Infectious Disease

ABSTRACT: The emergence of drug-resistant pneumococci has changed the empiric treatment of community-acquired pneumonia. Newer fluoroquinolones with activity against Streptococcus pneumoniae offer an alternative in the treatment of infection with penicillin-resistant strains. These agents are not recommended as first-line therapy because of concerns about the development of resistance. Reserve the fluoroquinolones for patients who are allergic to macrolides and β-lactams, have failed to respond to a first-line agent, or have a documented infection with a highly resistant strain. The pneumococcal vaccine is recommended for all persons aged 65 years and older, adults with chronic car-diopulmonary diseases, and immunocompromised persons. Consider revaccination every 6 years in asplenic patients and immunocompromised persons. In addition, vaccination against influenza can help prevent secondary pneumonia and reduce the need for hospitalization.

For 36 hours, a 75-year-old woman had experienced weakness of the right side of the face. She was unable to close the right eye and drooled from the right side of the mouth. There was no weakness, numbness, or tingling of the extremities.

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

I read with interest Michael Rothstein’s Practical Pointer,“No More (Foot) Fungus Among Us” (CONSULTANT, August2002, page 1185).

Cutaneous lesions can develop in anumber of pulmonary diseases, suchas tuberculosis and sarcoidosis, as wellas in other diseases that may have pulmonaryinvolvement, such as Wegenergranulomatosis, collagen vasculardiseases, varicella, and pneumococcalinfections. In many cases, knowledgeof the clinical and histologic characteristicsof the skin lesions associatedwith these diseases can greatly facilitatediagnosis.

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.

A 34-year-old woman complains of headaches that interfere with work. Her first headache episode, approximately 6 yearsearlier, was relatively mild. Initially, she experienced attacks only once every 3 to 4 months and managed them effectivelywith over-the-counter (OTC) agents. However, in the last 6 months the attacks have become more frequent-they occur atleast twice a month-and are so severe that she misses work.

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.

ABSTRACT: Systematic palpation can detect a trigger point; often, muscle spasms or a nodule will be present. Injection of the trigger point with a local anesthetic usually reduces pain promptly; the procedure can also effect long-term pain relief and increased range of motion. However, pain may recur and even worsen 1 to 3 days after an injection-either because additional injections are needed or because the trigger point was not completely injected. To maintain pain relief and improve strength and range of motion in the affected muscle following injection, recommend stretching exercises, physical or massage therapy, or rest. Trigger point injections can be associated with adverse effects (eg, temporary numbness, injection site irritation, and dizziness); complications include vasovagal syncope, skin infection, and compartment syndrome.

Patients with ankylosing spondylitis areat increased risk for fractures (particularlyextension fractures of the cervicaland thoracolumbar spine) and spinalcord injury. Fractures in these patientsare extremely unstable; in fact, they areamong the most complication-prone ofall cervical spine injuries likely to beseen in the primary care setting.

For the past 3 months, a 72-year-old man has had progressivelyworsening dyspnea on exertion and constantvague discomfort in the left chest that appears to have apleuritic component. He denies paroxysmal nocturnaldyspnea and has no history of chest trauma. However, hehas a chronic cough that sometimes produces purulentsputum-although it is not associated with hemoptysis.His feet swell occasionally, and he has mild anorexia andhas lost 20 lb in 6 months.

A 76-year-old woman is admitted to the hospital for increasing fatigue and weaknessthat began about 3 weeks earlier. Her symptoms have worsened duringthe past week to the point of profound weakness and both dyspnea and nearsyncopewith minimal exertion.

Satellite lesions are usually associated with Candidainfections but not with Bowen disease.

Frequently, I have seen cerumen removal with water picks and syringesresult in trauma, including significant tympanic membrane perforation,and infection; thus, I no longer use these devices.

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

For 10 years, a 22-year-old woman had had an erythematous, translucent patch of grouped blisters on her left thigh. A recent increase in the size of the patch prompted the patient to seek treatment. There was no burning or tingling at the site. The patient reported that the erythema occasionally cleared; however, the blisters always remained. She denied fever, weight loss, and other constitutional symptoms.

A 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.

The diagnosis of osteoarthritis (OA) is primarily clinical. Key historical clues to idiopathic OA include patient age greater than 45 years, joint pain that increases with activity and is relieved with rest, morning stiffness of 30 minutes duration or less, and involvement of one or more of the following: hips, knees, cervical or lumbar spine, basilar thumb joints, interphalangeal joints of the hands, midfoot joints, and first metatarsophalangeal joints.

Back pain is second only to upper respiratory tract infection as the most frequently reported illness in the United States; up to 20% of Americans experience back pain each year.

ABSTRACT: Topical agents can provide temporary relief from osteoarthritis symptoms with little or no risk. Acetaminophen is first-line oral therapy. Be alert for risk factors for NSAID-induced GI toxicity, such as concurrent use of prescription and OTC agents. Tramadol, narcotic analgesics, muscle relaxants, and antidepressants are options when NSAIDs are ineffective or contraindicated. Intra-articular injections of corticosteroids or hyaluronan are appropriate for patients who have a single joint exacerbation. Total knee and total hip arthroplasty are considered the most effective surgical interventions.

A 53-year-old man has hadmalaise, intermittent cough, and occasionalfever and night sweats for 2weeks. He has also lost some weightduring this time but denies hemoptysisand sputum production; he hasnot traveled abroad recently. His onlysignificant medical condition is hypertension,which is well controlled withmedication.

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.

ABSTRACT: Unless the cause of back pain is obvious, order anteroposterior and lateral radiographs of the spine, a complete blood cell count, erythrocyte sedimentation rate, and urinalysis. If you suspect infection, tumor, or bony abnormalities, obtain an MRI or CT scan. MRI has surpassed bone scanning as the gold standard for diagnosing spinal infections, because it confirms a specific anatomic diagnosis. Spondylolysis and spondylolisthesis are 2 of the most common causes of back pain in adolescents; the diagnosis is made with plain radiographs, which show slippage on the later-al view in patients with spondylolisthesis and fracture through the pars interarticularis on the oblique views in those with spondylolysis.

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.