1/10. The patient who could not be discharged. How far should patient autonomy extend?A male patient was admitted to the acquired immune deficiency syndrome (AIDS) unit for hemodialysis. His history revealed that he was homeless and that he had tested positive for human immunodeficiency virus (hiv ). He also had a history of alcohol and intravenous drug abuse and tuberculosis. Based on the results of a chest X-ray, he was placed in respiratory isolation. During the next few days of his hospitalization, he exhibited nonadherent behavior toward the treatment regime. Because of previous verbal and physical abuse to staff and patients, all local hemodialysis centers refused to accept him as a patient. Thus, he became a patient who seemingly could never be discharged. A discussion related to the theoretical and practical scope of patient autonomy, institutional altruism vs. institutional self-interest, and the need for social policy to facilitate a just and humane resolution to this ethical situation is presented here.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
2/10. noma (cancrum oris): case report in a 4-year-old hiv-positive South African child.Cancrum oris (noma) is a gangrenous infection that develops in the mouth and spreads rapidly to other parts of the face. The disease occurs mostly in conditions of poverty, poor hygiene and malnutrition. In sub-Saharan africa the frequency in several countries is estimated to be 1-7 cases per 1,000 population, and as many as 12 cases per 1,000 in the most affected communities. About 90% of these children die without receiving any care, yet the disease can, and should, be prevented. With increasing numbers of children who are malnourished and who have compromised immune systems (compounded by the hiv pandemic) the prevalence of conditions such as noma is likely to increase. Among the earliest features of noma are excessive salivation, marked fetor oris, facial oedema and a greyish-black discolouration of the skin in the affected area. This devastating gangrenous lesion may involve the cheek, the chin, the infra-orbital margin, palate, nose, antrum and virtually any part of the face. This report describes a 4-year-old hiv-positive African girl, who was abandoned, discharged from the plastics Unit and now lives in a child care sanctuary. Little is known about her history prior to her arrival at the home a few weeks previously. The clinical examination revealed a delay in growth and physical development equivalent to that of a 2-year-old child. The left cheek had a perforating ulcer in a healing phase. The perforation, about 1 cm in diameter, was surrounded by oedematous tissues showing a mild to moderate erythema. The peripheral oedema extended to the lower palpebral, the upper labial, left labial commissural, mandibular and pre-parotid regions. Submental, submandibular and cervical lymph nodes were mildly painful upon palpation. The child was not pyretic. The intra-oral examination revealed the features of acute necrotising gingivitis (ANG). ANG was generalised and showed classic interdental crater-like ulcers covered with whitish debris. halitosis was pronounced. Examination of the second quadrant revealed a large ulcer extending from the distal aspect of the deciduous canine to the distal aspect of the second deciduous molar. The adjacent palatal mucosa was severely oedematous. The alveolar bone supporting the first and the second molars was completely exposed to the fundus of the vestibulum. It was not possible to obtain intraoral photographs or radiographs. chlorhexidine gluconate (0.2% solution) and metronidazole tablets, 200 mg twice daily for 15 days were prescribed. The child was seen every alternate day for 10 days and her condition improved rapidly. halitosis had subsided. She was then referred to the Johannesburg Hospital for further treatment under general anaesthesia. The proposed treatment plan was as follows: removal of dental accretions and polishing of all teeth, extraction of the left maxillary teeth supported by non-vital bone, resection of the necrotic bone in the left maxilla and reconstructive surgery in the left cheek.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
3/10. salmonella enterica subsp houtenae serogroup O:16 in a hiv positive patient: case report.We described a case of salmonellosis in a 33-year old hiv-infected patient. The patient presented oral and esophageal candidiasis, intense epigastric and retrosternal pain. During the physical examination he was hypochloraemic, acyanotic, hypohydrated, anicteric and afebrile. Admittance laboratory tests indicated: red cells 3.6 millions/mm(3); hemoglobin, 10.1 g/dL; leukocyte count, 3,000/mm(3), with 1% of eosinophils, 14% of non-segmented and 53% of segmented neutrophils and 31% of lymphocytes. The blood culture was positive for salmonella enterica subsp houtenae serogroup O:16. This is probably the first human report of bacteremia due to salmonella enterica subsp houtenae in brazil associated to hiv-infected patient.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
4/10. Itch: a symptom of occult disease.BACKGROUND: pruritus, (the Latin word for itch), is defined as the 'desire to scratch'. It is a distressing, subjective symptom that may interfere significantly with the quality of a patient's life. OBJECTIVE: This article summarises the systemic causes of pruritus, describes the assessment of a patient presenting with itch without dermatological cause, and discusses the management of itch in patients with cancer. DISCUSSION: patients with pruritus that does not respond to conservative therapy should be evaluated for underlying systemic disease. Causes of systemic pruritus include cholestasis, thyroid disease, polycythaemia rubra vera, uraemia, hodgkin disease, and hiv. A thorough history and a complete physical examination are central to the evaluation of pruritus. In the absence of skin lesions, diagnostic testing is directed by the clinical evaluation and may include a complete blood count, liver function tests, serum creatinine, blood urea nitrogen levels, measurement of thyroid stimulating hormone, and chest X-ray. Removal of the causative agent and appropriate investigation and treatment of the underlying disease are essential first line measures in the treatment of pruritus.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
5/10. Cases from the Osler Medical Service at Johns Hopkins University. diagnosis: P. carinii pneumonia and primary pulmonary sporotrichosis.PRESENTING FEATURES: A 53-year-old man who had human immunodeficiency virus (hiv) presented to the Johns Hopkins Hospital with a 3-month history of increasing dysphagia, cough, dyspnea, chest pain, and an episode of syncope. His past medical history was notable for oral and presumptive esophageal candidiasis that was treated with fluconazole 6 months prior to presentation. Three months prior to presentation, he discontinued his medications, and his symptoms of dysphagia recurred. During that time he developed intermittent fevers and chills, progressively worsening dyspnea on exertion, and a cough productive of white sputum. He also reported a 40-lb weight loss over the past 3 months. On the day prior to presentation, he had chest pain and shortness of breath followed by weakness, dizziness, and a brief syncopal episode. He denied orthopnea, paroxysmal nocturnal dyspnea, lower extremity edema, jaundice, hemoptysis, hematemesis, melena, hematochezia, or diarrhea. There was no history of alcohol use, and he stopped smoking tobacco approximately 1 month previously. He smoked cocaine but denied injection drug use. The patient had never been on antiretroviral therapy and had never had his CD4 count or viral load measured. On physical examination, the patient was a thin, cachectic man who appeared older than his stated age. His vital signs were notable for blood pressure of 102/69 mm Hg, resting tachycardia of 102 beats per minute, resting oxygen saturation of 92% on room air, normal resting respiratory rate, and a temperature of 38.1 degrees C. His oropharynx was clear, with no signs of thrush or mucosal ulcers. His pulmonary examination was notable for diminished breath sounds in the lower lung fields bilaterally. Cardiac, abdominal, and neurologic examinations were normal. His skin was intact, with no visible petechiae, rashes, nodules, or ulcers. Laboratory studies showed a total white blood cell count of 3.2 x 10(3)/microL, with a total lymphocyte count of 330/microL, hematocrit of 30.2%, a serum sodium level of 129 mEq/L, and a serum lactate dehydrogenase level of 219 IU/L. The patient had an absolute CD4 count of 8 cells/mm3 and a hiv viral load of 86,457 copies/mL. His arterial blood gas on room air had a pH of 7.51, a PCO2 of 33 mm Hg, and a PO2 of 55 mm Hg. Electrocardiogram and serial serum cardiac enzymes were normal. A chest radiograph showed bilateral upper lobe patchy infiltrates with left upper lobe consolidation. Computed tomographic (CT) scan of the chest with contrast showed bilateral ground glass infiltrates with focal consolidation (Figure 1) and no evidence of pulmonary embolism. Induced sputum was negative for pneumocystis carinii, fungi, or acid-fast bacilli. A bronchoalveolar lavage was performed. What is the diagnosis?- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
6/10. Varicella-zoster virus encephalitis in an AIDS patient.A 37-year-old man with a three-year history of acquired immunodeficiency syndrome was admitted with impaired consciousness, seizures and fever. He was on highly active antiretroviral therapy and on neurotoxoplasmosis secondary prophylaxis. Laboratory exams from two months before showed a CD4 cell count of 37/microL and a viral load of 230,000 copies/mL. Three months before admission he developed herpetic skin rash in the right trunk and acyclovir was added to his treatment regimen. On physical exam he was drowsy and had motor and sensory aphasia. The patient had elevated protein levels and normal pressure in the cerebrospinal fluid (CSF). Contrast enhanced computed tomography scan of the brain showed a hypodense lesion in the left parietal lobe, with poorly defined margins and no contrast enhancement. The magnetic resonance scan (MRI) showed multiple hyperintensities in T2-weighted image in white and grey matters and hypointense products of hemorrhage in both hemispheres and in the cerebellum. He was empirically treated with intravenous acyclovir and prednisone. Viral dna of Varicella-zoster virus (VZV) was detected in the CSF by means of polymerase chain reaction (PCR) analysis. acyclovir was continued for 10 days and the patient became well, with improvement of aphasia.We present a case of VZV encephalitis, confirmed by nested PCR, in a patient with suggestive MRI findings, who succeeded with treatment. VZV encephalitis is a rare opportunistic infection, occurring in 0.1 to 4% of AIDS patients with neurological disease; it is related to severe immunodeficiency and has a high mortality.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
7/10. Fulminant disseminated toxoplasmosis in an hiv patient.Disseminated toxoplasmosis in AIDS is a rare condition. We present an unusual case of a fulminant form of disseminated toxoplasmosis in a young male homosexual. He was a 30-year-old hiv-positive (diagnosed 4 months earlier), admitted with a 5-day history of diarrhea, vomiting, fever, and cough. He had been generally healthy except for an 8-week history of weight loss and malaise. On admission, except for a temperature of 37.6 degrees C, the physical examination was normal. He was treated symptomatically. Four days after admission he suddenly became short of breath. Despite intensive management, he continued to deteriorate and expired 6 h later. Postmortem examination revealed disseminated toxoplasmosis involving the heart, lungs, brain, stomach, small intestine, and colon. This is an unusual presentation of disseminated toxoplasmosis because of its rapid course with no prior indication of infection. To our knowledge, such an atypical and rapid downhill course of toxoplasmosis (with minimal clinical and laboratory features) has not been reported previously. Increased awareness of this infection in all hiv patients and its possibly rapid course is needed.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
8/10. Syphilitic osteitis in a patient with secondary syphilis and concurrent human immunodeficiency virus infection.Destructive bone disease is a well-recognized complication of congenital and tertiary syphilis. Clinically significant osteitis and osteomyelitis are rare complications of primary or secondary syphilis in patients who are not infected with human immunodeficiency virus (hiv). We report a case of an hiv-infected man who presented with symptomatic, left ulnar osteitis as the initial manifestation of secondary syphilis. The patient's clinical course was complicated by a pathological fracture, but he responded to high-dose intravenous penicillin g therapy and surgical intervention. Results of physical examination on follow-up at 15 months were normal, and a serofast (rapid plasma reagin [RPR]) titer of 1:4 and a markedly decreased uptake on bone scintigraphy were observed. Our case report suggests that bone disease can represent an atypical manifestation of early acquired syphilis and that hiv-positive patients who present with orthopedic complaints or bone lesions should be evaluated for the presence of syphilitic bone disease.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
9/10. toxoplasmosis of the spinal cord in a patient with AIDS: case report and review.We present the case of a patient whose acute myelopathy almost completely resolved with empirical therapy for toxoplasmosis, and we review thirteen previously reported cases of myelopathy thought to have been caused by toxoplasma gondii in patients with AIDS. The most common symptoms and abnormal physical findings were motor loss (usually paraparesis), bilateral sensory loss, urinary bladder dysfunction, and local pain. The majority of patients had magnetic resonance images that showed abnormalities of the spinal cord and brain in association with positive serology for toxoplasma. Therapy for toxoplasmosis, when administered soon after the onset of symptoms, has resulted in clinical and radiographic improvement in the conditions of patients with toxoplasmosis.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
10/10. legionella bozemanii pneumonia in three patients with AIDS.legionella bozemanii is known to cause pneumonia often in immunocompromised hosts. To our knowledge, we describe the first three cases of L. bozemanii pneumonia in patients with AIDS. At the time of presentation, these patients had varied histories, physical findings, and radiological findings. All three patients had a uniformly excellent response to treatment despite receiving different antibiotic regimens. The cases illustrate the need for thorough diagnostic workups and prompt institution of antibiotic therapy when clinical suspicion for L. bozemanii infection is high.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
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