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Subacute Lymphocytic Thyroiditis

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82. Paraneoplastic Syndromes (Overview)

, neoplastic hypoalbuminemia, which is also related to reduced albumin synthesis. Gastrointestinal syndromes Gastrointestinal paraneoplastic disorders are related to production of molecules that affect the motility and secretory activity of the digestive tract, as follows: Medullary thyroid carcinomas (MTCs) may produce several prostaglandins (PGs) (eg, PGE2 and PGF2) that lead to malabsorption and, consequently, unavailability of nutrients Malignancies of the digestive system, especially those (...) enzymes into the bloodstream, leading to adipose nodular necrosis of subcutaneous tissues; this condition is characterized by painful pink to dark-reddish nodules under the skin; these nodules often ulcerate, causing leakage of an oily material Flushes can be observed in patients with acute leukemias, mastocytosis, carcinoids, medullary thyroid cancer, or pancreatic carcinomas that secrete vasoactive substances, mainly prostaglandins (alpha, E1, E2, F2, I2) Dermic melanosis results from melanin

2014 eMedicine.com

83. Nonneoplastic Epithelial Disorders of the Vulva (Overview)

contraceptives with antiandrogenic properties might trigger the early onset of lichen sclerosus in susceptible young women. [ ] Investigative studies aimed toward identifying an infection-causing agent (eg, spirochetes, viruses) have yielded inconclusive results. Lichen sclerosus has been weakly linked to autoimmune diseases and genetic factors. Approximately 21% of patients have an autoimmune disease, most commonly a thyroid disorder. Familial occurrence is also well recognized. Forty-four percent (...) is classified into systemic, subacute, chronic, or discoid forms. Genital involvement is uncommon, and vulvar manifestations have seldom been described. In one study, vulvar lesions were found in 2 (5%) of 42 women affected by the chronic form. Darier disease Darier disease is a heritable disorder of keratinization transmitted as an autosomal dominant trait. Altered keratinization is a result of the disruption of desmosomal proteins with consequent tonofilament detachment and acantholysis because

2014 eMedicine.com

84. Benign Vulvar Lesions (Follow-up)

contraceptives with antiandrogenic properties might trigger the early onset of lichen sclerosus in susceptible young women. [ ] Investigative studies aimed toward identifying an infection-causing agent (eg, spirochetes, viruses) have yielded inconclusive results. Lichen sclerosus has been weakly linked to autoimmune diseases and genetic factors. Approximately 21% of patients have an autoimmune disease, most commonly a thyroid disorder. Familial occurrence is also well recognized. Forty-four percent (...) is classified into systemic, subacute, chronic, or discoid forms. Genital involvement is uncommon, and vulvar manifestations have seldom been described. In one study, vulvar lesions were found in 2 (5%) of 42 women affected by the chronic form. Darier disease Darier disease is a heritable disorder of keratinization transmitted as an autosomal dominant trait. Altered keratinization is a result of the disruption of desmosomal proteins with consequent tonofilament detachment and acantholysis because

2014 eMedicine.com

86. Urticaria, Chronic (Diagnosis)

disease associated with chronic idiopathic urticaria: 2 case reports. J Investig Allergol Clin Immunol . 2009. 19(1):54-6. . Ryhal B, DeMera RS, Shoenfeld Y, Peter JB, Gershwin ME. Are autoantibodies present in patients with subacute and chronic urticaria?. J Investig Allergol Clin Immunol . 2001. 11 (1):16-20. . Kasumagic-Halilovic E, Beslic N, Ovcina-Kurtovic N. Thyroid Autoimmunity in Patients with Chronic Urticaria. Med Arch . 2017 Feb. 71 (1):29-31. . Palma-Carlos AG, Palma-Carlos ML. Chronic (...) in hereditary angioedema), and C1-esterase inhibitor (associated with hereditary angioedema) functional assays may be performed Thyroid function testing and antithyroid microsomal and peroxidase antibody titers: Patients with urticaria unresponsive to antihistamines or steroids may have elevated titers [ ] ; the plasma thyrotropin level (TSH) helps screen for thyroid dysfunction Chronic Urticaria (CU) Index: A nonspecific measure of basophil histamine release, which, if positive, may indicate the presence

2014 eMedicine.com

87. Decubitus Ulcers (Follow-up)

, a finding that has theoretical implications for wound healing. Because povidone-iodine can affect thyroid function, it could be contraindicated for some patients. [ ] Acetic acid (0.5%) is specifically effective against Pseudomonas aeruginosa , a particularly difficult and common organism in fungating lesions. Acetic acid can change the color of tissue and can mask potential superinfection. Rinsing with normal saline also is recommended. [ ] Sodium hypochlorite (2.5%) has some germicidal activity (...) of pressure injuries, including direct closure, skin grafting, skin flaps, and musculocutaneous flaps. Such management can provide skin coverage as well as soft tissue coverage. Flaps containing muscle provide a physiologic barrier to infection, eliminate dead space in the wound, and improve vascularity. Improved vascularity enhances local oxygen tension, provides extended soft-tissue penetration for antibiotics, and improves total lymphocyte function. [ , , ] The patient should be medically stable

2014 eMedicine Surgery

88. Urticaria, Chronic (Overview)

disease associated with chronic idiopathic urticaria: 2 case reports. J Investig Allergol Clin Immunol . 2009. 19(1):54-6. . Ryhal B, DeMera RS, Shoenfeld Y, Peter JB, Gershwin ME. Are autoantibodies present in patients with subacute and chronic urticaria?. J Investig Allergol Clin Immunol . 2001. 11 (1):16-20. . Kasumagic-Halilovic E, Beslic N, Ovcina-Kurtovic N. Thyroid Autoimmunity in Patients with Chronic Urticaria. Med Arch . 2017 Feb. 71 (1):29-31. . Palma-Carlos AG, Palma-Carlos ML. Chronic (...) in hereditary angioedema), and C1-esterase inhibitor (associated with hereditary angioedema) functional assays may be performed Thyroid function testing and antithyroid microsomal and peroxidase antibody titers: Patients with urticaria unresponsive to antihistamines or steroids may have elevated titers [ ] ; the plasma thyrotropin level (TSH) helps screen for thyroid dysfunction Chronic Urticaria (CU) Index: A nonspecific measure of basophil histamine release, which, if positive, may indicate the presence

2014 eMedicine.com

91. Cancer Associated and Related Autoimmune Retinopathies (Overview)

. If the result is normal and the index of suspicion of CAR remains high, a chest CT scanning is appropriate. Additional imaging studies to consider include CT of the abdomen and pelvis, mammography (in women), and total-body positron-emission tomography (PET) or CT/PET. Complete physical examination, including pelvic and breast examinations for women, is also recommended. Previous Next: Differential Diagnoses Acute or subacute unilateral or bilateral vision loss with a normal-appearing fundus suggests (...) found to be protective against antirecoverin antibodies in an animal model, but the efficacy in humans has not yet been demonstrated. Other research efforts involve activation of recoverin-specific antitumor cytotoxic T lymphocytes. Rituximab was found to be beneficial in a patient with CAR [ ] and autologous hematopoietic stem cell transplantation in a case of AR and optic neuropathy. [ ] A study of 30 patients with PR or AR found improvement in 21 (70%) using immunosuppressive agents

2014 eMedicine.com

92. Multifocal Choroidopathy Syndromes (Diagnosis)

of patients with MCP. Other infections that have been associated with MCP include , , , , Toxocara canis, and . [ , , , , ] Despite this, many investigators still believe that MCP results from an underlying autoimmune mechanism, possibly triggered by an infectious agent. Histopathologic studies of ocular specimens from patients with MCP have revealed a predominant B-lymphocyte and plasma cell infiltrate of the choroid and choriocapillaris. [ ] In addition, a deposition of compliment and immunoglobulins (...) lesion, there is a fairly rapid flattening of the well-demarcated dome-shaped lesion accompanied by thickening of the IS/OS junction and hyperreflectivity of the outer nuclear layer. Within about 2 weeks, the lesion evolves into stage 2, a subacute phase, with a distinct separation of the IS/OS junction and RPE layer visible with mild subretinal fluid accumulation present. The hyperreflectivity of the outer nuclear layer begins to fade and the layer thins at this stage. In Stage 3, the late phase

2014 eMedicine.com

93. Dementia Due to HIV Disease (Diagnosis)

function with HAART, leading to an intense inflammatory reaction with an influx of CD8 + lymphocytes. The influx of the CD8 cells may cause macrophage activation and control of infection but can also present with a subacute or acute encephalopathy. The imbalance between CD8 + /CD4 + cells may cause worsening of the HIV encephalopathy and can also produce an acute demyelinating process similar to multiple sclerosis or acute demyelinating encephalomyelitis. These cases may represent a specific (...) active antiretroviral therapy (HAART), dementia was a common source of morbidity and mortality in HIV-infected patients. It was usually observed in the late stages of acquired immunodeficiency syndrome (AIDS), when CD4 + lymphocyte counts fall below 200 cells/mL, and was seen in up to 50% of patients prior to their deaths. [ ] In 1986, the term AIDS dementia complex (ADC) was introduced to describe a unique constellation of neurobehavioral findings. [ , ] HIV associated neurocognitive disorder (HAND

2014 eMedicine.com

94. Dermatologic Manifestations of Cardiac Disease (Diagnosis)

cardiomegaly, a systolic ejection sound accompanied by a thrill, a loud single second heart sound, a harsh systolic murmur, a low-pitched middiastolic rumbling murmur, and bounding pulses. Facial dysmorphism; malformations of the limbs, kidneys, and intestines; atrophy or absence of the thymus gland; T-lymphocyte deficiency; and a propensity for infections also may be features of the clinical presentation. Systemic Lupus Erythematosus (Skin Changes and Myocarditis and Heart Block) Congenital heart block (...) findings, which typically appear in the first week of life, are similar to subacute cutaneous lupus erythematosus with annular, erythematous, scaly plaques in facial central areas, frequently involving the periocular and perioral areas. [ ] Patients should be evaluated for congenital heart block using serial echocardiograms. [ ] Amyloidosis Cardiomyopathy (restrictive) and cutaneous manifestations of primary systemic may coexist. Primary systemic amyloidosis consists of immunoglobulin light chains

2014 eMedicine.com

95. HIV-1 Encephalopathy and AIDS Dementia Complex (Diagnosis)

infiltration has been identified in patients with latent or inactive HIV infection of the brain due to restoration of T-cell function with HAART, leading to an intense inflammatory reaction with an influx of CD8 + lymphocytes. The influx of the CD8 cells may cause macrophage activation and control of infection but can also present with a subacute or acute encephalopathy. The imbalance between CD8 + /CD4 + cells may cause worsening of the HIV encephalopathy and can also produce an acute demyelinating (...) to the advent of highly active antiretroviral therapy (HAART), dementia was a common source of morbidity and mortality in HIV-infected patients. It was usually observed in the late stages of acquired immunodeficiency syndrome (AIDS), when CD4 + lymphocyte counts fall below 200 cells/mL, and was seen in up to 50% of patients prior to their deaths. [ ] In 1986, the term AIDS dementia complex (ADC) was introduced to describe a unique constellation of neurobehavioral findings. [ , ] HIV associated

2014 eMedicine.com

96. Benign Vulvar Lesions (Diagnosis)

contraceptives with antiandrogenic properties might trigger the early onset of lichen sclerosus in susceptible young women. [ ] Investigative studies aimed toward identifying an infection-causing agent (eg, spirochetes, viruses) have yielded inconclusive results. Lichen sclerosus has been weakly linked to autoimmune diseases and genetic factors. Approximately 21% of patients have an autoimmune disease, most commonly a thyroid disorder. Familial occurrence is also well recognized. Forty-four percent (...) is classified into systemic, subacute, chronic, or discoid forms. Genital involvement is uncommon, and vulvar manifestations have seldom been described. In one study, vulvar lesions were found in 2 (5%) of 42 women affected by the chronic form. Darier disease Darier disease is a heritable disorder of keratinization transmitted as an autosomal dominant trait. Altered keratinization is a result of the disruption of desmosomal proteins with consequent tonofilament detachment and acantholysis because

2014 eMedicine.com

98. Cancer Associated and Related Autoimmune Retinopathies (Diagnosis)

. If the result is normal and the index of suspicion of CAR remains high, a chest CT scanning is appropriate. Additional imaging studies to consider include CT of the abdomen and pelvis, mammography (in women), and total-body positron-emission tomography (PET) or CT/PET. Complete physical examination, including pelvic and breast examinations for women, is also recommended. Previous Next: Differential Diagnoses Acute or subacute unilateral or bilateral vision loss with a normal-appearing fundus suggests (...) found to be protective against antirecoverin antibodies in an animal model, but the efficacy in humans has not yet been demonstrated. Other research efforts involve activation of recoverin-specific antitumor cytotoxic T lymphocytes. Rituximab was found to be beneficial in a patient with CAR [ ] and autologous hematopoietic stem cell transplantation in a case of AR and optic neuropathy. [ ] A study of 30 patients with PR or AR found improvement in 21 (70%) using immunosuppressive agents

2014 eMedicine.com

99. Cardiomyopathy, Dilated (Diagnosis)

Comprehensive metabolic panel Thyroid function tests Cardiac biomarkers B-type natriuretic peptide assay Chest radiography Echocardiography Cardiac magnetic resonance imaging (MRI) Electrocardiography (ECG) In many cases of cardiomyopathy, endomyocardial biopsy is class II (uncertain efficacy and may be controversial) or class III (generally not indicated). Class II indications for endomyocardial biopsy include the following: Recent onset of rapidly deteriorating cardiac function Patients receiving (...) ventricular dysfunction. Interleukin (IL)–1b has been shown to depress myocardial function. One theory is that elevated levels of IL-2R in patients with class IV CHF suggest that T-lymphocytes play a role in advanced stages of heart failure. IL-6 stimulates hepatic production of C-reactive protein, which serves as a marker of inflammation. IL-6 has also been implicated in the development of myocyte hypertrophy, and elevated levels have been found in patients with CHF. IL-6 has been found to correlate

2014 eMedicine.com

100. Drug-Induced Hepatotoxicity (Diagnosis)

was based on the FDA's review of postmarketing safety reports and meetings held with the American Thyroid Association, the National Institute of Child Health and Human Development, and the pediatric endocrine clinical community. In 2009, the FDA issued guidelines to assist the pharmaceutical industry and other investigators who are conducting new drug development in assessing the potential for a drug to cause severe liver injury (ie, irreversible liver failure that is fatal or requires liver (...) in cases of possible autoimmune hepatitis. Positive ANA and ASMA findings may add to the diagnostic evaluation but are usually confusing and hence not used. The presence of antibodies to specific forms of CYP has been associated with hypersensitivity to some drugs. For example, some antibodies and the associated drugs involved are as follows: CYP 1A2, dihydralazine; CYP 3A1, anticonvulsants; and CPY 2E1, halothane. Their role in pathophysiology is uncertain but may help in diagnosis. Lymphocyte

2014 eMedicine.com

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