Case 1：A local craftsman who makes garments from the hides of goats visits his physician because over the past few days he has developed several black lesions on his hands and arms. The lesions are not painful, but he is alarmed by their appearance. He is afebrile and his physical examination is unremarkable.
案例1：一名使用鹿皮做皮衣的當地木匠來就醫，主訴過去幾天中手掌和手臂上出現幾個黑色皮膚損害。皮損無痛，但是外觀較為駭人。患者無發熱，體檢無異常發現。
1. What is the most likely diagnosis?
Cutaneous anthrax, caused by Bacillus anthracis. The skin lesions are painless and dark or charred ulcerations known as black eschar. It is classically transmitted by contact with the hide of a goat at the site of a minor open wound.
皮膚炭疽：由炭疽桿菌引起，皮損通常無痛、黑色或稱為焦痂樣潰瘍。主要通過鹿皮經由皮膚細小傷口傳播。
2. How will the causative microorganism appear on Gram staining?
B anthracis is a G+ spore-forming rod. The spores are resistant to many chemical disinfectants, heat, UV, and drying and are therefore a feared biological warfare.
微生物學特性：炭疽桿菌為革蘭氏陽性芽孢桿菌，由於芽孢能耐受大多數消毒劑、高溫、紫外線和烘乾，故常被作為生化武器。
3. What is the other spore-forming microorganism?
Clostridium species are the other G+ spore-forming bacteria. Bacillus and Clostridium species can be differentiated by their ability to neutralize oxygen fee radicals. Bacillus species have catalase and superoxide dismutase-enzymes that can survive in aerobic environments. Clostridium species don’t have these enzymes and therefore obligate anaerobics.
芽孢菌鑑別診斷：芽孢桿菌vs 梭狀芽孢桿菌。主要看其中和氧自由基的能力，芽孢桿菌有過氧化氫酶和超氧化物歧化酶，能分解氧自由基→兼性厭氧；梭狀芽孢桿菌則沒有→專性厭氧。
4. What is other manifestation of this infection?
B anthracis also causes pulmonary anthrax. In this condition, inhaled anthrax spores reach the alveoli, taken up by macrophages and carried to mediastinal lymph nodes. This can result in mediastinal hemorrhage and a bloody pleural effusion. X-ray of the chest reveals a widened mediastinum.
炭疽其他表現：主要是通過吸入芽孢導致肺炭疽→抵達肺泡→巨噬細胞攜帶芽孢到達縱隔淋巴結→縱隔出血、血性胸水，胸脯顯示縱隔擴大。
★炭疽病要點總結：特殊接觸史+特殊焦炭樣皮損+微生物學鑑定★
Case 2: A 49-year-old woman from rural area presents with diffuse, crampy abdominal pain that has persisted for 4 days. She has had no bowel movements since the pain started and has noticed a weight loss of 4.5kg over the past month. CT of the abdomen reveals an inflamed gallbladder and an irregular mass in the second portion of the duodenum. Stool sample reveals rough-surfaced eggs. Complete blood count and liver function test results are as follows:
WBC count: 14,000/mm3 ALT/AST/AKP: normal
Eosinophils: 20%
Total bilirubin/direct bilirubin: normal
Albumin: 3.2g/dL
案例2：49歲農村女性主訴瀰漫、痙攣性腹痛4天，腸蠕動減少。過去一個月體重減輕4.5kg。CT顯示膽囊炎症，十二指腸有不規則腫塊。糞檢顯示粗糙表明的球形蟲卵。血檢提示白細胞升高，嗜酸性粒細胞顯著升高。
1. What is the most likely diagnosis?
Ascariasis, caused by a nematode (roundworm) found in the rural and tropical climates. Ascariasis is the most common helminthic infection worldwide. Eosinophilia is a classic finding in helminth infection and is due to the release of eosinophilic of major basic protein.
蛔蟲病：由蛔蟲（圓線蟲）引起，多見於農村及熱帶地區。蛔蟲病是全世界範圍內最常見的蠕蟲感染，典型表現為嗜酸性粒細胞顯著升高，主要與蠕蟲感染後嗜酸性粒細胞大量釋放鹼性蛋白有關。
2. What tests can be used to confirm the diagnosis?
Analysis of a stool sample shows eggs with a knobby, rough surface.
蛔蟲病診斷：糞便檢查可見多結節、表面粗糙的球形蟲卵。
3. What are the appropriate treatments for this condition?
Mebendazole or albendazole is the drug of choice. The bendazoles work by disrupting helminthic microtubule synthesis, which weakens cell structure.
治療：甲苯咪唑或丙硫咪唑為首選藥物。機理為幹擾蠕蟲微管合成，破壞其細胞結構。
★蛔蟲病要點總結：特殊地區+腹痛、體重減輕病史+影像學檢查腸道有包塊（蛔蟲團塊）+嗜酸性粒細胞顯著升高+糞檢蟲卵陽性★