Infectious Disease

This 10-year-old boy presented forevaluation of a rash that developedduring a spring vacation on Florida’sAtlantic coast. After he had beenswimming in the ocean, a pruritic,erythematous, papular rash developedon his trunk, axillae, and groin. Approximately24 hours after the onsetof the rash, he experienced malaise,chills, and a sore throat. His past medicalhistory was unremarkable. Hehad been fully immunized and hadhad varicella infection.

A 30-year-old man presentedwith severe left flankpain radiating to his abdomenand gross hematuriaof 5 to 10 days’ duration.He also reported a 4- to 6-monthhistory of nausea with intermittentvomiting, anorexia, and progressiveweight loss. He took no medicationsand had no allergies.

Backyard cookouts . . . picnics at the beach . . . these warm-weather pleasures can heighten your patients' risk of exposure to food-borne pathogens. An egg salad sandwich, left in the hot sun too long, can become a breeding ground for Salmonella, and undercooked burgers can harbor Escherichia coli O157:H7.

Routine inspection of the oral cavity is not a part of every patient encounter. There exist, nevertheless, clear indications for physical examination of the mucosal surfaces between the lips and the anterior tonsillar pillars; these include symptoms such as pain, erythema, and swelling that are referable to this area.

For 24 hours, a 62-year-old woman had had severe weakness, abdominal pain, and watery diarrhea that had become bloody in the past 12 hours.She had no significant medical history.

For 3 days, a 47-year-old woman had a painful red swelling on her finger.The patient--a cellist--had tried to lance the lesion at home, but itprogressively worsened and was now “throbbing.” She denied fever andnail biting.

This crusted eroded area on the lower lip of a 67-year-old man has been presentfor several months.Which of the following statements are true?A. This condition preferentially affects the lower lip.B. It is more common in women.C. It is more common in immunocompromised patients.D. It is more likely to metastasize than similar lesions on nonmucosal surfaces.E. 5-Fluorouracil is contraindicated in this location.

A mildly painful, nonpruritic rash on the forearms and legs prompted a 42-year-old man to go to the emergency department. The patient noted the rashwhen he awoke that morning. He had had joint pain and fever for the past7 days and generalized malaise with chills that began about 3 days earlier.He had no significant medical history.

A 78-year-old man presents with anasymptomatic acute eruption on bothlegs that extends from the ankles tojust above the knees. Individual maculesrange from 4 to 10 mm in diameterand from light brown to red. Almostall of the lesions have multiple,tiny, discrete red puncta.

A 79-year-old man presents to theemergency department with a painfullesion on his right forearm. Three daysearlier, he had scratched his arm whileremoving crabs from a trap. Initially,the scratch had bled slightly, and hehad self-treated with an over-the-counterantibiotic ointment and an adhesivebandage.

A 17-year-old adolescent experienced an episode of generalized paralysis ofacute onset after physical exertion and consumption of a high-carbohydratemeal. Despite a good appetite, the patient had lost between 2 and 3 lb duringthe past month. He complained of heat intolerance and palpitations and reportedlosing his temper easily.

ABSTRACT: Acute and recurrent cystitis in young women, once identified, can be treated empirically without microbiologic confirmation. In these women, a urine dipstick test that is positive for nitrates or leukocyte esterase is considered diagnostic. The usual treatment is a 3-day course of an antibiotic. Prophylaxis is recommended for women who have more than 3 episodes of cystitis per year. Options include postcoital prophylaxis with a single dose of antibiotic or long-term low-dose antimicrobial therapy. In young women with acute pyelonephritis, fluoroquinolones are the treatment of choice. Empiric therapy is initiated as soon as possible in patients at risk for complicated urinary tract infections (UTIs). Alternative techniques, such as intermittent catheterization, may reduce the incidence of UTIs in patients with indwelling catheters.

ABSTRACT: Acute scrotal pain, a high-riding testicle, and the absence of the cremasteric reflex on the affected side signal testicular torsion-a surgical emergency. The pain associated with torsion of the appendix testis is usually of gradual onset and is exacerbated by movement. The tenderness is often localized over the infarcted appendix, and the infarction may be visible through the scrotal skin (the "blue dot sign"). Pain associated with epididymitis is usually gradual in onset; the patient may complain of dysuria, increased frequency, and discharge, particularly if the causative pathogen is Chlamydia trachomatis or Neisseria gonorrhoeae. Hydroceles are smooth and nontender, and the scrotum transilluminates. If the scrotum does not transilluminate and compression of the fluid-filled mass toward the external ring completely reduces the mass, then a hernia is the more likely diagnosis. A patient with a varicocele typically complains of a sensation of heaviness and of "carrying a bag of worms."

Most sport-diving problems are mild and self-limited; however, serious or life-threatening situations can arise. In a previous article (CONSULTANT, June 2004, page 961), we addressed fitness and safety issues. In this article, we review the principal medical problems associated with sport diving.

A painful rash suddenly developed on the chest wall of an otherwise healthy 8-year-old girl. Examination of the rash revealed grouped vesicles with an erythematous base in a linear distribution along the T5 dermatome. The child had not been vaccinated with varicella vaccine and had had chickenpox 3 years earlier.

For more than 20 years, a 55-year-old man had a faintly erythematous, papulosquamousrash with arciform borders on his groin and waistline. The rashhad been treated with a variety of medications. Topical and oral antifungalsand antibiotics and topical corticosteroids had been used but to no avail. Nolaboratory tests had been performed.

For 1 year, a 30-year-old man had an intermittent rash that was confined to thearea of his jockey shorts; no other part of the body was affected. The patientreported that the pruritic eruption arose and disappeared spontaneously andwas more prominent during the heat of summer.

A 50-year-old man had a long-standing rash on both soles. The patient’s toenails were yellow and dystrophic. These physical findings strongly suggested moccasin-variety tinea pedis and onychomycosis.

For years, a 39-year-old man had an eruption on his hand, which seemed to becontrolled with topical corticosteroids. The patient was a rancher.

For 2 months, an asymptomatic rash had been present on the upper arms of a 16-year-old boy of normal weight. The rash, as seen on the patient’s right arm, consisted of abundant fine papules. He had no other lesions.

A 33-year-old active-duty soldier who had been in Iraq for 6 months presented with a depressed lesion on his left lateral elbow of several months’ duration. It was neither healing nor enlarging. (The yellowish tint to the skin in the photograph was from a topical iodine solution.)

The continuous use of a corticosteroid cream briefly relieved the pruritus of anannular, papulosquamous eruption on the left anterior thigh of a 50-year-oldwoman. The lesion was present for 6 months and grew larger with applicationof the topical corticosteroid.

ABSTRACT: The chief causes of ingrown toenails are trauma, incorrect toenail trimming, and tight footwear. Conservative measures, which include decreased activity, warm soaks, antibiotic therapy, elevating the edge of the impinged nail, debridement, or removal of the corner of the toenail containing the spike, may relieve moderate inflammation and infection. For patients who have severe impingement with acute infection, partial or complete nail avulsion is the treatment of choice. If avulsion is followed by recurrent infection, partial or complete ablation of the nail matrix may become necessary after the infectious process has resolved. Teach patients to trim their toenails straight across and not to curve them toward the lateral margins.

ABSTRACT: Urinary incontinence is a widespread disorder that remains underdiagnosed, underreported, and undertreated. Nevertheless, it is highly treatable. Components of the initial office evaluation include a focused history taking, physical examination, a postvoid residual urine volume measurement, and urinalysis. Behavioral interventions are first-line therapy. These include bladder training, pelvic floor muscle training, biofeedback therapy, and caregiver-dependent interventions. The antispasmodics oxybutynin and tolterodine are the most commonly used agents for urge incontinence. Stress incontinence can be treated with pseudoephedrine or topical vaginal estrogen. Imipramine may be helpful in cases of nocturnal or mixed incontinence. Overflow incontinence caused by an anatomic obstruction may be treated with an α-blocker.

ABSTRACT: Consider prophylactic therapy for patients with frequent (5 or more per month), severe migraine attacks; commonly used agents include β-blockers, calcium channel blockers, antidepressants, and antiepileptic agents. Daily or alternate-day use of aspirin or an NSAID may also be helpful, and limited data suggest angiotensin II receptor blockers may provide effective migraine prophylaxis. For treatment of acute migraine attacks, triptans have emerged as the most effective agents. Controlled clinical trials have demonstrated that all the triptans have similar efficacy. The optimal strategy for an acute migraine attack is to initially administer a therapeutic agent at a dose sufficient to relieve symptoms. Intervention during the early, mild stages of an attack is more likely to alleviate pain than intervention after moderate to severe symptoms occur.

An obese 61-year-old man who hadchronic obstructive pulmonary diseaseand sleep apnea heard a “pop”in his stomach while lifting a heavyweight; severe abdominal pain followed.He was short of breath thenext morning, and his physician empiricallyprescribed cephalexin.

Azole antifungals are widelyused to treat numerousinfections.1 Manywell-documented, clinicallysignificant drug interactionsare associated with these agents1,2

ABSTRACT: Signs and symptoms of a full-blown ocular allergic reaction include deep red vessels in the conjunctiva, itching, and swelling of the conjunctiva and eyelids. Ocular allergy can resemble nonallergic conditions, including drug-induced conjunctivitis, blepharitis, and viral or bacterial infection. A history of itching confirms a diagnosis of allergy. To distinguish allergic conjunctivitis from more serious allergic ocular diseases, inspect the lids and cornea for papillae on the upper tarsal surface, which occur in giant papillary conjunctivitis and vernal or atopic keratoconjunctivitis. Local treatment of allergic conjunctivitis consists of over-the-counter and prescription antihistamines, with or without vasoconstrictors or mast cell stabilizers. Combination mast cell stabilizer/ antihistamine topical ophthalmic agents-the newest class of medication-are considered the most effective treatment of allergic conjunctivitis. Oral antihistamines are not indicated unless a patient has an allergic condition, such as rhinitis, dermatitis, or asthma.

ABSTRACT: The presence of blood in the urine is a significant finding that calls for prompt evaluation. Gross hematuria usually indicates a serious problem; its correlation with malignancy-typically a transitional cell carcinoma-is fairly high. Microscopically detectable blood is less likely to signal a major underlying condition; a finding of 0 to 3 red cells per high-power field is probably innocent. The workup for gross and microscopic hematuria focuses on disturbances of urinary tract function and includes a history and physical examination, urinalysis, radiologic imaging, urine cytology, and cystoscopy. The presence of hematuria, proteinuria, and renal insufficiency warrants referral to a nephrologist. A search for the cause of microscopic hematuria is much less likely than a workup for gross hematuria to uncover a life-threatening condition. If the hematuria persists, repeat the urinalysis and cytology every 6 months until the problem resolves or 3 years have passed.

A 40-year-old womanwith HIV infection has had an occasionallypruritic facial rash for severalmonths. The rash is not associatedwith any systemic symptoms.