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A 58-year-old woman was transferred to this hospital because of severe neck pain, fever, and a spinal epidural mass extending from the level of the fourth to the seventh cervical vertebrae, with evidence of mild cord compression seen on imaging studies.

2 to 3 weeks before admission, she noted swelling in the right anterior portion of the neck, which she thought was an enlarged lymph node; the swelling was associated with pain in her neck. Twelve days before admission, the patient went to the urgent care clinic at another hospital. She reported that intermittent right-sided neck pain and mild headaches had occurred for the past 3 months 3 days before admission, a 5-day course of azithromycin was prescribed. The next day, the temperature rose to 39.4°C; Specimens of blood were sent for cultures. The patient was a technologist in a microbiology laboratory. She reported occupational exposed to a clinical specimen of B melitensis Seven months earlier,

she had been monitored in the occupational health clinic for 4 months after the exposure. Serum samples obtained both 2 weeks and 4 months after exposure were tested for brucella antibodies, but the results were normal.

A 42-year-old man presented to Respiratory Disease Department with cough and hemoptysis for 30 years.  Tuberculosis have been diagnosed 30 years ago. CT of the chest are shown. What is the mass?

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On examination, there were inspiratory wheezes and rales, without expiratory wheezes. Chest imaging showed ground-glass opacities in both lower lobes.

Two questions help to frame the differential diagnosis in this patient: “Why is this patient ill?” and “Why is she ill at this time?” The answers to these questions will come from analyzing her current illness in the context of several factors:

(1)        Her immunocompromised state (since she is receiving a potent immunosuppressive medication),

(2)        Her underlying ulcerative colitis,

(3)        The medications that she is receiving to treat the underlying disease

(4)        An independent process that is unrelated to her ulcerative colitis or her medications.

A 10.8-year-old girl was seen in the pediatric dermatology clinic because of recurrent oral ulcers and cutaneous bullae since 2 years of age. White lesions in the mouth and vesicles and bullae on the dorsal and plantar surfaces of the feet, the knees, and the hands that ulcerated and became painful occurred at intervals of 3 to 4 months, lasted 4 days to 2 weeks, and resolved without scarring. Biopsy of a lesion 2 years earlier was reported to show features of epidermolysis bullosa.

Treatment with antibiotics was given on several occasions without improvement in the lesions. Ten days after the current visit, vesicular lesions developed on both feet after the patient wore new shoes. The patient carried a diagnosis of epidermolysis bullosa with laminin-5 deficiency. However, the author and the discussant considered that diagnosis to be unlikely, since the patient appeared well and had no scarring. Two punch biopsies of affected skin were performed. The sections of affected skin processed for routine histologic examination showed confluent intraepidermal vesicles with a dense inflammatory infiltrate within intraepidermal spaces.

Careful evaluation revealed that the mechanism of vesicle formation involve the degeneration of individual keratinocytes with ballooning degeneration, dyskeratosis, loss of intercellular connections, cell necrosis, and a secondary inflammatory response.

The patient’s medical history included hypertension, type 2 diabetes mellitus, hyperlipidemia, and gastroesophageal reflux with Barrett’s esophagus; He was a heavy smoker and He had worked with paint solvents approximately 2 weeks before coming to the hospital but reported no previous exposure to hydrocarbons.

  On admission, the patient has tachypnea, and his oxygen saturation was mildly depressed; there was conjunctival pallor and dried blood in the oropharynx. Crackles were heard at both lung bases. The cardiac examination revealed an early systolic murmur, grade 1 out of 6, A rectal examination revealed external hemorrhoids.

  The seemingly unrelated array of symptoms cannot be readily explained by a single diagnosis, but their simultaneous development tempts the clinician to find a unifying cause. this case of multiorgan disease has classic themes with interesting variations. A good clinical history with rigorous analysis enabled the discussant to deduce combined diagnoses.