Infectious Disease

A 24-year-old African American man presents for a routine eye examination. Theocular findings are unremarkable; however, well-circumscribed areas of whitenedskin are noted on his forehead and hands (A and B). The patient reportsthat the patchy loss of pigment has been progressing over a number of years.

Child abuse is common. Each year in thiscountry, nearly 3 million children are reportedto Child Protective Services. Approximately50% of reports are for neglect, 30% forphysical abuse, and 20% for sexual abuse.Retrospective studies suggest that 1 in 4 girls and 1 in 8boys are sexually abused before age 18.1

A 47-year-old woman is bothered by the numerous small, smooth, darkbrown papules that have developed on her face and neck during the pastdecade. She asks if the asymptomatic lesions can be removed.

A 55-year-old woman has had a lump under her right jaw for thepast 24 hours. She has difficulty in swallowing because of neck discomfort, andher voice is raspy. Both of these symptoms have progressed rapidly during thepast 12 hours. The patient has no difficulty in breathing, sore throat, or historyof recent illness. Her temperature is 38.5°C (101.5°F).

An 11-year-old boy has had a persistent foot rash since he started to play baseball2 months earlier. The eruption has not responded to over-the-counter antifungalcreams.

A 64-year-old woman presentsto the emergency department withworsening crampy abdominal painthat began the night before. Afterthe pain started, she had a bowelmovement containing a significantamount of blood; since then she hashad episodes of diarrhea. She hadbeen previously healthy, denies traumaand fever, and knows no one withsimilar symptoms. She reports norecent enema, endoscopy, or otherabdominal procedure.

A 36-year-old womanhas had a rash on her hands and feetfor the past week. She denies recentillness, pruritus, fever, chills, sorethroat, and abdominal discomfort.She is currently in a monogamousrelationship with her fiancé.

A 54-year-old Hispanic housewife presents to the emergencydepartment with a 3-week history of moderatelysevere, progressive, generalized, pulsating headache.The headache, which is partially relieved by propoxyphenenapsylate, is associated with weakness, vomiting of recentonset, and intermittent bilateral blurred vision. The symptomsbegan after an incident in which the patient’s sonwas stabbed.

In recent years, 2 large randomized,controlled studies have documentedthe efficacy of the anticonvulsantgabapentin in the management ofpainful diabetic neuropathy (PDN)1and post-herpetic neuralgia (PHN).2Although vastly different in origin,these 2 neuropathies have exhibitedsome similarities in their response totherapeutic agents of various classes.The discovery that yet another typeof pharmaceutical is useful in treatingpain from either PDN or PHN hasraised questions about the similaritiesand differences in the managementof these 2 painful neuropathicsyndromes.

For 3 days, a 60-year-old woman hashad a tender rash on her forehead. Thelesions erupted 2 days after she sustainedminor trauma to the left side ofthe forehead (Figure 1); no scratchesor bleeding were associated with theinjury. She noted a burning sensationand mild tenderness at the site shortlybefore the lesions arose.

Prolonged exposure to coldtemperatures can have a profoundeffect on the skin.When tissues are exposed toabove-freezing temperatures,localized vasoconstriction and increasedblood viscosity reduce bloodflow and decrease the amount ofoxygen available to tissues. Whentissues are exposed to freezing temperatures,water within those tissueschanges into ice crystals; this resultsin either intracellular or extracellulardamage and tissue necrosis.

Rifampin is associated with numerousclinically significantdrug interactions.1-4 New interactionswith rifampin-aswell as rifabutin-continue tobe reported in studies and clinical observations.Here we present highlightsof our recent update on the interactionsthat are most relevant toprimary care practice.5

My patient is a 7-year-old girl with multiple plantar warts on both feet.

A 3-year-old boy is brought to the office by his mother. Theprevious evening, she had noticed a single large red spot on the back of histhigh. This morning, his whole body was covered with a similar rash, andhe had a temperature of 38.8°C (102°F). The mother administered 1 doseof acetaminophen at home for the fever; the rash was asymptomatic.

A 60-year-old woman reportsthat she has felt intermittent“fullness” in her face for the past day.This sensation is present when sheis supine on the examination table.She denies shortness of breath, dysphagia,and chest discomfort. Thepatient has a 25 pack-year history ofcigarette smoking.

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 67-year-old man with poorly controlled type 2 diabetes mellitus presents withleg pain and swelling that began 3 days earlier. Multiple ulcers are noted at thelateral malleolus. His temperature is 38.9°C (102.1°F). Right lower extremitycellulitis is diagnosed, blood samples are taken for culture, and the patient ishospitalized.

A 28-year-old woman complains that her acne has worsened since she startedtaking minocycline for the skin condition 6 weeks earlier. She also uses a norgestimate/ethinyl estradiol oral contraceptive, which has an indication for acnetreatment. Numerous small, pruritic, erythematous follicular papules are presenton the patient’s forehead, cheeks, and nose

A 29-year-old woman presents with a painful erosive dermatitis that has spreadin a perioral distribution during the last 2 days. She complains of a low-gradefever and swollen lymph nodes. The patient has a history of atopy; she isotherwise healthy and takes no medications.

During the past few weeks, a 14-year-old boy has noticed blood on the proximalnail folds of the second and third fingers of his dominant hand. He deniesany pain or pruritus. The patient is otherwise healthy and takes no prescriptionmedications.

An 82-year-old man suddenly became extremely short of breath while helpinghis wife wash dishes. The dyspnea was not accompanied by pain, and it was notrelieved by sitting. He was taken to the emergency department after diaphoresisand cyanosis developed.

A39-year-old man is brought to theemergency department (ED)after his car struck a tree. He experienceda transient loss of consciousnesswith a 3-minute episode of retrogradeamnesia at the scene of the accident,despite wearing a seat belt andshoulder harness. He was disorientedto date and place.

For 2 days, a 43-year-old woman has had a slightly tender rash on her trunk andextremities. Five days earlier, the patient was given levofloxacin for an upperrespiratory tract infection; because she is prone to yeast infections while takingantibiotics, fluconazole also was prescribed. Her only other medication is an oralcontraceptive, which she has been taking for several years.

For 2 weeks, a 35-year-old woman has had a mass on her hand.Although it was initially painless, it now causes discomfort in the forearm,especially when the patient extends her wrist. She has no history of recenttrauma, illness, or a similar mass.

The parents of a 6-year-old child are concerned about blisterson her hands that erupted 3 days earlier and are spreading. The child isotherwise healthy and had attended a summer day camp. The parents areunaware of any trauma or exposure to allergens or toxic substances.

An 88-year-old woman is admitted for severe dyspnea thathas worsened over the past month. Dyspnea on exertionis now elicited by everyday activities, even walking acrossthe room. Orthopnea and paroxysmal nocturnal dyspneahave progressed to the point that she has been unable tosleep at all the past several nights. She also tires very easilyand thinks her ankles are more swollen than previously.She denies chest pain or pressure.

For several months, a 16-year-old girl has had an asymptomatic papulosquamousdescending linear eruption on 1 leg.

A 34-year-old man has had Crohn disease for 12years. He presented initially with ileitis and has had 3surgeries for obstructive complications. Ileum resectionhas resulted in bile salt and fat malabsorption. Recently,the Crohn disease has spread to the large bowel. For thelast 2 years, he has also had seronegative spondyloarthropathy-another complication of Crohn disease.

For 3 months, a 57-year-old woman has had a persistent green nail that is occasionallyslightly sore; the nail plate has lifted. Another physician prescribed a7-day course of levofloxacin for a suspected Pseudomonas infection; the treatmenthad no effect on the nail. A subsequent 7-day course of norfloxacin wasalso unsuccessful. The patient is otherwise healthy.

During a routine skin examination,periungual erythema and increasedcurvature of the nail plate are notedin a 78-year-old man. The patient hasemphysema and a smoking historyof more than 50 pack-years. Currently,he requires oxygen support forregular daily activity.