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Psoriasis Therapy: What’s NewIn recent years, the role of the immunesystem in the pathogenesis of psoriasishas been extensively delineated. Thisresearch has spawned a new classof medications that target specific immunefactors and hold great promiseas psoriasis therapies. The Table highlightsthe significant features of 4 ofthese biologic agents.
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Bronchoalveolar Carcinoma in a 58-Year-Old ManA 58-year-old man presents with exertionaldyspnea of 6 weeks’ duration, adry cough for 2 weeks, and decreasedappetite. He denies fever, chills, sputumproduction, hemoptysis, cigarette smoking,and significant weight loss. Thepatient, a retired electrician, was exposedto asbestos 20 years earlier.
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Predictors of Response to HAART: Part IIAs treatments for HIV-1 infection have become more effective, better tolerated, and more conveniently administered, treatment success has increased, but many factors influence treatment response. In addition to issues concerning when to initiate HAART and how to optimize therapeutic potency, challenges related to resistance to antiretroviral therapy in treatment-experienced patients as well as patient demographics and adherence affect antiviral response. [Infect Med. 2008;25:294-298]
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Underarm Eruption in a Teenaged BoyTopical steroids and antifungals have not only failed to resolve the bilateral rash; the teen says they’ve made it worse. Your Dx?
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Leiomyoma CutisThe red, 1- to 3-mm lesions on the right forearm of a 19-year-old man had recently become tender after being asymptomatic for 10 years. The patient described a shooting pain on palpation. Previous biopsy results showed no cancer. He had high blood pressure but was otherwise healthy. His father had similar lesions.
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Rheumatologists Embrace Biologics Despite Coverage LimitsAs the number of biologic agents for rheumatoid arthritis (RA)-and rheumatologists’ use of these agents for RA and other rheumatological diseases-grows, getting coverage for RA treatment is taking an increasing investment of physicians’ staff time. However, the majority of respondents to a recent survey say it is an investment in patient care that is worth making.
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Atypical Presentation of Visceral LeishmaniasisFever occurring twice daily, accompanied by profuse sweating, anorexia, and malaise of 15 days' duration resulted in hospitalization of a 31-year-old woman. At this time, her temperature was 37.6°C (99.7°F); blood pressure, 110/70 mm Hg; pulse rate, 90 beats per minute; and respiratory rate, 18 breaths per minute. A palpable spleen was about 3 to 5 cm below the left subcostal margin. Neither lymphadenopathy nor hepatomegaly was noted.
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Necrobiosis Lipoidica DiabeticorumThe atrophic patches on the lower legs of this 47-year-old woman who has haddiabetes mellitus for over 20 years are those of necrobiosis lipoidica diabeticorum.These areas involve degeneration of collagen and elastic fibers in thelower dermis and changes in blood vessel walls. The lesions usually begin assingle or multiple elevated reddish nodules, most commonly in the pretibialarea. Over time, they expand and coalesce into distinctive brownish yellowpatches. These areas may be somewhat tender, but as they spread, theyfrequently become painless-unless they ulcerate. Because the involved skinis fragile, ulcers can form after any minor trauma.
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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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Balanitis Cirumscripta PlasmacellularisFor 2 months, a 22-year-old uncircumcised man noticed an asymptomatic, erythematous, static lesion on the glans penis. He had applied an over-the-counter “jock-itch” ointment for 2 weeks but to no avail. The young man was otherwise healthy and denied having dysuria or a history of sexually transmitted disease.
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Fever and Rash: Infection or Kawasaki Syndrome?Kawasaki syndrome (KS) is a common and serious disorderthat most often affects children aged 1 to 8 years but mimicsa range of other diseases of childhood. Diagnosis of KS isbased on physical examination findings coupled with theexclusion of other causes. To provide optimal care for patients,it is important to be aware of the differential diagnosis of KS.We report a case of a 4-year-old boy who presented withpersistent fever and cervical lymphadenitis; later, mucousmembrane changes, rash, and conjunctival injectioncharacteristic of KS developed. [Infect Med. 2008;25:320-322]
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The Dermatologic Perils of Swimming: Swimmer’s ItchA 6-year-old girl (A) and an 11-year-old boy (B) each presentedfor evaluation of an erythematous, pruritic, papularrash that developed after swimming in a Wisconsin lake.Each child was otherwise completely healthy.
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Sexually Transmitted Diseases: Recognizing Telltale Skin Lesions Secondary Syphilis, Case 2Telltale skin lesions of syphilis, gonorrhea, human papillomavirus infection, and Haemophilus ducreyi infection.
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A Systematic-and Realistic-Approach to Functional Assessment of Elderly PersonsA 74-year-old man comes to your office because his wife and childrenhave noticed that his memory has become mildly impaired. He continuesto work part time in the family business. Recently, however, his daughter has found thathe is making significant errors with clients. For example, he has failed to show up for appointmentsthat he had scheduled, and has set up appointments with clients whom he has already served.Because of errors he has made in client billing, he has turned over the company’s bookkeepingresponsibilities to his daughter.
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Prophylactic Oseltamivir for Prevention of Nosocomial Influenza A Virus InfectionThe effectiveness of oseltamivir in preventing nosocomialinfluenza (influenza Avirus infection) during an influenzaepidemic was carried out in several wards of a universityhospital. Asurvey conducted during the 2005 influenza seasonidentified 30 staff members (nurses and doctors) and 3hospitalized patients who met the case definition for influenza.Adefinitive influenza diagnosis was made in 17 staff members(57%) and in 2 inpatients (66%) based on the results of a rapiddiagnostic test. Most of the 30 symptomatic staff membershad been vaccinated for influenza. Symptomatic staff memberswere sent home for 1 week, and the infected inpatients wereisolated. Oseltamivir (75 mg/d for 5 days) was administered to99 staff members and 2 inpatients who had close contact withthe infected patients. Although a relatively large number of thestaff had an influenza virus infection, the use of oseltamivirmay have effectively prevented a nosocomial outbreak.[Infect Med. 2008;25:49-50a]
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Thyrotoxicosis presenting as pulmonary hypertensionThe authors describe a woman who presented with severe pulmonary hypertension. A cardiopulmonary cause was initially sought, but thyrotoxicosis was the underlying cause.
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Hypertrichosis Pinnae and Maternal Diabetes MellitusA boy was born to a gravida 2, para 1, 26-year-old woman at 37 weeks' gestation. The pregnancy had been complicated by gestational diabetes.
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Cyclospora cayetanensis and AIDSA 32-year-old Hispanic woman with AIDS presented with a 1-month history of diarrhea; abdominal bloating and cramps; loss of appetite; and pronounced fatigue, malaise, and weight loss. She had no fever or chills and was not vomiting. Her CD4+ cell count was 12/µL. Results of a routine microscopic examination of stool for ova and parasites were negative; an acid-fast stain of stool demonstrated oocytes of Cyclospora cayetanensis measuring 8.8 mm in diameter (pictured, magnification ×1,000). This is about twice the size of the Cryptosporidium parvum oocyte, which typically is 4 to 5 mm.
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Lowering the Bar: Patient or Addict?Of the [ADHD] drug's effects he said, "It was instant; it fixed everything...All these problems that had ailed me my whole life were gone."
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Psychiatric Symptoms Associated With Parkinson DiseaseParkinson disease (PD) is associated with a number of nonmotor symptoms, including depression, drug-induced psychosis and impulse control disorders, cognitive impairment, anxiety, and sleep disturbances.
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ST-Segment Elevation Myocardial Infarction:What Role for Anticoagulants and Antiplatelet Agents?The goal of treatment in acute coronary syndromes is the restoration and maintenance of myocardial perfusion. To this end, numerous pharmacological agents are available, as well as percutaneous coronary intervention (PCI).
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OphiasisConcerned about their son's progressive hair loss during the last 6 months, his parents brought the 2-year-old into the office. The clinical appearance of hair loss extending in a band configuration around the temporal-occipital scalp margin confirmed the diagnosis of ophiasis.
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Yolk Sac Tumor in the Anterior Mediastinum: A Rare CaseInitially treated empirically for acute bronchitis, this patient came to the ED with a 6-week history of worsening cough, dyspnea, fevers, weakness, and a 20-lb weight loss.
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Lisfranc Ligamental InjuryAfter a fall during a soccer match 2 weeks earlier, a 26-year-old woman had pain of the right midfoot, with moderate swelling. The pain was aggravated with a normal gait and alleviated with an antalgic gait, specifically with inversion of the right ankle such that most of the weight from heel-strike through toe-off transmitted forces from the lateral calcaneus through the fifth metatarsus to the fifth phalanx.
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Heart Failure: Patient Selection and TreatmentABSTRACT: Angiotensin-converting enzyme (ACE) inhibitor therapy is recommended for all patients with heart failure (HF) and a reduced ejection fraction. It is generally initiated in the hospital at low doses as inotropic therapy is tapered. Angiotensin II receptor blockers may be a suitable alternative for patients who cannot tolerate ACE inhibitors. For patients who cannot tolerate either class of drug, a combination of hydralazine and a nitrate is recommended. ß-Blockers are first-line therapy for patients with current or previous symptoms of HF and reduced left ventricular function, as well as all patients hospitalized for HF. An aldosterone antagonist may be added to the regimen of patients with moderately severe to severe symptoms and reduced ejection fraction whose renal function and potassium concentration can be monitored.
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Managing Post-traumatic Stress Disorder: The Pharmacotherapy OptionFirst-line agents include selective serotonin reuptake inhibitors and venlafaxine.
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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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Effect of Health Plan and Physician Clinic Collaboration on Increasing Omeprazole UseA proposal for a pilot project to save money for a health plan was developed collaboratively with a clinic manager and the medical director of a local clinic. The goal was to encourage and support physicians in changing the proton pump inhibitor (PPI) medication prescribed for patients from a brand-name PPI to omeprazole, a more cost-effective generic option. The health plan identified members who had filled a prescription for a brand-name PPI and asked their physicians to consider switching the patients’ therapy to omeprazole. If the physician agreed to the change, the clinic would then send a letter to the patient, in which the physician recommended the change along with a new prescription for omeprazole. Following successful implementation in the initial pilot clinic, the program was extended to 4 more clinics. After achieving significant cost savings at all 5 clinics, the health plan is now expanding the program to more clinics as well as considering launching similar programs targeting other medication classes. (Drug Benefit Trends. 2009;21:158-163)
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Case In Point: Erythema Ab IgneA 14-year-old African American boy presented during the winter months with a painless, nonpruritic, periumbilical rash that had been present for approximately 1 month. Initially bluish, the rash had become dark brown.
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Clostridium subterminale - Infection Secondary to an Open FractureClostridia are anaerobic, spore-forming, gram-positive bacilli that are ubiquitious in nature. They can be isolated from soil and the GI tract of animals and humans.1
