03 October 2009

The Cardiovascular Examination

Valvular Heart Disease and the Cardiac Exam
By:Charlotte Bai, M.D.
Internal Medicine Board Review
May 28, 2009

* Clinical syndromes
* Overview of cardiac murmurs and maneuvers
* Left sided valvular lesions
o Aortic stenosis and sclerosis
o Mitral stenosis
+ Rheumatic fever prophylaxis
o Acute and chronic aortic regurgitation
o Acute and chronic mitral regurgitation
* Right sided valvular lesions
o Tricuspid valve disease
* Prosthetic valves
* Endocarditis prophylaxis
* Questions

General Appearance
* Marfan Syndrome
o Tall, long extremities
o Associated with: aortic root dilitation, MV prolapse
* Acromegaly
o Large stature, coarse facial features, “spade” hands
o Associated with: Cardiac hypertrophy
* Turner Syndrome
o Web neck, hypertelorism, short stature
o Associated with: Aortic coarctation, pulmonary stenosis
* Pickwickian Syndrome
o Severe obesity, somnolence
o Associated with: Pulmonary hypertension
* Fredreich ataxia
o Lurching gait, hammertoe, pes cavus
o Associated with: hypertrophic cardiomyopathy
* Duchenne type muscular dystrophy
o Pseudohypertrophy of the calves
o Cardiomyopathy
* Ankylosing spondylitis
o Straight back syndrome, stiff (“poker”) spine
o Associated with: AI, CHB (rare)
* Lentigines (LEOPARD syndrome)
o Brown skin macules that do not increase with sunlight
o Associated with: HOCM, PS
“Spade” hands in acromegaly
* Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu)
o Small capillary hemangiomas on the face or mouth
o Associated with: Pulmonary arteriovenous fistula
* Lupus
o Butterfly rash on face, Raynaud phenomenon- hands, Livedo reticularis
o Associated with: Verrucous endocarditis, Myocarditis, Pericarditis
* Pheochromocytoma
o Pale diaphoretic skin, neurofibromatosis- café-au-lait spots
o Associated with: Catecholamine-induced secondary dilated CM
* Sarcoidosis
o Cutaneous nodules, erythema nodosum
o Associated with: Secondary cardiomyopathy, heart block
* Tuberous Sclerosis
o Angiofibromas (face; adenoma sebaceum)
o Associated with: Rhabdomyoma
* Myxedema
o Coarse, dry skin, thinning of lateral eyebrows, hoarseness of voice
o Associated with: Pericardial effusion, LV dysfunction

Grading the Intensity of Cardiac Murmurs
* Grade 1
o Murmur heard with stethoscope, but not at first
* Grade 2
o Faint murmur heard with stethoscope on chest wall
* Grade 3
o Murmur hears with stethoscope on chest wall, louder than grade 2 but without a thrill
* Grade 4
o Murmur associated with a thrill
* Grade 5
o Murmur heard with just the rim held against the chest
* Grade 6
o Murmur heard with the stethoscope held away and in from the chest wall

Cardiac Murmurs

* Most mid systolic murmurs of grade 2/6 intensity or less are benign
o Associated with physiologic increases in blood velocity:
+ Pregnancy
+ Elderly
* In contrast, the following murmurs are usually pathologic:
o Systolic murmurs grade 3/6 or greater in intensity
o Continuous murmurs
o Any diastolic murmur

Diagnostic Testing
Aortic Stenosis
Progression of Aortic Sclerosis
* Hemodynamic progression usually slow
o Average rate of increase in aortic jet velocity of 0.3 m/s per year
o Increase in mean transaortic gradient of 7 mmHg
o Decrease in AVA of 0.1 cm2 per year
* Severe AS
o Aortic jet velocity > 4 m/s
o Mean transvalvular pressure gradient > 50 mmHg
o AVA < 1.0 cm2

Pathophysiology of Aortic Stenosis
* Obstruction of LV outflow increases intracavitary systolic pressures and leads to LV pressure overload
* Initial compensatory mechanism is myocardial hypertrophy with preservation of systolic function
* Diastolic function impaired as a consequence of increased wall thickness and abnormal myocardial relaxation
* Increased wall stress and afterload causes eventual decrease in ejection fraction

* Occurs in patients with impaired systolic function and aortic stenosis
o Unable to generate transvalvular gradient
* Careful diagnostic testing with dobutamine infusion protocols can aid in differentiating between true AS and pseudostenosis
* If the calculated AVA increases with augmentation of cardiac output, then pseudostenosis present
* If AVA does not increase with dobutamine, then obstruction fixed and true AS present

Clinical Presentation of Aortic Stenosis
* Cardinal symptoms:
o Angina
+ Occurs in >50% of patients, not sensitive due to prevalence of CAD
o Syncope
* Sudden cardiac death rare, <1% per year
* In earlier stages, AS presentation more subtle
o Dyspnea
o Decreased exercise tolerance
* Rarely, AS diagnosed in the setting of GI bleeding
o Heyde’s syndrome
+ Bleeding caused by AVM
+ Concurrent AS occurs at prevalence rate of 15-25%
+ Associated with an acquired von Willebrand syndrome due to disruption of vW multimers through a diseased AV

Management of Aortic Stenosis
* Prognosis in asymptomatic disease excellent
* Conservative approach with monitoring for symptoms recommended
* When severe stenosis present-
o 38% of asymptomatic patients develop symptoms within 2 years
o 79% are symptomatic within 3 years
* Once symptoms occur, AVR needed
* LV dysfunction and severe AS have increased perioperative mortality with AVR
o But outcomes still favorable with surgery
* Nitroprusside may transiently improve cardiac function as a bridge to valve replacement
o Does not supplant AVR in symptomatic patients

Aortic Valve Replacement
* Prophylatic AVR in asymptomatic patients not routinely performed due to surgical risks
o Thromboembolism, bleeding associated with anticoagulation, prosthetic valve dysfunction, and endocarditis
o Occurs at a rate of 2-3% annually
o Only should be considered:
+ If other cardiac surgery (such as CABG) planned
+ Severe LVH or systolic dysfunction
+ Women contemplating pregnancy
+ Patients remote from health care
* Surgical valve replacement with operative morbidity and mortality of 10%
* Percutaneous balloon aortic valvotomy rarely used

Mitral Stenosis
* Usually associated with history of rheumatic fever
* >40% of cases of RHD result in mitral stenosis
o Women affected more than men (2:1)
* Presentation 20-40 years after the initial episode of rheumatic fever
o If infected at a young age, latent period is a few years

Clinical Presentation of Mitral Stenosis
* Significant MS leads to ↑LA pressure and pulm HTN
* Symptoms include dyspnea with ↑ cardiac demand
o Exercise
o Pregnancy
* Survival excellent with asymptomatic or minimally symptomatic patients
o >80% survival at 10 years
* Survival in symptomatic patients much worse
o 10 year survival drops to 15% or lower (if pulm HTN present)
* Findings consistent with severe MS:
o Transvalvular diastolic pressure gradient >10 mmHg
o MVA <1.0 cm2
o Severe pulmonary hypertension (>60 mmHg)

Management of Mitral Stenosis
* Atrial fibrillation
Mitral Valve Repair
* Percutaneous valvotomy
Rheumatic Fever Prophylaxis
* Primary prophylaxis
* Secondary prophylaxis
Acute Aortic Regurgitation
Acute Mitral Regurgitation
Chronic Valvular Regurgitation
Chronic Aortic Regurgitation
Chronic Mitral Regurgitation
Treatment of Chronic Mitral Regurgitation
Timing of Intervention for Left-Sided Valvular Conditions
Repeat TTE yearly, repeat clinical evaluation biannually
Repeat TTE at least yearly, repeat clinical evaluation at least biannually depending on the severity of the LV dilitiation
Clinical evaluation at least annually, depending on the severity of the mitral stenosis
Depending on the severity of AS, at least annual clinical evaluation with TTE to monitor for symptom onset
Chronic Severe MR
Chronic Severe AR
Mitral Stenosis
Aortic Stenosis
Tricuspid Valve Disease
* Tricuspid stenosis is rare
o Associated with rheumatic heart disease
* TR usually occurs secondary to:
o Pulmonary hypertension
o RV chamber enlargement with annular dilatation
o Endocarditis (associated with IV drug use)
o Injury following pacer lead placement
* Other secondary causes: carcinoid, radiation therapy, anorectic drug use, and trauma
* Primary causes: Marfan’s syndrome and congenital disorders such as Ebstein’s anomaly and AV canal malformation
* Echo is diagnostic in most cases
Tricuspid Regurgitation
* Severe tricuspid regurgitation is difficult to treat and carries a poor overall clinical outcome
* Symptoms are manifestations of systemic venous congestion
* Surgical intervention usually considered if other cardiac surgery planned
* Surgical options include valvular annuloplasty or replacement

Prosthetic Valves- Mechanical
* Three types:
o Ball-cage valve
o Single tilting disk valve
o Bileaflet valve
* Durable but require life long anticoagulation
* For operative procedures, warfarin typically is discontinued for 48-72 hours and restarted postop as soon as possible, except for:
o Mechanical mitral prosthesis
o Atrial fibrillation
o Prior thromboembolic events
Ball-cage valve
Single tilting disk valve
Bileaflet valve
Prosthetic Valves- Biological
* Biological Valves
o Composed of autologous or xenograft biological material mounted on stents and a sewing ring
o Warfarin therapy not required due to lower thromboembolic potential
o Valve durability less when compared to mechanical valves
o Newer stentless valves with increased longevity

Anticoagulation Guidelines for Mechanical Valves
Prosthetic Valve Complications
* Common complications include:
o Structural valve deterioration
o Valve thrombosis
o Embolism
o Bleeding
o Endocarditis
* Endocarditis prophylaxis required for patients with all types of prosthetic valves
* Suspect valve dehiscence or dysfunction in:
o Acute CHF in the immediate postop period
o New cardiac symptoms
o Embolic phenomena
o Hemolytic anemia
o New murmurs
* TEE is the diagnostic procedure of choice
* Postop TTE should be done 2-3 months after surgery

Valve Thrombosis
* Incidence with mechanical prosthesis of 2-4 % per year
* Suspect in patients with new murmur, change in cardiopulmonary symptoms, or an embolic event
* Diagnosis based on clinical presentation, TTE/TEE, and fluroscopy
* In small thrombus, treatment with heparin may be adequate
* Optimal treatment for left sided thrombosis is emergency surgery
* Consider thrombolytic therapy for right sided thrombosis or if surgery cannot be performed with left sided disease
Endocarditis Prophylaxis

The Cardiovascular Examination.ppt


Heart Murmurs

Heart Murmurs
By: David Leder


I. Basic Pathophysiology
II. Describing murmurs
III. Systolic murmurs
IV. Diastolic murmurs
V. Continuous murmurs
VI. Summary

Basic Pathophysiology
Murmurs = Math
Describing a heart murmur

1. Timing
o murmurs are longer than heart sounds
o HS can distinguished by simultaneous palpation of the carotid arterial pulse
o systolic, diastolic, continuous
2. Shape
o crescendo (grows louder), decrescendo, crescendo-decrescendo, plateau

3. Location of maximum intensity
o is determined by the site where the murmur originates
o e.g. A, P, T, M listening areas
4. Radiation
o reflects the intensity of the murmur and the direction of blood flow

5. Intensity
o graded on a 6 point scale
+ Grade 1 = very faint
+ Grade 2 = quiet but heard immediately
+ Grade 3 = moderately loud
+ Grade 4 = loud
+ Grade 5 = heard with stethoscope partly off the chest
+ Grade 6 = no stethoscope needed

*Note: Thrills are assoc. with murmurs of grades 4 - 6

6. Pitch
o high, medium, low
7. Quality
o blowing, harsh, rumbling, and musical
8. Others:
i. Variation with respiration

+ Right sided murmurs change more than left sided

ii. Variation with position of the patient

iii. Variation with special maneuvers

+ Valsalva/Standing => Murmurs decrease in length and intensity

EXCEPT: Hypertrophic cardiomyopathy and Mitral valve prolapse

Systolic Murmurs
* Derived from increased turbulence associated with:

1. Increased flow across normal SL valve or into a dilated great vessel
2. Flow across an abnormal SL valve or narrowed ventricular outflow tract - e.g. aortic stenosis
3. Flow across an incompetent AV valve - e.g. mitral regurg.
4. Flow across the interventricular septum

Early Systolic murmurs
1. Acute severe mitral regurgitation
2. Congenital, small muscular septal defect
3. Tricuspid regurg. with normal PA pressures

Midsystolic (ejection) murmurs
* Are the most common kind of heart murmur
* Are usually crescendo-decrescendo
* They may be:
1. Innocent
2. Physiologic
3. Pathologic

Aortic stenosis
* Loudest in aortic area; radiates along the carotid arteries
* Intensity varies directly with CO
* A2 decreases as the stenosis worsens
* Other conditions which may mimic the murmur of aortic stenosis w/o obstructing flow:

1. Aortic sclerosis
2. Bicuspid aortic valve
3. Dilated aorta
4. Increased flow across the valve during systole

Hypertrophic cardiomyopathy
Pansystolic (Holosystolic) Murmurs
1. Mitral valve regurgitation
2. Tricuspid valve regurgitation
3. Ventricular septal defect
Diastolic Murmurs
* Almost always indicate heart disease
* Two basic types:

1. Early decrescendo diastolic murmurs
2. Rumbling diastolic murmurs in mid- or late diastole

Aortic Regurgitation
* Best heard in the 2nd ICS at the left sternal edge
* High pitched, decrescendo
* Blowing quality => may be mistaken for breath sounds
* Radiation:

Mitral Stenosis
* Two components:
1. Middiastolic - during rapid ventricular filling
2. Presystolic - during atrial contraction; therefore, it disappears if atrial fibrillation develops
Continuous Murmurs

1. Cervical venous hum
2. Mammary souffle
3. Patent Ductus Arteriosus
4. Pericardial friction rub
Back to the Basics
1. When does it occur - systole or diastole
2. Where is it loudest - A, P, T, M
I. Systolic Murmurs:
1. Aortic stenosis - ejection type
2. Mitral regurgitation - holosystolic
3. Mitral valve prolapse - late systole

II. Diastolic Murmurs:
1. Aortic regurgitation - early diastole
2. Mitral stenosis - mid to late diastole

A. Presystolic murmur
o Mitral/Tricuspid stenosis
B. Mitral/Tricuspid regurg.
C. Aortic ejection murmur
D. Pulmonic stenosis (spilling through S20
E. Aortic/Pulm. diastolic murmur
F. Mitral stenosis w/ Opening snap
G. Mid-diastolic inflow murmur
H. Continuous murmur of PDA

Heart Murmurs.ppt


Valvular Heart Disease

Valvular Heart Disease

Medical Surgical I
* Mitral Stenosis
* Mitral Regurgitation
* Mitral Valve Prolapse
* Aortic Stenosis
* Aortic regurgitation
* Tricuspid valve is affected infrequently
o Tricuspid stenosis – causes Rt HF
o Tricuspid regurgitation –causes venous overload

Tricuspid Valve
Rheumatic Heart Disease
* Inflammatory process that may affect the myocardium, pericardium and or endocardium
* Usually results in distortion and scarring of the valves
* Subjective symptoms
o Prior history of rheumatic fever
o General malaise
o Pain – may or may not be present
* Objective symptoms
o Temperature
o Murmurs
o Dyspnea
o polyarthritis
* Diagnosis
o H/P
o WBC and ESR
o C-reactive protein
o Cardiac enzymes
o Chest x-ray
o Echo
o Cardiac cath
o Cardiac output
* Nursing Care
o Vital signs
o Rest and quiet environment
o Give antibiotics, digitalis, and diuretics
o Provide adequate nutrition
o Monitor I/O
o Explain treatment and home care

Mitral Stenosis
* Usually results from rheumatic carditis
* Is a thickening by fibrosis or calcification
* Can be caused by tumors, calcium and thrombus
* Valve leaflets fuse and become stiff and the cordae tendineae contract
* These narrows the opening and prevents normal blood flow from the LA to the LV
* LA pressure increases, left atrium dilates, PAP increases, and the RV hypertrophies
* Pulmonary congestion and right sided heart failure occurs
* Followed by decreased preload and CO decreases
* Mild – asymptomatic
* With progression – dyspnea, orthopneas, dry cough, hemoptysis, and pulmonary edema may appear as hypertension and congestion progresses
* Right sided heart failure symptoms occur later
* S/S
o Pulse may be normal to A-Fib
o Apical diastolic murmur is heard

Mitral Regurgitation
* Primarily caused by rheumatic heart disease, but may be caused by papillary muscle rupture form congenital, infective endocarditis or ischemic heart disease
* Abnormality prevents the valve from closing
* Blood flows back into the right atrium during systole
* During diastole the regurg output flows into the LV with the normal blood flow and increases the volume into the LV
* Progression is slowly – fatigue, chronic weakness, dyspnea, anxiety, palpitations
* May have A-fib and changes of LV failure
* May develop right sided failure as well

Mitral Valve Prolapse
* Cause is variable and may be associated with congenital defects
* More common in women
* Valvular leaflets enlarge and prolapse into the LA during systole
* Most are asymptomatic
* Some may report chest pain, palpitations or exercise intolerance
* May have dizziness, syncope and palpitations associated with dysrhythmias
* May have audible click and murmur

Aortic Stenosis
* Valve becomes stiff and fibrotic, impeding blood flow with LV contraction
* Results in LV hypertrophy, increased O2 demands, and pulmonary congestion
* Causes – rheumatic fever, congenital, arthrosclerosis
* Atherosclerosis and calcification is primary cause in the elderly
* Complications – right sided heart failure, pulmonary edema, and A-fib
* S/S – Early: dyspnea, angina, syncope

Aortic Regurgitation
* Aortic valve leaflets do not close properly during diastole
* The valve ring that attaches to the leaflets may be dilated, loose, or deformed
* The ventricle dilates to accommodate the ^ blood volume and hypertrophies
* Causes: infective endocarditis, congenital, hypertension, Marfan’s
* May remain asymptomatic for years
* Develop dyspnea, orthopnea, palpitations, ,and angina
* May have ^ systolic pressure with bounding pulse
* Have a high pitch, blowing, decrescendo diastolic murmur

Assessment for Valve Dysfunction
* Subjective symptoms
o Fatigue
o Weakness
o General malaise
o Dyspnea on exertion
o Dizziness
o Chest pain or discomfort
o Weight gain
o Prior history of rheumatic heart disease
* Objective symptoms
o Orthopnea
o Dyspnea, rales
o Pink-tinged sputum
o Murmurs
o Palpitations
o Cyanosis, capillary refill
o Edema
o Dysrhythmias
o Restlessness

* History and physical findings
* Chest x-ray
* Cardiac cath
* Echocardiogram

Medial Treatment
* Nonsurgical management focuses on drug therapy and rest
* Diuretic, beta blockers, digoxin, O2, vasodilators, prophylactic antibiotic therapy
* Manage A-fib, if develops, with conversion if possible, and use of anticoagulation

* Assess vitals, heart sounds, adventitious breath sounds
* ^ HOB
* O2 as prescribed
* Emotional support
* Give medications
* I/O
* Weight
* Check for edema
* Explain disease process, provide for home care with O2, medications

Surgical Management of Valve Disease
* Mitral Valve
o Commissurotomy
o Mitral Valve Replacement
o Balloon Valvuloplasty
* Aortic Valve Replacement

Mechanical Valve
Porcine Valve
Tissue Valve

Valvular Heart Disease.ppt


Developmental Toxicology

Developmental Toxicology

* Structural malformations
* Growth retardation
* Functional impairment
* Death of the organism
4 manifestations of developmental toxicity

1. the study of malformations or serious deviations from the normal type in organisms

2. the branch of science concerned with the production, development, anatomy, and classification of malformed fetuses.

* Teratogen
o Any agent that causes a birth defect
o After Greek “monster creating”
* Environmental conditions (1200)
* Maternal nutritional deficiencies (1930)
* Rubella virus infection (1941)
* Thalidomide (1961)

Adverse Outcomes in Pregnancy
Cause of human birth defects
Chemical teratogenicity
Pregnancy Risk Categories
Therapeutic Drugs Teratogenic to Humans
* Anticonvulsants
o Phenytoin, primidone, trimethadione, valproic acid, carbamazepine
* Anticancer agents
o Alkylating agents –busulfan, cyclophosphamide, chlorambucil, mechlorethamine
o Antimetabolites-aminopterin, methotrexate, cytarabine
* Androgenic hormones-danazol
* Coumarin anticoagulants-warfarin
* Retinoids-accutane, isotretinoin, etretinate, acitretin
* Antihyperlipidemic agents-lovastatin, atorvastatin
* Other drugs-diethystilbestrol, thalidomide, penicillamine, lithium, fluconazole, misoprostol
Diethylstilbesterol (DES)
Alcohol (Ethanol)
Fetal Alchohol Syndrome (FAS)
Fetal Alchohol Effects (FAE)
* Cranial facial dysmorphism
* Intrauterine and postnatal growth retadation
* Retarded psychomotor and intellectual development
* IQ 68

Tobacco smoke
* Spontaneous abortions
* Perinatal deaths
* Lower birth weight
* Increased risk of
o Sudden infant death syndrome
o Behavioral attention disorders
o Orofacial cleft (particular xenobiotic gene polymorphisms)
o Gastroschisis (with variant alleles N053, ICAM1, NPPA)
o Branching morphogenesis and maturation of the lung
* Nicotine-related adverse nerodevelopmental outcomes
* At risk for premature labor, spontaneous abortion, increased perinatal mortality and fetal death.
* intrauterine growth retardation, microcephaly, altered presencephalic development, decreased birth weight, a neonatal neurologic syndrome of abnormal sleep, tremor, poor feeding, irritability, and occasional seizures.
* Genitaouinary tract malformation
* Impaired uditory process

Retinoic Acid
Retinoic acid is the active ingredient in “Accutane”, a drug used to treat severe acne. Since its introduction in September of 1982, an estimated 160,000 women of child bearing age have ingested the drug. Between 1982 and 1987, approximately 900-1300 malformed children, 700-1000 spontaneous abortions and 5000-7000 elective abortions are due to Accutane exposure. Exposed children may have hydrocephaly, ear malformations, cardiovascular defects and decreased IQ. Accutane carries a pregnancy category X warning, meaning it is a known human teratogen.
c acid
* Malformations of the face, limbs, heart, CNS, and skeleton
* RXR α receptor
* Schizophrenia
Retinoid Therapies
Tretinoin/ATRA (Vesanoid)
Adapalene (Differin),
Tretinoin (Renova),
Isotretinoin (Accutane)
Tazartene (Zorac),
Etritinate (Tegison)
RAR and RXR (Simple Version)
* Nuclear Receptors (like ER, PPAR, VDR and others)
* RXR/RAR Heterodimer is functional unit
* Bind selectively to REs in genome
* Act as transcription factors
* Up-regulate or Repress the expression of particular genes

Valproic acid was released in 1967 in Europe and in 1978 in the United States to treat epilepsy. Approximately 11,500 epileptic women become pregnant each year, many of which use valproic acid. By 1980, publications began linking malformed children to in utero exposure to valproic acid (greater than 500 mg/day).

Valproic Acid
* spina bifida with menigomyelocele or menigocele
* The proposed mechanism of action is that valproic acid influences folate metabolism

Angiotensin Converting enzyme inhibitors and angiotensin antagonists
* 2-3 trimester
* related reduced amniotic fluid volume and impaired fetal renal function
o Oligohydromnios
o Fetal growth retardation
o Pulmonary hypoplasia
o Renal failure
o Hypotension
o Death
* First trimester
o Congenital malformation

Wilson’s General Principles of Teratology (Table 10-2)
* Susceptibility to teratogenesis depends on the genotype of the conceptus and the manner in which this interacts with environmental factors.
* Susceptibility to teratogenic agents varies with the developmental stage at the time of exposure.
* Teratogenic agents act in specific ways (mechanisms) on developing cells and tissues to initiate abnormal embryogenesis (pathogenesis).
* The final manifestations of abnormal development are death, malformation, growth retardation, and functional disorder.
* The access of adverse environmental influences to developing tissue depends on the nature of the influences (agent).
* Manifestations of deviant development increase in degree as dosage increases from the no-effect to the totally lethal level.
Critical periods of susceptibility and endpoints of toxicity
* Gametogenesis and Fertilization

Mechanism unclear, may be related to imprinting
Cytosine methylation and change in chromatin conformation ethylene oxide, ethylmethane sulfonate, ethylnitrosourea→malformed fetus

DNA Methylation vs Genomic Imprinting
Mechanisms and pathologenesis of developmental toxicology

* Mutations
* Chromosomal breaks
* Altered mitosis
* Altered nucleic acid integrity or function
* Diminished supplies or precursors of substrates
* Decreased energy supplies
* Altered membrane characteristics
* Osmolar imbalance
* Enzyme inhibition
Example of cyclophosphamide (CP)
Single strand DNA break
A teratogenic chemotherapeutic agent
CP induces DNA damage
Advances in the Molecular basis of dysmorphogenesis
1.Using either singly or double gene knockout Retinoic acid receptor family (syndactyly)
2. Antisense oligonucleotide Wnt-1, Wnt-3a (mid and hindbrain malformation)
3. Reporter transgenes

Pharmacokinetics and metabolism in pregnancy
1.Changes in maternal physiology
hepatic metabolism, GI tract, cardiovascular system, excretory system, respiratory system
2.Overall decrease in hepatic xenobiotic transformation
3.Roles of placenta in influence embryonic exposure help to regulate blood flow
-offer a transport barrier-pH gradient, weak acid rapidly transfer
-metabolize chemicals
2-acetylaminofluorene (proteratogen)
7-hydroxyl metabolites(proximate teratogen)
4.Maternal metabolism of xenobiotics 2-methoxyethanol 2-methoxyacetic acid

Placental toxicity
* Metals, Cd, As, Hg, ethanol, cocaine, cigaratte, sodium salicylate
* Maternal injection vs fetal injection of Cd
* Production of metallothionein
* Interaction with Zn

Maternal toxicity-
* acetazolamide inhibits carbonic anhydrase forelimb ectrodactyly

* diflunsial results in anemia skeleton defects in rabbits
* phenytoin affects folate metabolism and heart rates
* metallothionein synthesis inducer-urathane, mercaptopurine, valproic acid Zn deficiency

Develpmental toxicity of endocrine-disrupting chemicals
Definition of endocrine-disrupting chemicals
“Exogenous agent that interferes with the production, release, transport, metabolism, binding, action, or elimination of natural hormones responsible for the maintenance of homeostasis and the regulation of developmental processes.”
Endocrine-disrupting chemicals
Four modes of action
1. Serving as steroid receptors ligands
2. Modifying steroid hormone metabolizing enzymes
3. Perturbing hypothalamic-pituitary release of trophic hormones
4. Uncharacterized proximate modes of action

Fetal Basis and Transgenerational Transmission of Reduced Fertility
Environmental Epigenetics
Decreased spermatogenic capacity and decreased fertility ..as well as increased prevalence of other diseases transferred via MALE germ line

* A transient embryonic exposure to endocrine disruptors at the time of gonadal sex determination can cause epigenetic transgenerational disease state of subfertility and spermatogenic defects in F1 through F4 generations
* Transgenerational disease phenotype was primarily transmitted through the male germ line
* Exposure appears to have caused an epigenetic reprogramming of the germ cell line that is “permanent” and transferred transgenerationally to subsequent generations

Modern safety assessment
* Regulatory guidelines for in vivo testing
* Multigeneration tests
* Children’s health and the food quality protection act
o Tenfold safety factor for children
* Alternative testing strategies
* Epidemiology
* Concordance of data (among species)
* Elements of risk assessment
use-in pregnancy rating: A, B, C, D, X

In Vivo Regulatory Protocol Guideline
The 17 intercellular signaling pathways by most metazoans
* Early development and later
* 1. Wnt pathway
* 2. Receptor serine/threonine kinase (TGFb) pathway
* 3. Hedgehog pathway
* 4. Receptor tyrosine kinase (small G proteins) pathway
* 5. Notch/Delta pathway
* Mid-development and later
* 6. Cytokine receptor (cytoplasmic tyrosine kinases)
* pathway
* 7. IL1/Toll NFkB pathway
* 8. Nuclear hormone receptor pathway
* 9. Apoptosis pathway
* 10. Receptor phosphotyrosine phosphatase pathway
* Larval/adult physiology
* 11. Receptor guanylate cyclase pathway
* 12. Nitric oxide receptor pathway
* 13. G-protein coupled receptor (large G proteins) pathway
* 14. Integrin pathway
* 15. Cadherin pathway
* 16. Gap junction pathway
* 17. Ligand-gated cation channel pathway

Sonic Hedge-hog signal pathway
Cholesterol synthesis inhibitor
Consequences of Folate Deficiency
* Result of low dietary intake, genetic error of folate metabolism, lifestyle exposures
* DNA Hypomethylation
o Gene overexpression, uncontrolled cell growth, genomic instability
* Hyperhomocysteinemia
o Excessive accumulation of Hcy
* Base Misincorporation
o Decrease in thymine synthesis; replaced by uracil
o DNA strands prone to nicks, breaks and vulnerable to mutagen insertion

1. Describe the possible mechanisms for teratogenic effects of the following chemicals.
a. aminoglycosides
b. ethylene oxide
c. captopril
d. danazol
e. aminopterin
f. Accutane

Developmental Toxicology.ppt


Forensic Anthropology

Forensic Anthropology
Why Forensic Anthropology

* Forensic pathologists are trained to analyze soft tissue and organs. Their experience with hard tissue (bone) is limited.
* The forensic anthropologist specializes in hard tissue morphology, structure and variability. In those cases in which soft tissue has been degraded by time, temperature, environment or other external forces, the only tissue remaining more or less intact is bone.
* Physical Anthropologists and Archeologists study human remains-and have become part of solving crimes.

What Questions Can Forensic Anthropology Answer?

* What is the race of the individual?
* What is the sex of the individual?
* What is the age of the individual?
* What is the stature of the individual?
* What pathologies did the individual have?
* What traumas did the individual have?
* What individual traits did the individual have?

Identity of Decomposed or Skeletal Remains

* Are the remains human or animal? (butchers remains and skeletal remains of dead pets etc. may be found in unlikely places)
* Are they really bones? (wood, stones)
* Are they human?
* How many bodies?
* How long dead? - recent or ancient (e.g. construction or digging at an old burial site)
* Cause of death?
How does this Work?

* Forensic anthropologists use regression equations to determine sex, age, stature, and race of skeletal remains.
* Regression equations are mathematical equations developed from studies of bones of individuals of known sex, age, race, and stature, and are used to predict such things of even fragmentary skeletal remains."

Sex Estimation
* The sex of an individual is determined, when soft tissue is not present, by a number of skeletal indicators.
* The more indicators used to determine sex, the more accurate the results.
* A forensic anthropologist is analytically limited by the bones present and the condition of the bones.
* In general, the muscles in a man are stronger and more developed than in a woman.
* Bones of men are larger and more robust than bones of women.
* Some bones display specific features which can be used to help determination of the sex of the skeleton. The best indicators are the:
o Skull
o Pelvis
o Head of the Femur
Sex Estimation – Adult
* Usually related to size in adult long bones
* Male bones: usually larger, longer in a single population – be cautious if different populations are involved
* Maximum diameter of head of humerus and head of femur may be used (Bass).
* Much more difficult to estimate sex in children’s skeletons.
Sex Estimation: Skull

* Good area for sex determination
* Generalization: male skull more robust, muscle-marked than female: ABSOLUTE
* Sex estimation: face, mandible, vault

Sex Estimation: Face
1. Supraorbital (Brow) ridges: more prominent in males
2. Superior orbital margin: sharper in females
3. Palate: larger in males
4. Teeth: larger in males (Bass)
5. Mastoid process: more prominent and rugged in males.
6. Orbit (Eye socket): Rounder in females, more rectangular in males
7. Chin: more pronounced in males and larger jaws.

* Women give birth. For this reason, the pelvis of a woman is larger than the pelvis of a man.
* The pelvis of a woman is wide and circular whereas the pelvis of a man is narrow and heart-shaped.
* Two angles, the sub-pubic angle and the sciatic notch, cause the differences in the shape of the pelvis.
* In women, the sub-pubic angle and sciatic notch are wide. In men, the sub-pubic angle and sciatic notch are narrow.

Male Pelvis Subpubic Notch
Female Pelvis Subpubic Notch
Pubis Bone Traits Related to Sex
Subpubic angle (degrees) angle made by the inferior borders of the articulated pubis bone
Pubis body width (mm)
Ventral arc: a roughened projection of bone visible on the anterior surface of the pubis bone
Head of the Femur
* In men, the diameter of the head of the femur is larger than 51 mm.
* In women, the diameter of the head of the femur is less than 45 mm.

Determining Ages of Skeletons
* Bone growth stops at about 20 yrs. of age in humans.
* Adult bone continuously adapts to prevailing stresses by appropriate deposition and resorption.
* Deposition and resorption are under hormonal control - integrated with regulation of blood calcium levels.
Skeletal Age
* Skeletal age is the estimated age at which a person died. Skeletal age can be determined by looking at the following:
o sutures of the skull
o teeth
o ribs
o vertebrae
o growth areas of the long bones: epiphyses
Sutures of the Skull
* When a baby is born, the skull is still growing.
* To accommodate this growth, the different bones of the skull are separate.
* By the age of 7, all the different bones have finished growing and the fontanelles have disappeared.
Skull Sutures

The Teeth
* The teeth are arranged in upper and lower arches. Those of the upper are called maxillary; those of the lower are mandibular.

Dental Tissues.
* Enamel. The protective outer surface of the anatomic crown. It is 96% mineral and is the hardest tissue in the body.
* Dentin. Located in both the crown and root, it makes up the bulk of the tooth beneath the enamel and cementum. It lines the pulp cavity.
* Cementum. This substance covers the surface of the anatomic root.
* Pulp. The central, innermost portion of the tooth. It has formative, sensory, nutritive, and functions during the life of the tooth.

* There are four types of teeth with very different shapes:
* Incisors (2)
* Canines (1)
* Premolars (bicuspids) (2)
* Molars (2-3)
* Individual teeth are quite distinct, even when lost from a jaw.

Dental Formula (from the midline)

* Primary (deciduous) teeth.
* It is said as: incisors, two upper and two lower; canines, one upper and one lower; molars two upper and two lower equals ten per side.
* Permanent teeth.
* It is said as: incisors, two upper and two lower; canines, one upper and one lower; premolars, two upper and two lower; and molars, three upper and three lower.

* The first teeth to appear are the incisors, which are followed by canines and molars.
* When chewing food, teeth grind down.
* Comparing different teeth gives an idea of how long the teeth have been used.
* Eventually teeth may be lost, due to caries or attrition.

X-Rays Are Used to Date Skulls
* This is the side view of the dentition of a six year old boy.
* There is still some variation from person to person in the order in which the teeth erupt.

Baby Teeth Permanent Teeth
Dental Disease - Cavities, Abscesses, and Attrition
* Because of breathing, the front part of the ribs is constantly moving.
* As a person gets older, the front part of the ribs begin to change and form bony spikes.
* As a person gets older, bony spikes can also start growing on the vertebrae.
* This starts at approximately 40 years of age.
Growth areas of the long bones
* From birth to ą25 years of age, a person grows at a relatively constant rate.
* Growth takes place at the ends of the long bones.
* At a certain age, growth is completed and this can also be seen on the bone.

Epiphyseal Fusion
* The pattern of fusion of bone ends (epiphysis) to bone shaft (metaphysis) in each bone indicates age.
* Charts & tables are used.
* The upper arm stops growing at the shoulder at approximately age 20 and at the elbow at approximately age 14.5.
* The upper leg stops growing at the hip at approximately age 17.5 and at the knee at approximately age 18.

Determining Ages of Skeletons
* Cranial suture fusion is less reliable.
* Pubic symphysis changes slightly with age.
* Arthritic changes and osteoporosis give further clues.

Arthritic changes and osteoporosis give further clues to the ages of skeletons.
Ossification Centers
* Useful only in fetuses and babies.
* May be determined radiologically or by cutting into ossification centers.
* May be confirmed histologically.
* Most important center in medico-legal work is the distal center of the femur.
* This is present at birth and indicates a full term baby.
Age Determination from Skeleton
* Long bone length (femur, tibia, humerus) is proportional to height.
* Tables are used.
* Fairly reliable up to the age of epiphyseal fusion.
* There are sex, race, nutrition and personal variations to consider.
Individual Characteristics
Head Injuries
Individual Characteristics
* Bone disease (Paget's disease, tumors)
* Previous injury to bone (fracture callus, prosthesis, metallic fragments).
* Comparison of trabecular pattern of bone.
* Pattern of skull's frontal air sinuses. Outline is unique and comparisons with clinical X-rays are useful.
Forensic Dentistry
* Teeth are commonly used to establish identity of deceased.
* Dental X-rays and dental casts are available often for 10 years after a patient visits the dentist last..
Body Type
Race or Ethnic Group Determination
Minimum Number of Individuals
Dating of Human Skeletal Remains
Age of Human Remains
* Naked eye appearance is unreliable:
* Tags of soft tissue, periosteum, ligaments etc, indicate less than 5 years old.
* Soapy texture of surface indicates age less than a few decades.
* Light, crumbling bones are likely to be a century or more old.

Laboratory Tests Can Help
* Immunological reaction between bone extract and anti human serum ceases within months of death.
* If blood pigments are present bones are usually less than 10 years old.
* Up to 20 amino acids may be identified in bones less than a century old.
* Fluorescence of freshly sawn bone surface under UV light diminishes after 100 years.
* New bones contain 4.0 - 4.5 gms% nitrogen; 2.5 gms% indicates approximately 350 years.
* Radioactive carbon dating indicates which century.
* Coined from the Greek words taphos, for "burial," and nomos, for "law."
* Forensic Taphonomy : The Postmortem Fate of Human Remains
* Skeletal trauma, decomposition, and dispersal of remains.
* Weathering, a taphonomic process, is very useful in determining the elapsed time since death.
Facial Reconstruction
* Skull can be scanned into a computer and "fleshed" by computer reconstruction to give likely facial appearance in life.
* Unfortunately eye color, hair color and lips are independent of bony structure.
* Pearl was a female who died in her early forties approximately three hundred years ago.
* She was Caucasian, of European ancestry and stood about 5'1".
* Her dental health was extremely poor and she had lost 63 per cent of her teeth prior to death. She had no teeth on either side of her jaw. This was most important as the loss of those teeth would evidence themselves in the final reconstruction as sunken cheeks. Of her remaining teeth, the condition was poor and she had several abscesses.
* During her lifetime, there are indicators that she also suffered from acute infections, rickets, sinusities, an upper respiratory infection, arthritis, and gout. Whew--all this in an era when aspirin didn't exist!
* On the other hand, it was determined that she was very muscular, as the ridges on her long bones were very developed.

Various items (glasses, clothing, hats) may be applied to better accentuate the features of the individual.
This method can be very successful.
Cause of Death
* Anthropologists can distinguish between marks from the result of a weapon attack and those resulting from the gnawing and biting of bones by scavenging animals.
* They can also determine the exact kind of weapon and animal, and they can tell if a wound is old or if it occurred at death.
* They can be called upon to testify as to the type of weapon used (saw vs. knife).

Lizzie Bordon’s Father’s skull: Ax Whacked.

* Two outstanding cases of the use of forensic anthropology to successfully solve unsolved mysteries are the cases of Francisco Pizarro.

Pizarro conquered the Incas.
* Pizarro was hated by the Peruvians because he was a brutal ruler. On June 26, 1541 (at age 66), he was stabbed to death by a crowd of angry subjects and in view of many witnesses (Dickerson 1993).
* His brutal death is not questioned due to the well documentation at the time. It was his remains that were questioned.
* In the 1890's, Peruvian officials decided to put Pizarro's remains on exhibit. "They asked officials at the Cathedral of the Plaza de Aramis in Lima for Pizarro's body and were directed to a mummy, which they put on view." (Dickerson 1993)
* In 1978 workers discovered a secret niche that had been walled over in the cathedral, and on a shelf in the niche was a box with a skull and an inscription that identified it as the head of Pizarro.
* Another box was found containing the bones of several unidentified individuals (Dickerson 1993).

* An investigation of the bones in the second box led to the discovery that the postcranial bones matched the skull in the first box.
* These bones and the skull were then placed together and prepared for study to determine if they had marks consistent with sword or knife wounds.

Forensic Anthropology.ppt


30 September 2009


Definition and Classification
* Non-caloric organic nutrients
* Needed in very small amounts
* Facilitators – help body processes proceed; digestion, absorption, metabolism, growth etc.
* Some appear in food as precursors or provitamins

Definition and Classification
* 2 classes, Table 7.1
o Fat soluble:
o Water soluble:
* Fat soluble vitamins
o Found in the fats and oils of food.
o Absorbed into the lymph and carried in blood with protein transporters = chylomicrons.
o *Stored in liver and body fat and can become toxic if large amounts are consumed.
* Water soluble vitamins
o Found in vegetables, fruit and grains, meat.
o Absorbed directly into the blood stream
o Not stored in the body and toxicity is rare. Alcohol can increase elimination, smoking, etc. cause decreased absorption.

Fat Soluble Vitamins
* Vitamin A (precursor – beta carotene)
o 3 forms: retinol (stored in liver), retinal, retinoic acid
o Roles in body:
+ Regulation of gene expression
+ Part of the visual pigment rhodopsin, maintains clarity of cornea (yes eating carrots is good for your eyesight)
+ Required for cell growth and division - epithelial cells, bones and teeth
+ Promotes development of immune cells, especially “Natural Killer Cells”
+ Antioxidant
* Vitamin A
o Deficiencies cause:
+ Night blindness, xerophthalmia (keratin deposits in cornea), macular degeneration.
+ Skin and mucous membrane dryness and infection, keratin deposits.
+ Anemia
+ Developmental defects – bones, teeth, immune system, vision

o Toxicities (RetinA/Accutaine, single large doses of supplements, eating excessive amounts of liver) cause:
+ Fragile RBCs, hemorrhage
+ Bone pain, fractures
+ Abdominal pain and diarrhea
+ Blurred vision
+ Dry skin, hair loss
+ Liver enlargement
o DRI: 700(women)-900(men) micrograms/day, UL 3000 micrograms
o Sources, see snapshot 7.1

* Vitamin D – precursor is cholesterol, converted by UV from sunlight exposure, therefore is a “non-essential” vitamin.
o Roles:
+ Increases calcium absorption in bone, intestines, kidney. Promotes bone growth and maintenance.
+ Stimulates maturation of cells – heart, brain, immune system, etc.

o Deficiencies: rickets (children), osteomalacia (adults). What are some of the causes of deficiencies?
o Toxicities (5X DRI)
+ Loss of calcium from bone and deposition in soft tissues.
+ Loss of appetite, nausea and vomiting, psychological depression.

Bowed legs – Characteristic of rickets

Beaded ribs – Characteristic of rickets
* Vitamin D
o DRI – 5 micrograms/day for ages 19-50, 10 for ages 51-70, 15 for ages >70.
o Sources, see snapshot 7.2

Fat Soluble Vitamins
* Vitamin E – tocopherol, *alpha-, beta -, gamma-, and delta-
o Roles:
+ Antioxidant (protects polyunsaturated fats)
+ Prevention of damage to lungs, RBCs, WBCs (immunity), heart
+ Necessary for normal nerve development
* Vitamin E
o Deficiencies (decreased absorption of fats- liver disease, low fat diets)
+ Premature babies – fragile RBCs (hemolysis)
+ Loss of muscle coordination, vision, immune functions
o Toxicities (more than 1000 milligrams/day)
+ Increases the effects of anticoagulants (Coumadin, Warfarin)
o DRI 15 milligrams/day (alpha-tocopherol)
o Sources, see snapshot 7.3
* Vitamin K – produced by bacteria in large intestine
o Roles
+ Promotes synthesis of blood clotting proteins (**Interferes with Coumadin)
+ Bone formation
o Deficiencies are rare but seen in infants, after prolonged antibiotic therapy, and in patients with decreased bile production.
o Toxicities (>1000 mg/day): rupture of RBCs and jaundice

o DRI: 90(women) – 120(men) micrograms/day
o Sources, see snapshot 7.4

Water Soluble Vitamins
* 8 B vitamins – Tender Romance Never Fails with 6 to 12 Beautiful Pearls (Thiamin, Riboflavin, Niacin, Folate, B6, B12, Biotin, and Pantothenic acid)
o Aid in metabolism of and energy release from carbohydrates, lipids, amino acids.
o Mode of action – coenzymes or parts of coenzymes that are necessary for the proper activity of enzymes, Without the coenzyme, compounds A and B don’t respond to the enzyme.

With the coenzyme in place, compounds A and B are attracted to the active site on the enzyme, and they react.
The reaction is completed with the formation of a new product. In this case, the product is AB.
Muscles and other tissues metabolize protein.
Brain and other tissues metabolize carbohydrates.
Bone tissues make new blood cells.
Liver and other tissues metabolize fat.
Digestive tract lining replaces its cells.

* Thiamin and Riboflavin
o Roles – energy metabolism in cells, part of nerve cell membranes.
o Deficiencies
+ Beri beri, edema &/or muscle weakness
+ Alcohol abuse – Wernicke-Korsakoff syndrome
o DRI thiamin:1.1(women) – 1.2(men) mg/day; riboflavin 1.1(women) – 1.3(men) mg/day
o Sources: All food groups except fats and oils
* Niacin – can be produced from the amino acid tryptophan.
o Roles: energy metabolism
o Deficiencies: Pellagra – dermatitis, diarrhea, dementia, death
o Toxicities (2 - 3X DRI): *prevents blood clotting, causes liver damage, enhances action of Coumadin
* Niacin
o DRI 14(women) -16(men) mg/day
o Sources, snapshot 7.8
+ Meats
+ Some vegetables and grains
* Folate
o Role: required for synthesis of DNA - ***pregnancy
o Deficiencies (drug interactions, smoking)
+ Anemia
+ Decreased immunity
+ Decreased digestive and cardiovascular function
+ Colon and cervical cancers
+ *Neural tube defects, ?other birth defects
o Toxicities (>1000 mg/day): rare, interferes with anticancer drugs.
o DRI 400 milligrams/day
o Sources, snapshot 7.8

* Vitamin B12 (requires intrinsic factor for absorption)
o Roles: works with folate, part of insulating sheath around nerves.
o Deficiencies:
+ Pernicious anemia
+ Paralysis
+ Nerve damage in fetus
o DRI 2.3 micrograms/day
o Sources, see snapshot 7.9
+ Meat and dairy
+ Implications for vegans??
* Vitamin B6
o Roles:
+ Conversion of amino acids to other amino acids
# Ex.: Tryptophan to niacin
+ Synthesis of hemoglobin and neurotransmitters
+ Release of glucose from glycogen
+ Immune function
+ Promotes steroid hormone activity
+ Development of nervous system
o Deficiencies
+ Anemia
+ Dermatitis
+ Muscle weakness
+ Behavioral problems
+ ?Heart disease
o Toxicities (>100 mg/day) – muscle weakness, nerve damage
o DRI 1.3 milligrams/day
o Sources, see snapshot 7.10
+ Meat and dairy
+ Vegetables and fruits
* Biotin and Pantothenic acid
o Roles:
+ Metabolism of carbohydrates, fats and proteins
+ Synthesis of lipids, neurotransmitters, steroid hormones, hemoglobin.
* “Non-B vitamins”: choline, carnitine, inositol, lipoic acid, etc. No beneficial effects proven!!

* Vitamin C, ascorbic acid – history of controversy
o Roles:
+ Connective tissue development, collagen
+ Antioxidant
+ Promotes iron absorption, immunity?
+ Protects vitamin E

o Deficiency – Scurvy (skin and mucous membrane damage), anemia.
o Toxicity (> 2grams/day) – pro-oxidant, activates oxidizing agents.
o DRI – 75(w) – (90(m) milligrams/day. Increased for smokers.
o Sources, see snapshot 7.11
o Notes: can interfere with diagnostic tests for diabetes, and blood clotting
o ??Prevents colds

Vitamin/Mineral Supplements

* Who needs them?
* Who does not need them?
* Oyo read - Controversy



Coagulation Testing

Coagulation Testing
By:Diane Jette
BioMedica Diagnostics Inc.

Composition of Blood
* Formed Elements
o Erythrocytes (RBC)
o Leukocytes (WBC)
+ Neutrophils
+ Eosinophils
+ Basophils
+ Lymphocytes
+ Monocytes
o Thrombocytes (Platelets)
* Plasma
o 92% water
o 7 to 9 % of solutes are proteins
+ 55 to 60% Albumin, 15% Globulins, 4% Fibrinogen
o Non-protein nitrogen substance, Enzymes, Antibodies, Electrolytes, etc.
o Serum: No fibrinogen or Factors II, V and VIII

Hemostasis is the arrest of bleeding from an injured blood vessel
* Vasoconstriction and compression of injured vessels
* Platelets adhere to the site of injury and form a platelet plug
* Platelets release factors to augment vasoconstriction and initial vessel wall repair
* Platelets provide surface membrane sites and components for the formation of enzyme/cofactor complexes in blood coagulation reactions

Coagulation Reactions Lead to the Formation of a Blood Clot
* Two pathways: Intrinsic and Extrinsic - Coagulation Cascade
* Formation of a prothrombin activator - complex of Factor Xa, Factor Va and procoagulant phospholipid on surface of platelets.
* Prothrombin activator cleaves prothrombin into two fragments to give Thrombin.
* Thrombin cleaves small peptides from fibrinogen to form fibrin monomers that polymerize.
* Thrombin activates Factor XIII to cross-link the fibrin to form an insoluble clot.

Coagulation Cascade
* Intrinsic Pathway: (APTT)
o Factors VIII, IX, XI, and XII.
o Activated on surface of exposed endothelium.
o Complexes form on platelet phospholipids.
* Extrinsic Pathway: (PT)
o Factors IV, V, VII, X
o Activated by Tissue phospholipids (Tissue Factor or Tissue thromboplastin) released into blood as a result of tissue damage.
* Common Pathway (Thrombin Time)
o Factors I and II
o Leads to the formation of Fibrin Clot
o Thrombin time does not measure deficiencies in Intrinsic or Extrinsic pathway

The Role of Calcium
* Ca ions are needed for most of the reactions in the Coagulation Cascade
* Ca-chelating agents are used in vitro as anticoagulants (Citrate, EDTA, Oxalate)
* When Coagulation Factors are synthesized without Vitamin K they cannot bind Ca and lose enzymatic function

Regulatory Mechanisms
* Inhibition of Factor Activity
o Plasma protease inhibitors: anti-thrombin III (ATIII), *2-macroglobulin, *1 - antiprotease
o Heparin converts ATIII from a slow acting inhibitor to an instantaneous inhibitor of Thrombin, Factor Xa and Factor IXa
o Protein C and Protein S are serine proteases that cleave Factors VIII and Factor Va rendering them inactive

* Fibrin clot is degraded by protolytic enzymes and fragments dissolved in blood
* Process is catalyzed by Plasmin
* Plasminogen is converted to Plasmin
* Activation by tissue plasminogen activator (tPA) and urokinase
* Fibron degrades into large fragments X and Y then smaller fragments D and E

Regulation of Fibrolysis
* Plasminogen activator inhibitors (PAIs) and plasmin inhibitors slow the fibrolysis process
* tPA and urokinase have short half-lives and are rapidly cleared through the liver
* Unbound plasmin is instantaneously neutralized by 2-antiplasmin

Hereditary Coagulation Disorders
* Hemophilia A
o Factor VIII deficiency
o 80% of all Hemophilia cases
* Hemophilia B
o Factor IX deficiency
* Prolonged ATPP
o Recovered by dilution 1:1 with normal plasma
* Normal PT and Normal Bleeding Time
* Factor XI Deficiency
o 5 to 9% of European Jews
* 2-antiplasmin Deficiency

Acquired Coagulation Disorders
* Liver Disease
o Impaired clotting Factor synthesis
o Increased fibronolysis
o Thrombocytopenia
* Desseminated Intravascular Coagulation (DIC)
o Something enters the blood that activates factors
o Complication of obstetrics, infection, malignancy, shock, severe brain trauma
o Elevated PT, APTT, D-Dimer and other fibron degradation products

Circulating Anticoagulants
* Antibodies that neutralize clotting factor activity
* Factor VIII Anticoagulants
o Antibody
o Same profile as Hemophilia A
o Clotting time not restored by mixing with normal plasma
o Life-threatening condition

Lupus Anticoagulants
* Antibodies to phospholipid binding sites on clotting factors
* Prevent factors from accumulating on phospholipid surfaces
* Elevated APTT clotting times not corrected with mixing with normal plasma
* PT normal or slightly elevated.
* Non-specific depression of clotting factor activities (Factors VIII, IX, XI, XII)
* Test sensitivity increased by using diluted reagent
o Dilute ATPP reagent, Russell’s viper venom time, Kaolin time
o Clotting times corrected with the addition of phospholipids

Oral Anticoagulant Therapy
* Coumadin or Warfarin
* Inhibitor of Vitamin K dependant Factor synthesis
* Oral anticoagulant
* Dose regulated by therapeutic effect
* PT assay to measure INR
* INR range established for optimum therapeutic effect (typically 2.0 to 3.0)

Prothrombin Time: PT
* PT reagent contains Calcium ions and Thromboplastin from brain tissue (Rabbit).
* Thromboplastin (Tissue Factor) protein-lipid complex found in tissues outside blood vessels.
* Measures the function of the Extrinsic Pathway.
* Sensitive to Factors IV, V, VII, X.
* Provided as a lyophilized reagent.
* Used to monitor oral anticoagulant therapy (Warfarin / Coumadin).

PT Reagent Calibration
* Reagents are calibrated against standard PT reagent established by the WHO.
* ISI = International Sensitivity Index.
* ISI is assigned by the manufacturer for each lot of reagent using reference material traceable to WHO.
* The lower the ISI the more sensitive the Reagent
o ISI of 1.8 to 2.4 = Low sensitivity (North American Standard PT)
o ISI of 1.4 to 1.8 = Average sensitivity
o ISI 1.0 to 1.4 = High Sensitivity

PT: INR Values
* INR = International Normalised Ratio.
* MNP = Mean Normal Plasma.
* An INR of 1.0 means that the patient PT is normal.
* An INR greater then 1.0 means the clotting time is elevated.

INR Calculation
* Example 1
o MNP = 12.0 s
o ISI = 1.25
o Patient Plasma = 20 s
o INR = (20.0 / 12.0)1.25 = 1.9
* Example 2
o MNP = 12.0 s
o ISI = 1.85
o Patient Plasma = 17 s
o INR = (17.0 / 12.0)1.85 = 1.9
* Example 3
o MNP = 12.0 s
o ISI = 1.4
o Patient Plasma = 20 s
o INR = (20.0 / 12.0)1.4 = 2.0
* Example 4
o MNP = 12.0 s
o ISI = 2.0
o Patient Plasma = 20 s
o INR = (20.0 / 12.0)2.0 = 2.8

Expected PT Values
* Mean Normal Plasma = 10 to 14 seconds.
* Mean Normal Plasma value varies with PT sensitivity. A high sensitivity (Low ISI) PT will give a high normal PT value (13 to 15 seconds).
* Oral anticoagulant monitoring = Target INR of 2.0 to 3.0.
* INR of greater than 5 or 5.5 = unacceptable high risk of bleeding.
* %CV between duplicates less than 5%

Performing a PT test
* Pre-warm PT reagent and sample to 37 oC
* Add 100 L sample to cuvette
* Add 200 L of PT reagent to cuvette
* Start timer
* Record time to clot in seconds
* Calculate INR
* see product insert for PT

Activated Partial Thromboplastin Time
* Reagent contains phospholipids and a ‘surface activator’; (Ellagic Acid, Micronized Silica)
* Calcium Chloride reagent added to start the reaction.
* APTT reagent mimics the surface of a platelet.
* Measures activity of clotting factors in the Intrinsic Pathway, factors VIII, IX, XI and XII
* No WHO calibration standard

Uses of APTT
* Sensitive to 30 to 40% deficiencies of all factors except VII and XIII.
* Heparin inhibits the activity of clotting factors in the Intrinsic Pathway.
* A standard curve (APTT time vs Heparin concentration) is prepared using a heparin standard.
* APTT is also sensitive to other non-specific Factor inhibitors such as Lupis Anticoagulant.
* Can be influenced by Vitamin K deficiency and Coumadin therapy.
* Negative APTT result usually rules out Hemophilia.

Expected APTT Values
* Normal Range: 26 to 40 seconds
* Slightly Elevated: 45 to 65 seconds
* Extremely Elevated = > 70 seconds
* %CV less than 7%

Performing an APTT Test
* Pre-warm Calcium Chloride reagent to 37 oC.
* Add 100 microL of sample to cuvette.
* Add 100 microL of APTT to cuvette and incubate for 3 minutes.
* Add 100 microL of Calcium Chloride reagent and start timer.
* Record the time to clot in seconds.
* See APTT product Insert

Heparin Monitoring
* Prepare Heparin Standards
o Prepare stock heparin (10 USP units/mL)
o Prepare working heparin dilutions (0.1 to 0.8 U/mL) by diluting stock in normal plasma
o Run heparin dilutions as samples in APTT assay
* Plot the results as U/mL vs Log Clotting times
* Run patient samples in APTT assay and determine heparin concentration from the plot.

Heparin Calibration Curve
Factor Substitution Tests:
* Dilute patient sample one to one with adsorbed plasma and serum to determine if normal clotting time is restored.
* Serum: Source of Factors IX, X, XI & XII
* Adsorbed Plasma: Source of Factors VIII, V, XI, & XII

Factor Plots: PT and APTT
* Dilute a normal plasma sample or control 1 to 10 in saline
* Dilute in saline: 100%, 50%, 25%, 12.5%. 6.25%, 3.12%,
* Mix one to one with a factor deficient plasma.
* Measure PT or APTT and plot Log % Factor vs Log clotting time.
* Dilute patient plasma 1 to 10 in saline.
* Mix one to one with a factor deficient plasma.
* All factors will be restored except the deficient factor. If the factor is present in test sample no reduction in clotting will be seen. (Same clotting time as the 100% standard)
* Determine percent factor from standard curve.

Factor Calibration Curve
Plasma Controls
* Used to monitor assay performance (QC)
* Made from pooled normal human plasma with some factors selectively adsorbed.
* Three levels available:
o Level 1 control represents a normal plasma
o Level 2 represents a slightly elevated plasma (INR ~ 1.5)
o Level 3 represents a severely elevated plasma (INR ~ 2.5)
* Each laboratory should establish expected ranges for PT and APTT.

Thrombin Time (TT or TAT)
* Measures common pathway.
* Fibrinogen --> Fibron Clot
* Not sensitive to deficiencies in Intrinsic or Extrinsic pathways.
* Reagent consists of animal thrombin.
* Normal Clotting time is 15 seconds.
* If elevated sample is mixed one to one with normal and re-tested. If normal clotting is not restored then an anti-coagulant is present.
Bleed Time Test
* An incision is made
* Time to stop bleeding is measured
* Normal clotting time is 7.5 minutes

D-Dimer Test
* D-Dimer is a fibrin monomer
* Product of fibrolysis
* Latex agglutination assay is used
* Anti-D-Dimer antibody coated on micro-latex beads
* Cardiac Infarction Marker

Activated Clotting Time (ACT)
* Clotting time of whole blood in the presence of silica based activator.
* Normal clotting times = 90 to 170 sec.
* Used to monitor heparin doses from 1 to 10 U/mL (APTT is sensitive to heparin at 0.2 to 1 U/mL).
* Used with invasive procedures that require on-site adjustment of heparin and protamine dosage. (ex. Cardiopulmonary bypass surgery).
* Not amenable for use with an optical instrument, too cloudy.
* Also called HMT, Heparin Management Test

Fibrin-1 Clot Detection
Clot Detection
Time in seconds
Optical Density
Change in slope > Threshold = CLOT

Coagulation Testing.ppt



By:Diane C. Jette, Ph.D.
BioMedica Diagnostics Inc.

Test Menu
* Infectious Diseases
* Cardiac Markers
* Cancer Screening
* Fertility / Hormones
* Drugs of Abuse
* Other Tests
o IgE
o Rh Factor
o Occult Blood
o TSH, T3, T4
o Blood Grouping

Test Formats Available
* Latex Agglutination
* Card Format
* Cartridge Format
* ELISA Format with Plate Reader

Structure of IgG
(150,000 Daltons)
Binding Site

Structure of IgM
(900,000 Daltons)
Binding Sites
Sandwich ELISA Procedure
* Antibody coated on plate.
* Incubate with sample containing antigen.
* Wash away unbound material.
* Incubate with antibody-enzyme conjugate.
* Wash away unbound conjugate.
* Add substrate.
* Enzyme acts on substrate and produces color change.
* Measure amount of color produced.
* Amount of antigen present is proportional to the amount of color produced.

ELISA: Sandwich Format
Sandwich Assay Results
Color Intensity (OD)
Antigen Concentration
Linear Range
ELISA: Inhibition Assay Procedure
* Antigen coated on plate.
* Incubate with sample containing antigen and enzyme-antibody conjugate.
* Antigen in solution binds to enzyme-antibody conjugate preventing binding to antigen on plate.
* Wash away all unbound material.
* Add substrate.
* Enzyme acts on substrate to produce a color change.
* Measure the amount of color.
* The amount of antigen present is inversely proportional to the amount of color produced.
ELISA: Inhibition Format
Inhibition Assay Results
Color Intensity (OD)
Antigen Concentration
Linear Range
Agglutination Assay Procedure
Antibody Detection
* Antigen coated on latex particles.
* Incubate with sample containing antibody.
* Antibody binding to antigen causes cross-linking of latex beads.
* Agglutination is observed.
Antigen Detection
* Antibody coated on latex particles.
* Incubate with sample containing antigen.
* Antigen binding to antibody causes cross-linking of latex beads.
* Agglutination is observed.
Latex Agglutination Assay
Latex Agglutination
Negative Result
Smooth gray appearance
Positive Result
Large aggregates in the center or periphery of the test circle
Absorbing Pad
Test Area
Maximum Level
Sample Pad
Negative Result
Positive Result
CARD Format
Negative Result
Positive Result
Cartridge Format
Negative Result
Positive Result



Urine Analysis

Urine Analysis
By:Diane C. Jette, Ph.D.
BioMedica Diagnostics Inc.

Reagent Test Strips
* Multiple test reagents on a ready to use test strip.
* Test results are read at different times after brief exposure to urine sample.
* The color on strip is compared to the reference color shown on test strip packaging.

Typical Test Strip Test
Specific Gravity
* 4 to 7 mmol/L
* 7 to 14 mol/L
* 0.5 to 1.0 mmol/L (Acetoacetic acid)
* 150 to 620 g/L (Hemoglobin)
* 0.15 to 0.3 g/L (Albumin)
* 13 to 22 mol/L
* 5 to 15 cells/ L
* pH 5.0 to 8.5
* 1.000 to1.030
* 0.2 to 8 mol/L

* Small amounts of glucose normally excreted by the kidney.
* Below sensitivity of the test.
* >6 mmol/L clinically significant.

* Normally no Bilirubin is detected in urine.
* Even trace amounts are clinically significant.
* Test detects acetoacetic acid in urine.
* Normal urine negative with this test.
* Detectable levels seen during physiological stress such as fasting, pregnancy, and frequent strenuous exercise.
* Large amounts with ketoacidosis due to starvation and abnormal carbohydrate or lipid metabolism.
Specific Gravity
* Range = 1.000 and 1.030
* Elevated specific gravity seen with elevated protein levels (1 to 7.5 g/L)

* Test measures hemoglobin and myoglobin.
* Trace amounts may be clinically significant.
* Often found in urine of menstruating females.
* False positives may be seen with urinary tract infections

* Range from pH 5 to 8.5.
* False results may occur if excessive urine remains on the strip.

* Test sensitive to albumin.
* Negative result does not rule out the presence of hemoglobin or globulins.
* Normally no protein present in urine.
* Greater than 0.3 g/L is clinically significant.

* Normal Range in urine = 3 to 17 mol/L
* Greater than 34 mol/L transition from normal to abnormal.
* Total absence of urobilinogen cannot be determined with this test.
* Dependant on the conversion of dietary nitrate to nitrite by Gram Negative Bacteria.
* Positive results may indicate presence of greater than 105 cells per mL.
* Color not proportional to the number of cells.

* Normally no leukocytes present in urine.
* Positive result is clinically significant.
* Some drugs interfere with the test

Urine Analysis.ppt


29 September 2009

Andrews’ Diseases of the Skin

Andrews’ Diseases of the Skin
By:Boris Ioffe, D.O.

Recalcitrant Palmoplantar Eruptions

* Recalcitrant pustular eruptions of the hands and feet are often examples of psoriasis
* Need to then search for lesions elsewhere on the body(e.g., scalp, ears, glans penis)
* Search also for a family history to confirm your suspicion

Dermatitis Repens
* Aka- acrodermatitis continua and acrodermatits perstans
* It’s a chronic inflammatory disease of hands and feet
* Rarely, can become generalized
* Usually, as a pustule or paronychia
* Occasionally, mucous membranes are involved
* Nails are often dystrophic or destroyed
* Lesions cause skin atrophy
* Crusted, eczematoid, and psoriasiform lesions may occur, and there may be moderate itching
* It is essentially unilateral in its beginning and asymmetrical throughout its entire course
* Histology
o similar to those seen in psoriasis
o the primary lesion is epidermal
o An intraepithelial spongiform pustule is formed by infiltration of pmn’s
* Treatment
o topical mechlorethamine, topical steroids, PUVA, fluorouracil, and sulfapyridine
o Acitretin, low dose cyclosporine, Acitretin plus calcipotriol

Palmoplantar Pustulosis
* AKA pustular psoriasis
* In contrast to dermatitis repens it is essentially bilateral and symmetrical
* Locations include: thenar/hypothenar eminences or central portion of the palms and soles
* Patches begin as erythematous areas in which pustules form
* Start as pinhead-sized, enlarge and coalesce to form small lakes of pus
* In the course of a week, they tend to dry up, leaving punctate brown scabs that eventually exfoliate
* Stages of quiescence and exacerbation characterize the condition
* Meds, such as lithium, have been reported to induce
* Nails may become malformed, ridged, stippled, pitted and discolored
* May be associated with psoriasis vulgaris
* Some regard palmoplantar pustulosis as a form of psoriasis, while others consider it a separate entity
* Female predominance; lack of seasonal variation; different histopathologic features and
* Associated with thyroid disorders and cigarette smoking
* May be predisposed to joint disease and possibly SAPHO syndrome-Synovitis, Acne, Pustulosis, Hyperostosis and Osteoarthritis
* It’s resistant to most treatments
* Acitretin is reportedly effective(1mg/kg/day)
* Low-dose cyclosporine (1.25mg/kg/day-3.75mg/kg/day)
* Intramuscular Kenalog (40-60mg)may be effective for short-term relief

Pustular Bacterid
* Characterized by a symmetric, grouped, vesicular or pustular eruption on palms and soles
* Marked by exacerbations and remissions over long periods
* No involvement of webs of fingers or toes or flexion creases of toes
* WBC may be elevated
* Scaling is usually present
* Etiology is thought to be a remote focus of infection; infection needs to be treated before resolution will occur

Juvenile Plantar Dermatosis
* Usually begins as a patchy, symmetrical, smooth, red, glazed macule on great toes, sometimes with fissuring and desquamation in children aged 3-13
* Toe webs are rarely involved; fingers may be
* Histologically, there is psoriasiform acanthosis and a sparse, lymphocytic infiltrate in the upper dermis
* Spongiosis is commonly present
* Tx: bed rest, cotton socks and topical steroids
* Spontaneous resolution within 4 yrs is the rule

Infantile Acropustulosis
* Intensely itchy vesicopustular eruption of hands and feet
* Begins at any age up to 10 months, clearing in a few weeks and recurring repeatedly until final resolution at 6 – 36 months of age
* Dapsone at 2mg/kg/day may help
* Potent topical steroids aid in symptomatic relief
* Should prompt an extensive workup to eliminate serious infectious causes (i.e., Tzanck prep, gram stain, KOH prep of pustule)
* Some suspect that this condition may be a persistent reaction to prior scabies

Infantile Acropustulosis
* Acropustulosis of infancy
* AKA dyshidrosis
* A vesicular eruption of palms and soles characterized by spongiotic intraepidermal vesicles and often accompanied by burning or itching
* Hyperhidrosis may be present
* Usually bilateral and symmetrical
* Bullae may form
* Contents are clear and colorless
* Attacks generally last a few weeks
* Lesions dry-up and desquamate rather than rupture
* Etiology- stress, atopy, and topical as well as ingested contactants
* Histopathology: spongiotic vesicles in the epidermis
* Differential dx:
o dermatophytid, contact dermatitis, atopic dermatitis, drug eruption, pustular psoriasis of palms and soles, acrodermatitis continua, and pustular bacterid
* Rarely, T-cell lymphoma can present with similar clinical findings, but biopsy of the vesicles will be diagnostic
* Tx: high potency corticosteroid creams
* Triamcinolone acetonide intramuscularly or a short course of oral prednisone is rapidly effective
* Oral or topical psoralen + UVA (PUVA) is effective but costly & inconvenient
* In more severe forms, immunosuppressive mycophenolate mofetil has been effective

Lamellar Dyshidrosis
* AKA dyshidrosis lamellosa, keratolysis exfoliativa
* A superficial exfoliative dermatosis of the palms and sometimes soles
* Referred to as recurrent palmar peeling
* Involvement is bilateral
* Can occur in association with dyshidrosis
* Often exacerbated by environmental factors
* Differential dx: dermatophytosis, chronic contact dermatitis
* Tx: difficult
* Spontaneous involution can occur in a few weeks for some
* Most tends to be chronic and relapsing
* Tar creams (Zetone cream) usually helps
* 5% tar in gel (Estar Gel) is an excellent tx
* Lac-Hydrin lotion and Carmol 10 or 20 are often effective
* NB-UVB may be helpful

Palmoplantar Keratoderma
* AKA tylosis, keratosis, hyperkeratosis
* Characterized by excessive formation of keratin on the palms and soles
* Acquired
o Keratosis Punctata of the Palmar Creases
o Punctate Keratoses of the Palms and Soles
o Porokeratosis Plantaris Discreta
o Keratoderma Climactericum
* Congenital

Punctate Keratosis of the Palms and Soles
* Primary lesion is a 1-5mm round to oval, dome-shaped papule distributed over left hand and hypothenar eminence
* Main symptom is pruritis
* Lesions number from 1 to >40
* Affects mainly blacks
* There’s a potential risk of developing lung and colon cancer

Keratosis Punctata of the Palmar Creases
* Common most often in black pts
* Primary lesion is a 1-5mm depression filled with a conical keratinous plug
* Primarily, in creases of palms or fingers, occasionally in soles
* Lesions are multiple
* Friction aggravates lesions causing them to become verrucoid or surrounded by callus
* Punctate keratoses of the palmar creases in an African-American
* PPPK-punctate palmoplantar keratoderma

Porokeratosis Plantaris Discreta
* Occurs in adults, Female:Male (4:1)
* Characterized by sharply marginated, rubbery, wide-based papule that does not bleed on removal
* Lesions are multiple, painful, 7-10mm in diameter
* Usually on wt bearing areas of sole, beneath metatarsal heads
* Tx: foot pads to redistribute wt, surgical excision, blunt dissection

Keratoderma Climactericum
* Characterized by hyperkeratosis of palms and soles beginning at about the time of menopause
* Descrete, thickened, hyperkeratotic patches most pronounced at pressure sites
* Fissuring may be present
* Tx: keratolytics -- 10% salicylic acid, lactic acid creams, etc.

Hereditary syndromes
* These have palmoplantar keratoderma as a feature
o Unna-Thost
o Papillon-Leferve
* Dominant inheritance; congenital thickening of epidermal horny layer of the palms and soles
* Usually symmetrical
* Epidermis becomes thick, yellowish, verrucous, and horny
* Striate and punctate forms occur

Unna Thost
* Occasionally nails become thickened
* 5% salicylic acid may help
* Lac Hydrin 12% may be tried
* Acitretrin or isotretinoin may be considered, but need for lifetime tx makes them impractical
* Focal palmoplantar keratosis of the striate type on the sole
* Diffuse non-epidermolytic palmoplantar keratosis
* Diffuse epidermolytic palmoplantar keratosis with diffuse hyperkeratosis

Papillon-Lefevre Syndrome
* Palmoplantar hyperkeratosis with peridontosis
* Usually develops within the first few months of life but may occur in childhood
* Well demarcated, erythematous, hyperkeratotic lesions on palms and soles
* Transverse grooves of fingernails may occur
* Early onset peridontal disease has been attributed to damage and alteration in PMN function caused by Actinomyces actinomycetemcomitans
* Disease associations include: acroosteolysis, and pyogenic liver abcesses
* There are asymptomatic ectopic calcifications in the choroid plexus and tentorium
* Therapy may retard both dental and skin abnormalities
* Treatment with Acitretin in four siblings was reported to be effective

Papillon-Lefevre Syndrome
* Papillon-Lefevre syndrome: plantar keratoderma

Mutilating Keratoderma of Vohwinkel
* Palmoplantar hyperkeratosis of the honeycomb type-associated with starfish-like keratosis on backs of hands and feet; linear keratoses of the elbows and knees, and annular constriction (pseudo-ainhum) of the digits, this may progress to autoamputation
* More than 30 cases have been reported world-wide
* More common in women and in whites
* Onset is in infancy or early childhood
* Vohwinkel’s mutilating syndrome: A.) diffuse keratoderma of palms with B.) pseudoaainhum formation

Palmoplantar Keratodermas & Malignancy
* Diffuse, waxy keratoderma of palms and soles occurring as an AD trait associated with esophageal carcinoma
* Other related factors are oral leukoplakia, esophageal srictures, squamous carcinoma of tylotic skin, carcinoma of larynx and stomach
* Acquired forms of palmoplantar keratodermas have also been associated with carcinoma of esophagus, lung, breast, bladder and stomach
* Focal PPK in association with carcinoma of the esophagus

Acrokeratoelastoidosis of Costa
* AD, more common in women
* Small, round, firm papules occurring over dorsal hands, knuckles, and lateral margins of palms and soles
* Appears in early childhood and progress slowly
* Most often asymptomatic
* Significant histologic finding is dermal elastorrhexis
* Therapies: liquid nitrogen, salicylic acid, tretinoin, and prednisone have been tried
* Focal acrokeratoelastoides: multiple skin-colored papules at the margin of the palmar skin
* Path: non-epidermolytic palmoplantar keratosis, acanthosis and hypergranulosis

Exfoliative Dermatitis
* Universal or very extensive scaling and itching erythroderma
* Often associated with hair loss
* Initially with erythematous plaques, which spread rapidly
* Onset accompanied by general toxicity
* Skin becomes scarlet and swollen and may ooze a straw-colored exudate
* Desquamation is evident within a few days

* Most common is preexisting dermatoses: (53%);
o atopic dermatitis, chronic actinic dermatitis, psoriasis,seborrheic dermatitis, vesicular palmoplantar eczema, pityriasis rubra pilaris, and contact dermatitis
* Drug eruptions(5%);
o allopurinol, gold, carbamazepine, phenytoin, and quinidine
* Cutaneous T-cell lymphoma(13%); Sezary syndrome and mycosis fungoides
* Paraneoplstic (2%); carcinoma of the lung and carcinoma of the stomach
* Leukemia cutis (1%)
* Idiopathic (26%)
* Mortality rate at a mean follow-up interval of 51 months was 43%
* Most commonly, histology is nonspecific
* Hyperkeratosis & focal parakeratosis
* Epidermis shows mild acanthosis, scant superficial upper dermal infiltrate of mononuclear cells
* May be small areas of spongiosis
* Generalization after withdrawal of methotrexate
* Exfoliation of scale with underlying erythema
* Generalized erythema with thick scale and crusted fissures on the plantar surface
* Topical steroids, soaks, and compresses
* Acitretin and cyclosporin-useful in psoriatic erythroderma, and isotretinoin in erythroderma caused by RPR; methotrexate
* Systemic corticosteroids in severe cases
* Discontinuing the offending drug in drug-induced cases
* Subungual hyperkeratosis and distal dystrophy

Parapsoriasis, Pityriasis Rosea, Pityriasis Rubra Pilaris
* Group of macular scaly eruptions with slow evolution
* These are all markedly chronic, resistant to treatment, and are without subjective symptoms
* They are divided into: pityriasis lichenoides chronica, pityriasis lichenoides et varioliformis acuta, and parapsoriasis en plaques

Pityriasis Lichenoides Chronica
* Erythematous, yellowish, scaly macules and lichenoid papules
* They persist indefinitely without change
* Mainly on sides of trunk, thighs, and upper arms
* May be confused with psoriasis and secondary syphilis
* Tx- UV light is beneficial; however intense doses may be needed for good results
* PUVA has been reported to be effective
* Oral tetracycline may be used with antihistamines
* PLC is a benign disease that clears spontaneously in a few yrs to months
* AKA: parasoriasis lichenoides, Habermann’s disease, Mucha-Habermann disease and parapsoriasis varioliformis acuta
* Sudden appearance of a polymorphous eruption composed of macules, papules, and occasional vesicles
* May run an acute, subacute, or chronic course
* Papules are usually yellowish or brownish-red, round lesions, which tend to crust, become necrotic and hemorrhage
* When exanthem heals it leaves a smooth, pigmented, depressed, varioliform scar
* Favorite sites are anterior trunk, flexural arms, and axillae
* Palms and soles are involved infrequently-mucous membranes are not
* Generalized lymphadenopathy can occur
* Usually a benign, self-limited disorder, but may be more chronic and severe
* Maybe a spectrum of cutaneous T-cell lymophoma
* Differential dx:
o leukocytoclastic angiitis, papulonecrotic tuberculid, psoriasis, lichen planus, varicella, PR, drug eruptions, maculopapular syphilid, viral, rickettsial diseases, lymphomatoid papulosis
* Histologically of PLEVA is characterized by epidermal necrosis, with prominent hemorrhage and primarily a dense perivascular infiltrate of lymphocytes in the superficial dermis
* Absence of neutrophils simplifies the distinction between leukocytoclastic angiitis
* Lymphomatoid papulosis differs by the presence of large, atypical mononuclear cells in the dermal infiltrate

* No one tx is reliably effective
* Tetracycline and erythromycin are worth trying
* UVB and PUVA
* Methotrexate, 2.5-7.5mg every 12 hrs for 3 doses 1 day each week
* Several serious reactions a few of them fatal have occurred with simultaneous administration of methotrexate and NSAIDs
* Dapsone and pentoxifylline(Trental), 400mg twice daily

Parapsoriasis en Plaques
* Small-plaque parapsoriasis is characterized by non-indurated, brownish, hypopigmented, or yellowish red scaling patches, round to oval, with sharply defined borders
Large Plaque Parapsoriasis
* Has patches 5-15 cm; otherwise is similar to small-plaque type
* Prognosis is benign, especially if pruritis is severe
* 10% may eventuate in T-cell lymphoma
* Large plaques parasporiasis: large, variably erythematous and mildly poikilodermatous patches in the bathing trunk region
* Small plaque parasporiasis: small(<5), erythematous, slightly scaly patches
* First line: UV radiation -- either natural or UVB
* Lubricants and Topical steroids
* PUVA but only if UVB fails
* Use of PUVA or high-potency topical streroids should be limited due to long-term adverse effects
* LPPP has the potential to develop lymphoma – thus, justifying more intense tx
* Vitamin D2 daily–250,000 units over 2-4 months has been effective

Pityriasis Alba
* AKA-pityriasis streptogenes, furfuraceous impetigo, pityriasis simplex, pityriasis sicca faciei, and erthema streptogenes
* Characterized by hypopigmented, round to oval, scaling patches on face, upper arms, neck, or shoulders
* Color is white (but never actually depigmented) or light pink
* Scales are fine and adherent
* Patches are usually sharply demarcated; edges may be erythematous and slightly elevated
* Lack of any early specifically follicular localization helps to distinguish this lesion from follicular mucinosis
* Vellus hairs are not lost in pityriasis alba, nor does hypesthesia to cold occur, as often happens in follicular mucinosis
* Usually asymptomatic; however there may be mild pruritis
* Disease mainly occurs in children and teenagers
* It is particularly a cosmetic problem in dark-skinned individuals
* Etiology unknown
* Excessively dry skin appears to be contributory
* Most lesions disappear with time
* Repigmentation can be accelerated with treatment
* Emollients and bland lubricants
* Low-strength corticosteroids plus Lac-Hydrin are helpful
* Others have recommended PUVA

Pityriasis Rosea
* Mild inflammatory exanthem of unknown origin ?viral
* Characterized by salmon-colored papules and patches which are oval and covered with a collarette of scale
* Disease frequently begins with a single herald patch, which may persist a week or more, then involutes
* Appears rapidly and last from 3-8 weeks
* Peak: ages 15-40
* Typically in Spring and Autumn
* More common in women
* Mainly affects the trunk
* Oral lesions are relatively uncommon, but present as aphthous lesions

Herald Patch
Pityriasis Rosea
* Papular PR is an unusual form common in black chidren under age 5
* Inverse PR is unusual, but not rare
* Relapses and recurrences are frequently observed
* A PR-like eruption can occur as a rxn to captopril, arsenicals, gold, bismuth, clonidine, methoxypromazine, tripelennaminehydrochloride, or barbituates
* Inverse pityriasis rosea: oval annular plaques in groin

* Supportive
* UVB should be used after acute inflammatory stage has passed
* Topical corticosteroids
* Antihistamines
* Emollients
* PR: There is focal parakeratosis, mild acanthosis, spongiosis, perivascular lymphocytes, and focal erythrocyte extravasation
* PR: papules and annular plaques
* PR: oval and round plaques, some with central scale and others with a collarette of scale
* PR in darkly pigmented skin: it tends to be more papular than in lightly pigmented skin-note associated hyperpigmentation

Pityriasis Rubra Pilaris
* Chronic skin disease characterized by small follicular papules, disseminated yellowish pink scaling patches, and often, solid confluent palmoplantar hyperkeratosis
* Disease generally manifests itself first by scaliness and erythema of the scalp

* Involvement is usually symmetrical and diffuse, with islands of normal
* Hyperkeratosis of palms and soles called, the “sandal”
* Nails may be dull, rough, thick, and brittle
* Itching in some cases
* Koebner’s phenomenon may be present
* A number of cases have been associated with Kaposi’s sarcoma, leukemia, basal cell, lung, unknown primary metastatic and hepatocellular carcinoma
* PRP may classified into familal or acquired types

in respect to the onset of the disease in childhood or adulthood

* Griffth’s classification: Type I, the classic adult type, is seen most commonly, with 80% involuting in 3 years
* Three types of juvenile-onset forms account for up to 40% of cases and have a poor prognosis for involution
* Etiology unknown-??AD
* Either sex affected
* Possible related to deficiency of

vitamin A
* Histology: hyperkeratosis, follicular plugging, and focal parakeratosis at follicular orifice
* Inflammatory infiltrate in dermis is composed of mononuclear cells
* PRP: psoriasiform dermatitis with follicular plugging
* Symptomatic: emollients-- Lac-Hydrin
* A several-month course of isotretinoin in doses of 0.5 – 2 mg/kg/day
* Vitamin A in doses of 300,00 to 500,000 untis daily, with possible addtion of vitamin E, 400 units 2-3 times daily
* Methotrexate 2.5mg alternating with 5mg daily
* Monitor and treat secondary infections
* Pityriasis rubra pilaris: diffuse erythroderma with desquamation and follicular hyperkeratosis
* Pityriasis rubra pilaris: follicular papules and confluent orange-red scaly plaques with islands of sparing
* Pityriasis rubra pilaris: orange-red waxy keratoderma of the palms

Andrews’ Diseases of the Skin.ppt

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