Infection

Each year almost 5 million Americans sustain an animal or human bite. Dog bites alone represent 0.4% to 1% of all emergency department (ED) visits and can range from trivial to life-threatening.

For years, cardiologists and primary care physicians have engaged in a spirited debate about the appropriate target for low-density lipoprotein cholesterol (LDL-C) lowering in patients with coronary artery disease.

This 11-year-old boy presented with pain and swelling of the right hand. The boy had been bitten by a German shepherd while trying to feed the animal a day earlier. He had cleaned the wound with water. The boy's tetanus immunization status was up-to-date, as was the rabies immunization status of the dog.

Urinary incontinence is common--especially among older adults--but underdiagnosed. Many persons with this disorder are reluctant to discuss it with their physicians; often, only direct questioning can uncover the problem.

57-year-old woman is hospitalized because of a 3-week history of persistent left-sided dull flank pain that worsens with movement and is associated with intermittent high fever.

Although proton pump inhibitors (PPIs) are highly effective, clinical failure in patients with gastroesophageal reflux disease (GERD) is seen regularly--not only in GI clinics but also in primary care offices. In fact, the prevalence of failure with PPIs has increased in proportion to the expanding indications for their use.

Is chronic fatigue syndrome related to infection? If so, how does this affect the approach to therapy? Because patients with chronic fatigue syndrome (CFS) frequently report an infection-like event at the onset of their condition, the possible role of viral or other infections has been extensively investigated.

Advances in the understanding of multiple sclerosis (MS) have translated into aggressive treatment regimens that enhance patients' quality of life. In this article, we discuss the therapeutic options, especially treatments that are directed toward the underlying immunologic mechanisms of the disease. Because of its direct effect on quality of life, aggressive management of symptoms is emphasized.

A 43-year-old man presents to the emergency department with worsening substernal chest pain that has developed over several hours. He describes the pain as dull and oppressive; it radiates to the left shoulder and jaw and worsens on inspiration and with recumbency. It is not associated with nausea, dizziness, or diaphoresis. He is given nitroglycerin, morphine, hydromorphone, and meperidine parenterally, but none of these relieve the pain.

Scaling patches that resist antifungals; an outbreak of red papules; a velvety,hyperpigmented rash--can you identify the disorders pictured here?

MRSA is the second most common pathogen isolated in the ICU setting, associated with 52.9% of nosocomial infections.1 Colonization of patients with S aureus (methicillin-sensitive and methicillin-resistant) has been found to be important for the development of subsequent infections, including bacteremia.2-4 The primary reservoir of S aureus in humans is the anterior nares and, to a lesser extent, the perineum and skin.5,6 As a result, topical antibiotics and antiseptics have been used to eradicate colonization in a variety of patient populations in an effort to prevent infection and to control transmission of MRSA.

Coccidioides immitis is a di-morphic fungus that causes pulmonary disease with a variety of clinical and radiographic presentations. Miliary pulmonary disease is very uncommon and is found almost exclusively in immunocompromised patients. The authors describe the case of an immunocompetent patient who had disseminated coccidioidomycosis with a miliary pulmonary disease pattern. Obtaining a careful travel history and considering regional fungal infections was integral to making a prompt diagnosis.

Abstract: The standard therapies for acute exacerbations of chronic obstructive pulmonary disease include short-acting bronchodilators, supplemental oxygen, and systemic corticosteroids. For most patients, an oxygen saturation goal of 90% or greater is appropriate. Bilevel positive airway pressure (BiPAP) is usually beneficial in patients with progressive respiratory acidosis, impending respiratory failure, or markedly increased work of breathing. However, BiPAP should not be used in patients with respiratory failure associated with severe pneumonia, acute respiratory distress syndrome, or sepsis. Systemic corticosteroids are appropriate for moderate to severe acute exacerbations; many experts recommend relatively low doses of prednisone (30 to 40 mg) for 7 to 14 days. Antibiotic therapy is controversial, but evidence supports the use of antibiotics in patients who have at least 2 of the following symptoms: increased dyspnea, increased sputum production, and sputum purulence. (J Respir Dis. 2005;26(8):335-341)

The authors describe a case of acute eosinophilic pneumonia (AEP) that occurred in a previously healthy young man. The presentation was similar to that of acute respiratory distress syndrome (ARDS), and the diagnosis was established by bronchoalveolar lavage (BAL). The authors note that it is important to recognize the subset of patients with AEP who present with an ARDS-like picture, especially since corticosteroids are very effective in this setting.

Abstract: Pleural tuberculosis and lymph node involvement are the most common extrapulmonary manifestations of tuberculosis. Most patients with pleural involvement complain of pleuritic chest pain, nonproductive cough, and dyspnea. The pleural effusion is usually unilateral and small to moderate in size. The diagnosis depends on the demonstration of acid-fast bacilli in pleural fluid or biopsy specimens, or the presence of caseous granulomas in the pleura. The gold standard for the diagnosis of lymph node tuberculosis is the identification of mycobacteria in smears on fine-needle aspiration cytopathology, histopathology, or mycobacterial culture. On ultrasonography and CT, the lymph nodes show enlargement with hypoechoic/hypodense areas that demonstrate central necrosis and peripheral rim enhancement or calcification. Treatment involves the combination of 4 antituberculosis drugs for 2 months, followed by 2-drug therapy for 4 months. (J Respir Dis. 2005;26(8):326-332)

While acute Q fever can cause pneumonia and other febrile illnesses, it is often asymptomatic. You may want to consider testing for Q fever if a patient is infected with another tick-borne pathogen, according to a report by Rolain and associates. They described 6 patients infected with organisms such as Rickettsia conorii who also were infected with Coxiella burnetii, the cause of Q fever.

Combination therapy with pegylated interferon alfa-2a or alfa-2b and ribavirin (RBV) results in a greater rate of sustained virologic response (SVR) than that seen with standard interferon alone. Patients infected with hepatitis C virus genotype 1 require higher doses of RBV and a longer duration of therapy than do patients infected with genotype 2 or 3. Closely monitor patients for neuropsychiatric effects, especially depression, and hematologic and other toxicities. Because of the teratogenicity of RBV, strict birth control must be used throughout the course of treatment and for 6 months afterwards. Patients who have not demonstrated a 100-fold reduction in viral load after 12 weeks of therapy are unlikely to achieve SVR; discontinuation of therapy may be considered.

A 69-year-old man seen because of a pruritic pretibial rash of 3 months' duration. Started as reddish brown papules that slowly enlarged and changed.

A 69-year-old woman presents with inflammation near the antecubital fossa of her right elbow that first appeared 4 days earlier. She has a cat but does not recall being scratched or bitten, and she does not recall injuring the area.

HCV is the most common cause of chronic liver disease and the leading indication for liver transplantation in the United States. It is responsible for 8000 to 10,000 deaths annually. In this article, we review the principal diagnostic guidelines for hepatitis C.

The parents of a 16-year-old girl report that during the past several months, she has exhibited behavioral changes, irritability, increased anger, depression, and anxiety. The girl had previously been healthy, and there has been no recent illness or trauma.

HANDY LIST TO KEEP

A tender nodule; an itchy truncal rash; multiple pruritic eruptions--can you identify the disorders pictured here?

ABSTRACT: Early treatment with disease-modifying anti-rheumatic drugs (DMARDs)--alone or in combination-- can prevent joint damage and minimize disability. Until recently, the DMARDs used predominantly in patients with rheumatoid arthritis had been methotrexate, sulfasalazine, and hydoxychloroquine. Older DMARDs such as gold, d-penicillamine, and azathioprine have fallen out of favor because of their long- term toxicities or modest benefit. Six newer DMARDs--leflunomide, etanercept, infliximab, adalimumab, rituximab, and anakinra--have greatly expanded the current treatment options.

Abstract: All children with asthma should have periodic office visits, usually every 3 to 6 months, in which asthma action plans are updated. Periodic assessment of lung function by peak expiratory flow or office spirometry can help determine the appropriate treatment strategy. Low daily doses of inhaled corticosteroids remain the first and most effective choice of therapy for persistent asthma. If this approach is inadequate, adding a second medication, such as a leukotriene modifier or a long-acting ß2-agonist, is suggested. Short-acting ß2-agonists remain the most important therapy for intermittent asthma. For most children, the best route is via a metered-dose inhaler with either a spacer or valved holding chamber. If these agents are inadequate, a short course of oral corticosteroids may be required. (J Respir Dis. 2005;26(8):348-358)

32-year-old man presents with a 4-day history of fever (temperature as high as 38.8 C to 39.4 C with severe rigors, chills, and profuse night sweats; generalized myalgias, including dull, aching headache; and dry cough.

A 54-year-old woman with a history of hypertension presented with a worsening headache and a left hemisensory defect. A CT scan of her head without contrast showed a right parietal hemorrhage with spreading edema; the masslike effect caused shifting of the midline to the contralateral side. The patient gradually became comatose and required intubation for airway protection. Intravenous corticosteroids were administered to decrease the effect of the lobar hemorrhage. Fever developed 3 days after admission.

A 79-year-old man has an elevated prostate-specific antigen (PSA) level(11.3 ng/mL). About 1 month earlier, when he was hospitalized for a seriousurinary tract infection (UTI), his PSA level was 13.3 ng/mL. The more recentlevel was obtained after he received antibiotic therapy for the UTI.

Abstract: The laryngeal mask airway (LMA) and intubating LMA are valuable alternatives in patients in whom intubation has failed and who need oxygenation and ventilation immediately. The dual-lumen, dual-cuffed airway tube is effective in a variety of settings and can tolerate ventilation at pressures as high as 50 cm H2O; it is contraindicated in awake patients who have intact airway reflexes, caustic ingestions, and upper airway obstruction from a foreign body or pathology. Surgical airways are lifesaving techniques when intubation is unsuccessful or impossible through the mouth or nose. It may be particularly appropriate in patients with laryngeal or facial trauma, upper airway obstruction, or oropharyngeal injury. When patients aged 12 years and older cannot be ventilated by mask or intubated with traditional methods, surgical or needle cricothyrotomy is the procedure of choice. (J Respir Dis. 2005;26(7):298-302)

Inflammation plays a major role in coronary artery disease (CAD), whereby inflammatory changes develop in the blood vessel walls.1 This observation has spurred interest in exploring the connection between CAD and markers of inflammation, including C-reactive protein (CRP), fibrinogen, serum amyloid A, and many other novel markers.