphomethoxazole (80/400 mg) every 12h, iv chloramphenicol 1gr every 6h, iv quinupristin/dalfopristin 500 mg every 8h, sc enoxaparin 60 mg every day, ranitidine 150 mg every 12h, acetylsalicylic acid 100 mg once daily, atorvastatin 20 mg once daily, isosorbide mononitrate 60 mg once daily, and metoprolol 50 mg every 12h. Laboratory indices of inflammation initially improved and fever stopped. However, her aortofemoral graft infection seemed to be resistant to medical treatment.

What is the appropriate management?

A 73-year-old male patient was admitted to our hospital because of fever and pain of the left tibia.

His past medical history was significant for diabetes mellitus (managed with oral antidiabetic agents) and lung cancer for which he underwent resection of the left upper lobe one year ago. The patient also received chemotherapy that was completed 1 month ago.

Physical examination showed a red area of the left tibia (Figure). His temperature was 37.40C. Routine laboratory testing showed: C-reactice protein 30.50 mg/dL (normal value (0-0.50 mg/dL), creatinine 1.7 mg/dL (0.8-1.3 mg/dL), urea 61 mg/dL (15-50 mg/dL), hematocrit 28.1% (41.0-53.0%), white blood cell count 9.19 K/ìl (4.50-11.00 K/ìl).

An ultrasound of the lower extremities arteries and veins was performed which showed a generalized atherosclerotic disease, including a total obstruction of the left superficial femoral artery.

What is your diagnosis? What should be done?

A 78-year-old male was presented to his local orthopedic surgeon for low back pain. The patient had no neurologic deficits, and with the presumptive diagnosis of degenerative spondylosis, he has been treated with non-steroidal anti-inflammatory medications and physiotherapy for 3 months.

The past medical history included hypertension, chronic obstructive pulmonary disease, atrial fibrillation and congestive heart failure. He was receiving b-blockers, loop diuretics, and digoxin for his cardiovascular problems and inhaled corticosteroids and ipratropium for his chronic obstructive pulmonary disease.

Three months later, the patient had worsening of his back pain. Plain radiographs, computed tomography and magnetic resonance imaging of the lumbar spine were obtained, which showed osteoarthritis of the lower lumbar facet joints. Facet joints injection was done using methyl-prednisolone acetate and bupivacaine hydrochloride 0.5%. The patient had temporary relief of his symptoms for 2 days followed by deterioration of his low back pain and acute onset of low-grade fever. Laboratory investigation revealed increased white blood cell count (16.010/ìl), erythrocyte sedimentation rate (83 mm/1st hour), and C-reactive protein (185 mg/l). Spine infection was suspected and ciprofloxacin was administered (500 mg per os, twice a day) for four weeks. However, this treatment led to minimal improvement of the clinical symptoms.

The patient was referred to us for further evaluation and treatment. At the time of his admission, his main signs and symptoms included low back pain and tenderness, and increased body temperature (37.8o). Magnetic resonance imaging of the lumbar spine showed end plate erosions of L3, L4, L5 vertebral bodies (Figure 1) and signal abnormalities at the L2-L3 and L3-L4 intervertebral discs (Figure 2).

What is the appropriate management?