Infectious Disease

A pruritic rash under the left breast has bothered a 67-year-old woman forthe past month. She takes an antihypertensive and is otherwise healthy.

For 3 months, a 66-year-old retired man has had increasingweakness of the lower legs with stiffness,tingling, and numbness; worsening ataxia; anergia; andexertional dyspnea of insidious onset. He has lost 8 lb,and his appetite is poor. He denies fever, cough, chest orabdominal pain, paroxysmal nocturnal dyspnea, orthopnea,ankle swelling, bleeding disorders, hematemesis,melena, headache, vision problems, sciatica, joint pain,bladder or bowel dysfunction, and GI symptoms. He hasnocturia attributable to benign prostatic hypertrophy.

A 52-year-old woman presents with a3-month history of a tender, erosivedermatitis on the nipples and in thevulvar/perineal region. Can youidentify these lesions?

For the past week, a 16-year-old boy has had a progressively worsening dry, irritating cough; dyspnea on exertion; and intermittent fever and chills. During the past 24 hours, he has had no appetite and has vomited greenish material 3 or 4 times.

Historically, tuberculosis (TB) was the most commoncause of hemoptysis. Classic operas, such asLa Traviata and La Bohème, featured dramatic scenes ofhemoptysis, often with the heroine dying following episodesof deep passion and coughing.

Q:My patient has an elevated hemoglobin concentration and hematocrit; however, the reticulocyte count, ferritin level, results of hemoglobin electrophoresis, and total iron-binding capacity are normal. What is the next step after common causes of an elevated hemoglobin concentration and hematocrit, such as chronic obstructive pulmonary disease, have been ruled out?

A 32-year-old man complains ofknee pain that resulted when he felland twisted his right knee skiing theday before. He suffered other minorcontusions from the fall, but none ofthese required medical attention. Heis otherwise in good health and hasno relevant medical history.

Quinolones are commonlyused to treat a widevariety of infectious diseases,such as community-acquired pneumoniaand urinary tract infections. Somequinolones are also given as prophylaxisfor spontaneous bacterial peritonitis.These popular antimicrobial agents areassociated with several clinically significantdrug interactions, which can beclassified into 2 major categories1-3:

A 56-year-old African American man presents with a painful “raw” lip that hasgradually developed during the summer. Physical examination reveals a geographic,superficial erosion; notably, the erosion is surrounded by hypopigmentedand, most distally, hyperpigmented rings. The patient believes that exposureto sunlight has aggravated the condition.

For several days, a 35-year-old woman has had a swollen, painfulfinger. She is otherwise healthy and has no significant medical history.

For 3 months, a 41-year-old womanhas had a pruritic acneiform eruptionon the lateral aspects of the neck andthe left side of the face. She is otherwisehealthy and takes no medication.

A 16-year-old boy presents for evaluation of various lesionsthat have appeared on his extremities since he joined thewrestling team 2 months earlier. He is otherwise healthyand takes no medications.

A thin 26-year-old man has hadintermittent diarrhea with abdominalpain, nausea, vomiting, and occasionalepisodes of hematochezia for8 months. He also complains of weaknessand fatigue and has lost 4.5 kg(10 lb) in the past year. The patientis homosexual and admits to havinghad unprotected sexual intercourse.He denies any significant travelhistory.

A 51-year-old woman has had a progressiverash on the trunk, proximalarms, and legs for 2 weeks, followingthe latest round of chemotherapy forbreast cancer. Around the time thatthe rash erupted, she was also takinglevofloxacin for a productive cough.Cutaneous lupus erythematosus wasdiagnosed years ago, but she hasbeen disease-free for the past 5 years.Chemotherapy is being withheldpending diagnosis of the rash.

For the past 3 days, a 45-year-old man has had discomfort andloss of hearing in one ear. There is no fever or history of trauma. The manwas recently treated for an ear infection at a local clinic. Physical examinationreveals erythema of the postauricular area and purulent exudate from the earcanal.

A 46-year-old man presents with right-sided facial paralysis. His symptoms beganthe previous evening when he had difficulty in closing his right eye; by morning,paralysis had developed. He also reports headache and mild photophobia.

To minimize pain when repacking anabscess, remove the old packing, thensquirt 1 mL of 1% lidocaine into theopen wound with a syringe (no needlenecessary).

Telithromycin (Ketek) from AventisPharmaceuticals Inc., is now availableto treat acute exacerbations of chronicbronchitis, acute bacterial sinusitis,and mild to moderately severe community-acquired RTI-includingthose caused by multidrug-resistantStreptococcus pneumoniae. Telithromycin,the first available ketolide, selectivelytargets common respiratorybacteria without significant effects onbacteria not normally associated withRTIs.

The FDA has approved rifaximin(Xifaxan), from Salix Pharmaceuticals,Inc., for treatment of traveler’sdiarrhea caused by noninvasive strains of Escherichia coli. Rifaximinis a nonsystemic, GI-selective, oralantibiotic; the recommended dosageis 200 mg tid for 3 days.

Among American children,acute otitis media(AOM) is the most commonbacterial infectiontreated with antibiotics.Rising rates of antibacterial resistancecoupled with the increasingcost of antibiotics have focused attentionon the need to prescribethese agents judiciously. Recently,the American Academy of Pediatricsissued recommendations on the diagnosisand management of uncomplicatedAOM in children aged 2months to 12 years.1 These guidelinesapply only to otherwise healthychildren who have no underlyingconditions that may alter the naturalcourse of AOM, such as cleft palate,Down syndrome, immunodeficiencies,or the presence of cochlear implants.Also excluded are childrenwho have recurrent AOM or AOMwith underlying chronic otitis mediawith effusion (OME). Highlights ofthe guidelines are presented here.

Tinidazole (Tindamax), from PresuttiLaboratories, Inc., has been approvedfor treatment of trichomoniasis, giardiasis,intestinal amebiasis, and amebicliver abscess. A single 2-g doseis recommended for patients with trichomoniasisor giardiasis; in amebicdysentery, the recommended dosageis 2 g/d for 3 days. Patients with amebicabscess from amebic hepatitis require2 g/d for 3 to 5 days.

Trospium chloride (Sanctura) recentlybecame available for the treatmentof overactive bladder and urge urinaryincontinence. This drug, fromIndevus Pharmaceuticals, is a muscarinicreceptor antagonist that relaxesthe smooth muscle tissue of thebladder, thereby decreasing contractionsand counteracting overactive orunstable detrusor muscle function.

abstract: The keystone of influenza prevention is still vaccination. The 2 available types of influenza vaccine--the inactivated vaccine, which is administered intramuscularly, and the attenuated vaccine, which is delivered via nasal spray--have efficacy rates of 70% to 80%. Unfortunately, only about 65% of persons who should receive the influenza vaccine are, in fact, vaccinated. The neuraminidase inhibitors oseltamivir and zanamivir are 70% to 90% effective in preventing influenza. These antivirals also are effective in reducing the severity of influenza symptoms and the duration of illness when administered within 48 hours of the onset of clinical disease. Some patients have difficulty in self-administering zanamivir because the inhalation process is fairly complicated. Because of the resistance pattern observed in 2005, amantadine and rimantadine are not currently recommended for prophylaxis or therapy. (J Respir Dis. 2007;28(1):21-29)

My patient-an 84-year-old woman with hypertension-presented with itchingand blistering of 3 days’ duration on her right foot (Figure).

What Are Trigger Points?Tender areas, swellings, or knots under the skin are referred to as“trigger points.” Injection of these trigger points with medication mayalleviate discomfort. At times you may feel pain in an area distant fromthe trigger point. Your doctor will feel the various muscle groups tolocate the trigger points and the most tender areas.