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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.
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Steroid Shots No Long-Term Help in Knee OAA new study found no major structural effect on the knee joint after 2 years of intra-articular steroid injections.
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Oropharyngeal candidiasis: Diagnostic clues, treatment tipsThe most common manifestation of oropharyngealcandidiasis (OPC) is pseudomembranous candidiasis, commonlyknown as "thrush," which appears as a whitish yellow,curdlike discharge on the mucosal surfaces. Other forms ofOPC include denture stomatitis, angular cheilitis, and glossitis.Patients with denture stomatitis are usually asymptomatic, butthe tissue beneath the denture is typically red and hyperplastic.Patients with angular cheilitis may complain of a burning sensationat the margins of the lips. Candidiasis involving thetongue can be exuberant and is usually associated with complaintsof a white tongue, taste alterations, and a burning sensationof the tongue. The diagnosis of OPC can be establishedby identifying typical fungal elements on potassium hydroxidepreparation or Gram stain of scraped material. Treatment optionsinclude clotrimazole, fluconazole, itraconazole, and nystatin.(J Respir Dis. 2008;29(3):128-135)
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Disseminated Mycobacterium avium-intracellulare complex InfectionA39-year-old man with a history of AIDS and nonadherence to highly active antiretroviral therapy (HAART) presented with frontal headache and scalp pain of 2 weeks' duration. These symptoms were accompanied by nausea, weight loss, and generalized weakness. Physical examination revealed a small, tender scalp lump, 2 × 2 cm over the left parietal area. The findings from the rest of the examination were unremarkable.
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Preventing Coronary Heart Disease in Women:Many of my older women patients think theyare at much higher risk for breast cancer thancoronary heart disease (CHD). How can we raise women'sawareness about their risks of CHD and therebyencourage them to take measures to prevent it?
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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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Gout Diagnosis: 4 Common MisconceptionsA definitive gout diagnosis is based on demonstration of monosodium urate crystals on aspiration of an affected joint or tophus.
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An Elderly Woman With IgA Lambda Multiple Myeloma and Kidney DiseaseA 92-year-old woman presented with a 6-month history of progressively worsening fatigue, weight loss, generalized bone pain, and dyspnea on exertion. A skeletal survey found lytic lesions in the pelvis, sacrum, and calvarium (shown here).
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Autosomal Dominant Polycystic Kidney Disease in a 38-Year-Old WomanAutosomal dominant polycystic kidney disease (ADPKD) is common. Presenting symtpoms include hypertension, hematuria, proteinuria, and renal insufficiency.
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Juvenile DermatomyositisThe diagnosis of juvenile dermatomyositis can be challenging when proximal muscle weakness develops without characteristic skin manifestations. In this patient, rash appeared 2 months after the onset of muscle weakness. As a result, the initial diagnosis was viral myositis, which led to delayed therapy.
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Raynaud Phenomenon as a Manifestation of Systemic DiseaseThe young female presented with a 1-month history of violaceous papules, petechiae, and healing ulcerations on the distal digits of both hands and feet.
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Polypharmacy in Elderly Patients: Practical Tips to Avoid Adverse Effects and InteractionsAn 81-year-old woman with a history of moderate Alzheimer dementia, depression, coronary artery disease, hypertension, and type 2 diabetes mellitus was accompanied to the office by her son for a routine follow-up appointment.
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Podcast: A Therapeutic Primer for Primary Care Physicians: The Value of Talk - Part 4: You and Your PatientAfter listening to the previous 3 podcasts, you may be wondering how to begin a therapeutically valuable conversation with your patient, which will provide the critical details that you need in the short time that you have. In his final podcast, Dr Lieberman offers a list of questions that you can use to break the ice and kick start a dialog with a patient whom you suspect has a mental health disorder.
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Hepatic and Splenic Infarction in Systemic Lupus ErythematosusSystemic lupus erythematosus (SLE) was diagnosed in an 18-year-old man who presented with polyarthritis, fever, hypoxia, fatigue, anemia, neutropenia, and abnormal urinary sediment. A renal biopsy showed diffuse mesangial proliferative glomerulonephritis (World Health Organization class II). Serologic tests were positive for fluorescent antinuclear antibody (FANA), SS-A, SS-B, anti-Sm and anti-dsDNA antibodies, and rheumatoid factor; a direct Coombs' test result was positive as well.
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Acute pneumonitis after in vitro fertilization with IM progesteroneA 34-year-old woman presented to the hospital with low-grade fever, fatigue, dyspnea with minimal exertion, and dry cough. She had emigrated from China 3 years earlier. She had been healthy and had no allergies or food intolerances.
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Quinolone Neurotoxicity: How to Avoid or Minimize the RiskFluoroquinolone antibiotics have activity against a wide range of gram-positive, gramnegative, and atypical bacteria.
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Acute Disseminated Histoplasmosis in a 48-Year-Old ManA 48-year-old man with jaundice, nausea, vomiting, and abdominal pain was hospitalized. The patient-a recovering alcoholic-was afebrile and reported abstinence from alcohol for 6 months.
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Cerebral air embolism resulting from an airplane flightThe authors describe a case of air embolism that developed during a plane flight in a woman who had a congenital cystic adenomatoid malformation. They review the pathophysiological mechanisms, risk factors, clinical features, and treatment of air embolism.
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Effort-Related Upper Extremity ThrombosisDuring the first quarter of a football game, a 17-year-old athlete noticed that his right (dominant) arm was swollen and heavy. Two days earlier, he had fired a shotgun right-handed multiple times while hunting.
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Scurvy, Pellagra, and Beri BeriA 38-year-old woman presented with bruising and pain of the lower extremities and dyspnea on exertion. She had had these symptoms for 3 weeks. She denied hematuria, melena, hematemesis, fever, or abdominal pain. Results of routine blood work showed a hemoglobin level of 6.4 g/dL (19 months earlier, this level was 15.8 g/dL).
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Exercise intolerance in severe COPD: A review of assessment and treatmentAbstract: Exercise intolerance is common in persons with chronic obstructive pulmonary disease and can result from multiple physiologic factors, including dynamic hyperinflation, gas exchange abnormalities, and pulmonary hypertension. In the initial assessment, keep in mind that many patients underestimate the degree of their impairment. The 6-minute walk test is very useful in assessing the degree of exercise intolerance; when more extensive assessment is indicated, cardiopulmonary exercise testing (CPET) is the gold standard. CPET is particularly useful for defining the underlying physiology of exercise limitation and may reveal other causes of dyspnea, such as myocardial ischemia or pulmonary hypertension. Strategies for improving exercise tolerance range from the use of bronchodilators and supplemental oxygen to participation in a pulmonary rehabilitation program. (J Respir Dis. 2006;27(5):208-218)
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Pulmonary arterial hypertension: Classification, diagnosis, and prognosisAbstract: Our understanding of the pathobiology of pulmonary arterial hypertension (PAH) has evolved considerably over the past 2 decades, with increasing recognition of the important role that aberrant vasoproliferative responses play in conjunction with disordered vasoconstriction. Classification of the many forms of PAH into categories sharing a similar pathophysiology and clinical presentations help the practicing clinician approach a complex differential diagnosis. Noninvasive tests can be used to narrow this differential but must be applied with an appreciation for their limitations. Transthoracic echocardiography is the screening tool of choice; the workup should also include chest radiography and electrocardiography. However, right heart catheterization is ultimately required to establish the diagnosis. While PAH remains a progressive and generally fatal disease, existing therapies have a significant impact on survival and new therapeutic targets offer great hope for improving the prognosis. (J Respir Dis. 2006;27(11):487-493)
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Lemierre Syndrome: A Forgotten DiseaseSymptoms closely resemble "strep" throat but suspicion for Lemierre should run high when pharyngitis and fever persist.
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Further Evidence That HTLV Protects Against HIV ProgressionPrevious case reports have suggested an association betweenhuman T-cell lymphotropic virus (HTLV) types 1 and 2infection and chronic nonprogressive HIV infection. Evidenceis lacking about the specifics of how the two are related. Wereport 2 cases of chronic nonprogressive HIV infection (of9 and 13 years' duration, respectively) in women in whomHTLV coinfection was diagnosed. These cases provide clinicalsupport that HTLV coinfection may serve as a protective factoragainst progression of HIV infection. Possible reasons for thisrelationship and potential future research are discussed.[Infect Med. 2008;25:416-420]
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Multiple Lung NeoplasmsFor the past 6 weeks, a 72-year-old woman with a history of ovarian cancer had had intensifying dyspnea. Initially, she thought her breathing problem was caused by progressive congestive heart failure.
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Sudden Loss of Consciousness in an Elderly WomanA comatose 82-year-old woman is brought to the emergency department. Her husband reports that after dinner she began to have difficulty in speaking, lost consciousness, and fell to the floor. He tried to rouse her, but was unsuccessful and called for an ambulance.
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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.
