Scary Stuff
While making rounds on the rehabilitation floor of your hospital, you see a 62-year-old female who was recently transferred from the acute-care section of the hospital where she was admitted for urosepsis. She is a liver-transplant recipient and her specialist has been tapering her immunosuppressive drug regimen for the last 2 months. According to the nursing staff the patient became hypoxic suddenly and had a low-grade fever and cough. You note that she looks ill and uncomfortable, and has an increased respiratory rate. A chest radiograph reveals diffuse bilateral interstitial infiltrates.
Which one of the following is the most likely diagnosis?
a) Pneumococcal pneumonia
b) Staphylococcal pneumonia
c) Pneumocystis pneumonia
d) Pulmonary tuberculosis
e) Pneumothorax
c) Pneumocystis pneumonia
The most likely diagnosis is Pneumocystis pneumonia. Initially named Pneumocystis carinii, the causative organism has been reclassified and renamed Pneumocystis jiroveci. It causes disease in immunocompromised patients. In non–HIV-infected patients, the most significant risk factors are defects in cell-mediated immunity, glucocorticoid therapy, use of immunosuppressive agents (especially when dosages are being lowered), hematopoietic stem cell or solid organ transplant, cancer, primary immunodeficiencies, and severe malnutrition.
The clinical presentation in patients without HIV/AIDS is typically an acute onset of hypoxia and respiratory failure, associated with a dry cough and fever. Characteristic radiographic findings include diffuse bilateral interstitial infiltrates.
A 17-year-old male with a history of type 2 diabetes sees you because of fatigue and a 15-lb weight loss in the past month. The patient reports excessive and frequent urination, thirst, and nausea. His only medication has been metformin, but he states that he stopped taking it 6 months ago. His current weight in your office is 93 kg (205 lb), which confirms the reported weight loss. His blood pressure is 130/78 mm Hg, his pulse rate is 90 beats/min, and his temperature is 37.0°C (98.6°F). A physical examination is otherwise unremarkable. A capillary blood glucose level is 348 mg/dL, a hemoglobin A1c is 11.5%, serum ketones are negative, and a urinalysis shows 3+ glucosuria with concentrated urine but is otherwise normal.
Which one of the following would be the most appropriate treatment?
a) Resuming oral metformin
b) Starting oral empagliflozin (Jardiance)
c) Starting subcutaneous insulin
d) Starting subcutaneous tirzepatide (Mounjaro)
e) Hospitalization for continuous intravenous insulin
c) starting subcutaneous insulin
This patient presents with symptomatic hyperglycemia in a catabolic state. In such cases insulin therapy is the most reliable way to control hyperglycemia and reverse catabolism. Oral metformin would not be adequate to control this degree of hyperglycemia and might not be tolerated well, given that the current symptoms include nausea and weight loss. Similarly, both empagliflozin, which increases glucosuria and volume contraction, and liraglutide, which decreases gastric emptying and is likely to exacerbate nausea, are likely to be poorly tolerated in this situation. While rapid and effective treatment is essential to prevent further complications, hospitalization is not necessary since the patient has no evidence of diabetic ketoacidosis.
A 14 y/o boy presents to the office with his parents for his annual well-child exam. History and physical unremarkable.
Parents wish to be UTD on vaccinations. On review of the state's immunization registry, it appears patient has had 2 doses of HPV quadrivalent vaccine. Last dose 6 weeks ago. Which of the following recommendations would you offer this patient and his parents.
a) Give 3rd dose of HPV vaccine today
b) Given the time-lapse since his last immunization, repeat the HPV vaccine series
c) Patient has completed series, no further HPV vaccine is required
d) Wait another 6 weeks at least before giving 3rd dose of HPV vaccine
c) Patient has completed series, no further HPV vaccine is required
Current CDC guidelines for HPV vaccination vary by age of initiation. Initiation from 9–14 years of age is a 2-dose series, whereas initiation at age 15 or older requires a 3-dose series.
A 34-year-old male presents with low back pain and stiffness that has been slowly worsening over the past 6 months. It is especially bothersome at night and in the morning when he gets out of bed. It improves with physical activity. He has taken ibuprofen, 400 mg several times a day, which provides moderate pain relief but is not working as well as it used to. He does not have any other joint pain, there is no history of trauma, and he is otherwise well. His BMI is 24 kg/m2. Radiographs of the lumbar spine show mild degenerative changes of the lumbar vertebrae without other abnormalities.
Which one of the following additional tests would most likely lead to a specific diagnosis?
a) erythrocyte sedimentation rate
b) C-reactive protein
c) Antinuclear antibody
d) HLA-B27
e) Rheumatoid factor
d) HLA-B27
This patient’s back pain is most consistent with an inflammatory cause rather than a mechanical cause. Morning stiffness and improvement with physical activity are key features of inflammatory back pain. Ankylosing spondylitis (AS), one subset of the broader diagnostic category of axial spondyloarthritis, is the likely diagnosis in this patient. Delays in diagnosis are common due to the widespread presence of mechanical low back pain. The identification of patients with inflammatory back pain is important, because early intervention with disease-modifying agents can preserve long-term joint function. HLA-B27 is found in 74%–89% of patients with AS and it can be diagnostic in a patient with typical inflammatory back pain symptoms.
Inflammatory markers such as the erythrocyte sedimentation rate and C-reactive protein are often elevated in patients with AS but are not specific to this diagnosis. Rheumatoid arthritis is not a likely cause of back pain in this patient without any other joint findings. Antinuclear antibody testing can assist in the diagnosis of systemic lupus erythematosus, which can cause an inflammatory arthritis, but it is similarly nonspecific and lupus typically has other findings in addition to back pain.
According to the 2022 American Academy of Family Physicians clinical practice guideline, treatment to a blood pressure target of <135/85 mm Hg in adults who have hypertension reduces which one of the following?
a) All-cause mortality
b) Cardiovascular mortality
c) Risk of myocardial infarction
d) Risk of stroke
c) Risk of myocardial infarction
The 2022 American Academy of Family Physicians clinical practice guideline recommends treating adults who have hypertension to a standard target of <140/90 mm Hg based on high-quality evidence. Moderate-quality evidence showed that treating adults to a lower blood pressure target of <135/85 mm Hg further reduced the risk of myocardial infarction compared to the standard target, with a number needed to treat of 137 over 3.7 years. There was no benefit in mortality or stroke risk. Of note, treating to a lower target blood pressure does increase the absolute risk of serious adverse events by 3%, with a number needed to harm of 33 over 3.7 years.
A 13-year-old female with a peanut allergy is brought to the urgent care clinic 15 minutes after she was inadvertently exposed to a peanut butter sandwich while at a friend’s house. She develops swelling of the tongue, wheezing, and difficulty breathing.
Which one of the following should be administered at this time? (check one)
Low-dose chest CT 12 weeks after treatment and again in 1 year
a) Intramuscular epinephrine
b) Intravenous epinephrine
c) Intravenous dexamethasone
d) Intravenous diphenhydramine
a) Intramuscular epinephrine
This patient is having an anaphylactic reaction to peanuts. Intramuscular epinephrine administered in the outer mid-thigh, preferably via an autoinjector, is the appropriate treatment. The absorption of epinephrine via the subcutaneous route is erratic and results in slow increases in plasma and tissue concentrations compared to the intramuscular route. Intravenous epinephrine needs trained personnel to administer it. Its administration is restricted to refractory cases of anaphylaxis as it is associated with higher cardiovascular complications. Corticosteroids and antihistamines are not first-line treatments.
A 56-year-old female comes to your office for an acute visit because she has had increased urinary frequency, thirst, and fatigue over the past month. Her medical history includes hypertension and type 2 diabetes with microalbuminuria, and her current medications are extended-release metformin, 1500 mg daily; losartan (Cozaar), 50 mg daily; and rosuvastatin (Crestor), 10 mg daily. Her current BMI is 36 kg/m2, and you note that she has lost 5 kg (11 lb) since her last visit 4 months ago. A point-of-care hemoglobin A1c is 12%.
Which one of the following would be the most appropriate pharmacotherapy to add at this time?
a) Basal insulin
b) DPP-4 inhibitor
c) GLP-1 receptor agonist
d) SGLT2 inhibitor
e) thiazolidinedione
a) Basal insulin
This patient presents with symptomatic hyperglycemia associated with uncontrolled type 2 diabetes. She is in a catabolic state, experiencing symptoms, and has a hemoglobin A1c ³10%. According to the American Diabetes Association (ADA) Standards of Care in Diabetes, early initiation of insulin is recommended. Once the acute glucose toxicity has resolved with insulin treatment, this patient could be switched to a noninsulin agent. With her comorbid hypertension, albuminuria, and obesity, a GLP-1 receptor agonist or an SGLT2 inhibitor with proven cardiovascular and renal benefits would be the next best choices. DPP-4 inhibitors have intermediate efficacy for lowering glucose with neutral cardiovascular and heart failure benefit and a neutral effect on weight and progression of chronic kidney disease. Thiazolidinediones have high efficacy for lowering glucose but are associated with weight gain and increased risk of heart failure.
Which one of the following tests should you obtain in a patient with lichen planus?
a) Antihistone antibodies
b) Hepatitis C antibody
c) HIV antibody
d) Sjögren syndrome–related antigen A (Ro) and Sjögren syndrome–related antigen B (La) antibodies
b) Hepatitis C antibody
Lichen planus is a disorder of unknown etiology affecting the skin, genitals, oral cavity, scalp, nails, and esophagus. Patients with lichen planus have a higher (up to sixfold) incidence of hepatitis C virus infection. Hence, screening for hepatitis C should be performed in patients with lichen planus even though the cause-and-effect relationship between hepatitis C and lichen planus is unknown. Antihistone antibodies are present in patients with medication-induced lupus erythematosus. HIV antibody is used in screening for HIV infection. Sjögren syndrome–related antigen A (Ro) and Sjögren syndrome–related antigen B (La) antibodies are present in patients with Sjögren syndrome.
A 3-year-old male is carried into the office by his mother. Yesterday evening he began complaining of pain around his right hip. Today he has a temperature of 37.6°C (99.7°F), cries when bearing weight on his right leg, and will not allow the leg to be moved in any direction. A radiograph of the hip is normal.
Which one of the following would be most appropriate at this time?
a) CBC and an erythrocyte sedimentation rate
b) serum antinuclear antibody level
c) Ultrasonography of the hip
d) MRI of the hip
e) In-office aspiration of the hip
CBC and ESR
This presentation is typical of either transient synovitis or septic arthritis of the hip. Because the conditions have very different treatment regimens and outcomes, it is important to differentiate the two. It is recommended that after plain films, the first studies to be performed should be a CBC and an erythrocyte sedimentation rate (ESR). Studies have shown that septic arthritis should be considered highly likely in a child who has a fever >38.7°C (101.7°F), refuses to bear weight on the affected leg, has a WBC count >12,000 cells/mm3, and has an ESR >40 mm/hr. If several or all of these conditions exist, aspiration of the hip guided by ultrasonography or fluoroscopy should be performed by an experienced practitioner. MRI may be helpful when the diagnosis is unclear based on the initial evaluation, or if other etiologies need to be excluded.
This virus is thought to be what inspired the legend of werewolves and zombies
Rabies
The preferred site for an emergency airway is:
a) thyrohyoid membrane
b) cricothyroid membrane
c) immediately below the cricoid cartilage
d) through the first and second tracheal rings
e) at the level of the thyroid isthmus
b) cricothyroid membrane
Fortunately, emergency tracheotomy is not often necessary, but should one be necessary the best site for the incision is directly above the cricoid cartilage, through the cricothyroid membrane. Strictly speaking, this is not a tracheotomy, because it is actually above the trachea. However, it is below the vocal cords and bypasses any laryngeal obstruction. The thyrohyoid membrane lies well above the vocal cords, making this an impractical site. The area directly below the cricoid cartilage—which includes the second, third, and fourth tracheal rings, as well as the thyroid isthmus—is the preferred tracheotomy site under controlled circumstances, but excessive bleeding and difficulty finding the trachea may significantly impede the procedure in an emergency.
A 56-year-old female with type 2 diabetes is hospitalized with acute epigastric pain, nausea, and vomiting. She reports that several of her diabetes medications were recently changed. Findings on physical examination and laboratory studies are consistent with acute pancreatitis.
Which one of the following classes of medications is the most likely cause?
a) Biguanides
b) GLP-1 receptor agonists
c) Insulin
d) SGLT2 inhibitors
b) GLP-1 agonists
GLP-1 receptor agonists should be discontinued in patients suspected to have pancreatitis. Additionally, therapy with GLP-1 receptor agonists should not be restarted once the pancreatitis has resolved. Although pancreatitis has been reported in clinical trials, the causality between GLP-1 receptor agonists and pancreatitis has not been established. Other medication classes such as DPP-4 inhibitors can also cause pancreatitis. Biguanides, insulin, and SGLT2 inhibitors do not cause pancreatitis
For a patient presenting for follow-up of monoclonal gammopathy of undetermined significance, which one of the following findings would be most concerning for progression to multiple myeloma?
a) A serum albumin level that is more than 1 g/dL below the lower limit of normal
b) A serum calcium level that is more than 1 mg/dL above the upper limit of normal
c) A hemoglobin level that is 2 g/dL above the upper limit of normalThe presence of 3 or more RBCs/hpf on microscopic urinalysis
d) The presence of 3 or more RBCs/hpf on microscopic urinalysis
e) An osteoblastic lesion seen on a skeletal radiograph
b) A serum calcium level that is more than 1 mg/dL above the upper limit of normal
Multiple myeloma (MM), a malignancy of plasma cells, represents 1.6% of all cancer cases and approximately 10% of the hematologic malignancies seen in the United States. Patients with monoclonal gammopathy of undetermined significance (MGUS) have a 1% annual risk of progression to MM. Patients who have progressed to MM typically manifest one or more of the classic CRAB findings: calcium (hypercalcemia of >11 mg/dL), renal impairment (a creatinine level >2 mg/dL or an estimated glomerular filtration rate <40 mL/min/1.73 m2), anemia (a hemoglobin level <10 g/dL), and bone involvement (osteolytic lesions, pathologic fractures, and/or severe osteopenia), which represent evidence of end-organ disease. Of the options listed, only hypercalcemia raises concern for progression of MGUS to MM. While patients with MM often have an elevated total serum protein level, the increase is from plasma cell–related proliferation and the resulting monoclonal protein production, not from an increase in albumin. Patients with MM would be expected to have a decrease in the hemoglobin level, not an increase. Renal manifestations typically involve a decrease in the serum creatinine level rather than microscopic hematuria. Finally, bone involvement in MM includes lytic, as opposed to blastic, lesions.
A 7-year-old female is brought to your office with a complaint of right hip pain and a limp with an insidious onset. There is no history of injury or repetitive use. Her vital signs are within normal limits and she has no history of fever or chills or other systemic symptoms. On examination you note that she cannot fully abduct her hip and she winces with pain on internal rotation. A FABER test is normal. Her right leg is 2 cm (¾ in) shorter than the left. Plain films reveal flattening and sclerosis of the proximal femur with joint space widening.
What is the most likely diagnosis in this patient?
a) Iliopsoas bursitis
b) Labral tear
c) Legg-Calvé-Perthes disease
d) Septic arthritis
e) Stress fracture
c) Legg-Calvé-Perthes disease
Legg-Calvé-Perthes disease results from interruption of the blood supply to the still-growing femoral head. It occurs in children 2–12 years of age and presents with hip pain and an atraumatic limp. Common physical findings include leg-length discrepancies, and limited abduction and internal rotation. Radiographs reveal sclerosis of the proximal femur with joint space widening. MRI confirms osteonecrosis.
Septic arthritis also causes atraumatic anterior hip pain but occurs in the acutely ill, febrile patient. A CBC, erythrocyte sedimentation rate, C-reactive protein level, and guided hip aspiration are recommended if septic arthritis is suspected. A diagnosis of stress fracture should be considered in patients with a history of overuse and weight-bearing exercise. These patients have pain that is worse with activity, and pain on active leg raising. MRI can detect fractures not seen on plain films.
Iliopsoas bursitis presents with snapping or popping of the hip on extension from a flexed position. Labral tears present with sharp anterior hip pain at times, with radiation to the thigh or buttock. Usually patients will have mechanical symptoms such as clicking with activity. The FABER (flexion, abduction, external rotation) and FADIR (flexion, adduction, internal rotation) impingement tests are sensitive for labral tears.
A 74-year-old female presents to the emergency department in respiratory distress with a slightly altered mental status. Her urine drug screen is positive for opioids. The patient and her family deny opioid use. You know this patient well and also doubt she is taking opioids. She has been taking dextromethorphan, guaifenesin, azithromycin (Zithromax), and pseudoephedrine.
Which one of these could be causing a false-positive test for opioids on her urine drug screen?
a) Dextromethorphan
b) Guaifenesin
c) Azithromycin
d) Pseudoephedrine
a) dextromethorphan
Dextromethorphan, diphenhydramine, ibuprofen, and even fluoroquinolones are among the many agents that can cause a false-positive urine drug screen for opioids. Pseudoephedrine can cause a false-positive test for amphetamines
You respond to a code blue in the obstetrics department. The patient is a 19-year-old primigravida at 35 weeks gestation, hospitalized with severe preeclampsia. A nurse anesthetist has placed an oral airway and is administering 100% oxygen to the apneic patient. She reports no difficulty ventilating the patient with a bag and valve, and no gagging with oral airway insertion. The patient’s blood pressure is 100/60 mm Hg and her pulse rate is 70 beats/min and regular. Her pupils are equal and sluggishly reactive, and she is flaccid and areflexic. The patient had been treated with a magnesium sulfate infusion and a recent bolus of labetalol.
Which one of the following medications should you administer initially?
a) Calcium gluconate
b) Fosphenytoin
c) Labetalol
d) Lorazepam (Ativan)
e) Dopamine
Calcium Gluconate
During the treatment of severe preeclampsia with intravenous magnesium, the occurrence of apnea and areflexia is most consistent with magnesium toxicity. In addition to hemodynamic support, calcium infusion is recommended as an antidote. Calcium chloride can be used if a central line has been established. Calcium gluconate would be safer with a peripheral intravenous site.
Lorazepam, phenytoin, and fosphenytoin are less useful in preventing eclamptic seizures than magnesium. Labetalol is not indicated given the patient’s current blood pressure level. Dopamine, a pressor agent, is not indicated in this scenario, and could aggravate the patient’s preeclampsia.
Insulin autoantibodies (IAA)
Glutamic acid decarboxylase (GAD)
Insulinoma-associated 2 (IA2)
Zinc transporter-8 (ZnT8A)
(at least 2 positive)
A 48-year-old female is treated appropriately for MRSA bacteremia. An echocardiogram is negative for endocarditis. There are no indwelling devices such as prosthetic heart valves or vascular grafts.
Assuming that the patient improves with an excellent response to antibiotics, which one of the following is recommended?
a) No repeat blood cultures
b) Repeat blood cultures when the antibiotic course is completed
c) Repeat blood cultures when the patient’s temperature is ≤37.5°C (99.5°F)
d) Repeat blood cultures 2–4 days after the initial set and as needed thereafter
e) Repeat blood cultures 2 weeks after the antibiotic course is completed
d) Repeat blood cultures 2–4 days after the initial set and as needed thereafter
This patient’s MRSA bacteremia is considered uncomplicated due to the effectiveness of the antibiotic therapy and the lack of endocarditis or implanted prostheses such as heart valves. Therefore, the Infectious Diseases Society of America recommends that follow-up cultures of blood samples be obtained 2–4 days after the initial cultures and as needed thereafter to document clearance of bacteremia
A 24-month-old female is brought to your office by her mother because the child will not stand on her right leg. Yesterday the patient was playing at the park and her mother did not notice any injury occur. There has been no recent illness or fever. The child was born at full term, has had no medical problems, and is up to date on vaccinations.
The patient’s vital signs are normal. A physical examination reveals a healthy-appearing child in no apparent distress. She grimaces and pulls away with palpation of the right leg over the lower tibia and she will not bear weight. She has full passive range of motion of her hip, knee, and ankle joints bilaterally without apparent pain. Anteroposterior and lateral radiographs of her right tibia and fibula show no abnormalities.
Which one of the following would be the most appropriate next step in management?
a) Reassurance only
b) CBC and C-reactive protein level
c) Immobilization with a cam boot, and repeat radiographs in 7 days
d) Bone scintigraphy
e) Referral to an orthopedic surgeon
c) Immobilization with a cam boot, and repeat radiographs in 7 days
A nondisplaced spiral fracture of the distal tibial shaft (toddler’s fracture) should be suspected in children from 9 months to 3 years of age who present with pain in the distal third of the tibia after minor or even unnoticed injury. Toddler’s fractures can have subtle radiographic findings and may not be visible on initial radiographs, so repeat radiography to look for healing is appropriate. Standard treatment is immobilization of the affected leg. While the fracture may heal without immobilization, reassurance alone is not recommended given the unclear diagnosis. If repeat radiography is negative and symptoms have resolved, reassurance may then be appropriate. For children with possible septic arthritis, laboratory studies should be considered, but in this case there are no signs of infection. Bone scintigraphy is more sensitive than radiography and can be considered if follow-up radiography is negative and symptoms persist. Toddler’s fractures routinely heal without complication, so referral to an orthopedic surgeon at this time would be premature.
This procedure was the only treatment for diabetic retinopathy in the 1960's
Pituitary ablation
A 36-year-old male laborer presents to an urgent care center 5 hours after falling off a ladder. He was 7–8 feet off the ground, and he fell directly on his anterolateral leg as he landed. Weight bearing is painful. Foot pulses are normal, as is a sensorineural examination of the foot and leg. The anterolateral lower leg is quite tender but only slightly swollen, and there is exquisite pain in that area with passive plantar flexion of the great toe. Radiographs of the lower leg and ankle are negative.
In addition to ice, elevation, and analgesia, which one of the following would be most appropriate?
a) Scheduled oral muscle relaxants
b) A 6-day oral corticosteroid taper
c) Physical therapy referral for early mobilization and ultrasound therapy
d) A short leg splint and non–weight bearing for 5–7 days
e) Urgent orthopedic referral for possible fasciotomy
e) Urgent orthopedic referral for possible fasciotomy
This patient most likely has acute compartment syndrome and must be urgently evaluated by an orthopedic surgeon. Typically, compartment pressure can be measured using a needle attached to a manometer, and if the pressure is elevated (usually >40 mm Hg) urgent fasciotomy is necessary to prevent muscle necrosis. If the classic “Five Ps” (pain, paresthesia, pallor, pulselessness, and paralysis) are all present, the outcome will most certainly be bad, even limb-threatening. Early identification with a high index of suspicion and urgent referral for fasciotomy is necessary to prevent tragic results.
Before the classic findings develop, patients will have tenderness out of proportion to the physical appearance of the injury and, most importantly, severe pain in the involved compartment with passive stretching of the involved muscles.
While rest, immobilization, non–weight bearing, and analgesia are all appropriate measures, none of these is sufficient treatment for this urgent problem.
A 32-year-old male presents with a 1-year history of increasing fatigue, polyuria, and a gradual 30-lb weight loss. Serum chemistries reveal a bicarbonate level of 23 mEq/L (N 22–28), a corrected anion gap of 8 mEq/L (N 3–11), and a glucose level of 658 mg/dL (N 60–110). The patient is admitted to the hospital and his serum glucose drops to 174 mg/dL after he is given 2 L of intravenous normal saline and 10 units of regular insulin subcutaneously. He is observed overnight and further laboratory testing is done the next morning.
Which one of the following is more consistent with type 2 diabetes mellitus than with type 1 diabetes mellitus?
a) The patient’s history of weight loss
b) The patient’s response to the initial dose of insulin
c) The time course of symptom onset
d) Morning laboratory studies showing a C-peptide level of <1.1 ng/mL (N 1.1–4.4)
c) The time course of symptom onset
This patient presents with marked hyperglycemia but no evidence of ketoacidosis or nonketotic coma. Differentiating between type 1 and type 2 diabetes mellitus is important for guiding therapy. The gradual onset of symptoms is more consistent with type 2 diabetes mellitus, whereas type 1 diabetes typically has a more rapid onset. Patients with type 1 diabetes typically need lower doses of insulin to correct hyperglycemia, as they lack the insulin insensitivity that is the hallmark of type 2 diabetes. Positive anti-GAD antibodies and low C-peptide at the time of the initial diagnosis are also consistent with type 1 diabetes, although C-peptide levels can also be low in long-standing type 2 diabetes. Weight loss occurs in both types of diabetes mellitus when glucose is profoundly elevated.
A 25-year-old male presents to your office after recently being diagnosed with HIV infection at the health department. You obtain blood work and note that his CD4+ count is 180 cells/mm3.
This patient should receive prophylaxis against which one of the following opportunistic infections?
a) Histoplasma capsulatum
b) Microsporidiosis
c) Mycobacterium avium-intracellular complex
d) Pneumocystis
e) Toxoplasma g
d) Pneumocystis
Patients with HIV infection and severe immunodeficiency are at risk for certain opportunistic infections. Susceptibility to opportunistic infections can be measured by CD4+ T lymphocyte counts. Patients with a CD4+ count <200 cells/mm3 should receive trimethoprim/sulfamethoxazole for prevention of Pneumocystis pneumonia, and prophylaxis against Toxoplasma gondii should also be given if the CD4+ level is <100 cells/mm3. Azithromycin is used to prevent infection with Mycobacterium avium-intracellulare complex when CD4+ counts are <50 cells/mm3. Itraconazole is used to prevent Histoplasma capsulatum infection when the CD4+ count is :150 cells/mm3 if the patient is at risk due to occupational exposure or living in a community with a hyperendemic rate of histoplasmosis (>10 cases per 100 patient years). There is no recommendation for prophylaxis against microsporidiosis.
A 55-year-old overweight male presents with a complaint of pain in the left big toe. He recently started jogging 2 miles a day to try to lose weight, but has not changed his diet and says he drinks 4 cans of beer every night. The pain has developed gradually over the last 2 weeks and is worse after running.
An examination shows a normal foot with tenderness and swelling of the medial plantar aspect of the left first metatarsophalangeal joint. Passive dorsiflexion of the toe causes pain in that area. Plantar flexion produces no discomfort, and no numbness can be appreciated.
Which one of the following is the most likely diagnosis?
a) Sesamoid fracture
b) Gout
c) Morton’s neuroma
d) Cellulitis
a) Sesamoid fracture
Pain involving the big toe is a common problem. The first metatarsophalangeal (MTP) joint has two sesamoid bones, and injuries to these bones account for 12% of big-toe injuries. Overuse, a sharp blow, and sudden dorsiflexion are the most common mechanisms of injury.
Gout often involves the first MTP joint, but the onset is sudden, with warmth, redness, and swelling, and pain on movement of the joint is common. Morton’s neuroma typically causes numbness involving the digital nerve in the area, and usually is caused by the nerve being pinched between metatarsal heads in the center of the foot. Cellulitis of the foot is common, and can result from inoculation through a subtle crack in the skin. However, there would be redness and swelling, and the process is usually more generalized
This disease is what may have inspired the legend of vampires
Porphyria