Condet

Jennifer Hsing Choe

• Assistant Professor of Medicine
• Member of the Duke Cancer Institute

https://medicine.duke.edu/faculty/jennifer-hsing-choe

In addition to their action on granulocytes and monocytes thyroid cancer neck buy generic levothroid 200 mcg, steroids may enhance susceptibility to infection by impairing wound healing thyroid cancer treatment guidelines buy 50mcg levothroid visa, increasing skin fragility thyroid gland damage safe levothroid 50 mcg, and depressing lymphocyte function thyroid cancer prognosis by stage levothroid 50mcg online, the production of cytokines, and humoral immune responses. The appropriate use of these hematopoietic cytokines in neutropenic cancer patients has been the topic of debate and is best guided by the recommendation from the American Society of Clinical Oncologists that restricts use to high-risk patients with a greater than 40% likelihood of fever associated with a neutropenic episode. It must be underscored that the use of new biologic agents in clinical practice should be guided by carefully conducted clinical trials. Chronic granulomatous disease has served as a prototype for diseases characterized by defective oxidative metabolism of phagocytes. Although chronic granulomatous disease represents a heterogeneous group of disorders from a molecular and genetic perspective, the common denominator is that phagocytes lack essential components of oxidative metabolism and fail to generate the respiratory burst in response to various stimuli, including certain pathogenic organisms. The organisms that cause serious infections in patients with chronic 1573 granulomatous disease are most often those that contain the enzyme catalase. In the absence of cellular production of H2 O2, the peroxide generated by non-catalase-containing organisms is enough to ameliorate the neutrophil deficiency and allow microbicidal activity. However, if the organism also contains catalase, the H2 O2 it produces is rapidly degraded and is not available for participation in oxidative-based killing. The majority of infections in patients with chronic granulomatous disease are caused by S. Serious recurrent infections usually begin in the 1st year of life in children with chronic granulomatous disease. The lung is the most common site of infection (pneumonias and abscesses), with other common infections including skin and soft tissue abscesses, visceral abscesses (particularly hepatic), osteomyelitis (especially of the small bones in the hands and feet), and suppurative lymphadenopathy. Uncommonly, chronic granulomatous disease can occur in adolescence or adulthood, although with a careful history, infectious complications often date back to childhood. Antibiotic prophylaxis with trimethoprim-sulfamethoxazole has been advocated by many investigators. Interferon-gamma has also been shown to reduce the incidence of serious infection and the number of hospital days for patients with chronic granulomatous disease. Myeloperoxidase deficiency is perhaps the most common of all granulocyte disorders, with an estimated frequency ranging from 1 in 2000 to 1 in 4000. Myeloperoxidase is a lysosomal enzyme that catalyzes the formation of hypochlorous acid from H2 O2 produced in the respiratory burst. Interestingly, most individuals identified with myeloperoxidase deficiency are healthy, and infectious complications are exceedingly rare. Systemic Candida infections have occurred in a small number of myeloperoxidase-deficient patients who also had diabetes mellitus. Chediak-Higashi syndrome is a rare disorder characterized by autosomal recessive inheritance, recurrent infections, partial oculocutaneous albinism, central and peripheral neuropathy, and increased bleeding time. Infections result from the combined effects of neutropenia and functional defects in phagocytes, which include impaired degranulation and defective chemotaxis. Infections frequently involve the skin, respiratory tract, and mucous membranes and are most commonly caused by S. Accordingly, neutrophils demonstrate defects in aggregation, margination, chemotaxis, and phagocytosis. The most common infections are skin and subcutaneous tissue infections, otitis, mucositis, gingivitis, and periodontitis. A number of disorders have been described that are characterized by defects in the chemotaxis of granulocytes and/or monocytes. Infections in these patients tend to be cutaneous, and the most common pathogens are S. The "lazy leukocyte" syndrome may also be associated with neutropenia and is characterized by gingivitis, recurrent otitis media, rhinitis, and stomatitis. Wound healing does not appear to be a problem, as it is in chronic granulomatous disease. Chemotaxis defects have been reported in patients with congenital ichthyosis and recurrent T. Defective cell-mediated immunity may lead to infections caused by bacteria, fungi, viruses, and protozoa. The predominant pathogens are intracellular organisms (those microbes that survive inside macrophages) and include mycobacteria (both M.

Non-biting flies such as houseflies thyroid cancer but normal thyroid levels purchase 200 mcg levothroid overnight delivery, flesh flies thyroid gland is responsible for buy levothroid 100mcg on-line, and blowflies (bluebottle flies) can transmit disease thyroid essential oils generic levothroid 100 mcg, particularly that caused by gastrointestinal pathogens thyroid cancer neck lump purchase 100 mcg levothroid visa, by acting as mechanical vectors. Other than biting and acting as vectors of disease, flies may affect humans by causing myiasis, infestation of the skin or a body orifice with fly larvae. A well-known example is the botfly found in the American tropics, which glues its eggs to a bloodsucking fly like the mosquito; when the mosquito bites humans, the larvae leave the mosquito, hatch, and penetrate the skin of their new host. A similar form of myiasis is caused by the tumbu or mango fly in Africa, which lays its eggs on the ground or on soiled clothing. The screw worm lays its eggs at the edge of wounds and may infect nose, eyes, ears, and other body orifices. Some larvae migrate in tortuous channels and produce a type of larva migrans (hypoderma). Other flies that feed on decaying tissue occasionally cause myiasis in humans; the larvae enter living tissue after feeding on necrotic wounds. Although usually confined to the skin or superficial wounds, myiasis can involve the genitourinary tract and the intestine; the larvae are usually passed spontaneously, although uretheral involvement sometimes requires cystoscopy. Areas of cutaneous myiasis are frequently misdiagnosed as pyogenic infection, and this diagnosis should be kept in mind for a "boil" that is refractory to medical therapy if a patient has visited an endemic area. Treatment for the cutaneous form requires mechanical removal with tweezers or by excision; this may be facilitated by covering the embedded larvae with petrolatum or strips of raw bacon fat, both of which encourage them to move upward, where they are grasped more easily. They are able to consume any human or animal food, dead plant or animal material, leather, glue, fabrics, grease, hair, wallpaper, and book bindings. They may function as mechanical vectors of pathogens and are sometimes intermediate hosts of helminths. Their glandular secretions can cause asthma when ingested, and cockroaches may be an important cause of asthma in children, in which group sensitization to cockroach allergens is commonly demonstrable. Bed bugs are 5-mm-long, flat, oval insects that resemble large ticks or small cockroaches. Bed bugs are not an important vector of disease, but their bites cause inflammation and occasionally hemorrhagic bullae. They are nocturnal feeders with a distinct odor and are capable of hiding successfully in the seams of mattresses, in couches, behind loose wallpaper, and under baseboards. The best known of these are the assassin bug (so named because it kills other insects) and the "kissing" bug (because it often bites around the lips and face). The bug defecates after eating, and it is the human host who scratches the trypanosomes into the skin. The bites of all these bugs are treated symptomatically, with topical antipruritic ointments and corticosteroids when needed, antihistamines for allergic reactions, and antibiotics for secondary infections. These insects have an ovipositor, designed to deposit eggs; however, the ovipositor has been modified to a stinging apparatus that injects venom, causing severe local inflammation and sometimes hypersensitivity. The familar honeybee is yellow and black striped and has an ovipositor that is barbed; thus, after the honeybee stings, the stinger and venom sacs are left in its victim and the bee dies. During stinging, the honeybee releases pheromones that attract other bees to attack. However, multiple swarms escaped from experimental colonies, and they have spread northward to Central America and the southern United States. The sting of the killer bee is not more toxic or allergenic than that of the domesticated honeybee, but the killer bee is more aggressive; it attacks with less provocation and exhibits massive stinging behavior in defense of the colony. In fact, up to 50% of the bees in a killer bee colony are guard bees that respond to perceived threats. The bumble bee is not as aggressive as the honeybee but otherwise exhibits similar behavior. They have familar black bands and produce a large honeycombed nest with a paper envelope. Paper wasps are the same size as yellowjackets but may be black, brown, red, or yellow.

These are all hallmarks of an extensive acute inflammatory response resulting in tissue damage thyroid symptoms itching all over levothroid 200 mcg lowest price. Many of the T cells are of the helper phenotype and are secreting lymphokines into their environment thyroid and acne buy levothroid 50mcg without prescription. T-cell migration into skin lesions is associated with mononuclear phagocyte differentiation into organized granuloma and is often associated with the rapid progression of peripheral nerve damage thyroid and weight loss buy cheap levothroid 200mcg on line. Such reactions may continue for weeks or months and are associated with severe morbidity leading to serious sequelae thyroid cancer cookbook generic 50 mcg levothroid visa. Antigen-presenting cells must recognize and cluster with appropriate T cells, leading to T-cell stimulation, differentiation, and replication. T helper cells synthesize and secrete a variety of hormone-like lymphokines, which enhance the microbicidal activity of monocytes and macrophages as well as stimulate other cells in the environment. Along with natural killer and lymphokine-activated killer cells, they serve as potent specific and non-specific cytotoxic effector cells. In lepromatous leprosy, in the absence of local lymphokine production, bacilli multiply in macrophages that have the capacity Figure 360-3 Lepromatous leprosy-cutaneous lesions. Acid-fast staining of histologic section (A) and transmission electron photomicrograph (B) of M. To modify this fertile intracellular culture environment, the host must destroy the heavily parasitized macrophage, liberating its contents into the extracellular milieu. This is the situation that occurs in the tuberculoid form of the disease and is lacking in the lepromatous state. The components and schedules vary depending on the presence of dapsone-sensitive strains and the part of the world in which the patient resides. To evaluate the dapsone sensitivity, the mouse foot pad assay must be used; this procedure is available only in specialized facilities. Multibacillary disease- a bacillary index of 1+ or more at any one of six skin sites. It should be noted, however, that many leprologists use rifampin at 450 to 600 mg/day for 2 to 3 years. Rifampin is the most rapidly effective bactericidal agent and kills the majority of M. Therapy with clofazimine, a phenazine derivative, has certain unpleasant side effects based on its lipophilicity. The compound is a red-purple dye taken up and concentrated by macrophages of the skin, causing increased skin pigmentation. Clofazimine is also deposited in the small intestine, where at high concentrations it causes segmental thickening associated with crampy pain and diarrhea. If clofazimine is unacceptable to patients, the physician should consider substitution with 100 mg/day of minocycline or 400 mg/day of ofloxacin. With severe episodes, high doses of corticosteroids (prednisone, 60 to 80 mg/day) are necessary and should be tapered off as soon as feasible. It is given initially at 200 mg twice a day and then tapered to levels of 50 to 100 mg/day. Thalidomide is a potent teratogen and should be assiduously avoided if pregnancy is possible. The chronicity and potential nerve damage of this cell-mediated reaction require high-dose corticosteroids and careful evaluation of peripheral nerve condition. Thalidomide is not used in this condition, but clofazimine along with corticosteroids allows the more rapid withdrawal of prednisone. A number of surgical procedures are available at specialized leprosy hospitals to help correct footdrop, hand deformities, madarosis, and lagophthalmos. Plastic surgical procedures can replace nasal septa and help close large plantar ulcerations. The presence of a cold abscess of a peripheral nerve with sudden increase in pain and functional loss requires immediate decompression by surgical drainage. Trials with more prolonged administration have demonstrated that a systemic response can be achieved. In lepromatous disease, prolonged courses of multiple drugs arrest the progression of the illness when compliance is good. It is the ability of the public health infrastructure to monitor compliance that is central to effective therapy.

Tissue invasion is most likely to occur in individuals with predisposing conditions associated with impaired local or systemic host defenses thyroid symptoms aches and pains generic levothroid 100 mcg on-line. In general thyroid cancer nih 100mcg levothroid otc, disease is slowly progressive and histopathologic findings resemble those seen in tuberculosis thyroid nodules ear pressure generic levothroid 50 mcg overnight delivery. In addition thyroid zija cheap 50 mcg levothroid with mastercard, colonization of asymptomatic individuals and environmental contamination of specimens can yield positive cultures in the absence of clinical disease. An additional criterion, failure of the sputum cultures to convert to negative with either bronchial hygiene or 2 weeks of specific mycobacterial drug therapy, is applied in the presence of a non-cavitary infiltrate not known to be due to another disease. The diagnosis is also established if transbronchial, percutaneous, or open-lung biopsy tissue reveals mycobacterial histopathologic changes and yields the organism. Extrapulmonary or disseminated disease is confirmed by isolation of the organism from normally sterile body fluids, closed sites, or lesions and when environmental contamination of specimens is excluded. The following discussion includes infections caused by selected species most likely to be encountered in clinical settings. Many treatment regimens contain new agents or older antimicrobial agents newly found to have activity against mycobacteria. Therapeutic decisions must weigh all potential drug toxicities and interactions as well as the results of susceptibility testing. Excisional therapy without chemotherapy is curative in about 95% of cervical adenopathy cases. Pulmonary infection usually occurs in individuals with underlying lung disease and generally follows an indolent or slowly progressive course. Differentiation between colonization and true infection may be difficult initially. Findings may include hepatosplenomegaly and generalized lymphadenopathy, including mediastinal adenopathy. Diagnosis of disseminated disease is commonly made by culture of the organism from blood, bone marrow, stool, or tissue biopsy. Every regimen should contain either azithromycin (600 mg once daily) or clarithromycin (500 mg twice daily). One or more of the following may be added as second, third, or fourth agents: rifabutin (300 mg/day), ciprofloxacin (750 mg twice daily), ofloxacin (400 mg twice daily) and, in some situations, amikacin (7. No specific regimen has emerged as being superior for pulmonary or disseminated disease, and the optimal duration of therapy remains unknown. Immunocompetent patients probably should receive a minimum of 18 to 24 months of therapy. Although adult white men are most commonly affected, infection can occur in individuals of any age, sex, or race. Extrapulmonary disease can involve any organ system, and risks of dissemination are increased in immunocompromised patients. Standard treatment of pulmonary disease is isoniazid (300 mg/day), rifampin (600 mg/day), and ethambutol (15 mg/kg/day) for 18 months. In patients who are unable to tolerate isoniazid, rifampin, and ethambutol with or without streptomycin for the first 3 months is an alternative regimen. Alternative agents such as clarithromycin (500 mg twice daily) or trimethoprim/sulfamethoxazole (160/800 mg twice or thrice daily), amikacin, ofloxacin, or sparfloxacin may be effective against M. Growth is rapid on subculture to solid media (<7 days), but primary isolation from clinical specimens may require 2 to 30 days. Sporadic, community-acquired infections have been reported from most areas of the United States. The spectrum of diseases ranges from localized to disseminated, with cutaneous involvement being most common. Most infections are acquired by inoculation after accidental trauma, surgery, or injection. Nosocomial epidemics or clusters have been reported in numerous settings, including augmentation mammaplasty, hemodialysis, plastic surgery, long-term venous catheters, cardiac surgery, and jet injector use. Susceptibility testing of individual isolates is important because resistance patterns vary by and within species subgroups. The newer macrolides, clarithromycin and azithromycin, are highly effective against most strains of rapidly growing mycobacteria. Treatment duration should be a minimum of 3 months for serious disease and 6 months for bone infections.

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References

• Gibilisco PA, Schumacher HR, Jr, Hollander JL, Soper KA. Synovial fluid crystals in osteoarthritis. Arthritis Rheum 1985; 28:511-5.
• Azinge NO, Ogidi-Gbegbaje EG, Osunde JA, Oduah D. Armillifer armillatus in Bendel State (Midwest) Nigeria (a village study in Ayogwiri Village, near Auchi, 120 kilometres from Benin City) phase I. J Trop Med Hyg 1978; 81(5):76-9.
• Voro-oy Y. Sobre el bloqueo del aparato reticuloe-dotelial del hombre e- algu-as formas de i-toxicacio- por el sublimado y sobre la tra-spla-tacio- del ri-o- cadaverico como metodo de tratamie-to de lo a-uria co-secutiva aquella i-toxicacio-. El Siglo Med. 1936;97:Hamilto- D-, Reid WA. Yu Yu Voro-oy a-d the first huma- kid-ey allograft. Surg Gy-ecol Obstet. 1984;159:289-294.
• The Lancet Oncology. Making precision oncology the standard of care. Lancet Oncol 2017;18(7):835.
• Aydogdu O, Burgu B, Gucuk A, et al: Effectiveness of doxazosin in treatment of distal ureteral stones in children, J Urol 182(6):2880n2884, 2009.