Infectious Disease

During an annual eye examination, a 65-year-old womanwith a 5-year history of type 2 insulin-dependent diabetescomplained that her vision had slightly worsened in botheyes. Her best corrected visual acuity was 20/30 in botheyes.

Sudden profound vision loss in her left eye prompted an82-year-old woman to seek evaluation. She also complainedof “just not feeling well” and reported new-onsettemporal and occipital headaches of 6 weeks’ duration.

A 49-year-old woman presented for aroutine eye examination. She had nohistory of systemic disease and tookno medications.

Colorectal cancer (CRC) is highly preventable; however, it remains a significant cause of morbidity and mortality in Western countries. CRC develops in more than 125,000 Americans each year, and about 50,000 die of it.1 Screening and early intervention significantly reduce morbidity and mortality, and a number of organizations have published screening recommendations (Table). Nevertheless, only 1 of every 3 eligible adults elects to be screened.2

Colorectal cancer (CRC) is highly preventable; however, it remains a significant cause of morbidity and mortality in Western countries. CRC develops in more than 125,000 Americans each year, and about 50,000 die of it.

Bronchodilators, preferably inhaled, are recommended for all patients with chronic obstructive pulmonary disease; ipratropium, with a 6- to 8-hour duration of action, is effective maintenance therapy. Tiotropium is currently being reviewed by the FDA for release in the United States; its once-daily dosing schedule may facilitate adherence. Criteria for long-term oxygen therapy are severe hypoxemia (PaO2, 55 mm Hg or lower) or a PaO2 of 60 mm Hg or lower with signs of cor pulmonale or secondary polycythemia (hematocrit higher than 55%). When symptoms are disabling despite optimal medical management, referral for pulmonary rehabilitation is the next step. Patients with upper lobe-predominant emphysema and low exercise capacity may benefit most from lung volume reduction surgery. Consider transplantation if the patient has severe lung disease that is refractory to medical therapy and survival is expected to be less than 2 to 3 years.

The key factor in reducing morbidity and mortality in patients with chronic obstructive pulmonary disease (COPD) continues to be smoking cessation. Newer formulations of nicotine replacement therapy-a nasal spray and an inhaler-provide rapid delivery of nicotine and may be appropriate for highly dependent smokers. Bupropion has been shown to improve smoking cessation rates, either when used alone or with a nicotine patch. Both the influenza and pneumococcal vaccines are recommended to reduce the morbidity and mortality associated with respiratory infections in patients with COPD.

Signs and symptoms that strongly suggest peripheral arterial occlusive disease include diminished or absent pedal pulses, a unilaterally cool limb, and atrophic skin that is shiny and hairless. An ankle-brachial index of less than 0.5 suggests multisegment disease. Management goals are to decrease functional impairment, treat underlying atherosclerosis, and control risk factors. Smoking cessation is imperative. A graduated walking program is a mainstay of treatment and is associated with greater improvement in pain-free walking than is drug therapy. Surgery and percutaneous intervention are generally reserved for patients with lifestyle-limiting claudication, ischemic pain at rest, tissue loss, or gangrene.

Several times a year a rash erupts on the chest, axillae, and neck of a 41-year-old woman. Her father and siblings have a similar history. A biopsy of the affected skin confirmed the suspected diagnosis of benign familial pemphigus, which is also called Hailey-Hailey disease.

Diffuse petechiae suddenly arose on the back and abdomen of a 79-year-old woman. Within several days, the asymptomatic lesions covered her arms and face as well.

ABSTRACT: A cough is considered chronic when it persists for 3 or more weeks. Typically, chronic cough is a lingering manifestation of a viral upper respiratory tract infection; other, more serious causes-such as asthma, sinusitis, or gastro- esophageal reflux-must also be considered. Look to the history for diagnostic clues and order a chest film, which may point to pneumonia, hyperinflation, atelectasis, or cardiac or pulmonary abnormality. Diagnostic test methods will depend, in part, on the child's age; for example, the American Academy of Pediatrics recommends against imaging of the sinuses in children 6 years or younger. Pulmonary function tests can be useful in diagnosing asthma if the child is able to cooperate. Consider ordering a barium swallow for a very young child whose cough may be the result of a vascular anomaly. A pH probe study can help you determine whether cough is secondary to gastroesophageal reflux. Treatment is directed at the underlying cause.

In November 2002, cases of an atypical pneumonia were reported in the Guangdong province of southern China. By the following June, outbreaks of the illness-known as severe acute respiratory syndrome (SARS)-had occurred in Germany, Ireland, the United States, Canada,Hong Kong,Singapore, and Vietnam.

For 3 months, a 50-year-old man had been bothered by a worsening and spreading rash on his feet and lower legs. The multiple, nodular, fungating lesions were nonpruritic. The heterosexual, unmarried patient did not use intravenous drugs and did not know his HIV status; he denied any significant medical history.

For 2 years, a slightly pruritic, light brown, scaly rash had been present on a 20-year-old man’s neck. During the past 8 months, the eruption spread to the upper chest and upper arms. The patient reported that the rash changes color with the seasons. Multiple round to oval, hypopigmented, slightly scaly macules were noted on the neck, chest, and upper arms. Tinea versicolor was strongly suspected.

Concerned that her 7-week-old daughter's left ear was far more prominent than the right one, the mother took the infant to the emergency department (ED) for evaluation. The swelling had begun 3 or 4 days earlier; the patient was otherwise asymptomatic.

A 34-year-old woman presented with a3-day history of painful blisters of theupper lip and nose. Five days earlier,a rapid antigen test had confirmedstreptococcal pharyngitis; amoxicillinwas prescribed. The patient had nohistory of herpes and was immunocompetent.She had several youngchildren and did not work outsidethe home.

A 62-year-old woman sought medicalevaluation for persistent swellingof her lower lip and right cheek. Thecondition had been present for 8 to9 months. A 6-month course of oralprednisone prescribed by anotherpractitioner had no effect. The patienthad no history of chronic diseaseand no pain, paralysis, ulcerations,scaling, or dental or tongue problems.

An uncircumcised 58-yearold man presented with a persistent “rash” on his penis of 5 years’ duration. He complained of localized irritation with coitus. Over-the-counter ointments and corticosteroid preparations had failed to clear the eruption. The patient had hypertension, hyperlipidemia, and coronary artery disease. He had been monogamous for the last decade and denied any risk factors for sexually transmitted diseases.

A 34-year-old woman (gravida 3, para 2) presented at 28 weeks’ gestation with a 3-week history of a pruritic rash that had progressively worsened. Multiple vesicles and bullae were noted; erosions and crusts on older lesions were also present. The patient had had no prodromal symptoms; she denied fever, chills, nausea, and vomiting. The purplish hue on her body resulted from application of the topical antibacterial agent, gentian violet, which the patient had obtained in Mexico.

A 38-year-old man was concerned that the small lesions on his lips were flatwarts. A biopsy identified Fordyce, or sebaceous, glands of the lips.

ABSTRACT: When influenza is present in the community, clinical symptoms are as accurate as rapid point-of-care tests for making the diagnosis; in this setting, the combination of cough and fever (temperature, 37.7°C [100°F] or higher) of acute onset has a positive predictive value of 77% to 79%. Accurate diagnosis ensures timely administration of antiviral agents and prevents unnecessary antibiotic use. In elderly persons, vaccination reduces illness severity, incidence of complications, and mortality. An intranasal vaccine is a new option for persons aged 5 to 49 years who are at risk for complications and refuse injection. Chemoprophylaxis with amantadine, rimantadine, or a neuraminidase inhibitor is a useful adjunct to vaccination in certain groups, such as nursing-home residents. Antiviral therapy started within 24 to 48 hours of symptom onset can reduce the duration of illness by 1 to 1.5 days and ameliorate symptoms in patients with uncomplicated influenza. However, treatment is expensive and does not prevent complications.

A 62-year-old obese woman with adult-onset type 1 diabetes mellitus had a 6-year history of bilateral leg edema. During the last year, the edema worsened and the skin on her legs thickened. She also had multiple, bilateral, painful, superficial ulcers that drained copiously.

A 12-year-old African American girl comes to youroffice for a well-child checkup. She is tall for herage (height above the 95th percentile) and obese(body mass index [BMI] above the 95th percentile).Physical examination reveals acanthosisnigricans on her neck, axilla, and upper abdominalregion (Figure) and a vaginal yeast infection.Routine urinalysis reveals a glucose level ofgreater than 1000 mg/dL, with negative proteinand ketones. A random blood glucose test, obtainedbecause of the glucosuria, is 249 mg/dL.

A 31-year-old man presents with a2-week history of a constant, dull acheand hearing loss in the right ear. Healso complains of intermittent sharppains that are usually followed bydrainage through the external auditorycanal. Another practitioner diagnosedacute otitis media with tympanic membraneperforation, for which he prescribeda 10-day course of amoxicillin.The patient completed the regimen buthas obtained no relief.

Because of recent threats of bioterrorism, smallpox vaccination was reinstated in the United States earlier this year. Since January 2003, more than 35,000 civilian and public health care workers in 54 jurisdictions have been vaccinated.

Foot ulcerations and infections are the leading cause of hospitalization amongpatients with diabetes; they occur in about 15% of these patients.

A slightly pruritic, red, scaly rash on an 8-year-old boy’shands has been progressively worsening since it appeared4 months earlier. Nail pitting also was noted. There are noother rashes on his body. The patient is active in sports;denies any new exposure to soaps, clothing, or other contactants;and spends time in the homes of his recently divorcedparents.

This condition features acutely tender nodules, marked erythema, and contusions that appear as a consequence of inflammation of subcutaneous fat.

A 41-year-old man complained of upper abdominal pain and malaise of several months duration. He had emigrated to the United States from Korea 5 years earlier.

An obese 55-year-old woman had intermittent dysuria and frequent urination for 4 days and fever, abdominal pain, and vomiting for 3 days. Her history included type 1 diabetes mellitus, hypertension, and angina; her medications included insulin, nifedipine, and nitroglycerin.