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The authors describe a case of acute eosinophilic pneumonia (AEP) that occurred in a previously healthy young man. The presentation was similar to that of acute respiratory distress syndrome (ARDS), and the diagnosis was established by bronchoalveolar lavage (BAL). The authors note that it is important to recognize the subset of patients with AEP who present with an ARDS-like picture, especially since corticosteroids are very effective in this setting.

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A 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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A 67-year-old woman presented to the emergency department (ED) with severe, sharp, central chest pain of sudden onset and mild shortness of breath. The pain had been present for 15 minutes. The patient was obese; her medical history included hypertension, myocardial infarction, and osteoarthritis.

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Increasingly severe dysphagia had bothered a 77-year-old woman for several months. By the time she sought medical attention, both food and liquids were sticking in the lower esophagus, leading to vomiting and weight loss.

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During the past few months, a 50-year-old woman had experienced cough, dyspnea, mild hemoptysis, and a 30-lb weight loss. She had no fever, chills, or rigors. The patient had smoked cigarettes for 30 years.

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A 2-year-old girl presents to the pediatric emergency department (ED) for evaluation of a fleshy mass protruding from her rectum. The mass, which had been present for 1 day, protruded spontaneously and not during defecation. There is no history of cough, constipation, diarrhea, vomiting, weight loss, or parasitic or chronic disease. However, the child has been having episodic, painless bleeding during the past month. There is no family history of GI disease.

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A 16-year-old boy removed a small sliver of wood from the palm of his hand with a pocket knife. However, the fledgling “surgeon” created a small puncture wound during this operation. Over the next month, a small, moist, friable papule grew at the site.

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Clinical Images to Help You Hone Your Diagnoses

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ABSTRACT: A thorough history and physical examination can establish the diagnosis of tension headache; further evaluation is generally unnecessary. In contrast, the workup of cervicogenic headache includes standard radiographs, 3-dimensional CT, MRI, and possibly electromyography; nerve blocks may also be used to confirm the diagnosis. Episodic tension headache can be treated effectively by trigger avoidance, behavioral modalities, and structured use of analgesics. Reserve opioids for patients with intractable headaches. Chronic tension headache is treated primarily by prophylactic measures, such as antidepressants and anticonvulsants, and behavioral and physical therapy. Treatment options for cervicogenic headache include analgesics; invasive procedures, such as trigger point injections, greater or lesser occipital nerve blocks, facet joint blocks, segmental nerve root blocks, and diskography; spinal manipulation; and behavioral approaches.

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Actinomyces odontolyticus isa rare cause of pleuropericardialinfection, with only 1 caseidentified in the literature. Inthat instance, the infectionwas believed to be secondaryto gastric surgery. We present apatient with pericarditis andpericardial tamponade causedby A odontolyticus. The infectionoccurred after an ultrasound-guided subcarinalbronchoscopic needle biopsyperformed for a suspicious mediastinalmass found on a CTscan of the chest. We describethe case presentation, the microbiologyand treatment of Aodontolyticus infection, andthe classic features of pericarditisand cardiac tamponade.

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Infective endocarditis (IE) starts as a vegetation on the valvular structures. The infection can extend to the adjacent periannular areas and erode into nearby cardiac chambers, leading to an aorto-cavitary fistula (ACF).1,2

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A 38-year-old man presented with a 2-week history of mental status changes and impaired memory. He also had a rash on both hands and feet that had been getting worse for the past few months.

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For 6 months, a 19-year-old woman had had sensitivity to cold. When outside in cold weather, she noticed swelling, erythema, and pruritus of her uncovered hands. After she held a cold drink on her arm for about 5 minutes, urticarial lesions developed on the skin in contact with the drink. The symptoms resolved about 20 minutes after the cold source was removed. She denied angioedema, respiratory symptoms, light-headedness, and tachycardia.

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The authors report the incidental finding of a persistent left superior vena cava (PLSVC) during the routine placement of a left subclavian central line in an elderly man with acute renal failure.

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The patient was a 41-year-old manwith a history of HIV infection diagnosed10 years before admission.He had been noncompliant withtreatment, and therapy with tenofovir,efavirenz, and lamivudinehad not been started until 2 monthsbefore admission, when he presentedto another hospital. At thetime, his CD4+ cell count was156/µL and his viral load was45,743 copies/mL. He also had ahistory of incarceration; had usedinjection drugs, cocaine, alcohol,and marijuana; and had a 20-packyeartobacco history.

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A 65-year-old woman with metastatic adenocarcinoma of the colon was undergoing chemotherapy following a colectomy and a hepatic wedge resection. The physical examination and laboratory data were unremarkable.

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The major causes of chronic cough include upper airwaycough syndrome (UACS, formerly known as postnasal dripsyndrome), asthma, nonasthmatic eosinophilic bronchitis, andgastroesophageal reflux disease. In fact, one or more of these isthe cause of cough in the vast majority of nonsmokers who arenot receiving angiotensin-converting enzyme inhibitors andwho have no evidence of active disease on chest radiographs. Ahigh index of suspicion is required, because each of these conditionsmay present with cough as the sole symptom. BecauseUACS may be the most common cause, it appears reasonableto try empiric UACS therapy in patients in whom other causesare not evident at initial evaluation. In many cases, the combinationof a first-generation antihistamine and a decongestantmay be most effective. (J Respir Dis. 2008;29(3):113-122)

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When I dry-shave patients in preparation for surgery or suturing, I find that a mailing label best removes the shaved hair.

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ABSTRACT: Education can help improve compliance with inhaled corticosteroid therapy or correct faulty metered-dose inhaler (MDI) technique. Options for patients with poor MDI technique include use of a spacer or an alternative device, such as a nebulizer or a dry powder inhaler. If therapy is ineffective, consider alternative conditions that mimic asthma, especially vocal cord dysfunction and upper airway obstruction. Treatment of comorbid conditions, such as gastroesophageal reflux disease or rhinosinusitis, may improve control. In refractory asthma, it is crucial to identify allergic triggers and reduce exposure to allergens. If another medication needs to be added to the inhaled corticosteroid, consider a long- acting b-agonist, leukotriene modifier, or the recombinant monoclonal anti-IgE antibody omalizumab.

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Each year almost 5 million Americans sustain an animal or human bite. Dog bites alone represent 0.4% to 1% of all emergency department (ED) visits and can range from trivial to life-threatening.

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A 48-year-old woman with a historyof hypertension and mildasthma has been transferred to themedical service because of an abnormalpostoperative ECG. She hadbeen admitted 2 weeks earlier to thegynecology-oncology service for localrecurrence of a previously resecteduterine sarcoma and underwent laparotomyfor debulking of the pelvicmass and resection of the rectosigmoidcolon. She did well until postoperativeday 14, when sudden chestpain and dyspnea developed.

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When you examine a young child's ears, position the patient on the parent's lap with his or her abdomen against that of the parent, one leg on either side of the parent's trunk, and the child's head against the parent's chest.

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A 38-year-old man found lying on the floor in his home was hospitalized because of alcohol intoxication. A chest radiograph showed a large calcified lesion in the left upper abdomen. A CT scan with intravenous contrast revealed a large, well-defined, cystic mass with mural calcification in the spleen. The CT findings were not consistent with a vascular malformation or echinococcal cyst-specifically, the mass was sharply demarcated, unilocular without septations, and round with a thin wall and attenuation similar to water. Urine Histoplasma antigen test results were negative.

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Endobronchial primary synovialsarcoma is an extremelyrare pulmonary tumor. We reportthe case of a 58-yearoldman who presented witha right-sided endobronchialmass, which was diagnosed asprimary synovial sarcoma onthe basis of histological appearanceand immunohistochemicalstaining. To the bestof our knowledge, this is onlythe third case report of endobronchialprimary synovialsarcoma.

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The laryngeal mask airway (LMA) has become a popularalternative to endotracheal intubation. Many cliniciansconsider it a safe procedure, but complications do occur.Although uncommon, retropharyngeal perforation withmediastinal abscess can become a life-threatening event. Wereport a case of mediastinal abscess in an 84-year-old womanwho received LMA ventilation during a surgical procedurefor total knee replacement. [Infect Med. 2008;25:180-185]

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Opportunistic fungal infections are increasingly common inpatients who undergo hematopoietic stem cell transplant(HSCT). Voriconazole is frequently used in allogeneicSCT recipients who receive immunosuppressant therapy forgraft versus host disease to prevent invasive aspergillosis.Indications for voriconazole use include invasive aspergillosis,candidemia, Scedosporium apiospermum infection, and fusariosis.We describe a case in which disseminated Fusarium infectiondeveloped in an HSCT recipient who was receiving voriconazoletherapy. [Infect Med. 2008;25:528-530]

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Recognition of a simultaneous viral and bacterial skin infectioncan be challenging. In the case presented here, an immunocompromisedpatient presented with a painful rash on the arm,pustules and papules on the chest, and crusted lesions onthe nares. Culture and immunofluorescent staining revealedStreptococcus and varicella-zoster virus, respectively. Afterappropriate treatment, the rash completely resolved. [InfectMed. 2008;25:240-241]

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Allergic disorders are becoming more common. For example, about 20% of Americans have allergic rhinitis, which accounts for more than 10 million office visits each year. Most of these visits are to primary care clinicians.

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Cumulative research with animal, normative, and clinical populations over several decades shows that the mechanisms underlying anxiety disorders differ from those of the normal emotion of anxiety. In persons with anxiety disorders, fear and tension are disproportionate to the actual threat and may be present when no real threat exists, thereby generating an expectation of danger and distorted perceptions related to danger and various types of threats. The most common anxiety disorders are social anxiety disorder (SAD), generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD). Persons with SAD can experience a wide range of social fears as well as severe functional consequences, whereas persons with GAD tend to experience emotional, interpersonal, and somatic symptoms of high levels of chronic anxiety. Persons with PTSD have vivid memories of and thoughts about a terrifying event or ordeal that lead to the development of anxiety, depression, and functional impairment. Effective treatment options-pharmacotherapy; psychotherapy, particularly cognitive-behavioral therapy; or a combination-can be discussed openly with the patient to make a collaborative, informed decision. A variety of medications can be used to successfully manage anxiety disorders, of which SSRIs and serotonin-norepinephrine reuptake inhibitors are the most effective. When properly used, medications can enhance a patient's own efforts to master anxiety; overcome fearful avoidance; and address troubling behaviors, patterns, or memories. (Drug Benefit Trends. 2008;20:101-113)