HIV AIDS

Man With Worsening Cough and Dyspnea

The mumps outbreak in midwestern states appears to be slowing, but as college students return home and engage in summer travel, it's possible that mumps will spread. Are you prepared?

Abstract: The introduction of helical CT dramatically improved the quality of CT images of the airways and other thoracic structures. Multi-detector row CT scanners have made further improvements with respect to spatial resolution, speed, and anatomic coverage. Axial CT images provide valuable information about the airway lumen and wall and adjacent mediastinal and lung structures, but they are limited in their ability to assess airway stenoses and complex airway abnormalities. These limitations can be overcome by multiplanar and 3-dimensional reconstruction images. State-of-the-art scanners allow all of the central airways to be imaged in a few seconds. This speed is particularly valuable for patients who cannot tolerate longer breath-holds and patients who may have tracheomalacia or vocal cord paralysis. (J Respir Dis. 2006;27(5):192-196)

Abstract: 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)

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.

Young Man With Painless Penile Ulcer

Infection with hepatitis C virus (HCV) was recently diagnosedin a 45-year-old man when a positive enzyme-linked immunosorbentassay was followed by a polymerase chain reaction assaythat showed a viral load of 835,000 copies/mL. The patient probablyacquired the infection when he was using intravenous heroin, a practice he quit 10 yearsago. The patient is immune to both hepatitis A and hepatitis B viruses, and there is no coinfectionwith HIV. Liver biopsy shows moderate cellular inflammation (grade 3) and bridging fibrosis(stage 3) but no evidence of cirrhosis. Iron staining shows no abnormal iron deposition in theliver. The HCV genotype is 1A.

Pyoderma gangrenosum is frequentlyassociated with systemic diseases,such as ulcerative colitis and Crohn’sdisease (Table). The occurrence of theskin ulcers does not necessarily correlatewith the activity of the underlyingdisorder.

A 52-year-old woman was admitted tothe hospital with progressive shortnessof breath of 2 days’ duration. Bronchialasthma had been diagnosed 6 monthsearlier; inhaled corticosteroids, bronchodilators,and leukotriene antagonistswere prescribed. Despite aggressivetreatment, the patient’s dyspneaand wheezing worsened.

A 28-year-old man presented with chest pain, hemoptysis, and wheezing. He had a history of intermittent shortness of breath that occurred at least 3 times a year in the past 3 years; fever; and loss of appetite associated with headache, vomiting, and weakness. His medical history also included asthma, chronic gastritis, and more than 5 episodes of pneumonia since 1996. A test for hepatitis C virus (HCV) had yielded positive results.

Abstract: Multidrug-resistant tuberculosis is defined as tuberculosis caused by strains that have documented in vitro resistance to isoniazid and rifampin. Treatment involves a regimen consisting of at least 4 or 5 drugs to which the infecting strain has documented susceptibility. These agents may include ethambutol, pyrazinamide, streptomycin, a fluoroquinolone, ethionamide, prothionamide, cycloserine, and para-aminosalicylic acid. In addition, an injectable agent, such as kanamycin, amikacin, or capreomycin, should be used until negative sputum cultures have been documented for at least 6 months. If the patient has severe parenchymal damage, high-grade resistance, or clinically advanced disease, also consider clofazimine, amoxicillin/clavulanate, or clarithromycin, although there is little evidence supporting their efficacy in this setting. Routine monitoring includes monthly sputum smear and culture testing, monthly assessment of renal function and electrolyte levels, and liver function tests every 3 to 6 months. (J Respir Dis. 2006;27(4):172-182)

A disorder similar to scleromyxedema, nephrogenic fibrosing dermatopathy, has been reported in patients receiving renal dialysis. Lichen myxedematosus, an atypical form of papular mucinosis, is not associated with sclerosis and paraproteinemia; however, it may represent an early presentation of scleromyxedema.

The most common chronic blood-borne infection in the United States is caused by hepatitis C virus (HCV), an RNA virus transmitted through blood-to-blood contact. In this article, we identify risk factors for HCV infection and discuss which patients should be tested and treated.

A 44-year-old homeless man complains of a “sore” onhis penis. The ulcer developed from a macular lesionon the glans penis about 5 days earlier. The painless ulcerhas not responded to a topical antibiotic ointment he receivedat another clinic.

A 47-year-old woman who wasseropositive for HIV-1 presented tothe emergency department with severemaculopapular, erythematouseruptions. Her antiviral regimen hadrecently been changed from zidovudine,300 mg bid; lamivudine, 150 mgbid; and saquinavir, 600 mg tid, tolamivudine, 150 mg bid; stavudine, 40mg bid; and nevirapine, 200 mg/d.

Recent headlines in the nation’s newspapers haveriveted public attention on medication errors-aproblem that has long plagued the medical community.1 Prescribing mistakes are common, andthey exact a costly toll: the US Institute of Medicineestimates that 98,000 Americans die each year becauseof a failure in the drug treatment process.2 Estimatessuggest up to 5% of all inpatients will experiencesome type of medication error.3,4

You routinely order laboratory screeningpanels, including serum liver enzymemeasurements, for nearly everypatient who has a complete physicalexamination or who is seen for any ofa host of other complaints. If you findabnormal liver enzyme levels, your familiaritywith the common causes andthe settings in which they occur mayenable you to avoid costly diagnosticstudies or biopsy.

A 37-year-old man presented withnew-onset fever and abdominal painof several days’ duration. No respiratorysymptoms were reported.The patient had a history of multiplestab wounds to the abdomenand back, resulting in chronic backpain and a neurogenic bladder.During a previous hospital admission,he was treated for Enterobacterpyelonephritis with intravenousgentamicin for 12 days.

Nongenital cutaneous warts--that is, common, plantar, filiform, and flat warts--are manifestations of the human papillomavirus (HPV). These warts are among the most common dermatologic complaints seen in primary care practices and are among the most common lesions treated by dermatologists.

A 45-year-old man comes to see you for a routine physical.He has no complaints and no significant medical history.However, while questioning him you discover that he usedintravenous heroin until about 10 years ago-and sometimesshared needles. He also drank 6 or more beers a day for about 20 years, a practicehe stopped at the same time that he quit using illicit drugs. He has multiple tattoos,which were done at commercial parlors. He is married but has no children. His wife hasno history of hepatitis. Physical examination is unremarkable.

A nonhealing ulcer recently developedin a painful facial rash that hadworsened over several months. The44-year-old patient is a heavy drinkerwith a history of elevated liver functionlevels. She has had numerousunprotected sexual contacts over theyears.

Although widely regarded as a raredisorder, hereditary hemochromatosisis the most common genetic disease inCaucasians. In certain populations ofnorthern European descent, 1 of every200 persons is homozygous for thecausative mutation.1

Abstract: In the assessment of community-acquired pneumonia, an effort should be made to identify the causal pathogen, since this may permit more focused treatment. However, diagnostic testing should not delay appropriate empiric therapy. The selection of empiric therapy can be guided by a patient stratification system that is based on the severity of illness and underlying risk factors for specific pathogens. For example, outpatients who do not have underlying cardiopulmonary disease or other risk factors can be given azithromycin, clarithromycin, or doxycycline. Higher-risk outpatients should be given a ß-lactam antibiotic plus azithromycin, clarithromycin, or doxycycline, or monotherapy with a fluoroquinolone. If the patient fails to respond to therapy, it may be necessary to do bronchoscopy; CT of the chest; or serologic testing for Legionella species, Mycoplasma pneumoniae, viruses, or other pathogens. (J Respir Dis. 2006;27(2):54-67)

My patient has been hospitalized for pneumonia several times by different physicians. He has never received the pneumococcal vaccine. Can this vaccine begiven during the patient’s hospital stay?

There's a curse frequently attributed to the Chinese, "May you live in interesting times." It seems that we find ourselves living in interesting times right now. The Department of Homeland Security recently heightened our threat levelfrom code yellow to code orange. Duct tape, plastic wrap, and flashlights are in short supply at local hardware stores. There’s been more talk about smallpox and the smallpox vaccine, and parents and colleagues are eager for more information.

Most pain in or around the oral cavity is attributable to tooth or mucosal pathology. However, tooth or mucosal pain may also be caused by a variety of other conditions, including brain pathology; vascular inflammatory and cardiac disease; jaw infection or neoplasm; neuropathic abnormality not associated with central pathology; pathology in the neck and thoracic region; myofascial and temporomandibular joint pathology; and disease of the ear, eye, or nose, or of the paranasal sinuses, lymph nodes, and salivary glands. Accurate diagnosis is facilitated when the features of pain presentation in this region are understood.

Abstract: Shortness of breath is a common complaint associated with a number of conditions. Although the results of the history and physical examination, chest radiography, and spirometry frequently identify the diagnosis, dyspnea that remains unexplained after the initial evaluation can be problematic. A stepwise approach that focuses further testing on the most likely diagnoses is most effective in younger patients. Early bronchoprovocation challenge testing is warranted in younger patients because of the high prevalence of asthma in this population. Older patients require more complete evaluation because of their increased risk of multiple cardiopulmonary abnormalities. For patients who have multiple contributing factors or no clear diagnosis, cardiopulmonary exercise testing can help prioritize treatment and focus further evaluation. (J Respir Dis. 2006;27(1):10-24)

ABSTRACT: A scheme-based approach, supported by a simple mnemonic, can narrow the broad differential diagnosis of thrombocytopenia. This approach uses findings from the complete blood cell count and the peripheral smear to organize the possible causes of thrombocytopenia into those that affect only platelet count, those that produce both a low platelet count and hemolytic anemia, and those that produce disturbances in all 3 blood cell lines. Causes of isolated thrombocytopenia include viral infections, immune-mediated platelet destruction, congenital diseases, gestational thrombocytopenia, conditions in which splenomegaly is a prominent feature, antiphospholipid antibody syndrome, infectious diseases of bacterial origin, and drugs. Causes of thrombocytopenia in conjunction with hemolytic anemia include hemolytic uremic syndrome, thrombotic thrombocytopenia purpura, and disseminated intravascular coagulation. Disorders that produce disturbances in all 3 blood cell lines include aplastic anemia, myeloproliferative syndromes, myelodysplasia (both primary and secondary), myelofibrosis, myelophthisis, and several other diseases in which splenomegaly is prominent.

ABSTRACT: A number of nondental conditions may cause significant oral pain. Pain associated with temporal arteritis is localized to the maxillary posterior teeth, the maxilla, or the frontal-temple region. This pain is often associated with exquisite tenderness of the scalp and face. The pain of trigeminal neuralgia is typically felt in the anterior maxillary or mandibular anterior teeth; it radiates along the mandible toward or into the ear on the ipsilateral side of the trigger. Pain may remit for months or years but is often severe when it recurs. Burning mouth syndrome preferentially affects postmenopausal women older than 50 years; one half to two thirds of patients experience spontaneous remission within 6 to 7 years, with or without treatment. The pain of postherpetic neuralgia is unilateral and restricted to the affected dermatome; it may be aggravated by mechanical contact or chewing.

56-year-old man with a history of diabetes mellitus and hypertension presents with chest pain, emesis, pallor, and diaphoresis.