Infectious Disease

A 2-week history of diarrhea mixed with bright red blood was the presenting complaint of a 40-year-old man who was seropositive for HIV. Stool studies and culture results were negative for microorganisms. Colonoscopy demonstrated only the raised vascular lesion seen here in the sigmoid colon, which may have been responsible for the bleeding.

A 20-year-old woman, who had been confused and delirious for 2 days, was brought to the emergency department (ED). She had no significant past medical history and was taking no medication but had recently returned from a trip to Southeast Asia. In the ED, the patient had several convulsions and rapidly became comatose. She was unresponsive; her temperature was 37.9°C (100.3°F), and her blood pressure measured 80/50 mm Hg. The neurologic examination showed no signs of meningeal irritation. Cranial nerve examination was normal and showed mild, bilateral, symmetric increase in deep tendon reflexes. All other physical examination findings were normal.

Purplish skin lesions appeared on the back and trunk of a 34-year-old homosexual man with HIV-1 disease. The spots had been growing larger over the past several weeks.

This 7-year-old presented with a pink, raised lesion on her upper left eyelid. The 1-cm lesion contained tiny vesicles and showed eccentric central clearing.

A 33-year-old man with AIDS presented to the emergency department with fever, dyspnea, cough, and pleuritic chest pain of 3 days' duration. He had had a Pneumocystis carinii infection 3 years before recently emigrating from the Dominican Republic to the United States. Promiscuous sexual activity was his only risk factor for HIV infection. The patient did not take antiretroviral medications or protease inhibitors because of their cost.

Ten days after ballet practice, a 9-year-old girl noticed a nonpruritic, petechial rash on her lower legs. Swelling of the ankles and knees was also apparent. The patient was afebrile, otherwise healthy, and had no abdominal pain. There was no family history of blood dyscrasias. The patient was taking no medications.

For more than 20 years, a 55-year-old man had a faintly erythematous, papulosquamous rash with arciform borders on his groin and waistline. The rash had been treated with a variety of medications. Topical and oral antifungals and antibiotics and topical corticosteroids had been used but to no avail. No laboratory tests had been performed.

Flesh-colored to red-brown nonpruritic papules developed most prominently on the elbows, forearms, and knees of a 2 1⁄2-year-old boy. The rash was preceded by a low-grade fever and mild, upper respiratory tract symptoms.

For 2 days, an 80-year-old woman had left ear pain and a rash around the ear canal and pinna. She also complained of pain and small papules in the back of her pharynx on the left side. She had no fever or chills and no rash elsewhere on her body. She denied drainage from the ear and previous ear infections or skin eruptions. Several years earlier, she had undergone surgery and chemotherapy for lymphoma but had been well since then.

A 21-year-old man slept in a car in upstate New York for three winter nights. Discomfort and swelling of his toes developed, which progressed to marked discoloration of the digits.

While watching TV, a 32-year-old man experienced acute right-sided pleuritic pain and was taken to the emergency department. He was seropositive for HIV but had never had Pneumocystis carinii pneumonia (PCP) and was not taking aerosolized pentamidine. Physical examination revealed hyperresonance with significantly decreased breath sounds over the right hemithorax.

A 23-year-old man complained of unsightly “flat warts” all over his chest. These lesions first appeared in early adolescence. The clinical suspicion of epidermodysplasia verruciformis was confirmed by a biopsy.

A 68-year-old woman was admitted to the hospital with rapidly increasing, painful swelling of the left eye. She had moderately severe, corticosteroid-dependent chronic obstructive pulmonary disease.

For 2 months, a 22-year-old uncircumcised man noticed an asymptomatic, erythematous, static lesion on the glans penis. He had applied an over-the-counter “jock-itch” ointment for 2 weeks but to no avail. The young man was otherwise healthy and denied having dysuria or a history of sexually transmitted disease.

A 24-year-old man presented for evaluation of pruritic vesicles on both feet. Ten days earlier, dyshidrotic eczema had been diagnosed by another physician who prescribed triamcinolone ointment. The patient reported that the foot eruption worsened after the topical medication was applied.

This 6-year-old boy was brought to his physician for evaluation of a rash. The child had been running a fever and, for the past 48 hours, had been complaining of a sore throat, headache, and abdominal pain.

Persistent, unremitting itch-which intensifies at night-is the chief complaint of patients with scabies. The female Sarcoptes scabiei mite (A) burrows into the stratum corneum, where she lays eggs. The parasite is transferred by intimate contact and fomites, such as infested clothing, towels, and bedding.

A painful swelling over the right lower eyelid with conjunctival injection was evaluated in a 28-year-old injection drug user. Cephalexin and corticosteroid ophthalmic drops failed to resolve the condition.

A 16-year-old girl had had tender, erythematous, nodular, shiny lesions on the extensor aspect of both shins for 2 weeks. There were no ulcerations or adenopathy. She denied fever, cough, sore throat, pruritus, and GI symptoms. Aside from oral contraceptives, she was not taking any medications.

A comatose 29-year-old woman was brought to the emergency department. Her family reported that she had been well until 4 days earlier, when headache and fever developed. She went to another hospital at that time and was told she had an abscessed tooth. She was given erythromycin, and the tooth was extracted the following day. The patient's headache and fever worsened; a sore throat also developed, and a rash appeared on her trunk, arms, and legs. The family denied any HIV risk factors, unusual medical history, recent travel, and exposure to persons with infectious diseases.

This self-limited eruption is characterized by erythematous, scaling, oval-shaped macules on the trunk and proximal extremities. Most outbreaks begin with a single, large patch-a mother or herald patch-that typically is found on the trunk. Commonly, this lesion is confused with ringworm.

The variable appearance of palatal petechiae is demonstrated by these two cases, presented by Robert P. Blereau, MD of Morgan City, La. The petechiae appear as discrete pinhead lesions in a 10-year-old boy, whereas they are manifested as minute hemorrhagic areas in a 30-year-old woman.

While playing outside, a 23-month-old girl became sleepy and difficult to arouse. The mother brought her daughter to the emergency department (ED); posturing and a dilated and fixed right pupil were noted. The child was hospitalized.

The left hand of a 45-year-old man was affected with the characteristic intact bullae and dried, crusted, ruptured bullae of bullous impetigo.

A pruritic rash of unknown origin had been present on the dorsum of a 26-year-old woman's foot for several months. Despite oral antibiotic therapy and applications of antifungal creams and topical corticosteroids, the condition did not resolve.

Congenital adrenal hyperplasia is an autosomal recessive disorder. Deficiency of 21-hydroxylase accounts for 95% of all cases.

Having been treated for pulmonary tuberculosis (TB) 25 years earlier, a 60-year-old man (a nonsmoker) now complained of a chronic cough. The cough was occasionally accompanied by yellowish sputum but no hemoptysis. Examination revealed persistent coarse crackles in the right posterior hemithorax, and the x-ray study seen here established the diagnosis of cystic bronchiectasis.

A 45-year-old man had a red, somewhat annular, slightly scaly plaque studded with red nodules that covered the back of his right hand. Nail dystrophy was evident on the middle finger. The patient's left hand was free of lesions, but the soles of both feet were slightly red and scaly, and there was an annular, serpiginous border on the left foot.

For the past 2 days, a 30-year-old man had experienced scant hemoptysis. He had also lost a significant amount of weight-5 kg (11 lb)-over the last 2 months. The patient, a recent emigrant from Ecuador, had no history of tuberculosis (TB) or of exposure to this disease, and he had not been skin tested with purified protein derivative (PPD). He denied exposure to risk factors for HIV infection.

An 82-year-old man underwent right pneumonectomy for squamous cell carcinoma of the right lower lobe. His postoperative course was complicated by prolonged air leak from the chest tube, suggesting a bronchopleural fistula secondary to leakage from the bronchial stump. Over the ensuing 3 months, the air leak slowly decreased, but the patient was left with a nonhealing scar on the anterior thoracic cavity, as seen here.