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Subacute Lymphocytic Thyroiditis

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101. The Approach to the Painful Joint (Treatment)

The synovial membrane is the principal site of inflammation in persons with rheumatoid arthritis (RA) and many other inflammatory arthritides. [ ] Synovitis is characterized pathologically by the following: Neovascularization Infiltration of the synovium with lymphocytes, plasma cells, and macrophages Synovial lining cell hyperplasia These cause synovial proliferation, clinically manifested by warmth, tenderness, and a boggy consistency of the soft tissues overlying the involved joint. The inflamed (...) and the inner aspect of the thigh. Tenderness can be elicited by local palpation of the adductor muscles, especially near their insertion on the front of the pelvis. Pain is increased by passive abduction of the thighs and active adduction against resistance. Treatment of adductor tendinitis consists of rest and ice packs during the acute phase. NSAIDs, ultrasonography, and progressive stretching exercises are used in the subacute phase. Local corticosteroid injections are reserved for patients resistant

2014 eMedicine.com

102. Oral Manifestations of Systemic Diseases (Treatment)

systemic evaluation, including referral for and biopsy with histopathologic correlation. The most common histologic findings in both oral and intestinal Crohn disease are noncaseating granulomas and both acute and chronic inflammation with lymphocytic and giant cell perivascular infiltrates. Also see . Pyostomatitis vegetans Although relatively rare, most PSV cases occur concurrently with either Crohn disease or UC. [ ] As such, PSV is considered a specific finding of IBD, and its presence can precede (...) based on clinical presentation. Reticular LP, the most common form, presents as white papules or plaques on a bed of erythema with Wickham striae. [ , ] The buccal mucosa, tongue, and gingivae may be involved. It is generally asymptomatic. [ ] Other less common forms of LP include erosive LP, erythematous (or atrophic) LP, and papular (or plaquelike) LP. [ , ] Rarely, bullous LP may be observed. [ ] Histology reveals a bandlike lymphocytic infiltrate with a saw-tooth appearance of the rete ridges

2014 eMedicine.com

103. Childhood HIV Disease (Treatment)

and poor small-bowel function. As many as 33% of patients with HIV have a negative vitamin B-12 balance. Folic acid deficiency causes the production of large oval erythrocytes, hypersegmented polymorphonucleocytes, and pancytopenia. Vitamin B-12 deficiency causes subacute combined degeneration of the spinal cord with high cortical dysfunction. Before treatment is started with supplemental parenteral vitamin B-12 and oral folic acid, serum folate and vitamin B-12 levels must be measured. A low or normal

2014 eMedicine.com

104. Benign Vulvar Lesions (Treatment)

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

105. Hyperthyroidism (Treatment)

thyroid-related orbitopathy. This patient also had optic nerve dysfunction and chemosis (conjunctival edema) from thyroid-related orbitopathy. Color flow ultrasonogram in patient with Graves disease. Generalized hypervascularity is visible throughout gland (note red areas), which often can be heard as hum or bruit with stethoscope. Absence of iodine 123 (123I) radioactive iodine uptake in patient with thyrotoxicosis and subacute painless or lymphocytic thyroiditis. Laboratory studies at time of scan (...) specialists), or thyroidectomy. However, antithyroid medications are not effective in thyrotoxicosis in which scintigraphy shows low uptake of iodine-123 ( 123 I), as in patients with subacute thyroiditis, because these cases result from release of preformed thyroid hormone. If a physician treats enough patients who are hyperthyroid, eventually he or she will encounter a patient who develops agranulocytosis or hepatitis from the antithyroid medications. Discussing these adverse effects with patients

2014 eMedicine.com

106. Cancer Associated and Related Autoimmune Retinopathies (Treatment)

. 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

108. Nonneoplastic Epithelial Disorders of the Vulva (Treatment)

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

109. Pneumocystis (carinii) jiroveci Pneumonia (Overview)

: Clinical Presentation of Pneumocystis jiroveci Pneumonia Patient history The symptoms of P jiroveci pneumonia (PJP) are nonspecific. PJP in patients with HIV infection tends to run a more subacute indolent course and tends to present much later, often after several weeks of symptoms, compared with PJP associated with other immunocompromising conditions. [ ] Symptoms of PJP include the following: Progressive exertional dyspnea (95%) Fever (>80%) Nonproductive cough (95%) Chest discomfort Weight loss (...) , such findings may be present in patients receiving aerosolized pentamidine for prophylaxis or in patients with advanced HIV infection who are not taking any prophylaxis. They may also occur in the absence of lung involvement. Based on most well-documented findings, Pneumocystis infection may present in almost any organ system, as follows: Central nervous system Bone marrow (may have necrosis with resultant pancytopenia) Lymphadenopathy Eyes (may have retinal cotton-wool spots) Thyroid (may present

2014 eMedicine.com

111. Pneumocystis (carinii) jiroveci Pneumonia (Treatment)

: Clinical Presentation of Pneumocystis jiroveci Pneumonia Patient history The symptoms of P jiroveci pneumonia (PJP) are nonspecific. PJP in patients with HIV infection tends to run a more subacute indolent course and tends to present much later, often after several weeks of symptoms, compared with PJP associated with other immunocompromising conditions. [ ] Symptoms of PJP include the following: Progressive exertional dyspnea (95%) Fever (>80%) Nonproductive cough (95%) Chest discomfort Weight loss (...) , such findings may be present in patients receiving aerosolized pentamidine for prophylaxis or in patients with advanced HIV infection who are not taking any prophylaxis. They may also occur in the absence of lung involvement. Based on most well-documented findings, Pneumocystis infection may present in almost any organ system, as follows: Central nervous system Bone marrow (may have necrosis with resultant pancytopenia) Lymphadenopathy Eyes (may have retinal cotton-wool spots) Thyroid (may present

2014 eMedicine.com

112. Paraneoplastic Autonomic Neuropathy (Overview)

paraneoplastic neurological syndromes include: Encephalomyelitis Limbic encephalitis Subacute cerebellar degeneration Opsoclonus-myoclonus Subacute sensory neuronopathy Chronic gastrointestinal pseudo-obstruction Lambert-Eaton myasthenic syndrome (LEMS) Dermatomyositis The most common non-classical paraneoplastic neurological syndromes include: Brainstem encephalitis Optic neuritis Cancer- or melanoma-associated retinopathy Stiff person syndrome Necrotizing myelopathy Motor neuron diseases Acute sensorimotor (...) neuropathies (ie, Guillain-Barre syndrome or brachial neuritis) Subacute/chronic sensorimotor neuropathies Neuropathies associated with paraproteinemia or vasculitis Autonomic neuropathies Myasthenia gravis Acquired neuromyotonia Acute necrotizing myopathy Patients with a definite PNS include those with the following: A classical syndrome and cancer that develops within 5 years of the diagnosis of the neurological disorder, regardless of the presence of paraneoplastic antibodies, A nonclassical syndrome

2014 eMedicine.com

113. Benign Vulvar Lesions (Overview)

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 of patients have one or more (...) mediated disorder. [ ] Some drugs have been found to induce lichen planus–type eruptions. [ ] Vulvar lesions may be more common than generally considered; a report found genital involvement in 51% of women with cutaneous disease. [ ] Involvement may sometimes be hypertrophic. [ ] Lupus erythematosus Lupus erythematosus is an idiopathic autoimmune disorder that can affect many organ systems. According to the degree of systemic involvement, the disease is classified into systemic, subacute, chronic

2014 eMedicine.com

114. Cardiomyopathy, Dilated (Overview)

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

115. The Approach to the Painful Joint (Overview)

The synovial membrane is the principal site of inflammation in persons with rheumatoid arthritis (RA) and many other inflammatory arthritides. [ ] Synovitis is characterized pathologically by the following: Neovascularization Infiltration of the synovium with lymphocytes, plasma cells, and macrophages Synovial lining cell hyperplasia These cause synovial proliferation, clinically manifested by warmth, tenderness, and a boggy consistency of the soft tissues overlying the involved joint. The inflamed (...) and the inner aspect of the thigh. Tenderness can be elicited by local palpation of the adductor muscles, especially near their insertion on the front of the pelvis. Pain is increased by passive abduction of the thighs and active adduction against resistance. Treatment of adductor tendinitis consists of rest and ice packs during the acute phase. NSAIDs, ultrasonography, and progressive stretching exercises are used in the subacute phase. Local corticosteroid injections are reserved for patients resistant

2014 eMedicine.com

116. Multifocal Choroidopathy Syndromes (Overview)

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

117. Hypothyroidism (Overview)

with age. Primary hypothyroidism Types of primary hypothyroidism include the following: Chronic lymphocytic (autoimmune) thyroiditis Postpartum thyroiditis Subacute (granulomatous) thyroiditis Drug-induced hypothyroidism Iatrogenic hypothyroidism Chronic lymphocytic (autoimmune) thyroiditis The most frequent cause of acquired hypothyroidism is chronic lymphocytic (autoimmune) thyroiditis (Hashimoto thyroiditis). The body considers the thyroid antigens as foreign, and a chronic immune reaction ensues (...) , resulting in lymphocytic infiltration of the gland and progressive destruction of functional thyroid tissue. The majority of affected individuals will have circulating antibodies to thyroid tissue. Anti–thyroid peroxidase (anti-TPO) antibodies are the hallmark of this disease. It should be noted that antibody levels can vary over time, may not be present early in the disease process, and usually disappear over time. Given this change in antibody concentration, it should be understood that the absence

2014 eMedicine.com

118. Hyperthyroidism (Overview)

thyroid hormone. A typical nuclear scintigraphy scan shows no radioactive iodine uptake (RAIU) in the thyrotoxic phase of the disease (see the images below). Thyroid hormone levels can be highly elevated in this condition. Absence of iodine 123 (123I) radioactive iodine uptake in patient with thyrotoxicosis and subacute painless or lymphocytic thyroiditis. Laboratory studies at time of scan demonstrated the following: thyroid-stimulating hormone (TSH), less than 0.06 mIU/mL; total thyroxine (T4), 21.2 (...) . This patient also had optic nerve dysfunction and chemosis (conjunctival edema) from thyroid-related orbitopathy. Color flow ultrasonogram in patient with Graves disease. Generalized hypervascularity is visible throughout gland (note red areas), which often can be heard as hum or bruit with stethoscope. Absence of iodine 123 (123I) radioactive iodine uptake in patient with thyrotoxicosis and subacute painless or lymphocytic thyroiditis. Laboratory studies at time of scan demonstrated the following: thyroid

2014 eMedicine.com

119. Hypertrophic Osteoarthropathy (Overview)

of lymphocytes and vascular hyperplasia are responsible for thickening of the vessel walls. Electron microscopy reveals Weibel-Palade bodies and prominent Golgi complexes, confirming structural vessel wall damage. [ ] Vast numbers of arteriovenous anastomoses may also be seen in the nail bed. [ ] Periosteum Subperiosteal new bone formation exists along the distal diaphysis of tubular bones, progressing proximally over time. The irregular periosteal proliferation affects predominantly the distal ends of long (...) of the subsynovial blood vessels and mild lining-layer hyperplasia may occur. [ , ] The edematous synovium becomes mildly infiltrated with lymphocytes, plasma cells, and occasional polymorphonuclear leukocytes, but the results from immunohistologic studies are negative. Electron-dense subendothelial deposits are present in vessel walls. [ , , ] In a study of a patient with primary hypertrophic osteoarthropathy and chronic arthritis, Lauter et al found multilayered basement laminae around small subsynovial blood

2014 eMedicine.com

120. Hepatitis, Viral (Overview)

lymphocytic sialadenitis, autoimmune thyroiditis, , lichen planus, and Mooren corneal ulcer. Some cases of can be attributed to HCV infection. Previous Next: Patient Education Refer patients with infectious hepatitis to their primary care providers for further counseling specific to their disease; the precise etiologic virus is unlikely to be known at the time of discharge from the emergency department. Counsel patients regarding the importance of follow-up care to monitor for evidence of disease (...) experience several relapses during the course of a year. Less than 1% of cases result in fulminant hepatic failure (FHF). HAV infection does not persist and does not lead to chronic hepatitis. Hepatitis B Hepatitis B virus (HBV) may be directly cytopathic to hepatocytes. However, immune system–mediated cytotoxicity plays a predominant role in causing liver damage. The immune assault is driven by human leukocyte antigen (HLA) class I–restricted CD8 cytotoxic T lymphocytes that recognize hepatitis B core

2014 eMedicine.com

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