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Bloody Diarrhea Caused by Infection With Klebsiella oxytoca in a Burn PatientClostridium difficile infections account for most cases of antibiotic-associated colitis.1 However, there is increasing evidence that Klebsiella oxytoca infection contributes to the development of C difficile–negative antibiotic-associated hemorrhagic colitis. Most cases have been reported in France,2-12
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Restenosis After Percutaneous Transluminal Coronary AngioplastyCoronary angiography was performed in a 54-year-old man with low-level stable angina. He had undergone percutaneous transluminal coronary angioplasty (PTCA) 3 months earlier. The angiogram showed tight stenosis of the proximal left anterior descending artery. The lesion was successfully dilated during a second PTCA, and a stent was placed using a flexible catheter.
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Cutaneous T-Cell TumorA 39-year-old man with HIV infection was being treated with antiretroviral therapy. He now sought help for multiple 2- to 3-cm violaceous papules on his right hip and the right lower abdominal area. A biopsy specimen showed intense, atypical lymphocytoid and monocytoid cells with prominent nucleoli, hyperchromatism, and bruised nuclei.
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Right Shoulder Pain in an Older ManFor 6 months, a 69-year-old man has experiencedpain in his right shoulder; hetakes NSAIDs for relief. During the lastmonth, the pain has worsened, weaknessand tingling have developed in his righthand, and the skin on the right side ofhis face has become dry. The patient alsoreports a 1-month history of melanoticstools. He had smoked 1 pack of cigarettesa day for 50 years before quittinglast year
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Recognizing lung disease in patients with rheumatoid arthritis, part 2ABSTRACT: Patients with rheumatoid arthritis (RA) often havepulmonary manifestations, such as interstitial lung disease.The most common cause of upper airway obstruction is cricoarytenoidarthritis. Patients often complain of a pharyngeal foreign-body sensation or hoarseness, but some present with severestridor. Bronchiolitis obliterans is characterized by a rapidonset of dyspnea and dry cough, with inspiratory rales andsqueaks on examination. This presentation, particularly in middle-aged women with seropositive disease, distinguishes bronchiolitisobliterans from other pulmonary manifestations ofRA. High-resolution CT may be more sensitive than pulmonaryfunction tests for detecting small-airways disease, and it frequentlyshows moderate to severe air trapping on expiratoryimages. (J Respir Dis. 2008;29(8):318-324)
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Older Woman With Dysphagia, Fatigue, Dyspnea, and Weight LossAn 80-year-old woman has a 3-month history of increasing dysphagia (withboth solids and liquids), fatigue, and dyspnea on exertion. She has also involuntarilylost 50 lb during the same period. She reports no abdominal pain orchange in bowel function.
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Man With Chronic Eustachian Tube Dysfunction, Otitis Media, and Hearing LossA 31-year-old man presents with a2-week history of a constant, dull acheand hearing loss in the right ear. Healso complains of intermittent sharppains that are usually followed bydrainage through the external auditorycanal. Another practitioner diagnosedacute otitis media with tympanic membraneperforation, for which he prescribeda 10-day course of amoxicillin.The patient completed the regimen buthas obtained no relief.
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New Lymphadenopathy in a Woman With a History of Colon CancerA 47-year-old woman who recently completed adjuvant chemotherapy for colon cancer has painless cervical lymphadenopathy of 1 to 2 cm. She has no fever, sore throat, cough, or unexplained weight loss, and she denies exposure to ill persons or animals.
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Phenytoin Drug Interactions: Effects of Phenytoin on Other DrugsA focus on the known clinically significant drug-drug interactions of phenytoin.
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Benzocaine-induced methemoglobinemia in bronchoscopyBenzocaine-induced methemoglobinemia has been a well-documented illness that is usually simple to cure but can be life-threatening if not recognized. As the use of "scope" procedures becomes more commonplace, the early recognition of hypoxemia resulting from methemoglobinemia is essential. The authors report a case of benzocaine-related methemoglobinemia following bronchoscopy.
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DPP-4 Antagonists: Benefits, Risks, and the FutureDipeptidyl peptidase-4 inhibitors, of the incretin class of antidiabetes drugs, are weight neutral, avoid hypoglycemia, and result in an average reduction in HbA1c of 0.5% to 1.0%
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Linear Verrucous Epidermal NevusA 7-year-old boy with a history of atopic dermatitis presented with an intensely pruritic linear rash on his upper extremity. His mother reports that the rash has been “growing” despite use of topical corticosteroid creams.
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Urinary Incontinence:Urinary incontinence is common--especially among older adults--but underdiagnosed. Many persons with this disorder are reluctant to discuss it with their physicians; often, only direct questioning can uncover the problem.
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Can You Identify This Puzzling Rash?Apreviously healthy 47-year-old woman presents with an ascending, nonpruritic rash of 3 days’ duration on her legs. She reports that the rash began on her ankles following a day of gardening. She does not recall any recent insect bites and denies chest pain, dyspnea, abdominal pain, fever, arthralgia, arthritis, cough, and hemoptysis. She has never had a similar rash before. The patient’s only medication is an oral antihistamine for seasonal allergies. She has no known drug allergies.
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Images of Hyperthyroidism: Graves DiseaseGraves disease presents commonly with exophthalmos and stare and striking pretibialmyxedema.
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Case In Point: Fever and a chest wall mass in a young manCoccidioides immitis is a di-morphic fungus that causes pulmonary disease with a variety of clinical and radiographic presentations. Miliary pulmonary disease is very uncommon and is found almost exclusively in immunocompromised patients. The authors describe the case of an immunocompetent patient who had disseminated coccidioidomycosis with a miliary pulmonary disease pattern. Obtaining a careful travel history and considering regional fungal infections was integral to making a prompt diagnosis.
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Recognizing the signs of bronchiolitis on HRCTAbstract: High-resolution CT (HRCT) can play an important role in the assessment of bronchiolitis. Direct signs of bronchiolitis include centrilobular nodules, bronchial wall thickening, and bronchiolectasis. Indirect signs include mosaic perfusion, hyperlucency, mosaic or diffuse airtrapping, vascular attenuation, and increased lung volumes. Expiratory HRCT scans are considered an essential part of the workup, because airtrapping may be evident only on these scans. In infectious cellular bronchiolitis, the centrilobular nodules typically have a branching, or "tree-in-bud," appearance, whereas in hypersensitivity pneumonitis, these nodules have a round or nonbranching pattern. The HRCT signs of constrictive bronchiolitis include mosaic perfusion, mosaic airtrapping, vascular attenuation, bronchiolectasis, and bronchiectasis; centrilobular nodules are usually absent. (J Respir Dis. 2005; 26(5):222-228)
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Plague: What You Need to Know NowPlague is caused by Yersiniapestis, a gram-negative, nonmotile,nonsporulating bacillus.It is a zoonotic disease, and rodentsare the primary reservoir.Plague can present as bubonic,pneumonic, or primary septicemic disease.Y pestis is usually transmitted tohumans via the bites of infected fleas,causing the bubonic form of the disease.Primary septicemic and secondarypneumonic disease are muchless common. Primary pneumonicdisease results from aerosol exposureto an infected animal or human withplague pneumonia; however, it too hasbecome uncommon as a natural event.Nonetheless, primary pneumonicplague, or a similar illness, is the mostlikely manifestation following a bioterroristattack.1,2 Despite the substantialinvestment by the former Soviet Unionin this agent as a potential weapon,there is little experience from whichto predict the clinical consequencesof intentional aerosolization of thisorganism.
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Atrial Fibrillation:When - and How - to Convert to Sinus RhythmYour patient with atrial fibrillation (AF)is hemodynamically stable and youhave successfully established rate control.Your next step is to weigh therisks and benefits of attempting to restoresinus rhythm. In up to one half ofpatients, AF of recent onset convertsspontaneously to normal sinus rhythmwithin 24 hours. Thus, in some cases,the most appropriate approach maybe to control the ventricular response,identify and treat comorbid conditions,initiate anticoagulation, and closelymonitor the patient.
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Health Reform Legislation Falls ShortThe recent signing of health reform legislation signals a watershed event in the delivery of health care in our country. It is the culmination of a tangled legislative battle, but it ignores 3 of the 4 pillars of health reform. In this article, I describe these pillars, and then outline where recent legislation falls short.
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Atypical Tuberculin Skin Test ResponsesTuberculin-type hypersensitivity is characterized by marked spongiotic dermatitis with intraepidermal and subepidermal vesiculation and scattered eosinophils.
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Multiple Sclerosis:Advances in the understanding of multiple sclerosis (MS) have translated into aggressive treatment regimens that enhance patients' quality of life. In this article, we discuss the therapeutic options, especially treatments that are directed toward the underlying immunologic mechanisms of the disease. Because of its direct effect on quality of life, aggressive management of symptoms is emphasized.
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Emphysematous Pyelonephritis Caused by Pasteurella multocidaEmphysematous pyelonephritis (EPN) is a rare but life-threatening infection characterized by widespread necrosis and production of gas within the kidney.
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Surgical Treatment of Obesity: Questions Physicians Often Ask About Laparoscopic Adjustable Gastric BandingBecause bariatric surgery has traditionally been associated with a high incidence of complications, it has been used primarily for superobese patients. A large body of evidence suggests that laparoscopic adjustable gastric banding is a much safer procedure that is also very effective. This procedure offers an additional option to patients who might benefit from bariatric surgery when diet, exercise, and pharmacologic approaches have failed. Here we address questions primary care physicians often ask about the procedure.
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Acute Low Back Pain in Children:ABSTRACT: Unless the cause of back pain is obvious, order anteroposterior and lateral radiographs of the spine, a complete blood cell count, erythrocyte sedimentation rate, and urinalysis. If you suspect infection, tumor, or bony abnormalities, obtain an MRI or CT scan. MRI has surpassed bone scanning as the gold standard for diagnosing spinal infections, because it confirms a specific anatomic diagnosis. Spondylolysis and spondylolisthesis are 2 of the most common causes of back pain in adolescents; the diagnosis is made with plain radiographs, which show slippage on the later-al view in patients with spondylolisthesis and fracture through the pars interarticularis on the oblique views in those with spondylolysis.
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Papillary Cystic Neoplasm of the PancreasA 24-year-old woman was concerned about a protruding epigastrium mass that had grown since it was first noted 4 months earlier. She had no abdominal pain, nausea, or vomiting.
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A "Slightly High" PSA:ABSTRACT: Although the widespread use of prostate-specific antigen (PSA) testing has led to an increase in the number of cancers detected, controversies about the benefits of screening persist. No conclusive evidence has yet emerged that PSA screening reduces the mortality associated with prostate cancer. Thus, mass screening is not universally endorsed. The American Urologic Association and the American Cancer Society recommend that digital rectal examination and PSA testing be offered annually to men 50 years and older with an estimated life expec- tancy of 10 years or more. High-risk patients (those with a positive family history or those of African American descent) are advised to begin screening at age 45. The decision to screen is based on the patient's preference following a thorough discussion of the benefits and limitations of PSA testing. Refer to a urologist any patient with a PSA greater than 4.0 ng/mL. Also, be alert for high PSA velocity changes in patients undergoing annual screening, and refer those with a PSA velocity of more than 0.75 ng/mL/y.
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Young Woman With Atypical Presentation of Fitz-Hugh-Curtis SyndromeA 22-year-old woman presented to her primary care physician’s office with right lower quadrant and suprapubic abdominal pain. She stated that the pain had begun earlier that day; she had no symptoms on awakening that morning.
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Chest Film Clinic: What caused the progressive dyspnea and cough in this tennis player?A 38-year-old man presented to the emergency department (ED) with a 2-week history of worsening shortness of breath and dry cough. He also complained of anorexia, a 14-kg (30-lb) weight loss over 3 months, pleuritic chest pain, and night sweats.
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What caused this woman’s pneumomediastinum?A 35-year-old woman presented to the emergency department (ED) with vague abdominal complaints. The patient had a complex medical history that included diverticulosis and relapsing polychondritis. Initially, her polychondritis was limited to involvement of the ears and nose. Within the past few years, however, her polychondritis flares had been associated with progressive dyspnea, which prompted intermittent and then long-term use of high-dose oral corticosteroids.
