A 62-year-old patient presented with fever and abdominal pain in the right upper quadrant. He had an 18-month history of adenocarcinoma of the colon (T3N1M1) with liver metastases, for which he underwent a right hemicolectomy and received chemotherapy with irinotecan and cetuximab; in addition he underwent chemoembolization of the liver lesion. His past medical history was significant for diverticulosis, atrial fibrillation, hypertension (amlodipine 5 mg every 12 hours per os and atenolol 25 mg once a day) and appendectomy.

On examination he was cachectic and febrile with a temperature of 380C. He had hepatomegaly and his liver was hard and irregular on palpation. A scar of his previous operation was evident. Otherwise the physical examination was normal.

Investigations showed a leukocytosis and increased erythrocyte sedimentation rate and serum C-reactive protein levels. Blood cultures and urine cultures were sterile. His chest X-ray and his electrocardiogram were normal. Computed tomography scan of the abdomen showed lesions in the liver (Figure).

A 32-year-old male presented with a 24-hour history of rash. He reported tingling and mild pain radiating to his right arm that started 2 days earlier. On physical examination, he had normal vital signs. There was a vesicular rash on deep blue base on his right shoulder (Figure 1). No other abnormal findings were noted. A complete blood count and biochemistry were within normal limits. The patient denied any previous or current use of medications, traveling abroad, or history of any disease.

What is the diagnosis?

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A 71-year-old woman was admitted to the hospital due to acute myocardial infarction. Prior medical history included arterial hypertension, insulin-dependent diabetes mellitus, and hyperthyroidism. The patient had no history of tobacco or alcohol use. On admission, she was afebrile. Oxygen saturation was 97 % on room air. Chest x-ray (CXR) was normal. Blood glucose was 288 mg/dl.

She stayed in the Coronary Care Unit (CCU) for 48 h and was treated with aspirin (100 mg per day), clopidrogel (75 mg per day), heparin (1.000 iu/h), and a monoclonal antibody against platelet receptor Gp IIb/IIIa. Percutaneous transluminal coronary angioplasty (PTCA) was performed. Two days following CCU discharge, the patient became febrile (38.5 oC) with non-productive cough and progressive dyspnoea. Three days later, she was readmitted to the medical Intensive Care Unit (ICU) due to severe dyspnea and type I respiratory failure. On admission, she was tachycardic (113 beats / min) and tachypneic (30 breaths/min). The temperature was 38.6 oC and ABG analysis disclosed a PaO2 of 58.0 mm Hg, a PaCO2 of 25.8 mm Hg, pH=7.39, and a HCO3 of 15.6 mmol/L. Chest auscultation revealed end-inspiratory crackles, bilaterally diminished breath sounds, and a grade I apical systolic heart murmur. The patient was intubated and admission-CXR revealed diffuse infiltrates in both lungs and pleural effusions. A white blood cell count of 17.600/ìL (89% polymorphonuclear leukocytes) was noted, as well as a hematocrit of 32 %, a platelet count of 344,000/ìL, and an erythrocyte sedimentation rate of 110 mm. Liver enzymes, and serum urea and creatinine were within normal limits.

The patient was treated with intravenous piperacillin-tazobactam, ofloxacin and teicoplanin. She remained febrile (39 oC) with no improvement in respiratory function and chest X-ray. Blood, urine and bronchial cultures were negative for common bacterial and fungal pathogens. A chest computerized tomographic (CT)-scan demonstrated confluent opacities in the right upper and middle lobes and in the left lower lobe as well as air-bronchograms, an extensive right pleural effusion and a pathological swelling of pretracheal lymph nodes (Figure 1).

What are possible causes of the pulmonary infiltrates?

A 61-year-old male patient was referred to our hospital because of gradual painful enlargement of the left parotid, buccal and parapharyngeal region, of three days duration. The patient complained of difficulty and pain while attempting to open his mouth or swallow. Low-grade fever of up to 37.6oC was reported. Treatment with oral antibiotics was introduced 2 days prior to presentation at the hospital, without signs of response to therapy.
The patient had a 3-year history of colorectal cancer with liver, bone and soft tissue metastases. Seven days prior to presentation, a course of radiation therapy to the cervical spine, administered for a paravertebral soft tissue metastasis, was completed. The patient was also receiving second line chemotherapy with cetuximab (an EGFR inhibitor) plus irinotecan, the last cycle being administered 20 days earlier. His treatment regimen also included chronic zoledronic acid monthly infusions, and dexamethasone, at a current total daily dose of 6 mg, as well as opiod analgesics.
Five months earlier, the patient had developed a pulp infection of the lower left second molar tooth, which required tooth extraction and antibiotic treatment. Although symptoms of local inflammation had completely resolved, the patient reported a persistent foreign body sensation in that area ever since. The rest of the patient's medical history was unremarkable, except for arterial hypertension.
Physical examination revealed a tender, crepitant, erythematous mass of the left parotid, buccal, infratemporal and parapharyngeal region (Figure 1). Trismus and dysphagia were also observed. Intraorally, a portion of exposed bone was identified at the molar area of the left mandible. The exposed bone had a yellow-white, smooth surface, and it was hard and painless. It was surrounded by erythematous, ulcerated and tender oral mucosa. The rest of the oral examination was normal. Despite the striking local findings, the general condition of the patient was not severely compromised, and body temperature was normal.
Baseline routine laboratory investigations showed a normal white blood cell count of 8,860/mm3 with predominance of neutrophils (95.4%), a 35-fold elevated C-reactive protein value of 17.7 mg/dl, along with an erythrocyte sedimentation rate of 83 mm/h, all consistent with acute inflammation. Hypoalbuminemia (2 g/dl) was also noted, as well as elevated blood urea nitrogen (47 mg/dl).
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