Infectious Disease

Chronic diarrhea presents difficulties for clinicians as well as for patients. Because the differential diagnosis is enormous, management can be challenging. In this article, we present a strategy for quickly narrowing the differential based on a simple analysis of stool characteristics. We then describe an appropriate workup for each of the basic types of diarrhea.

Low back pain is a widespread and costly complaint that affects virtually all Americans at some point in their lives. After the common cold, it is the second most frequent cause of work absence in the United States.

A 2 1/2-year-old child is hospitalized with a 1-month history of worsening persistent cough. She was initially treated with a 5-day course of oral amoxicillin, and her symptoms abated somewhat. However, for the past week, she has experienced high fever and chills associated with right-sided pleuritic chest pain.

An asymptomatic acneiform eruption; persistent, mildly pruritic papules; a pustular rash that resists antibiotics--can you identify the disorders pictured here?

A 51-year-old man with a history of AIDS (CD4 count of 59 cells/µL), anemia, neutropenia, and AIDS-related dementia presented with persistent fever, abdominal pain, and diarrhea of 2 months' duration. He did not adhere to his regimen of HAART and prophylactic therapy with atovaquone and azithromycin.

A 36-year-old homosexual man presented with a 2-week history of odynophagia to liquids and solids; he had no dysphagia or heartburn. The patient, who had been seropositive for HIV for 3 years, had refused all antiretroviral drugs and prophylactic agents against opportunistic infections.

An otherwise healthy 18-month-old boy presented with palpable purpura over the legs, arms, and buttocks; his face, neck, and trunk were spared. The patient was otherwise asymptomatic, alert, and playful. His mother reported that the child had a “stuffy nose and cough” 1 month earlier.

Telltale skin lesions of syphilis, gonorrhea, human papillomavirus infection, and Haemophilus ducreyi infection.

Telltale skin lesions of syphilis, gonorrhea, human papillomavirus infection, and Haemophilus ducreyi infection.

Telltale skin lesions of syphilis, gonorrhea, human papillomavirus infection, and Haemophilus ducreyi infection.

Telltale skin lesions of syphilis, gonorrhea, human papillomavirus infection, and Haemophilus ducreyi infection.

Telltale skin lesions of syphilis, gonorrhea, human papillomavirus infection, and Haemophilus ducreyi infection.

Telltale skin lesions of syphilis, gonorrhea, human papillomavirus infection, and Haemophilus ducreyi infection.

The authors describe the development of pneumonitis in a patient who had initially presented with edema of the lower extremities. Biopsy results supported the conclusion that the pneumonitis was caused by silicone injections the patient had received 5 years earlier.

The diagnosis of cystic fibrosis (CF) is typically made in childhood. However, there is increasing evidence that a mild and atypical form of this disease can present in adulthood. The author describes a patient who received the diagnosis of CF when she was 74 years old.

Researchers in the Netherlands investigating the relative risks of common infections in patients with type 1 or type 2 diabetes mellitus (DM1 or DM2, respectively) determined that both groups are at increased risk for lower respiratory tract infection, urinary tract infection, and skin and mucous membrane infection.

The initial evaluation of a patient with community-acquired pneumonia (CAP) should include a careful search for comorbidities, according to a study by Falguera and associates.

A 45-year-old man presented to the emergency department (ED) with fever and left-sided pleuritic chest pain. He had been in good health until 4 days earlier, when diffuse myalgias, weakness, and frontal headache developed. Two days later, these symptoms were accompanied by onset of fever (temperature, 39.4°C [103°F]) and left-sided pleuritic chest pain. He denied chills, rigors, shortness of breath, hemoptysis, and cough.

Abstract: In addition to causing pulmonary disease, infection with Mycobacterium tuberculosis can result in a wide range of extrapulmonary manifestations, including abdominal involvement. Patients with acute tuberculous peritonitis typically present with fever, weight loss, night sweats, and abdominal pain and swelling. Intestinal tuberculosis is characterized by weight loss, anorexia, and abdominal pain (usually in the right lower quadrant). A palpable abdominal mass may be present. Patients with primary hepatic tuberculosis may have a hard, nodular liver or recurrent jaundice. The workup may involve tuberculin skin testing, imaging studies, fine-needle aspiration, colonoscopy, and peritoneal biopsy. Percutaneous liver biopsy and laparoscopy are the main methods of diagnosing primary hepatic tuberculosis. Treatment includes antituberculosis drug therapy and, in some cases, surgery. (J Respir Dis. 2005;26(11):485-488)

Abstract: Important components of the workup for interstitial lung disease (ILD) include the history and physical examination, chest radiography, high-resolution CT (HRCT), pulmonary function testing and, in some cases, bronchoalveolar lavage (BAL) and/or biopsy. Pulmonary function tests usually show a restrictive ventilatory impairment. However, some patients have a mixed restrictive/obstructive pattern; in fact, almost 50% of patients with sarcoidosis have airflow obstruction at presentation. HRCT has an increasingly important role in the assessment of ILD. In some cases, the results may obviate the need for biopsy. BAL can help confirm the diagnosis of ILD; it also can identify conditions such as infection or hemorrhage or suggest an alternative diagnosis. Surgical lung biopsy has the advantage of yielding samples of lung tissue that are usually diagnostic, especially if HRCT is used to target lung regions. (J Respir Dis. 2005;26(11):466-478)

An HIV-positive 38-year-old man with a history of injection drug use presented to the emergency department with abdominal and back pain that worsened with motion. He denied fever and vomiting. During the past 2 months, the patient had been treated for a urinary tract infection (UTI) 4 times and evaluated for a renal calculus, which had been ruled out. He was currently receiving ciprofloxacin, ibuprofen, and HAART.

During a laparotomy for perforated sigmoid colon diverticulitis, a 75-year-old woman was found to have extensive peritonitis. She underwent sigmoid colon resection and colostomy. Postoperatively, she recovered slowly. The peritoneal fluid grew Escherichia coli, and she was given broad-spectrum intravenous antibiotic therapy.

New guidelines recommend a different regimen for patients with native valve endocarditis caused by MRSA.

Telltale skin lesions of syphilis, gonorrhea, human papillomavirus infection, and Haemophilus ducreyi infection.

As many as half of patients who are evaluated for abdominal pain do not receive a precise diagnosis. And for about half of those who are given a diagnosis, the diagnosis is wrong. In this article, I will use actual cases (not "textbook" examples) to illustrate an approach to abdominal pain that begins with a careful differential diagnosis. I also offer some general guidelines for evaluating patients.

An 81-year-old man is seen for follow-up of leukocytosis detected during a recent hospitalization for community-acquired pneumonia. The leukocytosis had not resolved by the time he was discharged.

A 35-year-old man with type 1 diabetes has had an asymptomatic rash on the lower extremities for the past several months. He denies trauma and recent illness. He has tried multiple "home remedies," but the rash has persisted. He smokes and drinks alcoholic beverages occasionally.

Progressive cough and dyspnea of 2 months' duration prompted a 23-year-old man to seek medical attention for the fourth time. On previous emergency department visits, he had received antibiotics, which failed to relieve his symptoms.

A 36-year-old woman with a history of HIV disease presented for evaluation of dyspnea of 1 week's duration. She had been taking trimethoprim-sulfa- methoxazole for Pneumocystis carinii pneumonia prophylaxis. Because of a presumed skin reaction to this medication, dapsone was recently substituted.

A previously healthy 40-year-old man presents with a 2-hour history of excruciating colicky pain of acute onset that emanates from the right flank and radiates to the groin. He rates the severity of the pain at 9 on a scale of 1 to 10. Before arriving at the emergency department, the patient experienced nausea and 2 episodes of nonbilious, nonbloody vomiting.