Lethal Botox

Two patients with CD4 counts under 200 are sitting in adjacent beds in an imaginary hospital. They both have AIDS. One patient has a history of IV drug use and the other patient has a history of unprotected intercourse. Which patient are you more likely to see the purplish vascular tumor the CDC considers an AIDS defining illness?

The patient with a history of unprotected intercourse.

The reason behind the different presentation is because Kaposi Sarcoma (KS) is caused by a pretty self-explanatory virus known as "Kaposi's Sarcoma-Associated Herpes Virus" aka Human Herpesvirus 8 (HHV-8). This oncogenic virus is sexually transmitted but will rarely cause any symptoms in people with intact immune systems. Before the AIDS epidemic KS was only seen in the developed world on the legs of old Mediterranean men and was pretty harmless and indolent.

The rate of HHV-8 infection among gay and bisexual men is higher than that of the general population, with one study in San Francisco observing seropositivity in 38 percent of 593 men who have sex with men (MSM) compared to none of 195 heterosexual men in the study. This explains why during the height of the AIDS epidemic in the 1980s about 50% of the AIDS cases (which were predominantly in men who have sex with men) presented with KS. Even though KS is the most common tumor in HIV-infected patients, it is rarely seen in women, IV-drug users, and transfusion recipients.

Before the advent of antiretroviral therapy (ART) these lesions would disseminate causing not only vascular tumors on the skin but also viscerally. When effecting the respiratory system (like seen in the photo below) patients would experience hemoptysis and airway obstruction, and the prognosis was poor.

Thankfully, now with ART, kaposi sarcoma is rarely seen except in undiagnosed AIDS patients who are put on ART which effectively treats the lesions by bringing the CD4 count back up to fight the oncogenic HHV-8 virus.

Photo credit:

Skin lesions: OpenStax College http://cnx.org/content/col11496/1.6/ CC-BY-3.0

Lung Lesions: Yale Rosen  CC-BY-SA-2.0

Snuffles is a cool word. The baby in the picture has snuffles. In the case of congenital syphilis snuffles are a  very important early sign indicating infection. They are blood tinged nasal secretions.

The signs that most students know as obvious signs of congenital syphilis, like saddle nose or saber shins (anterior bowing of the tibia), are actually late signs that occur after 2 years of age.

A famous triad for late symptoms of congenital syphilis is the Hutchinson triad which involves 3 signs:

1) Hutchinson Teeth: notching of the upper incisors.

2) Interstitial Keratitis: Inflammation of the corneas.

3) Deafness, due to cranial nerve 8 affection.

What antibiotic do we give to an infant with congenital syphilis that’s allergic to Penicilin G?

This is a post dedicated to the glorious fluid we excrete everyday that cleanses our body so very well of toxins.

Pee can come in many different colors than the usual amber yellow, and this can be due to a range of reasons from too much food coloring in your food to chronic illness.

Let's start with the basics: Are you hydrated?

Check the chart.

ROY G BIV that's how I learned the colors of the rainbow and that's how I'm going to describe the different colors a person's urine can be:

RED or Orange urine:

BLOOOOD?! AKA as hematuria, can be caused by a number of things like a long run, a urinary tract infection (UTI), an enlarged prostate, a stone, cancer.

Beets aka Beeturia

Is caused by eating delicious beets. I prefer pickling them.

Lead or Mercury poisoning can turn urine red.

Rhabdomyolysis

RIFAMPIN (the famous anti-tb antibiotic) can turn your urine red or orange.

Obstructive jaundice will cause orange urine because of that bilirubin that isn't reaching the intestine, making stool pale as well. More reasons to stare deeply into your toilet.

Let's skip yellow for obvious reasons.

Green is probably a Pseudomonas infection.

Blue

A medical cause behind blue urine is....blue diaper syndrome. Which is a familial hypercalcemia, a rare disorder.

                             Brown:

Case Number 106738

The girl above and her four clones decide to take a long run. They then go home and decide to pee. They are surprised to find that their urine is dark red, and think it’s one of the numerous deformities that occurred during their cloning process.

They then take a picture of their pee in a cup and post it on the internet.

Here it is:

What actually happened:

Turns out this was not an error that occurred because of their cloning procedure but something called Mechanical Hemolytic Anemia.

This is due to damage to their feet capillaries during their strenuous run that led to damage in their red blood cells and the release of hemoglobin, that resulted in hemoglobinuria. The dark red urine in the cup above is hemoglobinuria.

Moral of the story:

I'm not saying there are savage one-eyed giants running around like in Greek mythology. Neither am I implying that the guy from the X-men who has to wear uv-protection sunglasses to stop his eyes from laser-beaming you to death exists. I probably just really pissed off some comic-fan.

What I want to say is some people are born with one eye in the center of their face. 

                       The little guy above is found in a jar in a medical museum. Babies in jars is a thing.

Most cyclopic babies don't survive.

Some notable causes of Cyclopia:

1) Patau Syndrome AKA Trisomy 13

Some more symptoms of Patau are mental retardation, microcephaly, cleft palate and polydactly (extra fingers- image below). 

                          2) Ingesting Veratrum Californicum during pregnancy

And here are some more pictures of babies born with Patau syndrome:

Imagine whenever you spoke you would hear yourself just as if you were yelling right  into your own ear. Imagine if every time you chewed a piece of food you would hear the loud banging of your teeth, now imagine chewing a piece of gum with this over-sensitivity. This over-sensitivity to sounds isn't imaginary but a condition called: Hyperacusis.

There are many factors that can lead to hyperacusis, but the factor that I found interesting is hyperacusis caused by a failure of the acoustic reflex.

The last sentence might look like a bunch of medical jargon, so allow me to explain:

When we hear something, the sound waves hit the ear-drum, which is connected to a bony pathway that transmits the sound to the inner ear through a window called the oval window.

                          For us to properly hear, this pathway must remain intact. However, the question is do we want to hear everything?

The answer is No. We don't want to hear nagging, a gun-shot, or the sound of our food being slowly chewed.

Most people think the solution to avoiding these sounds is breaking up with your girlfriend, staying away from fights, and to quit eating so much. However, thanks to our own natural volume control center we don't have to avoid everything.

The volume control system:

When we hear a loud sound, the acoustic reflex is activated. This reflex depends on two muscles: the tensor tympani and the stapedius muscles. When the tensor tympani contracts it pulls the malleus (the first bone in the pathway) which is attached to the ear drum making the drum membrane more tense, making it harder to transmit noise. At the same time the stapedius muscle contracts pulling the stapes away from the oval window, decreasing the transmission of noise to the inner ear.

This genius reflex can be used and even manipulated in many different situation.

For example the stapedius will contract, every time you speak, or perform any type of vocalization so you don't hear the loudness of your voice. Hence, humming truly is a great way to literally not hear something you don't want to hear. If you can get away with it you can avoid most of the annoying stuff you hear.

Studies have even proven that less damage was done to the inner ear when someone was humming or doing any type of vocalization near a gunshot compared to those who were silent. I'm not sure why someone was humming when people were shooting within his proximity, but he ended up protecting those fragile hair cells inside his inner ear.

Keep the reflex in mind when you're having a telephone conversation too. I tend to give really bad examples to situations but here's a theoretical situation that might help explain the reflex. Let's say someone kidnaps a loved one, a random guy calls you to tell you they saw where the kidnapper took the person, you scream in excitement once you hear this piece of info, the stapedius reflex activates, the kidnapper gives you the details right after you scream in excitement, the reflex hasn't subsided yet, and you end up hearing nothing.

I hope the lessons taken from this post aren't to hum when someone's shooting at you, and that not saying a word during telephone calls is going to rescue your kidnapped loved ones.

Chewing is also one of those loud processes that go unnoticed because of this genius reflex. While chewing the tensor tympani pulls on the tympanic membrane (ear drum) so you don't have to deal with the loud teeth grinding.

So how does the volume control system go wrong?

The stapedius and tensor tympani are innervated by the 7th cranial nerve, the facial nerve. Hence, one of the symptoms of facial nerve dysfunction or paralysis is hyperacusis, hearing things louder than they are. One of the common diseases that cause facial nerve dysfunction/paralysis is Bell's Palsy.

Clinical Picture of Bell's Palsy:

                              In a previous post I talked about how pathologists love using food as a way to describe disease, and Cauliflower ear is no exception to this idea. To understand Cauliflower Ear more let's act like true medical professionals and use some food-oriented anatomical analogies to understand the Auricle (AKA Pinna) a part of the outer ear first. The Auricle is like a sandwich. The bun is the skin, the lettuce is the perichondrium (which is stuck to the bun) and last is the meat in the middle the elastic cartilage. Feel your ear and you'll understand what I'm talking about.

         So how does someone's ear end up looking like a vegetable? The cartilage gets is nutrients from the overlying skin. So say a boxer gets punched in his auricle (or any blunt trauma to the ear). Blood naturally will flow to the area which then will end up accumulating between the skin and perichondrium (which is very painful). Due to this separation the cartilage isn't getting its needed nutrients, which leads to cartilage necrosis. Cartilage necrosis then causes fibrosis, and the auricle starts to shrivel up and shrink causing the ear to supposedly look like cauliflower.

Not only does injury to the ear cause cauliflower ear but anything that generally causes a separation between the skin and perichondrium (the bun and the lettuce). So an unsanitary piercing for example in the upper auricle can lead to perichondritis and the inflammatory exudate from the infection can act the same way the accumulated blood acted in the boxer example.

Treatment of Cauliflower Ear Cauliflower Ear is treated by draining the blood clot or exudate between the skin and perichondrium so the cartilage doesn't die. Pro-athletes can prevent cauliflower ear by wearing head-gear. Antibiotics are also given in cases where infection is causing the separation of the layers, and to stop infection during drainage. Picture of drainage below:

                         Cool Facts About Cauliflower Ear It used to be a symptom of insanity because lots of patients with mental disease would have Cauliflower ear, thought to be because many patients would injure themselves. However, in many medical texts it says that Cauliflower ear is more common in the left ear of those labeled as insane. Doctors later noticed that this left ear pattern may be due to the abuse many patients received in mental asylums, because most of the staff in the asylums were right handed so the trauma would naturally appear on the left ear. Wrestlers and rugby players consider cauliflower ear as a badge of honor. The deformed auricle to many of them is seen as a sign of being badass.

Can you see the resemblance?

         Once Known as "the most dangerous lady in America," Typhoid Mary was the first healthy carrier of typhoid in America.

A healthy carrier is someone who spreads a disease without showing any symptoms of the disease. They're considered extremely dangerous because unlike cases, carriers don't seek medical treatment.

The most famous carrier is Mary Mallon, also known as Typhoid Mary. In the early 1900s she worked as a cook in many different homes and estates spreading the disease in each household then leaving, when the family would all fall ill, to another home. She had no idea that she was spreading the disease because she showed no signs of the disease.

Typhoid fever is spread through the feco-oral route where food contaminated by the feces of an infected person is ingested by a healthy person, thus causing the disease. A cook is by far the best job for spreading the disease and Mary Mallon happened to be one.

An owner of one of the estates Typhoid Mary worked in hired an epidemiologist to find the source of the disease and he concluded that only the cook, Mary, could have spread the disease. This medical Sherlock Holmes, George Soper, tracked Mary down and tried to get urine and stool samples from her but she constantly refused because she couldn't understand how she can be ill and symptomless. Until the police got involved arrested Typhoid Mary and quarantined her for three years in a clinic on North Brother Island.

     The picture above is of Typhoid Mary she's in the first bed.

Typhoid Mary was released signing a contract stating she would not work as a cook. She ended up breaking that contract causing more typhoid fever outbreaks. Ironically the place she chose to work as a cook was a women's hospital where they would jokingly call her Typhoid Mary because everyone was getting sicking, not knowing she really was Typhoid Mary, because she was working under the pseudonym Mary Brown.This led to her being quarantined for the rest of her life in a cottage alone on North Brother Island (17 Years).

She eventually died of Pneumonia, take that society, at the age of 69. Her autopsy revealed that her gallbladder was filled with live typhoid bacteria.

       One bar of butter is white the other is yellow, yes I did just state the obvious, but have you ever wondered why you see different colors of butter according to season? In the summer and spring butter sold at the market will be yellow while in the winter and fall it's white. The reason behind this change in color is Xanthophylls.

Xanthophylls are yellow (xantho is Greek for yellow) pigments from the carotenoid group. These pigments are found in green plants and leaves. So when cows are left in the spring and summer to graze on grass their fat absorbs these pigments turning it yellow; thus turning butter during those seasons yellow (lots of fat in butter). However, in winter and fall cows are fed corn which isn't a rich source of xanthophylls making the butter white. I know some people reading this had no idea that butter is white in winter considering the amounts of food coloring some companies put in their butter. If you see white butter in the market during summer and spring know it came from cows who are probably crowded in inhumane barns being force-fed.

So what color is your fat?

Pathologists love using food to describe diseases, and the most commonly used food-derived description you'll hear in medical school is 'cheese-like appearance'. The first thing that usually comes to mind when you hear the term 'cheese-like appearance' is tuberculosis.

                         The yellow cheese-like material in the picture above is found in cases of TB. Think of feta or cottage cheese.

However, many diseases cause a cheese-like appearance, because a cheese-like appearance is how caseous necrosis looks like. Caseous necrosis is a type of necrosis that occurs due to granulomatous reactions. For example in TB the body tries to wall off the bacteria from spreading by surrounding it with inflammatory cells, this walling off by using inflammatory cells is known as a granuloma. So what happens is the middle part of the granuloma starts to die resulting in the infamous 'cheese-like appearance'. Syphilis is an example of a granulomatous reaction hence caseous necrosis will result. Something you should keep in mind is that a specific amount of necrosis is needed for the caseous necrosis to appear, so the size of the granuloma is directly proportional with the amount of 'cheese-like appearance' you'll see. This is important because many people define sarcoidosis as non-caseating granulomas. That description isn't a rule, it can be non-caseating if the granulomas are small, which is sometimes the case, and it can be caseating and cheesy if the granulomas are large.

In 1867 an act called The Merchant Shipping Act required all ships of the Merchant Navy and the Royal Navy to provide a daily lime ration to sailors. They were trying to prevent Scurvy.

Because of the long sea trips sailors went on they didn't have many foods on board that were rich in Vitamin C AKA Ascorbic Acid, which led to Vitamin C deficiency which manifests in what is known as Scurvy.

Without vitamin C the body can't form collagen, an essential protein found all over the body. So the clinical manifestations of Scurvy would be based on the idea of the absence of collagen.    

    For example gums would bleed because blood vessels need collagen and teeth would fall because teeth depend on collagen for their attachment to the gingiva.

                       Petechia which are small hemorrhages would appear due to weakened capillary walls because of the lack of collagen.

                     Collagen is also present in bones, so naturally like the X-Ray above reveals a thinning of bones would occur during Scurvy.

Other Clinical Manifestations: Fatigue, Myalgia, Poor wound healing, Dry Mouth, Dry Eyes, Jaundice, Neuropathy, Edema, Convuslions, and eventually Death

The role of vitamin C in the formation of collagen: