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Osteoporosis:What to Tell Patients About Prevention and TreatmentOsteoporosis is no longer consideredage- or sex-dependent, although prevalencevaries by sex and race. Postmenopausalwhite women suffer almost75% of all hip fractures and havethe highest age-adjusted rate of fracture.Thanks to progress in our understandingof causes and treatments, thisdisease is largely preventable, and significantimprovements in morbidityand mortality are possible. The beststrategy for prevention and treatmentuses a team approach that involves thepatient, physician, health educators, dietitians,and physical therapists.
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Aspergilloma, or Fungus BallA 41-year-old man with a past history of tuberculosis presented to the emergency department with massive hemoptysis. The patient denied fever or chills but reported a 20-lb weight loss and intermittent hemoptysis during the last 6 months. Six years ago, he had been treated for tuberculosis.
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Case In Point: Middle-Aged Man With Worsening Cough and DyspneaA 52-year-old man with hypertension and hyperlipidemia presents to the emergency department with a 5-month history of cough and dyspnea.
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Chylothorax: A review of current management strategiesABSTRACT: The most common causes of chylothorax are neoplasm-particularly lymphoma-and trauma. The usual presentingsymptom is dyspnea resulting from the accumulationof pleural fluid. The diagnosis of chylothorax is established bymeasuring triglyceride levels in the pleural fluid; a triglyceridelevel of greater than 110 mg/dL supports the diagnosis. The initialapproach to management involves chest tube drainage ofthe pleural space. The administration of medium-chain triglyceridesas a source of fat is often useful. If drainage remains unchanged,parenteral alimentation should be started. Surgicalintervention is indicated if conservative management is notsuccessful or if nutritional deterioration is imminent. If chylothoraxpersists after ligation of the thoracic duct, options mayinclude percutaneous embolization, pleuroperitoneal shunt,and pleurodesis. (J Respir Dis. 2008;29(8):325-333)
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Immunologic Idiopathic Thrombocytopenic PurpuraA mother, fearing that her 4-year-old son had been abused at his day-care center, rushed him to the emergency department, where an evaluation revealed a platelet count of 1,000/µL. Except for bruises on the boy's face and legs, the physical findings were normal. Bone marrow aspiration showed numerous megakaryocytes and was otherwise normal. The youngster's history included treatment for bronchitis, sinusitis, and conjunctivitis 2 weeks earlier.
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Woman With Edema, Vomiting, and DiarrheaA 22-year-old woman has had chronic nausea, emesis with green vomitus, and diarrhea for the past 10 months. The diarrhea is frequent (about 3 to 8 times daily) and does not resolve with starvation.
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Octogenarian With Low Back Pain and an Enlarged SkullAn 81-year-old woman is hospitalizedwith localized nonradiating low backpain of 3 weeks’ duration. She has nohistory of trauma, weakness of the legs,or urinary or bowel incontinence.
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Abnormal Chest X-Ray in a Drug AbuserA 56-year-old man has been admitted on several prior occasions for left groin abcesses related to injection drug use.
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A case of pseudo-Meigs syndromeWe present a case of a 52-year oldwoman with exudativepleural effusion. Her workuprevealed an ovarian tumor,and the effusion completely resolvedafter resection of the tumor.Pathology revealed granulosacell tumor, which is anunusual cause of Meigs syndrome.This case shows theimportance of considering abdominopelvicpathology in unsolvedcases of pleural effusion.
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Migraine, Chronic Daily Headache, and Complex Regional Pain Syndrome: Researchers Establish LinksMigraine and chronic daily headache may be risk factors for the development of complex regional pain syndrome, according to the results of a study led by B. Lee Peterlin, DO, assistant professor of neurology, Drexel University College of Medicine in Philadelphia.
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Acute Dyspnea:ABSTRACT: The rate at which acute dyspnea develops can point to its cause. A sudden onset strongly suggests pneumothorax (especially in a young, otherwise healthy patient) or pulmonary embolism (particularly in an immobilized patient). More gradual development of breathlessness indicates pulmonary infection, asthma, pulmonary edema, or neurologic or muscular disease. A chest film best identifies the cause of acute dyspnea; it can reveal pneumothorax, infiltrates, and edema. Pulmonary embolism is suggested by a sudden exacerbation of dyspnea, increased ventilation, and a drop in PaCO2. A normal chest radiograph reinforces the diagnosis of pulmonary embolism, which can frequently be confirmed by a spiral CT scan of the chest. Pneumonia can be difficult to distinguish from pulmonary edema. In this setting, bronchoalveolar lavage and identification of the infectious organism may be necessary to differentiate between the 2 disorders.
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Paget's DiseaseA 74-year-old man, who had been aware of a gradual increase in hat size over the past 3 years, complained of a mild headache and backache. His serum phosphatase level was 1,475 U/L (upper normal limit, 120 U/L). Skull films showed calvarial enlargement caused by thickening of the cortical tables, radiolucency in the frontal and occipital regions, and patchy osteosclerosis that produced a cotton-wool appearance.
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Renal Artery StenosisAfter suffering with a severe, disabling headache for 2 weeks, a 20-year-old soldier sought medical treatment. He had no significant medical history other than his 6-year history of smoking.
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Bronchoalveolar CarcinomaA 52-year-old woman (a nonsmoker) was hospitalized after experiencing a low-grade fever and dyspnea for a month. No abnormalities were noted on physical examination, but the chest film showed multiple nodules, both well- and ill-defined. Lung biopsy confirmed the diagnosis of bronchoalveolar carcinoma.
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OnychogryphosisThis patient, a woman, presented with onychogryphosis, a severe nail change seen on the toes, especially the great toe. Thickening and hardening of the nail substance with a curved growth pattern produces this abnormal clawlike configuration.
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Cavitary Lung Cancer With MetastasesA 60-year-old woman with a 3-month history of cough, chest pain, and shortness of breath was brought to the emergency department. The patient denied any history of fever, chills, or rigors; she complained of mild hemoptysis for 1 week and a 9-kg (20-lb) weight loss during the last few months. The patient had smoked cigarettes for 40 years.
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Milroy's DiseaseA 46-year-old woman was examined because of cellulitis of the right leg, which she said had been swollen for 30 years.
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An unusual case of malignant invasive thymomaMalignant thymoma is an indolent tumor arising from the thymic epithelial cells located in the anterior mediastinum. These tumor cells spread via regional metastasis or invade surrounding structures, including the pleural space.
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An Unusual Cause of Pleural EffusionA 36-year-old man presents with a 10-day history of progressive dyspnea anddiscomfort on the left side of his chest.Three weeks earlier, he was dischargedfrom the hospital after a 2-week stayfor acute pancreatitis. He has a historyof long-term alcohol abuse and recurrentpancreatitis.
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Case In Point: Peripheral nerve sheath tumor mimicking pulmonary embolismWe describe a case in which a patient received thrombolytic therapy after he presented with a clinical picture consistent with submassive pulmonary embolism (PE). Two months later, a malignant peripheral nerve sheath tumor was diagnosed, and the patient died with metastatic disease. The filling defect in the left main pulmonary artery originally interpreted as PE was in fact a tumor. This case describes an unusual presentation of a rare disease (malignant peripheral nerve sheath tumor) mimicking a submassive PE.
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An Elderly Man With a Lung Mass and Neurologic SymptomsA 71-year-old man was admitted to the MICU for weaning from mechanical ventilation. The history revealed a global decline over the previous 3 to 4 weeks predominated by cognitive impairment, mood swings, somnolence, and limb weakness. No respiratory symptoms were noted.
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The Differential Diagnosis of Weakness: 5 CasesDetermining the cause of generalized weakness can be a daunting task, since the differential diagnosis is vast. An overall approach to the patient who complains of generalized weakness is presented in our article
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Community-Acquired Pneumonia in the Elderly:ABSTRACT: In addition to advanced age, factors such as comorbid illness and debility determine the risk of community- acquired pneumonia (CAP). Many elderly persons do not have the classic symptoms of CAP; instead, they may present with confusion, lethargy, tachypnea, anorexia, or abdominal pain. Even with thorough investigation, an infectious pathogen can be identified in only about half of patients. In addition to the causative organisms for pneumonia in younger adults, elderly persons are at risk for infection with organisms such as Haemophilus influenzae, Staphylococcus aureus, enteric gram-negative bacteria, and anaerobes, and for polymicrobial infection. Prompt empiric treatment is essential. Recommended initial therapy choices include a ß-lactam agent with a macrolide, or an antipneumococcal fluoroquinolone.
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Strategies to Promote Successful Aging: Part 2, The Physician's RoleA 65-year-old woman with well-controlled hypertension comes in for a routine checkup. During the past 10 years, she has gained 25 lb and lost 1.5 inches in height.
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PseudoporphyriaA 79-year-old nursing home resident was hospitalized for evaluation of hyperkalemia and leukocytosis. Her medical history included hypertension, respiratory failure with subsequent tracheostomy placement and ventilator dependency, and anemia. Both of her legs had been amputated above the knee secondary to complications of type 2 diabetes mellitus.
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Emerging Strategies in HIV PreventionHIV infection continues to exact a devastating toll worldwide.Advances in antiretroviral therapy have helped bring theHIV/AIDS epidemic under control in developed countries.Antiretroviral drugs, however, are not widely available inthose developing countries where HIV poses a catastrophicthreat. Effective strategies for HIV prevention are thereforecrucial to curbing the global epidemic. Vaccination, microbicideuse, and male circumcision are 3 key preventive interventions.Current research is focused on developing effective vaccinesand microbicides and on determining the extent to whichcircumcision helps prevent HIV acquisition and transmission.[Infect Med. 2008;25:63-72]
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Opportunistic Fungal Infections, Part 3: Cryptococcosis, Histoplasmosis, Coccidioidomycosis, and Emerging Mould InfectionsImmunocompromised hosts are at high risk for opportunisticinfections caused by endemic fungi such as Cryptococcus,Histoplasma, and Coccidioides. Moulds other than Aspergillusalso are being implicated in opportunistic fungal infections inimmunocompromised patients. Infections attributed toZygomycetes and Fusarium and Scedosporium species are beingreported with increased frequency. Because infection with theseorganisms cannot be distinguished from aspergillosis onradiographic imaging or histological examination, culture isrequired to confirm the diagnosis. Therapeutic success mayhinge on correct identification of the infectious organism.
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Respiratory infections in diabetes: Reviewing the risks and challengesABSTRACT: Although the organisms that cause community-acquiredpneumonia are similar in diabetic and nondiabetic patients,those who have diabetes mellitus (DM) may have moresevere disease and a poorer prognosis. Elevated blood glucoselevels are associated with worse outcomes in patients withpneumonia, and the mortality risk may be as high as 30% in patientswith uncontrolled DM. Thus, appropriate treatment-and possibly prevention-of bacterial pneumonia should includeaggressive efforts directed at glycemic control. Other respiratoryinfections, such as influenza, tuberculosis, and fungalpneumonia, also are associated with greater morbidity in patientswith DM. Diabetic patients with tuberculosis are morelikely to present with bilateral lung involvement and pleural effusions.(J Respir Dis. 2008;29(7):285-293)
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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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Acute hypoxemic respiratory failure as a manifestation of urinothoraxIn the case described here, hypoxemic respiratory failure occurred secondary to a right-sided pleural effusion associated with an obstructive uropathy. The patient, a 75-year-old man with a history of benign prostatic hypertrophy (BPH), presented with a gradual onset of shortness of breath, tachypnea, and oliguria. Renal ultrasonography and CT scanning revealed bilateral hydronephrosis. A right thoracentesis yielded fluid with characteristics consistent with urinothorax. The patient was given medication for BPH, taught how to do self-straight catheterization, and scheduled for an outpatient cystoscopy. At follow-up, his chest radiograph showed no effusions.
