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Infection-Associated Ocular Cranial Nerve Palsies
Published in Vivek Lal, A Clinical Approach to Neuro-Ophthalmic Disorders, 2023
Hardeep Singh Malhotra, Imran Rizvi, Neeraj Kumar, Kiran Preet Malhotra, Gaurav Kumar, Manoj K. Goyal, Manish Modi, Ravindra Kumar Garg, Vivek Lal
Infection is an important differential in patients presenting with ophthalmoparesis, painful, or otherwise. Frontal headache, peri-orbital, and orbital pain are common and may range from moderate to severe intensity. Diplopia is the most common presenting symptom in patients with ocular cranial neuropathy due to the asymmetrical involvement of ocular cranial nerves. Eyelid swelling, chemosis, conjunctival congestion, induration of skin, proptosis, periorbital, and orbital pain, further suggest an involvement of local orbital structures. Diplopia/ophthalmoparesis associated with oculo-sympathetic paralysis (Horner's syndrome) or involvement of trigeminal nerve suggests an involvement at the level of cavernous sinus. Angio-invasive causes involving the cavernous sinus (e.g., fungal infection) may in addition involve internal carotid artery and cause stroke in the respective territory. Additionally, it is important to ascertain the history of constitutional symptoms like fever, weight loss, etc. Table 16.1 highlights the important historical and clinical components that should be enquired to localize the syndrome anatomically. History of recent infection, diabetes mellitus, immunosuppressive therapy, organ transplant, HIV-infection, tuberculosis, recent dental surgery, facial or head trauma, intracranial surgery, etc. should raise the suspicion of ophthalmoparesis possibly arising as a result of infection.
The Nutrition-Focused History and Physical Examination (NFPE) in Malnutrition
Published in Michael M. Rothkopf, Jennifer C. Johnson, Optimizing Metabolic Status for the Hospitalized Patient, 2023
Michael M. Rothkopf, Jennifer C. Johnson
Constitutional symptoms include weakness, fatigue and diminished exercise tolerance. Although these symptoms are not listed on a table of criteria for PCM, it is often what patients notice most. Documenting these symptoms is helpful because it can be used as a component in your follow-up visit. As you continue providing nutritional support, you should see the patient rally and strengthen. Ask them if they are feeling less weakness and fatigue (NHS Choices 2009).
Fig-wart diseases and gonorrhea
Published in Dinesh Kumar Jain, Homeopathy, 2022
Kent said,There are two kinds of gonorrhea, one that is essentially chronic, having no disposition to recovery … one that is acute, and has a tendency to recover after a few weeks or months … The acute may really and truly be called a gonorrhea because about all there is of it is this discharge … The suppression of acute gonorrhea cannot bring on the constitutional symptoms called sycosis. It can not be followed by fig-warts, nor constitutional states such as anemia. But while constitutional symptoms cannot follow the suppression of acute miasm, they will follow suppression of the chronic miasm and become very serious. Most of the cases of true sycosis that are brought before the physician at the present time are those that have been suppressed.(Kent, 1993, p. 144)
Clinical pearls and promising therapies in myositis
Published in Expert Review of Clinical Immunology, 2023
Caoilfhionn M. Connolly, Julie J. Paik
Patients with positive anti-MDA-5 disease can present with rapidly progressive ILD that can be refractory to typical first-line agents with associated high rates of morbidity and mortality. Anti-MDA5 disease is associated with characteristic skin changes of palmar papules, deep ulcerations with punched out borders, and areas of frank skin necrosis [59–61], although these characteristic lesions may be absent at presentation. Constitutional symptoms may also be prominent. Many patients will have hypo/amyopathic disease and thus clinicians should have high index of suspicion in patients with rapidly progressive ILD. Of note, there is clinical heterogeneity among patients with positive anti-MDA-5 disease, and ethnicity appears to impact clinical phenotype and prognosis with higher reports of ILD among Asian patients [62]; three distinct clinical phenotypes were recently found on unsupervised analysis [63]. Early diagnosis and appropriate treatment are imperative to optimize outcomes; indeed, the 6-month survival rate in some studies is 40% despite the use of high-intensity immunosuppressive regimens including high-dose glucocorticoids, CNI and CYC [64,65]. No guidance statements exist for optimal treatment; however, often a combination of immunosuppressive therapies is needed. A Japanese group have suggested an upfront ‘triple therapy’ combination regimen of high-dose glucocorticoids, tacrolimus, and intravenous cyclophosphamide, based on a multi-center prospective study, which achieved an overall 89% 6-month survival rate versus 33% in a historical step-up treatment group (n = 15) [66].
Extramedullary chronic lymphocytic leukemia disguised as urinary tract infection
Published in Baylor University Medical Center Proceedings, 2022
Muhammad Osama, Hafsa Faisal, Mohammad Ammad Ud Din, Amir Mahmoud, Syed Ather Hussain, Basil Verghese
Chronic lymphocytic leukemia (CLL) is the most common B-cell malignancy in North America, accounting for 40% of all leukemias in the elderly population.1 CLL usually has an indolent course of disease progression, and most patients are diagnosed incidentally on routine blood examination. Symptomatic presentations include constitutional symptoms like fever, night sweats, weight loss, infections, or anemia.2 Extranodal and nonlymphoid organ involvement is rare, with the central nervous system and skin as common sites.3 CLL invasion of the urogenital tract is a rare phenomenon that has been documented in only a few female patients.4 Here, we present a case of an elderly man with CLL who presented with painless hematuria and was found to have bladder involvement with CLL. We also review previously documented cases with diagnostic and treatment considerations.
Current and innovative therapeutic strategies for the treatment of giant cell arteritis
Published in Expert Opinion on Orphan Drugs, 2021
Alwin Sebastian, Alessandro Tomelleri, Bhaskar Dasgupta
Giant cell arteritis (GCA), also known as temporal arteritis, is a critically ischemic large vessel vasculitis usually diagnosed in adults over the age group of 50 years, mainly affecting the aorta and its cranial and extra-cranial branches [1]. In its acute presentation, GCA can be responsible for ischemic and irreversible events (i.e. sight loss, ischemic stroke), whereas its chronic evolution can lead to significant vascular damage (i.e. stenosis, occlusions, aneurysms) [2–4]. From the clinical point of view, GCA patients can experience a wide range of symptoms, that can be classified into four non-mutually exclusive groups: cranial, ischemic, constitutional, and polymyalgic. A new onset headache is the most typical cranial symptom, along with scalp tenderness and jaw claudication. Constitutional symptoms are mainly represented by fever, weight loss, and drenching night sweats. Finally, about 50% of GCA patients complain of bilateral shoulder and/or hip pain and stiffness, and expression of polymyalgia rheumatica [5]. The common ischemic symptoms are jaw and tongue claudication and visual manifestations such as diplopia, blurred vision, and amaurosis fugax. The most feared acute ischemic complication of GCA, permanent blindness, occurs in about 15% – 25% of the patients at disease onset and it is mainly related to anterior ischemic optic neuropathy or central retinal artery occlusion [6].