Infectious Disease

Primary care physicians are usually the first to see patients with joint pain; consequently they represent the "front line" of RA care. This fact-coupled with the projection that the number of rheumatologists is expected to decline by 20% during the next 2 to 3 decades-underscores the pivotal role that primary care clinicians are now expected to play in the early diagnosis of RA.

Abstract: The use of sputum studies and blood cultures in patients hospitalized with community-acquired pneumonia (CAP) is somewhat controversial, and recommendations continue to evolve. A reasonable approach is to attempt to obtain sputum cultures from all patients before initiating antibiotic therapy. If antibiotics have already been given, sputum studies can be reserved for patients who are severely ill or who are at risk for infection with a resistant organism or an organism that is not covered by the usual empiric therapy. The Infectious Diseases Society of America and the American Thoracic Society both recommend obtaining blood cultures from all patients. However, cost considerations have led to alternative strategies, such as reserving blood cultures for those with severe CAP. (J Respir Dis. 2005;26(4):143-148)

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

A 67-year-old woman underwent right pneumonectomy for non-small-cell carcinoma of the right lung. Her postoperative course was uneventful, and she was discharged from the hospital on the fifth day.

Abstract: For some patients with allergic rhinitis, symptoms can be reduced substantially by the use of allergen avoidance measures. However, many patients require pharmacotherapy, including antihistamines, decongestants, and intranasal corticosteroids, to adequately control their symptoms. The oral antihistamines are effective in reducing rhinorrhea, itching, and sneezing but are not effective against nasal congestion. Intranasal azelastine has been shown to be beneficial in patients with moderate to severe symptoms that are not sufficiently controlled by an oral antihistamine. Additional therapies include intranasal ipratropium, which specifically targets rhinorrhea, and cromolyn, which can reduce many of the symptoms of allergic rhinitis and can be used prophylactically. (J Respir Dis. 2005;26(4):150-162)

A 38-year-old man presented to the emergency department (ED) with a 2-week history of worsening shortness of breath and dry cough. He also complained of anorexia, a 14-kg (30-lb) weight loss over 3 months, pleuritic chest pain, and night sweats.

Yellow, thickened nail plates; complete or partial loss of fingernails; asymptomatic greenish black discoloration--what do you suspect is the underlying cause in these cases?

A 13-year-old boy has had mild right knee pain for about 1 week; the pain was exacerbated by a collision and subsequent fall during soccer practice. He recently began playing soccer on a team that practices every weekday and has games on the weekends. He has played since his collision, but the knee pain has progressively worsened.

Two ringed, extremely pruritic lesions were noted on a 6-year-old girl receiving immunosuppressive therapy after she had undergone heart transplantation. The mother reported that the lesion on the chin had appeared 7 to 10 days earlier and had gradually increased to the present size; she did not know when the lesion on the upper chest had appeared. The child had no other lesions. Her cousin had had similar findings about 2 to 3 weeks earlier.

A 45-year-old Asian man presents with a 3-week history of weight loss, poor appetite, fatigue, intermittent sweats, and a nonproductive cough. The patient, a recent immigrant, denies previous illness.

Now that the role of inflammation in the pathogenesis of cardiovascular disease has been recognized, biomarkers of inflammation have become the subject of intense research interest. Once considered a novel cardiovascular risk factor, the inflammatory biomarker C-reactive protein (CRP) is currently believed to improve global risk prediction in patients not previously deemed at high risk.

A 69-year-old woman was hospitalized with fever, chills, and nausea. Three weeks earlier, she had received a 2-week course of oral levofloxacin for pneumonia, which resolved. Her history included rheumatic heart disease; diabetes mellitus; depression; a hysterectomy; 2 mitral commissurotomies; nonrepairable mitral valve regurgitation, for which she received a St Jude Medical bileaflet valve; a left-sided cerebrovascular accident; and paroxysmal atrial fibrillation. Her medications included verapamil, furosemide, metoprolol, potassium chloride, metformin, nortriptyline, and warfarin. She denied tobacco and alcohol use.

Instead of recommending that patients use gauze to protect their underwear after rectal surgery, tell them to try self-adhering feminine hygiene mini pads.

When a patient presents with unilateral abdominal pain, always consider shingles--especially if the patient is elderly.

A 39-year-old woman has a tender vesicular rash on her finger. A similar rash that had appeared on the same finger 1 year earlier responded slowly to a course of oral cephalexin

ABSTRACT: Although the widespread use of prostate-specific antigen (PSA) testing has led to an increase in the number of cancers detected, controversies about the benefits of screening persist. No conclusive evidence has yet emerged that PSA screening reduces the mortality associated with prostate cancer. Thus, mass screening is not universally endorsed. The American Urologic Association and the American Cancer Society recommend that digital rectal examination and PSA testing be offered annually to men 50 years and older with an estimated life expec- tancy of 10 years or more. High-risk patients (those with a positive family history or those of African American descent) are advised to begin screening at age 45. The decision to screen is based on the patient's preference following a thorough discussion of the benefits and limitations of PSA testing. Refer to a urologist any patient with a PSA greater than 4.0 ng/mL. Also, be alert for high PSA velocity changes in patients undergoing annual screening, and refer those with a PSA velocity of more than 0.75 ng/mL/y.

Painful cysts on the sternal and left axillary regions that had worsened over the past 3 weeks prompted a 42-year-old man to seek medical care. He reported that similar lesions in the same distribution first arose when he was 25 years old, and they recur each year. He denied having cystic acne in adolescence.

For a year, a 31-year-old man had asymptomatic, malodorous discoloration of the toe web spaces. He stated that his feet perspire heavily in the boots he is required to wear for work.

A 23-year-old man presents to theemergency department (ED) withacute chest discomfort, which startedin the morning. He describes the discomfortas more akin to palpitationsthan to actual pain. The discomfortis midsternal, nonradiating, nonpleuritic,and associated with dyspnea; itis neither exertional nor positional.There is no viral prodrome.

These painful eczematous lesionsat the angle of the mouth and thebase of the nostrils had been presentin a 52-year-old woman for 3days (A). Some of the vesicles hadulcerated and left a crust over theregion. The patient said she had hadsimilar attacks in the past. The diagnosisof recurrent herpes simplexvirus 1 (HSV-1) infection was made.The patient was treated with acyclovirfor 1 week, and all the lesionsdisappeared.

An 18-year-old man presented with a 3-day history of fever, sore throat, and neck swelling. He had previously been healthy, and his immunizations were up-to-date. There was no history of travel outside the country or of an animal bite or scratch.

For a year, a 31-year-old man had asymptomatic, malodorous discoloration of the toe web spaces. He stated that his feet perspire heavily in the boots he is required to wear for work.

Painful cysts on the sternal and left axillary regions that had worsened over the past 3 weeks prompted a 42-year-old man to seek medical care. He reported that similar lesions in the same distribution first arose when he was 25 years old, and they recur each year. He denied having cystic acne in adolescence.

When you suspect blunt nerve trauma, referral to a hand surgeon is prudent-even without evidence of acute compartment syndrome. The same is true if you discover ischemia in any part of the hand after injury. Try to control hemorrhage with compression and elevation of the involved extremity. If this is unsuccessful, use a short-duration tourniquet. Do not attempt to clamp a bleeding vessel; the risk of causing serious nerve or tendon damage is too high. Avoid exploring wounds in the region distal to the midpalmar crease and proximal to the proximal interphalangeal flexor crease because of the high risk of damaging the flexor tendons and the annular ligaments in this region. Explore more proximal injuries cautiously to determine occult injury to the flexor tendon.

ABSTRACT: To determine the stability of the injury, examine phalangeal and metacarpal fractures for intra-articular involvement. Suspect carpal bone fracture in any patient with wrist pain and tenderness; proper splinting is essential to prevent avascular necrosis of the bone, arthritis, and chronic disability. After successful reduction of a distal or proximal interphalangeal joint dislocation, order follow-up x-ray films. Apply stress testing of the joint space to all injured joints to ensure ligamentous integrity. Carpal and carpometacarpal dislocations require immediate consultation with a hand specialist. Therapy for bite wounds includes copious irrigation, debridement (in the operating room if necessary), and antibiotic prophylaxis. A patient with an infected bite wound requires hospitalization and intravenous antibiotics.

Appropriate foot care, preventive measures, and early intervention reduce the incidence of complications and lower extremity amputation in patients with diabetic foot ulcers. A thorough lower extremity examination includes assessment of the skin, interdigital areas, skin quality and integrity, and ulcerative or pre-ulcerative changes. The key to prevention is patient education and lifelong commitment to self-care.

A 65-year-old woman presented withdouble vision of 2 days’ duration.The diplopia mainly occurred whenshe looked toward her right. She deniednausea, vomiting, vision loss,headache, change in mental status,facial pain, weakness in the extremities,and sinus infection. She had nohistory of head trauma or systemicmalignancy.

The multiple, uniformly scaly, coin-shaped, papulosquamous lesions shown here on the lower leg of a 61-year-old man had persisted for 3 months despite application of topical clotrimazole and 1% hydrocortisone. The rash involved only the legs and was variably pruritic. The patient had a long history of dry skin.

A 58-year-old man with type 2 diabetes mellitus and hypertension was hospitalized with acute diarrhea characterized by several brown, liquid depositions per day. He also complained of lower abdominal pain and bloating and a 10-lb weight loss in the past 2 months. He denied fever or chills, use of corticosteroids, and travel outside the United States.

Unrelated abnormalities in the preauricular area were noted in a 50-year-old man who had presented with acute rhinosinusitis following an upper respiratory tract infection. The patient stated that he had had these deformities since birth.