Candidiasis. A diagnostic and therapeutic challenge

Candida infections are becoming more common for a number of reasons. Diagnosis of local infections is relatively simple, and therapy with topical antifungal drugs or ketoconazole (Nizoral) is usually adequate. However, diagnosis of disseminated candidiasis is more difficult, frequently requiring biopsy confirmation. Amphotericin B (Fungizone Intravenous), often in combination with flucytosine (Ancobon), may be appropriate. In catheter-induced fungemia, antifungal therapy may be necessary to avoid deep-seated infection with Candida.     

Viral and mycoplasmal pneumonias

Many different agents are known to cause nonbacterial pneumonias, but the clinical findings may not vary. An understanding of the epidemiology and pathogenesis of these infections—as well as the possible etiologic agents—is important in diagnosis, prevention, and treatment. Although treatment is now mainly symptomatic, new antiviral agents will soon be available for specific therapy.     

Viral pneumonias. Epidemic respiratory viruses

Influenza, respiratory syncytial, and parainfluenza viruses usually cause mild, self-limited illness in adults. However, elderly and immunocompromised persons are at increased risk for development of severe pneumonia. Clinical and radiographic features of epidemic viral pneumonias are often nonspecific. Newer and faster methods of viral culture and viral antigen detection have improved the capability for definitive diagnosis in recent years. Preventive measures for influenza virus pneumonia center on limiting exposure of high-risk patients to active cases of influenza, administering annual vaccinations, and providing chemoprophylaxis. Prophylaxis against RSV is effective in preventing complications. No effective vaccines have been developed against RSV or parainfluenza. Therapy for viral pneumonia is primarily supportive. Amantadine may be beneficial for influenza virus pneumonia, and ribavirin may be useful for RSV and parainfluenza virus disease. However, further definitive studies are necessary to determine their roles in these viral pneumonias.     

Viral pneumonias. Infection in the immunocompromised host

Three herpesviruses--herpes simplex, varicella-zoster, and cytomegalovirus--commonly cause respiratory tract infections in immunocompromised patients. Adenoviruses and measles virus are also significant causes of respiratory disease in this population. Diagnosis of herpesvirus infections is difficult because these viruses can establish latency and are often shed intermittently in the absence of invasive disease. A positive respiratory tract culture of herpesviruses alone is not diagnostic of active invasive disease. Preventive measures should focus on limiting the patient's exposure to active infection, broad use of available vaccines in children and susceptible adults, and use of hyperimmune globulin and chemoprophylaxis in high-risk patients. Adenovirus pneumonia is diagnosed by viral culture and rapid antigen detection assays, whereas measles pneumonia is often identifiable by the characteristic rash. Treatment of either adenovirus or measles pneumonia is primarily supportive.     

Bacterial biofilms: a diagnostic and therapeutic challenge

Bacteria have traditionally been regarded as individual organisms growing in homogeneous planktonic populations. However, bacteria in natural environments usually form communities of surface-adherent organisms embedded in an extracellular matrix, called biofilms. Current antimicrobial strategies often fail to control bacteria in the biofilm mode of growth. Treatment failure is particularly frequent in association with intracorporeal or transcutaneous medical devices and compromised host immunity. The rising prevalence of these risk factors over the last decades has paralleled the increase in biofilm infections. This review discusses the shortcomings of current therapies against biofilms both in theory and with clinical examples. Biofilm characteristics are described with a focus on new diagnostic and therapeutic targets.     

Bacterial biofilms: a diagnostic and therapeutic challenge

Bacteria have traditionally been regarded as individual organisms growing in homogeneous planktonic populations. However, bacteria in natural environments usually form communities of surface-adherent organisms embedded in an extracellular matrix, called biofilms. Current antimicrobial strategies often fail to control bacteria in the biofilm mode of growth. Treatment failure is particularly frequent in association with intracorporeal or transcutaneous medical devices and compromised host immunity. The rising prevalence of these risk factors over the last decades has paralleled the increase in biofilm infections. This review discusses the shortcomings of current therapies against biofilms both in theory and with clinical examples. Biofilm characteristics are described with a focus on new diagnostic and therapeutic targets.     

Chilaiditi's syndrome. A diagnostic challenge

Chilaiditi's syndrome should be considered in the differential diagnosis of abdominal and chest pain. Although interposition of the right colon is a relatively common radiologic finding, there is a distinct paucity of information in the medical literature. Chilaiditi's syndrome is usually asymptomatic, but when symptoms occur, conservative treatment is usually effective. Recognition is important because this syndrome can be mistaken for more serious abnormalities, which may lead to unnecessary surgical intervention.     

Viral pneumonias. Multifaceted approach to an elusive diagnosis

Despite enhanced laboratory techniques such as viral culture, rapid antigen detection, and gene amplification, a confident diagnosis of viral pneumonia continues to be a challenge. The nonspecific nature of clinical characteristics and the extreme sensitivity of laboratory techniques make the diagnosis difficult, even when a viral agent is detected. Understanding the limitations of these technological advances and the use of histopathologic techniques can greatly enhance a skilled clinician's ability to make an accurate diagnosis.     

Depression in later life: a diagnostic and therapeutic challenge

Depression in elderly persons is widespread, often undiagnosed, and usually untreated. The current system of care is fragmented and inadequate, and staff at residential and other facilities often are ill-equipped to recognize and treat patients with depression. Because there is no reliable diagnostic test, a careful clinical evaluation is essential. Depressive illness in later life should be treated with antidepressants that are appropriate for use in geriatric patients. A comprehensive, multidisciplinary approach, including consideration of electroconvulsive treatment in some cases, is important. The overall long-term prognosis for elderly depressed patients is good.     

Concomitant lymphoplasmacytic lymphoma,multiple myeloma,and amyloidosis: A diagnostic and therapeutic challenge

We report a case based on simultaneous occurrence of Waldenström macroglobulinemia, myeloma and amyloidosis as a collision neoplasm. The strangeness and severity of the case presented a diagnostic and therapeutic challenge, which required individualised treatment and close follow‐up to achieved stringent complete response.     

Nonconvulsive status epilepticus in terminally ill patients-a diagnostic and therapeutic challenge

Nonconvulsive status epilepticus (NCSE) is rarely considered as a cause of confusion in terminally ill patients. The clinical presentation varies from altered mental status to coma, without visible convulsions. Electroencephalogram is the most important diagnostic tool to identify epileptiform activity. Treatment should be initiated following a stepwise model, avoiding intubation and transfer to the intensive care unit. Although mortality rates are high, in some patients NCSE can be reversed by treatment. NCSE should be considered in a differential diagnosis of all terminally ill patients with sudden mental status changes. We present two cases and discuss treatment options and the borders of therapy.     

Nephrotic syndrome in adults. A diagnostic and management challenge.

The adult with nephrotic syndrome presents diagnostic and treatment challenges for the primary care physician. Early consultation with a nephrologist is advisable to assist in choosing between empirical therapy or renal biopsy to identify the specific causative lesion. Some patients respond to treatment of either the specific disorder or the underlying cause. All patients should be afforded specific therapy, where available, and nonspecific therapy to minimize the severity of the nephrosis and attenuate the incidence and severity of complications. Although the cause of most disorders resulting in nephrotic syndrome remains unclear, active research into the syndrome's pathogenesis and treatment options should prove fruitful.     

Mitochondrial disorders. A diagnostic challenge in clinical chemistry.

Mitochondria play a pivotal role in cellular metabolism and in energy production in particular. Defects in structure or function of mitochondria, mainly involving the oxidative phosphorylation (OXPHOS), mitochondrial biogenesis and other metabolic pathways, have been shown to be associated with a wide spectrum of clinical phenotypes. The ubiquitous nature of mitochondria and their unique genetic features contribute to the clinical, biochemical and genetic heterogeneity of mitochondrial diseases. We will focus on the recent advances in the field of mitochondrial disorders and their consequences for an advanced clinical and genetic diagnostics. In addition, an overview on recently identified genetic defects and their pathogenic molecular mechanisms will be given.     

Systemic lupus erythematosus. A diagnostic and therapeutic puzzle

Systemic lupus erythematosus (SLE) constitutes a model autoimmune disease characterized by a heterogeneous patient population, diverse manifestations, and disease flares and remissions. Consequently, individualized treatment programs are essential. Given the significant toxic effects of corticosteroid and immunosuppressive therapy, minor disease activity in SLE should be managed conservatively. In contrast, major disease activity is potentially life-threatening; thus, it should be treated as aggressively as possible to rapidly restore organ function. By using the clinical and laboratory parameters now available, the clinician can diagnose SLE early in its course and monitor disease activity and patient response to treatment.