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By S. Mannig. Hiram College. 2018.

Tuberculosis of the central nervous system The compromise of the central nervous system occurs in two basic forms: menin- goencephalitis and intracranial tuberculoma buy cytoxan 50mg free shipping treatment lower back pain. The clinical manifestations are due to the inflammatory process induced by the mycobacterial infection, and the symptoms depend on the site and intensity of 15. Meningoencephalitis generally has an insidious onset and a slowly progressive course, with symptoms including apathy, lethargy, fever, and mental disturbances such as irritability, understanding difficulties, personality alterations, disorienta- tion, and progressive mental confusion. Findings on physical examination are related to the stage of the disease and the nd rd affected area, such as cranial nerve involvement (the most affected are the 2 , 3 , th th 4 , and 8 nerve pairs), focal neurological deficits, and signs of meningeal and cerebellar irritation. The cerebrospinal fluid is generally clear, with a predominance of lymphocytes, an increase in proteins and a decrease in glucose levels. In the differential diagnosis the following conditions should be considered: other infectious meningitis, vascular pathologies, the collagen vascular disease sarcoido- sis, metastatic carcinoma, acute hemorrhagic leucoencephalopathy, and lymphoma. In the case of intracranial tuberculoma, the clinical manifestations depend on the location of the lesion, which generally grows slowly. When there is no compromise of the sub-arachnoid space, the cerebrospinal fluid is normal and the computerized tomography exhibits a mass, which is generally difficult to differentiate from neo- plasia (Azambuja 1993, Kasik 1994, Norris 1995). Bone involvement consists of osteomyelitis, and arthritis can occur either by extension of the osseous lesion to the joint or by direct hematogenic inoculation. The most frequent sites of bone involvement are the vertebrae (Pott’s disease) and the proximal extremities of the long bones. With evolution, it presents a wedged flattening and gibbus formation that can be associated with a paravertebral cold abscess (Figure 15-17). Image on X-ray is characterized by erosion of the anterior vertebral body margins with no preservation of the intervertebral space. The definitive diagnosis should be obtained by biopsy for culture and histopathological analysis (Ridley 1998, Schle- singer 2005). The diagnosis is established by puncture, biopsy, histo- pathological examination, and culture (Zylbersztejn 1993, Davidson 1994, Ridley 1998, Schlesinger 2005). Other extrapulmonary localizations Tuberculous involvement of other tissues, such the eye, skin (lupus vulgaris), genital, and digestive tract, may also be the result of hematogenous dissemination, but there are other possible routes of infection. Tuberculosis disease 507 and appropriate invasive and non-invasive procedures should be employed to en- sure an early diagnosis (Moore 2002, John 2002, Erkoc 2004). Fever and sweating It is believed that bacillary multiplication increases in the afternoon, with the daily circadian rhythm cortisol peak, which is followed by the evening fever characteris- tic of the disease. However, when there is massive hema- togenous or endobronchial dissemination, peaks of high fever can occur at any time of the day and are accompanied by chills. Weight loss is proportional to the duration and extent of the disease and is frequently accompanied by adynamia. Cough results from the stimulus caused by the alveolar inflammatory process or from the granuloma- tous impingement into the respiratory airways. At the onset of the disease, the cough is dry; but with progression, it becomes productive with mucous or mucopu- rulent expectoration, generally in small amounts, and sometimes with blood. Diagnostic approaches 509 smear microscopy in all respiratory symptomatic persons, defined as those with a productive cough of at least three weeks duration. Hemoptysis When hemoptysis occurs, the blood volume is variable, from bloody streaks mixed in the sputum (hemoptoic sputum) to massive hemoptysis (more than 400 mL/day), which is rare. A higher volume of hemoptysis is generally caused by erosion of Rasmussen’s aneurysms, which are free terminations of arteries within lung cavi- ties. Bleeding can also occur in small lesions during the formation of the cavities, when hemoptysis can be the first manifestation of the disease, which was known by the old phthysiologists as alert hemoptysis or bark. Therefore, dyspnea is not a common symp- tom, but can be caused by pleural effusions, pneumothorax or restriction caused by fibrosis in advanced disease. Dyspnea may be more frequent in the miliary form, due to diffuse interstitial disease and consequent hypoxemia. Generally of low intensity, it disappears within two or three weeks after effective treatment has begun. When cough and other symptoms are overlooked by the patient, hoarseness may be the sole reason for seeking medical assistance. The longer the duration of the disease, the more evident are the classic signs of consumption, such as pallor and weight loss. The extent and the form of the disease in the lung parenchyma determine the pres- ence of specific pulmonary signs. The most common auscultation findings are: coarse crackles in the area corresponding to the lesion (generally apical and poste- rior); wheezing and ronchi in the area of compromised bronchi; clinical signs of lung condensation in the forms with caseous pneumonia; decreased vesicular mur- mur and broncophony or tubular blow when pleural effusion is present; as well as the classic amphoric breath sounds near cavities.

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However cytoxan 50mg generic symptoms joint pain, the effects of prolactin depend heavily upon the permissive effects of estrogens, progesterone, and other hormones. Nevertheless, this hormone is capable of darkening of the skin by inducing melanin production in the skin’s melanocytes. Each of the thyroid lobes are embedded with parathyroid glands, primarily on their posterior surfaces. Surrounded by a wall of epithelial follicle cells, the colloid is the center of thyroid hormone production, and that production is dependent on the hormones’ essential and unique component: iodine. The following steps outline the hormones’ assembly: This OpenStax book is available for free at http://cnx. As a result, the concentration of iodide ions “trapped” in the follicular cells is many times higher than the concentration in the bloodstream. The oxidation of two iodide ions (2 I ) results in iodine (I ), which passes2 through the follicle cell membrane into the colloid. In the colloid, peroxidase enzymes link the iodine to the tyrosine amino acids in thyroglobulin to produce two intermediaries: a tyrosine attached to one iodine and a tyrosine attached to two iodines. When one of each of these intermediaries is linked by covalent bonds, the resulting compound is triiodothyronine (T ), a thyroid hormone with3 three iodines. Much more commonly, two copies of the second intermediary bond, forming tetraiodothyronine, also known as thyroxine (T ), a thyroid hormone with four iodines. There, lysosomal enzymes break apart the thyroglobulin colloid, releasing free T and T , which diffuse3 4 across the follicle cell membrane and enter the bloodstream. When blood levels of T and T begin to decline, bound T and3 4 3 T are released from these plasma proteins and readily cross the membrane of target cells. Functions of Thyroid Hormones The thyroid hormones, T3 and T , are often referred to as metabolic hormones because their levels influence the body’s4 basal metabolic rate, the amount of energy used by the body at rest. Adequate levels of thyroid hormones are also required for protein synthesis and for fetal and childhood tissue development and growth. They are especially critical for normal development of the nervous system both in utero and in early childhood, and they continue to support neurological function in adults. As noted earlier, these thyroid hormones have a complex interrelationship with reproductive hormones, and deficiencies can influence libido, fertility, and other aspects of reproductive function. Finally, thyroid hormones increase the body’s sensitivity to catecholamines (epinephrine and norepinephrine) from the adrenal medulla by upregulation of receptors in the blood vessels. When levels of T3 and T4 hormones are excessive, this effect accelerates the heart rate, strengthens the heartbeat, and increases blood pressure. Because thyroid hormones regulate metabolism, heat production, protein synthesis, and many other body functions, thyroid disorders can have severe and widespread consequences. But for much of the world’s population,3 4 foods do not provide adequate levels of this mineral, because the amount varies according to the level in the soil in which the food was grown, as well as the irrigation and fertilizers used. Marine fish and shrimp tend to have high levels because they concentrate iodine from seawater, but many people in landlocked regions lack access to seafood. Fortification of salt with iodine began in the United States in 1924, and international efforts to iodize salt in the world’s poorest nations continue today. Dietary iodine deficiency can result in the impaired ability to synthesize T3 and T , leading to a variety of severe4 disorders. As a result of this hyperstimulation, thyroglobulin accumulates in the thyroid gland follicles, increasing their deposits of colloid. The accumulation of colloid increases the overall size of the thyroid gland, a condition called a goiter (Figure 17. Other iodine deficiency disorders include impaired growth and development, decreased fertility, and prenatal and infant death. Neonatal hypothyroidism (cretinism) is characterized by cognitive deficits, short stature, and sometimes deafness and muteness in children and adults born to mothers who were iodine- deficient during pregnancy. Instead, inflammation of the thyroid gland is the more common cause of low blood levels of thyroid hormones.

Treatment _ Hot compress _ Topical antibiotics _ If the above treatment fails purchase cytoxan 50mg with mastercard medicine bg, referral for. External Hordeolum /stye/ ¾ An acute staphylococcal infection of a lash follicle and its associated gland of zeis or moll. Chalazion - A chronic lipogranulomatous inflammatory lesion caused by blockage of meibomian gland orifices and stagnation of sebaceous secretion - Patient with acne roscea or seborrheic dermatitis are at increased risk of Chalazion formation which may be multiple or recurrent. Symptom ¾ Painless nodule within the eye lid Sign ƒ Non tender, firm, roundish mass within the eye lid. Molluscum contagiosum - Uncommon skin infection caused by a poxvirus - It is common in children and immunocompromized patient. Sign ¾ Single or multiple ¾ Pale, waxy ¾ Umblicated nodules ¾ If the nodule is located on the lid margin it may give rise to ipsilateral chronic follicular conjunctivitis and occasionally a superficial keratitis Treatment ¾ Expression ¾ Shaving and excision ¾ Destruction of the lesion by cauterization, cryotherapy E. Blepharitis ¾ a general term for inflammation of the eyelid ¾ Can be associated with conjunctivitis There are two main types of blepharitis 1. Entropion - Means the eyelids turn in wards then the eyelashes rub and damage the globe Treatment - Referral for surgical correction C. It can cause ambylopia if it is unilateral Treatment - Referral for surgical correction 31 3. Treatment - Hot compression - Systemic antibiotic -Incision and abscess drainage may be required Complication - Preseptal cellulitis - Orbital cellulitis Chronic dacryocystitis Symptoms - Tearing - Swelling over the medial aspect of the eye - Mucoid or purulent discharge with pressure on the lacrimal sac area. Preseptal cellulitis Definition: it is infection of the tissues anterior to the orbital septum Symptom - No visual reduction - Mild periorbital pain - Localized eyelid redness and swelling Sign - V/A is normal - Tender and hot eyelid - Ocular motility is normal Treatment - Ciprofloxacillin 500mg po bid for seven days. Orbital cellulitis An infection of orbital tissue posterior to the orbital septum. Symptom -Pain -Proptosis -Fever - Limited ocular movement -Visual reduction 33 Sign - V/A is reduced -Tender eye - Reduced to absent ocular motility Treatment It is an ophthalmic emergency that needs admission; intravenous antibiotics and close follow up. Ahmed 4 - Albert and Jacoboiec Principle And Practice Of Ophthalmology 5 - Up to date - (C) 2001 - www. They will also be alert on the differential diagnoses ranging from self liming to sight threatening cause of red eye. They will be given a clear description on how to approach patients with red eye and what to do at their level. At the end of the course, students are expected to differentiate self limiting condition from sight threatening conditions; and to act early. If they are neglected and mismanaged they will complicate to the extent of sight threatening condition. Those patients who will not have improvement in less than 48 hrs need referral to a better center for better management. Epidemiology The prevalence of each is different in pediatric and adult population. The vast majority of pediatric cases are bacteria, while in adult’s bacterial and viral causes are equally common. Bacterial conjunctivitis • Commonly caused by staphylococcus aureus, streptococcus pneumonia, Hemophilic influenza, and moraxella catarrhalis • S. Symptoms:- • Patients typically complain of redness and discharge in one eye; although it can also be bilateral. Sign: - • On examination, patients will typically have purulent discharge at the lid margins and in the corners of the eye. More purulent discharge appears within minutes of wiping the lids • Red eye – due to dilatation of superficial blood vessels as apart of inflammation 36 • Edema of the conjunctiva (chemosis) and eyelids swelling • Cornea is mostly clear; but if it is involved, there will be different degree of corneal opacity it is common special in untreated and delayed patients (see color plate14) Diagnosis - Mostly clinical - Gram stains Course - It lasts for 1 - 2 weeks and then it usually resolves spontaneously. Symptoms _ Red eye _ Severe and persistent itching of both eyes _ Mucoid eye discharge _ No visual reduction Signs _V/A is normal _ papillary reaction to hypertrophy on tarsal conjunctiva Treatment _ Cold compress _Vasoconstrictor-antihistamine like cromolyn sodium _ Topical steroid -Terracortril eye suspension Neonatal Conjunctivitis (Ophthalmia Neonatorum) Defn: is conjunctivitis in a newborn (in the first 28 days of life) Etiology Gonococcus and Chlamydia are the commonest cause of which gonococcal is most serious Symptoms - profuse thin to thick purulent eye discharge Sign - purulent eye discharge, eye lids are swollen - If cornea is involved, ulcer, scarring, lately cornea will shrink. Treatment - It is sight threatening condition that needs systemic antibiotic and close follow up in better ophthalmic center - Start with tetracycline eye ointment 3-4 times a day - Urgent referral to ophthalmic center for further evaluation and management 38 Prevention - The eye lids should be cleaned with saline swabs as soon as the head was born and before the infant‘s eyes opened. The diagnosis of such diseases need experienced ophthalmic worker, appropriate instruments and especial diagnostic tests and procedures. Their visual out come highly depends on the time interval between onset of the disease and initiation of treatment and subsequent close follow up. Symptoms - Painful red eye - Sudden reduction of vision - Rapid progressive visual impairment. Symptoms - Painful disorder-typically a constant severe boring pain that worsens at night or in the early morning hours and radiates to the face and 42 periorbital region. To give a general over view on the burden of blindness on global and country levels 2.

This is then followed by septation buy cytoxan 50mg mastercard medicine etodolac, a complex process which converts this simple tube into a four chambered heart and covered in a later lecture and lab. During embryonic development there is extensive remodelling of the initially right and left symmetrical cardiovascular system and a contribution from the neural crest to some vessels. Recent findings suggest that Notch signaling acts as an inhibitor for this system, preventing sprouting of blood vessels. Notch is a transmembrane receptor protein involved in regulating cell differentiation in many developing systems. Fetal Oxygen levels Maternal Blood | -> umbilical vein -> liver -> anastomosis -> sinus venosus -> atria ventricles-> truncus arteriosus -> aortic sac -> aortic arches-> dorsal aorta-> pair of umbilical arteries | Maternal Blood. With embryo development this scheme is extensively remodelled leading to an asymmetric adult system in the body. The ventricles are rotated into their correct anatomical position by the growth of the heart tube, bending into an "S" shape. Cardiac inflow- at the bottom (sinus venosus) Cardiac outflow- at the top (truncus arteriosus) Heart neural crest The mouse model shows that the heart also has contributions from neural crest E8. Then through peri-aortic mesenchyme (lateral to pharynx), through pharyngeal arches (3, 4, 6) into the aortic sac. Cardiac neural crest of the mouse embryo: axial level of origin, migratory pathway and cell autonomy of the splotch (Sp2H) mutant effect. Formed by 3 layers consisting of a fibrous pericardium and a double layered serous pericardium (parietal layer and visceral epicardium layer). The region of the early heart tube that corresponds to the inflow and out flow respectively are: inferior vena cava and aortic arch portal artery and aorta sinus arteriosus and cordus bulbus truncus arteriosus and sinus venosus 3. The embryo cardinal venous vessels which drain into the sinus venosus are: anterior cardinal veins common cardinal veins inferior cardinal veins superior cardinal veins 5. Alberts, Bruce; Johnson, Alexander; Lewis, Julian; Raff, Martin; Roberts, Keith; Walter, Peter New York and London: Garland Science; c2002 - Figure 21-35. The function of the pathway will be to alter the cell directly or indirectly by changing gene expression. The placenta a mateno-fetal organ which begins Placental cord cross-section developing at implantation of the blastocyst and is delivered with the fetus at birth. Only recently have we begun to understand the many different functions this organ carries out in addition to its role in embryonic nutrition. The placenta and placental blood at birth has recently been seen as a new source for stem cells in bone marrow replacement therapy in many diseases. Fetal Membranes Early implantation Placenta at Birth Placenta (Greek, plakuos = flat cake) embryonic/maternal organ villous chorion/decidua basalis continuous with amniotic and chorionic sacks Dimensions at birth - discoid up to 20cm diameter and 3 cm thick (term) and weighs 500-600 gm Shapes - accessory placenta, bidiscoid, diffuse, horseshoe maternal and embryonic surface, both delivered at parturition retention may cause uterine hemorrhage Maternal Surface Fetus in utero, between fifth and sixth months Cotyledons - form cobblestone appearance, originally placental septa formed grooves covered with maternal decidua basalis Fetal Surface umbilical cord attachment - cord 1-2 cm diameter, 30-90cm long covered with amniotic membrane and attached to chorionic plate umbilical vessels branch into chorionic vessels which anastomose Placental Classification Classification of placenta is on the basis of histological (microscopic) structural organization and layers between fetal and maternal circulation, giving 3 main groups: Haemochorial - placenta where the chorion comes in direct contact with maternal blood (human) Endotheliochorial - maternal endometrial blood vessels are bare to their endothelium and these comes in contact with the chorion. See also Placental Layers Placental Types Discoid in humans, mice, insectivores, rabbits, rats, and monkeys. Diffuse in horses, pigs, camels, lemurs, opossums, kangaroos, and whales Chorionic Villi Primary chorionic villi Secondary chorionic Placenta anchoring villi villi primary villi - week 2, first stage of chorionic villi development, trophoblastic shell cells (syncitiotrophoblasts and cytotrophoblasts) form finger-like extensions into maternal decidua. Chorionoic Villi Location originally cover entire chorionic surface and become restricted to decidua basalis region forming 2 regions Frondosum - "leafy" where villi are mainly located Capsularis - smooth chorion, where villi are absent or not abundant Chorionoic Villi Trimester Development Trimester 1 and 2 In the first two trimesters immature intermediate villi, developmental steps towards the stem villi. Trimester 3 Mature intermediate villi develop during the last trimester, produce numerous terminal villi. Terminal villi are not active outgrowths caused by proliferation of the trophoblast, but rather passive protrusions induced by capillary coiling due to excessive longitudinal growth of the fetal capillaries within the mature intermediate villi. The arrangement of the capillary bed in the terminal villi can vary from simple U-like loops to a richly branched network due to capillary elongation and sprouting. Steroid Hormones progestins - progesterone, support of the endometrium and suppress uterine smooth muscle contractility. Later Hofbauer (lacental villi macrophages of mesenchymal origin) and stromal cells take over the stimulation of blood vessel development. Fibrin-type fibrinoid is a maternal blood-clot product which replaces degenerative syncytiotrophoblast 2. Estrogen and progesterone - receptive phase, luminal and glandular epithelial cells change in preparation for blastocyst adplantation. Human Chorionic gonadotropin - luminal epithelium endoreplication leading to epithelial plaque formation. Placenta spiral artery conversion Artery Dilatation - due to extravillous trophoblast cells invading uterine wall and maternal spiral arteries replacing both smooth muscle with fibrinoid material and part of vessel endothelium.