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The authors present a case in which the initial manifestation of systemic lupus erythematosus (SLE) was diffuse alveolar hemorrhage (DAH), which is a rare presentation that carries a high risk of death. The patient failed to respond to standard therapy but was successfully treated with plasmapheresis.

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ABSTRACT: Many patients with osteoarthritis (OA) try such complementary therapies as special diets, nutritional and herbal supplements, yoga, t'ai chi, magnets, and acupuncture-but only 40% of these patients tell their physicians. Glucosamine and chondroitin sulfate can produce at least symptomatic relief; in addition, glucosamine (1500 mg/d) may increase or stabilize cartilage in osteoarthritic knees. Alert patients to the potential toxicities of many herbal remedies, as well as the risks of harmful drug interactions and possible contaminants and impurities. Yoga postures may have a beneficial effect on knee OA; t'ai chi may reduce joint pain and swelling and increase mobility. Small studies have shown that applied pulsed electromagnetic fields can reduce pain and improve function in patients with chronic knee OA. Acupuncture has also been shown, in small studies, to alleviate the pain of OA. Autologous chondrocyte transplantation was recently approved for treatment of knee OA. The efficacy and safety of various types of gene therapy are currently being evaluated.

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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.

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Approximately 1 million cases of herpes zoster are diagnosed in the United States every year. Here, a refresher on the virus and a good look at the rash.

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An obese 56-year-old woman was hospitalized after 2 days of chest pain, shortness of breath, and palpitations. Physical examination revealed no abnormalities, and serial cardiac enzyme studies and an ECG ruled out myocardial infarction. However, transesophageal echocardiography showed a lesion in the mediastinum.

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abstract: Pulmonary disease caused by nontuberculous mycobacteria (NTM) can be challenging to diagnose and manage. Patients typically present with nonspecific symptoms, such as cough and fever, and they often have underlying lung disease, which further complicates both diagnosis and treatment. To avoid treating pseudoinfection, the diagnosis should be based on a combination of the history and results of physical examination, radiographic imaging, and smears and cultures of at least 3 sputum samples. Occasionally, it is necessary to perform bronchoalveolar lavage or obtain tissue via transbronchial or open lung biopsy for histopathology and to assess for tissue invasion. Treatment involves a long course of often costly multiple antimycobacterial drugs. However, treatment with the second-generation macrolides, clarithromycin and azithromycin, has significantly improved cure rates for specific NTM infections. (J Respir Dis. 2007;28(1):7-18)

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Which treatment approaches are effective in a woman who has persistent or refractory vaginal trichomoniasis? Should the male sex partner of a patient who has recurrent vulvovaginal candidiasis be treated? Answers to these and other questions can be found in the recently updated CDC guidelines on managing sexually transmitted diseases

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A 63-year-old African American man presented with severe epigastric pain of 1 day's duration. The pain was sharp and continuous and radiated toward the left flank. There were no aggravating or relieving factors or previous similar episodes.

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A 68-year-old man presents to the emergency department with diplopia and headache of acute onset accompanied by nausea and vomiting.

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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.

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Microscopic polyangiitis is a potentially fatal disease if it is notrecognized and treated early. In the case described here, what initiallypresented as a postinfectious residual cough was actuallyactive pulmonary hemorrhage, severe anemia, and a crescenticglomerulonephritis. Significant improvement was achieved withhemodialysis and aggressive treatment with corticosteroids andcyclophosphamide. This case exemplifies a classic presentationof microscopic polyangiitis and demonstrates the importance ofan expeditious diagnostic evaluation and early treatment to preventrapid deterioration. Early recognition and highly aggressiveimmunosuppressive treatment achieved significant suppressionof the disease.

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Our goal here is to help you master the shoulder examination. We review the basics of the examination, and we evaluate emerging concepts in the diagnosis of the more common shoulder conditions.

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Because the causes of syncope are numerous and the diagnostic tests have low yield, this disorder is often difficult to evaluate. Here we describe a practical approach to the workup that can help you rapidly identify serious underlying pathology. We also discuss treatment of the most common causes of syncope.

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"Typical aura without headache" is a relatively rare headache diagnosis and not easy to make. Three leading headache specialists offer guidance on how to recognize and treat.

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Although it has been evident since the early days of the HIV epidemic that a dementing illness often accompanies HIV infection and that the virus invades the nervous system soon after systemic infection, the clinical syndrome has evolved with the introduction of antiretroviral therapy.

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Traumatic hemothorax usually results from penetrating or contused thoracic injuries that lead to rib fracture and damage of intercostal or pulmonary vessels. Hemorrhagic shock can occur with massive blood loss into the pleural space. The shock state may be exacerbated by decreased venous return.

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A54-year-old white woman presentswith extremely tender,firm lesions on the right hip and legsthat have been increasing in size andnumber over the past few months.

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Unilateral agenesis of the hemidiaphragm is a very rare congenital anomaly. We present the case of an adult who was evaluated for persistent cough. Unilateral agenesis of the diaphragm was an unexpected finding on a chest radiograph.

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In recognition of Valentine's Day, we present 2 incidental heart-shaped findings we encountered within the hearts of 2 patients during 2-dimensional transthoracic echocardiographic studies.

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A 34-year-old woman who was coinfected with HIV and hepatitis C virus complained of acute abdominal pain and generalized pruritus of 3 weeks' duration. She was noncompliant with her antiretroviral medications.

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Antiretroviral Therapy: Darunavir: An Overview of an HIV Protease Inhibitor Developed to Overcome Drug Resistance

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For the past 7 years, a 32-year-old African-American man had multiple nonpruritic scalp abscesses. He also reported intermittent fever and joint pain. The abscesses had been drained on many occasions, and he had received several antibiotics, although no organisms had been isolated. Collagen vascular disease, SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, osteitis), discoid lupus, and cutaneous sarcoid had been ruled out. During the past 7 years, he had been treated with prednisone, methotrexate, and hydroxychloroquine without any response.

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Abstract: Rhinosinusitis affects millions of persons annually and has a marked impact on quality of life and work productivity. Chronic rhinosinusitis (CRS) is characterized by symptoms that last at least 12 weeks. The history and physical examination should include a search for underlying conditions, such as allergic or nonallergic rhinitis and nasal polyposis. An evaluation of underlying immunodeficiency is warranted in certain patients, particularly those with severe or difficult-to-treat disease or other recurrent infections. When radiologic evaluation is indicated, coronal sinus CT scanning is the procedure of choice. While antibiotics are indicated for bacte- rial rhinosinusitis, intranasal corticosteroids represent the mainstay of treatment for CRS and are particularly useful when polyp disease is present. Nasal irrigation with a saline solution can be a very beneficial adjunctive therapy. Depending on coexisting conditions, additional treatments may include antihistamines, leukotriene modifiers, and immunotherapy. (J Respir Dis. 2006;27(9):372-379)

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An 8-year-old boy presented with a 6-week history of shortness of breath, cough, and myalgias, but no fever. His pediatrician had made the diagnosis of bronchiolitis, and the patient was treated with azithromycin and albuterol via a metered-dose inhaler. Because the patient did not improve, he was given a 10-day course of amoxicillin, followed by a course of clarithromycin after a chest radiograph revealed bilateral infiltrates, suggesting atypical pneumonia.

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What do you get when you cross asthma with COPD? How does an asthma Dx reduce antibiotic Rx? And what about vitamin D and asthma, anyway? Get answers and evidence in 5 easy pages.

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ABSTRACT: In addition to appropriate pharmacotherapy and assistance with smoking cessation, a secondary prevention plan should include counseling about a heart-healthy diet, a structured exercise program and/or increased physical activity, and assessment of psychosocial risk factors, such as depression. Advise patients to reduce their intake of salt, sugars, refined carbohydrates, and saturated and trans fats; incorporate more fruits, vegetables, and fish into their diet; and balance caloric intake and physical activity to achieve and maintain a body mass index between 18.5 and 24.9 kg/m2. Cardiorespiratory fitness is the key to cardioprotection; the threshold for improving it in persons with coronary heart disease is about 70% of the mea-sured maximal heart rate. Encourage patients to engage in multiple short bouts of physical activity daily, such as taking the stairs instead of the elevator or walking the dog. Among previously sedentary persons, this approach has effects on cardiorespiratory fitness, body composition, and coronary risk factors similar to those of a structured exercise program.

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Abstract: The laryngeal mask airway (LMA) and intubating LMA are valuable alternatives in patients in whom intubation has failed and who need oxygenation and ventilation immediately. The dual-lumen, dual-cuffed airway tube is effective in a variety of settings and can tolerate ventilation at pressures as high as 50 cm H2O; it is contraindicated in awake patients who have intact airway reflexes, caustic ingestions, and upper airway obstruction from a foreign body or pathology. Surgical airways are lifesaving techniques when intubation is unsuccessful or impossible through the mouth or nose. It may be particularly appropriate in patients with laryngeal or facial trauma, upper airway obstruction, or oropharyngeal injury. When patients aged 12 years and older cannot be ventilated by mask or intubated with traditional methods, surgical or needle cricothyrotomy is the procedure of choice. (J Respir Dis. 2005;26(7):298-302)

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Case studies of athletes with isolated axillary neuropathy provide an overview of this injury's anatomy and function, which are key to definitive diagnosis and appropriate treatment.

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A 22-year-old man complained of progressive shortness of breath and abdominal distention. Three years before, he had completed chemotherapy for Hodgkin's disease and had since been in remission. Recently, he had been treated for tonsillitis with oral antibiotics.