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Subacute Lymphocytic Thyroiditis

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122. 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

123. 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

124. 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

125. 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

126. 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

127. 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

128. 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

129. Oral Manifestations of Systemic Diseases (Overview)

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

130. Optic Neuritis, Adult (Overview)

Classically, patients with optic neuritis are young, are often female, and have subacute vision loss associated with pain on eye movement. The patient’s history may reveal the following signs and symptoms of optic neuritis: Preceding viral illness Rapidly developing impairment of vision in 1 eye or, less commonly, both eyes: During an acute attack [ ] Dyschromatopsia (change in color perception) in the affected eye: Occasionally may be more prominent than the decreased vision [ ] Retro-orbital or ocular (...) of patients with optic neuritis See for more detail. Diagnosis The following blood tests can be performed when optic neuropathies other than optic neuritis are suspected: Erythrocyte sedimentation rate Thyroid function tests Antinuclear antibodies Angiotensin-converting enzyme Rapid plasma reagin Mitochondrial deoxyribonucleic acid (DNA) mutation studies Magnetic resonance imaging (MRI) is highly sensitive for and specific in the assessment of inflammatory changes in the optic nerves, and for central

2014 eMedicine.com

131. 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

132. HIV-1 Encephalopathy and AIDS Dementia Complex (Overview)

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

133. 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

134. Dermatologic Manifestations of Cardiac Disease (Overview)

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

135. Drug-Induced Hepatotoxicity (Overview)

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

136. Dementia Due to HIV Disease (Overview)

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 (...) 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) encompass

2014 eMedicine.com

138. 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

139. 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

140. 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

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