Xeloda

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mario J. Garcia, MD, FACC, FACP

• Chief, Division of Cardiology
• Montefiore Medical Center
• Professor of Medicine
• Albert Einstein College of Medicine
• Bronx, New York

This suggested the possibility of therapeutic side effect was hypertension women's health policy issues buy xeloda 500mg with amex, but the drug was otherwise utility for trastuzumab menstruation 10 days late buy generic xeloda online, which is a monoclonal antibody very well tolerated (20) menstruation uterine lining discount xeloda 500mg without a prescription. Five hundred eighty-four patients were included fluoropyrimidine-based first-line therapy womens health trumbull ct purchase xeloda with amex. We first need to address that he has an factors that may have contributed to developing this adequate means of maintaining nutrition, possibly a feedcancer. Which of the following modifiable risk factors ing tube or stent if he cannot swallow enough on his own, put him at increased risk for this malignancy Additional medical history is significant for diagastroesophageal junction adenocarcinoma with cisplbetes with an estimated glomerular filtration rate of atin and 5-fluorouracil. She comes to your office with multiple clinical on the tumor was 2+ and fluorescent in situ hybridizaresearch reports, including findings from the landtion was negative. Performance safely receive which of the following chemotherapy status is Eastern Cooperative Oncology Group 2. You are seeing a 45-year-old woman with a heavy smoking history, who recently underwent an upper 2. His priendoscopy in the emergency department after presentmary care physician ordered an upper endoscopy that ing with a food bolus impaction. A large fungating revealed a mass at the distal esophagus and biopsy demand partially obstructing mass was seen in the distal onstrated adenocarcinoma. You order a biopsy of one of surgeon, and the tumor was determined to be unrethe liver lesions to confirm metastatic disease. A 42-year-old man was diagnosed with squamous cell (D) Epirubicin, oxaliplatin, fluorouracil carcinoma of the upper esophagus. You are asked to give a second opinion regarding presence of Helicobacter pylori infection. He comes to treatment options for a 50-year-old man who was you for further management accompanied by his wife recently found to have a large mass in the middle and 3 children. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal (C) Referral for surgical resection with perioperative cancer. Individual patient data-based meta-analysis phagia that has been worsening over the past 2 months. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma esophageal perforation occurs, and the patient is taken of the stomach or gastroesophageal junction. Which of the motherapy and radiotherapy compared with radiotherapy alone in patients with cancer of the esophagus. Its classification In 2013, an estimated 21, 600 new cases of gastric cancer can be established based on the anatomical location of the were diagnosed in the United States, with 10, 990 deaths primary tumor and/or the histological pattern displayed. The incidence of gastric On the basis of the anatomical location in the stomach, cancer showed wide geographical variation. High incidence rates of the decrease of gastric cancer within Western populations, the disease are seen in China, Japan, Korea, and countries in proportion of tumors originating in the cardia has been Latin America and Eastern Europe. In contrast, low inciincreasing since 1975, which now represents the most dence rates are observed in Northern Africa, South and common location (3). Within the United States, gastric cancer forms rudimentary glands and displays this neoplasm has been in decline over the past 3 decades, varying degrees of differentiation, from well to moderate with an overall decrease of 5. This subtype arises in a ple from 1976 to 2010, corresponding to approximately background of intestinal metaplasia. This observation is likely related to ical subtype, diffuse gastric cancer, malignant cells fail to changes in dietary habits, improvement in food preparaform any recognizable structures resembling glands, with tion and storage, and treatment of Helicobacter pylori the classical appearance of signet ring cells, named due to infection. Mortality associated with the malignancy also intracellular mucin forcing the nucleus to the periphery. Approximately 28% ple risk factors involved in the pathogenesis of this disease, of the patients presented with localized disease, 34% with reflecting the multifactorial nature of gastric cancer. The locally advanced disease involving regional lymph nodes, strength of each association varies depending on the suband 38% with distant metastasis. Initially, the malignancy invades risk factors, thus impacting the burden of intestinal gastric locally into, along, and through the gastric wall, further cancer. In contrast, relationships between diffuse gastric advancing into neighboring organs and anatomical struccancer and specific environmental factors have not been tures. Lymph node involvement correlates with size cies of mismatch repair proteins and a diagnosis of Lynch and depth of the primary tumor and follows an orderly syndrome. Additionally, genetic factors have also been fashion spreading into regional lymph node stations. This strongly associated with the development of early onset, behavior influences the surgical principles underlying the diffuse gastric carcinoma. Venous invasion leads for the protein E-Cadherin, leads to the autosomal domito the development of distant metastasis, most commonly nant cancer genetic syndrome known as hereditary diflocated in the liver, lungs, and bone. The clinical utility of these other para-aortic structures (downward progression). Molecular characterization of gastric cancer has further defined our understanding and is impacting the therapy of this disease. It has been shown to be overexpressed and/or amplified in 1322% of gastric cancers (5). Molecular profiling has also revealed numerous able mass in the gastric fundus as well as mild gastritis 88 Tumor Board Review in the antrum. Biopsies demonstrated invasive adenocarof the tumor and simultaneously determines the presence cinoma. There was proximal and distal extent of the tumor, although it is less no evidence of distant metastatic disease. The utility of for total gastrectomy with Roux-en-Y esophagojejunoslaparoscopy, with or without cytology of peritoneal washtomy and placement of jejunostomy feeding tube. Especially in those patients planned to be treated with neoadjuvant therapy, laparoscopy may be performed in order to exclude the Evidence-Based Case Discussion presence of metastatic disease. The staging classificaThe staging workup for gastric cancer should include tion of gastric cancer is based on the data collected with history and physical examination, blood count and difthese procedures depicted previously. Regarding the extent of luminal resection, of micrometastasis, downstaging to improve rates of comtumors located distally can be addressed either by a total plete resection, and avoidance of disruption in the delivery gastrectomy or a distal subtotal gastrectomy. Several of adjuvant therapy following surgery due to postoperative prospective studies have shown no difference in terms of complications that may delay or prevent its use. However, Medical Research Council Adjuvant Gastric Infusional quality of life is superior after subtotal gastrectomy. Regarding the extent of lymphadenectomy as the extent of lymphadenectomy increases. A D1 dissecin this trial, approximately 40% of patients underwent tion includes perigastric lymph nodes located in the lesser some type of D2 dissection, 21% had D1 dissection, 20% and greater curvatures and is a minimum standard surhad surgical resection of the primary without lymph node gical treatment. A D2 dissection requires a when comparing trials testing other modalities of adjuhigh degree of expertise and should be performed only vant treatment. A D3 dissecChemoradiation therapy was evaluated in the randomtion involves removal of the portahepatic and periaortic ized Intergroup 0116 trial, a North American study that nodes. These regions are considered metastatic locations, compared surgery alone to surgery followed by combined and therefore this extent of lymphadenectomy is not often modality adjuvant treatment in 556 patients (8). It is anticipated the benefit of postoperative chemotherapy alone was that recent and current trials will inform future practice. Surgical treatment should provide were randomized to receive S-1 (a combination of the adequate gastric resection with at least D1 dissection and oral fluoropyrimidine tegafur with the dihydropyrimidine removal of >15 regional nodes. Sequencing of therapies is dehydrogenase inhibitors 5-chloro-2, 4-dihydroxypyridine, often centerand sometimes surgeon-specific. The utility of adjumodality therapy, but chemotherapy alone is an acceptable vant chemotherapy with S-1 in non-Japanese populations strategy. A second, more recent Asian trial conducted in additional adjuvant treatment offered following resection, South Korea, China, and Taiwan investigated adjuvant based on surgical and pathology findings. No difference Subsequently, with a diagnostic suspicion of dyspepsia, in overall survival was seen at the 34-month analysis, but he was initiated on treatment with a proton pump inhibimay be demonstrated with continued follow-up. In the following 2 weeks, A recent meta-analysis in resected gastric cancer comhe began to complain of pain in a band-like region across pared adjuvant chemotherapy to observation and demonthe upper abdomen, along with bloating and burping.

Syndromes

• Not growing well
• Lung disease
• Painful menstruation , which gets increasing worse
• Medications that are toxic to the liver
• Fissures
• Red rash that feels rough, and increased redness in the skin folds
• Fever and chills
• Renal cell carcinoma (kidney cancer)

In sites are the bones pregnancy problems order xeloda uk, adrenal glands breast cancer awareness month buy xeloda australia, and invasion front with little or no tumour cell the majority of cases a gradual transition brain menopause after 60 xeloda 500mg for sale. Recently breast cancer cookies discount xeloda 500mg online, disseminated dissociation, whereas the infiltrative patbetween carcinomatous and sarcomatous tumour cells were identified by means of tern shows an irregular invasion front and components has been observed on the immunostaining in the bone marrow of a marked tumour cell dissociation. Recurrence of cancer foltory stromal reaction, nuclear polymordies indicate that the sarcomatous spinlowing oesophageal resection can be phism and keratinization is extremely dle cells show various degrees of epithelocoregional or distant, both with approxvariable. Invasion noma is histologically comparable to commonly starts from a carcinoma in situ verrucous carcinomas arising at other with the proliferation of rete-like projecsites . On gross examination, its tions of neoplastic epithelium that push appearance is exophytic, warty, cauliA into the lamina propria with subsequent flower-like or papillary. It can be found in dissociation into small carcinomatous cell any part of the oesophagus. Along with vertical tumour cell cally, it is defined as a malignant papilinfiltration, usually a horizontal growth lary tumour composed of well differentiaundermines the adjacent normal mucosa ted and keratinized squamous epitheliat the tumour periphery. The carcinoma um with minimal cytological atypia, and may already invade intramural lymphatic pushing rather than infiltrating margins vessels and veins at an early stage of dis. The frequency of lymphatic and ma grows slowly and invades locally, with blood vessel invasion increases with a very low metastasising potential. A Typical exoblood vessels may be found progressiveThis unusual malignancy is defined as a phytic papillary growth. B High degree of differenly several centimetres beyond the gross squamous cell carcinoma with a variable tiation. In carcinoma in situ, the single case of a spindle cell carcinoma tion among the basaloid cells . In tous tumour component suggesting two cell carcinoma is also characterized by a a two-tier system, severe dysplasia and independent malignant cell clones . Histologically, it is composed of and Northern China, but there is no evitive risk: 2. Morphological A features of intraepithelial neoplasia include both architectural and cytological abnormalities. The architectural abnormality is characterized by a disorganisation of the epithelium and loss of normal cell polarity. Cytologically, the cells exhibit irregular and hyperchromatic nuclei, an increase in nuclear/cytoplasmic ratio and increased mitotic activity. B Small gland-like epithelium, whereas in high-grade dysan increase in basal cells, loss of polarity in the structures. Squamous cell carcinoma 15 middle third of the oesophagus, but multiple lesions occur. Histologically, cores of fibrovascular tissue are covered by mature stratified squamous epithelium. In Japan, oesophageal squamous cell carcinoma is diagnosed mainly based on nuclear criteria, even in cases judged to be non-invasive intraepithelial neoplasia (dysplasia) in the West. This difference in diagnostic practice may contribute to the relatively high rate of incidence and good prognosis of superficial squamous cell carcinoma reported in Japan . Well differentiated tumours have cytological and histological features similar to those of the normal oesophageal squamous epithelium. Architectural disarray, tion of large, differentiated, keratinocyteloss of polarity and cellular atypia are much greater than shown in. Changes in D extend to the like squamous cells and a low proportion parakeratotic layer of the luminal surface. The occurrence of keraThis lesion is histologically defined as an tinization has been interpreted as a sign otherwise normal squamous epithelium of differentiation, although the normal with a basal zone thickness greater than oesophageal squamous epithelium does 15% of total epithelial thickness, without not keratinize. In most cases, basal cell hypernantly consist of basal-type cells, which plasia is an epithelial proliferative lesion usually exhibit a high mitotic rate. However, since no Squamous cell papilloma is rare and generally accepted criteria have been usually causes no specific symptoms. The polypoid Undifferentiated carcinomas are defined lesions are smooth, sharply demarcated, by a lack of definite light microscopic and usually 5 mm or less in maximum features of differentiation. Rarely, giant papilstructural or immunohistochemical inveslomas have been reported, with sizes up tigations may disclose features of squa. This lesion was negative for human papillomapapillomas represent single isolated microscopically undifferentiated carcinovirus by in situ hybridisation. C Well differentiated areas (left) contrast with immature basal-type cells of a poorly differentiated carcinoma (right). Aneuploidy of cancer cells, depth of invasion and the presence of associated with a better prognosis as determined by flow cytometry or by nodal or distant metastases are inde{1660, 443}. However, the proliferation However, a prognostic impact independrecently, the prognostic significance of index does not appear to be an indeent of tumour stage has been shown only more sophisticated methods for the pendent prognostic factor {2189, 1005, in two studies {422, 1195}, whereas the determination of tumour spread have 1659, 779}. The prognostic impact of G:C>T:A tumour differentiation is equivocal, possiDeletions, insertions, complex mutations bly due to the poor standardisation of the grading system and to the high prognosG:C>A:T tic power of tumour stage. Other histopathological features associated 0 10 20 30 40 50 60 70 with a poor prognosis include the presence of vascular and/or lymphatic invasion {772, 1662} and an infiltrative growth pattern of the primary tumour . However, none margin and possibly to preoperative growth factors and their receptors , of the factors tested so far has entered chemotherapy {1890, 1027}. Hofler Definition higher incidence among whites and an sia at or immediately below the gastric A malignant epithelial tumour of the average age at the time of diagnosis of cardia {715, 1797, 1722} is discussed in oesophagus with glandular differentiaaround 65 years . Despite the mucosa in the lower third of the oesoAetiology broad advocation of endoscopic surveilphagus. Infrequently, adenocarcinoma Barrett oesophagus lance in patients with known Barrett originates from heterotopic gastric the epidemiological features of adenooesophagus, more than 50% of patients mucosa in the upper oesophagus, or carcinoma of the distal oesophagus and with oesophageal adenocarcinoma still from mucosal and submucosal glands. Barrett Chronic gastro-oesophageal reflux is the oesophagus {1605, 1827}, which has usual underlying cause of the repetitive Epidemiology been identified as the single most impormucosal injury and also provides an In industrialized countries, the incidence tant precursor lesion and risk factor for abnormal environment during the healing and prevalence of adenocarcinoma of adenocarcinoma of the distal oesophaprocess that predisposes to intestinal the oesophagus has risen dramatically gus, irrespective of the length of the segmetaplasia . This is paralleled by rised with gastro-oesophageal reflux disgreater the risk. It has been estimated that more than 80% of patients with adenocaradenocarcinoma was 43. A series of prospective endoscoprelation between gastro-oesophageal noma in the U. In the mid 1990s the oesophagus has shown an incidence of oesophageal adenocarcinoma has been incidence of oesophageal adenocarcinooesophageal adenocarcinoma in the postulated. The length of the oesophageal reflux disease include a mous cell oesophageal cancer in these oesophageal segment with intestinal markedly increased oesophageal exporegions. In Asia and Africa, adenocarcimetaplasia, and the presence of ulcerasure time to refluxed gastric and duodenoma of the oesophagus is an uncomtions and strictures have been implicated nal contents due to a defective barrier mon finding, but increasing rates are as further risk factors for the development function of the lower oesophageal sphincalso reported from these areas. Experimental and clinical data indicate the oesophagogastric junction share the biological significance of so-called that combined oesophageal exposure to some epidemiological characteristics ultrashort Barrett oesophagus or intestingastric acid and duodenal contents (bile that clearly distinguish them from squaal metaplasia just beneath a normal Z acids and pancreatic enzymes) appears mous cell oesophageal carcinoma and line has yet to be fully clarified . Whether adenocarcinoma of the gastric exposure to gastric juice or duodenal these include a high preponderance for cardia or subcardial gastric cancer is contents alone {1241, 1825}. Combined the male sex (male:female ratio 7:1), a also related to foci of intestinal metaplareflux is thought to increase cancer risk 20 Tumours of the oesophagus by promoting cellular proliferation, and by Histopathology exposing the oesophageal epithelium to Barrett epithelium is characterized by two potentially genotoxic gastric and intestindifferent types of cells, i. The goblet cells stain Smoking has been identified as another positively with Alcian blue at low pH (2. The hypoechoic tumour lies intestinal metaplasia (type I) with absorpObesity between the first and second hyperechoic layers tive cells and Paneth cells may be found. The continuity of the second layer (subThe mucous glands beneath the surface trol study, obesity was also associated mucosa) is respected. In this study the adjustsuggest that the columnar metaplasia ed odds ratio was 7. The pathogenetic basis of2 Barrett oesophagus as the precursor of Intraepithelial neoplasia generally has no the association with obesity remains to be most adenocarcinomas is clinically silent distinctive gross features, and is detected elucidated . The symptomatolby systematic sampling of a flat Barrett ogy of Barrett oesophagus, when presmucosa {634, 1573}. The area involved is Alcohol ent, is that of gastro-oesophageal reflux variable, and the presence of multiple In contrast to squamous cell oesopha. Rare dysplastic lesions have been conHelicobacter pylori Endoscopy sidered true adenomas, with an expandThis infection does not appear to be a the endoscopic analysis of the squamoing but localised growth resulting in a predisposing factor for the development columnar junction aims at the detection well demarcated interface with the surof intestinal metaplasia and adenocarciof columnar metaplasia in the distal rounding tissue . The anatomical landally assessed according to the system marks in this area are treated in the Localization chapter on tumours of the oesophagoAdenocarcinoma may occur anywhere in gastric junction. There are three hyperand two hypotic mucosa (Barrett oesophagus) but distal oesophageal segment is * 3 cm, it echoic layers; the tumour mass is hypoechoic. When the length is < 3 cm, it is a T1 the 2nd hyperechoic layer Barrett oesophagus is easily mistaken for short type. Single or multiple finger-like (submucosa) is continuous adenocarcinoma of the cardia.

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Pathogenesis: Infection is by ingestion of the organism pregnancy nightmares cheap xeloda 500 mg on line, (>10 to the power of 7) in 50% of cases penetrate the small intestine mucosa and reach the circulation with transient bactremia the bacilli are taken by the lymphatic to lymph nodes and they are engulfed by mononuclear phagocytic cells menstruation sponge discount xeloda online mastercard. The liver women's health clinic abu dhabi xeloda 500mg on-line, gallbladder menstrual bleeding for a month discount xeloda online amex, spleen, kidney and bone marrow become infected during this second bactermic phase, characterizing the clinical features of the diseases. Others include pseudomonas, Klebsiella, Salmonella in sickle cell anemic patients. Sites: Any bone may be affected but the metaphysics of long bones (distal femur, proximal tibia and humorus) adjacent to actively growing epiphyses and the vertebral column are most often involved. Pathogenesis: the location of the lesions within specific bones is influenced by the vascular circulation, which varies with age. In the neonate, the metaphysical vessels penetrate the growth plate resulting in frequent infection of the metaphysis, epiphysis or both. Infection spreads rapidly through marrow spaces which perpetuates the Haversian systems of the metaphysical cortex, elevates the periosteum and forms a subperiosteal abscess in children and adolescents as opposed to adults periosteum that is adherent to the bone. Small sequestra especially in children tend to be completely absorbed by osteoclastic activity. In the presence of a sequestrum, the periosteal reactive woven or laminar bone may be deposited as a 167 sleeve of living tissue known as involcrum, around the segment of devitalized bone (sequestrum). Tuberculosis infects one third of world populations and kills about three million people yearly and it is the single most important infectious disease. Etiology: Mycobacterium tuberculosis and Mycobacterium bovis are the regular infecting rod shaped, acid fast and alcohol fast, strict aerobic, non-spore forming bacteria with a waxy coat. It has a slow generation time of 4-6 weeks to obtain a colony of mycobacterium tuberculosis. Cord factor which is a cell wall glycolipid component is aviable on virulent strains 2. Tuberculosis heat shock protein is similar to human heat shock protein and may have a role in autoimmune reactions induced by M. Inhibition of acidification has been associated with urase secreted by the mycobacteria. First, the organisms are phagocytosed by alveolar macrophages and transported by these cells to hilar lymph nodes. Naive macrophages are unable to kill the mycobacteria, thus they multiply and lyse these host cells, infect other macrophages and sometimes disseminate through blood to other parts of the lung and elsewhere in the body. Lyses of these macrophages results in the formation of caseating granuloma and direct toxicity to the mycobacteria may contribute to the necrotic caseous centers. The primary infection of sub-pleural lesion, the intervening macrophage reactions within accompanying lymphangitis and the hilar lymph nodes caseous lesions is called primary complex (often called a Ghon focus). T-cell mediated immune response induces hypersensitivity to the organisms and controls 95% of primary infection. This is associated with progressive fibrosis and calcification of persistent caseous debris. However, if the infected person is immunologically immature, as in a young child or immunocompromized (eg. Such persons lack the capacity to coordinate integrated hypersensitivity and cell mediated immune responses to the organism and thus often lack the capacity to contain the infection. Granulomas are poorly formed or not formed at all, and infection progresses at the primary site in the lung, the regional lymph nodes or at multiple sites of disseminations. Progressive primary tuberculous pneumonia: commonly seen in children less than five years of age but it ours in adults as well in those with suppressed or defective immunity. Subpleural focus may discharge bacilli or antigen into the pleural cavity resulting in the development of pleural effusion. Hilar or mediastinal groups of lymph nodes enlargement with caseous necrosis that may result in: a. Obstruction of the bronchus by the enlarged lymph nodes leading to lobar collapse. The caseous hilar lymph node may penetrate the bronchial wall and resulting in rupture of the wall with pouring of caseous materials into the bronchus hence, tuberculosis broncho-pneumonia ensues. The caseous materials may be disseminated to other parts of the body via blood streams. Miliary tuberculosis It refers to disseminated sites that produce multiple, small yellow nodular lesions in several organs. The lungs, lymph nodes, kidneys, adrenals, bone marow, spleen, menings and liver are common sites for miliary lesions. Seeding of the bacilli in lungs, bones, kidneys, fallopian tubes, bladder, epididimis etc, that may persist in and their subsequent reactivation produces destructive, necrotizing granulmatious disease, sometimes known as end organ tuberculosis. Intestinal primary infection the primary complex is similar to that of the lungs the initial site may be in the gum with lymphatic spread of bacilli to the cervical lymph nodes the commonest location for the primary lesion is the illocaecal region with local mesenteric node involvement. Lymph nodes Tuberculous lymph adenitis is the most common type of extra pulmonary tuberculosis that frequently involves the cervical groups of lymph nodes with enlargement, and subsequent periadenitis followed by matting and eventual ulcerations if left untreated. Skin is also involved in various forms of tuberculosis Post primary (secondary) tuberculosis Conventionally the term post-primary tuberculosis is used for lung infections occurring 5 years or more after the primary infection. The commonest sites for post primary tuberculosis are the posterior or apical segment of the upper lobe and the superior segment of the lower lobe and their predilection for the anatomy location is due to good ventilation. Hypersensitivity reaction is well developed and it thus, restricts the granulomatous reactions locally. Pulmonary and bronchial arteries around caseous cavities are occluded by endarteritis obliterans where the wall of the artery may weaken resulting in aneurysm formation (mycotic aneurism) that may occasionally rupture and cause hemoptosis. Certain tissues are relatively resistant to tuberculous infection, so it is rare to find tubercles in the heart, skeletal muscle, thyrord and pancreas. This results in less well-formed granulomas, and more frequently necrotic material that contain more abundant acid-fast organisms histologically. These infections are usually widely disseminated throughout the reticuloendothelial systems causing enlargement of involved lymph nodes, liver and 10 spleen. The organisms are present in large numbers as many as 10 organism per gram of tissue. Leprosy Definiton: Leprosy or Hansen disease is a slowly progressive infection caused by Mycobacterium leprae affecting the skin and peripheral nerves and resulting mainly in deformity, paralysis and ulceration. Pathogenesis: the bacillus is acid fast, obligate intracellular organism that does not grow in culture and 0 it grows best at 32-34 C of the temperature of human skin. The bacilli thus produce either potentially destructive granulomas or by interference with the metabolism of cells. The bacilli are taken by alveolar macrophages; disseminate through the blood but grows only in relatively cool tissues of the skin and extremities. Two forms of the disease occur depending on whether the host mounts a T-cell mediated immune response (tuberculoid leprosy) or the host is anergic (lepromatous leprosy). The polar forms are relatively stable but the borderline forms (border line-tuberculoid, borderline-borderline, and borderline-lepromatous) are unstable without treatment. Patients with tuberculoid leprosy form granuloma with few surviving bacteria (paucibacillary disease). Antibody production is not protective in lepromatous leprosy and rather the formation of antigen antibody complexes in lepromatous leprosy leads to erythema nodosum leprosum, a life threatening vasculitis, and glomerulonephrits 173 Because of the diffuse parasite filled lesions lepromatous leprosy is more infectious than those with tuberculoid leprosy. Table: Differences between tuberculoid and lepomatous leprosy Tuberculoid leprosy Lepromatous leprosy Epitheoid granuloma without giant cell Active macrophages, with every many bacilli (globi) Dense zone of lymphocyte infiltration Scanty and diffuse around granuloma Nerves destroyed by granulomas May show neuronal damage but not infiltration or cuffing No clear sub-epidermal zone Clear sub-epidermal zone Bacilli in granuloma are not seen Numerous bacilli 5+ or 6+ Few macules + plaques with well defined Macules, papules, plaques and nodules edges present with vague edges Lesions distributed asymmetrically Lesions distributed symmetrically hair loss no hair loss Lesions are anesthetic Lesions are not anesthetic Nerve thickening often singly and early Nerve thickening is symmetrical and late (stocking & glove patterns) First manifestation may be neural First manifestation never neuronal Lepromin test is strongly positive Lepromin test is negative Clinical course and complications Lepromatous leprosy involves primarily the shin, peripheral nerves, anterior eye, upper airways (down to larynx), testis, hands and feet. The vital organs and the central nervous system are rarely affected presumably because the core temperature is too high for the growth of M. Syphilis Definition: Syphilis is a systemic infection caused by the spirochete Treponema pallidium, which is transmitted mainly by direct sexual intercourse (venereal syphilis) and less commonly via placenta (congenital syphilis) or by accidental inoculation from the infectious materials. Pallidum spirochetes cannot be cultured but are detected by silver stains, dark field examination and immunofluorescence technique. Pathogenesis: the organism is delicate and susceptible to drying and does not survive long outside the body. Morphology: Syphilis is classified into three stages Primary syphilis (chancre): Chancre appears as a hard, erythematous, firm; painless slightly elevated papule on nodule with regional lymph nodes enlargements.

Diseases

• Diaphragmatic agenesia
• GM2-gangliosidosis, B, B1, AB variant
• Metaphyseal chondrodysplasia Spahr type
• Oto palato digital syndrome type I and II
• Maroteaux Lamy syndrome
• Chromosome 3, trisomy 3q13 2 q25