Infectious Disease

From the Editor's Desk: In This Month's Issue

abstract: The mainstay of therapy for acute severe asthma includes ß2-agonists, anticholinergics, and corticosteroids. Other agents, such as leukotriene modifiers and magnesium sulfate, can be used in patients who have responded poorly to conventional therapy. Noninvasive positive pressure ventilation (NPPV) should be tried before intubation in alert, cooperative patients who have not improved with aggressive medical therapy. However, NPPV should not be attempted in patients who are rapidly deteriorating or in those who are somnolent or confused. Endotracheal intubation is recommended for airway protection or for patients who present with altered mental status or circulatory shock. Patients should be admitted to the ICU if they have difficulty in talking because of breathlessness, altered mental status, a forced expiratory volume in 1 second or peak expiratory flow rate of less than 25% of predicted, or a PaCO2 greater than 40 mm Hg after aggressive treatment in the emergency department. (J Respir Dis. 2007;28(3):113-117)

The influenza vaccine not only reduces the morbidity and mortality of influenza, it also reduces the risk of death in adults hospitalized with community-acquired pneumonia (CAP). Spaude and colleagues found that this protective effect covered in-hospital all-cause mortality, even after adjustment for pneumococcal vaccination status and the presence of comorbidities.

The authors present a case in which the initial manifestation of systemic lupus erythematosus (SLE) was diffuse alveolar hemorrhage (DAH), which is a rare presentation that carries a high risk of death. The patient failed to respond to standard therapy but was successfully treated with plasmapheresis.

a 1-Antitrypsin (AAT) deficiency is a genetic disorder that predisposes patients to early-onset emphysema and chronic liver disease. It is more common than is generally appreciated, occurring in about 1 in 2000 to 5000 persons.1,2 It has been estimated that 1% to 2.5% of persons with chronic obstructive pulmonary disease (COPD) in the United States have AAT deficiency.1,2

A 42-year-old woman returned from a 2-month stay in India with a rash and alow-grade fever. She also complained of fatigue, nausea, anorexia, and weightloss. Despite treatment with amoxicillin for a presumed streptococcal rash,her symptoms worsened. The pruritic rash spread over the patient’s body;only the face was spared.

A painful, indurated, erythematousswelling arose on the left wrist of a62-year-old man who had recentlyvisited Guatemala. Initially, the lesionwas about 2 cm in diameter andhad 2 central openings that drainedserosanguinous fluid on pressure.The patient denied trauma to thearea or insect bites.

This infection is caused by reactivationof varicella-zoster virus (VZV),which may remain latent in thedorsal root and cranial nerve gangliafor decades. Reactivation oftenoccurs for no apparent reason, althoughstress and immunosuppressionmay increase the risk.

A 15-day-old boy is brought for evaluation after his mother noted a "lump" in his left breast that morning. There is no history of illness or trauma. The infant's appetite and activities are normal, and he has no constitutional symptoms. He was delivered vaginally at full term and did not require a prolonged nursery stay or antibiotic therapy. Results of standard maternal screens were negative.

A 34-year-old woman who was coinfected with HIV and hepatitis C virus complained of acute abdominal pain and generalized pruritus of 3 weeks' duration. She was noncompliant with her antiretroviral medications.

A 3-year-old girl is brought to the office because of a1-week history of hematuria and dysuria. Her motherhad noticed bright red blood in the child’s urine anddiaper. The child did not have dysuria initially but latercomplained of a burning sensation.

A linear, severely pruritic rash erupted on the lateral and plantar aspectsof the left foot (A) of a 72-year-old woman who had recently been campingon a Caribbean beach. Antihistamines and locally applied antifungal agentsoffered no relief.

This infection is caused by reactivationof varicella-zoster virus (VZV),which may remain latent in thedorsal root and cranial nerve gangliafor decades. Reactivation oftenoccurs for no apparent reason, althoughstress and immunosuppressionmay increase the risk.

ABSTRACT: A 4-pronged approach that includes patient education, skin and nail care, appropriate footwear, and proactive surgeries can effectively prevent diabetic foot problems. Teach patients with diabetes to examine their feet daily to detect new onset of redness, swelling, breaks in the integrity of the skin, blisters, calluses, and macerated areas. Have them follow a daily foot care regimen that includes warm water soaks and lubrication, and have them keep toenails properly trimmed. Recommend that patients select shoes that fit properly and have sufficient padding and toe box space; have them use inserts, lifts, orthoses, or braces--as recommended-to correct abnormal gait patterns. Finally, if deformities develop, simple proactive surgical procedures can correct these problems before they result in the development of wounds.

ABSTRACT: In patients with jaundice and normal liver function, the cause of hyperbilirubinemia is an isolated disorder of bilirubin metabolism. In patients with hyperbilirubinemia who have abnormal liver enzyme levels, hepatocellular disease must be differentiated from cholestatic liver injury. In general, if the cause of jaundice is global hepatocellular dysfunction, the serum alanine aminotransferase and aspartate aminotransferase levels will be predominantly elevated. If the cause is cholestasis, the serum alkaline phosphatase and gγ-glutamyl peptidase levels will be elevated. In most patients, imaging studies will be needed. The initial workup should include abdominal ultrasonography, which can identify dilated intrahepatic and extrahepatic biliary ducts as well as findings that may suggest cirrhosis or signs of portal hypertension, including splenomegaly and ascites.

Images in HIV/AIDS: HIV-Associated Lymphogranuloma Venereum Proctitis

LOS ANGELES -- An investigational anti-HIV drug called maraviroc, the first CCR5 inhibitor, significantly outperformed placebo in patients who were failing anti-retroviral therapy, according to interim results from two major phase III trials.

LOS ANGELES -- Like the traditional HIV-associated opportunistic infections, the toll of conditions such as heart and liver disease is affected by the immune status of a patient, researchers reported here.

SAN DIEGO -- Allergic fungal sinusitis deserves a place of its own at the table of nasty chronic rhinosinusitis infections, researchers asserted here.

MILWAUKEE -- Treatment with vancomycin for bacterial sepsis can lead to life-threatening immune thrombocytopenia, researchers here reported.

FARMINGTON, Conn. -- Treating periodontal disease may pay off for cardiovascular health, researchers here found.

ATLANTA -- One in four women in the U.S. ages 14 to 59 are infected with human papillomavirus (HPV), according to the first nationally representative study. Some 3.4% of the women tested positive for the four major strains against which the new HPV vaccine protects, representing an estimated 3.1 million women.

LOS ANGELES -- Raltegravir (MK-0518), an investigational anti-retroviral drug that targets the HIV enzyme integrase, seems highly effective in patients resistant to existing classes of drugs.

SAN DIEGO -- A wheezing illness before the age of three years signals the likelihood of asthma by age six, and frequent rhinoviral infections in infancy may have something to do with it, according to investigators here.

CHICAGO -- The verdict on male circumcision and HIV transmission has been validated. Now the question is how to implement the finding that male circumcision cuts the risk of HIV infection by more than 50%.

NASHVILLE, Tenn. -- In a year-long study, more than one in four children admitted to the hospital with acute respiratory symptoms had a rhinovirus infection, according to researchers here.

SHANGHAI, China -- More than 80% of drug resistance among treated tuberculosis patients here is the result of a new infection with the resistant strain, called reinfection, rather than inadequate therapy, according to researchers here.

LONDON -- Treating herpes simplex with valacylovir (Valtrex) reduces the levels of HIV in women who are infected with both viruses, according to researchers here.

ORLANDO -- Swabbing the oral cavity with chlorhexidine (Peridex) reduces the risk of ventilator-associated pneumonia in some intubated intensive care patients, a Richmond, Va., researcher said here.

HOUSTON -- For establishing the tumor status of women with breast cancer, a gene-expression microarray appears to have accuracy approaching standard tests, researchers found here.