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Cryptococcal cavitary pneumonia in an immunocompetent patientCryptococcus neoformansmost commonly infects personswith an underlying T-cellimmunodeficiency. It hasbeen nicknamed the "sugarcoatedkiller" because it cancause a devastating disseminatedillness in immunosuppressedpatients. C neoformansrarely causes primaryinfection in an immunocompetentpatient. We present acase of pulmonary cryptococcosisthat occurred in an otherwisehealthy man.
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Older Man With Fever and Tender RashFor 1 week, a 77-year-old man had a fever and a tender, nonpruritic rash on both palms (Figure 1) and on the anterior aspect of both knees (Figure 2). Two weeks earlier, he had hives, which ameliorated after a 10-day course of cetirizine and a tapering course of prednisone. He also had headaches almost daily for the previous 6 to 8 weeks.
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An HIV-infected patient with bilateral pneumoniaA 43-year-old homeless woman presented with a 2-week history of fever, chills, sweats, generalized pain, and cough that was productive of purulent green-yellow sputum mixed with blood. She reported a 15-lb weight loss over the past 6 weeks.
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Case 5: Multiple Keloids in Pierced EarA 23-year-old woman presented with medial and lateralpruritic keloids on her right earlobe, which had beenpierced several years earlier. These lesions began to developduring the patient’s pregnancy 2 years earlier.Keloids also were noted on the presternal region. Thepatient reported that these had begun as pimples thatspontaneously enlarged.
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Erythema Nodosum Erythema on Forearms and Legs of a 42-Year-Old ManA mildly painful, nonpruritic rash on the forearms and legs prompted a 42-year-old man to go to the emergency department (ED). The patient noted the rash when he awoke that morning. He had had joint pain and fever for the past 7 days and generalized malaise with chills that began about 3 days earlier. He had no significant medical history.
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Answers to a reader’s question on: Throat cultures for pharyngitisI have seen conflicting recommendations concerning the use of throat cultures and empirical antibiotic therapy in patients with pharyngitis. When do you consider throat cultures to be indicated? Are your recommendations different for children than for adults?
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Foreign-Body Ingestion in a Man With Parkinson Disease DementiaA 74-year-old man who had Parkinson disease dementia presented with constipation and bloating associated with abdominal pain.
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Addressing Abuse and Misuse of Opioid AnalgesicsOpioid analgesics provide effective treatment for noncancer pain, but many physicians have concerns about adverse effects, tolerance, and addiction. Misuse of these drugs is prominent in patients with chronic pain. Recognition and early prevention of misuse helps physicians identify the causes and proceed with patient care. Most persons with chronic pain have a significant medical comorbidity (eg, asthma) that affects treatment decisions.
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Four Types of Kaposi SarcomaA 46-year-old man with AIDS (CD4+ cell count, 150/μL) presented with a painful nodular lesion on the plantar surface of his right foot. The lesion had appeared 1 month earlier as a painless, 1-cm, raised, reddish purple nodule and had progressively enlarged to 5 cm. Six months earlier, the patient had cryosurgery to remove a similar, larger lesion on the posterior aspect of his right midcalf.
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Head and Shoulder Lesions: Common Diseases, Uncommon LocationsThree cases of lesions often seen in primary care, 2 seen in uncommon locations. Test your visual diagnostic skills.
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Scabies: Timely Diagnosis Key to Containment, ReliefA 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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Acute lymphoblastic leukemia presenting with an acute fibrinous and organizing pneumoniaThe authors report a case of adult-onset acute lymphoblastic leukemia (ALL) presenting with a right upper lobe infiltrate associated with acute fibrinous and organizing pneumonia (AFOP), which resolved spontaneously during the course of chemotherapy.
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Allergic Rhinitis: Update on Your Therapeutic ChoicesMany pharmacological options exist for allergic rhinitis. Intranasal corticosteroids are the most effective medication class for patients with moderate to severe symptoms; those with milder intermittent symptoms can be treated with a second-generation oral or intranasal antihistamine.
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Drug Therapy in the Elderly:Numerous factors put elderly patients at risk for adverse drug events. On average, they take at least 6 medications a day, which increases the likelihood of drug-drug interactions. In addition, many drugs that are safe and effective in younger patients are inappropriate for older persons because of age-related changes and comorbid conditions that affect absorption, distribution, metabolism, and elimination. First-pass metabolism decreases with age, which may increase systemic absorption of some oral nitrates, ß-blockers, estrogens, and calcium channel blockers. The age-related rise in body fat increases the volume of distribution of lipid-soluble compounds, such as diazepam, and prolongs clearance. About two thirds of elderly persons have impaired kidney function; in these patients, the dosage of renally excreted drugs-such as digoxin-needs to be reduced. Other strategies for avoiding adverse drug events are detailed here.
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Two Feet - One Hand SyndromeA 41-year-old man presented with a 3-month history of itchy, scaly feet and right hand. The left hand was unaffected.
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Congenital RanulaA 1-day-old neonate was brought for evaluation of a mass on the floor of her mouth. The swelling was fluctuant and had a bluish tint. No bruit was detected. There was mild tongue elevation but no airway obstruction. Other than this swelling, physical examination findings were normal. The infant was born at term and was breast-feeding.
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Post-Test on Gout in Primary CareUse this short test to gauge how much you’ve learned about a condition that needs more primary care involvement.
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All About Gout for Primary Care: Treating Chronic DiseasePreventing further acute attacks and decreasing the tophi burden becomes a secondary goal.
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Large B-Cell LymphomaProgressively worsening nasal congestion and headaches with diplopia and left proptosis for 2 months prompted an ophthalmology consultation for a 67-year-old woman. She had been evaluated multiple times for allergic rhinitis and recurrent sinusitis.
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Editorial Comment: Foreign-born Latinos With HIV/AIDS–Improving Clinical CareAlthough the observations of del Rio and colleagues1 stemming from their study of foreign-born, HIV-infected Latinos are limited to a certain geographic area, their findings should stimulate further research to better understand and provide better health care to ethnic and minority groups living with HIV/AIDS in the United States.
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Disease Modifying Therapies: Do They Modify Short- and Long-Term in Multiple Sclerosis?Here: evidence that disease-modifying therapies can positively affect the long-term evolution of multiple sclerosis.
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Chest Film Clinic: What caused this man's dyspnea, chest pain, and atrial fibrillation?A 52-year-old man presented to his primary care physician with shortness of breath for 5 days, right-sided lower thoracic back pain, and dry cough. The patient was a 15-pack-year cigarette smoker who had emigrated from China to the United States in 1989. He had no significant history of occupational exposure or tuberculosis. He had no significant weight loss, and his past medical history was otherwise unremarkable.
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Time to Retire Beta-Blockers in Uncomplicated Hypertension?A comprehensive review of the evidence for the work-horse drugs indicates it's not quite time, yet.
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Arthropod Bites--Real and Imagined Fire Ant Stings Scabies FormicationRed imported fire ants (Solenopsis invicta) were introduced into the United States in the 1930s by ships from South America that docked in Mobile, Ala. Fire ants are now active throughout the southeast Sunbelt states. Colonies are also found in California; one of the largest is in Orange County.
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Pancreatic CarcinomaA 74-year-old man had vague abdominal pain, jaundice, pruritus, gray stools, and dark urine. A painless, palpable mass in his right upper quadrant was found at examination.
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10 Conclusions about Omicron Infection from an ID Specialist Who Just Had ItInfectious disease specialist Rodger MacArthur, MD, took a long-awaited vacation--and got COVID. He shares his conclusions about the BA.5 variant in particular.
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Academic Detailing: Focus Is on Appropriate CareThe practice of academic detailing is gaining interest and momentum in some health care circles. The primary aim of academic detailing is to prevent the overuse and misuse of certain medications. This is done by educating prescribers on the therapies that are clinically appropriate as well as the costs of therapeutically similar choices. It is less an issue of switching to generics than it is of favoring step therapy or moving toward cost-effective therapeutically equivalent options. A well-designed program should maintain prescriber autonomy and quality of care while helping manage drug costs for both health plans and patients.
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What Is Causing Headache and Neck Stiffness in This Patient?A 41-year-old African American man presented with the chief complaint of a constant, dull headache for 3 days. The headache had a gradual onset and was associated with nausea and mild neck stiffness that was not relieved by acetaminophen. The man denied experiencing visual disturbances, fever, night sweats, weight loss, cough, shortness of breath, emesis, or weakness. He had no recent history of trauma or sick contacts.
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Diagnosis is often delayed by a nonspecific presentation Update on strategies for managing pulmonary arterial hypertensionabstract: Pulmonary arterial hypertension (PAH) is 1 of 5 types of pulmonary hypertension (PH). Symptoms may include dyspnea on exertion, fatigue, near-syncope, and palpitations. Physical findings include lower extremity edema, jugular venous distention, and a loud P2. Findings on chest radiography, transthoracic echocardiography, and electrocardiography can suggest the presence of PAH; however, right heart catheterization is the gold standard for confirming the diagnosis and for differentiating PAH from other forms of PH. It is essential to exclude chronic thromboembolic PH, since this can be surgically corrected. The treatment of PAH depends on the severity. In addition to the standard treatments, such as diuretics and anticoagulation, more advanced treatment options include prostaglandin therapy (epoprostenol, treprostinil, and iloprost), endothelin receptor antagonists (bosentan), and phosphodiesterase inhibitors (sildenafil).
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How Doctors Can Win the Vaccine Debate With PatientsParental fears and misinformation about vaccines can be overcome, says this expert. Here are some suggestions.
