Infectious Disease

A34-year-old woman presents to the emergency department(ED) with rapidly progressive dyspnea.The patient has a history of metastatic vaginal clearcell adenocarcinoma secondary to diethylstilbestrol exposurein utero. Following her diagnosis in 1990, she wastreated with surgery, chemotherapy, and radiation. Shehad done well for years until a recurrence of the cancer tothe left lung was found last year. She completed a courseof chemotherapy with doxorubicin hydrochloride andcisplatin 1 month ago.

A 54-year-old woman presents with severe, throbbingpain in her right shoulder that began 3 daysearlier. She has no history of trauma or of problems withthis shoulder. She denies shortness of breath, fever,chills, and rash.

A 36-year-old man with a 15-year history of episodic migraine presents to the emergency department (ED) at 5 AM witha right-sided throbbing headache of 4 hours' duration. The headache awakened him, which is typical of his more severemigraine attacks. Unfortunately, the patient forgot to refill his prescription for pain medication and did not "catch" thisheadache in time. He took an over-the-counter combination of aspirin and caffeine, which seemed to help for about 60minutes, but the headache has returned full force. He has vomited twice-another characteristic typical of his migraineattacks

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.

I enjoyed the Photo Essay by Drs Alexander K. C. Leung and C. Pion Kao on infectiousdiseases in children (CONSULTANT, March 2001, page 459).

The patient might havebeen exhibiting a phenomenon sometimes seen in methamphetamine users that isreferred to as "crank bug bites." Patients claim to see and/or feel bugs on theirbody and attempt to remove them or pick at them until they create open woundsand scabs.

A 34-year-old woman awoke with apainful, crusted ulcer on her upperarm. She has been repairing dry wallin her home but recalls no trauma.The necrotic ulcer features an erythematousborder.

In 1978, a ricin-filled pellet-which was injected with aspring-loaded device disguised in an umbrella-wasused to assassinate Bulgarian defector Georgi Markov.A similar device was employed unsuccessfully against asecond defector in the same year.1

Seizures are among the most common neurologic conditionsencountered in the primary care setting. However, they havereceived scant attention in standard textbooks and in themedical literature generally-perhaps because the topic cutsacross so many specialties. Here, an international team ofexperts fills this void with a comprehensive discussion of thecauses and management of seizures associated with a widevariety of medical problems-including organ failure,organ transplantation, electrolyte imbalance, endocrine disorders,cardiorespiratory disorders, cancer, fever and systemicinfection, medication, alcohol, illicit drug use, andenvironmental toxins. Chapters cover the various types ofseizures and their pathophysiology, how to distinguishseizure from syncope, seizures in the ICU, and the use ofanticonvulsants.

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.

Numerous factors, includingother drugs, diseases,and diet, affectthe response to warfarin.Some of these factorsdecrease the response and maylead to therapeutic failure; othersenhance the response and may resultin life-threatening bleeding.

Abstract: In the assessment of central airway obstruction and disease, no imaging technique is an adequate substitute for bronchoscopy. The indications for rigid bronchoscopy include multiple malignant and benign disorders, with most interventions performed for treatment of complications of lung cancer. The rigid bronchoscope is a useful tool for managing most types of airway stenoses, and it facilitates other endobronchial therapies, including stent placement, argon plasma coagulation, balloon dilatation, electrocautery probes, and laser therapy. Certain patients with benign lesions or postintubation or post-tracheostomy stenosis may benefit from rigid bronchoscopic techniques instead of surgery. Although use of the rigid bronchoscope requires general anesthesia, it provides a stable airway and often results in fast removal of foreign bodies. (J Respir Dis. 2006;27(3):100-113)

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.

Abstract: Inhalation of Aspergillus is responsible for a variety of lung infections and diseases; Aspergillus fumigatus is the most common causative agent. Allergic bronchopulmonary aspergillosis (ABPA), caused by sensitivity to A fumigatus, is diagnosed primarily in persons with asthma or cystic fibrosis. Differentiating ABPA from other Aspergillus-related lung infections and diseases is often challenging. A patient's symptoms, underlying risk factors, and any prior pulmonary disease contribute to the diagnosis. Findings include pulmonary infiltrates, total serum IgE levels greater than 1000 IU/mL, IgE and IgA anti-A fumigatus antibodies, peripheral blood and pulmonary eosinophilia, and central bronchiectasis. Untreated ABPA often results in chronic bronchiectasis, pulmonary fibrosis, and dependence on corticosteroids; an accurate diagnosis of ABPA is critical to avoiding irreparable disease. (J Respir Dis. 2006;27(3):123-134)

This is a difficult question, because most "sinus headaches" are migraines.1-3 In fact, there is no such thing as a sinus headache. The International Headache Society (IHS) defines a headache attributable to rhinosinusitis according to the criteria listed in Table 1.4 This requires a diagnosis of acute rhinosinusitis and a headache that occurs at the same time.

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 39-year-old woman who had a fever and episodes of nonbloody vomiting for 5 days presented to the emergency department after the sudden onset of severe, left-sided flank pain (10/10 severity) that was sharp, constant, and radiated to the front. She had no associated urinary symptoms, vaginal discharge, or bowel disturbances. Her last menses, 10 days earlier, was regular. Aside from a urinary tract infection 2 years earlier, her medical history was insignificant.

For some time, diarrhea caused by Clostridium difficile has been a serious problem in hospitals. Recently, more virulent strains of this pathogen have started to show up in hospitals.

Breast Infection in a Woman With Diabetes

New recommendations for the treatment of coughs caused by colds and for the vaccination of adults against pertussis are among the changes in the revised guidelines on the mangement of coughs.

A 56-year-old man presents with diffuse erythema. He has not changed his routine or eaten anything unusual. The rash initially appeared the previous night as asymptomatic erythema on the face and body. On awakening in the morning, the patient noticed that the erythema had spread over most of his body and had become pruritic. Over-the-counter diphenhydramine did not relieve the symptoms.

During a basketball game, a 23-year-old soldier had been hit in the right eye with the ball. The eye was slightly red with copious lacrimation; vision was normal. Using a Wood lamp and fluorescein dye, MAJ Kenneth S. Brooks, APA-C, of Camp As Sayliyah, Doha, Qatar, examined the patient's eye for corneal abrasions and saw these results. Note the almost complete halo of dye, with gaps at the 6 o'clock and 11 o'clock positions on the iris. This curious phenomenon was baffling until the soldier was asked about recent eye surgeries; he answered that he had undergone photorefractive keratectomy (PRK) several months earlier.

Monday morning your nurse hands you charts for 4 new patients. Each patient is a woman with widespread body pain, stiffness, and fatigue. All have already been evaluated by another physician and were advised that they should reduce stress and practice distraction techniques. They are in your office today seeking a second opinion.

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.

A 64-year-old man has experienced melena 4 or 5 times in the previous24 hours. He has had no emesis but complains of moderate epigastric pain.He has had similar-although milder-pain in recent weeks.

A 43-year-old fireman comes to your office after a routine blood test revealedthat his serum alanine transferase (ALT) level was elevated to approximatelytwice the normal value. The level was confirmed by repeated testing.

The last naturally occurringcase of smallpox was reportedin Somalia in October 1977.Despite the eradication ofsmallpox, the causative agent,variola virus, remains in existence.1,2

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)