Nimodipine

Pedram Argani, M.D.


https://www.hopkinsmedicine.org/profiles/results/directory/profile/0010788/pedram-argani

Transmission of hepatitis C virus sion of hepatitis C virus from mothers to newborns muscle relaxant 771 buy nimodipine 30mg with amex. Mother to child transmission of vertically acquired and post-transfusion hepatitis C infection in chilhepatitis C virus: prospective study of risk factors and timing of dren muscle relaxant vs analgesic buy 30mg nimodipine with visa. Mother-to-infant hepatitis C virus transmission and breastthe implementation of blood-donor screening skeletal muscle relaxant quizlet order discount nimodipine on line. How to use virological tools for the in childhood: clinical patterns and evolution in 224 white children spasms vs fasciculations generic 30mg nimodipine fast delivery. European paediatric hepatitis C alpha2b plus ribavirin for 48 weeks or for 24 weeks versus interferon virus network muscle relaxant magnesium order nimodipine discount. Comparative study concerning the hepatitis C in children: liver biopsy findings in the Peds-C Trial spasms rib cage area buy generic nimodipine from india. Immune thrombocytopenia reactions resulting from the use of interferon and ribavirin. Effects of hepatitis C conjunction with combination therapy for chronic hepatitis C improves infection and renal transplantation on survival in end-stage renal sustained virus response rates in genotype 1 patients. Peginterferon alfa-2b plus antiviral therapy for chronic hepatitis C: anemia, neutropenia, and ribavirin for the treatment of hepatitis C recurrence following comthrombocytopenia. This information is meant for educational purposes, and should not replace other sources of information or your medical judgment. Develop understanding of the development of cirrhosis, portal hypertension and hepatocellular carcinoma in patients in whom active hepatitis C virus has been eradicated by current drug treatments. Understand the role of sarcopenia in cirrhosis, how to intervene, and the role of biomarkers in cirrhosis. Primary health-care providers are granted a non-exclusive licence to copy information for patient consultation. Efort has been made to get permission from copyright owners for use of copyright material. We apologise for any omissions or oversight and invite copyright owners to draw our attention to them so that we may give appropriate acknowledgment in subsequent reprints or editions. The statements or opinions that are expressed in this book refect the views of the contributing authors and do not necessarily represent the views of the editors or publisher. Every care has been taken to reproduce articles as accurately as possible, but the publisher accepts no responsibility for errors, omissions or inaccuracies contained therein or for the consequences of any action taken by any person as a result of anything contained in this publication. All terms mentioned in the book that are known to be trademarks have been appropriately capitalised. Use of a term in this book should not be regarded as afecting the validity of any trademark. Although every efort has been made to ensure that drug doses and other information are presented accurately in this publication, the ultimate responsibility rests with the prescribing clinician. For detailed prescribing information or instructions on the use of any product described herein, please consult the prescribing information issued by the manufacturer. Previous Edition Editors David Bradford, Jennifer Hoy and Gail Matthews 2014 writers/Reviewers Nicole Allard; Ingrid van Beek; Siobhan Bourke; Mary Burns; Tracey Cabrie; Andrew Carr; Indraveer Chatterjee; Wendy Cheng; Deborah Couldwell; Mark Danta; Ian Denham; Greg Dore; Seamus Dufy; Astrid Greenup; Paul Haber; Paul Harvey; Phillip Keen; Eric khong; Marianne Martinello; Gail Matthews; John McAllister; Anna McNulty; Treeny Ooi; David Orth; John Patten; Anna Roberts; Gary Rogers; Darren Russell; Simone Strasser; Vanessa Towell; Lynne wray; David Youds and Iryna Zablostka. Appendixes were reviewed by Murgen Stack, Ben Cowie, Sonja Hill, Tiia Harrison, Simone Strasser and Indraveer Chatterjee. Previous Edition writers Anthony Allworth; Jonathan Anderson; Paul Andrews; Kelly Beers; Siobhan Bourke; Christopher Bourne; David Bradford; Michael Bramwell; Alan Brotherton; Mary Burns; Wendy Cheng; Brad Crammond; Mark Danta; Gillian Deakin; Nicholas Demediuk; Gregory Dore; Robert Feller; Katherine Fethers; Warren Fitzgerald; Andrew Grulich; Paul Haber; Paul Harvey; Jennifer Hoy; Sarah Hufam; Phillip Keen; Michael Kidd; Anurag Kunwar; Stephen Locarnini; Bebe Lof; John McAllister; Daniel Madeddu; George Marinos; Gail Matthews; Ronald McCoy; Brian McDonald; Marilyn McMurchie; Nicholas Medland; David Menadue; Anne Mijch; Paul Nisselle; David Orth; John Patten; Jefrey Post; David Puls; Jacqui Richmond; Gary Rogers; Norman Roth; Joe Sasadeusz; Moira Sim; Jenean Spencer; Simone Strasser; Ingrid van Beek; Jack Wallace; Jef Ward; Steve Wesselingh; Jon Willis. The frst edition of this widely used We would like to acknowledge the signifcant work teaching and reference guide was frst produced in within a short timeframe of our lead reviewers and 2001, with a second in 2004 and a third edition in 2008. Burke, Seamus Dufy, Nicole Allard, Vanessa Towell, Physicians, medical students, nurses, allied health Tracey Cabrie, David Youds, Anna McNulty, Marianne professionals, as well as individuals with a specifc Martinello, Astrid Greenup and Anna Roberts. Changes to hepatitis C treatment We would also like to acknowledge the contribution have been signifcant and our knowledge of how to of the Expert Reference Group, who provided editorial test and treat people living with hepatitis B in Australia oversight in the review process of this fourth edition: has progressed; these advances are refected in the Michael Burke, Tracey Cabrie, Benjamin Cowie, Gregory rewriting of these chapters. Dore, Seamus Dufy, Gail Matthews, Ronald McCoy, Many organisations and individuals have Anna McNulty, Catriona Ooi, Simone Strasser, David contributed to the production of this new edition Youds and Iryna Zablotska. Chronic active hepatitis B may progress to cirrhosis and hepatocellular carcinoma, which is mitigated with effective therapy. The sharing of equipment during injecting drug use is the most common mode of transmission in Australia. A small proportion of individuals will progress to liver failure or hepatocellular carcinoma. These six In addition, there will be a brief discussion about infections are included because of their serious bacterial vaginosis because it is very common. The former is assembled into mature virions date back to the early part of the twentieth century that are then released from the cell. It incomplete and a full life cycle cannot occur from these has an outer envelope that surrounds two copies of integrated sequences. It their potential to promote the development of infects a potential host cell by adhering to its surface. The development and viruses, members of the human herpesvirus family licensing in Australia of two prophylactic vaccines and are exceptionally successful human pathogens. A characteristic which they share with other members of the human herpesvirus Australian immunisation programs now recommend family is the ability to establish latent infection, so Gardasil vaccination for all boys and girls at age 11-13 that they are able to persist throughout the life of years. During latency, the genome of the invading in April 2007 and there is already evidence of lower virus is maintained in stable form in the infected rates of genital warts in the vaccinated cohort with neural cell with no production of progeny virus for reductions of 85. Periodically, reactivation of virus replication in rates of cervical and anal cancer are also expected occurs with virus migrating back down axons to to fall in the vaccinated groups with time. Gonococci are gram-negative Trichomonas vaginalis bacteria which characteristically grow in pairs as Trichomonas vaginalis is a fagellated protozoan which diplococci. Bacterial vaginosis is a common, complex clinical syndrome of which the characteristic feature is an Gonococci possess surface molecules called pili which alteration in the normal vaginal fora. Normal are largely responsible for adhesion to mucosal lactobacilli are absent or greatly reduced and large surfaces and also for invasion into the submucosa. Atopobium vaginae, Mobiluncus sp, and Prevotella sp this accounts for the almost complete absence of replace them. Some of these organisms are highly acquired natural immunity against attacks of mucosal motile and tend to cluster around shed epithelial gonorrhoea. However, the condition is common in this ability continues to present a formidable challenge. The body mounts an immunological and therapeutic pressure, leads to immune response against invading treponemes, the presence in a given individual of a number of both humoral and cell mediated, and many of the closely related, but genetically distinct, viral variants unique clinical features of syphilis are due to the known as quasispecies. Bacteria are able to establish is the likely reason why infection with these viruses latency in lymphatic and splenic tissue and during results in chronic infection in most individuals this period of latency, which may last for many years despite a host immune response. Each one of the in untreated patients, the person with the infection virus-specifc enzymes previously discussed is the will be resistant to reinfection from a new challenge focus of intense research to develop potent and with T. Transmission through injecting drug use is uncommon the role of sexual transmission is still controversial. Transmission be increased when blood is present in the genital by needle-stick injury occurs in 0. Transmission rates can be reduced with of susceptible genital surfaces by contaminated careful and consistent condom use and suppressive secretions. Only an efective vaccine will via anal intercourse with multiple partners, fsting make a signifcant impact on the problem of herpes and use of contaminated sex toys. Laryngeal papillomatosis, while extremely rare, can be a very signifcant clinical problem in young children. There has been a long debate about resistant to environmental changes such as heat and the possibility of transmission by contaminated fomites drying. Transmission is therefore almost exclusively such as face cloths, towels and toilet seats. While it by sexual contact or from mother to infant at the is true that the organism is hardier than T. In this respect it difers from the Transmission is by direct mucous membrane-togonococcus and C. Vaginal intercourse mucous membrane contact or via infected genital appears to be the main way trichomoniasis is spread, secretions on a susceptible mucosal surface. Transmission from male to female via vaginal sex is slightly more efcient than from female to male Bacterial vaginosis and, similarly, transmission from the male partner to the receptive partner in anal sex is more efcient the aetiology of this condition is unknown. The pharyngeal mucosa is readily studies support sexual transmission of agents (known infected from an infected urethral meatus via oral sex and unknown) plays a part in its aetiology. A host immune response then develops, conjunctivae during transit through the infected 11 partially controlling viral replication, but is unable to maternal endocervical canal. An old study suggested that the risk of acquiring asymptomatic or sufer a more non-specifc illness. However, people with syphilis seem only able to latency, although very high levels of viral replication transmit it to sexual partners during the frst 2 years continue, especially in the lymphoid compartment. The outcome of infection is largely to sexual partners and probably account for most of determined by the age at which infection is acquired, the transmission that occurs in areas where syphilis 27 which relates to the maturity of the immune response. If, however, an individual is and can be associated with accelerated development infected acquires the infection as an adult, chronic of cirrhosis and liver failure. The exact mechanism(s) infection will occur in less than 5% of people, of the pathogenesis of this co-infection are presently although almost half will manifest clinical features unknown but are probably due to virological (higher of acute hepatitis. In Australia, migrants from these regions frequently have infection with such 3 Chlamydia trachomatis variants. Primary sites of genital infection with D to K serovars As a consequence, the majority of acute infections of C. Most of these infections people estimated to clear acute hepatitis C varies are mild and it is more likely that people with the between 25% and 40%, and clearance occurs more infection remain asymptomatic for a considerable frequently in patients who are symptomatic or who time rather than developing obvious symptoms and become jaundiced. In infants following mother-to-child transmission, community-based cohorts estimate the risk of primary sites of infection are the naso-pharynx, the progression to cirrhosis to be 7% at 20 years and 29 conjunctivae and, more rarely, the vagina or urethra. Estimates of hepatitis C-related mortality are 1% at 20 years and 4% at 40 Genital D to K chlamydia infections can spread from years. Sometimes transcoelomic spread can in people with compensated cirrhosis is around result in perihepatitis (the Fitz-Hugh-Curtis syndrome). In infants, naso-pharyngeal infection is often a precursor to the development of pneumonitis. Less commonly, infection Neisseria gonorrhoeae spreads to the epididymis and testis in men, causing an acute epididymo-orchitis. The infection eventually Neisseria gonorrhoeae targets exactly the same resolves, but, in the absence of early treatment, healing columnar cells in the mucous membrane of urethra, occurs with damaging scar tissue formation and endocervix, rectum, pharynx and conjunctiva as does fbrosis. Within a few days the infection scarring can permanently interfere with normal function. Thus, most strains systemic symptoms and disseminated skin and joint of gonorrhoea tend to produce visible signs of manifestations (disseminated gonococcal infection). Infection at other acute sight-threatening conjunctivitis which is sites is much less likely to cause readily recognisable recognised 2 or 3 days after birth. The but having positive syphilis serology and no history organism has been isolated from the prostate gland of having been treated for syphilis, is said to have and from epididymal aspirates, but its role in prostatitis latent syphilis. Trichomonal infection in pregnancy has been years of latent infection are called early syphilis associated with an increased risk of preterm delivery. There is an association with pelvic with a guide to accompanying serology results. The presence of bacterial condition, with ulceration healing within a few weeks vaginosis in pregnancy (both symptomatic and in untreated patients. Secondary syphilis is also selfasymptomatic) may lead to low birth weight in babies, limiting with clinical manifestations resolving over premature delivery and post-partum endometritis but several weeks, although, in at least 25% of untreated the results of studies of therapeutic interventions people, relapses of secondary syphilis continue to against bacterial vaginosis in early pregnancy have occur over the frst 2 years after infection. There is no clear consensus syphilis, cardiovascular and neurosyphilis occur at a on how best to manage bacterial vaginosis in variable period of time after infection, from as short pregnancy as yet, but some experts recommend as 1 year through to 40 years later.

If blood cultures remain positive for staphylococci for more than 3 to 5 days or if the clinical illness fails to improve back spasms 40 weeks pregnant cheap nimodipine 30 mg with mastercard, the central line should be removed back spasms 26 weeks pregnant safe 30mg nimodipine, parenteral therapy should be continued muscle relaxant injections generic 30mg nimodipine amex, and the patient should be evaluated for metastatic foci of infection 3m muscle relaxant buy nimodipine in united states online. Prophylactic administration of an antimicrobial agent intraoperatively lowers the incidence of infection after cardiac surgery and implantation of synthetic vascular grafts and prosthetic devices and often has been used at the time of cerebrospinal fuid shunt placement infantile spasms 2 month old buy cheap nimodipine 30mg on-line. Measures to prevent and control S aureus infections can be considered separately for people and for health care facilities spasms jerks 30mg nimodipine sale. However, strategies focusing on hand hygiene and wound care have been effective at limiting transmission of S aureus and preventing spread of infections in community settings. Specifc strategies include appropriate wound care, minimizing skin trauma and keeping abrasions and cuts covered, optimizing hand hygiene and personal hygiene practices (eg, shower after activities involving skin-to-skin contact), avoiding sharing of personal items (eg, towels, razors, clothing), cleaning shared equipment between uses, and regular cleaning of frequently touched environmental surfaces. Measures to prevent health care-associated S aureus infections in individual patients include strict adherence to recommended infection-control precautions and appropriate intraoperative antimicrobial prophylaxis, and in some circumstances, use of antimicrobial regimens to attempt to eradicate nasal carriage in certain patients can be considered. Routine hand hygiene should be emphasized for personnel and children in these facilities. Preprocedure detection and eradication of nasal carriage using mupirocin twice a day for 5 to 7 days before surgery can decrease the incidence of S aureus infections in some colonized adult patients after cardiothoracic, general, or neurosurgical procedures. These include general recommendations for all settings and focus on administrative issues; engagement, education, and training of personnel; judicious use of antimicrobial agents; monitoring of prevalence trends over time; use of standard precautions for all patients; and use of contact precautions when appropriate. When endemic rates are not decreasing despite implementation of and adherence to the aforementioned measures, additional interventions, such as use of active surveillance cultures to identify colonized patients and to place them in contact precautions, may be warranted. When a patient or health care professional is found to be a carrier of S aureus, attempts to eradicate carriage with topical nasal mupirocin therapy may be useful. To date, the use of catheters impregnated with various antimicrobial agents or metals to prevent health care-associated infections has not been evaluated adequately in children. Outbreaks of S aureus infections in newborn nurseries require unique measures of control. Other measures recommended during outbreaks include reinforcement of hand hygiene, alleviating overcrowding and understaffng, colonization surveillance cultures of newborn infants at admission and periodically thereafter, use of contact precautions for colonized or infected infants, and cohorting of colonized or infected infants and their caregivers. Scarlet fever occurs most often in association with pharyngitis and, rarely, with pyoderma or an infected wound. Other than occurrence of rash, the epidemiologic features, symptoms, signs, sequelae, and treatment of scarlet fever are the same as those of streptococcal pharyngitis. These toxins act as superantigens that stimulate production of tumor necrosis factor and other infammatory mediators that cause capillary leak and other physiologic changes, leading to hypotension and organ damage. Pharyngitis and impetigo (and their nonsuppurative complications) can be associated with crowding, which often is present in socioeconomically disadvantaged populations. The close contact that occurs in schools, child care centers, contact sports (eg, wrestling), boarding schools, and military installations facilitates transmission. Foodborne outbreaks of pharyngitis occur rarely and are a consequence of human contamination of food in conjunction with improper food preparation or improper refrigeration procedures. Pyoderma is more common in tropical climates and warm seasons, presumably because of antecedent insect bites and other minor skin trauma. Communicability of patients with streptococcal pharyngitis is highest during acute infection and untreated gradually diminishes over a period of weeks. From a normally sterile site (eg, blood, cerebrospinal fuid, peritoneal fuid, or tissue biopsy specimen) B. Defning the group A streptococcal toxic shock syndrome: rationale and consensus defnition. In streptococcal impetigo, the organism usually is acquired by direct contact from another person with impetigo. Impetiginous lesions occur at the site of breaks in skin (eg, insect bites, burns, traumatic wounds, varicella). A specimen should be obtained by vigorous swabbing of both tonsils and the posterior pharynx for culture and/or rapid antigen testing. False-negative culture results occur in fewer than 10% of symptomatic patients when an adequate throat swab specimen is obtained and cultured by trained personnel. Recovery of group A streptococci from the pharynx does not distinguish patients with true streptococcal infection (defned by a serologic response to extracellular antigens [eg, streptolysin O]) from streptococcal carriers who have an intercurrent viral pharyngitis. Specifcities of these tests generally are high, but the reported sensitivities vary considerably (ie, false-negative results occur). Because of high specifcity of rapid tests, a positive test result does not require throat culture confrmation. In assessing such patients, inadequate adherence to oral treatment also should be considered. Cultures of impetiginous lesions often yield both streptococci and staphylococci, and determination of the primary pathogen is not possible. A signifcant increase in antibody titers to streptolysin O, deoxyribonuclease B, or other streptococcal extracellular enzymes 4 to 6 weeks after infection can help to confrm the diagnosis if culture results are negative. Although different preparations of oral penicillin vary in absorption, their clinical effcacy is similar. Treatment failures may occur more often with oral penicillin than with intramuscularly administered penicillin G benzathine as a result of inadequate adherence to oral therapy. This approach is an acceptable treatment option if strict adherence to once-daily dosing can be ensured. For children who weigh less than 27 kg, penicillin G benzathine is given in a single dose of 600 000 U (375 mg); for heavier children and adults, the dose is 1. Discomfort is less if the preparation of penicillin G benzathine is brought to room temperature before intramuscular injection. Mixtures containing shorter-acting penicillins (eg, penicillin G procaine) in addition to penicillin G benzathine have not been demonstrated to be more effective than penicillin G benzathine alone but are less painful when administered. A number of antimicrobial agents, including clindamycin, cephalosporins, amoxicillin-clavulanate, azithromycin, and a combination of rifampin for the last 4 days of treatment with either penicillin V or penicillin G benzathine have been demonstrated to be more effective than penicillin in eliminating chronic streptococcal carriage. Of these drugs, oral clindamycin, given as 20 mg/kg per day in 3 doses (maximum, 1. With multiple lesions or with nonbullous impetigo in multiple family members, child care groups, or athletic teams, impetigo should be treated with antimicrobial regimens administered systemically. Inhibition of protein synthesis results in suppression of synthesis of the S pyogenes antiphagocytic M-protein and bacterial toxins. The total duration of therapy is based on duration established for the primary site of infection. Aggressive drainage and irrigation of accessible sites of infection should be performed as soon as possible. If necrotizing fasciitis is suspected, immediate surgical exploration or biopsy is crucial to identify deep soft tissue infection that should be debrided immediately. Parenteral antimicrobial therapy is required for severe infections, such as endocarditis, pneumonia, septicemia, meningitis, arthritis, osteomyelitis, erysipelas, necrotizing fasciitis, neonatal omphalitis, and streptococcal toxic shock syndrome. Suppurative sequelae, such as peritonsillar abscesses and cervical adenitis, usually are prevented by treatment of the primary infection. The risk of recurrence decreases as the interval from the most recent episode increases, and patients without rheumatic heart disease are at a lower risk of recurrence than are patients with residual cardiac involvement. The intramuscular regimen has been shown to be the most reliable, because the success of oral prophylaxis depends primarily on patient adherence; however, inconvenience and pain of injection may cause some patients to discontinue intramuscular prophylaxis. Most severe reactions seem to represent vasovagal responses rather than anaphylaxis. Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis. Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis. A scientifc statement from the American Heart Association, Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Reactions to continuous sulfadiazine or sulfsoxazole prophylaxis are rare and usually minor; evaluation of blood cell counts may be advisable after 2 weeks of prophylaxis, because leukopenia has been reported. Prophylaxis with a sulfonamide during late pregnancy is contraindicated because of interference with fetal bilirubin metabolism. Febrile mucocutaneous syndromes (erythema multiforme, Stevens-Johnson syndrome, or toxic epidermal necrolysis) have been associated with penicillin and with sulfonamides. Other macrolides, such as azithromycin or clarithromycin, also should be acceptable; they have less risk of gastrointestinal tract intolerance but increased costs. Some experts recommend secondary prophylaxis for these patients during the observation period. However, use of oral antiseptic solutions and maintenance of optimal oral health remain important components of an overall health care program. Late, late-onset disease occurs beyond 89 days of age, usually in very preterm infants requiring prolonged hospitalization. A guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Pilus-like structures are important virulence factors and potential vaccine candidates. Associated with implementation of widespread maternal intrapartum antimicrobial prophylaxis, the incidence of early-onset disease has decreased by approximately 80% to an estimated 0. The case-fatality ratio in term infants ranges from 1% to 3% but is higher in preterm neonates (20% for early-onset disease and 5% for late-onset disease). Black race is an independent risk factor for both early-onset and late-onset disease. Infants can remain colonized for several months after birth and after treatment for systemic infection. For ampicillin, the recommended dosage for infants with meningitis 7 days of age or younger is 200 to 300 mg/kg per day, intravenously, in 3 divided doses; the recommended dosage for infants older than 7 days of age is 300 mg/kg per day, intravenously, in 4 divided doses. For infants with uncomplicated meningitis, 14 days of treatment is satisfactory, but longer periods of treatment may be necessary for infants with prolonged or complicated courses. Septic arthritis or osteomyelitis requires treatment for 3 to 4 weeks; endocarditis or ventriculitis requires treatment for at least 4 weeks. Intrapartum chemoprophylaxis should be given to all pregnant women identifed as carriers of group B streptococci. Colonization during a previous pregnancy is not an indication for intrapartum chemoprophylaxis. Such treatment is not effective in eliminating carriage of group B streptococci or preventing neonatal disease. Women expected to undergo cesarean deliveries should undergo routine culture screening, because onset of labor or rupture of membranes can occur before the planned cesarean delivery, and in this circumstance, intrapartum antimicrobial prophylaxis is recommended. An alternative drug is intravenous ampicillin (2 g initially, then 1 g every 4 hours until delivery). If clindamycin susceptibility testing has not been performed, intravenous vancomycin (1 g every 12 hours) should be administered. Antimicrobial therapy is appropriate only for infants with clinically suspected systemic infection. The recommendations are intended to help clinicians promptly detect and treat cases of earlyonset infections. All other maternal antimicrobial agents or durations before delivery are considered inadequate for purposes of neonatal management. Routine cultures to determine whether infants are colonized with group B streptococci are not recommended. Cohorting of ill and colonized infants and use of contact precautions during an outbreak are recommended. Other methods of control (eg, treatment of asymptomatic carriers with penicillin) are ineffective. The principal clinical syndromes of groups C and G streptococci are septicemia, upper and lower respiratory tract infections, skin and soft tissue infections, septic arthritis, meningitis with a parameningeal focus, brain abscess, and endocarditis with various clinical manifestations. Among the viridans streptococci, organisms from the Streptococcus anginosus group often cause localized infections, such as brain or dental abscess or abscesses in other sites, including lymph nodes, liver, and lung. Among gram-positive organisms that are catalase negative and display chains by Gram stain, the genera associated most often with human disease are Streptococcus and Enterococcus. Members of the Streptococcus genus that are beta-hemolytic on blood agar plates include Streptococcus pyogenes (see Group A Streptococcal Infections, p 668), Streptococcus agalactiae (see Group B Streptococcal Infections, p 680) and groups C and G streptococci. S agalactiae subspecies equisimilis is the group C species most often associated with human infections. The anginosus group (S anginosus, Streptococcus constellatus, and Streptococcus intermedius) can have variable hemolysis, and approximately one third possess group A, C, F, or G antigens. Outbreaks and nosocomial spread in association with Enterococcus gallinarum also have occurred occasionally. Intrapartum transmission is responsible for most cases of early-onset neonatal infection caused by nongroup A and B streptococci and enterococci. Other agents with good activity include ampicillin, cefotaxime, vancomycin, and linezolid. Nonpenicillin antimicrobial agents with good activity against viridans streptococci include cephalosporins (especially ceftriaxone), vancomycin, linezolid, daptomycin, and tigecycline, although experience with daptomycin and tigecycline is limited, and these are not approved for use in children. The combination of high-dose penicillin or vancomycin and an aminoglycoside can enhance bactericidal activity. In general, children with a central line-associated bloodstream infection caused by enterococci should have the device removed promptly. Although most vancomycin-resistant isolates of E faecalis and E faecium are daptomycin susceptible, daptomycin is approved for use only in adults for treatment of infections attributable to vancomycinresistant E faecalis. Limited data suggest that clearance rates of daptomycin are more rapid in young children compared with adolescents and adults. Microbiologic and clinical cure has been reported in children infected with vancomycin-resistant E faecium who were treated with quinupristin-dalfopristin.

Carbamoyl phosphate synthetase deficiency

The disease responds rapidly to formed by redox reaction in the body (Chapter 3) and thus administration of 1 spasms cell cancer buy cheap nimodipine line,25-dihydroxy vitamin D spasms under right rib cage purchase genuine nimodipine online. The deficiency of poor endogenous synthesis of vitamin D zoloft spasms buy nimodipine, or as a result of vitamin E is mainly by conditioning disorders affecting its conditioned deficiency muscle relaxant starting with z order generic nimodipine. Low birth weight vitamin D muscle relaxant whole foods order on line nimodipine, osteoid matrix laid down fails to get mineraneonates muscle relaxant over the counter generic nimodipine 30mg overnight delivery, due to physiologic immaturity of the liver and lised. In H and E stained microscopic sections, this is bowel, may also develop vitamin E deficiency. Lesions of identified by widened and thickened osteoid seams vitamin E deficiency are as follows: (stained pink) and decreased mineralisation at the borders 1. Neurons with long axons develop degeneration in the between osteoid and bone (stained basophilic). Peripheral nerves may also develop myelin degeneration seams of unstained osteoid while the calcified bone is in the axons. Red blood cells deficient in vitamin E such as in premature i) muscular weakness; infants have reduced lifespan. In experimental animals, vitamin E deficiency can proiii) fractures following trivial trauma; duce sterility in both male and female animals. Vitamin K (K for Koagulations in Danish) i) normal or low serum calcium levels; exists in nature in 2 forms: ii) plasma phosphate levels lowered; and Vitamin K1 or phylloquinone, obtained from exogenous iii) raised serum alkaline phosphatase due to increased dietary sources such as most green leafy vegetables; and osteoblastic activity. Vitamin K2 or menaquinone, produced endogenously by It may be worthwhile to note here that another chronic normal intestinal flora. Phylloquinone can be converted into disorder of skeleton seen in elderly, osteoporosis, is clinically menaquinone in some organs. Since vitamin K is necessary for the manufacture of prothrombin, its iii) osteoporosis; and deficiency leads of hypoprothrombinaemia (Chapter 13). Subjects with levels below 70% of normal should Vitamin E (fififififi-Tocopherol) receive therapy with vitamin K. Out of many naturally-occurring tocoferols Because most of the green vegetables contain vitamin K and tocotrienols, fi-tocopherol is biologically the most active and that it can be synthesised endogenously, vitamin K fat soluble compound for humans. The of the ordinary foods such as vegetables, grains, nuts and conditions which may bring about vitamin K deficiency are oils. The newborn infants 251 are deficient in vitamin K because of minimal stores of vitamin K at birth, lack of established intestinal flora for endogenous synthesis and limited dietary intake since breast milk is a poor source of vitamin K. Bile is prevented from entering the bowel due to biliary obstruction which prevents the absorption of this fat-soluble vitamin. Surgery in patients of obstructive jaundice, therefore, leads to marked tendency to bleeding. Patients on warfarin group of anticoagulants have impaired biosynthesis of vitamin Kdependent coagulation factors. The use of broad-spectrum antibiotics and sulfa drugs reduces the normal intestinal flora. Administration of of tetrahydrofolate; and vitamin K to such patients is of no avail since liver, where role in iron metabolism in its absorption, storage and prothrombin synthesis utilising vitamin K takes place, is keeping it in reduced state. The lesions and clinical manifestations of scurvy are Vitamin C (Ascorbic Acid) seen more commonly at two peak ages: in early childhood and in the very aged. Vitamin C exists in natural sources as Lascorbic acid closely related to glucose. A marked tendency to bleeding vitamin C are citrus fruits such as orange, lemon, grape fruit is characteristic of scurvy. This may be due to deficiency of and some fresh vegetables like tomatoes and potatoes. It is intercellular cement which holds together the cells of present in small amounts in meat and milk. There may be haemorrhages in the easily destroyed by heating so that boiled or pasteurised milk skin, mucous membranes, gums, muscles, joints and may lack vitamin C. The most prominent change is the deranged the physiologic functions of vitamin C are due to its formation of osteoid matrix and not deranged mineralisation (c. Vitamin C has been fond to have antioxidant properties cartilage cells in rows which normally undergo provisional and can scavenge free radicals. Ascorbic acid is required for hydroxylation of proline to next step of laying down of osteoid matrix by osteoblasts is form hydroxyproline which is an essential component of poor and results in failure of resorption of cartilage. Besides collagen, it is necessary for the ground substance lar epiphyseal plates project as scorbutic rosary. The skeletal of other mesenchymal structures such as osteoid, chondroitin changes are further worsened due to haemorrhages and sulfate, dentin and cement substance of vascular haematomas under the periosteum and bleeding into the joint endothelium. There is delayed healing of such as: wounds in scurvy due to following: hydroxylation of dopamine to norepinephrine; deranged collagen synthesis; 252 poor preservation and maturation of fibroblasts; and dry beriberi (peripheral neuritis); localisation of infections in the wounds. This is because the most often normocytic normochromic type; occasionally it energy requirement of the brain and nerves is solely derived may be megaloblastic or even iron deficiency type. Now, vitamin B terised by cardiovascular involvement, generalised oedema, complex is commonly used for a group of essential compounds serous effusions and chronic passive congestion of viscera. The principal members of vitamin B complex are thiamine Microscopic examination of the heart shows hydropic (vitamin B1), riboflavin (vitamin B2), niacin/nicotinic acid degeneration of myocardial fibres, loss of striations, (vitamin B3), pantothenic acid (vitamin B5), pyridoxine interstitial oedema and lymphocytic infiltration. Thiamine hydrochloride is available in a variety of items of diet such Microscopic examination shows degeneration and as peas, beans, pulses, yeast, green vegetable roots, fruits, necrosis of neurons, hypertrophy-hyperplasia of small meat, pork, rice and wheat bran. The vitamin is absorbed from the intestine either by passive diffusion or by energy-dependent transport. Reserves of vitamin B1 are stored in the skeletal muscles, heart, liver, kidneys and bones. Thiamine after absorption is phosphorylated to form thiamine pyrophosphate which is the functionally active compound. In addition, thiamin plays a role in peripheral nerve conduction by an unknown mechanism. Thiamine deficiency can occur from primary or conditioned causes, chronic alcoholism being an important cause. The deficiency state leads to failure of complete combustion of carbohydrate and accumulation of pyruvic acid. This results in beriberi which produces lesions at 3 target tissues (peripheral nerves, Figure 9. Accordingly, beriberi is of 3 types: and globular appearance of the heart due to four-chamber dilatation. Toxicity due to administration of usually distributed in plant and animal foods such as the high doses of niacin as therapy for dyslipidaemia has been liver, beaf, mutton, pork, eggs, milk and green vegetables. It is characterised by Like other water-soluble vitamins, it is rapidly absorbed from flushing of skin and liver derangement. Pyridoxine or vitamin B6 is widely flavinosis) are as follows: distributed in all animal and plant foods such as meat, liver, 1. Ocular lesions consist of vascularisation of normally eggs, green vegetables and whole grain cereals. Subsequently, conjunctivitis, interstitial keratitis and pyridoxine, pyridoxal and pyridoxamine. Vitamin B6 and animal foods such as the liver, kidney, meat, green deficiency may result from inadequate dietary intake or may vegetables and whole grain cereals. Niacin includes result from secondary deficiency such as increased demand biologically active derivative nicotinamide which is essential in pregnancy and lactation, chronic alcoholism and intake for the formation of 2 oxidative coenzymes (dehydrogenases): of certain drugs. Convulsions in infants born to mothers who had been monophosphate shunt of glucose metabolism. Deficiency of niacin gravidarum (pyridoxine dependence) causes pellagra, so named because of the rough skin of such 2. Cheilosis and angular stomatitis from dietary deficiency in those who largely subsist on maize 4. Glossitis (bald tongue) since niacin in maize is present in bound form and hence not 5. Folate (Folic Acid) and Cyanocobalamin (Vitamin B) 12 Lesions in pellagra are characterised by 3Ds: Both these vitamins included in the B complex group are 1 Dermatitis: the sun-exposed areas of skin develop required for red cell formation. This may progress to chronic megaloblastic anaemia which is discussed in Chapter 12. Biotin is a water-soluble vitamin and a and colon and cause diarrhoea, nausea, vomiting and member of vitamin B complex group. Present data on the major physiologic functions of biotin are as under: animal experiments and human clinical studies indicates that 1. In gene expression they play a role in prevention of neurodegenerative diseases, 2. Biotin deficiency is Several minerals in trace amounts are essential for health rare and develops due to inborn errors of metabolism and in since they form components of enzymes and cofactors for patients on parenteral nutrients devoid of biotin. Besides calcium and phosphorus required of biotin deficiency are as under: for vitamin D manufacture, others include: iron, copper, iodine, 1. Mental and neurologic symptoms such as hallucination, zinc, selenium, manganese, nickel, chromium, molybdenum, fluorine. However, out of these, the dietary deficiency of first depression, paraesthesia five trace elements is associated with deficiency states which 2. In concluding the discussion of vitamin B complex, it must be mentioned that many of the animal and plant foods iii) Phosphorous: Rickets, osteomalacia. Their iv) Copper: Muscle weakness, neurologic defect, anaemia, deficiency, whether primary from poverty, ignorance etc, or growth retardation. Before closing the discussion of nutritional pathology, it is the major physiologic functions of choline are as under: worthwhile to sum up relationship of these factors to 1. In maintenance structural integrity of cell membranes carcinogenesis discussed in previoius chapter. In transmembrane signaling pathways possible mechanisms on which the story of this relationship 3. Choline deficiency i) the most important example in this mechanism comes develops in patients on choline-free parenteral nutrients. The from naturally-occurring carcinogen aflatoxin which is lesions of choline deficiency are as under: strongly associated with high incidence of hepatocellular 1. Fatty liver with deranged liver enzymes carcinoma in those consuming grain contaminated with 2. Flavoonoids are a form of polyphenols present in several fruits and vegetables and are the 2. Endogenous synthesis of carcinogens or promoters: constituents which imparts colour, flavour and taste to these i) In the context of etiology of gastric carcinoma, nitrites, edible products. The major physiologic functions of flavonoids are as ii) In the etiology of colon cancer, low fibre intake and high under: animal-derived fats are implicated. In cell signaling pathways metabolites produced by intestinal bacteria which act as carcinogens. Inadequate protective factors: 255 provide adequate protection to the mucosa and reduces the As already mentioned, some components of diet such as stool bulk and thus increases the time the stools remain in vitamin C, A, E, selenium, and fi-carotenes have protective role the colon. These substances in normal amounts in the iii) In the etiology of breast cancer, epidemiologic studies have body act as antioxidants and protect the cells against free implicated the role of animal proteins, fats and obesity with radical injury but their role of supplementation in diet as as yet unsubstantiated evidence. In the western effects are categorised as under: countries, developmental and genetic birth defects constitute about 50% of total mortality in infancy and childhood, while Agenesis means the complete absence of an organ. Cytogenetic (Karyotypic) defects: chromosomal abnorAtresia refers to incomplete formation of lumen in hollow malities viscus. Multifactorial inheritance disorders Developmental dysplasia is defective development of cells 5. Other paediatric diseases and tissues resulting in abnormal or primitive histogenetic Though many of diseases included in the groups above structures. The branch of science dealing with the study of developmental anomalies Examples of Developmental Defects is called teratology. Certain chemicals, drugs, physical and biologic agents are known to induce such birth defects and A few common clinically important examples are given are called teratogens. The morphologic abnormality or defect below: in an organ or anatomic region of the body so produced is 1. While anencephaly results from failure of neural tube closure, spina Pathogenesis bifida occurs from incomplete closure of the spinal cord and the teratogens may result in one of the following outcomes: vertebral column, often in the lumbar region. Thalidomide is the best iii) Functional defects known example of teratogenic drug which was used as a iv) Malformation sedative by pregnant women in 1960s in England and the effects of teratogens in inducing developmental Germany and resulted in high incidence of limb-reduction defects are related to the following factors: anomalies (phocomelia) in the newborns. Variable individual susceptibility to teratogen: All patients exposed to the same teratogen do not develop birth defect. Babies born to mothers on Intrauterine stage at which patient is exposed to teratogen: anti-epileptic treatment with hydantoin have characteristic Most teratogens induce birth defects during the first trimester facial features and congenital heart defects. Ethanol is another potent Dose of teratogen: Higher the exposure dose of teratogen, teratogen. Consumption of alcohol by pregnant mother in greater the chances of inducing birth defects. A, sex chromatin as seen in scraped chromosomal abnormalities is called cytogenetics squamous cells from oral cavity. In a female, one of the two X chromosomes (paternal or maternal derived) is inactivated during embryogenesis as stated in Lyon hypothesis.

Marles Greenberg Persaud syndrome

Mucinous cystadenoma Women with hereditary breast-ovarian cancer susceptibility 2 spasms gums buy 30mg nimodipine mastercard. Malignant (immature) teratoma factors muscle relaxant natural remedies order nimodipine online, several complex genetic syndromes are associated 3 spasms pregnancy after tubal ligation cheap nimodipine on line. Endodermal sinus (yolk sac) tumour ii) Peutz-Jeghers syndrome with ovarian sex cord-stromal D muscle relaxer 86 62 purchase 30mg nimodipine with visa. Others (embryonal carcinoma muscle relaxant high blood pressure cost of nimodipine, polyembryoma muscle relaxer kidney buy cheap nimodipine, mixed germ iii) Gonadal dysgenesis with gonadoblastoma. Sertoli-Leydig cell tumours (Androblastoma, arrhenoblastoma) years, and account for 80% of all ovarian neoplasms. Others malignant ovarian tumours are discovered when they grow sufficiently to cause abdominal discomfort and distension. Urinary tract and gastrointestinal tract symptoms are studded with multiple small (0. The medullary stroma Ascites is common in both benign and malignant ovarian is abundant, solid and grey. Malignant tumours subcortical cysts are lined by prominent luteinised theca usually spread beyond the ovary to other sites before the cells and represent follicles in various stages of maturation diagnosis is made. Based on this categorisation of biologic behaviour, groups Tumours derived from the surface (coelomic) epithelium of surface epithelial ovarian tumours are described below: called common epithelial tumours form the largest group of ovarian tumours. This group constitutes about 60-70% of all Serous Tumours ovarian neoplasms and 90% of malignant ovarian tumours. These tumours frequently the presence of clear, watery, serous fluid in these have prominent cystic component which may have a single predominantly cystic tumours. About 60% of serous tumours or multiple loculations and hence the descriptive prefix are benign, 15% borderline and 25% malignant. In addition, surface epithelial benign tumours occur bilaterally, whereas 65% of both tumours may differentiate along urothelium to form Brenner borderline and malignant serous tumours have bilateral tumour, and along mesonephroid pattern forming clear cell ovarian involvement. In general, the criteria for diagnosis of differentiates along tubal-type of epithelium. Papillary projections, if borderline and malignant serous tumours are large (above present, are covered by the same type of epithelium without 5 cm in diameter) and spherical masses. Serous cystadenoma is characteristically lined by which may be present in varying combinations include: stratiproperly-oriented low columnar epithelium which is fication (2-3 layers) of the epithelial cells but generally sometimes ciliated and resembles tubal epithelium. It shows an enlarged ovary replaced with a large unilocular cyst with intracystic papillae (arrow). As compared with serous tumours, usually has stratification (2-3 layers) of benign serous type mucinous tumours are more commonly unilateral. There is detachment of cell clusters from mucinous tumours occur bilaterally in 5% of cases while their site of origin and moderate features of malignancy borderline and malignant are bilateral in 20%. Serous cystadenocarcinoma has multilayered adenocarcinoma is made after excluding metastatic tumours malignant cells which show loss of polarity, presence of to the ovary, while bilateral mucinous adenocarcinoma of solid sheets of anaplastic epithelial cells and definite the ovary is invariably metastatic deposits to the ovary. Papillae formations are more Mucinous tumours occur principally between 2nd and 5th frequent in malignant variety and may be associated with decades of life. Mucinous cystadenocarcinoma usually psammoma bodies but mere presence of psammoma develops in women above the age of 40 years. Histogenesis of mucinous tumours, in line with that of serous tumours, is by metaplasia from the coelomic Mucinous Tumours epithelium that differentiates along endocervical type or intestinal type of mucosa. Mucinous tumours are somewhat less common than serous tumours and constitute about 20% of all ovarian tumours and 10% of all ovarian cancers. Grossly, mucinous 15% are borderline (atypical proliferating) and 5-10% are tumours are much larger than serous tumours. These predominantly cystic tumours contain smooth-surfaced cysts with characteristic multiloculations mucin which was previously described as pseudomucin. Well-differentiated borderline mucinous tumours are Benign tumours generally have thin wall and septa associated with mucinous ascites termed pseudomyxoma dividing the loculi are also thin and often translucent, but Figure 24. Microscopic features include stratification of low columnar epithelium lining the inner surface of the cyst and a few psammoma bodies. In forming solid sheets, papillary formation, adenomatous younger patients, an element of teratoma may be pattern and infiltration into stroma with or without pools recognised in the firm areas of the tumour. Histologically, the most distinctive feature is the characteristic tall columnar nonciliated epithelium lining the Endometrioid Tumours loculi (Fig. Other features are as under: Endometrioid tumours comprise about 5% of all ovarian 1. Most of them are malignant accounting for about these cells having basal nuclei and apical mucinous vacuo20% of all ovarian cancers. About 40% of ovarian is identified by the same histologic criteria as for endometrioid carcinomas have bilateral involvement. Mucinous cystadenocarcinoma likewise is characHistogenesis of these tumours in majority of cases is terised by piling up of malignant epithelium, at places believed to be from ovarian coelomic epithelium differenFigure 24. The cyst wall and the septa are lined by a single layer of tall columnar mucin-secreting epithelium with basally-placed nuclei and large apical mucinous vacuoles. Grossly, these tumours Brenner tumours are uncommon and comprise about 2% of are partly solid and partly cystic and may have foci of all ovarian tumours. They are characteristically solid ovarian haemorrhages, especially in benign variety. Histologically, the endometrioid adenocarcinoma is Most Brenner tumours are benign. Papillary pattern and foci of serous and by metaplastic transformation into transitional epithelium mucinous carcinoma may also be found. Occasionally, a few scattered tiny cysts may be present Clear Cell (Mesonephroid) Tumours on cut section. Clear cell (mesonephroid) tumours are almost always Histologically, Brenner tumour consists of nests, masses malignant and comprise about 5% of all ovarian cancers; rare and columns of epithelial cells, scattered in fibrous stroma benign variety is called clear cell adenofibroma. These epithelial cells resemble urothelial cells clear cell or mesonephroid carcinomas because of the close which are ovoid in shape, having clear cytoplasm, histologic resemblance to renal adenocarcinoma. Nearly 95% of them are benign and occur chiefly characterised by tubules, glands, papillae, cysts and solid in young females, vast majority of them being benign cystic sheets of tumour cells resembling cells of renal adenoteratomas (dermoid cysts). The ovary is enlarged and shows a large unilocular cyst containing hair, pultaceous material and bony tissue. Less often, the cyst may contain have their counterparts in the testis (Chapter 23) and mucoid material. For instance, benign cystic teratoma of the cyst wall by stratified squamous epithelium and its or dermoid cyst so common in ovaries is extremely rare in adnexal structures such as sebaceous glands, sweat glands the testis. Though ectodermal derivatives are most prominent features, tissues of Teratomas mesodermal and endodermal origin are also commonly Teratomas are tumours composed of different types of tissues present. In view of cartilage, bone, tooth, smooth muscle, neural tissue, wide spectrum of tissue elements found in these teratomas, salivary gland, retina, pancreas and thyroid tissue. Thus, their histogenesis has been a matter of speculation for a long viewing a benign cystic teratoma in different microscopic time. Cytogenetic studies have revealed that these tumours fields reveals a variety of mature differentiated tissue arise from a single germ cell (ovum) after its first meiotic elements, producing kaleidoscopic patterns. Less than 1% of patients with a dermoid cyst develop Teratomas are divided into 3 types: mature (benign), malignant transformation of one of the tissue components, immature (malignant), and monodermal or highly most commonly squamous cell carcinoma. Vast majority of ovarian malignant teratomas of the ovary are rare and account for teratomas are benign and cystic and have the predominant approximately 0. Benign cystic teratomas are more frequent in young in prepubertal adolescents and young women under 20 years women during their active reproductive life. Grossly, malignant teratoma is a unilateral solid mass Grossly, benign cystic teratoma or dermoid cyst is which on cut section shows characteristic variegated characteristically a unilocular cyst, 10-15 cm in diameter, appearance revealing areas of haemorrhages, necrosis, usually lined by the skin and hence its name. On tiny cysts and heterogeneous admixture of various tissue sectioning, the cyst is filled with paste-like sebaceous elements. GeneMicroscopically, parts of the tumour may show mature rally, in one area of the cyst wall, a solid prominence is tissues, while most of it is composed of immature tissues 747 Figure 24. Microscopy shows characteristic lining of the cyst wall by epidermis and its appendages. All dysgerminomas are malignant and are extremely glandular structures, neural tissue etc, and are distributed radiosensitive. An important factor in grading and determining the is a solid mass of variable size. Cut section of the tumour prognosis of immature teratoma is the relative amount of is grey-white to pink, lobulated, soft and fleshy with foci immature neural tissue. The tumour cells are other germ cell tumours such as endodermal sinus arranged in diffuse sheets, islands and cords separated tumour, embryonal carcinoma and choriocarcinoma. The tumour cells are uniform in appearance and large, with vesicular nuclei and clear Grade I tumours having relatively mature elements and cytoplasm rich in glycogen. It is a teratoma composed exclusively of thyroid tissue, recognisable grossly as well as microscopically. This is an ovarian teratoma arising from argentaffin cells of intestinal epithelium in the teratoma. Dysgerminoma Dysgerminoma is an ovarian counterpart of seminoma of the testes (page 709). About 10% of are separated by scanty fibrous stroma that is infiltrated by lymphocytes. More often, endodermal sinus tumour is found in combination with other germ cell tumours rather than in pure form. Histologically, like its testicular counterpart, the endodermal sinus tumour is characterised by the presence of papillary projections having a central blood vessel with perivascular layer of anaplastic embryonal germ cells. Such structures resemble the endodermal sinuses of the rat placenta (Schiller-Duval body) from which the tumour derives its name. Gestational choriocarcinoma of placental origin tumours, pure thecomas, combination of granulosa-theca cell is more common and considered separately later (page 752). Pure granulosa cell origin is rare while its combination with other germ cell tumours may occur at all ages. The patients are usually young but occasionally may have more aggressive and malignant girls under the age of 20 years. Most granulosa cell tumours secrete oestrogen which may Ovarian choriocarcinoma is more malignant than that of be responsible for precocious puberty in young girls, or in placental origin and disseminates widely via bloodstream older patients may produce endometrial hyperplasia, to the lungs, liver, bone, brain and kidneys. Rarely, granulosa cell tumour may elaborate androgen which may have masculinising effect on the patient. Other Germ Cell Tumours Certain other germ cell tumours occasionally encountered Grossly, granulosa cell tumour is a small, solid, partly in the ovaries are embryonal carcinoma, polyembryoma and cystic and usually unilateral tumour. Thus, these include tumours originating from granulosa cells, theca cells and Sertoli-Leydig cells. Since sex cord-stromal cells have functional activity, most of these tumours elaborate steroid hormones which may have feminising effects or masculinising effects. Specimen of the uterus, cervix Granulosa-theca cell tumours comprise about 5% of all and adnexa shows enlarged ovarian mass (arrow) on one side which on ovarian tumours. The group includes: pure granulosa cell cut section is solid, grey-white and firm. Microscopically, the granulosa cells are arranged in a combination of fibroma and thecoma is present called variety of patterns including microand macrofollicular, fibrothecoma. The microfollicular pattern is characterised by the presence of characteristic Sertoli-Leydig Cell Tumours rosette-like structures, Call-Exner bodies, having central (Androblastoma, Arrhenoblastoma) rounded pink mass surrounded by a circular row of Tumours containing Sertoli and Leydig cells in varying granulosa cells (Fig. CharacMorphologic appearance alone is a poor indicator of teristically, they produce androgens and masculinise the clinical malignancy but presence of metastases and invasion patient. Their peak outside the ovary are considered better indicators of incidence is in 2nd to 3rd decades of life. Histologically, these tumours recapitulate to some extent Thecomas are typically oestrogenic. Three histologic types are hyperplasia, endometrial carcinoma and cystic disease of distinguished: the breast are some of its adverse effects. Well-differentiated androblastoma composed almost thecoma may secrete androgen and cause virilisation. Tumours with intermediate differentiation have a biphasic Microscopically, thecoma consists of spindle-shaped theca pattern with formation of solid sheets in which abortive cells of the ovary admixed with variable amount of tubules are present. Poorly-differentiated or sarcomatoid variety is composed rich and vacuolated which reacts with lipid stains. Mixture of both granulosa and theca cell elements in the same ovarian tumour Gynandroblastoma is seen in some cases with elaboration of oestrogen. Fibromas of the ovary are more common and there is combination of patterns of both granulosa-theca cell account for about 5% of all ovarian tumours. There is a small group of ovarian Histologically, they are composed of spindle-shaped welltumours that appears as soft yellow or yellow-brown nodules differentiated fibroblasts and collagen.

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