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Primary Adrenal InsufficiencyFor 2 weeks, a 43-year-old white female had worsening nausea and multiple episodes of vomiting. Her symptoms began with increased malaise and decreased appetite. The emesis was unrelated to meals and was sometimes accompanied by mild abdominal distention. She had occasional fevers but denied any recent contact with ill persons. She also reported a 12-lb weight loss, decreased energy level, and an increased tan complexion over the past several months.
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The Dyslipidemia of Type 2 Diabetes: When and How to TreatABSTRACT: Low-density lipoproteins are the most common atherogenic particles in diabetic dyslipidemia; therefore statins, which dramatically reduce low-density lipoprotein (LDL) cholesterol, are first-line therapy for patients with diabetes. These agents produce equivalent relative risk reductions in those with and without diabetes but confer greater absolute risk reduction because of the increased incidence of ischemic cardiovascular events in those with diabetes. The LDL cholesterol goal for patients with diabetes who do not have coronary heart disease is below 100 mg/dL. For secondary prevention, the goal is below 70 mg/dL. High-dose statin therapy may be required to achieve these goals. Fibric acids are a reasonable initial option for patients with triglyceride levels above 200 mg/dL and high-density lipoprotein (HDL) cholesterol levels below 40 mg/dL; in such patients they reduce risk as effectively as statins. Intermediate-release niacin raises HDL cholesterol levels; the effect is enhanced when niacin is combined with a statin.
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What's New in the Treatment of Hypertension?An oral renin inhibitor, aliskiren, recently became available. Does it have any advantages over angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs)?
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Girl With Palpable Purpura and EcchymosesTen days after ballet practice, a 9-year-old girl noticed a nonpruritic, petechial rash on her lower legs. Swelling of the ankles and knees was also apparent. The patient was afebrile, otherwise healthy, and had no abdominal pain. There was no family history of blood dyscrasias. The patient was taking no medications.
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Is It a Seizure? Differentiating Epileptic Seizures from Nonepileptic EventsEarly differentiation of epileptic from nonepileptic seizures is important. Clues that suggest epilepsy are a history of febrile seizures (particularly if prolonged), past brain injury from trauma or infection, and epilepsy in first-degree relatives.
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Managing CA-MRSA Infections: Current and Emerging OptionsMethicillin-resistant Staphylococcus aureus (MRSA) must be recognized now as one of the most common causes of infections acquired in the community. The majority of these infections involve the skin and soft tissue structures and confer significant morbidity on those affected.
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Older Woman With Dyspnea and Large Abdominal EcchymosisTHE CASE: A 77-year-old woman who has had shortness of breath and intermittent left flank pain for the past 2 to 3 days is brought by her family for evaluation. The dyspnea worsens when she lies down. She denies chest pain, back pain, and syncope. She has also had mild nonbloody diarrhea of 2 days’ duration but no vomiting or oral intake intolerance.
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Acute Suppurative Thyroiditis in a Patient With Aplastic AnemiaAcute suppurative thyroiditis (AST) is a rare inflammatorycomplication in patients with hematological malignancy.Infection spreads to the thyroid from a distant site throughthe bloodstream or the lymphatics. Defects such as persistentthyroglossal duct and pyriform sinus fistula are associatedwith the development of AST. Ultrasonography, bariumswallow testing, CT, and fine-needle aspiration are usedfor diagnosis. Treatment includes the administration ofparenteral antibiotics, drainage, and excision. We describea patient with aplastic anemia and bacteremic AST.[Infect Med. 2008;25:339-342]
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Scrub Typhus: Two Cases Presenting as Abdominal PainScrub typhus, which is caused by Orientia tsutsugamushi, has various systemic manifestations, including GI symptoms. We describe one patient with scrub typhus who presented with symptoms that suggested acute appendicitis and another who presented with symptoms of acute cholecystitis.
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Medical Problems of the Athlete:As the world of sport has embraced the participation of women and girls, the incidence of health problems that pertain specifically to premenopausal female athletes has increased significantly. One of these is the female athlete triad, which consists of 3 interrelated medical conditions associated with athletic training
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Disseminated Echinococcosis Involving the Pulmonary ArteryDisseminated echinococcal disease can present complex management issues that require a multidisciplinary approach to care. We describe a patient with hydatid disease who had multiple cysts in the liver, lungs, and pulmonary artery that were caused by Echinococcus granulosus infection.
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Cryptococcal cavitary pneumonia in an immunocompetent patientCryptococcus neoformansmost commonly infects personswith an underlying T-cellimmunodeficiency. It hasbeen nicknamed the "sugarcoatedkiller" because it cancause a devastating disseminatedillness in immunosuppressedpatients. C neoformansrarely causes primaryinfection in an immunocompetentpatient. We present acase of pulmonary cryptococcosisthat occurred in an otherwisehealthy man.
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Infant With a "Tail"A 6-cm midline tail-like soft tissue appendage was noted on the back of this newborn infant at the level of L5. An epithelialized mid-sacrum dimple was also present inferior to the appendage. The infant otherwise appeared to be normally developed.
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Invasive pulmonary aspergillosis, part 2: TreatmentABSTRACT: In general, the management of invasive pulmonaryaspergillosis is based on antifungal therapy and reversal of immunosuppression.Voriconazole is the preferred treatment inmost cases. Liposomal preparations of amphotericin B, caspofungin,and posaconazole are alternatives in patients whocannot tolerate voriconazole or have refractory aspergillosis.Prophylaxis in high-risk patients has gained popularity withthe availability of oral extended-spectrum azoles; posaconazoleis approved for prophylaxis in patients with acute leukemia,myelodysplastic syndrome, and graft versus host disease.(J Respir Dis. 2008;29(11):429-434)
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When should you suspect asbestos-related pulmonary disease?Abstract: A number of factors complicate the diagnosis of asbestos-related pulmonary diseases. Most persons who have had heavy exposure to asbestos are now aged at least 65 years and, therefore, are more likely to have other respiratory problems, such as chronic obstructive pulmonary disease, that may be difficult to differentiate from asbestosis. An accurate assessment of exposure history is particularly challenging because of poor recall of events by patients and because critical variables, such as fiber type, size, and length, can be difficult to evaluate. High-resolution CT (HRCT) has better sensitivity and specificity for asbestos-related pleural disease and neoplasms than does chest radiography. However, HRCT findings in patients with asbestosis are relatively nonspecific. Bronchoalveolar lavage and lung biopsy can provide definitive information about the extent of asbestos exposure. (J Respir Dis. 2005;26(11):499-510)
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Bacterial ArthritidesGonococcal infection is the leading cause of bacterial arthritis in adults.
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A Comparison of the Clinical Effectiveness and Cost-Effectiveness of Treatments for Moderate to Severe PsoriasisThis study investigated the clinical effectiveness and cost-effectiveness of treatments for moderate to severe psoriasis from a managed health care systems perspective. An analysis was conducted of randomized clinical trials evaluating biologic and oral systemic medications and phototherapy for patients with moderate to severe psoriasis.
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ChondrosarcomaA firm mass projected from the deltoid muscle region of a 24-year-old man's right shoulder.
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In Multiple Sclerosis, Motivational Interviewing Can Improve Exercise ExperiencePhysical inactivity is more common among patients with multiple sclerosis (MS) than the general public-even though studies have shown that exercise can reduce the frequency and intensity of MS symptoms. Here's a motivational technique that may help.
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Today's approach to the treatment of heparin-induced thrombocytopeniaAbstract: Failure to recognize heparin-induced thrombocytopenia (HIT) can lead to devastating thrombotic events, including pulmonary embolism and stroke. In most cases, the problem develops within 5 to 14 days after a first-time exposure to heparin. HIT can occur with either unfractionated heparin or low molecular weight heparin (LMWH), but the incidence is much lower with LMWH. When HIT is suspected clinically, a functional assay and immunoassay should be performed. However, treatment should not be delayed while waiting for laboratory confirmation. All forms of heparin should be eliminated, and treatment with an alternative anticoagulant should be initiated to prevent new thromboembolic events. Argatroban and lepirudin are the direct thrombin inhibitors that have been approved for the treatment of HIT. Because of the risk of warfarin-induced venous limb gangrene or skin necrosis, warfarin should be avoided in patients with acute HIT until their platelet counts have recovered and they are improving clinically. (J Respir Dis. 2006;27(6):248-259)
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Acute Gouty Arthritis and Gouty TophusA 5-day history of pain and swelling in the right third finger (A) were the complaints of a 76-year-old man. A few days earlier, another physician had prescribed indomethacin, 25 mg tid, but it had not helped, and the patient believed that his condition had worsened. He had had an attack of gout 5 years before but had not been taking any maintenance medication. The distal interphalangeal (DIP) joint of the affected finger was now erythematous and tender, with chalky subcutaneous deposits. A diagnosis of acute gouty arthritis and gouty tophus was made.
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Cystic Hygroma in a Young GirlA 21-month-old previously healthy child is brought to the pediatrician's office because of increasingly labored breathing that began the night before. The father reports that the child has had fever, congestion, nonproductive cough, and irritability for 2 days and that she is slightly hoarse.
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Mercury PoisoningA minimally responsive 26-year-old man was brought to the emergency department after being found in his home by a friend. A suicide note lay next to his body. The patient had a history of depression.
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Subclinical Hypothyroidism: REFERENCES: EvidencE-based medicine: Relevant guidelines:ABSTRACT: Subclinical hypothyroidism is associated with elevated low-density lipoprotein (LDL) cholesterol levels and several factors related to atherosclerosis, including increased C-reactive protein levels and impaired endothelium-dependent vasodilatation. However, considerable controversy exists about screening for and treating this thyroid disorder. Thyroxine therapy lowers elevated LDL cholesterol levels in patients whose serum thyroid-stimulating hormone (TSH) concentrations are higher than 10 mIU/L ; thus, most experts recommend treatment for such patients. However, there is no consensus regarding the management of patients with TSH levels of less than 10 mIU/L. Although the evidence supporting treatment of these patients is not compelling, it is reasonable to offer a therapeutic trial of thyroxine to those who have symptoms.
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Chronic Hepatitis C:The most common chronic blood-borne infection in the United States is caused by hepatitis C virus (HCV), an RNA virus transmitted through blood-to-blood contact. In this article, we identify risk factors for HCV infection and discuss which patients should be tested and treated.
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Various Manifestations of Rheumatic Disorders: Case 4 Idiopathic DermatomyositisA 76-year-old woman complained of progressive proximalmuscle weakness; achy pain in the buttocks, thighs, andcalves; and lilac discoloration of her eyelids, cheek, nose,knuckles, and fingernails.
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BlisterThis huge blister developed spontaneously on the foot of a woman withdiabetes mellitus. There was no area of redness around the blister, whichnormally occurs with burns and inflamed lesions. Spontaneous blisters andother skin manifestations are common in persons with diabetes.
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Update on the Therapy for SporotrichosisSporotrichosis is a fungal infection that typically results in cutaneous or lymphocutaneous disease, although other, more severe, life-threatening manifestations do occur. This article reviews updated treatment guidelines, which state that itraconazole has become the preferred therapy for most forms of infection. Amphotericin B remains the mainstay of treatment for severe cases, but lipid formulations are now preferred because of their more favorable toxicity profile. Also, fluconazole has been shown to be less effective than itraconazole and is no longer recommended except as an alternative for cutaneous and lymphocutaneous disease. [Drug Benefit Trends. 2010;22:49-52]
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Emerging Treatments for Rheumatoid Arthritis:ABSTRACT: Early treatment with disease-modifying anti-rheumatic drugs (DMARDs)--alone or in combination-- can prevent joint damage and minimize disability. Until recently, the DMARDs used predominantly in patients with rheumatoid arthritis had been methotrexate, sulfasalazine, and hydoxychloroquine. Older DMARDs such as gold, d-penicillamine, and azathioprine have fallen out of favor because of their long- term toxicities or modest benefit. Six newer DMARDs--leflunomide, etanercept, infliximab, adalimumab, rituximab, and anakinra--have greatly expanded the current treatment options.
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Heterozygous Familial HypercholesterolemiaA 56-year-old woman was referred for management of severe hyperlipidemia. Her family history included hypercholesterolemia and premature coronary artery disease.
