HIV AIDS

A 37-year-old man presents with new-onset fever and abdominal pain of several days' duration. What does the PA film show, and what further action would you take to arrive at a diagnosis?

Rates of gonorrhea and chlamydial infection are highest among females 15 to 24 years old. Annual screening of all sexually active adolescents is warranted.

Early diagnosis enables patients to derive maximum benefit from highly active antiretroviral therapy (HAART). Primary care practitioners can play a key role in the timely identification of HIV infection.

ROCKVILLE, Md. - The FDA has given accelerated approval to Prezista (darunavir), a novel protease inhibitor for salvage treatment of patients with HIV.

ATLANTA - Six unrelated clusters of community-acquired methicillin-resistant Staphylococcus aureus infection involving 44 people in three states have been linked to 13 unlicensed street-corner tattoo artists.

SEATTLE - Among newly sexually active women, consistent condom use by their partners reduced the risk of human papilloma virus (HPV) infection, researchers reported.

SALT LAKE CITY - A restless leg syndrome diagnosis can be ruled out by a single question, a researcher said here.

WHITE RIVER JUNCTION, Vt ? TV and newspaper reports emerging from major medical meetings are so overstated or so lacking in context that viewers and readers would be better off paying no attention to them whatsoever, say a pair of Dartmouth investigators.

ATLANTA ? After 25 years, the AIDS pandemic has killed more than 25 million people round the world. Today, nearly 40 million people live with HIV.

A 25-year-old man reports that he has had a swollen eye for thepast several days. He noticed a small amount of yellow discharge the previousevening. He denies systemic complaints, including fever, chills, nausea, vomiting,and recent trauma. He also tells you that he has a drip in my private area.

Some sexually transmitteddiseases (STDs), such assyphilis and gonorrhea, arecenturies-old scourges; othershave attained clinicalsignificance only in recent years.Despite the availability of effectivetherapy for many of these diseases,they remain an important publichealth problem.

Patients with psychiatric disordersoften present a diagnostic challenge-even for psychiatrists. Their demeanormay not readily reveal the nature orseverity of the problem. Nevertheless,there are clues that can help you sortthrough the differential and arrive atthe correct diagnosis.

abstract: Pulmonary hypertension is an increasingly recognized complication of HIV disease. Echocardiography is the most useful imaging modality for an early diagnosis; the most frequent findings are systolic flattening of the interventricular septum, right atrial and right ventricular enlargement, and tricuspid regurgitation. Other components of the workup include comprehensive laboratory tests (complete blood cell count, measurement of prothombin time and partial thromboplastin time, hepatic profile, etc), chest radiography, pulmonary function tests with arterial blood gas analysis, ventilation-perfusion lung scanning, and spiral CT scanning. The treatment of this condition is complex and controversial, and the drug of choice has not yet been established. The therapies currently used include antiretroviral agents, bosentan, calcium channel blockers, epoprostenol, and sildenafil.

Pulmonary arterial hypertension (PAH) can be difficult to diagnose because the symptoms are nonspecific and the physical findings are usually subtle (Table). In 2004, the American College of Chest Physicians (ACCP) published clinical practice guidelines for the diagnosis and management of PAH.1 Highlights of the ACCP's recommendations for patient assessment include the following:

The authors describe a woman who presented with severe pulmonary hypertension. A cardiopulmonary cause was initially sought, but thyrotoxicosis was the underlying cause.

abstract: Pulmonary arterial hypertension (PAH) is 1 of 5 types of pulmonary hypertension (PH). Symptoms may include dyspnea on exertion, fatigue, near-syncope, and palpitations. Physical findings include lower extremity edema, jugular venous distention, and a loud P2. Findings on chest radiography, transthoracic echocardiography, and electrocardiography can suggest the presence of PAH; however, right heart catheterization is the gold standard for confirming the diagnosis and for differentiating PAH from other forms of PH. It is essential to exclude chronic thromboembolic PH, since this can be surgically corrected. The treatment of PAH depends on the severity. In addition to the standard treatments, such as diuretics and anticoagulation, more advanced treatment options include prostaglandin therapy (epoprostenol, treprostinil, and iloprost), endothelin receptor antagonists (bosentan), and phosphodiesterase inhibitors (sildenafil).

Man With Worsening Cough and Dyspnea

The mumps outbreak in midwestern states appears to be slowing, but as college students return home and engage in summer travel, it's possible that mumps will spread. Are you prepared?

Abstract: The introduction of helical CT dramatically improved the quality of CT images of the airways and other thoracic structures. Multi-detector row CT scanners have made further improvements with respect to spatial resolution, speed, and anatomic coverage. Axial CT images provide valuable information about the airway lumen and wall and adjacent mediastinal and lung structures, but they are limited in their ability to assess airway stenoses and complex airway abnormalities. These limitations can be overcome by multiplanar and 3-dimensional reconstruction images. State-of-the-art scanners allow all of the central airways to be imaged in a few seconds. This speed is particularly valuable for patients who cannot tolerate longer breath-holds and patients who may have tracheomalacia or vocal cord paralysis. (J Respir Dis. 2006;27(5):192-196)

Abstract: Exercise intolerance is common in persons with chronic obstructive pulmonary disease and can result from multiple physiologic factors, including dynamic hyperinflation, gas exchange abnormalities, and pulmonary hypertension. In the initial assessment, keep in mind that many patients underestimate the degree of their impairment. The 6-minute walk test is very useful in assessing the degree of exercise intolerance; when more extensive assessment is indicated, cardiopulmonary exercise testing (CPET) is the gold standard. CPET is particularly useful for defining the underlying physiology of exercise limitation and may reveal other causes of dyspnea, such as myocardial ischemia or pulmonary hypertension. Strategies for improving exercise tolerance range from the use of bronchodilators and supplemental oxygen to participation in a pulmonary rehabilitation program. (J Respir Dis. 2006;27(5):208-218)

The patient was a 41-year-old manwith a history of HIV infection diagnosed10 years before admission.He had been noncompliant withtreatment, and therapy with tenofovir,efavirenz, and lamivudinehad not been started until 2 monthsbefore admission, when he presentedto another hospital. At thetime, his CD4+ cell count was156/µL and his viral load was45,743 copies/mL. He also had ahistory of incarceration; had usedinjection drugs, cocaine, alcohol,and marijuana; and had a 20-packyeartobacco history.

Young Man With Painless Penile Ulcer

Infection with hepatitis C virus (HCV) was recently diagnosedin a 45-year-old man when a positive enzyme-linked immunosorbentassay was followed by a polymerase chain reaction assaythat showed a viral load of 835,000 copies/mL. The patient probablyacquired the infection when he was using intravenous heroin, a practice he quit 10 yearsago. The patient is immune to both hepatitis A and hepatitis B viruses, and there is no coinfectionwith HIV. Liver biopsy shows moderate cellular inflammation (grade 3) and bridging fibrosis(stage 3) but no evidence of cirrhosis. Iron staining shows no abnormal iron deposition in theliver. The HCV genotype is 1A.

Pyoderma gangrenosum is frequentlyassociated with systemic diseases,such as ulcerative colitis and Crohn’sdisease (Table). The occurrence of theskin ulcers does not necessarily correlatewith the activity of the underlyingdisorder.

A 52-year-old woman was admitted tothe hospital with progressive shortnessof breath of 2 days’ duration. Bronchialasthma had been diagnosed 6 monthsearlier; inhaled corticosteroids, bronchodilators,and leukotriene antagonistswere prescribed. Despite aggressivetreatment, the patient’s dyspneaand wheezing worsened.