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Eloise J. Prijoles, M.D.

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The bcl-2 protein rate of hiv infection in jamaica purchase mebendazole 100 mg mastercard, expressed in follicular lymphoma antiviral immune response purchase mebendazole 100 mg on-line, is localized in the mitochondrial membrane and functions as an apoptosis inhibitor antiviral nucleoside analogues order 100 mg mebendazole. Choices A hiv gum infection 100mg mebendazole overnight delivery, D, and E (abl, myc, and retinoic acid receptor) represent translocations in other disorders. Follicular hyperplasia refers to enlarged lymph follicles (principally in the cortex of the lymph node), which consist of B lymphocytes. Reactive follicular hyperplasia of lymph nodes represents a response to infections, inflammation, or tumors. Hyperplasia of the secondary follicles, germinal centers, and plasmacytosis of the medullary cords indicate B-lymphocyte immunoreactivity. Hyperplasia of the deep cortex or paracortex (interfollicular of diffuse hyperplasia) is characteristic of T-lymphocyte immunoreactivity (choice D). The cellular debris of apoptotic tumor cells is cleared by macrophages, whose scattered appearance is termed "starry sky macrophage. Choices A, C, and E are not endemic in Africa, and choice D (reactive follicular hyperplasia) is a nonmalignant disorder. The disease ranges from asymptomatic involvement of a single site, such as bone or lymph nodes, to an aggressive systemic disorder that involves multiple organs. Proptosis may complicate infiltration 36 42 37 38 43 39 250 Chapter 20 of the orbit. The classic triad of diabetes insipidus, proptosis, and defects in membranous bones characterizes HandSchuller-Christian disease. Hodgkin lymphoma (choice A) often features eosinophils but does not have this clinical presentation. Diagnosis: Langerhans cell histiocytosis an indolent malignant lymphoma that mainly affects the elderly. Thrombocytopenia may be observed in the other choices but is usually associated with other systemic signs and symptoms. Diagnosis: Idiopathic thrombocytopenic purpura the answer is A: Antibody-mediated platelet destruction. In common with idiopathic thrombocytopenic purpura and certain drug-induced thrombocytopenias, systemic lupus erythematosus is associated with increased platelet destruction due to immune-mediated damage and removal of circulating platelets (antibody-mediated platelet destruction). Diagnosis: Idiopathic thrombocytopenic purpura, systemic lupus erythematosus the answer is C: Hemolytic anemia. Reticulocytes are nonnucleated cells that represent the last stage before mature erythrocytes. The nucleus is extruded from the orthochromatic erythroblast, leaving mitochondria and hemoglobinproducing polyribosomes in the reticulocyte. After release from the bone marrow, the reticulocyte loses its capacity for aerobic metabolism and hemoglobin synthesis, and after 1 to 2 days, it becomes a mature erythrocyte. Hemolytic anemias are characterized by a compensatory increase in production and release of red cells by the bone marrow, manifested in the blood by polychromasia of red cells and an increased reticulocyte count. Diagnosis: Hemolytic anemia, idiopathic thrombocytopenic purpura the answer is A: Autoantibodies directed against the erythrocyte membrane. The peripheral blood smear from this patient shows clumped red cells caused by cold agglutinins (autoantibodies). Cold agglutinins may be idiopathic or develop secondary to an underlying condition, most frequently infections (Epstein-Barr virus) or lymphoproliferative disorders. These aggressive, but potentially curable neoplasms include Burkitt lymphoma and diffuse large-cell B-cell lymphoma. As in follicular lymphoma, bcl2 gene rearrangements are often seen, suggesting a potential germinal center origin. Hairy cell leukemia is a clonal B-cell proliferation of small- to medium-sized lymphocytes that display abundant cytoplasm and hairlike protrusions of the cell membrane.

Listeria monocytogenes is the third most common cause of neonatal meningitis (2%) symptoms of hiv infection in window period order mebendazole 100mg with visa. Streptococcus pneumoniae is a gram-positive coccus that is found in chains hiv infection rates uk generic 100mg mebendazole fast delivery, but it is not a significant cause of meningitis in neonates hiv infection pics cheap mebendazole 100mg otc. However hiv infection to symptom timeline generic mebendazole 100 mg fast delivery, in children ages 6 months to 6 years, it is the leading cause of meningitis. This sudden event is followed by the onset of hepatomegaly, pain, ascites, and jaundice. The ultrasound result further supports the diagnosis by suggesting hepatic venous occlusion. However, cholecystitis is inflammation of the gallbladder, usually due to blockage of the cystic duct by a gallstone. Primary biliary cirrhosis is an intrahepatic autoimmune disease that leads to granulomatous destruction of bile ducts, ultimately causing cirrhosis due to biliary obstruction. Both can lead to liver failure, but primary biliary cirrhosis would not cause the flow obstruction seen in the hepatic veins in this patient. A conversion disorder mimics dysfunction in the voluntary motor or sensory system. Common presentations include pseudo seizures, vocal cord dysfunction, blindness, tunnel vision, deafness, and a variety of paresthesias and paralyses. On careful clinical examination and with the aid of laboratory investigations, these symptoms lack physiologic explanation. A clinical example is the presence of normal deep-tendon reflexes and normal sensation in a person with a "paralyzed" arm. Patients with conversion disorder involuntarily have loss of function, usually in response to an unconscious conflict, and seek secondary gain in the form of assumption of the sick role. Patients with malingering voluntarily have loss of function, usually consciously in response to known situations, and seek secondary gain in the form of tangible gain (monetary, housing, or avoidance of responsibilities). The fact that the patient has no medical history, normal reflexes, and normal results of physical examination, other than the left-arm weakness, indicates he is unlikely to have had a stroke. The events surrounding the situation make it more likely that he has conversion disorder. Tuberous sclerosis is a genetic condition (autosomal dominant) characterized by nodular proliferation of multinucleated atypical astrocytes. These form tubers, which are found throughout the cerebral cortex and periventricular areas. The classic triad, which is manifest in only the most severe of cases, consists of seizures, mental retardation, and facial angiofibromas (also known as adenoma sebaceum). Half of patients with tuberous sclerosis develop rhabdomyomas, primary tumors of cardiac muscle that, although benign, may compromise cardiac function, especially of the atrioventricular valves. Note that hypertrophic cardiomyopathy also causes ventricular outflow obstruction and is often responsible for sudden death in young athletes. These can create ball-valve obstructions and are most often located in the left ventricle, right atrium, or atrial septum. However, in conjunction with the history suggesting tuberous sclerosis, lipoma is a less likely diagnosis. Transposition of the great vessels is a situation in which the pulmonary trunk arises from the left ventricle and the aorta arises from the right ventricle. This arrangement is incompatible with life, and a compensatory anomaly such as a patent ductus arteriosus is necessary. This nerve innervates the medial rectus, the superior rectus, the inferior rectus, and the inferior oblique muscles of the eye. The pupil is dilated because of involvement of the parasympathetic fibers that run on the outside of the oculomotor nerve and can be compressed by structures such as tumors and aneurysms. If it is a pupilsparing third nerve palsy, then infarction of the nerve is commonly the cause. The optic nerve does not innervate any of the extraocular muscles and therefore cannot account for the findings above. The trochlear nerve innervates the superior oblique muscle, which depresses and intorts the eye. In trochlear nerve palsy, the affected eye is elevated and extorted, and the patient often tilts their head away from the affected eye to compensate.

Erythroblastosis fetalis does not ordinarily occur during the first pregnancy hiv infection may lead to proven 100 mg mebendazole, because the quantity of fetal blood necessary to sensitize the mother is introduced into her circulation only at the time of delivery examples of antiviral drugs buy discount mebendazole 100 mg online, too late to affect the fetus hiv infection and teenage pregnancy cheap 100mg mebendazole mastercard. However hiv infection 3 years generic 100 mg mebendazole overnight delivery, when the sensitized mother again bears an Rh-positive fetus, much smaller quantities of fetal D antigen can elicit an increase in IgG antibody titer. However, even after multiple pregnancies, only 5% of Rh-negative women are ever delivered of infants with erythroblastosis fetalis. The severity of erythroblastosis fetalis varies from a mild hemolysis to fatal anemia, and the pathological findings are determined by the extent of the hemolytic disease. Hydrops fetalis refers to the most serious form of erythroblastosis fetalis, and is characterized by severe edema secondary to congestive heart failure caused by severe anemia. Diagnosis: Erythroblastosis fetalis, hydrops fetalis the answer is D: Spontaneous resolution. Some birth injuries relate to poor obstetric manipulation, whereas many are unavoidable sequelae of routine delivery. Factors that predispose to birth injury include cephalopelvic disproportion, dystocia (difficult labor), prematurity, and breech presentation. Cephalohematoma is defined as a subperiosteal hemorrhage that is confined to a single cranial bone and becomes apparent within the first few hours after birth. Kernicterus, also termed bilirubin encephalopathy, is defined as a neurological condition associated with severe jaundice and characterized by bile staining of the brain, particularly of the basal ganglia, pontine nuclei, and dentate nuclei in the cerebellum. Kernicterus (German: kern, nucleus) is essentially confined to newborns with severe unconjugated hyperbilirubinemia, usually related to erythroblastosis fetalis. The bilirubin derived from the destruction of erythrocytes and the catabolism of the released heme is not easily conjugated by the immature liver, which is deficient in glucuronyl transferase. The development of kernicterus is directly related to the level of unconjugated bilirubin and is rare in term infants when serum bilirubin levels are below 20 mg/ dL. Premature infants are more vulnerable to hyperbilirubinemia and may develop kernicterus at levels as low as 12 mg/dL. Bilirubin is thought to injure the cells of the brain by interfering with mitochondrial function. Severe kernicterus leads initially to loss of the startle reflex and athetoid movements, which in 75% progresses to lethargy and death. Most surviving infants have severe choreoathetosis and mental retardation; a minority have varying degrees of intellectual and motor retardation. Exchange transfusions may keep the maximum serum bilirubin at an acceptable level. However, phototherapy, which converts the toxic unconjugated bilirubin into isomers that are nontoxic and excreted in the urine, has greatly reduced the need for exchange transfusions. The other choices are not complications of untreated hyperbilirubinemia in newborns. Diagnosis: Kernicterus, physiological jaundice the answer is B: Embryonic lethality. If a conceptus is exposed to harmful exogenous influences, the noxious agent exerts the same effect on all blastomeres and also causes death. Thus, either a conceptus dies or development proceeds uninterrupted, since the interchangeable blastomeres replace the loss. As a rule, exogenous toxins acting on preimplantationstage embryos do not produce errors of morphogenesis and do not cause malformations. The most common consequence of toxic exposure at the preimplantation stage is death of the embryo, which often passes unnoticed or is perceived as heavy, albeit delayed, menstrual bleeding. Approximately 30% of fertilized ova are aborted spontaneously, without the woman being aware that pregnancy had occurred. Placenta accreta (choice C) is an abnormal adherence of the placenta to the underlying uterine wall. The other choices are errors of morphogenesis that manifest at later stages of development. Physical examination reveals marked jugular distension, hepatomegaly, ascites, and pitting edema. Examination of the lungs at autopsy would most likely disclose which of the following pathologic changes Five months later, the patient presents with profound lethargy, pallor, muscle weakness, failure of lactation, and amenorrhea.

When these features are complicated by convulsions antiviral foods for warts purchase mebendazole 100mg otc, the term eclampsia is applied antiviral proteins secreted by t cells cheap 100 mg mebendazole. On histologic examination hiv infection symptoms time order 100 mg mebendazole mastercard, the glomeruli are uniformly enlarged and the endothelial cells are swollen antiviral influenza drugs cheap mebendazole 100mg line, an appearance that results in an apparently bloodless glomerular tuft. Tubular epithelial cells, with their high rate of energyconsuming metabolic activity and numerous organelles, are particularly sensitive to hypoxia and anoxia. Necrosis of individual tubular epithelial cells is evident both from focal denudation of the tubular basement membrane and from the individual necrotic epithelial cells present in some tubular lumina. Acute interstitial nephritis (choice A) and eosinophilic interstitial nephritis (choice C) feature interstitial inflammation, which is not seen in this case. Hypertensive nephrosclerosis (so-called benign nephrosclerosis) leads to obliteration of glomeruli and may lead to end-stage kidney disease. Hypertensive nephrosclerosis is identified in approximately 15% of patients with benign hypertension. On histologic examination, most glomeruli are hyalinized, and the tubules are either atrophic or replaced by fibrous tissue. Arterioles exhibit concentric hyaline thickening of the wall, often with the loss of smooth muscle cells or their displacement to the periphery. Because they absorb and concentrate the chemicals, tubular epithelial cells are preferred targets for certain toxins, including some antibiotics, radiographic contrast agents, heavy metals. The photomicrograph shows widespread necrosis of proximal tubular epithelial cells with sparing of distal and collecting tubules. Tubulointerstitial nephritis (choice E) may be a response to certain drugs but features interstitial inflammation. The term malignant hypertension refers to a severely elevated blood pressure that results in rapidly progressive vascular disease, affecting the brain, heart, and kidney. Malignant hypertension injures 195 44 endothelial cells and causes increased vascular permeability, which leads to the insudation of plasma proteins into the vessel wall and morphologic evidence of fibrinoid necrosis. Acute injury is rapidly followed by smooth muscle proliferation and a concentric increase in the number of layers of smooth muscle cells, yielding the so-called "onion skin" appearance. This form of smooth muscle cell hyperplasia may be a response to the release of growth factors derived from platelets and other inflammatory cells at the site of vascular injury. Renal artery stenosis causes cells of the juxtaglomerular apparatus to release renin, which induces aldosterone-mediated retention of sodium and water by the kidney (renovascular hypertension). In cases of unilateral renal artery stenosis, the level of renin in the renal vein of the ischemic kidney is elevated, whereas it is normal in the contralateral kidney. Renal artery stenosis is caused by atherosclerosis in adults, but in children it reflects fibromuscular dysplasia of the renal artery. Aldosterone (choice A), angiotensin (choice B), and plasminogen (choice D) are not synthesized in the kidney. The toxin injures endothelial cells, thereby setting in motion the sequence of events that produces thrombotic microangiopathy. Postinfectious glomerulonephritis (choice A) follows streptococcal infections and is not characterized by acute renal failure. Hemolytic uremic syndrome (choice C) is caused by exposure to Shiga toxin-producing strains of Escherichia coli and is not associated with angiopathy outside of the kidney. Nephrolithiasis and urolithiasis are stones within the collecting system of the kidney (nephrolithiasis) or elsewhere in the collecting system of the urinary tract (urolithiasis). The pelves and calyces of the kidney are common sites for the formation and accumulation of calculi. Calcium oxalate stones are the most common (80%) form of kidney stones in the United States, whereas calcium phosphate stones (choice B) are more common in England. Both are usually related to idiopathic calciuria and increased absorption of calcium in the intestine. Magnesium ammonium phosphate stones (choice D) are typically formed in urine made alkaline by urea-splitting bacteria. Uric acid stones, found in 25% of patients with gout, are smooth, yellow, hard, and radiolucent. Cystine stones (choice C) occur in children with hereditary cystinuria, an inborn error of amino acid metabolism marked by an excess of cystine in the urine.

With the expanding use of screening mammography hiv infection europe order mebendazole 100mg fast delivery, more than half of the breast cancers currently diagnosed in the United States manifest as stage I disease hiv infection rate vancouver discount mebendazole 100 mg overnight delivery, and almost all of these women will be cured by surgery antiviral and antibiotics mebendazole 100mg. The biopsy reveals intraductal carcinoma in situ hiv infection symptoms ppt purchase mebendazole 100mg on-line, which arises in the terminal duct lobular unit, greatly distorting the ducts by its growth. Intraductal carcinoma in situ has two main histologic types, namely comedocarcinoma and noncomedocarcinoma. The patterns are classified as micropapillary, cribriform (shown in the image), and solid. The tumor cells and nuclei are smaller and more regular than those of the comedo type. Noncomedo intraductal carcinoma in situ is less likely than the comedo type to incite a desmoplastic response in the surrounding tissue. Ductal carcinoma in situ, treated only by biopsy, carries a 20% to 30% risk of developing invasive carcinoma in the same breast over the ensuing 20 years. Choices A and B are incorrect because they suggest that the risk of invasive carcinoma is very small, whereas choices D and E are far too great. Overexpression can be determined by immunohistologic detection of the c-erbB2 protein 14 15 18 19 16 the Breast biopsy will develop invasive cancer within 20 years of diagnosis. However, about half of these invasive cancers will arise in the contralateral breast and may be either lobular or ductal cancers. Thus, lobular carcinoma in situ, more than ductal carcinoma in situ, serves as a marker for an enhanced risk of subsequent invasive cancer in both breasts. Untreated, the infection may progress to abscess formation, which is a complication that necessitates surgical intervention. Acute bacterial mastitis may be treated successfully by aggressive mechanical suction, with frequent emptying of the breasts, and by the administration of antibiotics. Invasive lobular carcinoma is the second most common form of invasive breast cancer. Because the amount of fibrosis is variable, the clinical presentation of invasive lobular carcinoma varies from a discrete firm mass, similar to ductal carcinoma, to a more subtle, diffuse, indurated area. Microscopically, classic invasive lobular carcinoma consists of single strands of malignant cells infiltrating between stromal fibers, which is a feature termed "Indian filing" (see photomicrograph). Despite the innocuous cytologic characteristics of this form of invasive carcinoma, it is biologically as aggressive as the invasive ductal type. Twenty-five percent of invasive carcinomas have features of both ductal and lobular carcinoma. Invasive ductal carcinoma may share features of invasive lobular carcinoma, but it usually forms glands, particularly the tubular type (choice B). Medullary carcinomas present as fleshy, bulky tumors measuring 5 to 10 cm in diameter. They are generally larger at the time they are detected than infiltrating ductal carcinomas (average size, 2 to 3 cm). On gross examination, medullary carcinoma appears as a well-circumscribed, fleshy, pale gray mass. Microscopically, it is composed of sheets of cells that are highly pleomorphic and have a high mitotic index. The pathologic definition of medullary carcinoma includes a lymphoid infiltrate encompassing the periphery of the tumor. Despite the highly malignant histologic appearance of this neoplasm, it has a distinctly better prognosis than infiltrating ductal or lobular carcinoma. Paget disease of the nipple refers to an uncommon variant of ductal carcinoma, either in situ or invasive, that extends to involve the epidermis of the nipple and areola. This condition usually comes to medical attention because of an eczematous change in the skin of the 233 nipple and areola. Microscopically, large cells with clear cytoplasm (Paget cells) are found singly or in groups within the epidermis. The prognosis of Paget disease is related to that of the underlying ductal cancer.

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