Danis et al. Journal of Medical Case Reports 2010, 4:46 http://www.jmedicalcasereports.com/content/4/1/46 chest radiography, esophagography, abdominal ultraso- nography and pulmonary-function studies were all within normal limits. Bone marrow aspirate smears showed 60% eosinophils. A full-thickness biopsy of his left calf revealed active fasciitis (Figure 1A). Magnetic resonance imaging of his lower limbs revealed that his left-limb muscle group was thicker than his right (Fig- ures 2A and 2B). Finally, a diagnosis of EF was established from these clinical and laboratory findings. His symptoms disap- peared completely after a few days of treatment with 1 mg/kg/day oral methylprednisolone. Case report 2 A 63-year-old Turkish man was admitted to our clinic with edema, erythema, pain and itching of his upper and lower extremities for 10 days, which started after strenuous physical activity working with an axe in the forest. Mobile, palpable lymph nodes were found in the right anterior cervical (2 × 1 cm), left submandibular (3 × 1 cm) and left submental (2 × 2 cm) regions of his body. His shoulder and elbow joints were warm, while their range of movement, as well as the flexion and extension of his wrist, were limited. Both knee joints were warm and painful on flexion. His WBC count was 12.9 × 109/L, while his neutrophils was 5.3 × 109/L, eosinophils was 4.9 × 109/L (37.9%), and ESR was 98 mm/h. His ANA was positive, and his RF was 0.59 IU/ L. Peripheral blood smears showed 34% eosinophils. An examination of his stool specimens returned negative for ova and parasites. His electrolytes, renal, thyroid and liver function values were all within normal limits. Results of his chest radiography, abdominal ultrasono- graphy, and pulmonary-function studies were also within normal limits. Mild hepatomegaly (165 mm) was detected upon abdominal ultrasonography. A full- Page 2 of 4 thickness biopsy revealed active fasciitis (Figure 1B). A diagnosis of EF was established from these clinical and laboratory findings. His symptoms improved completely after a few days of treatment with 1 mg/kg/day oral methylprednisolone. Discussion EF is an uncommon disease and only a few hundred cases have been reported in the literature. It is charac- terized by acute or subacute symmetric swelling of the skin and the subcutaneous tissues. The forearms, flanks and upper legs are usually affected, while the hands and face are spared [4]. However, our first patient had asym- metric edema and pain in his right limb, shoulder and face, which differed from other cases reported in the literature. While the etiology of EF is still unknown, possible causes include strenuous exercise, initiation of hemodia- lysis, and infection with Borrelia burgdorferi [1,5,6]. In addition, exposure to some drugs has been implicated. Cutaneous side effects following simvastatin treatment, including the development of EF, have been well-docu- mented [7]. None of these causes were obvious in the first case we presented, but strenuous exercise appeared to be the triggering factor for the second patient. There was no suspicion of relevant environmental or toxic exposure in either of our patients. Paraneoplastic disease, progressive systemic sclerosis, and infection with B. burgdorferi were thus excluded. The majority of patients with EF have peripheral blood eosinophilia during the acute phase of the disease. In one series, 33 out of 52 patients had eosinophilia. Elevated ESR (29%) and polyclonal hypergammaglobuli- nemia (35%) can also be found [8]. ANA positivity has Figure 1 Mixed-type infiltration of eosinophils and other inflammatory cells in muscle and fat tissues of (A) patient 1 and (B) patient 2. Hematoxylin and eosin stain, magnification ×200.