Infection

Enterobiasis-an infection by pinworms-is caused by the nematode Enterobius vermicularis. Treatment is a single dose of oral albendazole, mebendazole, or pyrantel pamoate.

A 76-year-old woman had a 40-year history of rheumatoid arthritis (RA). She had repeatedly refused treatment with disease-modifying drugs, including methotrexate. Nodules began to develop 15 years after the initial diagnosis; they recurred after surgical removal.

A variety of rheumatic diseases-systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and the vasculitides among them-manifest as “lumps, bumps, and holes” involving the extremities. Each of these diseases works through specific mechanisms on different structures of the skin to produce a distinctive pathology. In doing so, each provides clues to the cause, which the history and physical examination can help confirm.

Pyoderma gangrenosum (PG) is a chronic, recurrent condition characterized by cutaneous ulceration. In half of patients, PG is associated with an underlying illness, such as inflammatory bowel disease, RA, SLE, or a lymphoproliferative disorder.

Persistent, purulent drainage from the perirectal region for 3 months prompted a 60-year-old man to seek medical evaluation. He also complained of minimal bleeding from the anus and perianal itching. The patient reported that he recently obtained some relief after a boil in the same area spontaneously burst.

A 29-year-old man presented with a complaint of venereal warts and a long history of mild psoriasis, which he had treated with fluocinolone. He returned 3 months later complaining of chest congestion of 10 days' duration; it had been treated with ciprofloxacin at an urgent care facility.

A 48-year-old man with jaundice, nausea, vomiting, and abdominal pain was hospitalized. The patient-a recovering alcoholic-was afebrile and reported abstinence from alcohol for 6 months.

A 65-year-old man was hospitalized with dyspnea and fever of a few days' duration. He complained of excessive malaise, fatigue, and weight loss but denied any hemoptysis. The patient had a history of alcohol abuse.

For the past 3 months, a 66-year-old man has suffered fatigue and loss of appetite and weight. He was not coughing, nor had he experienced fever, chest pain, or hemoptysis. He had no history of notable respiratory disease, and he was not aware of having had tuberculosis (TB).

After 1 day of upper abdominal pain, nausea, and vomiting, a 32-year-old man sought medical care. He had no significant medical history. The patient had tenderness and guarding in the right upper quadrant; no mass was detected. The remainder of the physical examination was normal.

A 41-year-old man with a past history of tuberculosis presented to the emergency department with massive hemoptysis. The patient denied fever or chills but reported a 20-lb weight loss and intermittent hemoptysis during the last 6 months. Six years ago, he had been treated for tuberculosis.

A swollen, painful eyelid prompted a 39-year-old man to seek medical attention. The patient had noticed swelling, redness, and irritation in his left lateral eyebrow area 2 days earlier. Upon awakening on the morning of his appointment, the left upper eyelid also felt full and tender and was drooping. A pointed draining area of purulent material had formed in the lateral brow region (not visible here). The patient was afebrile and denied any recent periorbital trauma. He was otherwise healthy; his only medication was a daily multivitamin.

A 29-year-old woman complained of 6 months of tinnitus, hearing loss in the left ear, and leff-sided facial numbness. There was no history of trauma or recognized antecedent infection. Physical examination of the external and middle ears was unremarkable. Vestibular test results and tympanometry results were normal. An audiogram demonstrated nearly total sensorineural hearing loss in the left ear.

A 74-year-old nursing home resident was admitted to the hospital with shortness of breath and stridor. Radiographic examination of the neck revealed the “thumb sign” of a swollen epiglottis (Figure, white arrow); the black arrow indicates the normal posterior wall of the pharynx. Acute epiglottitis was diagnosed.

A 56-year-old man who consumed moderate amounts of alcohol was awakened by an intense burning pain in the right great toe; local erythema and edema were also present. Within hours, the pain became excruciating, and the same symptoms developed in the left great toe. Acetaminophen provided no relief. The patient's serum uric acid level was 8.8 mg/dL.

An obese 61-year-old man who had chronic obstructive pulmonary disease and sleep apnea heard a “pop” in his stomach while lifting a heavy weight; severe abdominal pain followed. He was short of breath the next morning, and his physician empirically prescribed cephalexin.

A 42-year-old man with a 2-year history of AIDS sought medical advice for intractable diarrhea, which he had had for several months. Standard AIDS medications were prescribed, but his compliance with the drug regimen was poor.

An 18-year-old woman presented with diminished vision and recent onset of floaters in the right eye. Her medical and ocular histories were noncontributory.

The mother of an 8-year-old girl sought medical care for her daughter who had complained of intermittent chest pain for 3 days. The patient denied nausea, vomiting, and diarrhea. There was no shortness of breath, chills, fever, or diaphoresis. Her travel history included 2 trips to Mexico within the past year; the most recent trip ended 3 months before the pain started.

A 70-year-old man-nursing home resident-had had a cough, fever, and copious foul-smelling sputum for 1 week. Hemoptysis was noted off and on during the previous 3 days. The patient had no recent weight loss. A chest x-ray film and a CT scan showed an air-fluid level in the left oblique fissure of the lung as well as pleural thickening and infiltrates in the left lower zone.

A 70-year-old man was brought from a nursing home to the emergency department with abdominal distention and vomiting of recent onset and a 2-day history of fever and abdominal pain. The patient had chronic obstructive pulmonary disease, type 2 diabetes mellitus, and hypertension. His gastric feeding tube, which had been placed via percutaneous endoscopic gastrostomy, was blocked.

A 75-year-old woman with a bioprosthetic aortic valve, who had undergone surgical repair of an aortic root aneurysm 9 months earlier was hospitalized with fever, headache, and altered mental status of 1-day's duration.

The 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.

A 37-year-old man presented with fever, chills, myalgia, headache, and left-sided pleurisy of 2 weeks' duration. He also complained of weight loss and loss of appetite. The patient had recently returned from a family visit to Missouri.

Systemic lupus erythematosus (SLE) was diagnosed in an 18-year-old man who presented with polyarthritis, fever, hypoxia, fatigue, anemia, neutropenia, and abnormal urinary sediment. A renal biopsy showed diffuse mesangial proliferative glomerulonephritis (World Health Organization class II). Serologic tests were positive for fluorescent antinuclear antibody (FANA), SS-A, SS-B, anti-Sm and anti-dsDNA antibodies, and rheumatoid factor; a direct Coombs' test result was positive as well.

Here are two cases that demonstrate the discovery of aortic aneurysms through careful and complete physical examination and via radiographic studies obtained to evaluate other conditions.

A 32-year-old woman with insulin-dependent diabetes noted a painful erosion at the site of "the rose tattoo," which she had gotten 5 days before.

One week after an upper respiratory tract viral infection, a 36-year-old woman began to have progressive paresthesias of the lower extremities and right thorax. She sought medical evaluation 2 weeks later.

A 9-year-old girl was bitten around the right eye by a neighbor's dog. She sustained multiple punctures and lacerations of the right upper and lower eyelids

The wounds on the back of this boy's head resulted from an encounter with his neighbor's dog. The youngster's anxious parents brought him in for evaluation 1 hour after he was bitten.