3C and positive Giordano’s sign on the left. The patient’s blood pressure was 128/62 mmHg, with oxygen saturation value of 96% and 18 breaths per minute. The ultrasound showed only wall thickening of the intrahepatic Selumetinib price bile ducts. The abdominal discomfort deteriorated within the next hours. The patient was found with positive rebound in the right abdominal side and pain in the lower right abdominal side. The X-ray computed tomography showed only a small hiatal hernia. Cefuroxime and metronidazole were intravenously administered, after the notification of a positive blood culture for gram-positive organisms. Subsequently, the abdominal pain resolved

progressively and the body temperature decreased to normal levels. The patient developed diarrhea, during the second day of hospitalization, which lasted for 3 days. The clinical examination found decreased breath ATM inhibitor sounds on the right lung base, while the X-ray showed a consolidation in the same side, on the third day of hospitalization. Streptococcus pneumonia was isolated from the blood culture and Penicilline G was administered based on the sensitivities of the antibiogram (MIC 0.006 μg/ml). Edema, pain and

tenderness were observed inside the right brachial shoulder joint, during the fourth day of hospitalization. The symptoms migrated progressively to the left brachial shoulder joint, to the interphalangeal joints of the left and right hand, the interphalangeal joints of the left and then the right foot (Fig. 1a and b) and finally resolved up until the 6th day of hospitalization. Among the results of

the laboratory examinations, the urinalysis showed sterile pyouria with 80–90 white blood cells on her admission to the emergency nearly station, and the subsequent tests were negative for pyouria. The blood test showed white blood cells within the normal levels on the admission (initially: 9.96 K/μl, 86.7% neutrophils – finally: 5.65 K/μl, 54.3% neutrophils). Among the other markers of inflammation, only c-reactive protein was elevated at the admission and decreased progressively (initially 393.3 mg/L, finally 26.5 mg/L; normal values <6). The remaining biochemical markers remained within the normal levels, namely: urea 19–39 mg/dL, creatinine 0.7–0.9 mg/dL, total bilirubin 0.49–0.66 mg/dL, indirect 0.22–0.26 mg/dL direct 0.27–0.40 mg/dL, alkaline phosphatase 67–97 U/L, gamma-glutamyl transpeptidase 8–18 U/L, SGPT 19–32 U/L, SGOT 17–35 U/L, LDH 144–159 U/L, natrium 141–146 mEq/L, potassium 3.1–3.8 mEq/L. The patient had normal temperature throughout their hospitalization, while the blood pressure was within the normal levels. The oxygen saturation ranged between 94 and 97% and the number of breaths was 16–18 per minute. The patient was discharged from the hospital after 7 days in a good clinical condition with instructions.