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A 67-year-old woman noted the appearance of several non-tender, rock-hard, purple-colored nodules on her legs. Her medical history was significant for distant non-Hodgkin lymphoma.

A 67-year-old woman noted the appearance of several non-tender, rock-hard, purple-colored nodules on her legs. Her medical history was significant for distant non-Hodgkin lymphoma. The violaceous color and configuration of the skin lesions suggests which of the following? 

Clinical Topics

Hard Purple Nodules: Your Dx?

A 76-year-old woman seeks your attention for an asymptomatic “red spot” on her neck. She has a history of multiple non-melanoma skin cancers.

Squamous cell carcinoma in situ (Bowen  disease)

Lichenoid keratosis (an inflammatory variant of seborrheic keratosis)

A 76-year-old woman seeks your attention for an asymptomatic “red spot” on her neck. What does this look like to you?

What's This "Red Spot"?

With respiratory virus season underway, primary care physicians (PCPs) face the challenge of managing the "triple threat" of influenza, respiratory syncytial virus (RSV), and COVID-19 in their patient populations. With new vaccines, updated recommendations, and heightened awareness of respiratory viruses, primary care practices play a pivotal role in not only treating infection but also in educating patients and preventing severe disease across vulnerable populations. This season, as case surges are expected, a proactive, evidence-based approach is essential to protect high-risk patients and minimize strain on healthcare systems.

Each year, seasonal respiratory illnesses pose a predictable challenge to the health care system, but the convergence of COVID-19, influenza, and RSV has intensified that challenge. According to the US CDC, the 2022-2023 influenza season alone led to an estimated 31 million cases, 360 000 hospitalizations, and 21 000 deaths.

 Preliminary data for 2023-2024 show similar numbers with an estimated 34-75 million cases, 380 000-900 000 hospitalizations, and 17 000-100 000 deaths since October 1, 2023.

While COVID-19 cases have decreased from the peak pandemic levels, SARS-CoV-2 continues to evolve with new variants, causing surges that threaten at-risk populations.

 Meanwhile, RSV hospitalizations, especially among infants and older adults, continue to stress health care resources. Each year in the US, RSV leads to approximately 58 000-80 000 hospitalizations among children aged less than 5 years and 100 000-160 000 hospitalizations among adults aged 60 years and older, according to the CDC.

“Vaccines help protect patients, families, communities, and loved ones so we encourage everyone who is eligible to get vaccinated against COVID-19, the flu, RSV, and other CDC-approved immunizations,” said Tochi Iroku-Malize, MD, MPH, former board chair of the American Academy of Family Physicians (AAFP) in an interview with 

The CDC updated its vaccine recommendations for the 2024-2025 respiratory virus season to address the ongoing threats of COVID-19, influenza, and RSV, emphasizing the importance of immunization across various age groups.

The CDC advises that everyone aged 6 months and older receive the 

2024-2025 COVID-19 monovalent vaccine formulation

 regardless of prior vaccination history. The new formulation is based on the JN.1 lineage, which has been modified to include the KP.2 strain, aligning better with the circulating variants expected this fall and winter. The 

 that adults aged 65 years and older and people who are moderately or severely immunocompromised receive a second dose of 2024-2025 COVID-19 vaccine 6 months after their first dose. They also recommend that people who are moderately or severely immunocompromised receive 3 or more doses under shared clinical decision making.

The influenza vaccine composition has been revised to include updated strains. It is a trivalent formulation covering the H1N1, H3N2, and B/Victoria lineage. The CDC advises annual vaccination for all individuals aged 6 months and older, with specific recommendations for higher-risk groups, including older adults and those with underlying health conditions.

The CDC now recommends a single lifetime dose of 

 for all adults aged 75 years and older. “The other recommendation for the RSV vaccine is that people aged 60 to 74 years who are at a higher risk for severe RSV—including those who are immunocompromised or with diabetes, chronic kidney disease, and [chronic obstructive pulmonary disease] or asthma—should receive a vaccine, even though they are not 75 years and older,” said Steven Furr, MD, past president of the AAFP in an 

“This is a shift from last year’s recommendations, which stated adults aged 60 years and older should receive the vaccine based on shared decision making,” Iroku-Malize said to 

“Part of the reason for the change is that between 2016 and 2020, the CDC estimated that RSV led to approximately 90 000 to 140 000 hospitalizations per year in adults aged 65 years and older, and 10 000 to 20 000 hospitalizations for adults aged 60-64 years.”

, the agency recommends either the pregnant mother receive an RSV vaccine, or the infant gets immunization with an RSV monoclonal antibody, such as nirsevimab (Beyfortus, AstraZeneca and Sanofi). Real-world data from the CDC showed that 

 at preventing RSV-associated hospitalization in infants during their first RSV season.

While vaccines are effective in preventing disease, not everyone is rolling up a sleeve come immunization time. “We know that about 48% of adults and 54% of children received the flu vaccine last year,” Iroku-Malize said to 

“And that is unfortunate because that’s lower than it was the previous to the COVID-19 pandemic.”

 of 1006 people aged 18 years and older, 37% received vaccines in the past but did not plan to in 2024. The same percentage of respondents said they don’t believe they need any of the vaccines surveyed in the poll, including influenza, COVID-19, and RSV. The survey also found that a slight majority (56%) of adults have gotten or plan to get the influenza shot this fall, but less than half (43%) have gotten or plan to get the COVID-19 vaccine.

Vaccine hesitancy is fueled by a variety of factors including misinformation, barriers to access, and concerns about vaccine safety.

 of 1496 US adults, 28% of respondents incorrectly believed that COVID-19 vaccines have led to thousands of deaths, an increase from 22% in June 2021. One in 5 adults surveyed said it is safer to be infected with COVID-19 than to get the vaccine. The results also showed that many Americans question the efficacy of established vaccines, including RSV for older adults (37%), HPV (32%), RSV during pregnancy (47%), and pneumonia (23%).

“There's still a lot of misunderstanding because there's so much that has changed. There are additional vaccines and new vaccines, such as the RSV vaccine,” Furr said. “To tell you the truth, people are kind of confused and lost track, even us physicians, trying to keep up with the recommendations.”

Furr continued: “Some of the vaccine hesitancy is a lack of understanding of [which] vaccines are needed. In fact, patients can get multiple vaccines at once. They can get their influenza vaccine, COVID-19 vaccine, and RSV vaccine (if due), all at the same time.”

Another barrier to vaccine uptake is access. For some patients, it can be a challenge to coordinate time for an appointment to get immunized, especially if they live in a rural area with limited number of physicians. One option that may help improve access to vaccines is a self-administered option. In September, the 

Insights on how to manage the "triple threat" of flu, RSV, and COVID-19 this season.

Respiratory Virus Season 2024-2025: Expert Insights to Help Primary Care Prepare

David T. Ahn, MD

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