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A 43-year-old homeless woman presented with a 2-week history of fever, chills, sweats, generalized pain, and cough that was productive of purulent green-yellow sputum mixed with blood. She reported a 15-lb weight loss over the past 6 weeks.

Although the results of a thorough history and physicalexamination often suggest the diagnosis of asthma, confirmatorytesting is required and may be helpful in more subtlecases. Spirometry before and after bronchodilator administrationis the first step for the initial diagnosis; it also is an importantcomponent of the long-term assessment of asthma control.When the results of spirometry are normal in a patient in whomasthma is suspected, bronchoprovocation challenge testingwith methacholine is generally considered the next diagnosticstep. Numerous alternative methods of bronchoprovocationtesting have been developed, such as the challenge with adenosine5'-monophosphate. Novel methods such as the forced oscillationtechnique and the measurement of exhaled nitric oxidehold promise for more effective diagnosis and monitoringof asthma in the future. (J Respir Dis. 2008;29(4):157-169)

A 5-month-old boy presented with fever, cough, and tachypnea that he had had for 1 month. There also was a history of poor weight gain for 2 months. The child was born full-term at a private hospital, and the mother's antenatal course was uneventful. There was no postnatal history of bleeding, jaundice, diarrhea, poor feeding, vomiting, or seizures. There was no family history of tuberculosis.

When encountering a patient who may have occupational asthma, what is your approach to the initial evaluation? What are the most useful questions to ask?

The foundation of arterial blood gas (ABG) analysisconsists of determining whether the patient has acidosis or alkalosis;whether it is a respiratory or metabolic process; and,if respiratory, whether it is a pure respiratory process. If the patient'spH and PCO2 are increased or decreased in the same direction,the process is metabolic; if one is increased while theother is decreased, the process is respiratory. In a number ofclinical situations, pulse oximetry is preferred to ABG analysis.However, pulse oximetry may not be accurate in patients whoare profoundly anemic, hypotensive, or hypothermic. Whilevenous blood gas (VBG) analysis does not provide any informationabout the patient's oxygenation, it can help assessthe level of acidosis or alkalosis. VBG analysis may be particularlyuseful in patients with diabetic or alcoholic ketoacidosis.(J Respir Dis. 2008;29(2):74-82)

Pseudomonas aeruginosa is a major cause of nosocomial infections, including ventilator-associated pneumonia (VAP). Effective management of pneumonia caused by this pathogen has been hindered by the increased incidence of multidrug resistance and limited treatment options. The results of a study conducted in Spain underscore the importance of choosing the right antibiotic-or combination of antibiotics-for the initial empiric therapy.

Two studies provide further evidence that relatively low levels of air pollution have adverse respiratory effects. However, one of the studies suggests that improvement in air quality can slow the decline in pulmonary function.

We present a case of a 52-year oldwoman with exudativepleural effusion. Her workuprevealed an ovarian tumor,and the effusion completely resolvedafter resection of the tumor.Pathology revealed granulosacell tumor, which is anunusual cause of Meigs syndrome.This case shows theimportance of considering abdominopelvicpathology in unsolvedcases of pleural effusion.

The case presented here illustratesthe diagnostic challengesand potential severity of a fungalinfection.

Dull, intermittent, midepigastric abdominal pain of 1 day's duration prompted a 73-year-old man to seek medical attention. He had no other symptoms.

A 26-year-old white man had blurred vision for 4 weeks. A sluggish light reflex was noted in the left eye. Funduscopic examination showed left-sided optic disc swelling with dot hemorrhages and hard exudates.

Methicillin-resistant Staphylococcus aureus (MRSA) first came to the attention of health care providers as a nosocomial pathogen.1 More recently, MSRA has emerged as an important community-acquired pathogen2 and has been a cause of infection in men who have sex with men (MSM)3,4 and in persons with HIV-1 infection.5-7 Other reports include clusters of MRSA infection in prison inmates,8 military recruits,9 and athletes.10

Histoplasmosis is a fungal infection caused by Histoplasma capsulatum. Although immunocompetent persons with H capsulatum infections are usually asymptomatic, several clinical syndromes can manifest in immunocompromised patients.

How best to reduce the risk of osteonecrosis of the mandible in patients who take bisphosphonates? Bisphosphonates have a profound effect on osteoclast function: they inhibit bone remodeling, and then cellular apoptosis occurs. These drugs have been remarkably effective in the management of diverse diseases.

Systemic lupus erythematosus (SLE) is an unpredictable multisystem disease that affects more than 1.5 million Americans and at least 5 million persons worldwide, according to the Lupus Foundation of America (LFA).

A 39-year-old woman complained of excruciating pain that radiated from a chronic lesion on the left upper lip to the entire left side of the face. She had AIDS (CD4+ cell count, 68/µL; HIV RNA level, greater than 750,000 copies/mL) but was not receiving antiretroviral therapy. The lesion first appeared as a blister, which ruptured after it was struck by a toy thrown by her son. It enlarged and became more painful despite antibiotic therapy and a 1-month course of valacyclovir. During this period, she had no fever. She used marijuana and alcohol for pain control.

Case 1: During the past few weeks, a 14-year-old boy has noticed blood on the proximal nail folds of the second and third fingers of his dominant hand. He denies any pain or pruritus. The patient is otherwise healthy and takes no prescription medications.Which of these questions do you ask the patient?A. What sports do you play?B. What are your extracurricular activities?C. Do you bite your nails?D. Do you take any over-the-counter medications or alternative remedies?E. All of the above. (Answer on next page.)

Cancer of the anal canal is a relatively uncommon disease in the United States. It accounts for about 2% of the cancers of the GI tract; about 5000 cases will be diagnosed this year. Squamous cell carcinoma of the anus (anal SCC) is of particular interest to the infectious disease specialist because it is one of the cancers associated with HIV infection in men who have sex with men (MSM).