Infection

Before considering the infection control strategies recommended during the current H1N1 influenza pandemic, it is useful to review the transmission characteristics of influenza viruses-including H1N1-that form the basis for these strategies:

The ability to recognize cases of the new H1N1 flu and distinguish these from seasonal influenza and other respiratory illnesses is perhaps the overriding concern of primary care practitioners. Prompt and accurate identification of this entity is the key to both effective management of individual illness and effective public health measures.

Be alert for a potential dosing error when you prescribe oral-suspension oseltamivir (Tamiflu).

The first 2009 H1N1 influenza vaccine to become available will be a nasal spray that contains live attenuated virus, said CDC health officials.

On Sept 15, 2009, the FDA approved 4 vaccines against the H1N1 influenza virus. Distribution of the vaccine to about 90,000 sites across the United States will begin in mid October.

More than half of travelers to the developing world experience a health-related problem during their trip, with 8% requiring medical attention on their return because of persistent symptoms. The GeoSentinel database, a collaborative effort among 31 travel medicine clinics on 6 different continents, suggests that the most common diagnoses in these persons continue to be malaria (24%), dengue fever (6%), acute traveler’s diarrhea (4%), and typhoid fever (2%).

For a month, an obese 50-year-old woman with type 2 diabetes mellitus, hypercholesterolemia, and hypertension had blurry vision in both eyes. During this time, she also had ataxia and right-sided numbness. For the past 2 days, she had had horizontal, binocular diplopia with right gaze.

For 2 months, a 60-year-old man has had this pruritic eruption on his arms, legs, and trunk. It is itchy enough at times to interfere with his sleep. He has taken the same antihypertensive medication for more than a year.

This pruritic eruption appeared on the arms, thighs, and buttocks of a 28-year-old woman after the uneventful delivery of her second child.

Hold your ground when the worried well come into your office this fall demanding prescriptions for Tamiflu and Relenza

As a reflection of the disproportionate impact that the swine flu is having on young children, the CDC’s gift shop in Atlanta is now selling a swine flu toy-a soft 7 inch model of the virus that can be used by adults to explain H1N1 infection to youngsters.

A 46-year-old dentist presents for evaluation of chronic hand dermatitis of 1 year’s duration. He has no other rashes. Standard patch testing was negative. Another physician prescribed a high-potency corticosteroid cream that controls the rash but does not clear it. The patient takes no other medications.

When you encounter unexplained seizures or mental status changes in children who have influenza-like illness, send respiratory specimens for diagnostic testing and promptly start empirical antiviral therapy, especially in hospitalized patients.

Reserve antivirals for adults and children over age 1 who have severe novel H1N1 influenza or who are at high risk for complications.

This painful, purulent, malodorous, 5 x 5-cm ulcer developed a few days after the 71-year-old patient had struck his foot against a radiator. For the past 24 hours, he had subjective fevers and chills. He denied recent travel and saltwater or freshwater exposure. He had chronic lymphedema and admitted to drinking alcohol socially.

The purple-stained urine bags and tubing of 2 elderly patients are shown here. Neither patient received urine-discoloring medications.

A 77-year-old woman with hypertension, diabetes mellitus with neuropathy and nephropathy, coronary artery disease, and previous stroke with residual right hemiparesis was hospitalized because of abdominal pain, nausea, and vomiting of sudden onset. She also reported subjective fever, dysuria, and foul-smelling urine.

At 1 week postpartum, a 32-year-old woman presents with an itchy rash of sudden onset. Famciclovir, 500 mg bid, is prescribed, but the rash persists.

This pruritic rash developed in a 43-year-old woman who had undergone a lumpectomy and lymph node dissection for breast cancer. She completed radiation therapy and chemotherapy 3 weeks ago. The rash has been present for 5 days. Levofloxacin was started 1 day ago.

A 33-year-old woman presents with arm and leg weakness of about 2 months’ duration.

At least 2 double-blind, randomized, placebo-controlled trials have shown that minocycline is superior to placebo for relief of signs and symptoms of RA.

In 2000, the World Allergy Organization (WAO) published a consensus definition of anaphylaxis as a severe, life-threatening generalized or systemic hypersensitivity reaction. The reaction is caused by the release of bioactive mediators from mast cells and basophils.

When you encounter unexplained seizures or mental status changes in children who have influenza-like illness, send respiratory specimens for diagnostic testing and promptly start empirical antiviral therapy, especially in hospitalized patients.

All elements of the skin are affected by age. In this 2-part article, I discuss how the blood vessels, the lymphatics, and the ground substance- which surrounds these vessels- respond to age, and I show how the aging elements of the vasculature can engender a variety of pathological cutaneous conditions.

Federal health officials stressed the need to start planning now for the fall influenza season when they met with state delegates at the H1N1 Influenza Preparedness Summit. "Over the course of coming weeks and months, we will move aggressively to prepare the nation for the possibility of a more severe outbreak of the H1N1 virus," said Secretary of Health and Human Services Kathleen Sebelius.

For 2 weeks, a 52-year-old man had progressive fatigue and myalgias. On the morning of presentation, he could not walk. He took no medications but reported chronic, intermittent use of alcohol, intranasal cocaine, and marijuana. He had ingested alcohol 2 weeks earlier and had used cocaine 3 days earlier. Vital signs were normal. The patient had bilateral upper and lower extremity weakness. The proximal muscle groups were affected to a greater degree, with 2/5 strength in the shoulder and hip girdles bilaterally compared with 4/5 strength distally. He had significant difficulty in raising himself to a seated position and when attempting to stand. Results of a complete blood cell count and basic chemistry panel were normal. Serum creatine kinase (CK) was mildly elevated at 9030 U/L. Urinalysis showed 3+ blood, with coarse granular casts but no red blood cells.

Palpitations and dizziness prompted a previously healthy 21-year-old cable lineman from southeastern Pennsylvania to seek medical attention. An ECG showed first-degree heart block. The young man was scheduled for outpatient cardiology consultation, but his symptoms worsened and he presented to an emergency department with chest pain and fever 2 days later. Further evaluation revealed that for the past 3 weeks he had myalgia; arthralgia; fatigue; and an expanding, erythematous, nonpruritic rash on his trunk and extremities. He did not recall any tick bites.

I advise my patients who are carriers of methicillin-resistant Staphylococcus aureus (MRSA) to keep their fingernails trimmed. Long nails make the subungual spaces good havens for bacteria. S aureus, including MRSA, has been isolated from the subungual spaces of the hands of many at-risk patients who are MRSA carriers

For a few months, a 51-year-old woman has had an asymptomatic rash on her proximal thighs. She claims to have no other rashes and denies any exposure history.

The mother of a 10-year-old boy brings him for evaluation of a persistent rash on his shins of a few months’ duration. The rash has not responded to topical corticosteroids.