Kyamalya Ismailova, MD


Disseminated Mycobacterium avium-intracellulare complex Infection

A39-year-old man with a history of AIDS and nonadherence to highly active antiretroviral therapy (HAART) presented with frontal headache and scalp pain of 2 weeks' duration. These symptoms were accompanied by nausea, weight loss, and generalized weakness. Physical examination revealed a small, tender scalp lump, 2 × 2 cm over the left parietal area. The findings from the rest of the examination were unremarkable.

Lael Desmond, MD


Man With Painful Shoulder Abscess

For 2 weeks, a 31-year-old man has had a nonhealing, painful abscess on his left shoulder. A week before presentation, he sought treatment at a walk-in clinic; the abscess was incised and drained, and he was given gatifloxacin.

Lakeisha Conley, MD


Achalasia in a Previously Healthy Young Man

For 3 weeks, a previously healthy 24-year-old man had repeated episodes of nonbloody, nonbilious emesis. He denied dysphagia, but he did report a 40-lb (18-kg) weight loss and heartburn.

Lakshmi Varadarajalu, MD


Nonspecific symptoms are among the obstacles to diagnosis Pulmonary alveolar proteinosis: An easy-to-miss diagnosis key words: Alveolar proteinosis, Surfactant, Whole lung lavage

abstract: Pulmonary alveolar proteinosis (PAP) is characterized by the accumulation of lipoproteinaceous material in the alveoli. The most common symptoms are dyspnea on exertion and nonproductive cough. Weight loss, fatigue, chest pain, and hemoptysis have also been reported. Chest radiographs typically show bilateral, symmetrical airspace disease with an ill-defined nodular or confluent pattern, which gives a "bat wing" appearance, as is seen in heart failure. Pulmonary function tests usually demonstrate mild restrictive disease. Findings on examination of sputum specimens or bronchoalveolar lavage fluid can suggest the diagnosis; however, open lung biopsy is the diagnostic gold standard. Whole lung lavage remains the standard of care for PAP and is warranted in patients with severe dyspnea and hypoxemia. Subcutaneous human recombinant granulocyte-macrophage colony-stimulating factor appears to be a promising alternative to whole lung lavage for symptomatic patients. (J Respir Dis. 2007;28(5):177-184)

Lalitha Sivaswamy, MD


Neurologic Complications of Chemotherapy

Leukemia, brain tumors (glioma, medulloblastoma), and neuroblastoma constitute the most common types of childhood cancers.

Lane M. Robson, MD


Ecchymosis From Cupping

A 14-year-old boy presented with a 3-day history ofrunny nose, cough, and fever. His temperature was37.7°C (100ºF); heart rate, 78 beats per minute; and respirationrate, 26 breaths per minute. Several symmetric,circular ecchymotic lesions that measured 4 cm in diameterwere noted on the upper chest. There was no evidenceof external injury to other parts of the body. Thechild reported that the bruises resulted from cupping,performed by a Chinese practitioner in an attempt torelieve the fever.

Larry Borish, MD


Aspirin-exacerbated respiratory disease: An easy-to-overlook diagnosis

Abstract: Patients who have aspirin-exacerbated respiratory disease (AERD) usually experience upper and lower respiratory tract symptoms about 1Z|x to 2 hours after taking aspirin or another NSAID that inhibits the enzyme cyclooxygenase-1. In addition to symptoms such as nasal congestion, rhinorrhea, paroxysmal sneezing, periorbital edema, laryngospasm, and intense flushing, patients may have severe--often life-threatening--exacerbations of asthma. AERD occurs in about 10% to 20% of patients with asthma and in about 30% of asthmatic patients with nasal polyposis. However, AERD also occurs in patients who do not have any of these predispos- ing conditions. In patients with AERD, aspirin desensitization can improve asthma control, reduce the need for corticosteroids, and reduce the need for sinus surgery. (J Respir Dis. 2006;27(7):282-290)

Larry Hudgins, MD


Case In Point: Middle-Aged Man With Worsening Cough and Dyspnea

A 52-year-old man with hypertension and hyperlipidemia presents to the emergency department with a 5-month history of cough and dyspnea.

Larry Husten, CardioBrief


CardioBrief: Slow Down Urged on SPRINT

The 25% reduction in relative risk seen in patients treated to 120 vs 140 mm Hg corresponds to an absolute risk reduction of 1.6%.

Larry I. Lutwick, MD


6 Things That Might Persuade Parents to Vaccinate

When parents play out worst case scenarios in protest against routine vaccination, maybe one or two of these 6 options for response will come in handy.

Larry S. Schlesinger, MD


Differentiating colonization from infection can be difficult Nontuberculous mycobacterial infections: Diagnosis and treatment key words: Pulmonary infections, Nontuberculous mycobacteria, Mycobacterium avium complex, Rapidly growing mycobacteria

abstract: Pulmonary disease caused by nontuberculous mycobacteria (NTM) can be challenging to diagnose and manage. Patients typically present with nonspecific symptoms, such as cough and fever, and they often have underlying lung disease, which further complicates both diagnosis and treatment. To avoid treating pseudoinfection, the diagnosis should be based on a combination of the history and results of physical examination, radiographic imaging, and smears and cultures of at least 3 sputum samples. Occasionally, it is necessary to perform bronchoalveolar lavage or obtain tissue via transbronchial or open lung biopsy for histopathology and to assess for tissue invasion. Treatment involves a long course of often costly multiple antimycobacterial drugs. However, treatment with the second-generation macrolides, clarithromycin and azithromycin, has significantly improved cure rates for specific NTM infections. (J Respir Dis. 2007;28(1):7-18)

Larry Sikolsky, MD


Prompt diagnosis and therapy are keys to reducing mortality Extrapulmonary tuberculosis, part 5: Pericardial involvement key words: Tuberculosis, Pericarditis, Pericardial effusion

abstract: Tuberculous pericarditis, while relatively rare in the United States, is an important cause of pericardial disease in countries where tuberculosis is prevalent. Patients are most likely to present with chronic disease--effusive and/or constrictive. Those with effusive pericarditis often present with tamponade. Patients with constrictive pericarditis exhibit features of systemic and pulmonary venous congestion. An elevated level of adenosine deaminase in pericardial fluid is a good marker for tuberculosis. The presence of granulomas or case-ation necrosis in pericardial tissue confirms the diagnosis. If treatment of effusive tuberculous pericarditis is delayed, constrictive or effusive-constrictive disease usually develops, resulting in a high mortality risk. In addition to a standard antituberculosis regimen, treatment of tuberculous pericarditis may include adjuvant therapy with corticosteroids, pericardiocentesis, and/or pericardiectomy. (J Respir Dis. 2007;28(7):278-282)

Larry Sokolosky, MD


Livedo Reticularis

A 62-year-old woman was seen prior to cholecystectomy. She had no cardiac or pulmonary disorders. Examination was unremarkable other than a purplish-reddish, lace-like pattern on the thighs and forearms.

Lasse Skovgaard, MA, MA (Ed)


“Complementary” Therapies in Multiple Sclerosis

What happens when complementary and alternative therapies are combined with traditional treatments in patients with multiple sclerosis? A new study suggests some positive benefits. Details here.

Lasse Skovgaard, MA, MA (Ed.)


Complementary Therapies in Multiple Sclerosis: Why Mind-Set Is Everything

Here: a project that sheds some light on the potential of an integrated and holistic approach to therapy for patients with multiple sclerosis.

Latha Rajagopal, MD


Pasteurella Pneumonia Associated With Cutaneous Trauma

Community-acquired pneumonia is a frequent cause ofhospital admission in adults. It usually results from infectionwith pathogens such as Streptococcus pneumoniae, Haemophilusinfluenzae, Mycoplasma, and Chlamydia, among others. In a fewcases, pneumonia develops from infection with unusualpathogens, such as Pasteurella multocida, a gram-negativeorganism commonly found in the mouths of cats and dogs.We report a case of P multocida pneumonia associated with skintrauma caused by cat scratches in a woman with a history ofchronic obstructive pulmonary disease. [Infect Med. 2008;25:487-489]

Laura A. Hogan, NP


Tension and Cervicogenic Headaches:

ABSTRACT: A thorough history and physical examination can establish the diagnosis of tension headache; further evaluation is generally unnecessary. In contrast, the workup of cervicogenic headache includes standard radiographs, 3-dimensional CT, MRI, and possibly electromyography; nerve blocks may also be used to confirm the diagnosis. Episodic tension headache can be treated effectively by trigger avoidance, behavioral modalities, and structured use of analgesics. Reserve opioids for patients with intractable headaches. Chronic tension headache is treated primarily by prophylactic measures, such as antidepressants and anticonvulsants, and behavioral and physical therapy. Treatment options for cervicogenic headache include analgesics; invasive procedures, such as trigger point injections, greater or lesser occipital nerve blocks, facet joint blocks, segmental nerve root blocks, and diskography; spinal manipulation; and behavioral approaches.

Laura Davisson, MD


Green Nail Syndrome

Green discoloration of the fingernailsdeveloped 6 weeks after a 29-year-oldwoman had artificial nails placed duringa manicure. The patient was a doctorof pharmacy degree candidate whowas married and had 2 children.

Laura Higgins, MD


Woman With Transient Year-Round White, Numb, Cold Hands

A woman has white, numb, cold hands after vigorous exercise, emotional stress, and exposure to cold. Is this caused by Buerger disease (thromboangiitis obliterans), acute arterial occlusion, Raynaud disease, or acrocyanosis?

Lauren M. Czosnowski, PharmD


Managing Drug Interactions That Can Reduce Levothyroxine Efficacy

Levothyroxine is one of the most commonly prescribed medications for the treatment of persons with hypothyroidism and the suppression of thyroid neoplasms.1 Most persons with hypothyroidism require lifelong therapy with levothyroxine.

Lauren Patton, MD


Linear Gingival Erythema

Bleeding gums for the past 2 days was the complaint of this 22-year-old woman. She is HIV-positive but has been clinically asymptomatic. Her CD4 lymphocyte count is 84/μL, and her viral load is 160,885 copies/mL. Despite maintaining good oral hygiene, she has a distinct fiery red band along the gingival margin.

Laurence Baker, MD


The Solitary Lung Nodule:

ABSTRACT: When a solitary lung nodule is detected, the key question is whether the lesion is malignant. The initial evaluation includes a careful history taking focused on risk factors for malignancy, a thorough physical examination, comparison of current chest films with previous ones, and CT scanning. Radiologic signs that suggest malignancy include lesion size greater than 2 cm in diameter, spiculated margins, lack of calcification, and change in size. Video-assisted thoracoscopic surgery or thoracotomy is the next step for patients with a suspected malignant lesion. If the results of the initial evaluation are equivocal, positron emission tomography (PET) scanning is the preferred follow-up.

Laurie Elit, MD, MSc


Oncology Q&A

Is prophylactic oophorectomy recommended for healthy postmenopausal women with a strong family history of cancer?

Laurie Martin


6 Top Primary Care Items From Around the Web

A look around the web at breaking news -- not all of it medical.

Laurie Meng, PA-C


Acute Protrusion of the Scapula

Several hours after he had installed ceramic tile, a 33-year-old man experienced muscle spasms and felt pressure in his right shoulder. He denied previous injury to the area.

Lavanya Viswanathan, MD


Blue Rubber Bleb Nevus Syndrome

BRBNS is a rare GI disorder characterized by distinctive cutaneous and GI venous malformations that can lead to occult or massive GI bleeding.

Lawrence A. Schiffman, DO


Malignant Melanoma in a Patient withMulti-organ Metastatic Disease

This truncal lesion was revealed when a 47-year-old man disrobed for examination after he had fallen on a sheet of ice and broken a rib. The patient-a truck driver and 30 pack-year cigarette smoker-had been aware of the enlarging lesion for about a year but had not sought medical attention because it was asymptomatic.

Lawrence Kaplan, MD


Woman Who Has Felt Unwell for Many Years

A 41-year-old woman presents as a new patient, with complaintsof chest pain and palpitations that occur intermittentlyand are not associated with activity, meals, or position.She says these symptoms have been present forsome time, and she expresses frustration that her previousphysician was unable to find their cause or to amelioratethem.

Lawrence R. Schiller, MD


Clostridium difficile-Associated Diarrhea:

For some time, diarrhea caused by Clostridium difficile has been a serious problem in hospitals. Recently, more virulent strains of this pathogen have started to show up in hospitals.

Lawrence Sokolsky, MD


Bronchoscopy Clinic: Emerging options for managing foreign-body aspiration

Endobronchial foreign bodies can be life-threatening, but once they are detected, they can usually be removed, leading to prompt resolution of symptoms. Chest radiography and CT scanning can be helpful in some cases, but bronchoscopy is necessary for definitive diagnosis and treatment.

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