Infectious Disease Cases

A 35 year old white man went to an urgent care clinic twice over the course of 3 days befroe being admitted in the month of AUgust to the hospital with high fever, myalgies, and sever headache. Additional symptoms included phhotophobia, nausea, and anorexia. The social and medical histories were unremarkable. Ten days before his first visit to the clinic, he had returned from a boating trip. T = 38.8 C, P = 116/min, R = 16/min, BP = 110/64 mmHg. On exam, an ill=appearing patient with erythematous and swollen conjuctiva.

Leptospira interroganas (a presumptive diagnosis of leptospirosis) - penicillin g

A 3 year old boy was brought to a clinic for complaitnts of low-grade fever, swollen lymph nodes, and a rash for 3 days. Because of his family's religious beliefs, he had not had any vaccinations. A close family friend had also been sick with a similar illness 2 weeks earlier. T = 38C, P= 118/min, R= 20/min, BP = 112/64mmHg. On exam, young child in no acute distress. A diffuse maculopapular rash was present over the trunk and extremities; no lesions were present in the mouth. Cervical lymphadenopathy was also noted.

Rubella

A 41 year old man presented with a 4 month history of worsening abdominal pain, diarrhea, and vomiting with blood. His abdominal pain was mainly in his right upper quadrant. The man had recently immigrated to the United States from Kenya. T and P elevated other vitals normal. On exam, an ill appearing male in mild distress due to abdominal pain; enlargement of the liver and spleen, with mild tenderness, was noted. CBC showed elevated eosinphils. Abdominal ultrasound showed enlarged liver and spleen with evidence of portal hypertension.

Schistosoma mansoni (schistosomiasis; bilharziasis). Treat with praziquantel.

In August, a friend brought a 69-year-old woman with a history diabetes mellitus to the emergency department following a 2-day history fever, headache, vomiting, weakness, and confusion. The woman had been in good health previously, and her diabetes was well controlled. She commonly spent much time outdoors in her yard and garden. T = 38.5 C, P = 102/min, R = 20/min, BP = 118/60 mmHg. On examination, the patient was difficult to arouse and did not respond appropriately to questioning. A coarse tremor was present in the chin and upper and lower extremities.

West Nile Virus (Flaviviridae)

A 35 year old man with AIDS presented to his primary care physician with a complaint of several weeks of watery diarrhea. Symptoms of low-grade fever, nausea, and anorexia were also present. In the past 2 weeks, the diarrhea had worsened considerably, and he had developed severe fatigue and weakness. He had also lost 20 lbs. He had been off his highly active antiretroviral therapy (HAART) for several months due to intolerance. Elevated T and P low BP. On exam, Cachetic, ill-appearing male in no acute distress. Abdominal exam revealed mild, diffuse tenderness.

Cryptosporidium parvum (cryptosporidosis). In AIDS patients give HAART to restore immune function otherwise hydrate because disease is self-limiting. Nitazoxanide for Immunocompetent

A 38 year old man was seen by his family physician for two weeks of fever, productive cough, right-sided pleuritic chest pain, a 12 lb weight loss, and a painful lesion on this left arm. The patient, a long time resident of Tennessee, had no significant past medical history. He had worked outdoors as a landscaper for the last 18 years. Family history was unremarkable. He had been treated with oral cefuroxime and erythromycin for suspected pneumonia 10 days prior to this visit, but his symptoms had not improved. Elevated T and R. Examination was remarkable for crackles in the left lung a verrucous skin lesion (1 x 1 cm) on his left arm that was tender and erythematous. A chest x-ray revealed multiple nodular lesions, some of which were cavitating, the left upper lobe. Left arm x-ray revealed no body abnormalities.

Blastomyces dermatitidis (blastomycosis). Treat with Itraconazole for immunocompetent use amphotericin B for severely ill patients or those with brain lesions.

A 38 year old man developed a flu-like syndrome with fever, headache, and anorexia. During the ensuing 8 weeks, he noted continuing fevers, sweats, 30-lb weight loss, and depression. He saw his family physician, complaining of acute pain in joints, especially his lower back. He was a computer programmer and had recently traveled to Crete to visit his grandmother. During his stay on the Mediterranean island he enjoyed drinking unpasteurized goat milk. Six weeks after his return to the United States he developed the current illness. T elevated other vitals normal. On exam, generalized lymphadenopathy and mild splenomegaly were noted. Tenderness in his sacroiliac joint was also noted. Plain x-rays of the lumbosacral spine were unrevealing.

Brucella melitensis (presumptive diagnosis of brucellosis). Treat with doxycycline and rifampin.

A 27 year old woman presented to the emergency department of a city medical center complaining of lower abdominal pain, vaginal discharge, and dysuria for 1 week. She also complained of fevers and chills for the past 2 days. She had had four sexual partners in the previous year and used a contraceptive measure (condoms) only occasionally. She had never been treated for a sexually transmitted disease (STD), and she had not seen a physician in 2 years. T = 38.4 C, P = 104/min, R = 16/min, BP = 112/68. Pelvic examination revealed a reddened cervical os. Lower abdominal tenderness, adnexal tenderness, and cervical motion tenderness were noted. The uterus, fallopian tubes, and ovaries were also tender but were not enlarged.

Chlamydia trachomatis (and anaerobes) - tx azithromycin (preferred) or doxycycline

A 67 year old man presented with fever, abdominal cramping, and frequent diarrhea (six to nine bowel movements per day) for 4 days. Three weeks before the current episode, he had undergone a hip replacement and was rehabilitating in an orthopedic unit. During that hospitalization, he developed a nosocomial pneumonia and was treated empirically with cefuroxime and clindamycin. He gradually improved and was discharged a week before his current presentation, with maintenance oral antibiotics, to recuperate at home. His wife had no similar symptoms. T = 39C, P = 114/min, R = 18/min, BP = 94/50 mmHg. The patient appeared confused and very pale. He could not answer questions about his current condition. His skin showed decreased turgor, and his oral mucosa was dry. Sigmoidoscopy revealed erythematous and friable colonic mucosa.

Clostridium difficle - associated dirrhea. (CDAD) - tx metronidazole, vancomycin

A 35 year old man was admitted to the hospital with a 3 week history of fever, night sweats, headache, joint pains, dry cough, and severe fatigue. He had lost 16 lbs in the past two weeks. The patient had returned to his home in New York, one month after a brief visit with his mother in Phoenix, Arizona. Elevated T, R, P. On exam, the patient appeared ill and slightly pale. Rales were heard in the right lower lobe. Erythema nodosum lesions on his back were noted. A chest x-ray revealed infiltrates in both lung fields with a large cavity in the right upper lobe.

Coccidioides immitis (coccidioidomycosis). Oral fluconazole or itraconazole, then Amphotericin B for sever infections.

A 9 year old girl presented with low grade fever, sore throat, and malaise for 2 days. These symptoms developed 10 after arriving at a summer camp operated by a religious group. Recently, she was noted to have a dry cough and difficulty breathing. Her parents then brought her to the emergency department. The family had emigrated from Ukraine one year before. The child's immunization status could not be determined. She had been otherwise healthy. T = 38.9 C, P = 140/min, R = 45/min, BP = 92/50 mmHg. On exam, the patient was in sever distress; respiratory stridor was prssent; exudative pharyngitis and bilateral cervical adenopathy ("bull neck") were noted. A yellowish, leathery, thick membrane extending to the uvula and soft palate was also seen. Chest x-ray was normal.

Corynebacterium diptheriae (diptheria) - erythromycin

A 45 year old white homosexual man was brought by his partner to the emergency department of a general hospital because of fever, severe headache, nausea, vomiting, and mental status changes that had been progressive over the course of the past two weeks. The patient had been diagnosed with HIV infection 2 years before and was not currently on retroviral therapy. Elevated T and P. On exam, the patient was lethargic and disoriented. Nuchal rigidity was noted as well as a positive Kernig sign (flexion of the neck when the knee is flexed). Chest x-ray and head CT scan were normal.

Cryptococcus neoformans (cryptococcal meningitis). Treat with amphotericin B with addition of flucytosine as combination therapy. Fluconazole has been approved for treatment of acute cases but is usually reserved for maintenance therapy.

A 36 year old man was brought to the hospital for complaints of persistent high fever, dry cough, and worsening shortness of breath for a week. He had been diagnosed with acute myelogenous leukemia 6 months before. He was taking Bactrim for prophylaxis of pneumocystis pneumonia. T = 39C, P = 122/min, R= 36/min, BP 120/82 mmHg. On exam, thin male in moderate respiratory distress; lungs with crackles diffusely in both lungs. A chest x-ray revealed bilateral interstitial infiltrates.

Cytomegalovirus (CMV pneumonitis) - tx ganciclovir

A 21 year old male college student came to the emergency department of a local hospital complaining of fever, headache, and sore throat with severe fatigue and difficulty swallowing of ten days' duration. The patient had no significant past medical history. he was not sexually active, although he started dating a new girlfriends a week, and he admitted to kissing several girls in the past month. Family history was unremarkable. T = 39.3 C, P= 104/min, R = 14/min, BP = 124/72 mmHg. On exam, pharyngeal erythema and bilaterally enlarged tonsils with exudates were noted; posterior cervical lymph nodes were enlarged and tender (lymphadenopathy); spleen was enlarged and a palpable liver was tender (hepatosplenomegaly); faintly jaundiced skin was also noted. Abdominal ultrasound revealed hepatosplenamegaly. No focal lesions were observed.

Epstein-Barr Virus (IM).

A 24 year old sexually active woman visited a family practice clinic because of burning pain during urination, increased frequency, and urgency for 1 day. She also complained about blood-stained debris at the end of urination. Symptoms had rapidly worsened in the past 6 hours. On exam, mild suprapubic tenderness was noted.

Escherichia coli (uncomplicated UTI or cystitus) treat with amoxicillin or cephalosporin group but depends on profile.

In late September, a 51 year old man with a one week history of fever, headache, and muscle aches was taken to a clinic. He noted an ulcer on his right hand that had not healed and pain in his right axilla. The patient lived in Oklahoma and had a hobby of sewing together tanned rabbit hides to make more blankets. In the week before the onset of his illness, he had skinned and tanned a rabbit killed by the family dog. T, P, and BP elevated. On exam, remarkable physical findings included an indurated erythematous rash with an ulcerated lesion on the dorsal skin the right hand and painful axillary adenopathy.

Francisella tularensis (presumptive diagnosis of tularemia). Treat with Streptomycin or gentamycin/doxycycline alternatives.

A 54 year old woman presented to her family physician complaining of abdominal pain that had been worsening for the past 2 weeks. She stated that it often improved immediately after meals or taking antacids. She also noted occasional heartburn but denied fevers, nausea, or vomiting, diarrhea, or bloody stools. The patient was a schoolteacher who worked with a crowded class of seven students under stressful conditions. There were no other notable prior social or medical histories. T elevated other vitals normal. Abdominal exam revealed mild midepigastric tenderness with no rebound. Rectal exam was normal; no blood on Hemoccult testing was noted.

H. pylori (peptic ulcer disease). Treat with PPI, amoxicillin, and clarithromycin.

Five workers between the ages of 29 and 48 years presented to an acute care clinic with 1-week history of fever, chills, night sweats, cough, headache, fatigue, myalgia, and weight loss. Two weeks before the onset of symptoms, these five workers had begun partial demoliton of an abandoned building in a small city near the Ohio River. At the time of demolition of an abandoned building in a small city near the Ohio River. At the time of demolition, a colony of pigeons was observed int he building, and pigeon droppings were found throughout the building. During the demolition, none of the workers wore personal protective equipment (respirators, eye protection, gloves, or protective clothing). T and R elevated. On exam, crackles were noted on auscultation of the lung. A chest x-ray from patient X was remarkable for enlarged hilar and mediastinal nodes and multiple nodular infiltrates.

Histoplasma capsulatum (histoplasmosis). Most infections are self-limiting but oral itraconazole can be used.

A 64 year old woman was brought to the emergency department with 5 days of fever, headache, and confusion. She had had diarrhea for 2 days that resolved a few day before her current symptoms began. She had a history of rheumatoid arthritis, for which she had been taking prednisone daily for the past several months. T and P elevated. R normal. BP slightly elevated. On exam, the patient was unable to answer simple questions and appeared agitated; exam revealed no nuchal rigidity and no focal neurological deficits. Head CT was normal. Brain MRI showed meningeal enhancement but no focal lesions.

Listeria monocytogenes (listeria meningitis). Treat with amoxicillin and gentamycin.

An 8 year old white boy was brought to the dermatology clinic for the examination of raised lesions on his head. he was otherwise healthy. The lesions were first noticed a month before as erythematous areas that enlarged and coalesced over a period of several weeks. He had received a dog for his birthday a few months before, which was apparently without illness. Slightly elevated T. On exam, the lesions were raised nodules in the center and scaling at the peripheries, covering a large area on his head. There were also a few small pustules on the scalp.

Microsporum canis (ringworm; tinea capitis). Treat with prescription drugs such as griseofulvin, terbinafine, itraconazole, fluconazole, and ketoconazole. Nonprescription drugs are undecylenic acid, tolnaftate, or miconazole.

A 7 year old girl presented with a 2 day history of fever, headache, earache, and swelling and tenderness at the parotid and submaxillary areas. She also found it difficult to open her jaws (to eat, swallow, or talk). The child had been in good health. However, she recieved only one does of the usual childhood vaccinations because the family had moved when she was four months old and she was lost to follow-up. T = 39.6 C. Examination revealed enlargement of the parotid glands (lymphadema of the neck and upward displacement of the ear); redness and swelling at the opening of the Wharton duct were also noted.

Mumps

A 44 year old white man presented with a 3 month history of intermittent fever, chills, and cough production of green sputum. He also complained about weakness, weight loss, chest pain, and shortness of breath. He had also complained about weakness, weight loss, chest pain, and shortness of breath. He had been given several courses of antibiotics without significant improvement and had noted the presence of a headache for the past few weeks. He had a history of COPD and had been on chronic steroids for the past 6 months. T = 39 C, P = 118/min, R = 36/min, BP = 148/90 mmHg. The patient appeared ill. Decreased breath sounds in the right lung were heard. Slight weakness of the left upper extremity was also noted. A chest x-ray revealed extensive nodular infiltrates in the right middle and upper lobes and cavitary disease.

Nocardia asteroides (nocardiosis) - sulfonamides

Within 48 hours of a college football game in Philadelphia, 158 students with symptoms of gastrointestinal disease visited the university health service. The predominant symptoms included nausea in 99%, vomiting in 75%, diarrhea in 48%, and headache fever, and myalgias. Marching band members, football players, and faculty and staff from both universities had similar symptoms. A total of several hundred individuals were afflicted with similar symptoms. (In one of the patients) T = 38.6 C, P = 96/min, R = 16/min, BP = 104/60 mmHg. On exam a young female in mild distress due to abdominal pain and nausea; abdominal exam showed mild tenderness, and rectal exam revealed no blood.

Norovirus.

A 9 year old boy was brought to the hospital by his parents with complaints of repeating intense chills and daily high fever for 4 days. The parents said that when his fevers would abate, he would become drenched in sweat and feel exhausted and drained. The parents also reported diarrhea, nausea, and abdonminal pain. On the day of admission the patient was noted to be lethargic and difficult to arouse. A generalized seizure was witnessed in the emergency department. The family had immigrated to the United States from West Africa 3 weeks before the onset of the current illness. T, P, R highly elevated BP very low. On exam, thin male minimally responsive to verbal commands. Pupils were reactive and neck was supple. Conjunctiva was pale, and abdominal exam showed hepatosplenomegaly. Head CT was unremarkable.

Plasmodium falciparum (malaria). Treat with chloroquine or mefloquine for resistant types.

An 18 year woman presented with a worsening of her chronic cough for the past week. She had had a low=grade fever, as well as fatigue and shortness of breath. The cough was productive of greenish sputum that was thick and tenacious. She was diagnosed with cystic fibrosis at age 4 and had had multiple hospital admissions for respiratory infections. On examination, the patient was a pale, chronically ill-appearing young woman with increased respiratory effort and rapid breathing. Lung examination revealed bilateral rales and wheezing; heart exam demonstrated distant heart sounds. A chest x-ray showed a small heart, hyper inflated lung fields, and patch bilateral infiltrates.

Pseudomonas aeruginosa (pneumonia) - tx ceftazidime

A 31 year old white man was brought in to the emergency department of a general hospital with the complaints of fever and visual hallucinations. Four days before his arrival at the ED, the patient developed malaise and back pain while working on a roadside clean-up crew. The next day, he sought medical attention, complaining of muscle pains, vomiting, and abdominal cramps, which were treated with acetaminophen. T = 37.8 C, P = 116/min, R = 28/min, BP = 168/104 mmHg. On exam, the patient was alert, with increased tone in the right forearm and hyperesthesia over the entire right side of the body. During the next 12 hours, he became increasingly agitated and less well-oriented. His condition worsened, and he developed hydrophobia, because even the sight of water set off severe spasms of the neck and chest. Hypersalivation and wide fluctuations in body temperature and blood pressure were also noted.

Rabies virus (rabies encephalitis).

In December, a 71-year-old man from a nursing home was brought to the hospital in acute respiratory distress. he had been in his usual state of health until 10 AM the previous day, when he suddenly developed fever, chills, muscle aches, cough, and prostration. Several other nursing home residents had developed a similar illness during the previous week. His past medical history was unremarkable, and he had not seen a physician in the past year. T = 40 C, R = 28/min, P = 118/min, BP = 140/90 mmHg. On physical exam you note an acutely ill, prostrated elderly man; lung exam was unremarkable. He had a frequent, weak cough.

Respiratory: Influenza

A 58 year old man presented with a 3-week history of progressive, mildly painful skin lesions on his left thumb. A reddish streak was apparent along these lesions. The patient did not have any fevers or chills. He enjoyed working in his garden but did not recall any specific injury. Elevated T. On exam, multiple erythematous lesions were seen on his left arm from his thumb to his elbow, associated with lymphangitic streaking. There was a dry, shallow, ulcerated lesion on his thumb.

Sporothrix schenckii (sporotrichosis). Treat with itraconazole.

In July, a 61 year old homeless man was brought to the hospital by paramedics with complaints of fever, malaise, and worsening headache for the past 3 days. He also noted nausea, vomiting, and diarrhea. The paramedics who treated him stated that he appeared somewhat confused. It had been a hot summer, and the mosquito population had been hard to control. T = 40 C, P = 108/min, R = 18/min, BP = 138/78 mmHg. (On exam) The patient was not able to anser more than simple questions, and he frequentyly seemed to drift into sleep. The neck was supple, but neurologic exam was difficult due to poor cooperation. Slight tremors of the face and extremities were noted.

St. Louis encephalitis virus. (an arbovirus)

Twenty-four people became ill within 3 hours after eating a meal at an office party. All had nausea, most had vomiting, and several had crampy abdominal pain. Three of the individuals sought medical care at the emergency department of a local hospital. All 24 individuals had been in good health. The day before the office party, a food preparer had purchased a 17 pound precooked packaged ham, baked it at home at 400 F for 1.5 hours, and transported it to her work place, a large institutional kitchen, where she sliced the hot ham on a commercial slicer. The ham was served cold at the party the next day. T = 37 C, P = 84/min, R = 14/min, BP = 136/80 mmHg. Patient X appeared in mild distress due to abdominal pain. Abdomen was soft and nontender, with normal bowel sounds.

Staphylococcus aureus (food poisoning) - naficillin, vancomycin

A 28-year-old Hispanic man was brought to the emergency department of a general hospital for severe headaches and two generalized seizures. He had first noticed headaches, which had been getting more frequent, several weeks before. He denied fevers or chills. The patient was a recent immigrant from Mexico. There was no previous history of seizures. Elevated T. On exam, young male in moderate distress due to headache; neurological exam was normal. Elevated eosinophils. A CT scan of his brain revealed an intracranial calcified cyst, and further imaging with MRI confirmed the presence of similar lesions, some with a scolex visible.

Taenia solium (neurocysticercosis). Asymptomatic cysts do not require treatment. Hydrocephalus from intracranial hypertension may require CSF shunting. Treatment is possible using praziquantel or albendazole.

A 24 year old man presented to the emergency department with a complaint of a chickenpox-like rash that he noticed the day before. Four days earlier, he had developed the sudden onset of fever, severe headache, and back pain, which were resolving when the rash began. he thought the rash was unusual because he was certain he had had chickenpox as a child. he was otherwise healthy and had no medical problems. t = 38 C, P = 84/min, R = 14/min, BP = 124/80 m Hg. On exam, papulovesicular lesions were noted mostly on the face and extremities (including the palms and soles), with a few on the chest and abdomen. the bumpy lesions, filled with a thick, opaque fluid, appeared to be a similar stage of development.

Variola major (smallpox)

On a summer day in August, an 18 year old man was taken to the emergency department of a local hospital because of a 2 day history of fever, weakness, pain in his left groin, and diarrhea. The groin pain was so severe that he walked with a limp, with his left leg abducted. He also had small rashes on his leg. The patient lived in Flagstaff, Arizona. He had maintained good health before the current event. Elevated T,R,P, low BP. On exam, the patient was alert but restless and was in moderate distress due to pain. A left groin mass (~6cm), which was firm and exquisitely tender, was noted, with mild erythema, and there were small hemorrhages on the skin of his right leg.

Yersinia pestis (plague, a presumptive diagnosis). Southwest is important geographic location. Treat with streptomycin and chemoprophylaxis with tetracycline.

A 20 year old man presented to the emergency department with a 3 week history of moderate fever, cough, shortness of breath, weight loss, and anorexia. He had complained about a draining lesion on his left chest wall. The patient had recently emigrated from Pakistan and had a history of severe periordontal disease. T = 38 C, P = 82/min, R = 24/min, BP = 136/84 mmHg. The patient was ill-appearing and had a productive cough with foul-smelling sputum. Abnormal breath sounds were heard, and a sinus tract from the right chest wall with drainage containing yellow granules was noted. Chest x-ray revealed left lung infiltrates with upper lobe cavity.

Actinomyces israeli (thoracic actinomycosis) - penicillin G

A 14 year old girl presented to the emergency department with a 2 day history of fever, sore throat, and a red left eye, which felt like there was sand in it. She had been at summer camp for the past 2 weeks where several other children had a similar illness. Activities at the camp included swimming in a local pool. The patient had no significant medical history and denied being sexually active. Family history was unremarkable. T = 38 C, P = 94/min, R = 12/min, BP = 124/82 mmHg. Examination revealed preauricular lymphadenopathy, an erythematous pharynx and conjunctivitis of the left eye.

Adenovirus.

A 2 month old white girl suffered from cough for more than 2 weeks. The patient's mother became concerned when the child turned blue after a series of coughing spells that ended with vomiting. She brought her to a pediatrician. The patient had not yet received any vaccinations. She had been healthy without any underlying medical problems. Vitals normal. On exam, paroxysmal cough, whoop, and post-tussive vomiting were noted during examination. Conjunctival hemorrhages and facial petechiae were also noted. There were no signs of lower respiratory illness. Chest x-ray did not reveal any pulmonary infiltrates.

Bordetella pertussis (pertussis). Supportive care and then treat with erythromycin if needed. Vaccine part of DTaP.

A 29 year old woman suffered a dry cough, shortness of breath, and pleuritic chest pain. She continued to have these symptoms for more than a week and subsequently developed fever, chills, and bloody cough. Two weeks before this episode, the patient had been admitted for treatment of leukemia to a hospital that was in the midst of a major reconstruction project. While hospitalized, she recieved cytotoxic chemotherapy and developed sever neutropenia, which had persisted to the current presentation. T, P, R elevated. On exam, an ill-appearing female in moderate respiratory distress. Bilateral rales over both lungs were heard. CBC showed leukopenia and thrombocytopenia. A chest x-ray showed a wedge-shaped lesion in the left lung and right middle lobe infiltrate. A CT scan revealed small pulmonary nodules and a hazy rim (halo sign) with ground-glass attenuation.

Aspergillus fumigatus (invasive pulmonary aspergillosis). Treat with voriconazole, old standard was Amphotericin B.

A 3 year old girl was brought to the emergency department of a general hospital following a 3 week history of nausea, poor appetite, and abdominal pain. She had not had any bowel movements for the last 2 days. The patient was of Mexican origin and had recently moved from Mexico with mother to South Texas. Vitals relatively normal. On exam, young child in moderate distress due to abdominal pain. Abdomen was distended and mildly tender. CBC showed eosinophilia. X-rays of her abdomen were consistent with intestinal obstruction.

Ascaris lumbricoides (ascariasis). Treatment with Mebendazole and albendazole are the drugs of choice. Other effective agents include pyrantel and piperazine.

A 63 year old man awoke early with nausea, vomiting, and confusion and was taken to a local emergency department for evaluation. His illness, which began 5 days prior to arrival at the ED, during a trip to North Carolina, was characterized by fever, chills, sweats, malaise, anorexia, and headache. He had a dry cough for the past 2 days. No history of chest pain, myalgias, dyspnea, abdominal pain, diarrhea, or skin lesions was reported. Past medical history included hypertension and cardiovascular disease. He did not smoke. T = 39.2 C, P = 109/min, R = 24/min, BP = 110/64 mmHg. On admission, the patient was alert and interactive but spoke nonsensically. Initial pulmonary, cardiac, and abdominal examinations were reported as normal. No nuchal rigidity was observed. He was not oriented to person, place, or time. A chest x-ray showed a widened mediastinum.

Bacillus anthracis. (Anthrax) - ciprofolaxcin

A 27 year old man was broguht to the emergency department of a hospital with high, spiking fevers, severe diffuse pain over the ower abdomen, and loss of appetite. Two weeks earlier he first noticed mild abdominal pain and anorexia, which gradually progressed to include fevers and night sweats. The day before admission his abdominal pain became severe, and his fever became constant. T = 39.5 C, P = 118/min, R = 20/min, BP = 92/50 mmHg. Examination revealed tenderness in the right lower quadrant of his abdomen, with rebound tenderness. CT scan showed an intra-abdominal fluid collection consistent with an abscess in the right lower quadrant.

Bacteroides fragilis (polymicrobic infection) - tx clindamycin or metronidazole

One summer evening, a 63 year old white man came to the emergency department of a nearby hospital presenting with a 6 day history of fever, moderate headache, generalized myalgia, arthralgias, and fatigue. He had noticed a rash under the armpit that day that had spread rapidly, prompting him to seek medical attention. He had lived in Connecticut and had recently moved to a cottage in a wooded area outside a small town. He noted multiple tick bites after his daily walks in the woods. He had otherwise maintained good health. T = 38.8C, P = 102/min, R = 14/min, BP = 134/82 mmHg. On exam, an expanding erythematous skin lesion (erythema migrans) was noted under the axilla that had a central area of clearing.

Borrelia burgdoferi (Lyme disease LD) - ceftriaxone, doxycycline

A 9 day old female newborn was taken to a hospital by her parents, who reported a 10 hour history of an inability to nurse and difficulty in opening her jaw. The patient's parents had noticed a foul-smelling discharge from her umbilical cord during the preceding 2 days. T = 38 C, P = 130/min, R = 36/min, BP = 94/48 mmHg. The newborn had trismus, opisthotonus, and hyper-responsiveness to external stimuli. The umbilical cord was covered with dry caly, which when retracted revealed a foul-smelling yellow-green discharge.

C. tetani (tetanus)

A 21 year old woman seen in a clinic complained of bothersome vulvar itching and thick, whitish vaginal discharge lasting for several days. She had had no previous episodes. SHe denied being sexually active. She stated that she had recently completed a course of antibiotics for a sinus infection. Vitals normal. On exam, vulvar erythema was presetn, and a thick whitish discharge was also noted.

Candida albicans (vulvovaginal candidiasis). Treat with topical antifungal agents such as clotriamazole, miconazole, or nystatin or to systemic treatment with a single oral dose of fluconazole (especially for bloodstream infections). Intravenous ampotericin B, caspofungin, and voriconzaole have a broad spectrum.

A 3 month old female infant was brought to the emergency department of a general hospital with a 5 day history of decreased activity, decreased oral intake, upper airway congestion, and general irritability. There was no history of fever or vomiting. During the previous 2 weeks, she had been constipated, and twice her mother had given her a tablespoon of honey for treatment. T = 36.1 C, P = 120/min, R = 20/min, BP = 90/65 mmHg. On exam, the patient was listless and slightly pale but otherwise well nourished, with weight and height above the 50th percentile for age. Positive findings included moderately dry oral mucosa, upper airway congestion, a sluggish pupillary response to light, mild abdominal distention with hypoactive bowel sounds, and significant hypotonia.

Clostridium botulinum.

A 66 year old white man underwent surgery for colon carcinoma, and 2 days later he experienced severe pain at the surgical wound site. Within several hours, local edema and tenderness developed at the wound, as well as a thin, brownish discharge. Prior to surgery and this episode, he had always maintained good health. His social history was unremarkable. T = 37.6 C, P = 136/min, R = 26/min, BP = 90/52 mmHg. The patient appeared very ill. The surgical wound site exhibited discoloration of skin and hemerrhagic bullae. There was a serosanguineous discharge from the infected wound. The affected muscles showed failure to bleed, and there was extensive gas in the soft tissues.

Clostridium perfringens (gas gangrene) - tx clindamycin

A 75 year old man experienced the acute onset of sever abdominal cramps. Later in the morning, watery diarrhea occuring every 15 - 30 minutes developed, initially with small amounts of visible blood. Diarrhea subsequently became markedly bloody. He was nauseated but not vomiting. Worried about his illnes and his age, his son took him to a nearby hospital emergency department for evaluation. Recent food intake history was remarkable for eating a hamburger at a back yard BBQ 2 days earlier. The patient recalled that the meat inside was pink. He said his teenage grandson ate at the BBQ and the same illness but with milder symptoms. Elevated T and P. Normal R and BP. On exam, clinical examination of the abdomen was unremarkable except for increased bowel sounds. Stool was grossly bloody. Abdominal x-ray was normal.

E. coli serotype O157;H7 or EHEC. Treat by giving supportive therapy and monitoring for HUS (dialysis if gets serious)

A 49 year old woman presented with high fever and chills, jaundice, and upper abdominal pain for 3 days. The patient was a recent immigrant form Argentina. One year before, she first noticed a sensation of fullness in the right upper quadrant of her abdomen. Her past medical history was unremarkable. In her country of origin, she had been healthy and active, working in the field and breeding and raising sheepdogs. Elevated T and P low BP. On exam, the patient appeared acutely ill and was obviously jaundiced. Right upper quadrant abdominal tenderness was noted. A CT scan of the liver demonstrated a large multiloculated cyst with bile duct dilation.

Echinoccus granulosus (hydatied cyst disease or echinococcosis). Treat with albendazole.

During a 4 week period in August in rural county in the Midwest, a total of 29 persons (between the ages of 9 and 15 years) had a rapid onset of fever, headache, stiff neck, and photophobia. Some patients had diarrhea for a few days preceding the headache. (On one of the individuals) T = 39.2 C, P = 112/min, R = 16/min, BP = 130/84 mmHg. On exam, an ill-appearing male in moderate distress due to headache; he had some phophobia and mild nuchal rigidity, but negative Kernig sign (flexion of the neck when the knee is flexed).

Echovirus

A 36 year old man presented to the emergency department of a general hospital with a 10 day history of intermittent diarrhea and tenesmus, with blood and mucus visible in the stool. He had just returned from a working trip to India, where had visited a rural town in the last week of his trip. Elevated T. On exam, an ill-appearing male in mild distress; abdominal exam revealed mild diffuse tenderness,, and rectal exam was positive for blood. Sigmoidoscopic examination revealed multiple small hemorrhagic areas with ulcers.

Entaamoeba histolytica (amebic dysentery). Treat with metronidazole.

A 25 year old man presented to a hospital clinic with a 2 week history of sustained diarrhea (three to five movements per day), nausea, flatulence, and lack of appetite. He described his diarrhea as initially watery, and then greasy and foul smelling. He added that he had a bloating sensation. He did not have fever or chills. The patient had been in good health. Four weeks previous to seeing his physician, he had visited Colorado for several days of backpacking in the Rocky Mountains. T and BP slightly elevated. On exam, abdomen was distended and mildly tender; no hepatosplenomegaly. Rectal exam was normal and Hemoccult negative.

Giardia ambila (giardiasis) treat with metronidazole.

A 23 year old woman visited her family physicians for her routine physical exam and Pap smear. She had a few small, raised lesions on the cervix but was otherwise asymptomatic. She had been sexually active since she was 15, with many sexual partners. Vital signs are normal. On exam, Labial venereal warts (condylomata acuminata) and a friable, erythematous cervix were noted during pelvic examination. Colonoscopy confirmed the presence of lesions on the cervix.

HPV.

A 64 year old man presented to a clinic with complaints of low-grade fever, productive cough of yellow-green sputum, and worsening of his chronic shortness of breath for several days. He had recovered from a mild cold just before the current symptoms began. He had long history of chronic obstructive pulmonary disease (COPD) and had been on oxygen for the past 2 years. He had been taking his inhalers as directed. Vitals are all elevated. On exam, thin male in moderate respiratory distress; lung exam revealed diffuse wheezes and rhonchi. Chest x-ray revealed hyper-inflated lungs but no infiltrates.

Haemophilus influenzae (acute exacerbation of chronic bronchitis). Treat with ceftriaxone and a macrolide.

A 23 year old man presented to the emergency room of a general hospital with a 5 day history of fever, jaundice with dark yellow urine and pale colored stools. He also complained about malaise, fatigue, abdominal pain, intermittent nausea, and vomiting, and he noted loss of appetite, to the point that even the sight of food made him nauseated. He denied a history of IV drug use and he had no sexual contact for the previous 2 months. Five weeks ago, he attended a family reunion. T - 38.4C, P = 94/min, R = 14/min, BP = 124/80 mmHg. Physical examination revealed an icteric patient with hepatomegaly but no evidence of splenomegaly.

Hepatitis A virus.

A 27-year-old woman was seen in a clinic for complaints of fevers, chills, headache, malaise, anorexia, and abdominal pain for several days. She stated she came today because she noticed that her eyes had turned yellow, and she had developed a very bothersome generalized itching. She admitted to using IV drugs for the past few years, saying she frequently shared needles with friends. She had one sexual partner in the last year. T = 38.8 C, P= 104/min, R= 16/ min, BP = 112/70 mmHg. Physical exam shows she was in mild distress due to pruritus. Scleral icterus and jaundice were present. Her liver was enlarged and mildly tender.

Hepatitis B virus.

A 48-year-old man presented to an internist for a physical exam, since he had not been to a physician for many years. He was asymptomatic, but routine chemistry panel showed elevated transaminases. He denied IV drug use, but on further questioning, he did recall that he received a blood transfusion 25 years before, after an appendectomy. T = 37C, P= 72/min, R = 12/min, BP = 124/76 mmHg. Physical exam was unremarkable.

Hepatitis C virus.

The family of a 56 year old man became concerned when they noted changes in his personality that began gradually over several days making him more irritable and confused. He also developed fevers and headache and progressively became unable to perfom daily activities. He was brought to the emergency department of a local general hospital by his wife after she noticed a left-sided weakness and then witnessed him having a seizure. He had no other medical problems and was on no medications. T = 38 C, P = 86/min, R = 16/min, BP = 124/80 mmHg. On exam, he was confused and unable to coherently answer questions. Pupils were equal and reactive, and his neck was supple. Neurologic exam revealed left arm and leg weakness, but further exam was difficult due tot lack of cooperation.

Herpes simplex virus (HSV) type 1 (herpes simplex encephalitis [HSE])

A 26 year old liberal arts college student visited a primary care clinic seeking medical attention. He was very concerned about the painful, itchy sores (blisters) that had developed on the shaft of his penis. He had low-grade fever, malaise, and a mild headache. The patient had no significant medical history. he admitted to unprotected sex with a new girlfriend 3 days before arrival at the clinic. T = 38.2 C, P = 90/min, R = 14/min, BP = 120/82 mmHg. Examination revealed erythematous, vesicular lesions on the penile shaft. There was also a clear discharge from the urethra and tender inguinal lymphadenopathy.

Herpes simplex virus (HSV) type 2 (genital herpes) - tx acyclovir

A 27 year old man presented to an ambulatory care clinic with complaints of fever, headache, sore throat, and malaise for over a week and a rash for the past 2 days. he admitted to having unprotected sex with other men. His last encounter was 3 weeks earlier. he denied prior transfusions or IV drug use. T = 39.2 C, P = 94/min, R = 14/min, BP = 136/82 mmHg. On exam, pharynx was erythematous; cervical and axillary lymphadenopathy was present. A diffuse maculopapular rash was observed on his abdomen.

Human immunodeficiency virus type 1 (HIV-1) - tx HAART

A 41 year old white man was admitted with a day history of high fever and dry cough. His initial symptoms progressed to include headaches, muscle aches, and confusion. Past history was unremarkable except for his being a chain smoker for the last 15 years. he had recently started working in a home-improvement center in the show room area with whirlpools and spas. T = 40.3 C, P=88/min, R = 40/min, BP = 110/60 mmHg. Examination revealed a distressed patient with inspiratory rales. He had a cough that was productive of scanty, clear sputum. Serum analysis showed low sodium levels. A chest X-ray revealed bilateral lower lobe patchy (intersitial) infiltrates.

Legionella pneumophila (legionellosis) - tx erythromycin

A 66 year old white man presented with a cought, fever, night sweats, and chest pain. He also noted a 12 lb weight loss over 3 weeks. He was a homeless man, who admitted to drinking 2 quarts of vodka per day. He vaguely remembered he was cough free a month ago, and his coughs had become progressively worse since then. In the last several days he had produced abundant, thick, tenacious , and blood tinged (currant jelly) sputum. On exam, an ill-appearing man in soiled, torn clothes; he had rales and rhonchi at the right lung base and an enlarged liver with mild tenderness. A chest x-ray revealed right upper lobe infiltrate with cavitary lesion.

Klebsiella pneumoniae (bacterial pneumonia) treat with piperacillin.

A group of 28 college students traveled to India. Several of the students had not received childhood immunization because of nonmedical exemptions. Six of these students became sick with a febrile rash disease while they were in India. The index patient returned to the United Stees early despite recommendations not to do so by the local public health authority. During his travel, he had fever, cough, conjunctivitis, and coryza, and within 25 hours of this arrival, he developed a rash that began on his forehead and spread to his trunk and extremities. T = 48.* C, P = 104/min R = 16/min, BP = 126/68 mmHg. On exam an ill-appearing patient with Koplik spots on the buccal mucosa; a red, blotchy rash on his trunk and extremities was also noted.

Measles

A 32 year old hispanic woman presented with a cough for several weeks and 15-lb weight loss. She also had night sweats and subjective fevers and felt fatigued. Despite erythromycin treatment for suspected pneumonia given by her family physician, her fever and cough progressively got worse. She complained about coughing blood-tinged sputum. She had emigrated from Venezuela to the United States three years before her illness, but she frequently returned to Venezuela to visit relatives. T = 38.6 C, P = 96/min, R = 18/min, BP = 112/60 mmHg. Examination was remarkable for bilateral rales and lymphadenopathy. A chest X-ray revealed right upper lobe infiltrates.

Mycobacterium tuberculosis - tx isonazid, rifampin

A 21 year old white woman developed fever, headache, and a gradually progressive dry cough. Over the next 2 days, her cough worsened, becoming productive of small amounts of clear sputum. She was previously in good health. Her 19 year old brother had had similar symptoms 2 weeks earlier. T = 39.3 C, P = 105/min, R = 28/min, BP = 105/66 mmHg. On exam, the patient appeared slightly pale. Mild pharyngeal erythema was noted with minimal cervical adenopathy but no exudates. Chest exam was completely normal. A chest X-ray revealed bilateral patchy infiltrates consistent with atypical pneumonia.

Mycoplasma pneumoniae. (walking pneumonia) - tx tetracycline, erythromycin

An 18 year old male high school student presented with a 48 hour history of painful urination with a yellowish penile discharge. He returned 2 days ago from Daytona Beach, where he had been sexually active with several female partners during spring break. He denied previous such episodes, and said he was generally in good health. Vitals = normal. On exam, purulent urethral discharge was noted. No sign of genital ulcers was found. No rash or skin ulcers were seen, and the inguinal lymph nodes were not enlarged or tender.

Neiserria gonorrhoeae - tx ceftriaxone, azithromycin, doxycycline

A 20 year old white male college student was brought to an emergency department in early January with a 12-hour history of high fever, chills, and severe headache. Soon after arriving at the ED, he vomited twice. He looked confused and was highly agitated. He was admitted to the hospital, and within two hours he developed purpuric skin lesions. He had recieved all appropriate immunizations and was otherwise healthy. T = 39.9 C, P = 124/min, R = 38/min, BP = 71/54 mmHg. On exam, the patient was unable to answer questions or follow commands. Neck stiffness was present, and a purpuric rash mainly on his extremities was noted. Head CT was normal.

Neiserria meningitidis - tx ceftriaxone and rifampin prophylaxis

A 55 year old woman presented with pain and swelling on her right hand. She had a high fever, chills, and pain in the axilla. The patient had been bitten on her right hand two days before by her cat. She had otherwise been in good health. Elevated temp and BP. On exam, the patient's right hand was erythematous, swollen and tender. A small wound was noted on dorsum of her first finger. Axillary tenderness and lymphadenopathy were also noted.

Pasteurella multocida (pasteurellosis). Treatment is penicillin G. Alternatives are Amoxicillin/clavulanate then cephalosporins.

On a cold day in December, a 16-month-old boy was brought to a clinic for a runny nose, hoarseness, barking cough, and a low-grade fever. According to his mother, the child had developed the barking cough the night before. His breathing was forced and noisy, especially with inspiration. He had been healthy and received immunizations up to date. There was no family history of note. T = 38.1 C, P = 138/min, R = 28/min, BP = 102/58 mmHg. The patient was obviously distressed and had a runny nose, nasal congestion, sore throat, and cough. A hoarse cry, with intermittent stridor, and a harsh, brassy, bark-like cough were also noted. Suprasternal retractions were noted. Chest X-ray revealed visible upper respiratory airway narrowing (steeple sign).

Parainfluenza virus (PIV) or one of the other respiratory viruses including RSV. Respiratory croup (laryngotracheobronchitis).

A 23 year old man was admitted to the hospital for fever, nonproductive cough, progressive shortness of breath, and fatigue for 2 weeks. He had been diagnosed as HIV positive 2 years before, at which time he presented with thrush. He had stopped taking all his HIV-related medications several months ago because of intolerance, and he had progressed to AIDS. Elevated T, P, R. On exam, patient appeared ill and cachectic. Thrush was present, along with mild crackles bilaterally on lung exam. Very low CD4 count. A chest radiograph revealed bilateral air-space consolidation with interstitial and alveolar marking.

Pneumocytis jiroveci (pneumocystis pneumonia). Treat with high dose of treimethoprim-sulfamethoxazole (TMP-SMX)

A 44 year old female presented to the emergency department with complaints of fever, cough, myalgias, and mild shortness of breath for 2 days. She also had a moderate headache and had experienced several episodes of diarrhea in the last 24 hours. She was a nurse's aide and had been working in a busy medical unit of a hospital. She had taken care of a patient with severe respiratory illness 4 days before feeling ill. She did not have underlying disease. T = 38.6 C, P = 110/min, R = 22/min, BP = 104/50mmHg. The patient appeared anxious and in mild respiratory distress, but she was able to speak in complete sentences. Exam revealed inspiratory crackles bilaterally. Pulse oximetry was 94% on room air.

Pneumonia: SARS-associated Coronavirus.

A 46 year-old man presented with a 6 month history of increasing forgetfulness, depression, and personality changes. Electroencephalographic (EEG) examination and head CT scan were unremarkable, and no specific diagnosis was made. A few months later, he was hospitalized for increasing confusion, ataxia, and movement tremors of his extremities. He had lived the United Kingdom for several years, and he returned to the United States 2 years ago. Normal vitals. On exam, patient was disoriented and confused and had resting tremors of all extremities. Myoclonus was noted when he was startled. Chest x-ray was norma. A MRI of the brain demonstrated mild, nonspecific enhancement along the inferior parasagittal occipital lobe. A repeat EEG showed normal waves.

Prion agent (new-variant Creutzfeldt-Jakob disease). No treatment is available patient died in 3 months.

A 5-month-old girl was brought to the pediatric clinic of a local general hospital in February with a 2-day history of cough, respiratory difficulty with nasal discharge, and low-grade fever. She had begun attending a daycare center 4 weeks before. All of her immunizations were up to date, and no one else at home was ill. T = 38.1 C, P = 135/min, R = 60/min, BP = 92/60mmHg. On physical exam the patient was in respiratory distress. Rhinorrhea, expiratory and inspiratory wheezes, hyperinflation of chest, and atelectasis were noted. Crackles were also noted bilaterally.

Respiratory: Respiratory Syncytal virus (RSV)

On a hot summer day, a 23 year old man was brought to the emergency department 3 days after the onset of fever, severe headache, and muscle pain. He was also experiencing nausea, vomiting, and abdominal pain. A fine, spotted rash was seen on his extremities and trunk; the patient said the rash had appeared earlier that day. He lived in North Carolina and had no prior history of illness. He had received all appropriate childhood immunizations. T, P, R elevated BP slightly low. On exam, the patient appeared ill and had an erythematous maculopapular and petechial rash on his extremities, including on his palms and soles.

Rickettsia rickettsii (Rocky Mountain Spotted Fever). Treat with doxycycline.

A 9 month old baby girl was brought to the emergency department of a local general hospital during the winter with a 2 day history of vomiting, watery diarrhea, and fever. The patient had been well until 24 hours before her presentation, when she had experienced the acute onset of vomiting followed by multiple episodes of diarrhea. She refused to eat, and she drank very little fluid. her parents were concerned about dehydration. The family had not traveled outside the United States recently, ut the mother related that she had been leaving her baby in a daycare center for 3 days a week for the past 3 months. T = 39.2 C, P = 145/min, R = 32/min, BP = 90/44 mmHg. The patient's mucous membranes were dry, and she was listless and febrile. Her neck was supple. Her chest was clear, and heart sounds were normal. Her abdomen was nontender. Bowel sounds were normal.

Rotavirus.

A 41 year old white man was brought to the emergency department with a 3 day history of shaking chills, high fever, headache, abdominal pain, and generalized weakness. Mild diarrhea had started 2 days earlier and had been improving when the fever began. The patient had returned to the United States 10 days earlier, after a 3 week visit to India. He recalls eating a variety of local foods, particularly from street vendors. He had not received any travel-related vaccines. Past medical history was unremarkable. T, P, R elevated. BP low. On examination, the patient appeared ill and confused. His abdomen was diffusely tender, and his liver and spleen were enlarged, although there was no evident jaundice. Erythematous maculopapular lesion ("rose spots") were noted on his chest. Abdominal CT scan was remarkable for enlarged liver and spleen with no focal lesions.

Salmonella typhi (typhoid fever). Treatment standard has been chloramphenicol, ampicillin, or trmethoprim sulfamethoxazole (TMP/SMX), but multidrug resistance has lead to use of ceprofloxacin.

Six individuals from a single family presented over the course of 2 days with low-grade fever, abdominal cramp, vomiting, and diarrhea. All six individuals had eaten Thanksgiving dinner together in a private home, and they had all eaten the turkey and stuffing approximately 24 hours before the onset of first symptoms. Elevated T, R, P, normal BP. On exam, an ill-appearing patient with dry mucous membranes; abdominal exam revealed mild, diffuse, tenderness. Abdominal x-ray was normal.

Salmonella typhimurium (salmonella enteritis). No treatment for non-typhoidal Salmonella enteritis.

A 71 year old male returned home after a 2 week stay in Mexico. The day after his return, he experienced an acute onset of fever, crampy abdominal pain, and watery diarrhea. By the next day, he had tenesmus and noticed mucus and a bloody tinge of the stool. The stool became grossly bloody and increased in number. Worried about his condition, his daughter took him to a hospital emergency department. During his stay in Mexico the patient was in a rural area and had drunk water on several occasions from a well, but he had not come in contact with other sick persons. Elevated T and P. Normal R. Lower BP. On exam, a sick-appearing, somnolent, elderly man with lower abdominal tenderness, mild dehydration, and hyperactive bowel sounds; rectal exam was very painful and showed gross blood. Abdominal x-rays were unremarkable, and sigmoidoscopy showed ulcers and an erythematous, friable mucosa.

Shigella flexneri (bacillary dysentery). Treatment is mainly supportive but TMP/SMX has been choice for years, if resistant can give fluroquinolones.

In early summer, a previously healthy 42-year-old man was admitted to his local hospital with a 1-week history of fever, muscle aches, and malaise. For 2 days before the admission, he noted shortness of breath, and on the day of admission, he felt extremely weak. In the 3 weeks before becoming unwell, the patient had been stationed at a rural campsite in New Mexico. He had reported that in and around his tent, there had been many deer mice, although he had not been bitten. T = 38 C, P = 124/min, R = 36/min, BP = 76/40 mmHg. On exam, the patient appeared ill and crackles were heard on lung examination.

Sin Nombre virus (hantavirus pulmonary syndrome [HPS])

A 62 year old white man was admitted to the hospital in the month of January with fever, shortness of breath, productive cough, and chest pain. He also complained of a thick, yellowish discharge in his eyes that prevented him from opening his eyes in the morning. He was a chain smoker (three packs a day), did not drink alcohol, and had no chronic underlying diseases. The patient had not received the current flu vaccine, and 10 days prior to admission, the patient experienced sudden onset of fever, chills, sore throat, and arthralgias. His symptoms had gradually resolved over the following week, before the development of his current symptoms. T = 39.4 C, 120/min, R = 30/min, BP = 140/80 mmHg. The ill-appearing man was mild respiratory distress. On chest examination, decreased breath sounds and rales were heard at the left base. Unilateral erythematous palpebral conjunctiva, watery eye, and purulent exudate were also noted. A chest x-ray revealed an alveolar infiltrate in the posterior segment of the left lower lobe.

Staphylococcus aureus (secondary bacterial pneumonia and concurrent acute conjuctivitis) - naficillin, vancomycin

An 18 year old male college student was brought to the emergency department of a hospital with the complaints of fever, chills, and pain while walking. The patient had experienced progressively spreading boils on his left leg for the past week. The boils were painful and tender, and he had fever. He had not sought medical attention earlier, hoping the infection would resolve spontaneously. T = 39.4 C, P = 112, R = 18/min, BP = 124/70 mmHg. On exam, the lower left leg was swollen and tender. The overlying skin was warm and red with multiple necrotic-appearing lesions. The knee joint was normal with full range of motion.

Staphylococcus aureus (staphylococcal osteomyeltitis) - naficillin, vancomycin

A 3 week old baby boy was brought to the emergency department with a 24 hour history of fever, poor feeding, irritability, and a seizure that occured just before arriving at the ED. He was born preterm (32 weeks' gestation) with very low birth weight (1490 g) after a normal vaginal delivery. T = 38.2 C, P = 142/min, R = 32/min, BP = 90/42 mmHg. On exam, male infant who was irritable, with nuchal rigidity. Neurologic exam was otherwise nonfocal.

Streptococcus agalactiae (group B streptococcus [GBS]) type 2 meningitis - tx ampicillin

A 67 year old white man was rbought by his wife to the ED for the abrupt onset of shaking chills, high fever, and pain on the right side of this chest that began the prior evening. His wife reported that in the last 24 hours, he had experienced shortness of breath and a cough that was productive of rust-colored sputum. The patient was diabetic and smoked two packs of cigarettes per day. he had been a chain smoker for the last 20 years. he had not sought medical care in the past and had not received any vaccinations in the last 20 years. T = 39.6 C, P = 130/min, R = 32/min, BP = 159/77 mmHg. Examination revealed an ill-appearing, confused man in moderate respiratory distress. Dullness to percussion over the right uppoer thorax, assocaited with increased fremitus, was noted. Auscultation revealed bronchial breath sounds and crackles over this area. A chest x-ray revealed consolidation of the right upper lobe. Bands on the CBC was elevated.

Streptococcus pneumoniae (pneumococcal pneumonia) - tx macrolides, ceftriaxone, amoxicillin

A 24 year old man was brought to a local hospital emergency department because of severe pain and swelling that had developed in his left thigh that day. The pain had progressed rapidly; before seeking treatment he developed a high fever and became extremely weak and was unable to walk without assistance. The patient had always been in good health, but the day before this illness, a minor injury occurred to his leg while he was playing soccer. He noted that it started as a small area of redness at the site of the injury on his left thigh, but in the last several hours it appeared more grayish. T = 40 C, P = 138/min, R = 24/min, BP = 70/40 mmHg. On exam, a young male in moderate distress due to pain who appeared to be acutely ill. The left thigh was dusky and purplish, swollen and tense. Pulses in that leg were diminished. CT showed edema of the soft tissues and possible compression of the vessels.

Streptococcus pyogenes (streptococcal necrotizing fasciitis) - beta lactams

A 6 year old girl came home from school feeling miserable on a cold day in January. She had a high fever and complained of an itchy throat. She had difficultly swallowing any food, refused to eat, and cried almost all evening. the next day her grandpa took her to their family physician's clinic. It was noted that several children from her school had reported sore throats recently. The patient had received all standard childhood immunizations at the appropriate times. T = 39.4 C, P = 120/min, R = 16/min, BP = 110/60 mmHg. Red throat (pharyngeal erythema) with petechiae on the soft palate and patchy grayish-whitish tonsillar exudates were seen. Enlarged and tender anterior cervical lymph nodes were also noted. The patient did not have any cough.

Streptococcus pyogenes (streptococcal pharyngitis) - tx beta lactams

A 42 year old man presented to a clinic with complaints of 3 weeks of worsening diarrhea, abdominal pain, and fevers. He had noticed an itchy rash over his buttocks and groin area for the past 2 weeks. A 15 lb weight loss was also noted. A month before his symptoms started, he had returned from a 3 month trip to El Salvador, where he worked in a rural area. Elevated T. On exam, an erythematous maculopapular rash was present on his groin and buttock area. Eosinophilia was noted on CBC.

Strongyloides stercoralis (strongyloidiasis). Treat with ivermectin with thiabendazole as an alternative.

A 30 year old white woman was brought to the emergency department of a local hospital with a 2 week history of progressively severe headache, nausea, and vomiting; several seizures had occurred over the past 2 days. She had been HIV positive for 3 years and had been diagnosed with AIDS a year before the current episode. She had been on HIV therapy, but was currently failing fer regimen. She was also on aerosolized pentamidine because of a Bactrim allergy. Her brother, who brought her to the ED, could not recall any history of seizures. T elevated BP low. On exam, she was in moderate distress due to the headache but was able to answer questions. Mild right-sided weakness was apparent on exam. Head MRI revealed ring-enhancing lesions in the left parietal lobe and right frontal lobe.

Toxoplasma gondii (Toxoplasma encephalitis) Treat with Sulfadiazine and pyrimethamine with or without leucovorin are drugs of choice.

A 31 year old African American woman presented with low grade fever, malaise, and a rash. She recalled having had painless ulcers, which appeared on the vulva one month before this new episode. She did not seek medical attention at that time, and the ulcers spontaneously resolved in 10 days. The patient revealed that she had had four sexual partners in the month preceding the development of ulcerative lesions. She had not traveled outside the United States in recent months. T = 38.1 C, P = 90/min, R = 14/min, BP = 124/72 mmHg. Examination was remarkable for inguinal lymphadenopathy, a generalized rash on palms and soles, and pustular cutaneous lesions and condylomata lata on her face.

Treponema pallidum (secondary syphillis) - penicillin V

A 26 year old woman came to a city sexually transmitted disease (STD) clinic complaining of profuse yellow, foamy vaginal discharge with foul odor. The discharge began 2 days before with vulvar irritation and itching. She said she was also having pain during intercourse. The patient had been sexually promiscuous with multiple partners. The medical history was unremarkable. Vitals normal. Pelvic examination revealed homogeneous vaginal discharge and vulvar erythema. A diffuse macular erythematous lesion of the cervix ("strawberry cervix") was noted. Lower abdominal tenderness was also noted.

Trichomonas vaginalis (trichomoniasis). Treat with metronidazole.

A 55 year old woman presented to her family physician with a 3 day history of burning and pain over her left forearm. The symptoms were rather abrupt in onset, and she had not experienced anything like this before. Over the previous 2 days, several vesicles had developed in a band-like distribution on her arm, and new ones were erupting daily. On the day she went to see her family doctor, the lesions had started turning purplish. At no time did she have any fever, but her appetite was markedly reduced. She had previously been healthy except for childhood illnesses of measles, chicken-pox, and mumps. The patient worked as a caregiver to elderly individuals. She had no known allergies. She did smoke on pack of cigarettes per day. t = 37.5 C, P = 112/min, R = 16/min, BP = 116/64 mmHg. On exam, the patient was in mild distress due to the pain in her arm. It was readily evident that there was a vesicular rash over the left arm. Numerous vesicles measuring 2 to 3 mm, with a hemorrhagic base, were present in a dermatomal distribution. One or two of the vesicles had crusted over.

Varicella=zoster virus (VZV; zoster or shingles). tx - acyclovir

A 31 year old man returned to the United States in late summer from a 3 week long trip to Bangladesh. On the second day after his return, he presented with sudden, severe, profuse watery diarrhea. In the emergency department, he passed a large, watery stool with a rice-water appearance. He vomited several times and became slightly sweaty. He complained of muscle cramps and dizziness. He was on an H2 blocker drug for ulcer disease. Otherwise, he had always maintained good health. T, R, P elevated BP very low. On exam, he was somewhat anxious; his pulse was rapid and weak.

Vibrio cholerae (cholera). Rehydration is absolutely key but doxycycline and ciprofloxacin can be used.

A 76 year old man was seen in his family physicians's office for complaints of low-grade fevers, night sweats, and fatigue for 3 weeks. The patient had a history of a heart murmur but had never undergone extensive evaluation. He had been in generally excellent health with normal exercise tolerance. Approximately 6 weeks ago he underwent an uncomplicated extraction of an impacted wisdom tooth but received no antibiotics prior to the procedure. T = 38 C, P = 104/min, R = 14/min, BP = 130/82 mmHg. On exam, the patient was alert; a rough, diamond-shaped systolic murmur, heard loudest in the upper left sternal border, was noted. A "splinter hemorrhage" in the nail of this right finger and conjunctival petechiae were also noted. His spleen was palpable as well.

Viridans streptococci (native-valve endocarditis) - penicillin G