Infection

A 28-year-old woman presents with milky discharge in both breasts and throbbing occipital headaches of 4 months' duration. The headaches begin gradually, do not radiate, and have no apparent triggers or relieving factors.

Tinea is caused by dermatophytes that can infect the stratum corneum epidermidis, hair, and nails. Dermatophytosis is a common infection worldwide, and about 20% of the US population is infected.1 Although numerous fungi can cause tinea, Trichophyton, Microsporum, and Epidermophyton are the genera that cause most cases of tinea.2 Classified by the part of the anatomy that is infected, tinea is referred to as tinea pedis, tinea manuum, tinea cruris, tinea corporis, tinea capitis, tinea faciei, tinea barbae, and tinea unguium.

Black discoloration appeared on the fingernails of a 51-year-old white man who had sustained burns on 15% of his body in a house fire 2 months earlier. The discoloration is a typical side effect of silver nitrate, which was applied to his skin and fingernails during the month he was hospitalized. This topical broad-spectrum bacteriostatic agent is used to reduce the risk of infection and mortality in burn patients.

For 2 months, a 30-year-old man with a history of cocaine abuse had had a painful gingival mass and difficulty in eating. Examination revealed a large, fungating mass in the anterior oropharynx that extended posteriorly up to the retromolar region. Posterior cervical lymph nodes were enlarged bilaterally, with no other peripheral lymphadenopathy.

A 36-year-old man presented with a 2-week history of pain, swelling, and redness of the right elbow. He also had decreased range of motion during elbow flexion. There was no associated fever or recent illness.

A young woman recently came to my office for contraception management and a Papanicolaou test; she complained of mild dyspareunia. I sent a vaginal sample for culture to rule out gonorrhea and chlamydial infection.

A previously healthy 21-year-old man presented with high fever, cough, and pleuritic chest pain. His illness began 6 days earlier with a sore throat that was followed by worsening dyspnea.

My patient is a 45-year-old otherwise healthy, asymptomatic woman from Iran in whom a hydatid cyst (Echinococcus granulosus) was incidentally discovered. The immunologically confirmed cyst is located in the left lobe of the liver, and it pushes slightly on the pancreas; its dimensions are 13 3 2.5 cm.

An 8-week-old boy is brought for evaluation of gradually worsening yellow skin discoloration of about 1 week's duration. His parents report that he has had constipation for the past several days; before that, he had green diarrhea and occasionally spit up after breast-feeding.

A 71-year-old man complains of left elbow pain that increases with movement and has worsened over the past 12 hours. He has also had a cough with sputum production for the past several days.

I work for the Child Protection Team at a local university. Recently, I saw a 9-year-old girl who had been taken to the local emergency department (ED) with sudden left-sided abdominal pain.

Parents of young children know that colds are extremely common, especially from fall until spring. Colds account for a large number of pediatric office visits and telephone calls-particularly during "cold season."

A 53-year-old man, who had initially presented with an upper respiratory tract infection, was found to have a stage IV follicular low-grade lymphoma with malignant cells that were positive for CD19, CD20, CD10, surface kappa, and CD45 and negative for CD5. A grade 1 tumor (follicular center cell lymphoma/follicular small cleaved) was suspected. Enlarged lymph nodes (2.5 to 4.0 cm) were found in the mediastinum, azygoesophageal recess, and periaortic region as well as in the porta hepatis, peripancreatic, mesenteric, and celiac regions.

For 3 years, my 30-year-old patient has had outbreaks of small, vesicular, frequently pruritic lesions on the neck and upper trunk.

A 22-year-old woman has had chronic nausea, emesis with green vomitus, and diarrhea for the past 10 months. The diarrhea is frequent (about 3 to 8 times daily) and does not resolve with starvation.

For 2 weeks, a 49-year-old woman has had mild, intermittent epistaxis with left-sided facial pain, swelling, and otalgia; the severity of the bleeding has increased during the past 24 hours. She also has congestion of the left naris of 1 month's duration.

Several recent studies from Europe and the United States confirm that tailoring the dosage and duration of pegylated interferon alfa 2b and ribavirin therapy can optimize treatment of hepatitis C virus (HCV) infection.

New guidelines for community-acquired pneumonia (CAP) issued jointly by the Infectious Diseases Society of America and the American Thoracic Society emphasize the need for communities to adapt the recommendations to local conditions.

In the vast majority of nonsmokers who are not receiving angiotensin converting-enzyme inhibitors and who have no evidence of active disease on chest radiographs, chronic cough is caused by postnasal drip syndrome (recently renamed upper airway cough syndrome [UACS]), asthma, non-asthmatic eosinophilic bronchitis, or gastroesophageal reflux disease (GERD), alone or in combination.

A 57-year-old woman presents for follow-up several months after a series of thrombotic episodes. Four days after she underwent ankle fusion to relieve pain and edema associated with a leg fracture that had occurred 40 years earlier, she sustained a massive myocardial infarction (MI).

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.

Dermclinic

Transverse depressions like the one shown here appeared on all the other nails of this 68-year-old man several weeks after he had suffered a myocardial infarction.

Dr Thomas Fekete's recent article on emerging infections (CONSULTANT, October 2007) was timely, given recent evidence that the incidence of methicillin-resistant Staphylococcus aureus (MRSA) infection, both hospital-acquired and community-acquired, has assumed pandemic proportions.

The first step in the workup of a patient with a persistent asymptomatic alkaline phosphatase (ALP) elevation is to measure gamma-glutamyltranspeptidase to determine whether the elevation is liver-related or bone-related.

Nephropathy develops in about 30% of patients with diabetes. Screen for albuminuria at the time type 2 diabetes is diagnosed and within 5 years of diagnosis of type 1 diabetes.

Dermclinic

Acute abdominal pain, fever, and chills prompted a 51-year-old man to visit his local hospital twice in one week. On both visits, a clinical and laboratory workup was negative. He then presented to a tertiary care center with worsening symptoms. His history included hypertension and tobacco and alcohol use.

A 44-year-old man presented to the emergency department (ED) with pain and swelling of the left ankle and a petechial rash in the pretibial area that developed the night before. He also reported "fluttering" in his chest.

A 75-year-old man is concerned about the discoloration of his fingernails: each nail has dark bands with a clearing in the middle.