HIV AIDS

During the past week, a rash on theright thumb and forefinger of a 4-yearoldboy has progressed to involve theentire arm.

A52-year-old white man presented with a pruritic eruption on the neck of 3 months’ duration. The rash had not responded to a potent topical corticosteroid prescribed by another practitioner for the presumed diagnosis of eczema. The patient reported no current health problems. His history included a pubic louse infestation and several episodes of uncomplicated urethral gonorrhea. He readily admitted to having unprotected sexual intercourse with prostitutes.

A methodical approach to diagnosis usually reveals the cause of fever. In patients with simple fever, a careful history taking and physical examination combined with basic laboratory and imaging studies (complete blood cell count with differential, urinalysis, and possibly a chest film and blood cultures) usually yield the diagnosis. In patients with prolonged fever whose cause remains undiagnosed after extensive examination (fever of unknown origin), repeat the history taking and physical examination; also order routine laboratory studies, an HIV test, a tuberculin skin test, 3 sets of blood cultures, and chest films. In addition, abdominal CT scanning is often useful. Further testing at this point may include fluorodeoxyglucose positron emission tomography, technetium-tagged white blood cell scanning, transesophageal echocardiography, liver biopsy, bone marrow examination, and/or temporal artery biopsy. Exploratory laparotomy is rarely indicated.

A 49-year-old woman presented for aroutine eye examination. She had nohistory of systemic disease and tookno medications.

ABSTRACT: A cough is considered chronic when it persists for 3 or more weeks. Typically, chronic cough is a lingering manifestation of a viral upper respiratory tract infection; other, more serious causes-such as asthma, sinusitis, or gastro- esophageal reflux-must also be considered. Look to the history for diagnostic clues and order a chest film, which may point to pneumonia, hyperinflation, atelectasis, or cardiac or pulmonary abnormality. Diagnostic test methods will depend, in part, on the child's age; for example, the American Academy of Pediatrics recommends against imaging of the sinuses in children 6 years or younger. Pulmonary function tests can be useful in diagnosing asthma if the child is able to cooperate. Consider ordering a barium swallow for a very young child whose cough may be the result of a vascular anomaly. A pH probe study can help you determine whether cough is secondary to gastroesophageal reflux. Treatment is directed at the underlying cause.

For 3 months, a 50-year-old man had been bothered by a worsening and spreading rash on his feet and lower legs. The multiple, nodular, fungating lesions were nonpruritic. The heterosexual, unmarried patient did not use intravenous drugs and did not know his HIV status; he denied any significant medical history.

An uncircumcised 58-yearold man presented with a persistent “rash” on his penis of 5 years’ duration. He complained of localized irritation with coitus. Over-the-counter ointments and corticosteroid preparations had failed to clear the eruption. The patient had hypertension, hyperlipidemia, and coronary artery disease. He had been monogamous for the last decade and denied any risk factors for sexually transmitted diseases.

An examination the most recent data on the pharmacodynamics, efficacy, and safety of 5 commonly used herbs: echinacea, St John's wort, ginkgo biloba, saw palmetto, and black cohosh.

Because of recent threats of bioterrorism, smallpox vaccination was reinstated in the United States earlier this year. Since January 2003, more than 35,000 civilian and public health care workers in 54 jurisdictions have been vaccinated.

Foot ulcerations and infections are the leading cause of hospitalization amongpatients with diabetes; they occur in about 15% of these patients.

Several asymptomatic, erythematous papules and plaques had appeared on the hands of an otherwise healthy 11- year-old girl. The personal and family medical histories were noncontributory.

A 60-year-old man with a long historyof psoriasis vulgaris required a systemiccorticosteroid for a severe exacerbationof asthma. Soon after theErythrodermic or Pustular Psoriasiscorticosteroid was discontinued, generalizederythema and scaling of theskin developed.

Bullae had recently appeared on the dorsa of the hands and fingers of a 46-year-old man. His medical history was significant for alcoholism, discoid lupus erythematosus (DLE), and hepatitis C. Systemic lupus erythematosus (SLE) was ruled out; the patient’s symptoms did not meet the American Rheumatism Association criteria for SLE.

As a result of regular screening with the Papanicolaou (Pap) test, deaths from cervical cancer among American women have decreased by more than 70% during the last 50 years.

A 47-year-old woman who wasseropositive for HIV-1 presented tothe emergency department with severemaculopapular, erythematouseruptions. Her antiviral regimen hadrecently been changed from zidovudine, 300 mg bid; lamivudine, 150 mgbid; and saquinavir, 600 mg tid, tolamivudine, 150 mg bid; stavudine, 40mg bid; and nevirapine, 200 mg/d.

What are the appropriate laboratory tests for an infant whose mother has hepatitisC virus (HCV) infection?

A 32-year-old previously healthywoman presents to the emergencydepartment with skin lesions, suprapubicpain, and generalized myalgia of1 week’s duration. Trimethoprim-sulfamethoxazolefor a presumed urinarytract infection is prescribed, and thepatient is discharged. The symptomspersist; she is hospitalized 2 days later.

ABSTRACT: Many patients with osteoarthritis (OA) try such complementary therapies as special diets, nutritional and herbal supplements, yoga, t'ai chi, magnets, and acupuncture-but only 40% of these patients tell their physicians. Glucosamine and chondroitin sulfate can produce at least symptomatic relief; in addition, glucosamine (1500 mg/d) may increase or stabilize cartilage in osteoarthritic knees. Alert patients to the potential toxicities of many herbal remedies, as well as the risks of harmful drug interactions and possible contaminants and impurities. Yoga postures may have a beneficial effect on knee OA; t'ai chi may reduce joint pain and swelling and increase mobility. Small studies have shown that applied pulsed electromagnetic fields can reduce pain and improve function in patients with chronic knee OA. Acupuncture has also been shown, in small studies, to alleviate the pain of OA. Autologous chondrocyte transplantation was recently approved for treatment of knee OA. The efficacy and safety of various types of gene therapy are currently being evaluated.

Q:Should I prescribe isoniazid prophylaxis for an elderly patient withmultiple health problems who recently converted from negative topositive tuberculin status?

Primary care providers are seeingan increasing number ofpatients who have snakes orbarbwire coiling around theirarms or gold rings danglingfrom their eyebrows and navels. Tattooingand body piercing are particularlypopular among adolescents andyoung adults-many of whom may notbe aware of the possible medical complicationsof these ancient practices.

The most common blood-borne infection in the United States, hepatitis C is also one of the leading causes of chronic liver disease in this country. About 35,000 new hepatitis C virus (HCV) infections are diagnosed each year; by 2015, the number of persons with documented HCV infection is expected to have increased 4-fold from what it was in 1990.

ABSTRACT: Patients can greatly reduce the risk of traveler's diarrhea by drinking only bottled water and eating only hot foods prepared in sanitary conditions or peelable fruits and vegetables. Antibiotic prophylaxis for traveler's diarrhea is no longer routinely recommended; reserve it for patients who may have to consume food and beverages of questionable safety, those with reduced immunity, and those likely to experience serious consequences of illness. Adequate hydration is the first step in treating traveler's diarrhea. Drug therapy-loperamide or fluoroquinolones in adults and bismuth subsalicylate or azithromycin in children-can ameliorate symptoms and speed recovery. Recommend that patients who are prone to motion sickness take an antiemetic/antivertigo agent before symptoms begin. Acetazolamide can be used both to prevent and to treat altitude sickness. Contraindications to air travel include a resting oxygen saturation of less than 90%, pregnancy of more than 36 weeks' duration, pneumothorax, recent myocardial infarction or chest or abdominal surgery, active infectious diseases, and poorly controlled seizures or sickle cell anemia.

A 78-year-old man presented to theemergency department with a 3-weekhistory of progressive shortness of breathand cough with blood-streaked, yellowishsputum. The patient had dyspnea onexertion limited to 2 blocks, 2-pilloworthopnea, paroxysmal nocturnal dyspnea,and nocturia. Neither fever norchills were present. He had lost 7.2 kg(16 lb) during the last year.

Fourteen months of intermittent, foul-smelling, perianal discharge prompted a 45-year-old man to seek medical evaluation. He also complained of occasional bright red rectal bleeding and soreness of the perianal region; he denied fever.

A 32-year-old man who was seropositive for HIV presented with a tender lesion on his right foot of about 3 months' duration. The patient's only medication was zidovudine. His CD4+ cell count was 120/µL.