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For more than 30 years, serumdigoxin concentrations (SDCs)have been monitored toensure safe, effective therapy.1,2Although the therapeuticrange for SDCs is often listed as either0.8 to 2.0 ng/mL or 0.5 to 2.0ng/mL, the results of clinical trials inthe 1990s suggest an upper limit of1.0 ng/mL for treatment of heart failure.3-11 An upper limit for the SDC of1.0 ng/mL is also recommendedfor patients who have heart failureand atrial fibrillation with rapid ventricularresponse.

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We describe a patient with intravascularpulmonary lymphomawho presented withprogressive dyspnea and hypoxemiawith normal chest radiographicfindings. After anunrevealing noninvasive evaluation,a high-grade B-cellintravascular lymphoma wasdiagnosed by bronchoscopywith transbronchial biopsy.Treatment with a modifiedCHOP regimen resulted in resolutionof the patient’s hypoxemiaand exercise limitation.Although intravascular pulmonarylymphoma rarely presentswith pulmonary symptoms,it should be consideredin the differential diagnosis ofpatients presenting with hypoxemiaand normal chest radiographicfindings.

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Over the past 2 decades, there has been an alarming increase in opportunistic fungal infections with an associated rise in morbidity and mortality. This trend has been attributed to the growing number of patients who are immunocompromised because of bone marrow or solid organ transplant, immunosuppressive drugs, AIDS, and hematological malignancies. Advances in trauma and critical care medicine that lead to longer survival of more patients with immunocompromising conditions also play a role.

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A 16-year-old boy was evaluated for elephantiasis in a remote village in the mountains of Kenya. He complained of drainage from his left leg and reported that for the past several months, after the limb swelled, fluid began to weep from the bottom of the foot. He denied pain in his leg or foot and reported no fever, chills, or sweats.

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A 32-year-old woman presents with weight loss of 6.4 kg (14 lb) during the past 8 months and diarrhea of recentonset. Menstruation had ceased 10 weeks earlier. She appears anxious, with pressured speech. Physical examination detectsbaseline sinus tachycardia, sweaty palms, and a diffusely enlarged thyroid gland. Laboratory tests reveal a thyroid-stimulatinghormone (TSH) level of 0.00 µU/mL (normal, 0.45 to 4.5 µU/mL), a free thyroxine (FT4) level of 4.8 ng/dL (normal,0.61 to 1.76 ng/dL), and a positive thyroid-stimulating immunoglobulin (TSI) level with high titer.

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A 53-year-old man, who had initially presented with an upper respiratory tract infection, was found to have a stage IV follicular low-grade lymphoma with malignant cells that were positive for CD19, CD20, CD10, surface kappa, and CD45 and negative for CD5. A grade 1 tumor (follicular center cell lymphoma/follicular small cleaved) was suspected. Enlarged lymph nodes (2.5 to 4.0 cm) were found in the mediastinum, azygoesophageal recess, and periaortic region as well as in the porta hepatis, peripancreatic, mesenteric, and celiac regions.

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A 52-year-old woman presented with a 12-day history of diarrhea and mild stool incontinence that began 2 to 3 hours after a routine screening colonoscopy. Six or 7 bowel movements of liquid, orange-yellow feces occurred each day for 12 days. The patient reported that associated nausea, flatulence, and severe abdominal cramping were relieved by the bowel movements. She also reported that a small amount of mucus was occasionally observed in the stool and that bright red blood streaks appeared on used toilet paper, although the stool itself was not bloody. She was able to tolerate a full diet, although food exacerbated the urgency. She was afebrile during this illness.

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Rhodococcus equi is an emerging human pathogen. It is mostfrequently associated with pulmonary infections; however,manifestations may be protean. It can be easily mistaken fora diptheroid-like contaminant or a mycobacterium. Therefore,a high suspicion of R equi infection and specialized testing areencouraged. Vancomycin-based therapy is recommended.Because human infection with this organism is uncommon,thorough reporting will help identify further characteristicsof infection and will help in devising treatment guidelines.[Infect Med. 2008;25:391-393

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Some eager medical cannabis experts ask why cannabidiol is not mandatory for athletes to address TBI. Others are more cautious.

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Use this short test to gauge how much you’ve learned about a condition that needs more primary care involvement.

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A scabies diagnosis can be made with a history of pruritus that is worse in the evening with a rash in a typical distribution and a history of itching in close contacts.

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For 3 days, a 42-year-old man has had episodic dullchest pain. The anterior precordial and retrosternalpain intensifies with inspiration and movement. He has nohistory of recent viral infection, hypertension, coronaryartery disease, cardiac surgery, diabetes mellitus, or hyperlipidemia.There is no family history of cardiovasculardisease.

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A 49-year-old man presented to theemergency department (ED) andcomplained of fever and cough thatproduced bloody sputum for 1 day.He had AIDS and recently receiveda diagnosis of large B-cell lymphoma.His most recent CD4+ cellcount was 24/µL. He had optedagainst receiving highly active antiretroviraltherapy and prophylaxisfor opportunistic infection.

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Cleft lip and palate is a common congenital facial malformation that occurs once in about every 750 births among Caucasians.

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A 65-year-old woman with a long history of hypertension treated with metoprolol and felodipine complained of dizziness, headache, nausea, and vomiting of acute onset. Her blood pressure was 220/110 mm Hg. She was drowsy and unable to stand or walk.

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A 37-year-old man found unresponsiveat home with erratic respiration andurinary incontinence was brought tothe emergency department (ED). Accordingto his family, the patient hadbeen complaining of headaches, vertigo,and mild neck pain for 2 months.During that time, a CT scan of thesinuses revealed chronic sinusitis; thepatient had completed a course ofprednisone, naproxen, and meclizinewithout symptomatic improvement.The day before he was brought to theED, he had presented to a differenthospital with the same complaints andwas given a prescription for antibioticsfor a presumed sinus infection. He haddiet-controlled hypercholesterolemiaand did not smoke.

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A 30-year-old woman was brought to the hospital with syncope, bradycardia, and hypotension. For the past 6 years, she had vomited after eating meals and after occasional episodes of binge eating.

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Salivary gland enlargement, most commonly involving one or both parotid glands, is sometimes seen in association with HIV infection. Enlargement of the parotid gland may be due to diffuse infiltrative lymphocytosis syndrome; lymphoepithelial cysts; or malignant tumors, such as squamous cell carcinoma, Kaposi sarcoma, and Hodgkin and non-Hodgkin lymphomas.1,2 Non–HIV-related causes of parotid enlargement include acute and chronic viral infection, granulomatous disease, malnutrition, alcoholism, and diabetes mellitus.3,4 Here we report the case of a 41-year-old HIV-infected man with fat maldistribution syndrome associated with type 2 diabetes and hyperlipidemia. Sialadenosis developed presumably as a result of HIV infection and hypertriglyceridemia.

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We live in a world of toxins and potential toxins, and thus we are often just a misstep away from a toxic exposure and its consequences. Even that which is meant to cure can kill. All substances are poisons; there is none which is not a poison. The right dose differentiates a poison and a remedy; exposure to the wrong dose of a medication (whether accidental or not) remains a common form of toxic exposure.

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Influenza develops in about 20% of the global population each year. In the United States, annual influenza epidemics typically occur between late December and early March. While influenza may affect persons of any age, infection rates are highest among children.

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Abstract: Although cystic fibrosis (CF) is typically diagnosed during infancy or childhood, it may escape detection until adulthood. Diagnostic accuracy can be sharpened by maintaining a high index of suspicion for CF in an adult who is pancreatic-sufficient but has unexplained recurrent respiratory infections, bronchiectasis, or nutritional deficiencies. The workup begins with the quantitative pilocarpine iontophoresis sweat test. If necessary, additional tests include mutation analysis, full-gene sequencing of CF transmembrane conductance regulator protein, and measurement of nasal transepithelial potential difference. Multidisciplinary care is essential and includes nutritional support, chest physiotherapy, exercise, appropriate antibiotics, and other pulmonary interventions. Dornase alpha, inhaled tobramycin, and azithromycin have been associated with improved outcomes and are considered to be the standard of care for patients with moderate lung involvement. (J Respir Dis. 2006;27(1):32-41)

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In its classic form, ALS affects motor neurons at 2 or more levels supplying multiple regions of the body.

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Cocaine abuse is associated with many dermatological manifestations, vasculitides, and infections. Consider this diagnosis in patients with unexplained chronic skin lesions, an ambiguous medical history, previous examinations that found no source of symptoms, labile affect, and delusional behavior.

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A 54-year-old man with chronic renal insufficiency presented with shortness of breath, nonproductive cough, and chest pain. The patient had hypertension, type 2 diabetes mellitus, and a 30-pack-year history of cigarette smoking. He denied alcohol or illicit drug use and prolonged exposure to asbestos, chemicals, or fumes.

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Autosomal dominant polycystic kidney disease (ADPKD) is common. Presenting symtpoms include hypertension, hematuria, proteinuria, and renal insufficiency.

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Two weeks after being treated for a fracture of the left humerus and several palpable breast lesions, a 63-year-old African American woman was hospitalized for generalized weakness and confusion. She had a history of type 2 diabetes mellitus, hypertension, coronary artery disease, chronic kidney disease, and low-grade B-cell lymphoma (which had been in remission for 2 years).

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A 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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Autosomal dominant polycystic kidney disease (ADPKD) is common. Presenting symtpoms include hypertension, hematuria, proteinuria, and renal insufficiency.

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Microscopic colitis is a noninfectiouscolitis that is characterizedby chronic nonbloodydiarrhea and macroscopicallynormal colonic mucosa. Extraintestinalmanifestationsare rarely seen. In this report,we describe a nonspecific interstitialpneumonitis in a patientwith lymphocytic colitis.