Tongue Pathology
Geographic tongue, fissured tongue, and hairy tongue are the most common tongue problems and do not require treatment. Median rhomboid glossitis is usually associated with a candidal infection and responds to topical antifungals. Atrophic glossitis is often linked to an underlying nutritional deficiency of iron, folic acid, vitamin B12, riboflavin, or niacin and resolves with correction of the underlying condition. Oral hairy leukoplakia, which can be a marker for underlying immunodeficiency, is caused by the Epstein-Barr virus and is treated with oral antivirals. Tongue growths usually require biopsy to differentiate benign lesions (e.g., granular cell tumors, fibromas, lymphoepithelial cysts) from premalignant leukoplakia or squamous cell carcinoma. Burning mouth syndrome often involves the tongue and has responded to treatment with alpha-lipoic acid, clonazepam, and cognitive behavior therapy in controlled trials. Tongue lesions of unclear etiology may require biopsy or referral to an oral and maxillofacial surgeon, head and neck surgeon, or a dentist experienced in oral pathology.
Recognition and diagnosis of tongue abnormalities require examination of tongue morphology and a thorough history, including onset and duration, antecedent symptoms, and tobacco and alcohol use. A complete head and neck examination, with careful assessment for lymphadenopathy, is essential.
Satyendra Dhar MD, @DharSaty
#tongue #Geographictongue, #fissuredtongue, #hairytongue #Medianrhomboidglossitis #candida #Atrophicglossitis #Oralhairyleukoplakia
Cryofibrinogenemia Summary
Cryofibrinogenemia Epidemiology:
• 40-70 years with a modest female predominance
Cryofibrinogenemia:
• The precipitation of a complex when plasma is cooled from the normal body temperature of 37°C to the near-freezing temperature of 4°C.
• This precipitating complex contains fibrinogen, fibrin, fibronectin, small amounts of fibrin split products, albumin, immunoglobulins and other plasma proteins which can plug blood vessels.
• Cryofibrinogen is distinguished from cryoglobulin (CG) since, it precipitates only in plasma and not in serum.
• Cryoglobulins precipitate in serum + plasma
Cryofibrinogen - Cryofibrinogen is a cold insoluble complex of:
• Fibrin
• Fibrinogen
• Fibrin split products with:
- Albumin
- Cold insoluble globulin
- Factor VIII
- Plasma proteins
Cryofibrinogenemia Symptoms:
• Asymptomatic or combination of:
- Hyperviscosity,
- Vascular reactivity (Skin necrosis)
- Thrombosis (Thrombotic vasculopathy)
• Paradoxical spontaneous bleeding may occur due to the depletion of clotting factors
Cryofibrinogenemia Can Be Divided Into Two Types:
1. Primary (essential)
2. Secondary form associated with autoimmune diseases, malignancies, vasculitis, sepsis or cryoglobulinemia
Associated Disorders:
• Malignancy
• Infections including coronavirus disease 2019 (COVID-19)
• Inflammatory processes:
• Systemic rheumatic diseases
• Thromboembolic conditions
Cryofibrinogenemia Clinical Manifestations - Findings may include:
• Cold sensitivity
• Painful ulcers
• Skin necrosis
• Purpura
• Livedo reticularis
• Painful or pruritic erythema (perniosis) of the extremities
• Arthralgias
• Raynaud phenomenon
• Simulates calciphylaxis clinicopathologically,
- Related conditions: Stroke, myocardial infarction, limb and bowel ischemia or infarction, thrombophlebitis, pulmonary emboli, and ocular thrombi including retinal arterial and/or venous occlusions, as well as gangrene
Cryofibrinogenemia Diagnosis:
• + Clinical findings/Presentation
• Asymptomatic: Plasma (CF) cryofibrinogen levels < than 50 mg/L
- Significant levels >1g/L
• Negative cryoglobulins
• Negative causes of secondary cryofibrinogenemia.
• Biopsy: Typical pathologic findings on biopsy of affected tissue
• Angio: Occlusion of small to medium-sized arteries
• Secondary CF: Presence of associated disease
Cryofibrinogenemia DDX:
• Calciphylaxis
• Cryoglobulinemia
• TTP, HUS and HIT
• Antiphospholipid syndrome
• Warfarin-induced skin necrosis
• DIC
• Septic emboli
• Frostbite
• Atherosclerotic PVD
• Atheroemboli
#Cryofibrinogenemia #diagnosis #rheumatology #hematology
Weakness - Differential Diagnosis Framework
Approach To Weakness:
• Non-neuromuscular disorder (Cardiac, pulmonary etc)
• CNS -> PNS -> NMJ -> Muscle
• Muscle weakness (generalized, distal, proximal, or localized)
1. Upper Motor Neuron Impairment:
• Acute stroke syndromes
• Space occupying lesions of the central nervous system: Brain tumor
• Lesions of the spinal cord
• Inflammatory: Vasculitis
• Infectious: Brain abscess
• Toxic/drug: Radiation
• Metabolic/endocrine: Vitamin B12 deficiency
• Congenital leukodystrophies
2. Lesions Of The Peripheral Nervous System:
• Symmetric polyneuropathy: DM
• Mononeuropathy: Nerve compression
• Mononeuritis multiplex (DM, Vasculitis-polyarteritis nodosa)
• Toxic/drug: Lead
• Neoplastic: Paraneoplastic syndrome
• Inflammatory: Myeloma/amyloid
• Infectious: Leprosy
3. Neuromuscular Junction:
• Exercise-induced weakness: Fatiguability - Consider NMJ
• Nerve Side Presynaptic:
- Lambert-Eaton
- Isaacs' syndrome
- Tick-paralysis
- Botulism
- Aminoglycosides
- Envenomation (venom from animal bites)
• Synaptic Cleft:
- Organophosphate toxicity
- Carbamate toxicity
• Muscle Side:
- Postsynaptic: Myasthenia Gravis
- Lack of UMN/LMN signs
- Lack of sensory changes
- Common pattern: Symmetric proximal weakness
Myopathy:
• Inflammatory disorders: Polymyositis
• Immune mediated necrotizing myopathy
• Autoimmune: Inclusion body myositis
• Endocrinopathies: Hypothyroid
• Metabolic myopathies: Hypoglycemia
• Drugs and toxins: Steroids, Statins, amiodarone, Alcohol
• Infections:
- Viral - Influenza, parainfluenza, Coxsackie, HIV, CMV, EBV
- Bacterial - Pyomyositis, Lyme myositis
• Rhabdomyolysis
• Neoplastic: Malignancy-associated myositis
• Genetic: Muscular dystrophies
Work Up:
• Chem: CPK aldolase, lactate dehydrogenase, and the aminotransferases
• Serology:
- Anti-Ro/SSA, anti-La/SSB, anti-Sm, and anti-RNP
- (Myositis) anti-histidyl-t-RNA synthetase [anti-Jo-1]
- (Vasculitis) ANCA titers, hepatitis B and C serologies, and cryoglobulins
• PNS, NMJ, Nerve: Nerve conduction and electromyographic (EMG) studies
• MRI: Inflammation of the muscle
• Muscle Biopsy: Dermatomyositis, polymyositis, inclusion body myositis, certain drug-induced myopathies, the muscular dystrophies, or vasculitis
#Weakness #Differential #Diagnosis #neurology
Irritable Bowel Syndrome (IBS) Treatment Options
Amitiza (Lubiprostone)
Antidepressants: Celexa, Wellbutrin, Prozac, Paxil, Nortriptyline, and Zoloft
Bentyl (Dicyclomine)
Creon
Ducolax
Imodium, Maalox, Kaopectate (Loperamide)
Levsin (Hyoscyamine)
Librax (Chlordiazepoxide and Clidinium)
Linzess (Linaclotide)
Lotronex (Alosetron)
Marijuana
Miralax (Polyethylene glycol)
Nexium (Esomeprazole), Protonix (Pantoprazole), Prevacid (Lansoprazole), Prilosec (Omeprazole)
Reglan (Metoclopramide)
Rifaxamin (Xifaxan)
Viberzi (Eluxadoline)
Zantac (Ranitidine)
#irritable #bowel #syndrome #ibs #diarrhea #constipation #management #pharmacology #table
