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Case In Point: Does this woman with cough and dyspnea really have CHF?A 47-year-old African American woman presented to the hospital after a 5-day history of cough and shortness of breath. The patient also described worsening cough with yellow sputum production over that same time but denied any fevers, chills, nausea, vomiting, abdominal pain, and urinary symptoms. Her condition began to rapidly deteriorate on arrival to the emergency department (ED).
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Update on Cause and Management of Catscratch DiseaseMore than 22,000 persons in the United States are affected bycatscratch disease (CSD) annually. Despite the discovery of thecausative organism more than a decade ago, much is still unknownabout this illness. Recent data suggest that ticks, as wellas cats, may transmit the disease to humans. Immunofluorescenceassay is proving to be the most efficient and noninvasivetechnique for diagnosing CSD. Among available antimicrobials,azithromycin has proved to be especially useful, although randomized,double-blind, placebo-controlled trials are warrantedto define the best treatment method for patients with CSD.[Infect Med. 2008;25:242-246, 250]
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Superior Mesenteric Vein ThrombosisA 65-year-old woman with metastatic adenocarcinoma of the colon was undergoing chemotherapy following a colectomy and a hepatic wedge resection. The physical examination and laboratory data were unremarkable.
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Ovarian Hyperstimulation SyndromeWith assisted reproduction widespread, all physicians, including primary care providers, should be familiar with presenting symptoms of OHSS.
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Neurotic ExcoriationA 42-year-old woman sought medical advice for a facial rash of 4 weeks' duration. She denied any drug allergies, changes in her routine, or use of new laundry products.
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Case In Point: Middle-Aged Man With Worsening Cough and DyspneaA 52-year-old man with hypertension and hyperlipidemia presents to the emergency department with a 5-month history of cough and dyspnea.
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MalariaDuring a flight from Houston to New York, a 46-year-old man had fever, chills, rigors, and body aches. After he landed, he sought treatment at a local hospital. The patient was on his way back to Liberia, where he works. He had been at home in Houston for several weeks. In the emergency department, he complained only of subjective fever.
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Perianal Crohn's DiseaseA 56-year-old man complained of perianal swelling and discomfort. He reported a history of diarrhea and mucus discharge from the rectum with intermittent rectal bleeding. A colonoscopy confirmed the diagnosis of Crohn's disease of the rectum and sigmoid colon.
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Villous Adenoma in a 61-Year-Old ManEndoscopic evaluation of a 61-year-old man hospitalized with a 4-month history of rectal bleeding, mucus discharge, and change in bowel habits revealed this large, sessile villous adenoma.
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Strangulated Rectal ProlapseIncarcerated rectal prolapse is uncommon and seen mainly in elderly female patients. If ischemia is present, perineal proctosigmoidectomy is the only remaining treatment option.
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What to Include in the Workup of an Elevated Hemoglobin Concentration and Hematocrit?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?
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Appendicitis: Jump to Make the DiagnosisDiagnosing the cause of abdominal pain in a child can be difficult. When I suspect appendicitis, I ask the patient to jump down from the exam table. If this causes no pain, the diagnosis is most likely not appendicitis. Pain indicates rebound tenderness, and further workup is likely needed.
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Osler NodesOsler nodes may accompany bacteremia without endocarditis, septic endarteritis, typhoid fever, gonococcemia, systemic lupus erythematosus, and nonbacterial thrombotic endocarditis.
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Glioblastoma MultiformeA 57-year-old man was brought to the emergency department with severe bifrontal headache, which he had had for 3 weeks. Family members reported that the patient exhibited episodes of confusion and loss of recent memory since the onset of the headache.
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Apple Core LesionA 48-year-old woman was hospitalized for acute-onset abdominal pain. She had a history of adult-onset Still disease and severe osteoarthritis. She had been taking 650 mg of aspirin every 4 hours to relieve her arthritis pain and fevers.
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Primary synovial sarcoma presenting as an endobronchial massEndobronchial primary synovialsarcoma is an extremelyrare pulmonary tumor. We reportthe case of a 58-yearoldman who presented witha right-sided endobronchialmass, which was diagnosed asprimary synovial sarcoma onthe basis of histological appearanceand immunohistochemicalstaining. To the bestof our knowledge, this is onlythe third case report of endobronchialprimary synovialsarcoma.
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Eosinophilic Meningitis Due to Angiostrongylus cantonensisThe case concerns a patient with eosinophilic meningitisattributed to the helminthic parasite Angiostrongyluscantonensis. Before the onset of illness, our patient had ahistory of travel to Hawaii, the only area in the United Stateswhere A cantonensis is endemic. Finding eosinophils in thecerebrospinal fluid (CSF) can narrow the differential diagnosisin a patient with meningitis. In our patient, the proportion ofeosinophils in the CSF was 55%. The case is unique because thepatient was a strict vegetarian. This infection usually developsin persons who inadvertently ingest snails or slugs that containthe parasite. [Infect Med. 2008;25:366-368]
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Cystic Hygroma in a Young GirlA 21-month-old previously healthy child is brought to the pediatrician's office because of increasingly labored breathing that began the night before. The father reports that the child has had fever, congestion, nonproductive cough, and irritability for 2 days and that she is slightly hoarse.
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Further Evidence That HTLV Protects Against HIV ProgressionPrevious case reports have suggested an association betweenhuman T-cell lymphotropic virus (HTLV) types 1 and 2infection and chronic nonprogressive HIV infection. Evidenceis lacking about the specifics of how the two are related. Wereport 2 cases of chronic nonprogressive HIV infection (of9 and 13 years' duration, respectively) in women in whomHTLV coinfection was diagnosed. These cases provide clinicalsupport that HTLV coinfection may serve as a protective factoragainst progression of HIV infection. Possible reasons for thisrelationship and potential future research are discussed.[Infect Med. 2008;25:416-420]
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Tick-Borne DiseasesThe rash of tick tularemia is seen here on the arm of a 5-year-old boy. He also had a tick bite on his back that became necrotic and ulcerated. Within 2 weeks of his having been bitten, axillary lymph nodes developed.
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Heart Failure: Part 2, Update on Therapeutic OptionsABSTRACT: Angiotensin-converting enzyme inhibitors and ß-blockers are the cornerstone of heart failure medical therapy; unless contraindicated, start these agents as soon as possible after volume status has been optimized. Aldosterone receptor antagonists, angiotensin-receptor blockers, and a fixed-dose combination of hydralazine and isosorbide dinitrate (the last recommended especially for African Americans) can be used as add-on therapy. Prophylactic implantable cardioverter defibrillators reduce long-term mortality in symptomatic patients with a left ventricular ejection fraction (LVEF) of 35% or less. Cardiac resynchronization therapy improves symptoms and ventricular remodeling in some patients; indications include wide (more than 20 milliseconds) QRS complex on ECG, impaired LVEF (35% or less), and advanced heart failure symptoms (NYHA classes III and IV) despite optimal drug therapy. Measurement of natriuretic peptides and impedance cardiography both show promise for monitoring patients with heart failure and for guiding therapy, but definitive data to justify their routine use are still lacking.
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CarbuncleThis lesion had erupted on the back of an elderly man with diabetes mellitus. The inflammatory process involved contiguous follicles with pus evident at several openings.
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Whats Wrong With This Picture?: Woman With Painful Necrotic Skin LesionsA54-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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Gram-Negative Bacteria as Cause of Foot IntertrigoFor a year, a 31-year-old man had asymptomatic, malodorous discoloration of the toe web spaces. He stated that his feet perspire heavily in the boots he is required to wear for work.
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Atrial Myxoma That Mimics Mitral StenosisFor 2 years, a 60-year-old woman with long-standing hypertension had experienced worsening dizzy spells, fatigue, and chest discomfort. She also had cold extremities, significant dyspnea on exertion, and orthopnea. The patient was taking amlodipine and furosemide.
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Osteoporosis:What to Tell Patients About Prevention and TreatmentOsteoporosis is no longer consideredage- or sex-dependent, although prevalencevaries by sex and race. Postmenopausalwhite women suffer almost75% of all hip fractures and havethe highest age-adjusted rate of fracture.Thanks to progress in our understandingof causes and treatments, thisdisease is largely preventable, and significantimprovements in morbidityand mortality are possible. The beststrategy for prevention and treatmentuses a team approach that involves thepatient, physician, health educators, dietitians,and physical therapists.
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Cutaneous Mycobacterium InfectionThis rash, which covered a 68-year-old woman's body, was noted to have worsened during the past 2 months. A cephalosporin antibiotic had failed to clear the condition. The patient, a nursing home resident, suffered from emphysema, asthma, and heart disease. She had been receiving oxygen therapy and prednisone for 1 year.
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Low Back Pain Triggers: Many Are ModifiableBrief exposure to a variety of modifiable factors-physical and psychosocial-increases the risk of back pain.
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Pericardial tamponade caused by Actinomyces after bronchoscopyActinomyces odontolyticus isa rare cause of pleuropericardialinfection, with only 1 caseidentified in the literature. Inthat instance, the infectionwas believed to be secondaryto gastric surgery. We present apatient with pericarditis andpericardial tamponade causedby A odontolyticus. The infectionoccurred after an ultrasound-guided subcarinalbronchoscopic needle biopsyperformed for a suspicious mediastinalmass found on a CTscan of the chest. We describethe case presentation, the microbiologyand treatment of Aodontolyticus infection, andthe classic features of pericarditisand cardiac tamponade.
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Using low molecular weight heparins as "bridging anticoagulant therapy"Abstract: Bridging anticoagulant therapy is used to minimize the risk of thromboembolic complications when warfarin therapy must be temporarily interrupted because of surgery or another procedure. The decision to use this strategy depends on the patient's risk of thromboembolic complications and the risk of bleeding associated with the specific procedure. One approach is to withhold 4 or 5 daily doses of warfarin before surgery and initiate low molecular weight heparin (LMWH) 3 or 4 days before surgery. The last dose of LMWH is administered at least 24 hours before the procedure. After the procedure, prophylactic-dose LMWH can be administered subcutaneously once daily. The use of therapeutic-dose LMWH should be deferred until at least 24 or 48 hours after procedures that have a low or moderate risk of bleeding and until 48 or 72 hours after high-risk procedures. (J Respir Dis. 2005;26(4):170-172)
