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Subacute Lymphocytic Thyroiditis

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142. 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

143. 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

144. 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

145. 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

146. 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

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

149. Hyperthyroidism (Diagnosis)

of catecholamine excess, and adrenergic blockade can improve these symptoms. Previous Next: Etiology Hyperthyroidism (thyroid causes of thyrotoxicosis) in childhood include the following: Graves disease Toxic adenoma, toxic nodular goiter McCune-Albright syndrome Subacute (viral) thyroiditis Chronic lymphocytic thyroiditis (ie, hashitoxicosis in its early stage) Bacterial thyroiditis Pituitary causes of thyrotoxicosis in childhood include pituitary adenoma and pituitary resistance to T4. Other causes (...) disease, either during the pregnancy or at some time in the past. Neonatal Graves disease is caused by the transplacental passage of TSI. The mother may have clinical hyperthyroidism, may be on antithyroid medication, or may have a history of radioablation or thyroid surgery. Rarely, the mother has a history of chronic lymphocytic (Hashimoto) thyroiditis. Maternal elevation of TSI titers is a consistent finding in these cases. Neonatal Graves disease is rare even among mothers with known

2014 eMedicine Pediatrics

150. Hyperthyroidism (Follow-up)

: Symptomatic Treatment Self-limited causes of hyperthyroidism, such as subacute thyroiditis, iodine-induced hyperthyroidism, and exogenous administration of T 4 , can be treated symptomatically. For more significant cardiovascular symptoms, beta-adrenergic blockade with propranolol can be helpful. Initial response to antithyroid medications depends on the level of preformed thyroid hormone. Because antithyroid medications do not block the release of preformed hormone, patients may need 3-12 weeks (...) ' disease: an effective definitive treatment. Pediatr Surg Int . 2012 Jun. 28(6):609-14. . Chen Y, Masiakos PT, Gaz RD, et al. Pediatric thyroidectomy in a high volume thyroid surgery center: Risk factors for postoperative hypocalcemia. Journal of Pediatric Surgery . 2015-08-01. Volume 50, Issue 8:1316-1319. . Klatka M, Grywalska E, Partyka M, Charytanowicz M, Rolinski J. Impact of methimazole treatment on magnesium concentration and lymphocytes activation in adolescents with graves' disease. Biol Trace

2014 eMedicine Pediatrics

151. Human Immunodeficiency Virus Infection (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 Pediatrics

152. Thymoma (Diagnosis)

. [ ] Normal thymic epithelium tissue arises from the third branchial cleft and the third and fourth branchial pouches. Dendritic cells and macrophages found in large quantities at the corticomedullary junction arise from mesodermal tissues (bone marrow). The epithelial cells and these other stromal tissues of the thymus influence the selection and maturation of the T lymphocytes. Dysregulation of this system in thymoma is believed to be a cause of accompanying paraneoplastic syndromes. In the normal (...) thymus, bone marrow–derived precursor cells destined to become thymocytes (or T lymphocytes) enter the thymus at the corticomedullary junction and differentiate as they pass through the thymus. These cells can be characterized in their developmental progression by changes in expression of 3 cell surface markers: CD4, CD8, and the T-cell receptor (TCR)–CD3 complex. Initially, the cells undergo positive selection; thus, those cells that fail to receive a signal (ie, do not recognize self) die

2014 eMedicine Pediatrics

153. Human Immunodeficiency Virus Infection (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 Pediatrics

154. Hyperthyroidism (Treatment)

: Symptomatic Treatment Self-limited causes of hyperthyroidism, such as subacute thyroiditis, iodine-induced hyperthyroidism, and exogenous administration of T 4 , can be treated symptomatically. For more significant cardiovascular symptoms, beta-adrenergic blockade with propranolol can be helpful. Initial response to antithyroid medications depends on the level of preformed thyroid hormone. Because antithyroid medications do not block the release of preformed hormone, patients may need 3-12 weeks (...) ' disease: an effective definitive treatment. Pediatr Surg Int . 2012 Jun. 28(6):609-14. . Chen Y, Masiakos PT, Gaz RD, et al. Pediatric thyroidectomy in a high volume thyroid surgery center: Risk factors for postoperative hypocalcemia. Journal of Pediatric Surgery . 2015-08-01. Volume 50, Issue 8:1316-1319. . Klatka M, Grywalska E, Partyka M, Charytanowicz M, Rolinski J. Impact of methimazole treatment on magnesium concentration and lymphocytes activation in adolescents with graves' disease. Biol Trace

2014 eMedicine Pediatrics

155. Hyperthyroidism (Overview)

of catecholamine excess, and adrenergic blockade can improve these symptoms. Previous Next: Etiology Hyperthyroidism (thyroid causes of thyrotoxicosis) in childhood include the following: Graves disease Toxic adenoma, toxic nodular goiter McCune-Albright syndrome Subacute (viral) thyroiditis Chronic lymphocytic thyroiditis (ie, hashitoxicosis in its early stage) Bacterial thyroiditis Pituitary causes of thyrotoxicosis in childhood include pituitary adenoma and pituitary resistance to T4. Other causes (...) disease, either during the pregnancy or at some time in the past. Neonatal Graves disease is caused by the transplacental passage of TSI. The mother may have clinical hyperthyroidism, may be on antithyroid medication, or may have a history of radioablation or thyroid surgery. Rarely, the mother has a history of chronic lymphocytic (Hashimoto) thyroiditis. Maternal elevation of TSI titers is a consistent finding in these cases. Neonatal Graves disease is rare even among mothers with known

2014 eMedicine Pediatrics

156. Hepatitis, Viral (Diagnosis)

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

157. Hepatitis (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 Emergency Medicine

158. 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 Emergency Medicine

159. Nonneoplastic Epithelial Disorders of the Vulva (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

160. Paraneoplastic Syndromes (Diagnosis)

, 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

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