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Antimicrobial Resistance Update: Klebsiella pneumoniae CarbapenemasesThe rapid spread of Klebsiella pneumoniae carbapenemases (KPCs) is limiting the effectiveness of carbapenems in the treatment of multidrug-resistant infections. The resistance genes found in KPCs have been identified in other organisms as well and have properties that have raised concerns regarding their transmissibility and epidemic potential.
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Wilms Tumor: A Rare Finding in an AdultA 43-year-old woman was admitted to the hospital with left flank pain. The physical examination revealed a left abdominal mass. Laboratory test results identified normochromic-normocytic anemia (hematocrit, 33%; hemoglobin, 10.8 g/dL; and mean corpuscular volume, 88 fL) and microscopic hematuria (10 red blood cells per high-power field).
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Under what circumstances is outpatient therapy possible? Using low molecular weight heparins to treat venous thromboembolism key words: Deep venous thrombosis, Pulmonary embolism, Heparin, Anticoagulant therapyabstract: Low molecular weight heparins (LMWHs) have proved to be as safe and effective as unfractionated heparin for the treatment of venous thromboembolism. They have the advantage of not requiring frequent measurement of activated partial thromboplastin time and subsequent dosage adjustments. Patients who have deep venous thrombosis can be treated with once- or twice-daily subcutaneous doses. Hospital admission is necessary for patients with risk factors for major bleeding complications, for those with symptomatic pulmonary embolism, or when noncompliance is likely. Symptomatic proximal deep venous thrombosis and asymptomatic pulmonary embolism may be managed on an outpatient basis if there are no contraindications. Although heparin-induced thrombocytopenia occurs less frequently with LMWHs than with unfractionated heparin, the platelet count must still be monitored during therapy. (J Respir Dis. 2007;28(4):132-138)
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Bronchoalveolar CarcinomaA 52-year-old woman (a nonsmoker) was hospitalized after experiencing a low-grade fever and dyspnea for a month. No abnormalities were noted on physical examination, but the chest film showed multiple nodules, both well- and ill-defined. Lung biopsy confirmed the diagnosis of bronchoalveolar carcinoma.
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“Snakeskin” Gastric MucosaCirrhosis and ascites developed in a 52-year-old man with a history of chronic hepatitis C and alcohol abuse. He was hospitalized because of bleeding esophageal varices, which were successfully treated with elastic band ligation.
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Teenager With Small Red Papules on Her Arms and Thighs17-Year-old girl with a 7-month history of small, red papules on her arms and thighs. Rash is not painful or itchy. Otherwise in good health.
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Tuberculous ArthritisA 72-year-old woman was hospitalized after 8 years of pain and swelling of the right metatarsophalangeal joint. (In this film, the dark area over the distal joint of the large toe is an artifact.) Results of a purified protein derivative tuberculin test were positive, and a chest film revealed apical changes compatible with old tuberculosis (TB).
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Research Focus: Recent Developments in HIV TherapeuticsResearch Focus: Recent Developments in HIV Therapeutics
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An Uncommon ECG Finding in a Man With Acute MIA 49-year-old man presented to the emergency department (ED) with substernal chest pain that had started an hour earlier. The pain radiated to the left arm, was constant, and was associated with diaphoresis, nausea, and dyspnea. A similar episode 4 days earlier had spontaneously resolved. He denied fever or chills, pleuritic chest pain, vomiting, and diarrhea.
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Surgical Treatment of Obesity: Questions Physicians Often Ask About Laparoscopic Adjustable Gastric BandingBecause bariatric surgery has traditionally been associated with a high incidence of complications, it has been used primarily for superobese patients. A large body of evidence suggests that laparoscopic adjustable gastric banding is a much safer procedure that is also very effective. This procedure offers an additional option to patients who might benefit from bariatric surgery when diet, exercise, and pharmacologic approaches have failed. Here we address questions primary care physicians often ask about the procedure.
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Practical Practical: Streamlined Joint Fluid DrainageTo easily drain an ulnar bursa or a patellar effusion of any size--and simplify preparation of the aspirate for transfer--use an evacuated blood draw kit with an 18-gauge needle attachment, a see-through-labeled tube coated with whatever anticoagulant your laboratory specifies, and several large additive-free tubes. Begin with the coated tube
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Thyrotoxic Periodic ParalysisAttacks of muscle weakness associated with this condition can range in severity from mild deficit to complete paralysis. Episodes may alternate with periods of normal muscle function.
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Clinical Consultation: Could your patient's flu-like illness really be inhalation anthrax?In 2001, 11 US residents contracted inhalation anthrax as a result of the deliberate mailing of 4 letters containing anthrax spores. Five died as a result. Several of these patients presented to physicians before becoming fatally ill, but their illness was misdiagnosed as influenza.1
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Bedbug Bites in a 34-Year-Old WomanA 34-year-old woman presented with a blistering, intensely pruritic rash that had erupted 3 days earlier. Multiple papular lesions were densely clustered on areas of exposed skin. Excoriations were present, but there was no evidence of bacterial infection.
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Case In Point: Fever and a chest wall mass in a young manCoccidioides immitis is a di-morphic fungus that causes pulmonary disease with a variety of clinical and radiographic presentations. Miliary pulmonary disease is very uncommon and is found almost exclusively in immunocompromised patients. The authors describe the case of an immunocompetent patient who had disseminated coccidioidomycosis with a miliary pulmonary disease pattern. Obtaining a careful travel history and considering regional fungal infections was integral to making a prompt diagnosis.
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Epidermoid Cysts Treated With Phosphatidylcholine InjectionsEpidermoid cysts may be treated with intralesional injections of phosphatidylcholine to avoid potential recurrence, eliminate scarring, and reduce cost.
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The Future of Inhaled Insulin TherapyDiabetes is a destructive disease that kills thousands eachyear in the United States and disables thousands more, and its incidence hasbeen rising dramatically. Glycemic control is imperative to forestallcomplications; however, it can be difficult for patients to achieve glycemicgoals.
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Blue Rubber Bleb Nevus SyndromeBRBNS is a rare GI disorder characterized by distinctive cutaneous and GI venous malformations that can lead to occult or massive GI bleeding.
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Clinical InvestigationThe CDC estimates that more than 850,000 people are living with HIV/AIDS in the United States today,1 with African Americans and Latinos being disproportionately affected.2 Over the past decade, the Latino population in the United States has been growing. In fact, in 2002 for the first time, Latinos surpassed African Americans as the largest US minority group. However, the term "Latino" is applied to a very heterogeneous group from different countries and different cultures.3 In addition, a large proportion of Latinos is undocumented in the United States and thus marginalized from the health care system.
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Acute pneumonitis after in vitro fertilization with IM progesteroneA 34-year-old woman presented to the hospital with low-grade fever, fatigue, dyspnea with minimal exertion, and dry cough. She had emigrated from China 3 years earlier. She had been healthy and had no allergies or food intolerances.
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Clinical InvestigationThe CDC estimates that more than 850,000 people are living with HIV/AIDS in the United States today,1 with African Americans and Latinos being disproportionately affected.2 Over the past decade, the Latino population in the United States has been growing. In fact, in 2002 for the first time, Latinos surpassed African Americans as the largest US minority group. However, the term "Latino" is applied to a very heterogeneous group from different countries and different cultures.3 In addition, a large proportion of Latinos is undocumented in the United States and thus marginalized from the health care system.
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Woman With Acromegaly Presenting as Unilateral Vision LossA 36-year-old woman presented to the emergency department with loss of vision in the right eye that had initially involved the peripheral field and progressed over 2 months to the central and nasal fields. During this period, she also had headaches, vomiting, and generalized weakness. She had had amenorrhea for 1 year.
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A Young Boy With High Fever and LethargyA Young Boy With High Fever and LethargyA 5-year-old boy is brought to the emergency department(ED) by his parents. They report that, for thepast week, the child has had a high fever (temperatureup to 40oC [104oF]), generalized weakness, lethargy, andlack of appetite. The boy’s eyes are bloodshot and he hasrefused food and drink. The child has no history ofcough, shortness of breath, hematemesis, melena, headaches,vision problems, or seizures. He has not been incontact with sick persons, has not traveled abroad, doesnot have a pet, and is not taking any medications. His immunizations are up-to-date.
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Carotid-Cavernous Sinus FistulaRedness, irritation, and diplopia developed over 2 to 3 weeks in a 55-year-old man's left eye. The injection worsened and was unresponsive to eye drops. Ptosis, mild proptosis, and elevated intraocular pressure developed. A bruit was auscultated over the affected eye.
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Diagnostic Criteria for PIISD – Private Insurance Induced Stress DisorderThe essential feature of private insurance induced stress disorder (PIISD) is the development of characteristic symptoms following exposure to an insurance-induced traumatic stressor involving direct personal experience of an event or witnessing an event that threatens another person. Traumatic events include, but are not limited to, recission of health insurance after developing a costly illness, denial of health insurance due to a pre-existing condition such as being female and fertile or delay of needed treatment or medication due to requirements for pre-authorization. In the case of physicians, traumatic events include witnessing the deterioration of patients due to financial ruin resulting from uncovered costs of care. Similar to some forms of PTSD, this disorder is prone to be severe because the stressor is of human/corporate design. Note: this diagnosis is not currently reimbursed by health insurance carriers.
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Answers to readers’ questions on aspiration as a cause of coughCough can be a sign of aspiration in patients with dysphagia. Therefore, in evaluating patients with cough, the history should include a search for conditions associated with increased risk of impaired swallowing. These include conditions that require oropharyngeal suctioning, acute and degenerative neurological diseases (such as stroke, amyotrophic lateral sclerosis [ALS], and head trauma), cervical or brain surgery, head and neck cancer, and use of sedatives.1
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Psoas AbscessA 49-year-old woman with a history of alcoholic cirrhosis, esophageal varices, coronary artery disease, diabetes mellitus, and hypertension presented to the emergency department with a 2-day history of fever, chills, nausea, and back and abdominal pain. The pain began on the right side, progressed to the lower back, and radiated into the right anterior thigh and groin area.
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What caused this woman’s pneumomediastinum?A 35-year-old woman presented to the emergency department (ED) with vague abdominal complaints. The patient had a complex medical history that included diverticulosis and relapsing polychondritis. Initially, her polychondritis was limited to involvement of the ears and nose. Within the past few years, however, her polychondritis flares had been associated with progressive dyspnea, which prompted intermittent and then long-term use of high-dose oral corticosteroids.
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Catscratch Disease Presenting as Acute Respiratory DistressSuperficial adenopathy is the most common symptom ofcatscratch disease (CSD) attributed to Bartonella henselaeinfection. More complicated adenopathy with pulmonaryinvolvement can occur. We report a case of a 15-year-oldboy with pleural symptoms related to B henselae–associatedCSD. [Infect Med. 2008;25:248-250]
