Infectious Disease

As a screener and admissions committee member at our medical school (University of California School of Medicine at Davis), I am privileged to review the personal statements of many, many applicants who want to be doctors in spite of the recent hard times in our country that have led more than a few American physicians to believe that our profession is less valued and less desirable as a life work than it has been in the past.

A 62-year-old woman presents with epistaxis from the right nostril. Thenosebleed has lasted about 90 minutes, and she has become alarmedby the amount of blood on the tissues and washcloth she has applied to hernose.

Read the details from 3 unique cases on GI disorders: dieulafoy lesion, colovesical fistula, and intussusception.

Physical changes that occur in aging skin (eg, dryness and thinning) can result in pruritus and cause patients to rub, scratch, and pick at their skin. These activities produce various dermatoses and reactive changes in the skin, such as postinflammatory pigmentary alteration. Lichen simplex chronicus (LSC) develops as a physiological cutaneous response to repetitive scratching or rubbing. First-line treatment consists of topical corticosteroids and application of ice to reduce the sensation of itching. Like LSC, prurigo nodularis results from rubbing and scratching the skin. Treatment is similar; however, intralesional corticosteroids and UV therapy play more of a role because prurigo nodularis is more intensely pruritic than LSC.

What is the role of the primary care practitioner in the care of patients with HIV infection?Although the treatment of human immunodeficiency virus type 1 (HIV-1) infection is usually directed by subspecialists, many patients who are taking highly active antiretroviral therapy (HAART) continue to see their primary care physician. What is the most effective regimen-and what complications should we be on the lookout for?

We lie awake in our one-room hut before dawn listening to the cacophony of sounds emanating from the forest as the birds awake. The Bwindi Impenetrable Forest of Southwest Uganda contains over 350 species of birds, and it seems that they are all chattering to each other at once. The Bwindi Forest is also home to more than half of the world’s 650 mountain gorillas.

A documented anti–varicella-zoster virus (VZV) titer is generally accepted as evidence of protection against VZV infection, and a known case of shingles, such as that described in the Photoclinic case of an older man with ophthalmic zoster (Tran KT, Qualm AS, Shannon MA. CONSULTANT, December 2009, page 767), might reasonably be expected to boost anti-VZV titers in the affected patient. Why then would administration of the zoster vaccine be included in this patient’s treatment plan?

A 51-year-old man is seen because of a painful groin rash. Has not cleared despite 3 months’ topical corticosteroids and antifungals.

H1N1 influenza has paid an unwelcome visit to a number of nursing homes, reports the CDC.

Most travelers to Third World countries encounter health-related problems during their stay and may require medical attention on returning home. Although malaria is still the most common diagnosis among travelers to the developing world, several other infectious diseases, such as dengue fever, chikungunya fever, and leishmaniasis, are growing in importance. Clinicians need to stay informed about travel requirements and vaccine recommendations for US citizens.

A 38-year-old man had fever and fatigue for the past 6 days and tenderness in the left upper abdominal quadrant for the past 3 days. He also had a facial butterfly rash that had been present for 10 years and a 1-year history of lupus nephritis, treated with prednisone and mycophenolate. He denied respiratory complaints or recent weight loss.

In 2010, CONSULTANT marks its 50th year of service to primary careclinicians. On our golden anniversary, it seems appropriate to reflect onthe challenges, rewards, and frustrations of current medical practice.

MedImmune is recalling 13 lots of monovalent 2009 H1N1 influenza nasal spray vaccine whose potency has decreased or is expected to decrease shortly.

A single dose of 2009 influenza A (H1N1) vaccine induced protective antibody titers in more than 90% of children in an Australian study.

For 1 month, a 60-year-old white man has had increasing fatigue, generalized weakness, and exertional dyspnea. He becomes short of breath after he walks only 100 to 150 yards on level ground or climbs only 1 flight of stairs. In addition, he has unintentionally lost 12 lb in the past month and has experienced intermittent dysphagia with solid foods. He attributes this last symptom to long-standing gastroesophageal reflux disease (GERD), for which he regularly takes over-the-counter omeprazole.

For 3 months, a 43-year-old Bolivian woman had worsening thoracic and lumbar pain associated with tingling and tightness in the anterior upper and lower abdominal area, and numbness in the lower extremities. Her symptoms also included difficulty in walking (with frequent falls from imbalance), occasional urinary incontinence for the past few weeks, occasional afternoon low-grade fevers, and poor appetite with an associated 10-lb weight loss within the past 4 months.

A 31-year-old Bangladeshi man presented with dull, aching abdominal pain primarily in the right flank. The pain began a week after he underwent exploratory laparotomy for a perforated duodenal ulcer. He had been taking oxycodone/acetaminophen, docusate sodium, and omeprazole since the surgery.

Although the prevalence of tuberculosis (TB) in the United States continues to decline (from 2006 to 2007, the total number of TB cases declined 4.2%, from 13,779 cases to 13,293), the rate of decline has slowed in recent years.1 The rate in foreignborn persons is much higher than in US-born persons and appears to be increasing.1

For 10 days, a 55-year-old man had a productive cough and progressively worsening rightsided chest pain that was sharp, nonexertional, and worse with deep inspiration and movement. He denied hemoptysis, fevers, sick contacts, or recent travel.

Several days earlier, a 69-year-old man had a mild headache, fatigue, and tingling and prickly facial sensations. Shortly afterward, this painful, “weepy” rash developed on his forehead, upper cheek, and nasolabial folds and vision in the right eye became blurry. The patient’s history included type 2 diabetes mellitus, hypertension, and childhood varicella.

Case 4: An obese 59-year-old man presents with a chronic malodorous, itchy rash in his groin.

Candida infection causes pruritus, burning, and erythema in the vulvovaginal area.

A 28-year-old man presents for evaluation of a nonresolving rash in his groin. The rash has persisted despite the patient’s use of over-the-counter antifungal creams. What do you suspect?

Scabies is often seen in axillary folds and the periumbilical area; severe nocturnal itching is a hallmark.

Although the future clinical implications of mutations in the H1N1 influenza virus remain unclear, these changes do not pose an immediate threat.

Nail lesions shown here: Onychogryphosis, pseudomonal infection, myxoid cyst, onycholisis.

Contemporary “weekend warriors” are not impressed by the sporting and recreational pursuits of their parents. As a result, they have invented novel games and intensified other activities already considered rigorous a generation ago.

A 51-year-old man with a 12.5-pack-year smoking history had symptomssuggestive of gastroesophageal reflux disease for 6 weeks.

Both seasonal and H1N1 influenza pose a greater risk of severe illness and complications in patients with diabetes-and these infections can also wreak havoc with blood glucose levels.

This abdominal rash developed while a 63-year-old woman was traveling in Israel. She was admitted to the hospital, where she received intravenous antibiotics, and was discharged after 5 days. She now returns to the United States and wonders what she had, because she did not understand what the physician in Israel had told her. She has brought all of her medical records.