HIV AIDS

Shortly after the introduction of combination antiretroviral therapy, it was noted that a significant fraction of patients, from 8% to 17%, had poor CD4+ T-cell recovery despite suppression of HIV RNA to undetectable levels for at least 6 to 12 months.1

The 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.

abstract: Pulmonary disease caused by nontuberculous mycobacteria (NTM) can be challenging to diagnose and manage. Patients typically present with nonspecific symptoms, such as cough and fever, and they often have underlying lung disease, which further complicates both diagnosis and treatment. To avoid treating pseudoinfection, the diagnosis should be based on a combination of the history and results of physical examination, radiographic imaging, and smears and cultures of at least 3 sputum samples. Occasionally, it is necessary to perform bronchoalveolar lavage or obtain tissue via transbronchial or open lung biopsy for histopathology and to assess for tissue invasion. Treatment involves a long course of often costly multiple antimycobacterial drugs. However, treatment with the second-generation macrolides, clarithromycin and azithromycin, has significantly improved cure rates for specific NTM infections. (J Respir Dis. 2007;28(1):7-18)

A 44-year-old man presented to the emergency department with complaints of neck swelling, bothersome cough, and difficulty in breathing. His breathing difficulty began 3 days earlier and progressively worsened.

US researchers recently reported initial phase 1 results from 2 vaccine candidates that successfully produced immune responses in healthy uninfected adults (Gibian JJ. United Press International. November 16, 2006). Eventually, the approach may be used to protect against HIV infection. Barney Graham of the NIH Vaccine Research Center and colleagues performed the tests (Graham BS, Koup RA, Roderer M, et al. J Infect Dis. 2006;194:1650-1660; Catanzaro AT, Koup RA, Roderer M, et al. J Infect Dis. 2006;194:1638-1649).

An agitated and confused 51-year-old man is brought to the emergency departmentby his family and friends. Recently, he had been drinking heavilyand smoking cocaine. He stopped using alcohol and cocaine 2 days earlier,after he began to vomit.

For the past week, a 16-year-old boy has had a progressively worsening dry, irritating cough; dyspnea on exertion; and intermittent fever and chills. During the past 24 hours, he has had no appetite and has vomited greenish material 3 or 4 times.

A thin 26-year-old man has hadintermittent diarrhea with abdominalpain, nausea, vomiting, and occasionalepisodes of hematochezia for8 months. He also complains of weaknessand fatigue and has lost 4.5 kg(10 lb) in the past year. The patientis homosexual and admits to havinghad unprotected sexual intercourse.He denies any significant travelhistory.

For the past 3 days, a 45-year-old man has had discomfort andloss of hearing in one ear. There is no fever or history of trauma. The manwas recently treated for an ear infection at a local clinic. Physical examinationreveals erythema of the postauricular area and purulent exudate from the earcanal.

abstract: The keystone of influenza prevention is still vaccination. The 2 available types of influenza vaccine--the inactivated vaccine, which is administered intramuscularly, and the attenuated vaccine, which is delivered via nasal spray--have efficacy rates of 70% to 80%. Unfortunately, only about 65% of persons who should receive the influenza vaccine are, in fact, vaccinated. The neuraminidase inhibitors oseltamivir and zanamivir are 70% to 90% effective in preventing influenza. These antivirals also are effective in reducing the severity of influenza symptoms and the duration of illness when administered within 48 hours of the onset of clinical disease. Some patients have difficulty in self-administering zanamivir because the inhalation process is fairly complicated. Because of the resistance pattern observed in 2005, amantadine and rimantadine are not currently recommended for prophylaxis or therapy. (J Respir Dis. 2007;28(1):21-29)

An asymptomatic 42-year-old woman who has HIV/AIDS presents for aroutine check-up. She denies abdominal pain, nausea, vomiting, diarrhea,paresthesias, and muscle weakness.

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.

Drug interactions and adverse drug reactions result in thehospitalization (or extended hospitalization) of more than100,000 Americans each year. Here an international teamof experts from such fields as pharmacology, toxicology, medicine,and nutrition discuss drug-drug interactions as wellas interactions that occur between drugs and certain foods,alcohol, nicotine, or performance-enhancing agents. Amongthe drug classes covered are benzodiazepines, anticonvulsants,opioids and opiates, monoamine oxidase inhibitors,tricyclic antidepressants, selective serotonin reuptake inhibitors,antipsychotic agents, cardiovascular drugs, antimicrobials,HIV/AIDS medications, and NSAIDs. The authorsreview the pharmacology, pharmacodynamics, pharmacokinetics,chemistry, and metabolism of each class. Also includedis an overview of the theories of liability used in recentdrug interaction litigation and a discussion of the role ofpsychotropic medications in criminal defenses. A detailedindex is provided.

A 48-year-old African Americanwoman with HIV infection who hadbeen hospitalized several days earlierfor presumed Pneumocystis cariniipneumonia (PCP) is readmittedbecause of worsening dyspnea and atemperature of 38.8oC (102oF).She also complains of painful swellingand erythema on her right arm.Her symptoms have worseneddespite treatment with trimethoprimsulfamethoxazole.

A24-year-old man who worked ina warehouse is brought tothe emergency department following2 days of high fever with rigors, generalizedweakness, and a purplishrash on both lower legs that had progressedrapidly during the past24 hours. He had become ill about5 days previously, with a worseningsore throat and achiness that did notrespond to over-the-counter lozengesand ibuprofen.

Good nutritional care can improve the short-and longtermcourses of many illnesses that are common in olderadults. The experts who have contributed to this handbookdiscuss the disorders that can seriously affect andbe affected by nutrition, and they present specific recommendationsfor secondary prevention and management.

A46-year-old white man is hospitalized with increasing dyspnea of 3weeks’ duration. He has a history of stable chronic obstructive pulmonarydisease secondary to heavy smoking (2 packs of cigarettes a day for 27years, discontinued 6 years previously) and uses inhaled bronchodilators.

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.

For nearly 3 years, my patient has had frequent recurrences (now, almost monthly)of erythematous, slightly pruritic lesions on the lower back, inguinal area, orbuttocks-but never on the genitalia.

An 84-year-old man complains of worsening angina pectoris that started3 months earlier. The patient has had aortic stenosis for about 10 years. Healso has diabetes, which is controlled with oral agents.

Two winters ago, the members of CONSULTANT’sEditorial Board met for 3 days with the journal’seditorial staff to brainstorm ways in whichCONSULTANT might best address the educationalneeds of primary care clinicians. One idea in particulargenerated unanimous enthusiasm: an entire issuedevoted to the health care problemsand needs of African Americans.

Q:What is the most common radiographicpresentation of pulmonary tuberculosis (TB)among persons with HIV infection?

For several weeks, a 29-year-old woman has had worsening left lower backpain that is aggravated by sitting and walking. The pain is most severe aboveher left buttock; it radiates into the buttock and very slightly into the leg. Overthe-counter analgesics have been ineffective. Assuming a supine position providessome relief, but the pain still occasionally awakens her at night. She deniesweakness, other neurologic symptoms, and any symptoms of bowel orbladder dysfunction.

A 62-year-old man has had nightsweats and worsening fever andcough for the last 4 days; 2 days agohe had an episode of hemoptysis. Hedenies trauma or travel to a foreigncountry but has a 30-pack-year smokinghistory. The medical history isotherwise noncontributory.

The emphasis in this clinically focused text is on syndromesand patient care rather than on pathogens. Among the topicscovered are antimicrobial pharmacokinetics and pharmacodynamics;head and neck infections; upper respiratory tractinfections; bronchitis and pneumonia; endocarditis; pericarditisand myocarditis; peritonitis, liver abscess, and biliary tractinfections; viral hepatitis; CNS infections; skin and soft tissueinfections; animal and human bites; osteomyelitis and infectiousarthritis; foot infections in patients with diabetes; scarletfever and toxic shock syndromes; fever of unknown origin;bacterial, viral, and protozoal diarrhea; obstetric-gynecologicinfections; urinary tract infections; sexually transmitted diseases;infectious complications of HIV infection; tuberculosis;tropical diseases; zoonoses; bioterrorism; and fungal infections.Color and black-and-white photographs, photomicrographs,CT scans, radiographs, drawings, tables, and flowchartshighlight seminal points in the text.

A 52-year-old woman is hospitalized because she has had jaundice, anorexia,and occasional nausea and vomiting for about 2 weeks. She has also had moderatepain in the epigastrium and right upper quadrant, but it has not been severeenough to require analgesics. She denies hematemesis and hematochezia.

An 18-year-old college studentpresents with a 4-day history ofincreasing throat pain, low-gradefever, and extreme exhaustion. Previously,she had been healthy and participatedactively in sports, includingmarathon running. Her appetiteand intake have been poor. No historyof cough, chest pain, shortness ofbreath, nausea, vomiting, diarrhea,or abdominal distention. She has noallergies, takes no medications, anddoes not smoke or drink alcohol.She is sexually active with a single partner.

Your patients who want to stop smoking need all the helpthey can get. Where can they turn for support?

Over the past 8 years, fragile vesicles,painful ruptured bullae, and erosionshave developed on the sun-exposed skinof a 57-year-old man. Some of the vesicleserupt at sites of minor trauma; othersarise spontaneously. A corticosteroidcream prescribed by another practitionerfor presumed atopic dermatitisfailed to clear the lesions.

A 53-year-old man complains ofdyspnea and a cough that has progressivelyworsened over the pastweek. He denies recent trauma.