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There are several mechanisms by which drugs can induce hemolysis order 40 mg prednisolone free shipping allergy forecast oakland ca; two well-recognized mechanisms are immunologic media- tion (e buy prednisolone 10mg cheap allergy symptoms versus cold. Oxidative stress can occur as a result of hemoglobins becoming unsta- ble or through a decrease in reduction capacity (as would result from G6PD deficiency). Penicillins and cephalosporins produce immune hemolysis by acting as a hapten in the red cell membrane. The protein/drug complex elicits an immune response. An IgG anti- body is generated that acts against the drug-red cell complex. In such patients, the direct Coombs test is positive, but the indirect Coombs test is negative. Other drugs induce hemolysis by altering a membrane antigen. IgG autoantibodies that cross-react with the native antigen are produced. The direct Coombs test is also positive in this form of drug reaction. Methyldopa is the classic example of this form of interaction, although other drugs such as procainamide and diclofenac have been clearly implicated. Diclofenac can produce massive hemolysis with concomitant disseminated intravascular coagulation and shock. Sucrose lysis is still used to screen for membrane fragility. The most common dis- order associated with this abnormality is paroxysmal nocturnal hemoglobinuria (PNH). The lack of associated cytopenias, the acuteness of the onset of symptoms, and the lack of history of venous thrombosis (especially thrombosis at unusual sites such as the inferior vena cava or the portal mesenteric system or thrombosis that produces Budd-Chiari syn- drome) makes PNH an unlikely cause of this patient’s symptoms. Some unstable hemo- globins, such as HbE, are susceptible to hemolysis from oxidative stress. This patient was exposed to both furosemide (a drug with a sulfa moiety) and nitroglycerin. This hemoglo- binopathy is diagnosed by hemoglobin electrophoresis. However, this disease is seen almost exclusively in individuals from Southeast Asia (Cambodia, Thailand, and Vietnam). The most likely diagnosis in this case is G6PD deficiency. This enzymopathy affects 10% of the world population. The red cell becomes hemolyzed when exposed to an oxidative stress. Older red cells are more susceptible to hemolysis because levels of G6PD decrease as red cells age. The results of the G6PD assay should be interpreted carefully. On occasion, the results of the G6PD assay will be normal in patients with G6PD deficiency; this occurs when the assay detects G6PD in very young cells (reticulocytes) that are being released as a result of the brisk hemolysis. A 17-year-old African-American woman is referred to you from the blood bank for evaluation of micro- cytic anemia detected at the time of screening for blood donation. Her menstrual period appears to be normal in frequency and volume of blood loss. Homozygous α-thalassemia-2 Key Concept/Objective: To understand the interpretation of the red cell count in patients with anemia, the results of hemoglobin electrophoresis in patients with thalassemia, and differences in genotype among the thalassemias Microcytic and hypochromic anemia is common in clinical practice. The most likely cause is iron deficiency anemia, especially in women of childbearing age. In iron deficiency ane- mia, the production of red cells is deficient.

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In generalized pustular psoriasis prednisolone 5mg on-line allergy welts, the body is covered with sterile pustules generic prednisolone 40mg line allergy medicine okay to take while breastfeeding. As with erythrodermic psoriasis, the protective functions of the skin are lost, and patients may succumb to infection or hypovolemia and electrolyte imbalance caused by loss of fluid through the skin. Although fever and leukocytosis are commonly found in patients with pustular psoriasis, the possibility of infection should not be overlooked; patients with pustular psoriasis have died of staphylococcal sepsis. As with erythrodermic psoriasis, pus- tular psoriasis is most commonly precipitated by withdrawal of systemic corticosteroids, but it can also result from therapy with antimalarial drugs or lithium, and it can develop spontaneously. A 32-year-old woman presents to clinic to establish primary care. The patient’s medical history is significant for psoriasis, for which she has been treated with methotrexate, 20 mg a week for 6 years. Which of the following should NOT be done to monitor for methotrexate toxicity? Monitoring of the complete blood cell count (CBC) D. Bone marrow biopsy Key Concept/Objective: To understand monitoring for methotrexate toxicity in patients with psoriasis The antimetabolite methotrexate was considered effective for the treatment of psoriasis because of its antimitotic effect on proliferating keratinocytes. However, tissue culture studies have suggested that activated lymphoid cells in the lymph nodes, blood, and skin are a likely target of methotrexate; proliferating macrophages and T cells are 100 times more sensitive to methotrexate than proliferating epithelial cells. These findings may be relevant to the mechanism of action of methotrexate in other immunologically based dis- orders, including psoriatic arthritis, rheumatoid arthritis, and Crohn disease. Methotrexate is best given in a single weekly oral dose of up to 30 mg or in three divided doses at 12- hour intervals during a 24-hour period (e. Side effects of methotrexate therapy include bone marrow suppression, nausea, diar- rhea, stomatitis, and hepatotoxicity. Methotrexate is teratogenic and can cause reversible oligospermia. Evaluation by tests of liver function, renal function, and blood elements must be made before and throughout the course of methotrexate therapy. Cases of pancy- topenia after low-dose methotrexate therapy underscore the hazards of use of the drug in patients with renal insufficiency or in patients who are concomitantly receiving drugs that increase methotrexate toxicity. The use of liver biopsy to monitor patients on methotrexate has been a source of great controversy. Liver biopsies are not routinely performed in patients with rheumatoid arthritis who are undergoing treatment with methotrexate, but liver biopsy has been advo- cated in patients with psoriasis. Patients with psoriasis who are treated with methotrexate are more prone to hepatic fibrosis, possibly because of their underlying disease or because of the concomitant treatments they are given. Current guidelines call for the use of liver biopsy in patients with psoriasis who have received a cumulative dose of 1 to 1. Biopsy should be performed early in the course of treatment in patients with a history of hepatitis C, alco- holism, or other liver disease. Risk factors for hepatotoxicity include heavy alcohol intake, obesity, a history of diabetes or hepatitis, and abnormal results on liver function testing. Although methotrexate causes bone marrow suppression, routine bone marrow biop- sies are not indicated. A 32-year-old high school teacher reports a mildly itchy new rash over the past week. He has been gen- erally healthy, although he did take a course of penicillin for culture-positive streptococcal pharyngitis several weeks ago. He does not smoke, drinks alcohol only occasionally, and has been monogamous with his wife over the 5 years they have been married. He has had no fever, chills, eye symptoms, anorexia, nausea, diarrhea, bloody stool, abdominal pain, penile sores or discharge, dysuria, or joint pains. On examination, the patient is afebrile, with multiple sharply demarcated scaly papules 3 to 10 mm in diam- eter distributed symmetrically on his trunk, arms, palms, and penis.

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Metastatic prostate cancer 11 NEUROLOGY 17 Key Concept/Objective: To understand the relationship of immunosuppression with the risk of malignancy This patient has HIV disease with poor control of viral burden buy prednisolone 10 mg with mastercard allergy vs sinus infection. As such buy cheap prednisolone 20 mg on line allergy symptoms 5 dpo, he is at negligible risk for a number of opportunistic infec- tions, including primary CNS lymphoma and toxoplasmosis. He is still at risk for cryptoc- cocal disease; however, a negative serum antigen coupled with the presence of extensive intrathoracic disease makes this diagnosis very unlikely. Primary CNS tumors are much less common than metastatic disease to the CNS. Astrocytomas and oligodendrogliomas more commonly present as infiltrating lesions. Meningiomas arise from the dura mater and are almost always solitary masses. Acoustic neuromas can be single or bilateral, but they affect the eighth cranial nerve. The radiologic characteristics in this patient favor the diagnosis of metastases to the CNS. Tumors that frequently metastasize to the CNS include tumors of the breast and lung and melanomas. Prostate cancer almost never metastasizes to the brain. The presence of extensive intrathoracic disease, the history of tobacco exposure, and the MRI pattern sup- port the diagnosis of lung carcinoma. A 55-year-old white woman with known breast cancer that was treated 10 years ago with mastectomy comes for evaluation of rhythmic movement of the right arm. These episodes occurred on three occa- sions over the past 2 weeks; each episode lasted 5 to 10 minutes. No loss of consciousness or inconti- nence of the bladder or bowel was associated with the episodes. The patient denies having headache, blurry vision, or diplopia. Her family notes that the patient seems less prone to engage in conversation and seems to be sleeping more than usual. A prosthesis of the left breast is noted; otherwise, the physical examination is unre- markable. The lesion exhibits the same density as the sur- rounding brain parenchyma. Which of the following is the most likely diagnosis? Meningioma Key Concept/Objective: To understand the relationship between meningioma and breast cancer and the radiologic characteristics of different CNS tumors Breast cancer is known to metastasize to the CNS. As with other metastatic tumors, breast cancer tends to produce multiple lesions that are most commonly located at the junction of the white matter and gray matter. These lesions are characteristically surrounded by a significant amount of edema; occasionally, the edematous area is out of proportion with the size of the metastasis. In this patient, the amount of time that has elapsed since her mastectomy makes this possibility unlikely, although tumor recurrence after 10 years has been reported. Both astrocytomas and oligodendrogliomas are tumors situated within the brain parenchyma. Both types tend to present as solitary masses without clearly defined mar- gins. Edema, although frequently present, is less significant than the cerebral edema asso- ciated with metastatic disease. Schwannomas occur in the cranium or peripheral nerves. Schwann cells produce myelin, which accounts for why these tumors are adjacent to nerves.

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