Infection

A painful scalp eruption of 4 days’duration brings an 81-year-old man toyour office. He has taken a lipid-loweringagent and an antihypertensivefor years but has not started any newmedications recently. One week earlier,he had a haircut. He denies recenttrauma to the scalp.

Q:What is the most common radiographicpresentation of pulmonary tuberculosis (TB)among persons with HIV infection?

A 9-year-old boy, who has no significantmedical history, presents with a generalizedpruritic eruption of 2 weeks’ duration.One week earlier, another practitionerruled out scabies and treatedhim presumptively for varicella.

Francisella tularensis is anonsporulating, nonmotile,aerobic gram-negative coccobacillusthat is usually transmittedto humans frominfected rabbits and other small animalsvia ticks, fleas, or deer flies orby direct contact

When a patient complains of dizziness, ask him or her todescribe symptoms without using the word “dizzy.”

For 2 weeks, a 58-year-old woman has experienced increasingfatigue with activity. She has needed to nap duringthe day, has not been able to perform her usual activities,and has missed 3 days of work. She also complains of“muscle aches”-mainly in her back. She denies headache,dyspnea, fever, hot or cold intolerance, and alteredmentation.

Impetigo developed on the face of a 7-year-old boy who had chickenpox. Thepatient was given a 10-day course of oral cephalexin and mupirocin ointment;the infection resolved promptly.

For 2 days, a 35-year-old woman has had a tender eruption on the right palm.She takes no medications. The patient recalls that 1 or 2 years earlier a similarrash cleared following a course of antibiotics.

A 67-year-old woman has had an ulcer on her left heel for at least several weeks.She applied a homemade dressing and cut her shoes to try to relieve pressureon the ulcer; however, in the past week, areas around the ulcer have becomepainful. These areas, as well as the dorsum of the foot, are red and swollen.

Ask patients with nonhealing colostomy wounds if theyare cleaning the area with hydrogen peroxide.

This 2 1/2-year-old boypresents for evaluation ofan asymptomatic, nonpruritic,nonblanchable rashthat is primarily confined tohis cheeks. There is someerythema on the extensorsurfaces of the proximalextremities. The motherreports that the child hadan upper respiratory illnessabout 3 days earlier, withcough and a slight fever.He took no medication forthat illness. Because thesymptoms were so mild,she had not brought thechild in for medical attention.The rash appearedafter the fever and coughresolved. The child isotherwise healthy and hetakes no medication.

This 40-year-old woman has had multiple lesions on her facefor several months. She also reports occasional fevers, slight weight loss, andintermittent fatigue.

A70-year-old African American man, who is a retiredelectrician, presents with increasing fatigue anddull back pain of 4 months’ duration. Although he usuallywalks about 2 miles a day, he now becomes exhaustedafter half a block. He reports exertional dyspnea but noparoxysmal nocturnal dyspnea or orthopnea. Recently, henoticed ankle edema.

Over the past 6 months, a 76-year-old African American woman has had increasingdifficulty in swallowing solid food and has lost 40 lb. She can now tolerateonly liquids and foods with a pudding-like consistency. Ingestion of moresolid food produces the sensation that it is “sticking in her chest,” and shesubsequently regurgitates it undigested. She denies heartburn, reflux, nausea,hematemesis, abdominal pain, and melena.

A 27-year-old man is referred by an occupational health clinic for evaluation ofa heart murmur. The murmur was detected during a company-mandated examinationfor a flu-like illness that had caused him to miss several days of work.Before the onset of this illness, he had felt well and had no unusual complaints.He denies symptoms of congestive heart failure.

For several months, a 26-year-old man has had persistent bumps on his scalpand the back of his neck. Some hair loss has also occurred at the site.

Accurate diagnosis of nonviralinfectious diseases ofthe vagina is largely contingenton the clinician’s abilityto do a sophisticated wetmount/potassium hydroxide (KOH)preparation examination-more specificallywhat is termed a “level II wetmount examination” (Table). Clinicalassessment in conjunction with a properwet mount/KOH analysis will usuallyidentify the causative organism orsuggest exclusion of diagnostic possibilities(Figure).

For several weeks, a 29-year-old woman has had worsening left lower backpain that is aggravated by sitting and walking. The pain is most severe aboveher left buttock; it radiates into the buttock and very slightly into the leg. Overthe-counter analgesics have been ineffective. Assuming a supine position providessome relief, but the pain still occasionally awakens her at night. She deniesweakness, other neurologic symptoms, and any symptoms of bowel orbladder dysfunction.

Smallpox, which is caused byinfection with poxvirus variola,may follow variouscourses. An erythematouseruption can precede theappearance of tense, deep-seatedpapules that rapidly transform intovesicles. The lesions may be sparseor so numerous that they becomeconfluent.

The emphasis in this clinically focused text is on syndromesand patient care rather than on pathogens. Among the topicscovered are antimicrobial pharmacokinetics and pharmacodynamics;head and neck infections; upper respiratory tractinfections; bronchitis and pneumonia; endocarditis; pericarditisand myocarditis; peritonitis, liver abscess, and biliary tractinfections; viral hepatitis; CNS infections; skin and soft tissueinfections; animal and human bites; osteomyelitis and infectiousarthritis; foot infections in patients with diabetes; scarletfever and toxic shock syndromes; fever of unknown origin;bacterial, viral, and protozoal diarrhea; obstetric-gynecologicinfections; urinary tract infections; sexually transmitted diseases;infectious complications of HIV infection; tuberculosis;tropical diseases; zoonoses; bioterrorism; and fungal infections.Color and black-and-white photographs, photomicrographs,CT scans, radiographs, drawings, tables, and flowchartshighlight seminal points in the text.

A 32-year-old woman is admitted to the hospital because of nausea, vomiting,and mild jaundice. For 4 days, her health has steadily deteriorated: hepatictransaminase and bilirubin levels are elevated, prothrombin time is prolongedand, most recently, obtundation and changes in mentation have developed.Serologic studies for infection with hepatitis A, B, and C viruses are negative,as are tests for Epstein-Barr virus mononucleosis.

A 52-year-old woman is hospitalized because she has had jaundice, anorexia,and occasional nausea and vomiting for about 2 weeks. She has also had moderatepain in the epigastrium and right upper quadrant, but it has not been severeenough to require analgesics. She denies hematemesis and hematochezia.

An 87-year-old man had recently been hospitalized for5 days for treatment of hypernatremia and dehydration.His condition improved following hydration and cautiouscorrection of the hypernatremia, and he was discharged.However, within 48 hours the patient's caregiver notedthat he was obtunded and less responsive; she broughthim to the emergency department.

An 81-year-old woman is hospitalizedwith localized nonradiating low backpain of 3 weeks’ duration. She has nohistory of trauma, weakness of the legs,or urinary or bowel incontinence.

An 18-year-old college studentpresents with a 4-day history ofincreasing throat pain, low-gradefever, and extreme exhaustion. Previously,she had been healthy and participatedactively in sports, includingmarathon running. Her appetiteand intake have been poor. No historyof cough, chest pain, shortness ofbreath, nausea, vomiting, diarrhea,or abdominal distention. She has noallergies, takes no medications, anddoes not smoke or drink alcohol.She is sexually active with a single partner.

A 52-year-old man presented to theemergency department (ED) with a12-hour history of cramping abdominalpain, nausea, vomiting, andwatery, brown diarrhea. Mid upperquadrantpain had begun suddenlythe night before, 1 hour after the patienthad lifted heavy bags of rocks.The GI symptoms persisted with varyingintensity throughout the night.

A 12-year-old black girl is hospitalized because of increasinglysevere dyspnea and sore throat. The sorethroat started about a week earlier and was accompaniedby fever and chills. The patient was evaluated at an urgentcare center when her symptoms worsened, where she wasgiven ampicillin for a presumptive “strep throat.” A generalizedmaculopapular erythematous rash developed within24 hours of the start of therapy, and the ampicillin waspromptly withdrawn. The rash cleared gradually thereafter.Now the patient’s sore throat has worsened to the pointthat she has difficulty with drinking and eating. She hasbecome increasingly dyspneic during the past 24 hours.

Over the past 8 years, fragile vesicles,painful ruptured bullae, and erosionshave developed on the sun-exposed skinof a 57-year-old man. Some of the vesicleserupt at sites of minor trauma; othersarise spontaneously. A corticosteroidcream prescribed by another practitionerfor presumed atopic dermatitisfailed to clear the lesions.

A 21-year-old man presents to the emergency department with abdominal painof 6 hours’ duration. When the pain began, it was diffuse and periumbilical; now,it is worse and localized to the right lower quadrant. It has been accompanied byanorexia but not by diarrhea or emesis. Lying down, consuming liquids, andshowering have not provided relief.

A 1 X 0.5-cm hemorrhagic, polypoid lesion that had been present for 2 monthson a 13-year-old boy’s left anterior chest was excised. Pathologic examinationconfirmed the diagnosis of pyogenic granuloma.