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Subacute Lymphocytic Thyroiditis

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141. Oral Manifestations of Systemic Diseases (Follow-up)

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

142. HIV-1 Encephalopathy and AIDS Dementia Complex (Follow-up)

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

143. Pneumocystis (carinii) jiroveci Pneumonia (Follow-up)

: 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

144. Nonneoplastic Epithelial Disorders of the Vulva (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

145. Multifocal Choroidopathy Syndromes (Follow-up)

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

146. Miliary Tuberculosis (Follow-up)

because of socioeconomic and medical risk factors. No genetic predisposition has been identified. Miliary disease is more difficult to detect in patients who are very young or very old. Children younger than 5 years who acquire miliary TB are more likely to develop life-threatening miliary and/or meningeal TB. The disease usually follows primary infection, with no or only a short latency period. Adults older than 65 years have a higher risk of miliary TB. Clinically, it may be subacute or may (...) pneumonia Viral pneumonia Other problems to be considered include the following: Fungal infection Histiocytosis X (Langerhans cell histiocytosis) HIV-related pulmonary opportunistic infections Lymphangitic spread of cancer (eg, thyroid carcinoma, malignant melanoma) Measles Pancreatic abscess Pulmonary alveolar microlithiasis Talc granulomatosis Previous Next: Laboratory Studies for Miliary TB Chemistry A decrease in sodium levels may correlate with disease severity, and the ( ) or hypoadrenalism may

2014 eMedicine.com

147. Hyperthyroidism (Follow-up)

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

148. Thyrotoxicosis

-releasing hormone. Neoplasms leading to thyrotoxicosis include autonomously functioning toxic nodules and toxic, multinodular goiters (TMNGs). Infections that can produce thyrotoxicosis include subacute thyroiditis (SAT) and, very rarely, acute suppurative thyroiditis. is a type of thyrotoxicosis in which accelerated thyroid hormone biosynthesis and secretion by the thyroid gland produce thyrotoxicosis. However, hyperthyroidism and thyrotoxicosis are not synonymous. [ ] This is because, although many (...) . Thyroid imaging and radiotracer thyroid uptake measurements, combined with serologic data, enable specific diagnosis and appropriate patient treatment. [ , , , ] The common causes of thyrotoxicosis have different pathophysiologic features and include autoimmune diseases, functioning thyroid adenomas, and infections. Autoimmune diseases resulting in thyrotoxicosis include the following: Graves disease (the most common cause of hyperthyroidism; see the images below) Lymphocytic thyroiditis

2014 eMedicine Radiology

149. Pituitary Adenoma

it controls most of the body's endocrine functions by means of the hypothalamic-pituitary axis (see the images below). The anterior lobe of the pituitary gland secretes 6 hormones: thyroid-stimulating hormone (TSH), previously adrenocorticotropic hormone (ACTH), follicle-stimulating hormone (FSH), leuteinizing hormone (LH), growth hormone (GH), and prolactin (PRL). The posterior pituitary gland secretes vasopressin and oxytocin. T1-weighted sagittal MRI through the pituitary fossa shows a normal (...) or intracavernous carotid arteries. MRI features include a mass of heterogeneous signal intensity due to flow effects and thrombus formation. Low signal intensity is caused by high flow and chronic thrombus; high signal intensity may represent slow flow or subacute thrombus. Flow in the patent lumen may also cause a band of artifact in the phase-encoding direction on spin-echo images. Magnetic resonance angiography (MRA) is useful in confirming an aneurysm. A potential pitfall in diagnosis is a pneumatized

2014 eMedicine Radiology

150. Childhood HIV Disease (Follow-up)

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

151. Cancer Associated and Related Autoimmune Retinopathies (Follow-up)

. 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

152. Dermatologic Manifestations of Cardiac Disease (Follow-up)

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

153. Dementia Due to HIV Disease (Follow-up)

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

154. Drug-Induced Hepatotoxicity (Follow-up)

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

155. The Approach to the Painful Joint (Follow-up)

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

158. 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

159. 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

160. 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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