By C. Flint. University of Pittsburgh at Bradford.
Food affects drug absorption by enhancing gastric blood fow in conjunc- tion with delayed gastric emptying or by altering dissolution generic 100mg cordarone with visa. Food can increase discount cordarone 100 mg free shipping, decrease generic 200mg cordarone overnight delivery, or have no effect on the absolute systemic availability of a medication discount 100 mg cordarone visa. In most cases, altering the rate of absorption of a drug alone without affecting the total amount absorbed should not affect its effcacy. Blood fow can be slightly reduced by a liquid glucose meal and doubled by a high-protein liquid meal. Continued meal intake, especially with high-fat-content foods, will also slow the rate of gastric emptying, which may subsequently cause a delay in drug absorption from the gastrointestinal tract. Changes in gastric emptying are related not only to the physicochemical properties of the drug but also to the type of meal itself. Hot meals, highly viscous solutions, or those rich in fat have the most signifcant effect in decreasing gut motility. Alternatively, food may reduce the presystemic clearance of some lipophilic basic drugs through transient, complex effects on splanchnic–hepatic blood fow. This misconception was based on the premise that drug absorption was a passive process and the role of the intestine in drug elimination was minimal. It is known that diets high in carbohydrates may induce the expression of several lipo- genic and glycolytic hepatic enzymes. High-extraction drugs can then rapidly pass through the liver, allowing higher drug concentrations in the systemic circulation. Nutrient–Drug Interactions 135 Specifc dietary proteins can also affect medication response. Tyramine is an indirect sympathomimetic amine that releases norepinephrine from the adrenergic neurons, resulting in a signifcant pressor response. Normally, tyramine is metabolized by the enzyme monoamine oxidase before any signifcant increases in blood pressure occur. If the enzyme is blocked, however, severe and potentially fatal increases in blood pressure can occur when tyramine-rich foods are ingested. Patients should avoid ingesting large amounts of tyramine while being treated with these medications. The binding of dietary proteins to a drug may underscore changes in bioavailability after a protein meal. For example, ciprofoxacin when taken with milk or other dairy prod- ucts not only undergoes complexation with calcium but also adsorbs to the surface of proteins, which further decreases the absorbable amount of ciprofoxacin and may increase the chance of treatment failure or resistance. DietaRy fat Lipids are an essential part of cell membrane structure and are involved in many of the normal enzymatic activities located within the cell membrane. This contributes to a reduction in the extent of frst-pass metabolism due to enhanced splanchnic blood fow. Fat delays gastric emptying to a greater degree than does protein or carbohydrate. On the other hand, lipophilic medications having good bioavailability are less likely to 136 Nutrition–Infection Interactions and Impacts on Human Health be affected by a high-fat meal. Foods fortifed with multivalent minerals, such as calcium, are presenting a new challenge. For example, any medication carrying a warning to avoid milk, dairy products, or nutritional supplements can be affected by calcium-fortifed orange juice. Patients need to be counseled that consuming fortifed foods may decrease the clinical eff- cacy, thereby increasing the risk of treatment failure. Both serve as sources of trace minerals that are contained in metalloenzymes, including several antioxidants. Many plants contain favonoids, isothiocyanates, and allyl sulfdes that are potent modulators of the cytochrome monooxygenase system. Typically, induction of these enzyme systems is rapid and plateaus within 5 days of continued daily inges- tions of the food with the enzyme-inducing capacity. The plasma half-lives of most of the drugs studied were not affected, suggesting that the systemic clearance or hepatic metabolism of these drugs was unchanged by grapefruit juice, as this interaction occurs in the enterocytes and not in the hepatocytes. This sug- gests that simply separating the administration time between grapefruit juice and the potential interacting drugs cannot prevent this interaction. Medications with greater polarity are eliminated mainly by excretion and are more dependent on uptake transporters rather than passive diffusion. Rather than empirically reducing the dose of the affected drugs to avoid toxicity, it is more advisable to suggest that patients avoid grapefruit juice if they are taking an interacting drug since the magnitude of interaction is inconsistent among individuals and diffcult to predict. For example, patients receiving aminoglycosides, amphoteri- cin B, cisplatin, or radiocontrast media in conjunction with a low sodium diet have an increased risk for hemodynamic nephrotoxic and ischemic acute renal failure. They are typi- cally classifed as alcoholic, caffeinated, fruit/vegetable juices milk-based, or min- eral waters. Dairy products decrease the absorption of tetracyclines and reduce their bioavailability due to the formation of insoluble chelates between the drug and the calcium present in the beverage. Soft drinks, such as colas, may decrease drug absorption for a variety of reasons. The phosphoric acid and sugar present in these drinks can slow gastric emptying, and the tendency to serve them chilled may also reduce the rate of blood fow within the intestines. Bacterial overgrowth can result in a progressive decline in intestinal function due to impaired motility and depressed enzyme activity. Both may alter the rate and extent of absorption of specifc nutrients as well as various drugs. Decreases in nutri- ent absorption include fat, iron, peptides, and vitamins A and B12, as well as drugs such as chloramphenicol, chloroquine, tetracycline, and rifampin. The direct systemic effect of a medication on one nutrient may have secondary effects on another nutrient. For example, isoniazid and cimetidine inhibit the hydrox- ylation of vitamin D in the liver and kidney, whereas barbiturates promote the break- down of vitamin D metabolites, each resulting in a functional defciency of vitamin D and secondary to impaired calcium absorption. They may inhibit the essential intermediary metabolism of a nutrient, usually a vitamin, or promote the catabolism of the nutrient. Medications with these properties may be used thera- peutically, as in the case of coumarin anticoagulants. In other cases, this may be an unwanted side effect, as in the case of pyridoxine antagonism seen in isoniazid use. Isoniazid use can result in pyridoxine defciency by the inhibition of pyridoxal kinase. In the event of an isoniazid overdose, administration of pyridoxine can eliminate the resulting seizures and metabolic acidosis. In the case of chronic drug therapy with a corresponding marginal nutrient intake, signs of vitamin defciency can result. For example, patients treated with cephalosporin antibiotics may develop hemorrhagic states secondary to drug-induced vitamin K defciency. Renal wasting of potassium, resulting in hypokalemia, has been associated with amphotericin B and antipseudomonal penicillins. The impact of medications on phosphorus balance is important in patients receiving nutritional support as the synthesis of new cells increases the need for phosphorus. Patients already at risk for refeeding syndrome are particularly susceptible to the effects of drugs known to decrease available phosphorus stores. Conversely, patients with renal dys- function are at risk for development of hyperphosphatemia due to the inherent phosphate content present in the phospholipid emulsifers in intravenous fat emul- sion or clindamycin phosphate injection. Hypoglycemia is the most common metabolic abnormality associated with pen- tamidine therapy. Drugs used chronically may be more problematic as they may predispose the patient to atherosclerosis. The resulting hyperlipidemia contributes to central fat deposition and insu- lin resistance. Others, however, can be signifcant and result in severe gastrointestinal illness (e. Drug-induced esophagitis can occur with such antibiotics as doxycycline and tetra- cycline. Administering the problematic drug with plenty of water or switching to the liquid formulation of the medication often helps alleviate the situation. Often these signs and symptoms of nutrient defciencies are nonspecifc and may mimic those of other diseases and conditions. A secondary response may also occur when an adverse response to food caused by the drug results in a loss of appetite.
Dawn generic cordarone 100mg line, “Obesity and the skin: Skin physiology and skin manifestations of obesity order cordarone 200 mg with visa,” Journal of the American Academy of Dermatology 56 (2007): 917–920 generic 200 mg cordarone amex. Rosella trusted cordarone 200 mg, “Obesity and respiratory hospitaliza- tions during infuenza seasons in Ontario, Canada: A cohort study,” Clinical Infectious Disease 53 (2011): 413–421. Beck, “The impact of obesity on the immune response to infec- tion,” Procedures of the Nutrition Society 71 (2012): 298–306. Alpert, “Promising new causal explanations for obesity and obesity-related diseases,” Biological Research for Nursing 8 (2007): 223–233. Kochan, “The role of iron in bacterial infections, with special consideration of host- tubercle bacillus interaction,” Current Topics in Microbiology and Immunology 60 (1973): 1–30. Role of Oxidative Stress 5 and Infammation in Nutrition–Infection Interactions and the Potential Therapeutic Strategy Using Antioxidants and Modulating Infammation Elena Puertollano and Maria A. It recognizes and destroys foreign agents through two primary defense mechanisms: innate immunity and acquired immunity. On the other hand, the acquired immune system (specifc immune response) is acquired later in life (immunization or exposition to pathogens) and includes special cells called B lymphocytes and T lymphocytes that are capable of secreting a large variety of specialized chemicals (antibodies and cytokines) to regulate the immune response (Figure 5. The innate arm of immunity prevents the entry of foreign microorganisms into the body, playing a crucial role in the early control of infectious agents, as well as in the initiation and subsequent course of the acquired immunity. Therefore, innate response constitutes the frst line (early phase) of defense against pathogens. It is obvi- ous that innate immunity represents an important mechanism that rapidly destroys and eliminates microorganisms. In fact, innate immunity is the most effcient mech- anism to eliminate intracellular growth microorganisms. Innate resistance does not distinguish among microorganisms and does not change in intensity upon reexpo- sure. On the other hand, acquired immunity requires the identifcation of molecules from an invading agent. The recognition of antigens is carried out by B lymphocytes and T lymphocytes, which constitute the main arm of acquired immunity and pro- duce antibodies (B cells) or recognize the antigens on the surface of cells (B or T cells). Hence, infection with intracellular pathogens will induce the differentiation along the Th1 pathway, whereas infection with extracellular pathogens will promote the differentiation along the Th2 pathway. Once the body has identifed the antigen, the immune system response to a second exposition is faster and more effective the next time that antigen is recognized. Thus, the infectious agent is eliminated and immunological memory remains (Figure 5. However, many of the protective functions of immune cells depend on cell mem- brane fuidity. It is clear that lipid peroxidation decreases membrane fuidity, which adversely affects immune responses. Therefore, the relevance of antioxidants is par- ticularly critical for the functionality of the immune system. Nutritional status is an important factor contributing to immunocompetence, and the profound interactions among nutrition, infection, and immune system have been widely recognized (Scrimshaw and SanGiovanni, 1997; Klasing and Leshchinsky, 2000). Nowadays, it is clearly established that nutritional defciency is related to an inadequate function of immune response, especially cell-mediated immunity, phago- cyte activity, cytokine production, or antibody synthesis. In addition to protein– energy malnutrition, defciencies of trace elements, vitamins, and essential fatty acids are responsible for an impairment of immunity (Chandra, 1999). It is obvious that an inadequate immune functionality increases the risk and incidence of infections, leading to augmentation in morbidity and mortality rates. Moreover, infections exac- erbate micronutrient defciencies by reducing nutrient intake, increasing losses, and interfering with utilization by altering the activity of metabolic pathways (reviewed in Wintergerst et al. In the past years, numerous investigations have focused on the role of nutrition and particularly on the contribution of dietary antioxidants to an optimum and adequate functioning of the immune system. Cells that constitute the immune system depend on cell–cell communication, through membrane-bound receptors, to carry out an adequate transmission of signals. Cell membranes are rich in phospholipids, which, if peroxidized, can lead to a loss of membrane integrity or to an alteration of membrane fuidity (Baker and Meydani, 1994), and as a result both cell functions and intracellular signaling are intensely impaired. It has been demonstrated that exposure to potential prooxidants can involve a reduction in cell membrane recep- tor expression in those cells that are not suitably protected by antioxidants (Gruner et al. For these reasons, it is obvious that adequate amounts of neutralizing antiox- idants not only are required to protect cells against oxidative stress but also to prevent damage of the immune cells, reducing morbidity and mortality. By contrast, insuf- fcient intake and status of dietary antioxidants may lead to a profound suppression of immune functions, which increases the risk of sepsis and predisposition to infections. As oxidant agents, free radicals are composed of atoms or molecules highly reactive due to the unpaired electrons in the outer orbital. Nevertheless, all the major classes of biomolecules are vulnerable to free radical damage. In addition, the continuous generation may also cause oxidative damage to lipids or proteins, and consequently their accumulation may lead to the oxidative destruction of cells. Thereby, long-chain lipids (especially polyunsaturated fatty acids, which contain double bonds) are more susceptible to free radical attack leading to lipid oxidative destruction of fatty acids called lipid peroxidation, a key consequence of oxidative stress (De Pablo and Alvarez de Cienfuegos, 2000). The physiological protection systems to neutralize free radicals are consti- tuted by (i) endogenous antioxidants, which may be both nonenzymatic and enzy- matic and by (ii) exogenous antioxidants (Table 5. Oxygen radicals are identifed as mediators of various chronic disorders such as diabetes, cancer, rheumatoid arthritis, brain dysfunctions, and immune altera- tions. In: Bioactive Food as Dietary Interventions for Arthritis and Related Infammatory Diseases, Watson, R. Obviously, the oxidant/ antioxidant balance is a crucial determinant that contributes to improve immune Cytokines, bacterial or viral infections, stress Stimulus (e. The most important source of antioxidants that protect cells from oxidative stress is provided by nutrition. Thus, increased oxidative stress induced by a dietary defciency in antioxidant nutrients would be expected to affect the host immune response against infection by infectious microorganisms. The presence of inadequate antioxidant defenses is responsible for the existence of oxidative stress in the cells. This is due to changes in the presence of antioxidant enzymes such as superoxide dismutase and catalase, or a reduction in vitamins C and E, and reduced glutathione. To avoid the immunosuppressive action that oxidative stress exerts, immune cells have a high content of antioxidants such as vitamins, which exert a protec- tive role against oxidation of molecules present in the cells as polyunsaturated fatty acids (Bendich and Machlin, 1988). Thus, nutrients that affect the antioxidant sta- tus have important effects on immune function. The intake of vitamins and trace 88 Nutrition–Infection Interactions and Impacts on Human Health elements with antioxidant activity are essential for proper immune system activity (Wintergerst et al. Se supplementation is involved in enhancing Th1-type immune responses to a greater extent than Th2-type responses. Defciency promotes loss of immunocompetence (both cell-mediated immunity and B-cell function may be impaired) Copper Adequate intake supports a Th1 response. Defciency reduces antibody production, phagocytic activity, T-cell proliferation, and B-cell numbers Zinc Cytosolic defense against oxidative stress. Vitamins C and E at high doses both exert a protective role by reducing the adverse effects of oxidative stress in sepsis. Vitamin C plays an important function particularly against oxidative stress in leukocytes. This vitamin is essential for the maintenance of adequate immune response to infection, especially in infammatory cells. Finally, β-carotene is a potent quencher of singlet oxygen and acts as an antioxidant in biologically relevant systems, and it also affects several aspects of human immune system functions. Vitamin C Vitamin C or ascorbic acid is defned as the major water-soluble cytosolic chain-breaking antioxidant that plays an important role in the host defense against oxidative damage, especially in leukocytes. In addition, vitamin C provides important antioxidant protec- tion to plasma lipids and lipid membranes and can neutralize phagocyte-derived oxidants released extracellularly, preventing oxidant-mediated tissue damage especially in sites of infection (Frei et al. Indeed, a number of investi- gations have reported that vitamin C levels are decreased in plasma and leukocytes in patients with common cold or pneumonia, but moderate intake of ascorbic acid had no apparent effect on the duration or severity of the common cold, although it decreases the frequency of common cold (Sasazuki et al. A number of results from studies in vitro and in vivo (in humans and other species) underline the functional signifcance of vitamin C in infection resistance. In vitro and in vivo studies demonstrate that low levels of ascorbic acid increases the sus- ceptibility to candidiasis (Anderson and Theron, 1979; Rogers et al. A recent study has determined that the administration of both vitamins C and E together with antimicrobial therapy promotes and effective eradication of Helicobacter pylori (Sezikli et al. Vitamin E is involved in an increased resistance against infectious microorganisms, indicating that higher vitamin E intake induces a Th1 cytokine– mediated response and suppresses the Th2 response, offering protection against the 90 Nutrition–Infection Interactions and Impacts on Human Health Nutrition–Infection Interactions and Potential Therapeutic Strategy 91 92 Nutrition–Infection Interactions and Impacts on Human Health intracellular growth of microorganisms such as viruses and bacteria (Meydani et al.
On occasion purchase 100 mg cordarone amex, the lef subclavian artery is never heal discount cordarone 200 mg without prescription, we think it important to construct them with a displaced cephalad and to the lef cordarone 200 mg online, making access from heavier suture and generally use 3-0 or 2-0 polypropylene order cordarone 200mg mastercard. Among potential risk factors for mammary arteries facilitates subsequent reconstruction. The extent of aortic replace- technique in 163 consecutive patients (96 male, 67 female) ment varied, and many patients had concomitant proce- who underwent aortic arch resection between September dures. An feed ﬂexible balloon-tipped catheters into the arch vessels elephant trunk was placed in 156 (95. The duration of cardiopulmonary bypass event, our philosophy has been to avoid all manipulation was 236. This technique avoids manipulation of the ofen- Adverse outcome was seen in 11 patients (6. There diseased vessel ostia, which may prevent embolic stroke, were seven hospital deaths (4. However, the cephalad portions of the bra- The most frequent complication was respiratory; pro- chiocephalic vessels can reproducibly be atached to the longed intubation (> 48 hours) was necessary in 22 (13. Transient neurological dysfunction was noted in 31 minutes in the current series) which most surgeons 9 patients (5. Return to the operating room for control would consider well within safe limits at deeply hypo- of post-operative hemorrhage was required in 5 patients thermic temperatures. While gentle occlusion of the lef com- Rationale and additional considerations mon carotid artery is required, ﬂow to the vessel is ret- rograde, which may help avoid embolization. Accordingly, most recent large clinical series using sionally are required to replace the aortic arch . The present series illustrates that use of over techniques  that retain a (Carrel) patch of native a trifurcated grafto the brachiocephalic vessels is a simple, aorta containing the origins of the cerebral vessels in that reliable, and safe method for aortic arch replacement. J Thorac Cardiovasc Surg 1975; with dilatation of the arch and descending aorta, leaving 70: 1051−1053. The graf is placed through tory arrest in operations on the thoracic aorta: determinants the arch into the proximal descending aorta; the aorta is of operative mortality and neurologic outcome. J Thorac closed proximally incorporating the graf, and the bra- Cardiovasc Surg 1994; 107: 788−797. Surgical treatment of tic arch remains pressurized until the descending aortic aneurysm or dissection involving the ascending aorta resection or stent-graf insertion takes place. Retrograde cerebral perfusion studies support the use of low temperatures for prolonged does not protect the brain in non-human primates. Retrograde report mean perfusion pressures of about 50 mmHg, with cerebral perfusion provides limited distribution of blood to ﬂow rates of approximately 10 ml/kg/min. J Thorac Cardiovasc Surg 1997; 114: perfusion pressures might be advantageous in these ofen 660−665. Outcome after ascending the risk of increased delivery of emboli, remains unclear. J Thorac Cardiovasc Surg 2001; 121: higher hematocrits than those used currently would be 1107−1121. Arch-first technique Conclusion performed under hypothermic circulatory arrest with retro- grade cerebral perfusion improves neurological outcomes At present, the optimal cerebral protection strategy for for total arch replacement. Eur J Cardiothorac Surg 2005; 27: total arch replacement would seem to be one relying on 821−825. Retrograde cerebral cerebral blood flow dynamics during retrograde cerebral perfusion versus selective cerebral perfusion as evaluated perfusion using power M-mode transcranial Doppler. Ann by cerebral oxygen saturation during aortic arch reconstruc- Thorac Surg 2003; 76: 704−709. Total arch hypothermic cardiopulmonary bypass on cerebral hemo- replacement using aortic arch branched grafts with the aid dynamics and metabolism. Antegrade cerebral per- antegrade selective cerebral perfusion during aortic arch fusion with cold blood: a 13-year experience. Ann Thorac perfusion via innominate artery in aortic arch replacement Surg 1997; 63: 1533−1545. Contemporary rience with the arch-first technique and bilateral anterior results of total aortic arch replacement. Technical advances with a branched graft and limited circulatory arrest of the in total aortic arch replacement. J Thorac thermic asanguinous cerebral perfusion (cerebroplegia) Cardiovasc Surg 2004; 128: 378−385. The ring is 25 mm long, Introduction which facilitates its handling and positioning in the aortic lumen. We use rings with a diameter ranging from 22 introduced into the lumen of the artery. The preparation of the ring is done during the  and Ablasa  published the ﬁrst experiences with the surgical procedure. Afer opening the diseased aorta, we use of intraluminal prostheses for the treatment of acute measure the caliber of the vessel and from this choose a dissections of the aorta. The vascular intraluminal prosthesis presented complications such as prosthesis is then passed through the oriﬁce of the lumen thrombosis, embolism, stenosis, the formation of pseudo- (Figure 22. These cover its groove, thereby transforming a common vascu- complications caused various surgical groups to lose their lar prosthesis into an intraluminal one (Figure 22. When confronted with such poor results, our can be used with a distal or proximal ring, with a double group developed an intraluminal ring model for the treat- ring, or with an elephant trunk extension (Figure 22. Afer con- ducting a series of experimental studies, we concluded that the intraluminal prosthesis mounted with an intraluminal ring  was eﬃcient and safe, without observing any of the previously described complications. Nearly 20 years ago, we began to use the intraluminal ring for the treatment of acute ascending dissections of the aorta, and obtained favo- (b) rable results with a marked reduction in mortality. Based on our encouraging early experience using the intraluminal ring, we gained enough conﬁdence to begin using this tech- nique in all segments of the aorta, especially in cases where conventional anastomosis was diﬃcult and presented a serious risk of bleeding. We have used intraluminal ring grafs to repair the ascending aorta and/or aortic arch in approximately 500 patients with respectable results. Repeating prosthesis into an intraluminal prosthesis of any length the process at the opposite end of the graft creates a double-ring prosthesis. The ring anastomosis of the intraluminal prosthesis can be placed proximal or distal to the left subclavian artery, rechanneling the aortic flow and occluding the entrance of the false lumen. Choosing the best access is onto the body of the ring and then tied to its groove (note that the diameter diﬃcult because diseases of this segment ofen extend to of the ring should be 4 mm smaller than the prosthesis). Although perfusion and cerebral protection techniques have developed, these extensive repairs of the aorta involve multiple sutures that are diﬃcult to Overall experience access, leading to bleeding, prolonged time of cerebral ischemia, and serious complications. In our experience, the intraluminal ring has been used [6,7] described the use of the intraluminal ring graf for in all segments of the aorta and in many clinical setings, treatment of diseases of the ascending aorta and the aor- including dissection and aneurysm rupture [5,6]. In 785 patients, we employed the that the technique transforms very complicated aortic intraluminal ring as the anastomotic technique. We used a reconstructions into simpler and faster procedures with total of 1098 rings. For example, we have used the intraluminal ring, 201 of them had acute ascending the intraluminal ring in high-risk patients with compli- aortic dissection (25. The stand- Aortic arch surgery ardization of the surgical technique for aortic arch repair with the placement of the intraluminal ring via sterno- The surgical approach to the aortic arch continues to be tomy (Figure 22. A bifurcated graft was used to restore circulation to the innominate and left common carotid arteries, and the intraluminal ring with an elephant trunk was secured to the aortic wall proximal to the left carotid artery. The aortic root was replaced using the Cabrol technique for coronary reattachment. Prior to the sternotomy, we introduce an arterial cannula into the right axillary and right femoral arter- ies (Figure 22. When the ascending aorta and arch are main trunk of the bifurcated prosthesis, and the cerebral enlarged or ruptured, we also insert a venous cannula in ﬂow is then maintained on the right and lef by means of the femoral vein to ensure a drainage pathway. Afer the axillary perfusion with a ﬂow from 10 to 15 ml/kg/min; sternotomy and exposure of the heart, we insert a venous this ﬂow rate is chosen to prevent hyperperfusion and cannula into the right atrium, leaving a double arterial post-operative cerebral edema. At this point, we clamp the infusion pathway and a double venous drainage path- femoral pathway, maintaining perfusion only by means way. When the patient has reached this tem- under control, we proceed to open the ascending aorta by perature, we begin treating the aorta.
On examination buy 200 mg cordarone, you find the lesion to be (E) Prescription of a food-elimination diet well demarcated both at the base and at the circum- ference of its shallowly raised (i generic 100mg cordarone with mastercard. In ivy discount cordarone 100mg free shipping, 2 days after he worked in his garden with short addition discount cordarone 200mg, you find three other similar lesions that are sleeves, for the first time in several years. The dorsal located on the back of the torso that range from 5 mm aspects of his forearms manifest weeping areas involv- to 1. Which of midportions where there had been blebs that rup- the following is the most likely diagnosis? He hyperpigmented spotty areas on her lower legs, espe- admits to morning stiffness. The reminds you that, last month, you treated her suc- remainder of the integument is within normal limits. She is concerned from (A) Rheumatoid arthritis the cosmetic point of view and worries as to the (B) Psoriatic arthritis cause. The patient has taken neither 15 Your patient, a 45-year-old white woman, complains prescription nor over-the-counter medications. Since to you of having irregular menses, being overweight, onset, the course has been steady, without waxing or and having hair on her upper lip. The lesions are papulosquamous addition to the foregoing, you notice a pigmented and ovoid with their long axes oriented more or less velvety thickening of the skin in 3- to 4-cm patches horizontally, tilting downward and laterally. The patient says he has not changed (B) Seborrheic keratoses soaps and wears cotton T-shirts that are tucked out- (C) Nummular eczema side of his underwear that is made of a synthetic fiber. Which of 16 Regarding the patient in Question 12, to which of the following is the most likely diagnosis? Examination reveals (B) Dermatomyositis 1- to 3-mm vesicles on the right cheek against the (C) Polymyositis erythematous background. Which of the following (D) Charcot–Marie–Tooth disease is the most likely diagnosis? The incorrect statement regarding The mononucleosis test is not reliable until the illness has scarlatina is that the rash spreads to the palms. The sandpaper rash has sometimes nearly always manifests tender adenopathy if the nodes been called pampiniform. Rubeola causes indeed a morbilliform erup- as a form of beta-hemolytic streptococcal pharyngitis, it tion, but the exudative pharynx is not part of the picture. That said, the disease is much less frequent which may account for the occasional pruritic aspect of and more benign than it was two generations ago. For a baby on a common formula self-limited, systemic symptoms occur in the majority of (e. Successful treatments include polymyxin B the feeding schedule beyond liquid formula, common spray and oral cipromycin. Although topical glucocorticoids may the latter (hypoglycorrhachia) signaling meningitis in this be employed for infantile eczema, preparations such as disease, caused by Rickettsia ricketsii, carried by the dog triamcinolone are too potent and carry a high rate of tick in the east and the wood tick in the west. The pete- complications of atrophy and scarring striae at the areas chial rash begins on the legs before spreading to the hands. Antibiotics, Immunofluorescence titers do not rise until the 2nd week either systemic or topical, have no place in a noninfec- of symptoms. Treatment in children under 9 years is tious inflammatory process such as infantile eczema. The patient has what is variously called neuro eczema, nummular eczema, and neuroderma- 4. There is a predisposition for atopic diseases in these occurs on the face, and the mean age at onset is between patients. In the accessible areas referred to in the lips usually occurs during the juvenile years, and the the vignette, scratching and rubbing causes a thickening, lesions in this case are farther from the mouth than the called, by dermatologists, lichenification. Candidiasis affects the intertriginous lichenification causes the threshold for pruritus to be fur- areas, opposite from the rash in this case, which involves ther lowered and leads to further rubbing and the vicious the tops of the folds of skin. This cycle is effectively infection that occurs in a focal area, not in separate dis- interrupted in the vast majority of cases by topical gluco- tinct patches, and it would not manifest chronicity as the corticoids. Systemic glucosteroids are not effective, and patient’s illness would bring the affair to an early crisis. Although some allergists may try infantile eczema but also the fact that this disorder is a food elimination in intractable cases, food allergy is rarely manifestation of the heavily familial-inherited group of a factor and usually the elimination diet is ineffective. Infectious mononucleosis is noted saline or Burrow solution, and the most moistening are for an associated morbilliform rash when the patient has occlusive agents such as petrolatum (Vaseline). Basal cell carcinoma displays a very slow pro- noninfectious inflammatory process as in contact derma- gression, often pearly appearance, and sometimes central titis, not as a part of a chronic connective tissue disease, ulceration. In any of the foregoing situations, a biopsy is glucocorticoids are a legitimate therapeutic modality. In this case, the presence of diabetes is relatively of dermal manifestations of psoriasis by varying amounts contraindicated because of predictable certain rocketing of time. As an inflammatory arthritis (psoriasis is an auto- levels of blood sugar during their use. In the latter cases, immune disease), this arthritis exhibits morning stiffness topical glucocorticoids are not only more effective but are and gelling after periods of inactivity. What differentiates also fraught with complications involving skin atrophy psoriatic arthritis from rheumatoid arthritis is its asym- and local striae formation if the preparation is too potent metrical involvement of hands and feet and that it includes or used for too long a period. The pinpoint-type pitting of fingernails is a hallmark is chosen rather than a potent preparation such as a fluo- of psoriasis, occurring in 30% of patients. Dermatitis herpetiformis is a vesicu- is mentioned as a red herring, given the patient’s history of lating disease of the skin that makes its onset during the basketball activity and presumed history of numerous 3rd and 4th decades and then is generally lifelong. Traumatic arthritis is a form of osteoar- vesicles are approximately the size of those found in vari- thritis and thus is noninflammatory, manifesting no sig- cella and occur on the extensor surfaces of the body nificant stiffness. The vesicles are often not pres- in this age group without more classic presentations such ent on examination because of the excoriations (which as great toe metatarsophalangeal joint involvement. Pityriasis rosea occurs without a dis- vesicles that recur and lead to scratching. Diagnosis requires an index of suspicion suggesting standard of care dictates a serologic test for syphilis in all skin biopsy that shows immunoflourescently visible cases. An alternative, sulfapyridine, for unreachable areas such as the upper back; classically, it those with allergy or intolerance to the foregoing, or affects the antecubital and popliteal fossae among other colchicine, in usual dosages has been found to be effective. Food allergies follow a waxing–waning course, Neither psoriasis nor discoid lupus is pruritic. Intermittent intense sun exposure formis, does not produce vesicles and tends to affect the constitutes a greater skin cancer risk than daily less intense axillae and web spaces. Seborrheic keratosis is typically well years and daily but less intense exposure to the head, neck, demarcated, often pigmented and rough on the surface and forearms. It has been described by der- found to a much greater degree on the thighs and lower matologists as waxy and “stuck on” in appearance as if it legs than in the head, neck, and forearms, the latter areas could be peeled off. Squamous cell carcinoma nearly having received many more hours of sun exposure than always displays an inflammatory appearance and an irreg- the intermittently and more intensely exposed areas. Melanoma also is likely to be irreg- Preventive Services Task Force) is advisable but does not ular at the edges or early manifesting inflammatory foci confer secure protection against skin aging and cancer. Charcot–Marie–Tooth disease is a African, Southeast Asian, or other ethnic origin, manifest, demyelinating disease of the central nervous system as a result of the subacute phase of an inflammatory pro- involving the distal extremities, leading to the stork-leg cess, a muddy-looking hyperpigmentation locally. Contact dermatitis seldom occurs on the face mation that lasts much longer causes the opposite, that is, except in reaction to cosmetics and virtually always is a loss of pigmentation. The rash occurs simultane- being insulin resistant, hence prediabetic type 2 or clini- ously or within 2 to 3 days after the onset of the pain and cally diabetic. Acanthosis nigricans accompanies such last about 10 days through phases of subsequent crusting, conditions in a minority but significant proportion of dark colored eschar, and resolution, sometimes with scar cases. Seborrheic keratoses may be pig- of a complete dermatome or as this case, a cranial nerve, 2 mented, but they occur as “stuck on” 1-cm lesions on the that is, the ophthalmic branch of cranial n. Nummular eczema is pruritic and herpetiformis, contact dermatitis, and eczema are all pru- pigmented only in dark-skinned people. New York : McGraw-Hill/Appleton & Lange ; diseases have no particular association with pigment 2004 : 1062 – 1145. Louis/ of the 40s and 50s, acanthosis nigricans is associated also San Francisco:McGraw-Hill; 1971. Current Medical Diagnosis and Treat- sentation involves the purple discoloration of the eyelids ment.