Danis et al. Journal of Medical Case Reports 2010, 4:46 http://www.jmedicalcasereports.com/content/4/1/46 Page 3 of 4 Figure 2 Coronal and axial magnetic resonance imaging of patient 1. His left extremity was thicker than his right extremity, as shown on coronal (A) and axial (B) images. not been reported previously in EF with any consistency [3], and RF is almost always negative. Both our patients had hypereosinophilia, and our second patient had an increased RF (0.59 IU/L) and a positive ANA test. Defi- nitive diagnosis requires histopathological examination from a full-thickness (epidermis to muscle) biopsy [9]. The biopsy results of both patients were consistent for EF upon histopathological examination. There is substantial agreement among published cases or case series that corticosteroids are the first-line treat- ment for EF and are usually effective in >70% of cases. Other treatments include NSAIDs, D-penicillamine, chloroquine, cimetidine, methotrexate, azathioprine, cyclosporin A, infliximab, UVA-1, and bath PUVA [10,11]. Spontaneous remission rate in patients with EF is 10% to 20% at the time of presentation or relapse after dis- continuing corticosteroid therapy [12]. Our first patient had a history of spontaneous remission. In one series, hematological disorders other than eosinophilia were present in 5 out of 52 patients [8]. Hematological abnormalities that have been described in association with EF include aplastic anemia, acquired amegakaryo- cytic thrombocytopenia, myeloproliferative disorders, myelodysplastic syndromes, lymphoma, leukemia, and multiple myeloma [8]. However, there was no hematolo- gical abnormality in our patients we described. The presence of lymphadenopathy is unusual. Ten reported cases of EF with enlarged lymph nodes have been identified previously. Six of these patients had lym- phoma and four had reactive lymphadenopathy [13]. Our second patient had cervical, submandibular and submental mobile lymphadenopathy, with an enlarged liver and no haematological disease. Two cases of EF with rheumatoid arthritis (RA) have been reported previously, but the diagnosis of RA had been established in these patients before the diagnosis of EF [14,15]. In the second case we described, our patient’s symptoms at first were like those of RA. How- ever, the symptoms began shortly after strenuous exer- cise, which is not typical for RA, and eosinophilia and histopathological evaluation revealed the correct diagno- sis. Furthermore, the symptoms did not meet RA cri- teria. Most EF patients with arthritis complain of morning stiffness and exhibit changes on joint radio- graphs similar to patients with RA [8]. This condition may thus lead to misdiagnosis. Magnetic resonance imaging (MRI) can be used for the diagnosis of EF [9,15,16]. In two retrospective stu- dies involving seven patients, MRI detected fascial thick- ening and signal abnormalities in patients with EF at the time of diagnosis [9,15]. MRI showed evidence of dis- ease activity in both of our patients. Conclusions EF can present with various symptoms. When patients exhibit eosinophilia, arthralgia and myalgia, EF should be considered as a possible diagnosis. It is notable that the first patient described in this case report also dis- played unusual features including high eosinophil count and asymmetrical presentation. Consent Written informed consent was obtained from our patients for publication of this case report and any accompanying image. Copies of the written consent are available for review by the Editor-in-Chief of this journal. Abbreviations EF: Eosinophilic fasciitis; RA: Rheumatoid arthritis; ANA: Antinuclear antibody; ESR: Erythrocyte sedimentation rate; MRI: Magnetic resonance imaging.