Spot Diagnosis # 5

A 70 years old male presented with earache deep inside the left ear radiating to pinna. On examination, his left external canal and pinna showed vesicular rashes with drooping left side of the mouth.  What is your spot diagnosis?

Answer:
The diagnosis is Ramsay Hunt Syndrome (RHS). It is a reactivation syndrome of herpes zoster virus in an L-shaped ganglion of facial nerve named  as geniculate ganglion, present in facial canal. RHS occurs when herpes zoster virus infects facial nerve and presents with painful shingle rash with fluid filled vesicles seen on, in or around the single ear. It may present with ear pain, hearing loss, ringing of ear, difficulty in closing the eye on the affected side as well as vertigo, change in taste and facial paralysis. All the signs and symptom described in the scenario above support the diagnosis of Ramsay Hunt Syndrome or herpes zoster oticus.

Spot Diagnosis # 4

Keywords: Earache, Vesicular rash, Drooping mouth, Ramsay Hunt Syndrome or herpes zoster oticus

Spot Diagnosis # 4

A 25 years old boy, a treated case of tuberculosis presents with shortness of breath and painful tense, distended abdomen (image of the abdomen is shown below). Echocardiography shows a thin pericadial effusion around the heart. Ultrasound shows splenomegaly. What is your spot diagnosis?

Tense distended abdomen

Please write your spot diagnosis below in the "comments section". The answer will be given after a week!

Spot Diagnosis # 3

Keywords: Tuberculosis, Thin pericardial effucion, Distended abdomen

Spot Diagnosis # 3

A 90 years old emaciated female with the given image of reddened palmar aspect of her hands. She is known case of metastatic hepatic cancer. She has not applied and colour or mehndi. What is your spot diagnosis?

Palmar redness

Answer:

Diagnosis: Palmar Erythema (PE) due to hepatic CA

What is palmar erythema?

Palmar erythema is a non-specific condition where palms of the hands become red, especially at thenar (at the base of thumb) and hypothenar (at the base of little finger) eminences. Palmar erythema may be normal, may be physiological or may be pathological. It may be primary palmar erythema (e.g. pregnancy, heredity and idiopathic) or secondary palmar erythema (various conditions/diseases).

What causes palmar erythema?

The exact cause of palmar erythema is yet not known. However, some experts are in view that high levels of estrogen in the blood cause palmar erythema as this hormone has been seen raised in cirrhosis of liver and during the pregnancy. It is thought that estrogen increases vascularity, leading to redness of palms. Redness of palms in palmar erythema varies person to person and may extend to the fingers and nail beds.

Which conditions have palmar erythema?

A lot of conditions have palmar erythema as a sign. The following conditions/diseases show PE:

1. Pregnancy- PE in pregnancy is a type of primary PE and is shown by about 30% of the pregnant women.
2. Chronic liver disease- About 23% patients with CLD show secondary PE.
3. Portal hypertension
4. Polycythemia
5. Rheumatoid arthritis- More than 60% patients with RA show secondary PE.
6. Thyrotoxicosis- About 18% patients with thyrotoxicosis show secondary PE.
7. Eczema or psoriasis
8. Drug-induced- Drugs such as amiodarone, gemfibrozil, cholestyramine, topiramate and albuterol also cause secondary PE as a side effect. 
9. Metastatic and primary brain neoplasms- Increased angiogenic factors and estrogens levels in the patients with metastatic and primary brain neoplasms show secondary PE.
10. Smoking- An environmental cause of PE
11. Chronic mercury poisoning- An environmental cause of PE

What is the treatment of palmar erythema?

There is no treatment of palmar erythema except treating the cause. Drug-induced PE can be abolished by discontinuing the same drug.

Spot Diagnosis # 2

Keywords: Palmar erythema, PE, Pregnancy, CLD, RA, Rheumatoid arthritis, Hepatic cancer, Metasatic liver cancer, CA liver, Red hands, Palmar redness

Spot Diagnosis # 2

A 65 years old male patient presents with red, hot and painful right leg with some pus-filled blisters (as shown in the image below). The patient is known case of liver cirrhosis. What is your spot diagnosis?

A 60 years old male with red, hot and painful leg

Answer:

Diagnosis: Cellulitis

What is cellulitis?

Cellulitis is a serious and spreading infection of skin and underlying tissue. This infection can occur anywhere in the body; however, skin of the lower limbs is affected most of the times.

What causes cellulitis?

Cellulitis is a bacterial infection. Most often staphylococcus and streptococcus are the culprits. Other bacteria include methicillin-resistant Staph aureus, Hemophilus influenzae, Pneumococcus, and Clostridium.

What are the risk factors of cellulitis?

Cuts and cracks, insect bites, surgical incisions, weakened immune system, eczema and athlete’s foot, IV drug use and abuse, previous history of cellulitis, and chronic or debilitating disease, especially diabetes, liver cirrhosis and renal failure.

What are the sign and symptoms of cellulitis?

The patient with cellulitis presents with pain, redness and swelling of the affected area. On examination, the affected area is observed swollen, red, hot, tender and with tight glossy appearance. The patient is febrile and the skin may have sores.

What is the treatment of cellulitis? 
Depending upon the severity of the infection, oral or intravenous antibiotics are given. Penicillin is the drug of choice for cellulitis. Analgesics are used to relieve from pain. Elevation and compression dressing of the affected area are mandatory to reduce edema. Amclav 1g (Amoxicillin 875mg, Clavulanic acid 125mg) orally, twice a day, is used as adult dose in cellulitis. Amclav 1.2g IV twice a day is also used in severe cellulitis.

What to do to prevent cellulitis? 
You can prevent cellulitis by keeping the skin moist (to avoid skin cracks), treating the skin infections promptly, wearing protective covering while working and inspecting the skin on daily basis.

Spot Diagnosis# 1

Keywords: Cellulitis, Cellulits treatment, Signs and Symptoms, Red hot leg, Painful, Pus-filled blisters

Spot Diagnosis # 1

A 4-5 years old male child presented with the black spots on his both legs along with bleeding from oral mucosa (as shown in the images below). His hemoglobin level was found to be 12 gm/dl, total leukocyte count 7400/cumm and platelets 51000/cumm. What is your spot diagnosis?

Answer:

Diagnosis: Idiopathic thrombocytic purpura (ITP)

What is ITP?
ITP is a blood disorder where platelets (a kind of blood cells) are destroyed autoimmunically by the spleen.
What causes ITP?
ITP is caused by antiplatelet autoantibodies, leading to destruction of platelets through the process of phagocytosis.
What are the risk factors of ITP?
Usually it is seen that viral infections precipitate the development of ITP. In its acute form, ITP occurs after two weeks of infection with self-limiting bruises, petechiae and purpura. In its chronic form, it runs an indefinite course of signs and symptoms like bleeding, purpura, bleeding from nose or heavy menstruation.
What are signs and symptoms of ITP?
ITP may present as bleeding from mucus membranes like oral mucosa and tiny hemorrhages or black spots on the body.
Does ITP cause splenomegaly?
Bear in mind, in ITP, there is no splenomegaly.
What tests are carried out in ITP?
Bone marrow examination shows increased number of megakaryocytes in marrow. Antiplatelet autoantibodies may also be seen in the blood. Mild disease may not need any treatment.
How to treat ITP?
If the condition is symptomatic or platelets are below 20000/L, prednisolone 1mg/kg/day should be started (and reduce the dose after remission). The target of the therapy is to keep platelets above 30000/L.
If ITP relapses?
If ITP relapses, splenectomy results in 80% cure. Immunosupression (azathioprine or cyclophosphamide) may be started if the management still fails.
Should we transfuse platelets?
Do not transfuse platelets.
What to do during pregnancy?
Intravenous immunoglobulins may raise platelet count temporarily in conditions such as surgery and pregnancy.

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Keywords: ITP, Diagnosis, Splenomegaly, Haematology, Platelet disorder, Low platelets

Measles: Supplementary Immunization Activity in Pakistan Year 2014 (Field Guide)

Measles is an infectious disease, largely affecting the children. It presents with fever, flu, red eyes, white patch on the inner side of the mouth and rashes over the body. The rashes start from the face and neck and then spread over the other parts of the body. Measles becomes fatal if not managed on time.

In 2012, Pakistan had to face a number of cases and deaths with measles. Now measles immunization is the part of extended program immunization schedule (EPI schedule) in Pakistan. Children are given measles vaccine injections at 9th and 25th months of age. The following images are the photos field guide for measles supplementary immunization activity 2014 in Pakistan. All the photos show text in Urdu language. The pictures below cover the following topics about measles:

What is supplementary immunization activity?

How to maintain measles cold chain?

How to inject measles vaccine?

How to protect measles vaccine?

What are the adverse events following immunization (AEFIs) and how to manage them?

How to mobilize people for measles vaccination?

How to spread the news?

How to monitor measles vaccine activity?

How to monitor and supervise measles vaccination activity?

Answers to frequently asked questions?

Field Guide: Supplementary immunization activity (SIA)

List of topics covered

Introduction

Words of Thanks!

Supplementary immunization activity

Cold Chain Management

Selsun 2.5%: An Effective Antidandruff Shampoo

Selsun 2.5%, an effective antidandruff shampoo, is a rich lathering hair and scalp conditioner. Selsun shampoo contains selenium sulfide 2.5% W/V for the control of dandruff with regular use. It is marketed by Sanofi-Aventis Pakistan Limited. The price of one bottle of Selsun shampoo is Rs. 170.

Selsun 2.5%

How to use Selsun shampoo?

First of all shake the Selsun shampoo bottle well. Wash your hair with bland soap and rinse them fully. Apply one to two teaspoonful of Selsun suspension (shampoo) into your scalp using warm water to lather. Be careful about your eyes and avoid contact with the eyes. Wait for 2-3 minutes so that the suspension system breaks to be active on to the scalp. Rinse your scalp thoroughly after 2-3 minutes. You can also use bland soap to help remove the Selsun suspension. Also, wash your hands thoroughly to avoid eye contact of shampoo. Use Selsun shampoo twice a week for two weeks and then reduce to once a week as needed.

Selsun shampoo is only for external use. Avoid exposure to heat and light and keep away from your children to avoid accidental ingestion by the children.

Questions and Answers:

What is dandruff?

Dandruff refers to a diffuse, slight-to-moderate scaling or flaking of the scalp with varying degrees of itching or erythema.

What causes dandruff?

Dandruff may be caused by seborrheic dermatitis thought to be caused by yeast organism Malassezia. Dandruff is also the sign of psoriasis and fungal infection.

What is selsun shampoo?

Selsun is an antidandruff shampoo marketed by Sanofi-Aventis Pakistan Limited.

What is the formula contained in Selsun?

Selsun contains selenium sulfide 2.5% W/V.

What is selenium sulfide?

Selenium sulfide is a chemical which controls dandruff through its anti-Pityrosporum and anti-seborrheic properties. It also reduces scalp cell turnover through its cytostatic effect on the epidermis and follicular epithelium.

What is the price of Selsun (selenium sulfide 2.5%)?

The price of Selsun (selenium sulfide 2.5%) is Rs. 170.

Is Selsun shampoo gluten free?

Selsun suspension is synthetically prepared and the company does not guarantee of its gluten free property as it is not tested for its gluten sensitivity.

Does Selsun shampoo contain animal products?

Although Selsun suspension is prepared synthetically; however, Sanofi-Aventis does not guarantee of not having animal products in its Selsun suspension.

How long should the shampoo be on your head?

You should wait for 2-3 minutes before rinsing your hair.

When can I use Selsun suspension?

Selsun shampoo can be used when you have dandruff and seborrheic dermatitis. Selsun shampoo is useful controlling itch, flakes and flakes caused by dandruff and seborrheic dermatitis.

When not to use Selsun shampoo?

Do not use Selsun shampoo on acutely inflamed scalp.

What are the precautions to be taken while using Selsun shampoo?

Shake well before use; keep away from children; avoid its exposure to heat and light; avoid contact with eyes.

What are the side effects of Selsun shampoo?
Side effects of Selsun shampoo are rare. However, stop the use of Selsun shampoo and immediately contact your doctor if any allergic reaction happens to occur. Allergic reaction may present with itching, redness, peeling, skin irritation and difficult breathing. 

With what brand names selenium sulfide is marketed?

Selsun 2.5%, Selsun Blue, Chattem Inc., Exsel 2.5%, Selseb, Head & Shoulders

What is the treatment of severe dandruff?

Nizoral shampoo (ketoconazol) is useful for severe dandruff. Selsun is effective for moderate to severe dandruff.

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Keywords: Dandruff, Selsun shampoo, Selenium, Seborrheic dermatitis, Psoriasis, Malassezia, Antidandruff shampoo, Head & shoulders, Nizoral shampoo

Types of Hypersensitivity with Examples

Hypersensitivity refers to an undesirable reaction of  the body's immune system. This reaction may be a kind of allergy or may be the manifestation of an autoimmune condition. Medically, hypersensitivity has been divided into four types:

• Type I hypersensitivity- anaphylactic and atopic

• Type II hypersensitivity- antibody mediated

• Type III hypersensitivity- Immune complex medicated

• Type IV hypersensitivity- delayed or T-cell mediated

Type of hypersensitivity	Examples
Type I hypersensitivity- anaphylactic and atopic Antigen provokes presensitized mast cells and basophils through IgE, causing the release vasoactive amines like histamine. Histamine acts on postcapillary venules.	Anaphylaxis Bee stings Food allergy Asthma Rhinitis Hay fever Eczema Hives Drug allergy Allergic or atopic conditions like:
Type II hypersensitivity- antibody mediated Antibodies IgM or IgG bind to the antigen present on the enemy’s cell and trigger lysis or phagocytosis. Three mechanisms can be explained: opsonizing the cells or activating the complement system, recruiting neutrophils and macrophages for tissue damage, and binding to the normal cellular receptors to cause dysfunction.	Hemolytic anemia  Pernicious anemia  Erythroblastosis fetalis  ITP (Idiopathic thrombocytopenic purpura)  Acute hemolytic transfusion reaction Rheumatic fever  Goodpasture’s syndrome Bullous pemphigoid  Pemphigus vulgaris  Myasthenia gravis  Grave’s disease  SLE (only blood manifestations)
Type III hypersensitivity- Immune complex medicated Immune complexes provoke complement system which in turn attacks neutrophils. Neutrophils release lysosomal enzymes, causing tissue damage.	SLE (Systemic lupus erythematosus)  Rheumatoid arthritis  Polyarteritis nodosum  Serum sickness  Arthus reaction (swelling and inflammation after certain vaccine administration)  Farmer’s lung (Hypersensitivity pneumonitis)  Post streptococcal glomerulonephritis
Type IV hypersensitivity- delayed or T-cell mediated Sensitized lymphocytes encounter/confront antigens by releasing lymphokines which in turn activate macrophages.	Type I diabetes mellitus  Multiple sclerosis  GBS (Guillain-Barre syndrome)  PPD test for tuberculosis  Contact dermatitis (e.g. poison ivy, nickel allergy, skin tattooing)  Graft-versus-host (GVH) disease  Hashimoto’s thyroiditis

The table given below describes each type of hypersensitivity with examples:

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Keywords: Type I hypersensitivity, Anaphylaxis, Atopic conditions, Type II hypersensitivity, Antibody mediated reaction, Type III hypersensitivity, Immune complex medicated reaction, Type IV hypersensitivity- delayed or T-cell mediated