Infectious Disease

ABSTRACT: The rate at which acute dyspnea develops can point to its cause. A sudden onset strongly suggests pneumothorax (especially in a young, otherwise healthy patient) or pulmonary embolism (particularly in an immobilized patient). More gradual development of breathlessness indicates pulmonary infection, asthma, pulmonary edema, or neurologic or muscular disease. A chest film best identifies the cause of acute dyspnea; it can reveal pneumothorax, infiltrates, and edema. Pulmonary embolism is suggested by a sudden exacerbation of dyspnea, increased ventilation, and a drop in PaCO2. A normal chest radiograph reinforces the diagnosis of pulmonary embolism, which can frequently be confirmed by a spiral CT scan of the chest. Pneumonia can be difficult to distinguish from pulmonary edema. In this setting, bronchoalveolar lavage and identification of the infectious organism may be necessary to differentiate between the 2 disorders.

A 51-year-old patient asked me whether she should receive the influenza vaccine. She was last vaccinated in 1976; symptoms that resemble Guillain-Barré syndrome developed shortly afterwards. She has not received the vaccine since then; however, because she teaches schoolchildren, she wondered whether she should be vaccinated.

For several months, a 59-year-oldwoman has had numerous asymptomaticlesions on her arms andlegs. During this period, she has notbeen exposed to the sun and hastaken no new medications.

A 72-year-old woman first noticed progressive enlargement of the maxillary area of her face 18 years earlier. She denied facial trauma and significant dental caries. Her medical history consisted of breast cancer managed by a mastectomy and type 2 diabetes mellitus of 3 years’ duration.

ABSTRACT: A host of evidence supports the treatment of high levels of low-density lipoprotein (LDL) cholesterol with HMG-CoA reductase inhibitors (statins), which are effective in both primary and secondary prevention of coronary heart disease (CHD). Studies have shown that statins prevent first cardiac events in otherwise healthy persons with elevated LDL cholesterol and low high-density lipoprotein cholesterol levels. Statins are also associated with a reduction in cardiac death, stroke, hospitalization, and the need for revascularization in patients with established CHD and hyperlipidemia. Secondary prevention trials of statin therapy that included persons aged 65 to 75 years found significant risk reduction in this age group. Among the concerns associated with statin treatment are lack of proper titration, failure to achieve LDL target goals, and underuse in patients with established CHD.

ABSTRACT: Asymmetry-whether of strength, reflexes, or sensory function-is an important localizing finding in the neurologic evaluation. Asymmetric deficits of strength may indicate an acute CNS lesion. Symmetric hyperreflexia or hyporeflexia alone is not diagnostic; compare reflexes between sides of the body and between upper and lower extremities. The extensor plantar response (Babinski reflex) suggests an upper motor neuron lesion. During the sensory examination, look for asymmetry and determine whether both light touch and pinprick sensation are intact. Simultaneous stimulation with 2 sharp objects on opposite sides of the body-done to detect extinction of response on 1 side-can uncover subtle sensory deficits.

ABSTRACT: First steps in the treatment of irritable bowel syndrome (IBS) are dietary modification, smoking cessation, and other lifestyle changes. Treatment of mild symptoms includes increased soluble dietary fiber and osmotic laxatives for constipation, antispasmodics for cramping, and over-the-counter antidiarrheals. For moderate disease, serotonergic agents work primarily in the intestine to relieve the global symptoms of IBS. Alosetron decreases gut motility and visceral sensitivity in women with chronic, severe diarrhea-predominant IBS who have not responded to conventional therapies. Tegaserod relieves pain, bloating, and constipation in women with constipation-predominant IBS. Psychotherapy, hypnotherapy, biofeedback, and other nonpharmacologic modalities may also be helpful for patients with IBS. Antidepressants are reserved for refractory symptoms; they can be combined with other modalities if needed.

ABSTRACT: The diagnosis of urinary tract infection (UTI) can be difficult in elderly patients, who may present with vague complaints or atypical symptoms. Office-based urine testing is less sensitive and specific in these patients because they are less likely to have pyuria and more likely to have contaminated specimens than younger adults. Antibiotics used to treat uncomplicated UTIs in the elderly include trimethoprim-sulfamethoxazole (TMP-SMX), fluoroquinolones, fosfomycin, nitrofurantoin, cephalosporins, carbenicillin, and trimethoprim. When you select an agent, consider the side-effect profile, cost, bacterial resistance, likelihood of compliance, and the patient's renal function. The optimal duration of treatment of uncomplicated UTIs in elderly women is still a matter of debate. Options for prophylaxis in patients who have recurrent uncomplicated UTIs include estrogen replacement therapy (vaginal or oral) and nitrofurantoin.

A 67-year-old woman with insulin-dependent diabetesmellitus and uncontrolled hyperglycemia complained offatigue and malaise. For 2 years, a draining ulcer hadbeen present on the bottom of her left foot.

High-grade fever, chills, fatigue, malaise, and anorexia developed in a 35-year-old man following subclavian catheterization because of chronic renal failure of unknown cause. The patient, who had long-standing diabetes mellitus, was admitted to the ICU with the diagnosis of possible sepsis. The next day, he was found to have a grade 2/6 systolic murmur compatible with tricuspid regurgitation. This was confirmed when a 4-chamber echocardiogram (A) revealed a large single piece of vegetation (2 arrows) lying on the tricuspid valve, flapping in and out of the right ventricle. In a 2-dimensional echocardiogram of the right atrium and right ventricle (B), 3 arrows point to the vegetation. (RV, right ventricle; LV, left ventricle; RA, right atrium; LA, left atrium; TV, tricuspid valve.)

A 30-year-old man has had painful genital lesions for the pastseveral days. He recently returned from a business trip during which hehad several unprotected sexual encounters.

A 48-year-old man with jaundice, nausea, vomiting, and abdominal pain was hospitalized. The patient- a recovering alcoholic- was afebrile and reported abstinence from alcohol for 6 months.

Several hours after he had installed ceramic tile, a 33- year-old man experienced muscle spasms and felt pressure in his right shoulder. He denied previous injury to the area.

A male infant was born to a 29-year-old woman (gravida 3, para 2), following an uncomplicated pregnancy and normal vaginal delivery. At birth, a brownish 1-cm nodule was noted on the right side of the upper abdomen. The infant was otherwise healthy.

ABSTRACT: The cardinal feature of irritable bowel syndrome (IBS) is abdominal pain or discomfort associated with altered bowel habits. Because no serologic marker or structural abnormality exists, the diagnosis is based on clinical findings. A systematic symptom-based approach, including the Rome II criteria, ensures diagnostic accuracy. Determine whether a specific event-such as gastroenteritis, antibiotic use, or a food-borne illness-precipitated the IBS symptoms. Be alert for warning signs of cancer, infection, or inflammatory bowel disease, such as fever or unexplained weight loss. Only minimal laboratory testing is required; however, further evaluation may be warranted if a patient does not respond to treatment or loses weight, if the dominant symptom changes, or if other "red flags" are identified.

An 83-year-old woman is brought by her daughter for evaluation becauseof increasing confusion during the past few days. The patienthas early Alzheimer dementia, hypertension, and type 2 diabetes. She takes donepezil, 10 mg/d;lisinopril, 5 mg/d; and glipizide, 5 mg bid. She is unable to bathe and dress herself as well as previously,has been crying for no apparent reason, and has lost her appetite.

A 67-year-old woman presented with a painful genital ulcer. She denied new sex partners and previous genital lesions.

Ezetimibe/simvastatin (Vytorin)recently became available for thetreatment of high LDL cholesterollevels, as adjunctive therapy to dietarymodification, in patients withprimary hypercholesterolemia ormixed hyperlipidemia. This drug,from Merck/Schering-Plough Pharmaceuticals,inhibits the productionof cholesterol in the liver and blocksthe absorption of cholesterol in theGI tract, including cholesterol obtainedfrom food.

For 8 months, a 44-year-old man hashad a 2-mm superficial ulcer on histongue. The lesion is surrounded bya thin white rim and an area of whitediscoloration. The patient believesthat the ulcer resulted from thescratching of the rough edge of atooth against his tongue.

ABSTRACT: The early signs of diabetic neuropathy can be detected during a routine clinical examination. Inspect patients' feet for deformities and sensory loss, which indicate risk of ulceration. Prolonged poor glycemic control, alcohol abuse, and obesity increase the risk of amputation. Autonomic dysfunction, which can lead to sexual dysfunction and gastropathy, can be detected by measurement of heart rate and blood pressure. A resting heart rate of about 100 beats per minute and a decrease of about 30 mm Hg in systolic blood pressure within 2 minutes of standing are abnormal findings. Electromyography and nerve conduction studies confirm the diagnosis. Improved metabolic control is the main goal of treatment. Analgesics, neuromodulators, and tricyclic antidepressants are effective for managing pain. In patients with autonomic neuropathy, treat the associated symptoms.

When palatal petechiae are present along with exudative tonsillitis and cervical adenitis, and test and culture are positive, a Strep diagnosis is more secure.

An 81-year-old woman presented with abdominal pain of 6 months’ duration, anorexia, and a 4.5-kg (10-lb) weight loss. Her history was otherwise unremarkable. She denied fever, chills, diarrhea, and vomiting. The pain was diffuse; no rebound or guarding was noted. The peripheral lymph nodes were not palpable.

A 20-year-old woman presents with a 3-week history of a pruritic, progressivelyenlarging erythematous lesion on one arm. She has a cat and recentlystarted horseback riding lessons. She is otherwise healthy and takes nomedication.

Despite the manydouble-blind,placebo-controlledtrials thathave demonstratedthe efficacy of statins inreducing the risk of cardiovascularevents, a largenumber of patients who aretreated with these drugsstill experience suchevents. This may be becausepatients who requireintensive lipid lowering arenot receiving adequatedosages of statins.

A 65-year-old woman sought evaluation of a unilateral, asymptomatic rash that involved the oral mucosa and lips. The rash consisted of ulcerations and vesicles. The suspected diagnosis of herpes zoster was confirmed 4 days later when the patient experienced lancinating pain throughout the affected area and into her scalp and neck.

For a few days, this 73-year-old woman had had an itchy, painful rash on the right side of her face. Despite its proximity to her eye, she had no ocular involvement and no blurring of vision.

Two weeks earlier, this 66-year-old man had been hospitalized because of leftsided chest pain. However, cardiac evaluation revealed no abnormalities.

For 3 days, a 44-year-old man had several crops of tiny vesicles with raised erythematous bases on the right side of his neck and 2 elongated maculopapular lesions at the base of the neck. All of the lesions were within the C3 dermatome.

A 37-year-old man presents for evaluationof 3 reddish, tender, 2-cm, elevatedlesions on his right ankle that havefailed to respond to oral amoxicillin/clavulanate prescribed by anotherphysician. The lesions have beenpresent for 8 weeks. Each lesion has acentral opening and watery yellow drainage (Figure 1). The patient recentlyreturned from a trip to CentralAmerica, where he had sustained multiplemosquito bites.

35-year-old Hispanic man presented with nonproductive cough; dyspnea; fever; and a painful, ulcerated, 1.5-cm, red-brown plaque on the left flank. He had had the lesion for 3 months and the symptoms for 1 week. The patient had grown up in Arizona, and he traveled there 4 months before the lesion arose.