Professional Documents
Culture Documents
Hematology
PRIMARY HEMOSTATIC (PLATELET PLUG) DISORDERS
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Physiological Classification of Anemia Based on Reticulocyte Production Index
Anemia
Hemolysis/hemorrhage
Red cell morphology
Blood loss
Normocytic Intravascular hemolysis
Micro or
Normochromic
macrocytic
Metabolite defect
Hemoglobinopathy
Marrow damage Cytoplasmic defects
Infiltration/fibrosis Iron deficiency Immune destruction
Aplasia Thalassemia
Iron deficiency Sideroblastic anemia Fragmentation hemolysis
IMPORTANT POINTS
The World Health Organization defines anemia as a hemoglobin level <13 g/dL in men and <12
g/dL in women.
Normal reticulocyte count is 1-2%
Prematurely released reticulocytes into the circulation are called “shift cells”.
The normal serum iron range from 50-150 µmol/dL, whereas the normal TIBC is 300-360 g/dL;
the normal transferring saturation ranges from 25 to 50%.
The minimum number of stem cells necessary to support hematopoiesis is estimated to be 400-
500 at any one time.
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Hematopoietic disorders
CLASSIFICATION OF PURE RED CELL APLASIA
Self-limited
Transient erythroblastopenia of childhood
Transient aplastic crisis of hemolysis (acute B19 parvovirus infection)
Fetal red blood cell aplasia
Nonimmune hydrops fetalis (in utero B19 parvovirus infection)
Hereditary pus red cell aplasisa
Congenital pure ted cell aplasia (Diamond Blackfan anemia)
Acquired pure red cell aplasia
Cancer
Thymoma
Lympjhoid malignancies (and more rarely other hematologic diseases)
Parancoplastic to solid tumors.
Connective Tissue Disorders
SLE
JRA,RA
Viruses
Persistent Parvovirus B19,hepatitis,EBV
DRUGS
Phenytoin,azathioprine,chloramphenicol,INH,Procainamide
Malignant Nonmalignant
Acute leukemia (lymphocytic, myelogenous, megakaryocytic) HIV infection
Chronic myeloid leukemia Hyperparathyroidism
Hairy cell leukemia Renal osteodystrophy
Hodgkin‟s disease Systemic lupus
Primary myelfibrosis erythematous
Lymphoma Tuberculosis
Polycythemia vera
Systsemic mastocytosis
Systemic mastocyrosis
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DIAGNOSIS OF MICROCYTIC ANEMIA
TYPE OF ANITBODY
Clinical Setting Cold, Mostly IgM, Optimal Warm, Mostly IgG, Optimal
Temperature 4-30oC temperature 37oC; or mixed
Primary CAD AIHA (idiopathic)
Secondary to viral infection EBV HIV
CMV Viral vaccines
Other
Secondary to/associated with CAD in : AIHA in :
other disease Waldenstrom‟s disease SLE
Lymphoma CLL
Other malignancy
Chronic inflammatory disorders
(e.g., IBD)
After allogeneic HSCT
Secondary to drugs : Small minority (e.g., with Majority: currently most
Drug-induced immune lenalid-drugs : common culprit drugs are
cefotetan, ceftriaxone,
Hemolytic anemia piperacillin
Drug-dependent: antibody destroys red cells only when drug
present (e.g., rarely penicillin)
Drug-independent : antibody can destroy red cells even when drug
no longer present (e.g., methyldopa)
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Abbreviations : AIHA-autoimmune hemolytic anemia; CAD-Cold agglutinin disease; CLL-Chronic
lymphocytic leu7kemia; CMV-cytomegalovirus; EBV-Epstein-Bar virus HIV human
immunodeficiency virus. HSCT. Hematopoietic stem cell transplantation IBD-inflammatory bowel
disease: SLE-Systemic lupus erythematosus.
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CAUSES OF THROMBOCYTOSIS
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THE ANN ARBOR STAGING SYSTEM FOR HODGKIN’S LYMPHOMA
Stage Definition
I Involvement of a single lymph node region or lymphoid structure (eg., spleen, thymus,
Waldeyer‟s ring)
II Involvement of two or more lymph node regions on the same side of the diaphragm (the
mediastinum is a single site; hilar lymph nodes should be considered “lateralized” and, when
involved on both sides, constitute stage I disease)
III Involvement of lymph node regions or lymphoid structure on both sides of the diaphragm
III1 Subdiaphragmatic involvement limited to spleen, splenic hilar nodes, celiac nodes, or portal
nodes
III2 Subdiaphragmatic involvement includes paraaortic, iliac, or mesenteric nodes plus structures
in III1
IV Involvement of extranodal site(s) beyond that designated as “F” More than one extranodal
deposit at any location Any involvement of liver or bone marrow
A No symptoms
B Unexplained weight loss of > 10% of the body weight during the 6 months before staging
investigation
Unexplained, persistent, or recurrent fever with temperatures >38oC during the previous
month
Recurrent drenching night sweats during the previous month
E Localized, solitary involvement of extra lymphatic tissue, excluding liver and bone marrow
IMPORTANT POINTS
Most common type of Non-Hodgkin‟s lymphoma is Diffuse large B cell lymphoma.
Most common presentation of mantle cell lymphoma is palpable lymphadenopathy
Most common presentation for follicular lymphoma is with new, painless lymphadenopathy
Most common site of MALT lymphoma is stomach.
Most common lymphoid leukemia is B cell CLL/small lymphocytic lymphoma.
Patients with hairy cell leukemia are prone to unusual infections, including infection by
Mycobacterium avium intracellulare.
In Adult T-cell lymphoma/leukemia, peripheral smear reveals characteristic, pleomorphic
abnormal CD4-positive cells with indented nuclei, which have been called “flower” cells.
Most common initial manifestation of Hodgkin‟s lymphoma is mediastinal lymphadenopathy.
Most important cytokine involved in myeloma cell proliferation is IL-6
Most common symptom of myeloma is bone pain.
Most common infections in myeloma patients are pneumonias and pyelonephritis
Most common cause of renal failure in myeloma patients is hypercalcemia.
Earliest manifestation of renal tubular damage in multiple myeloma is Fanconi‟s syndrome.
Normocytic normochromic anemia occurs in ~80% of myeloma patients.
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Most common serum M component in multiple myeloma is IgG.
Serum Beta 2 microglobulin is the single most powerful predictor of survival in multiple
myeloma
International Staging System (ISS) for myeloma is based on serum Beta 2-microglobulin and
albumin levels.
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flushing, and white nails); (e) papilledema; (f) thrombocytosis/polycythemiad
a
Myloma-related organ or tissue impairment (end organ damage); calcium levels increased serum
calcium >0.25 mmol/L above the upper limit of hormal or >2.75 mmol/L; renal insufficiency:
creatinine >173 mmol/L; anemia: hemoglobin 2 g/dL below the lower limit of normal or hemoglobin
>10g/dL; bone lesions: lytic lesions or osteoporosi with compression fractures (magnetic resonance
imaging or computed tomography may clarigy); other: symptomatic hyperviscosity, amyloidosis,
recurrent bacterial infection (>2 episodes in 12 months). bIf flow cytometry is performed, most plasma
cells (>90%) will show a “neoplastic” phenotype. cA small M component may sometimes be present.
d
These features should have no attributable other causes and have temporal relation with each other.
Features Details
Thrombocytopenia Platelet count of < 100,000/L or a decrease in platelet
count of > 50%
Timing Platelet count falls 5-10 days after starting heparin
Type of heparin More common with unfractionated heparin than
low-molecular-weight heparin
More common in surgical patients and patients with
cancer than general medical patients; more common
in women than in men
Thrombosis Venous thrombosis more common than arterial
thrombosis
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MANAGEMENT OF HEPARIN-INDUCED THROMBOCYTOPENIA
Advantage Consequence
Better bioavailability and longer half-life Can be given subcutaneously once a twice daily for both
after subcutaneous injection prophylaxis and treatment
Dose-independent clearance Simplified dosing
Predictable anticoagulant response Coagulation monitoring is unnecessary in most patients
Lower risk of heparin-induced Safer than heparin for short or long term
thrombocytopenia administration
Lower risk of osteoporosis Safer than heparin for extended administration
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meningococci, gram negative bacilli Immunotherapy
Viral Graft versus host disease
Mycotic
Parasitic
Rickettsial
Trauma and Tissue Injury Drugs
Brain injury (gunshot) Fibrinolytic agents
Extensive burns Aprotinin
Fat embolism Warfarin (especially in neonates with protein
C deficiency)
Rhabdomyolysis
Prothrombin complex concentrates
Recreational drugs (amphetamines)
Vascular Disorders Envenomation
Giant hemangiomas (Kasabach Merritt Snake
syndrome) Insects
Large vessel aneurysms (eg. aorta)
Obstetrical Complications Liver Disease
Abruptio placentae Fulminant hepatic failure
Amniotic fluid embolism Cirrhosis
Dead fetus Fatty liver of pregnancy
Septic abortion
Cancer Miscellaneous
Adenocarcinoma (prostate, pancreas, etc) Shock
Hematologic malignancies (acute Respiratory distress syndrome
promyelocytic leukemia) Massive transfusion
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Cardiovascular System
CLASSIFICATION OF MYOCARDIAL INFARCTION
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IMP POINTS
Differential cyanosis refers to isolated cyanosis affecting the lower but not the upper extremities
in a patient with a large patent ductus arterious (PDA) and secondary pulmonary hypertension
with rightto-left to shunting at the great vessel level.
Palmar crease xanthomas are specific for type III hyperlipoproteinemia.
Pseudoxanthoma elasticum, a disease associated with premature atherosclerosis, is manifested
by a leathery, cobblestoned appearance of the skin in the axilla and neck creases and by angioid
streaks on fundoscopy.
Bifid uvula has been described in patients with Loeys-Dietz syndrome.
Straight back syndrome refers to the loss of the normal kyphosis of the thoracic spine and has
been described in patients with mitral valve prolapsed (MPV) and its variants,
Patients with the Holt-Oram syndrome have an unopposable, fingerized thumb.
Kussamaul’s sign is defined by either a rise or a lack of fall of the JVP with inspiration and is
classically associated with constrictive pericarditis, although it has been reported in patients with
restrictive cardiomyopathy, massive pulmonary embolism, right ventricular infarction, and
advanced left ventricular systolic heart failure.
The length and width of the blood pressure cuffbladder should be 80% and 40% of the arm‟s
circumference, respectively.
Orthostatic hypotension is defined by a fall in systolic pressure > 20 mmHg or in diastolic
pressure > 10 mmHg in response to assumption of the upright posture from a supine position
within 3 min.
The character of the pulse is best appreciated at the carotid level.
A weak and delayed pulse (pulsus parvus et tardus) defines severe aortic stenosis (AS).
Some patients with AS may also have a slow, notched, or interrupted upstroke (anacrotic pulse)
with a thrill or shudder.
With chronic severe AR, the carotid upstroke has a sharp rise and rapid fall-off (Corrigan’s or
water-hammer pulse).
Some patients with advanced AR may have a bifid or bisferiens pulse in which two systolic peaks
can be appreaciated. A bifid pulse is also described in patients with hypertrophic obstructive
cardiomyopathy (HOCM), with inscription of percussion and tidal waves. A bifid pulse4 is easily
appreciated in patients on intraaortic balloon counterpulsation (IABP), in whom the second pulse
is diastolic in timing.
Pulsus paradoxus refers to a fall in systolic pressure > 10 mmHg with inspiration that is seen in
patients with pericardial tamponade but also is described in those with massive pulmonary
embolism, hemorrhagic shock, severe obstructive lung disease, and tension pneumothorax.
Pulsus alternans, is defined by beat-to-beat variability of pulse amplitude. It is seen in patients
with severe left ventricular systolic dysfunction and is thought to be due to cyclic changes in
intracellular calcium and action potential duration.
Most common acquired cause of thrombophilia is Antiphospholipid antibody syndrome and is
associated with venous or arterial thrombosis
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Most common gas exchange abnormalities in pulmonary embolism are arterial hypoxemia and an
increased alveolar-arterial O2 tension gradient.
The sensitivity of the D-dimer is >80% for DVT (including isolated calf DVT) and >95% for PE.
The D-dimer is less sensitive for DVT than for PE because the DVT thrombus size is smaller.
Most specific ECG finfing in pulmonary embolism is the S1Q3T3 sign : an S wave in lead 1, a Q
wave in lead III, and an inverted T wave in lead III.
The best-known indirect sign of pulmonary embolism on transthoracic echocardiography if
McConnell‟s sign : hypokinesis of the RV free wall with normal or hyperkinetic motion of the RV
apex.
A normal or nearly normal chest x-ray often occurs in Pulmonary embolism. Well-
established abnormalities include focal oligemia (Westermark‟s sign), a peripheral wedged-
shaped density above the diaphragm (Hampton‟s hump), and an enlarged right descending
pulmonary artery (Palla‟s sign).
May Thurner syndrome – Left iliac vein is occluded or stenosed by extrinsic compression
from the overlapping right common iliac artery.
Most common presenting symptom of pulmonary hypertension is dyspnea.
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DIFFERENTIAL DIAGNOSIS OF ST-SEGMENT ELEVATIONS
Ischemia/myocardial infarction
Noninfarction, transmural ischemia (Prinzmetal‟s angina, and probably Tako-tsubo syndrome, which
may also exactly simulate classical acute infarction)
Acute myocardial infarction
Postmyocardical infarction (ventricular aneurysm pattern)
Acute pericarditis
Normal variants (including benign “early repolarization” patterns)
Left ventricular hypertrophy/left bundle branch blocka
Other (rarer)
Acute pulmonary embolisma
Brugada patterns (right bundle branch block-like pattern with ST elevations in right precordial leads)a
DC cardioversion
Hypercalcemiaa
Hyperkalemiaa
Hypothermia (J [Osborn] waves)
Nonischemic myocardial injury
Myocarditis
Tumor invading left ventricle
Trauma to ventricles
a
Usually localized to V1-V2 or V3.
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dilation; mitral appears involvement; frequent septum interaction;
earlier during mitral and tricuspid mitral regurgitation
decompensation: regurgitation, rarely
tricuspid regurgitation severe
with right ventricular
dysfunction
Congestive symptomsa Left before right, Right often dominates Left-sided congestion at
except right prominent rest may develop late
in young adults
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knock
Electrocardiogram
Low ECG ++ ++ ++ – ++
voltage
Electrical ++ – – – +
alternans
Echocardiogram
Thickened – +++ – – ++
pericardium
Pericardial – ++ – -
calcification
Pericardial +++ – – ++
effusion
RV size Usually Usually Usually normal Enlarged
small normal
RA and RV +++ – – –
Exaggerated +++ – +++ +++
respiratory
variation in (flow
velocity)
CT/MRI
Thickened ++ – +++ –
pericardium
Cardiac
catheterization
Equalization of ++ – +++ +++
diastolic pressures
Abbreviations : +++, always present: ++, usually present. +, rare; DC diastolic collapse; ECG
electrocardiograph: RA, right atrium, RV, right ventricle; RVMI, right ventricular myocardial
infarction.
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MEMBRANOPROLIFERATIVE GLOMERULONEPHRITIS
Absolute indications
Sjögren‟s syndrome
Sarcoidosis
SLE interstitial nephritis
Adults with TINU
Idiopathic and other granulomatous interstitial nephritis
Relative Indications
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CLASSIFICATION FOR LUPUS NEPHRITIS
Class I Minimal mesangial Normal histology with mesangial deposits
Class II Mesangial proliferation Mesangial hypercellularity with expansion of
the mesangial matrix
Class III Focal nephritis Focal endocapillary + extracapillary
proliferation with focal subendothelial
immune deposits and mild mesangial
expansion
Class IV Diffuse nephritis Diffuse endocapillary + extracapillary
proliferation with diffuse subendothelial
immune deposits and mesangial alterations
Class V Membranous nephritis Thickened basement membranes with diffuse
subepithelial immune deposits; may occur
with class III or IV lesions and is sometimes
called mixed membranous and proliferative
nephritis.
Class VI Sclerotic nephritis Global sclerosis of nearly all glomerular
capillaries
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Respiratory System
IMPORTANT POINTS
The excess frequency of lung cancer in asbestos workers is associated with a minimum latency of
15-19 years between first exposure and development of the disease.
Relatively shortterm asbestos exposures of < 1-2 years, occurring up to 40 years in the past, have
been associated with the development of mesotheliomas.
The clinical and pathologic features of acute silicosis are similar to those of pulmonary alveolar
proteinosis.
In Silicosis, the chest radiograph may show profuse military infiltration of consolidation and there
is a characteristic HRCT pattern knows as “crazy paving”.
Calcification of hilar nodes may occur in as many as 20% of cases of silicosis and produces a
characteristic “eggshell” pattern.
Because silica is cytotoxic to alveolar macrophages, patients with silicosis are at greater risk of
acquiring lung infections that involve these cells as a primary defense (Mycobacterium
tuberculosis, atypical myobacteria and fungi)
Caplan syndrome, first described in coal miners but subsequently in patients with silicos, is the
combination of pneumoconiotic nodules and seropositive rheumatoid arthritis.
Byssinosis is characterized clinically as occasional (early-stage) and then regular (late-stage)
chest rightness toward the end of the first day of the workweek (“Monday chest tightness”).
Bronchiectasis is more common among women than among men.
The most common form of bronchiectasis is cylindrical or tubular.
Bronchiectasis seen in associated with cystic fibrosis and post radiation fibrosis mostly involves
the upper lung fields.
Bronchiectasis resulting from infection by nontuberculous mycobacteria (NTM), most commonly
the Mycobacterium avium-intracellulare complex (MAC), often preferentially affects the midlung
fields.
Congenital bronchiectasis in association with immotile cilia syndrome involves predominantly the
midlung fields.
Allergic Bronchopulmonary aspergillosis also is associated with central bronchiectasis.
Most common cause of superior vena cava syndrome is small cell carcinoma lung.
Erosion of the pedicles (the “winking owl” sign) is the earliest radiologic finding of vertebral
metastatic tumor.
Tumor lysis syndrome (TLS) is characterized by hyperuricemia, hyperkalemia,
hyperphosphatemia, and hypocalcemia and is caused by the destruction of a large number of
rapidly proliferation neoplastic cells.
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• Hermansky-Pudlak syndrome is an autosomal recessive disorder in which granulomatous colitis
and ILD may occur.
• Lymphocytic Interstitial Pneumonitis is a rare form of ILD, that has been reported in Sjogren
syndrome and HIV infection.
• Light‟s criteria for differentiating exudative and transudative pleural effusion. Exudative pleural
effusions meet at least one of the following criteria, whereas transudative pleural effusions meet
none.
1. Pleural fluid protein/serum protein > 0.5
2. Pleural fluid LDH/serum LDH > 0.6
3. Pleural fluid LDH more than two-thirds the normal upper limit for serum.
• A pleural fluid N=terminal pro-brain natriuretic peptide (NT-proBNP) >1500 pg/mL is virtually
diagnostic that the pleural effusion is secondary to congestive heart failure.
• The three tumors that cause – 75% of all malignant pleural effusions are lung carcinoma, breast
carcinoma and lymphoma.
• The most common cause of chylothorax is trauma (most frequently thoracic surgery)
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beryllium
Silicosis Dust particles by polarized light microscopy
Lipoidosis Accumulation of specific lipopigment in alveolar
macrophages.
Apnea-hypopnea index (AHI)a Number of apneas plus hypopneas per hour of sleep
Respiratory disturbance index (RDI) : Number of apneas plus hypopneas plus RERAs per hour
of sleep
Mild OSAH: AHI of 5-14 events/h
Moderate OSAHS : AHI of 15-29 events/h
Severe OSAHS : AHI of >30 events/h
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CLINICAL DISORDERS COMMONLY ASSOCIATED WITH ARDS
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DIAGNOSTIC CRITERIA FOR IRRITABLE BOWEL SYNDROMEa
Recurrent abdominal pain or discomfortb at least 3 days per month in the last 3 months associated
with two or more of the following :
1. Improvement with defecation
2. Onset associated with a change in frequency of stool
3. Onset associated with a change in form (appearance of stool)
a
Criteria fulfilled for the 3 months with symptom onset at least 6 months prior to diagnosis.
Discomfort means an uncomfortable sensation not described as pain In pathophysiology research and
clinical trials, a pain/discomfort frequency of at least 2 days a week during screening evaluation is
required for subject eligibility.
– + – – – 1. Immunization with
HBsAg (after
vaccination)
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SIMPLIFIED DIAGNOSTIC APPROACH IN PATIENTS PRESENTING WITH ACUTE
HEPATITIS
Serologic Tests of Patient’s Serum
HBsAg IgM Anti-HAV IgM Anti-HBc Anti-HCV Diagnostic
Interpretation
+ – + – Acute hepatitis B
+ – – – Chronic hepatitis B
+ + – – Acute hepatitis A
super-imposed on
chronic hepatitis B
+ + + – Acute hepatitis A
and B
– + – – Acute hepatitis A
– + + – Acute hepatitis A
and B (HB-sAg
below detection
threshold
– – + – Acute hepatitis B
(HBsAg below
detection
threshold)
– – – – + Acute hepatitis C
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a
Antibodies to liver kidney microsomes type 1 (autoimmune hepatitis type 1 and some cases of
hepatitis C). bAdministered as a triple drug combination with PEG IFN and ribavirin. 2 additional
drugs are also approved for hepatitis C, simeprevir and sofosbuvir (see www.hcvguidelines.org)
„Early clinical trials suggested benefit of IFN-a therapy, PEG IFN-α is as effective, if not more so, and
has supplanted standard IFN-α dAntinuclear antibody (autoimmune hepatitis type 1). “Antibodies to
soluble liver antigen (autoimmune hepatitis type III).
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Treatment Algorithm For Alcoholic Hepatitis
Alcoholic Hepatitis
Alcoholic abstinence
Nutritional support
Treatment options
Preferred Alternative
As identified by a calculated discriminant function >32 patients with severe alcoholic hepatitis,
without the presence of gastrointestinal bleeding or infection, would be candidates for either
glucocorticoids or pentoxifylline administration.
A discriminant function calculated as; 4.6× (the prolongation of the prothrombin time above control
[seconds]) + serum bilirubin (mg/dL) can identify patients with a poor prognosis (discriminant
function > 32). The drug of choice for alcoholic hepatitis with poor discriminant function is steroids.
Zieve‟s syndrome is a unique form of hemolytic anemia that occurs in patients with severe
alcoholic hepatitis.
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CONTRAINDICATIONS LIVER TRANSPLANTATION
Absolute Relative
Uncontrolled extrahepatobiliary infection Age >70
Active, untreated sepsis Prior extensive hepatobiliary surgery
Uncorrectable, life-mimiting congenital Portal vein thrombosis
anomalies Renal failure not attributable to liver disease
Active substance or alcohol abuse Previous extrahepatic malignancy (not including
Advanced cardiopulmonary disease nonmelanoma skin cancer)
Extrahepatobiliary malignancy (not including Severe obesity
non-melanoma malignancy skin cancer) Severe malnutrition/wasting
Metastatic malignancy to the liver Medical noncompliance
Cholangiocarcinoma HIV seropositivity with failure to control HIV
AIDS viremia or CD4 <100/µl
Life threatening systemic diseases Intrahepatic sepsis
Severe hypoxemia secondary to right to left
intrapulmonary shunts (PO2, <50 mm Hg)
Severe pulmonary hypertension (mean
pulmonary artery pressure >35 mm Hg)
Uncontrolled psychiatric disorder
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NEUROLOGY
FEATURES THAT DISTINGUISH GENERALIZED TONIC-CLONIC SEIZURE FROM
SYNCOPE
Cerebrovascular Diseases
Dementia associated with cerebrovascular disease can be divided into two general categories:
multi-infarct dementia and diffuse white matter disease (also called leukoaraiosis, subcortical
arteriosclerotic leukoencephalopathy, or Binswanger‟s disease.)
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CLASSIFICATION OF SEIZURES
1. Focal seizures
(Can be further described as having motor, sensory, autonomic, cognitive, or other features)
2. Generalized seizures
a. Absence
Typical
Atypical
b. Tonic clonic
c. Clonic
d. Tonic
e. Atonic
f. Myoclonic
3. May be focal, generalized, or unclear
Epileptic spasms
Focal seizure – Focal seizures are usually associated with structural abnormalities of the brain. In
contrast, generalized seizures may result from cellular, biochemical, or structural abnormalities
that have a more widespread distribution.
With the new classification system, the subcategories of “simple focal seizures” and “complex
focal seizures” have been eliminated. Instead, depending on the presence of cognitive impairment,
they can be described as focal seizures with or without dyscognitive features.
Remember three additional features of focal motor seizures :
1. JACKSONIAN MARCH – Abnormal motor movements may begin in a very restricted
region such as the fingers and gradually progress (overseconds to minutes) to include a larger
portion of the extremity. Thisphenomenon represents the spread of seizure activity over a
progressively larger region of cerebral cortex.
2. TODD’s PARALYSIS – Localized paresis for minutes to many hours in the involved region
following the seizure.
3. EPILEPSY PARTIALIS CONTINUA – Seizure may continue for several hours or days.
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ADMINISTRATION OF INTRAVENOUS RECOMBINANT TISSUE PLASMINOGEN
ACTIVATOR (rtPA) FOR ACUTE ISCHEMICF STROKE I (AIS)
Indication Contraindication
Onset of symptoms to time of drug Platelets <100,000; HCT <25%; glucose <50 or >400 mg/dL
administration < 4.5 h
Use of heparin within 48 h and prolonged PTT, or elevated
CT scan showing no hemorrhage or INR
edema of > 1/3 of the MCA territory
Rapidly improving symptoms
Age 18 > years
Prior stroke or head injury within 3 months; prior intracranial
Consent by patient or surrogate hemorrhage
Coma or stupor
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SIMPLIFIED DIAGNOSTIC CRITERIA FOR MIGRAINE
Repeated attacks of headache lasting 4-72 h in patients with a normal physical examination, no
other reasonable cause for the headache, and :
At Least 2 of the Following Features : Plus at Least 1 of the Folloiwng Features :
Unilateral pain
Throbbing pain
Aggravation by movement Nausea/vomiting
Moderate or severe intensity Photophobia and phonophobia
Calcitonin gene related peptide is an important vasoactive neuropeptide implicated in the
pathogenesis of migraine.
CGRP receptor antagonists 9gepants) have now been shown to be effective in the acute treatment
of migraine, and monoclonal antibodies to CGRP have been shown effective in two early phase
clinical trials.
Data also support a role for dopamine in the pathophysiology of migraine.
Most drugs effective in the treatment of migraine are members of one of three major
pharmacologic classes : nonsteroidal anti-inflammatory drugs, 5-HT1B/1D receptor agonists, and
dopamine receptor antagonists.
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Alzhemer’s Disease
Most common cause of dementia in the elderly (though it can manifest as young as the third
decade).
The most important risk factors are old age and a positive family history.
The major genetic risk for AD is apolipoprotein E4 (Apo E4).
Several genes play an important role in the pathogenesis of AD One is the APP gene on
chromosome 21. Adults with trisomy 21 (Down‟s syndrome) consistently develop the typical
neuropathologic hallmarks of AD if they survive beyond age 40 years.
The other risk factors are female sex, history of head trauma, low educational status, diabetes
mellitus.
Elevated homocysteine and cholesterol levels; hypertension; diminished serum levels of folic
acid; low dietary intake of fruits, vegetables and red wine; and low levels of exercise are all being
explored as potential risk factors for AD.
Patients most often present with an insidious loss of episodic memory followed by a slowly
progressive dementia that evolves over years.
At autopsy, the earliest and most severe degeneration is usually found in the medial temporal lobe
(entorhinal/perirhinal cortex and hippocampus), lateral temporal cortex, and nucleus basalis of
Meynert.
The characteristic microscopic findings are neuritic plaques and neurofibrillary tangles.
Increaisng evidence suggests that soluble amyloid species called oligomers may cause cellular
dysfunction and represent the early toxic molecule in AD.
Donepezil, Rivastigmine, Galantamine and Memantine are approved by PDA for treatment of
AD.
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impulsitivity, or apathy)
Shortly thereafter, a progressive oculomotor syndrome ensues that begins with square wave jerks,
followed by slowed saccades 9vertical worse than horizontal) before resulting in progressive
supranuclearophthalmoparesis.
Dysarthria, dysphagia, and symmetric axial rigidity can be prominent features that emerge at any
point in the illness.
A stiff unstable posture with hyperextension of the neck and a slow, jerky, toppling gait are
characteristic.
Frequent unexplained and sometimes spectacular falls are common secondary to a combination of
axial rigidity, inability to look down, and poor judgment.
The dementia overlaps with behavioural FTD, featuring apathy, frontal-executive dysfunction,
poor judgement, slowed through processes, impaired verbal fluency, and difficulty with sequential
actions and with shifting from one task to another.
Response to L-dopa is limited or absent; no other treatments exist.
RADIOLOGY : Hummingbird sign and Mickey mouse sign are MRI signs (occurs due to
midbrain atrophy).
IMPORTANT POINTS
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IMPORTANT POINTS
Tangier disease is caused by mutations in the ATP-binding cassette transporter 1 (ABC1) gene,
which leads to markedly reduced levels of high-density lipoprotein (HDL) cholesterol levels,
whereas triacylglycerol levels are increased. The tonsils may appear swollen and yellowish-
orange in color.
Most common cause of Familial Amyloid Polyneuropathy is mutation in the gene coding for
transthyretin.
Distal Symmetric Sensory and Sensorimotor Polyneuropathy (DSPN) is the most common form
of diabetic neuropathy.
Most common cranial nerve affected in sarcoidosis is seventh nerve.
Most common cranial nerve affected in Lyme disease is seventh nerve.
Distal Symmetric Polyneuropathy (DSP) is the most common form of peripheral neuropathy
associated with HIV infection and usually is seen in patients with AIDS.
Lumbosacral polyradiculoneuropathy in AIDS patients is usually secondary to CMV infection.
INH related peripheral neuropathy is more common among the slow acetylators.
Vitamin B6, or pyridoxine, can produce neuropathic manifestations from both deficiency and
toxicity.
The neuropathy affecting lateral femoral cutaneous nerve is called Meralgiaparesthetica.
Immune-Mediated Brachial Plexus Neuropathy is also known as acute brachial plexitis,
neuralgicamyotrophy or Parsonage-Turner syndrome.
The most common surgical procedures associated with brachial plexopathy as a complication are
those that involve median sternotomines (e.g: open-heart surgeries and thoracotomies).
Polyclonal antineuronal antibodies (IgG) directed against the so called “Hu antigen”, are found in
the sea or CSF in the majority of patients with paraneoplastic sensory neuropathy.
World Federation of Neurology has established diagnostic guidelines for ALS. Essential for
the diagnosis is simultaneous upper and lower motor neuron involvement with progressive
weakness and the exclusion of all alternative diagnoses. The disorder is ranked as : “definite”
ALS when three or four of the following are involved: bulbar, cervical, thoracic, and
lumbosacral motor neurons.When two sites are involve, the diagnosis is “probable” and when
only one site is implicated, the diagnosis is “possible.”
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SUBTYPES OF GUILLAIN-BARRE SYNDROME (GBS)
Acute motor sensory Mostly adults; Axonal Same AMAN, but also
axonal neuropathy uncommon; recovery affects sensory nerves
(AMSAN) slow, often incomplete; and roots; axonal
closely related to damage usually severe
AMAN
Antibiotics
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Beta-blocking agents
Botulinum toxin
Quinine derivatives
Magnesium
Penicillamine
May cause MG
Cyclosporine
Broad range of drug interactions, which may raise or lower cyclosporine levels..
Azathioprine
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Peripheral Neuropathy
Guillain-Barre syndrome
Miller Fisher syndrome
Neuromuscular Junction
Botulism
Lambert-Eaton syndrome
Myasthenia gravis
Congenital myasthenia
Myopathy
Mitochondrial myopathies
Kearns-Sayre syndrome
Progressive external ophthalmoplegia
Oculopharyngeal and oculopharyngodistal muscular dystrophy
Myotonic dystrophy (ptosis only)
Congenital myopathy
Myotubular
Nemaline (ptosis only)
Hyperthyroidism/Graves‟ disease (ophthalmoplegia without ptosis)
Hereditary inclusion body myopathy type 3
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to adult girdle muscles
Able to walk
after age 15
Respiratory
failure may
develop by fourth
decade
Limb-girdle AD/AR Several Early Slow progressive + Cardiomyo-
childhood weakness of pathy
to early shoulder and hip
adult girdle muscles
Emery-Dreifuss XR/AD Emerin. Childhoo Elbow/knee/ankl Cardiomyopathy
Lamin A/C d to adult e contractures,
Nesprin-1, humeral and
nesprin 2, peroneal
TMEM43 weakness
Congenital AR AR Several At birth Hypotonia, CNS
or within contractures, abnormalities
first few delayed (hypomyelination
months milestones , malformation)
Progression to Eye abnormalities
respiratory
failure in some;
static course in
others
Myotonic(DM1, AD DM1 : Childhoo Slowly Cardiac
DM2) Expansion d to adult; progressive conduction
CTG repeat possibly weakness of face, defects
DM2 : infancy if shoulder girdle, Mental
Expansion mother and foot impairment
CCTG repeat affected dorsiflexion Cataracts
(DM1 Preferential Frontal baldness
only) proximal
Gonadal atrophy
weakness in
DM2
FSHD1 AD DUX44q Childhoo Slowly Deafness
d to adult progressive
weakness of face,
shoulder girdle,
and foot
dorsiflexion
FSHD2 AD SMCHD1 Coats‟ (eye)
disease
Oculopharyngea AD Expansion, Fifth to Slowly
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l poly A RNA sixth progressive
binding decade weakness of
protein extra-ocular,
pharyngeal, and
limb muscles
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DRUG-INDUCED MYOPATHIES
Lipid-lowering agents Drugs belonging to all three of the major classes of lipid-lowering
Fibric add derivatives agents can produce a spectrum of toxicity, asymptomatic serum
creatine kinase elevation, myalgias, exercise-induced pain,
HMG-CoA reductase inhibitors
rhabdomyolysis, and myoglobinuria.
Niacin (nicotinic acid)
Drugs of abuse
Alcohol All drugs in this group can lead to widespread muscle breakdown,
Amphetamines rabdomyolysis, and myoglobinauria.
Cocaine Local injections cause muscle necrosis, skin induration, and limb
comtractures
Heroin
Phencyclidine
Meperidine
Autoimmunie toxic myopathy - Use of this drug may cause polymyositis and myasthenia gravis.
Penicillamine
Amphophilic cationic drugs All amphophilic drugs have the potential to produce painless,
Amiodarone proximal weakness associated with autophagic vacuoles in the
muscle biopsy.
Chloroquine
Hydroxychloroquine
Antimicrotubular drugs This drug produces painless, proximal weakness especially in the
Colchicine setting of renal failure. Muscle biopsy shows autophagic vacuoles.
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IMPORTANT POINTS
Prolactin is unique among the pituitary hormones in that the predominant central control
mechanism is inhibitory reflecting dopamine mediated suppression of PRL release.
Most abundant anterior pituitary hormone is growth hormone, and GH-secreting somatotrope
cells constitute up to 50% of the total anterior pituitary cell population.
Growth hormone receptor antagonist (Pegvisomant) is approved for the treatment of acromegaly.
Most common hormone deficiency after cranial irradiation is growth hormone.
Homozygous or heterozygous mutations of the GH receptor are associated with partial or
complete GH insensitivity and growth failure (Laron‟s syndrome).
Hypogonadism is the most common presenting feature of adult hypopituitarism even when other
pituitary hormones are also deficient.
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Pituitary adenomas are the most common cause of pituitary hormone hypersecretion and
hyposecretin syndromes in adults.
Hyperprolactinemia is the most common pituitary hormone hypersecretion syndrome in both men
and women.
Amenorrhea, galactorrhea, and infertility are the hallmarks of hyperprolactinemia in women.
In men with hyperprolactinemia, diminished libido, infertility, and visual loss (from optic nerve
compression) are the usual presenting symptoms.
The female-to-male ratio for microprolactinomas (<1 cm) is 20:1, whereas the sex ratio is near 1:1
for macroadenomas (>1 cm).
Children with GnRH producing hypothalamic hamartomas present with precocious puberty,
psychomotor delay, and laughing-associated seizures. (gelastic seizures)
MEDNIK syndrome (mental retardation, enteropathy, deafness, neuropathy, ichthyosis,
keratodermia) is a rare multi-system disorder of copper metabolism with both features of
Menkes and Wilson‟s disease.
CRANIOPHARYNGIOMAS
Benign, suprasellar cystic masses derived from the Rathke‟s pouch
They are often large, cystic, and locally invasive
Many are partially calcified, exhibiting a characteristic appearance on skull x-ray and CT images.
More than half of all patients present before age 20, usually with signs of increased intracranial
pressure, including headache, vomiting, papilledema, and hydrocephalus.
Associated symptoms include visual field abnormalities, personality changes and cognitive
deterioration, cranial nerve damage, sleep difficulties, and weight gain.
Hypopituitarism can be documented in about 90%, and diabetes insipidus occurs in about 10% of
patients
About half of affected children present with growth retardation.
MRI is generally superior to CT for evaluating cystic structure and tissue components of
craniopharyngiomas. CT is useful to define calcifications and evaluate invasion into surrounding
bony structures and sinuses.
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Female : Male %
Causes of Cushing’s Syndrome Ratio
ACTH-Dependent Cushing’s 90
Cushing‟s disease (=ACTH-producing pituitary adenoma) 4:1 75
Ectopic ACTH syndrome (due to ACTH secretion by bronchial or 1:1 15
pancreatic carcinoid tumors, small-cell lung cancer, medullary thyroid
carcinoma, pheochromocytoma and others)
ACTH-Independent Cushing’s 4:1 10
Adrenocortical adenoma 5-10
Adrenocortical carcinoma 1
Rare causes: macronodular adrenal hyperplasia; primary pigmented <1
nodular adrenal disease (micro-and/or macronodular); McCune-Albright
syndrome
1. Headaches
2. Profuse sweating
3. Palpitations and tachycardia
4. Hypertension, sustained or paroxysmal
5. Anxiety and panic attacks
6. Pallor
7. Nausea
8. Abdominal pain
9. Weakness
10. Weight loss
11. Paradoxical response to antihypertensive drugs
12. Polyuria and polydipsia
13. Constipation
14. Orthostatic hypotension
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15. Dilated cardiomyopathy
16. Erythrocytosis
17. Elevated blood sugar
18. Hypercalcemia
The classic “rule of tens” for pheochromocytoma states that ~10% are bilateral, ~10% are
extraadrenal and ~10% are malignant.
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MTC only (FMTC) is a variant in which MTC is the some manifestation of the syndrome.
MTC is the most common feature of MEN 2A and MEN 2B and occurs in almost all affected
individuals.
Patients with MEN 1 associated tumors such as pituitary adenomas, and pancreatic NETs,
occurring in association with gonadal, adrenal, renal and thyroid tumors have been reported to
have mutations in the gene encoding the 196 amino acid cyclin-dependent kinase inhibitor (CK1)
p27kipl (CDNKIB). Such families with MEN 1 associated tumors and CDNKIB mutations are
designated to have MEN-4.
I. Type 1 diabetes (beta cell destruction, usually leading to absolute insulin deficiency)
A. Immune-mediated
B. Idiopathic
II. Type 2 diabetes (may range from predominantly insulin resistance with relative insulin
deficiency to a predominantly insulin secretory defect with insulin resistance)
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E. Drug or chemical-induced–glucocorticoids, vacor (a rodenticide), pentamidine, nicotinic acid,
diazoxide, adrenergic agonists, thiazides, calcineurin and mTOR inhibitors, hydantoins,
asparaginase, interferon, protease inhibitors, antipsychotics (atypicals and others),
epinephrine
F. Infections–congenital rubella, cytomegalovirus, coxsackievirus
G. Uncommon forms of immune-mediated diabetes–“stiff-person” syndrome, anti-insulin
receptor antibodies
H. Other genetic syndromes sometimes associated with diabetes–Wolfram‟s syndrome, Down‟s
syndrome, Klinefelter‟s syndrome, Turner‟s syndrome, Huntington‟s chorea, Laurence-
Moon-Biedl syndrome, myotonic dystrophy, porphyria, Prader-Willi syndrome.
Maturity onset diabetes of the young (MODY) and monogenic diabetes are subtypes of DM
characterized by Autosomal dominant inheritance, early onset of hyperglycemia (usually <25 years;
sometimes in neonatal period), and impaired insulin secretion.
Index Goal
Glycemic controlb
HbA1c <7.0%c
Preprandial capillary plasma glucose 4.4-7.2 mmol/L (80-130 mg/dL)
Peak postprandial capillary plasma glucosed <10.0 mmol/L (<180 mg/dL)
Blood pressure <140/90 mmHge
Lipidsf
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As recommended by the American Diabetes Associateion; goals should be individualized for each
patient. Goals may be different for certain patient populations. bHbA1c is primary goal. cDiabetes
Control and Complications Trial-based assay. d1-2h after beginning of a meal. eGoal of <130/80
mmHg may be appropriate for younger individualsf in decreasing order of priority. Recent guidelines
from the American College of Cardiology and American Heart Association no longer advocate
specific LDL and HDL goals. gGoal of 1.8 mmol/L (70 mg/dL) may be appropriate for individuals
with cardiovascular disease.
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First step in evaluating patients presenting with hepatic decompensation is to establish disease
severity, which can be estimated with the Nazer Prognostic Index. Patients with scores <7 can usually
be managed with medical therapy. Patients with scores >0 should be considered immediately for liver
transplantation. For patients with scores between 7 and 9, clinical judgment is required in deciding
whether to recommended trans plantation or medical therapy.
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PROGNOSTIC INDEX OF NAZER
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DISEASES OF IMMUNITY
COMPLEMENT DEFICIENCIES AND ASSOCIATED DISEASES
Component Associated Diseases
Classic Pathway
Clq, Clr, Cls, C4 Immune-complex syndromes,a pyogenic infections
C2 Immune-complex syndromes,a few with pyogenic infections
C1 inhibitor Rare immune-complex disease, few with pyogenic infections
C3 andAlternative Pathway C3
C3 Immune-complex syndromes,a pyogenic infections
D Pyogenic infections
Properdin Neisseria infections
I Pyogenic infections
H Hemolytic-uremic syndrome
Membrane Attack Complex
C5, C6, C7, C8 Recurrent Neisseria infections, immune-complex disease
C9 Rare Neisseria infections
a
Immune-complex syndromes include systemic lupus-erythematosus (SLE) and LSE-like syndromes,
glomerulonephritis, and vasculitis syndromes.
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CLASSIFICATION CRITERIA FOR RHEUMATOID ARTHRITIS
SCORE
Joint involvement 1 large joint (shoulder, elbow, hip, knee, ankle) 0
2-10 large joints 1
1-3 small joints (MCP PIP, thumb IP MTP wrists) 2
4-10 small joints 3
>10 joints (at least 1 small joint) 5
Serology Negative RF and negative ACPA 0
Low-positive RB or low-positive anti-CCP 2
antibodies
(<3 times ULN) 3
High-positive RF r high-positive and – CCP
antibodies (>3 times ULN
Actual-phase reactants Normal CRP and normal ESR 0
Abnormal CRP or abnormal ESR 1
Durartion of symptoms <6 weeks 0
>6 weeks 1
Note : These criteria are aimed at classification of newly presenting patients who have at least one
joint with definite clinical synovitis that is not better explained by another disease A score of
>6fulfills requirements for definite RA.
Abbreviatins : ACPA, anti-circullinated peptide antibiotics; CCP, cyclic circullinated peptides: CRP,
C-reactive protein; ESR, erythrocyte sedimentation rate; IP, interphalanagitis joint; MCR
metacarpohalangeal joint. MTP metatarsophalangel joint; PIP, Proximal interphalangeal, joint; RF,
rheumatoid factor, ULN, upper limit of normal.
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DISORDERS ASSOCIATED WITH RELAPSING POLYCHONDRITISa
Systemic vasculitis
Rheumatoid arthritis
Systemic lupus erythematosus
Overlapping connective tissue disease
Spondyloarthritides
Bechcet‟s disease
Polymyalgia rheumatic
Primary biliary cirrhosis
Pulmonary fibrosis
Hashimoto‟s thyroiditis
Myelodysplastic syndrome
a
Systemic vasculitis is the most common association, followed by rheumatoid arthritis and systemic
lupus erythematosus.
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ONCOLOGY
TUMOR MARKERS
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ANTIBODIES USED IN CANCER TREATMENT
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Immunoregulatory Antibodies
Alemtuzumab CD52 CLL, T cell lymphomas;
activates complement after
binding to cell surface; infusion
reactions, hypersensitivity, tumor
lysis, activation of infections,
dcytopenias
Ipilimumab CTLA4 Melanoma inhibits the negative
proliferative signal to T cells
acting through CTLA4, resulting
in prominent T cell activation;
side effects include immune-
mediated toxicity to liver, skin,
pituitary, gut, which if severe
calls for steroids, which inhibit
antineoplastic effect
Pembrolizumab PD-1 Melanoma unresectable or
metastatic and if B-RAF V600
mutated, refractory to a B-BAF
inhibitor; also can cause immune
related colitis, hepatitis,
hypophysitis, nephritis, and
altered thyroid function; also
consider steroids for treatment of
severe adverse events.
Abbreviations : CLL-Chronic Lymphocytic Leukemia: EGFR-Epidermal growth factor receptor; GI-
Gastrointestinal; HBP-High blood pressure; VEGF-Vascular Endothelial Growth Factor.
Tumor-regulatory antibodies target tumor cells directly or indirectly to modulate intracellular
functions of attract immune or stromal cells.
Immunoregulatory antibodies target antigens expressed on the tumor cells or host immune cells to
modulate primarily the host‟s immune responsiveness to the tumor.
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PARANEOPLASTIC HEMATOLOGIC SYNDROMES
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INFECTIOUS DISEASES
TYPICAL CSF PROFILES MENINGITIS AND ENCEPHALITS
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EPIDEMIOLOGIC FACTORS SUGGESTING POSSIBLE CAUSES OF COMMUNITY-
ACQUIRED PNEUMONIA
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IMPORTANT POINTS
Organisms Causing Major Clinical Forms of Endocarditis
Most common cause of native valve endocarditis – Staph aureus
Most common cause of prosthetic valve endocarditis < 1 year after valve surgery – Coagulase
negative Staph
Most common cause of prosthetic valve endocarditis > 1 year after valve surgery – Strep viridans
Most common cause of right sided endocarditis in i.v drug users – Staph aureus
Most common cause of left sided endocarditis in i.v drug users – Enterococci > Staph aureus
Most common cause of endocarditis in i.v drug users overall – Staph aureus
Major Criteria
1. Positive blood culture
Typical microorganism for infective endocarditis from two separate blood cultures
Viridans streptococci, streptococcus gallolyticus, HACEK group organisms,
staphylococcus aureus, or
Community acquired enterococci in the absence of a primary focus,
Or
Persistently positive blood culture, defined as recovery of a microorganism consistent with
infective endocarditis from Blood cultures drawn > 12 h apart, or
All of 3 or a majority of >4 separate blodd cultures, with first and last drawn at least 1 h
apart
Or
Single positive blood culture for Caxiellaburnetti or phase 1 IgG antibody titer of >1800
2. Evidence of endocardial involvement
Positive echocardial involvement
Positive echocardiogramb
Oscillating intracardiac mass on valve or supporting structures or in the path of
regurgitant jets or in implanted material, in the absence of an alternative anatomic
explanation, or
Abscess, or
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Indication Antibiotic
Preterm infants to infants <1 month Ampicillin + cefotaxime
Infants 1-3 months Ampicillin + cefotaxime or ceftriaxone
Immunocompetent children >3 months and adults Cefotaxime, ceftriaxone, or cefepime +
<55 vancomycin
Adults >55 and adults of any age with alcoholism Ampicillin + cefotaxime, ceftriaxone or
or other debilitating illnesses cefepime + vancomycin
Hospital acquired meningitis, posttraumatic or Ampicillin + ceftazidime or meropenem +
postneurosurgery meningitis, neutropenic vancomycin
patients, or patients with impaired cell-mediated
immunity
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Infected Site Early (<1 Month) Middle (1-4 Months) Late (>6 Months)
Donor organ Bacterial and fungal CMV infection EBV infection (may
infections of the graft, present in allograft
anastomotic site, and organ)
surgical wound
Systemic Bacteremia and CMV infection (fever, CMV infection,
candidemia (often bone marrow especially in patients
resulting from central suppression) given early post-
venous catheter transplantation
colonization) prophylaxis; EBV
proliferative syndromes
(may occur in donor
organs)
Lung Bacterial aspiration Pneumocystis infection; Pneumocystis infection;
pneumonia with CMV pneumonia granulomatous lung
prevalent nosocomial (highest risk in lung diseases (nocardial and
organisms associated transplantation), reactivated fungal and
with intubation and Aspergillus infection mycobacterial diseases)
s3edation (highest risk (highest risk in lung
in lung transplantation) transplantation)
Kidney Bacterial and fungal Kidney transplantation; Kidney transplantation:
(Candida) infections BK virus infection bacterial infections
(cystitis, (associated with (late urinarty tract
pyelonephritis) nephropathy); JC virus infections, usually not
associated with urinary infection associated with
tract catheters (highest bacteremia); BK virus
risk in kidney infection (nephropathy,
transplantation) graft failure,
generalized
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Infected Site Early (<1 Month) Middle (1-4 Months) Late (>6 Months)
vasculopathy)
Live and biliary tract Cholangitis CMV hepatitis CMV hepatitis
Heart Toxoplasma gondii t. gondii (highest risk in
infection (highest risk heart transplantation)
in heart
transplantation);
endocarditis
(Aspergillus and gram-
negative organisms
more common than in
general population)
Gastro-intestinal tract Peritonitis, especially Colitis secondary to Colitis secondary to C
after liver Clostridium difficile difficile infection (risk
transplantation infection (risk can can persist)
persist)
Central nervous Listeria infection Listerial meningitis;
system (meningitis); T. gondii cryptococcal
infection; CMV meningitis; nocaridal
infection abscess; JC virus-
associated PML
IMPORTANT POINTS
Most common cause of septic arthritis in native joints in both adults and children is Staph.
Aureus.
Most common coagulase negative staph causing human infection is Staph epidermidis.
Most abundant bacterial species in normal skin flora of humans is Staph epidermidis.
Drug of choice for listeriosis is Ampicillin.
Granulomatosis infantiseptica is an overwhelming listerial fetal infection with military
microabscesses and granulomas, most often in the skin, liver and spleen.
Most common clinical manifestation of gonorrhea in male patients is acute urethritis.
Most common bacterial cause of exacerbation of COPD is non-typhable H.influenzae.
Most common species isolated from cases of HACEK endocarditis is Haemophilus
parainfluenzae.
Most common mode of transmission of Legionella is aspiration > aerosolization.
Urinary antigen test is highly sensitive and specific for detection of legionella.
Most common heart valve affected in Bartonella endocarditis is aortic valve.
Most common form of nocardial disease in the respiratory tract is pneumonia.
Most common extra-pulmonary site of dissemination of nocardia is brain.
Drug of choice for nocardiosis is sulfonamide.
Most common site of post-primary disease in tuberculosis is apical and posterior segments of
upper lobe.
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Most common site of spinal TB in children-upper thoracic spine.
Most common site of spinal TB in adults – lower thoracic and upper lumbar vertebrae.
First bacterium to be etiologically associated with human disease was Mycobacterium leprae.
“Fish tank granuloma” is associated with Mycobacterium marinum.
First antimicrobial agent used for the treatment of tuberculosis was Streptomycin.
Least potent first line drug against Mycobacterium tuberculosis is Ethambutol.
Pyrazinamide is more active against slowly replicating M. tuberculosis than against actively
replicating organisms.
Most common causative organism of nongonococcal arthritis and postgonococcal arthritis is
Chlamydia trachomatis.
Most common clinical manifestations of first episode of HSV-1 infection is gingivostomatitis and
pharyngitis.
Most common clinical manifestation of reactivation of HSV-1 infection is recurrent herpes
labialis.
Most common cause of recurrent lymphocytic meningitis (Mollaret meningitis) is HSV.
Neonatal HSV infection is more commonly caused by HSV-2 >HSV-1.
Most common infectious complication of varicella is secondary bacterial superinfection of the
skin, which is usually caused by Streptococcus pyogenes or Staphylococcus aureus.
Most common extracutaneous site of involvement of chickenpox in children is the CNS.\
Most common clinical manifestation of CMV infection in immunocompetent hosts beyond the
neonatal period is heterophile-antibody negative mononucleosis syndrome.
Most common viral pathogen complicating organ transplantation is CMV.
Most common hematologic abnormalty in HIV infected patients is anemia.
Most common abnormal fundus finding in HIV infection are cotton wool spots.
Most common aspergillus species implicated in fungal ball (aspergilloma) is A. fumigatus
Most common form of mucormycosis is rhino-orbito-cerebral mucormycosis.
Primary amebic meningoencephalitis is caused by Naegleria fowleri.
Granulomatous amebic encephalitis is caused by Acanthamoeba species.
Enlargement of the nodes of the posterior cervical triangle, or Winterbottom‟s sign is a classic
finding in sleeping sickness.
Cutaneous larva migrans is also known as “creeping eruption”.
Most common cause of human eosinophilic meningitis is Angiostrongylus cantonensis.
Angiostrongylus cantonensis is also known as “rat lungworm”.
Largest intestinal nematode parasite of humans is Ascaris lumbricoides.
Most common cestode infection is Hymenolepiasis nana.
Hymenolepiasis nana is also known as “dwarf tapeworm”.
Brucellosis Tuberculosis
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Brucellosis Tuberculosis
Site Lumbar and others Dorsolumbar
Multiple or contiguous Contiguous
Diskitis Late Early
Body Intact until late Morphology lost early
Canal compression Rare Common
Epiphysitis Anterosuperior (Pom‟s sign) General : upper and lower disk
regions, central, subperiosteal
Osteophyte Anterolateral (parrot beak) Unusual
Deformity Wedging uncommon Anterior wedge, gibbus
Recovery Sclerosis, whole-body Variable
Paravertebral abscess Small, well-localized Common and discrete loss,
transverse process
Psoas abscess Rare More likely
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disease
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Miscellaneous
WELLS CLINICAL PREDICTION RULE FOR PULMONARY EMBOLISM
Hemoptysis 1.5
Interpretation
Pregnenolone Norepinephrine
25-Hydroxyvitamin D Insulin
Aldosterone Parathormone
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Melanonin
Postherpetic neuralgia
Diabetic neuropathy
Tension headache
Migraine headache
Rheumatoid arthritis
Chronic low back pain
Cancer
Central poststroke pain
IMPORTANT POINTS
Anomic aphasia is the single most common language disturbance seen in head trauma,
metabolic encephalopathy, and Alzheimer‟s disease.
Aphemia is a severe form of acute speech apraxia that presents with severely impaired
fluency (often mutism).
In approximately 90% of right-handers and 60% of left-handers, aphasia occurs only after
lesions of the left hemisphere.
- Bilateral involvement of the network for spatial attention, especially its parietal
components, leads to a state of severe spatial disorientation known as Balint’s syndrome.
It involves :
i. Deficits in the orderly visuomotor scanning of the environment (oculomotor
apraxia).
ii. Accurate manual reaching toward visual targets (optic ataxia)and
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iii. The ability to integrate visual information in the center of gaze with more
peripheral information (simultanagnosia).
Parinaud’s Syndrome
This is a distinct supranuclear vertical gaze disorder caused by damage to the posterior
commissure.
Also known as dorsal midbrain syndrome.
It is a classic sign of hydrocephalus from aqueductal stenosis. Pineal region or
midbraintumors, cysticercosis, and stroke also cause Parinaud‟s syndrome.
Features include lo0ss of upgaze (and sometimes downgaze), convergence-retraction
nystagmus on attempted upgaze, downward ocular deviation (“setting sun” sign), lid
retraction (Collier’s sign). Skew deviation, pseudoabducens palsy, and light-near dissociation
of the pupils.
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- Jevell and Lange Neilson syndrome
- Norrie‟s disease
- Pendred‟s syndrome
- Treacher Collins syndrome
- Usher‟s syndrome
- Waardenburg‟s syndrome
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CAUSES OF EPISODIC GENERALIZED WEAKNESS
1. Electrolyte disturbances, e.g., hypokalemia hyperkalemia, hypercalcemia, hypernatremia,
hyponatremia, hypophosphatemia, hypermagnesemia
2. Muscle disorders
a. Channelopathies (periodic paralyses)
b. Metabolic defects of muscle (impaired carbohydrate or fatty acid utilization; abnormal
mitochondrial function
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CLINICAL DIFFERENTIATION OF THE MAJOR DEMENTIAS
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CLINICAL FEATURES OF APHASIAS AND RELATED CONDITIONS COMMONLY
SEEN IN CEREBROVASCULAR ACCIDENTS
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SAAG
Ascitic protein < 2.5 g/dl Ascitic protein > 2.5 g/dl
UNa > 20 UNa < 20 UNa > 20 UNa > 20 UNa < 20
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CAUSES OF HIGH-ANION GAP METABOLIC ACIDOSIS
B. Hyperkalemia
1. Generalized distal nephron dysfunction (type 4 RTA)
a. Mineralocorticoid deficiency
b. Mineralocorticoid resistance (PHA 1, autosomal dominant)
c. Voltage defect (PHA I, autosomal recessive, and PHA II)
d. Tubulointerstitial disease
C. Normokalemia
1. Chronic progressive kidney disease
III. Drug-induced hyperkalemia (with real insufficiency)
A. Potassium-sparing diuretics (amiloride, triamterene spironolactone eplerenone)
B. Trimethoprim
C. Pentamidine
D. ACE-Is and ARBs
E. Nonsteroidal anti-inflammatory drugs
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F. Calcineuria inhibitors
IV. Other
A. Acid loads (ammonium chloride, hyperalimentation)
B. Loss of potential bicarbonate: ketosis with ketone excretion
C. Expansion acidosis (rapid saline administration)
D. Hippurate
E. Cation exchange resins
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