Infectious Disease

ABSTRACT: Recent evidence suggests that viral infection is the most likely underlying cause of Bell's palsy. Rapidity of onset is a clue to the diagnosis; unilateral facial weakness or paralysis develops over 24 to 48 hours. Rule out other causes of peripheral facial paralysis, such as Ramsay Hunt syndrome and Lyme disease. Although most cases of Bell's palsy resolve without medical or surgical intervention, older patients and those with abnormal electroneurographic results are less likely to have complete recovery of facial function. Early treatment with an oral corticosteroid is likely to enhance recovery; concurrent use of acyclovir may also be helpful. Surgical decompression has been effective in patients with abnormal electroneurographic results.

Several lesions had appeared 1 week earlier on the left distal thigh of a 47-year-old woman. The affected area featured erythema with irregular faded borders and central redness with very fine papules over the L3 dermatome. The indurated and tender central areas suggested inflammation or necrosis. There were no vesicles and there was no drainage.

A 60-year-old man presented to the emergency department (ED) with fever of 1 day’s duration and midabdominal pain. The cramping pain had begun 3 days earlier in a bandlike distribution around the upper abdomen. Ingestion of food exacerbated the discomfort. The patient had a history of intermittent constipation; he denied alcohol or illicit drug use, nausea, vomiting, and weight loss. He did not use any herbal or over-the-counter medications.

ABSTRACT: Serum levels of aspartate aminotransferase and alanine aminotransferase that exceed 1000 IU/L indicate acute viral hepatitis (A, B and, rarely, C), acute drug toxicity (eg, acetaminophen overdose or isoniazid hepatotoxicity), or ischemic liver injury. In chronic hepatitis (ie, hepatitis B or C or autoimmune), values range from mildly elevated to usually less than 400 IU/L. Elevated levels of alkaline phosphatase and gamma;-glutamyltransferase (GGT) are consistent with cholestatic disease: primary biliary cirrhosis, primary sclerosing cholangitis, idiosyncratic drug reactions, or mechanical biliary obstruction (eg, biliary stones or tumor). Elevation in the GGT level can also be induced by alcohol consumption or medications (eg, phenytoin). Isolated unconjugated hyperbilirubinemia suggests Gilbert syndrome or a hematologic disorder; conjugated hyperbilirubinemia reflects impaired hepatic excretion. Serum bilirubin and albumin and INR have prognostic significance in chronic liver disease; bilirubin and INR are more useful in acute liver failure because albumin has a long half-life.

A 12-month-old infant is brought to your office for evaluation of ared, swollen left index finger, which her parents first noted the prior evening.The mother denies any known trauma or recent illness. She tells you that theinfant is slightly fussy and is not taking her bottle as well as usual.

A network of purplish pink lesions recently developed on a 28-year-old woman’sarms and legs. The asymptomatic rash becomes more prominent with exposureto cold. The patient denies fever, aches, arthralgias, oral erosions, chestpain, and photosensitivity.

Sir William Osler once called pneumococcalpneumonia “the captain of themen of death.”1 Pneumonia is the sixthleading cause of death in the UnitedStates and the fourth leading causeamong Americans 80 years of age andolder.2

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.

A 64-year-old man underwent a right pneumonectomy forsquamous cell carcinoma of the right lung. He was dischargedfrom the hospital on the fifth day after surgery.

Three weeks after coronary artery bypass graft (CABG)surgery, a 52-year-old woman complained of pain at thesternal scar. The patient had a history of diabetes and hypertension.She had smoked cigarettes for many years.

This lesion on her knee had been present for 5 years, reported a 22- year-old woman. It was not related to any trauma; its size had not changed, but occasionally it became darker or lighter.

Leprosy, or Hansen disease, had recently been diagnosed in a 39-year-old man. He presented to the tropical disease unit of Harare Hospital, Zimbabwe, for follow-up.

Excessive belching, abdominal bloating, and flatulence caused an 89-year-old woman to seek medical attention. She reported that these previously mild and intermittent symptoms of 20 years’ duration had worsened during the last 2 years.

A 64-year-old man underwent a right pneumonectomy forsquamous cell carcinoma of the right lung. He was dischargedfrom the hospital on the fifth day after surgery.

Three weeks after coronary artery bypass graft (CABG)surgery, a 52-year-old woman complained of pain at thesternal scar. The patient had a history of diabetes and hypertension.She had smoked cigarettes for many years.

Traditionally, urologists have cared for patients with benign prostatic hyperplasia (BPH). However, because of demographic fluctuations, changes in the health care system, and the development of effective pharmacologic therapy for BPH, primary care physicians are increasingly involved not only in initial patient evaluation but also in continuing management. Here we provide guidelines for treatment of uncomplicated BPH--with special emphasis on medical therapies.

Even before Joseph Lister recommended that surgeons apply carbolic acid to their hands prior to procedures, physicians were aware that cleansing hands with an antiseptic agent could help control the spread of disease.

ABSTRACT: The emergence of drug-resistant pneumococci has changed the empiric treatment of community-acquired pneumonia. Newer fluoroquinolones with activity against Streptococcus pneumoniae offer an alternative in the treatment of infection with penicillin-resistant strains. These agents are not recommended as first-line therapy because of concerns about the development of resistance. Reserve the fluoroquinolones for patients who are allergic to macrolides and β-lactams, have failed to respond to a first-line agent, or have a documented infection with a highly resistant strain. The pneumococcal vaccine is recommended for all persons aged 65 years and older, adults with chronic car-diopulmonary diseases, and immunocompromised persons. Consider revaccination every 6 years in asplenic patients and immunocompromised persons. In addition, vaccination against influenza can help prevent secondary pneumonia and reduce the need for hospitalization.

For 36 hours, a 75-year-old woman had experienced weakness of the right side of the face. She was unable to close the right eye and drooled from the right side of the mouth. There was no weakness, numbness, or tingling of the extremities.

What are the appropriate laboratory tests for an infant whose mother has hepatitisC virus (HCV) infection?

I read with interest Michael Rothstein’s Practical Pointer,“No More (Foot) Fungus Among Us” (CONSULTANT, August2002, page 1185).

Cutaneous lesions can develop in anumber of pulmonary diseases, suchas tuberculosis and sarcoidosis, as wellas in other diseases that may have pulmonaryinvolvement, such as Wegenergranulomatosis, collagen vasculardiseases, varicella, and pneumococcalinfections. In many cases, knowledgeof the clinical and histologic characteristicsof the skin lesions associatedwith these diseases can greatly facilitatediagnosis.

A 32-year-old previously healthywoman presents to the emergencydepartment with skin lesions, suprapubicpain, and generalized myalgia of1 week’s duration. Trimethoprim-sulfamethoxazolefor a presumed urinarytract infection is prescribed, and thepatient is discharged. The symptomspersist; she is hospitalized 2 days later.

A 34-year-old woman complains of headaches that interfere with work. Her first headache episode, approximately 6 yearsearlier, was relatively mild. Initially, she experienced attacks only once every 3 to 4 months and managed them effectivelywith over-the-counter (OTC) agents. However, in the last 6 months the attacks have become more frequent-they occur atleast twice a month-and are so severe that she misses work.

ABSTRACT: Many patients with osteoarthritis (OA) try such complementary therapies as special diets, nutritional and herbal supplements, yoga, t'ai chi, magnets, and acupuncture-but only 40% of these patients tell their physicians. Glucosamine and chondroitin sulfate can produce at least symptomatic relief; in addition, glucosamine (1500 mg/d) may increase or stabilize cartilage in osteoarthritic knees. Alert patients to the potential toxicities of many herbal remedies, as well as the risks of harmful drug interactions and possible contaminants and impurities. Yoga postures may have a beneficial effect on knee OA; t'ai chi may reduce joint pain and swelling and increase mobility. Small studies have shown that applied pulsed electromagnetic fields can reduce pain and improve function in patients with chronic knee OA. Acupuncture has also been shown, in small studies, to alleviate the pain of OA. Autologous chondrocyte transplantation was recently approved for treatment of knee OA. The efficacy and safety of various types of gene therapy are currently being evaluated.

ABSTRACT: Systematic palpation can detect a trigger point; often, muscle spasms or a nodule will be present. Injection of the trigger point with a local anesthetic usually reduces pain promptly; the procedure can also effect long-term pain relief and increased range of motion. However, pain may recur and even worsen 1 to 3 days after an injection-either because additional injections are needed or because the trigger point was not completely injected. To maintain pain relief and improve strength and range of motion in the affected muscle following injection, recommend stretching exercises, physical or massage therapy, or rest. Trigger point injections can be associated with adverse effects (eg, temporary numbness, injection site irritation, and dizziness); complications include vasovagal syncope, skin infection, and compartment syndrome.

Patients with ankylosing spondylitis areat increased risk for fractures (particularlyextension fractures of the cervicaland thoracolumbar spine) and spinalcord injury. Fractures in these patientsare extremely unstable; in fact, they areamong the most complication-prone ofall cervical spine injuries likely to beseen in the primary care setting.

For the past 3 months, a 72-year-old man has had progressivelyworsening dyspnea on exertion and constantvague discomfort in the left chest that appears to have apleuritic component. He denies paroxysmal nocturnaldyspnea and has no history of chest trauma. However, hehas a chronic cough that sometimes produces purulentsputum-although it is not associated with hemoptysis.His feet swell occasionally, and he has mild anorexia andhas lost 20 lb in 6 months.

A 76-year-old woman is admitted to the hospital for increasing fatigue and weaknessthat began about 3 weeks earlier. Her symptoms have worsened duringthe past week to the point of profound weakness and both dyspnea and nearsyncopewith minimal exertion.

Satellite lesions are usually associated with Candidainfections but not with Bowen disease.