Infectious Disease

Numerous infections that are generally caused by Staphylococcus aureus also may be caused by Streptococcus species and vice versa.

For 2 to 3 weeks, a 64-year-old woman has had a worsening eruption around her neck and inner thighs. She says it is tender rather than itchy. She has never had a similar eruption, and she denies any exposure history.

For 6 months, a 54-year-old woman has had a chronically pruritic and tender eruption that is confined to her arms. She has been treated with ciprofloxacin, clarithromycin, mupirocin, and topical corticosteroids. About 2 years earlier, she underwent spinal fusion. She takes unknown pain medications, omeprazole, buspirone, propranolol, and estrogen.

THE CASE: A 7-year-old boy has had left ankle pain for 2 days. Neither he nor his mother can recall any recent trauma to the joint. He is usually very active, but he has been unable to bear weight on the left foot and has been resting in bed. His mother reports that he had some tactile fevers, which were transiently relieved with ibuprofen, and that he has been eating and drinking normally. Despite the application of ice and elevation, the ankle has become red and swollen.

A 51-year-old man is admitted to the hospital with painful ulcers on both lower extremities, severe anemia, and a 45-kg (100-lb) weight loss over the past year. Pain from the ulcers prevents him from walking. The ulcers developed about 5 years earlier, as a result of his wearing high boots for work; they began as small sores and grew over time.

An 83-year-old man examined on admission for end-of-life care due to profound dementia. His wife states that his penis has not changed in appearance, but knows that he always had concerns about it. To her knowledge he never had trouble voiding. Patient too impaired to discuss any topic coherently. Wife considers it unlikely he would have disclosed any symptom of this type to her.

A 30-year-old man with a 15 packyear smoking history presented for a follow-up evaluation of an asymptomatic whitish lesion on the tongue of 4 months’ duration. The lesion had not responded to oral therapy with either nystatin or fluconazole. The patient was distressed about the lesion’s appearance and his inability to remove it with a toothbrush.

In a patient receiving antifungal therapy for onychomycosis, it can be difficult to tell how much change has occurred in a treated nail from one visit to the next. To make it easier to monitor treatment progress, I notch the nail at the most proximal point affected by the fungal infection when antifungal therapy is initiated. Keeping track of the notch can help you determine whether the infection is receding.

This lesion appeared on the left outer thigh of a 28-year-old man after he took amoxicillin. The antibiotic had been prescribed for an upper respiratory tract infection with fever. Two years earlier, a lesion had appeared in the same anatomical region after ingestion of amoxicillin. A skin biopsy of the current lesion confirmed the diagnosis.

Diffuse abdominal pain with nausea, vomiting, and constipation developed in a 69-year-old man with poorly differentiated mesothelioma several days after he was hospitalized for left-sided intractable pleuritic chest pain that warranted opiates.

When a prescription is written for warfarin, all the risks of therapy are usually appreciated. The same may be said for other potentially problematic drugs, including lithium and phenytoin. Is the same circumspect reflection exercised during the all-too-common practice of prescribing antibiotics for trivial illnesses, such as viral upper respiratory tract infections (URTIs)?

For several months, a 45-year-old woman had ocular irritation, tearing, blurred vision, and swelling of the eyelids in both eyes. During that time, she had been treated for allergic conjunctivitis and blepharitis by several physicians, including an ophthalmologist. Her medical history included lupus and seasonal allergies, for which she was taking hydroxychloroquine and loratadine.

Benign prostatic hyperplasia (BPH)-histologically defined as stromal and epithelial hyperplasia beginning in the periurethral transitional zone of the prostate-affects up to 80% of 80-year-old men.[1,2] With progressive prostatic enlargement, bladder outlet obstruction can result. Although the exact mechanism is unknown, lower urinary tract symptoms (LUTS) can signal progressive BPH.

Using the Patient Health Questionnaire– 9 (PHQ-9) makes office visits for depression (both initial and follow- up) go faster and more smoothly.

The edges of some toenails curve inward and grow into the side of the toe, resulting in infection and the need for office surgery.

The patient is severely ill. Temperature is 39°C (102.2°F). Shortly after admission, she requires intubation with ventilatory support. Hypotension, acrocyanosis, and an ecchymotic rash consistent with purpura fulminans (A) rapidly develop.

This 14-year-old girl who is being treated for acne presents for a follow-up visit. Acne has cleared on her chest and face, except for the forehead. She tried tretinoin, clindamycin/benzoyl peroxide, and a sulfur/sulfacetamide compound with limited results. Her menses are regular, and she does not have excessive facial or body hair.

A 22-year-old man seeks medical attention at his college’s infirmary. He had been in excellent health until 1 week earlier, when he noted onset of fever, headache, and malaise.

An 89-year-old woman is seen because of a white area on the tongue. She has been hospitalized on a behavioral health unit for 2 weeks; 1 day ago, enoxaparin was begun for a new left leg deep venous thrombosis. Recent antibiotic therapy for a urinary tract infection; candidal vulvitis followed and was treated with topical clotrimazole. Has penicillin allergy.

The patient has a small-fiber sensory neuropathy that is managed with lamotrigine. She is a physical therapy student who has frequent patient contact. She drinks alcohol occasionally but denies smoking and illicit drug use; she says she is not sexually active.

In his “Dermclinic” discussion of tinea corporis (CONSULTANT, June 2008, page 517), Dr David Kaplan stated that “the family was advised to have their dog examined by a veterinarian because the pet was the suspected source of the dermatophyte.” Examination of the family dog is probably not necessary and can be an expensive recommendation. It is true that ringworm is a zoonotic infection that can be passed to and from both dogs and cats.

A 71-year-old man with diabetes seen on transfer to a rehabilitation unit after transmetatarsal amputation of left foot. Gangrene had occurred despite surgical revascularization.

Methicillin-resistant Staphylococcus aureus (MRSA) was once considered a strictly nosocomial pathogen. Over the past decade, however, MRSA has emerged as a prominent cause of community-associated infections in both adults and children. Although community-associated MRSA strains occasionally cause severe invasive infections, they are most frequently isolated from patients with skin and soft tissue infections.

This 43-year-old woman presents with a painful eruption of sudden onset; it is confined to her trunk. She is otherwise healthy.What is your clinical impression?

Persons who are unresponsive to the standard hepatitis B virus (HBV) vaccine regimen may benefit from a revaccination series using a double dose of the combined hepatitis A virus (HAV) and HBV vaccine.1,2