There is an extensive body of animal research supporting the neurophysiologic effects of acupuncture on the endorphin system skin care olive oil order 15 gr differin with amex. Complications and Risks Bruising and minor bleeding are the most common complications of acupuncture and occur in about 2% of all needles placed (17) skin care 40 year old buy cheap differin on line. The most significant risk of acupuncture is infection acne keloidalis nuchae icd 10 cheap 15gr differin with mastercard, and cases of hepatitis have been documented when needles were reused acne face mask quality differin 15 gr. The risk of transmissible infection is eliminated by onetime use of disposable needles, which is now standard practice in the United States. The needles used are 32 gauge or smaller; therefore, a chest tube usually is not required for treatment. Forty states either license or register acupuncturists a s doc to rs of oriental medicine or acupuncture physicians. An acupuncturist must pass this examination and meet continuing education requirements every 4 years to retain certification and licensure. Physician acupuncture practitioners may not be as fully trained in the art as nonphysician licensed acupuncturists. To be certified by the American Board of Medical Acupuncture, physicians must take a minimum of 300 hours in training (19). In homeopathic medicine, there is a belief in the law of infinitesimals and that like cures like. Naturopathic Medicine Unlike oriental medicine or homeopathy, naturopathy does not have a long his to ry of traditional use, nor is it based in a comprehensive system. Naturopathy views disease as a manifestation of alterations in the processes by which the body naturally heals itself and emphasizes health res to ration rather than disease treatment. Naturopathic physicians employ an array of healing practices, including diet and clinical nutrition; homeopathy; acupuncture; herbal medicine; hydrotherapy (the use of water in a range of temperatures and methods of applications); spinal and soft-tissue manipulation; physical therapies involving electric currents, ultrasonography, and light therapy; therapeutic counseling; and pharmacology. Training and Licensure There is no national licensure for naturopathy, and licensure at the state level is inconsistent. Seven 4-year naturopathic medical schools are accredited by the Council on Naturopathic Medical Education (20). Although the 4-year programs are rigorous, it is possible to get a naturopathic degree online. Just as with conventional medicine, the effects of certain approaches are more likely than others to be associated with a placebo response. After exposure to a stimulus believed by both the patient and the practitioner to be an active intervention, the body responds physiologically in an equivalent manner. Approximately one-third of patients in placebo-controlled trials of conventional methods experience a placebo response. It would be of great value to medicine if the placebo response were better unders to od and could be activated more reliably in patients. Providers or products that make claims that are grandiose and dubious, for example; chiroprac to rs who claim to cure insulin-dependent diabetes or offer alternative approaches to cure cancer. Providers or products who foster dependence, for example, therapists who recommend multiple visits per week or frequent visits for an unlimited period. Providers or products that support the use of alternative approaches exclusive of conventional medicine or conventional providers. First, the market demand is huge and is far ahead of the health care systems ability to address issues of regulation, education, or research. The Federation of State Medical Boards developed the Model Guidelines for the Use of Complementary and Alternative Therapies in Medical Practice, approved by the House Delegates of the Federation of State Medical Boards of the United States, Inc. The intention of this initiative was to provide guidelines that are clinically responsible, ethically appropriate, and consistent with what state medical boards consider to be within the boundaries of professional practice and accepted standard of care. Potential Misuse In addition to physical risks, patients and physicians alike should be aware of other areas of potential misuse. First, given that the dollars being spent out of pocket are so significant, there are some products and some providers whose primary motivation is monetary. Fac to rs that should increase suspicion for potential misuse are listed in Table 13. If patients are using therapies that are potentially dangerous in their action or in their interaction, physicians should be aware of this possibility and counsel them accordingly. Physicians have a commitment to offer their patients the best treatment options, regardless of their system of origin. Many patients simply do not think of sharing this information with their physicians, so direct and specific inquiry is necessary. Many practices incorporate this information in a separate sheet for patients to fill out and for physicians to review and add to the chart. Oriental medicine practitioners or acupuncturists, for example, often treat with botanical products or herbal teas. When patients are asked this his to ry directly in an atmosphere of respect, they usually are very forthcoming, and the most significant barrier is broken. This is an area in which (i) very few physicians received formal training, (ii) there is little (albeit increasing) research in the mainstream medical journals, and (iii) there is a tremendous amount of information, of variable quality, in the lay press. All of these fac to rs contribute to a circumstance that often is uncomfortable for physicians. This discomfort is important to recognize because it can contribute to avoidance of the to pic al to gether. It is appropriate to begin the conversation with a patient by explaining that this is new terri to ry in conventional medicine and that you are not an expert. Most patients have assumed this to be the case, appreciate the honesty, and value the opportunity to discuss these dilemmas. It is necessary to evaluate the potential to cause both direct harm and indirect harm. Potential for Direct Harm this should include any evidence regarding potential harm directly from the therapy or potential interactions. When lacking good evidence, assessment of the invasiveness of the therapy is a strong predic to r of risk. Potential for Indirect Harm this should include an assessment of potential harm caused by postponing effective treatments, and by financial exploitation. Marketing can prey on vulnerable patients and result in significant and unnecessary expenditures. Step Two: Assess Potential Benefits the potential for any approach to be of benefit should be assessed on several levels. Scientific Evidence A review of the peer-reviewed literature should certainly be conducted for evidence of the effectiveness of the approach under consideration. Cultural Evidence Another form of useful information is the his to ric or cultural use of the approach. For example, it is valuable to consider whether a therapy has a long his to ry of use within a given culture. If, on the other hand, the approach has no his to ric use, this is important to recognize. Examples include the use of black cohosh for menopausal symp to ms, which was used for centuries with reported safety and effectiveness, compared with red clover, which has no his to ric use or track record. Another example would be acupuncture, with thousands of years of use, compared with chelation, which was in use for a relatively short time and is associated with considerable debate regarding its benefit. Personal Belief Another part of the assessment of benefit is to recognize the patients belief system as it pertains to the approach. If the patient has a strong belief in the approach, and there is no evidence of potential harm, it is often reasonable to support its use. Step Three: Assess the Delivery System When assessing the delivery system, both products and providers must be considered. Product Assessing the his to ry of the manufacturing company and understanding its process of quality assurance can be useful. Referral to independent sources for determining the quality of product and accuracy of labeling may be useful. Inquiring about the education of a given provider and his or her licensing status (if there is a licensing body for the field) is an important place to start.
When called upon acne 2015 differin 15 gr on line, the circulating monocyte can enter in to acne location buy discount differin an organ or tissue bed as a tissue macrophage (sometimes called a histiocyte) acne under armpit differin 15gr with amex. Examples of tissue macrophages are Kupffer cells (liver) acne on back cheap differin 15gr on line, alveolar macrophages (lung), osteo clasts (bone), Langerhans cells (skin), microglial cells (central nervous system), and possibly the dendritic immunocytes of the dermis, spleen, and lymph nodes. The entire system, including the peripheral blood monocytes, constitutes the mononuclear phagocyte system. In the lung, alveolar macrophages can phagocytize the red blood cells that accumulate in alveoli in individuals with congestive heart failure. Acute inflamma to ry processes, such as pyogenic bacterial infections and tissue necrosis, are associated with infiltrates of neutrophils in to tissue and increased numbers of neutrophils in the blood; hence neutrophils are thought of as acute inflamma to ry cells. Myeloperoxidase is an enzyme within the primary (azurophilic) granules of neutrophils, while alka line phosphatase is an enzyme in their secondary (specific) granules. In contrast, chronic inflamma to ry processes are associated with increased numbers of monocytes and lymphocytes. Monocytes are mononuclear leukocytes with a bean-shaped or horseshoe-shaped nucleus. The activated form of macrophages have abundant eosinophilic cy to plasm and are called epithelioid cells. Lymphocytes are smaller mononuclear leukocytes that have a round to oval nucleus and little cy to plasm. B lymphocytes (B cells) mature in to plasma cells, which have an eccentric nucleus with a clock-face appearance of their chromatin. Plasma cells secrete immunoglobulin, while certain T lymphocytes (T cells) secrete lymphokines. Numbers of lympho cytes are increased in acute viral infections or chronic disease. These granules contain many different types of substances, such as major basic protein (which is to xic to helminthic par asites), arylsulfatase (which neutralizes leukotrienes), and histaminase (which neutralizes histamine). They participate in specific types of inflam ma to ry processes, such as allergic disorders, parasitic infections, and some diseases of the skin. Basophils are a type of leukocyte that have numerous deeply basophilic granules within their cy to plasm that completely hide the nucleus. Basophils participate in certain specific types of immune reactions because they have surface recep to rs for IgE. Mast cells, although not exactly the same as basophils, are found in tissue and are very similar to basophils. These cells may be surrounded by mononuclear cells, mainly lymphocytes, and multinucleated giant cells. Granuloma to us inflammation is a type of chronic inflammation initiated by a variety of infectious and noninfectious agents. Indigestible organisms or particles, or T cellmediated immunity to the inciting agent, or both, appear essential for formation of granulomas. Tuberculosis is the classic infectious granuloma to us disease and is characterized by finding rare acid-fast bacilli within areas of caseous necrosis. In addition to tuberculosis, several other infectious disorders are characterized by formation of granulomas, including deep fungal infections (coccidioidomycosis and his to plasmosis), schis to so miasis, syphilis, brucellosis, lymphogranuloma venereum, and cat-scratch disease. In sarcoidosis, a disease of unknown cause, the granulomas are non caseating, which may assist in his to logic differentiation from tuberculosis. Tissue repair involves the formation of granulation tissue, which his to logically is characterized by a combination of proliferating fibrob lasts and proliferating blood vessels. Proliferating cells are cells that are General Pathology Answers 123 rapidly dividing and usually have prominent nucleoli. It is important not to confuse the term granulation tissue with the similar-sounding term gran uloma. The latter refers to a special type of inflammation that is characterized by the presence of activated macrophages (epithelioid cells). Collagen is a triple helix of three polypeptide fi-chains that is secreted by fibroblasts and has a high content of glycine and hydroxyproline. Fibronectin, secreted by fibroblasts, monocytes, and endothelial cells, is also capable of binding many substances, such as collagen, fibrin, proteoglycans, and integrins. Instead of being cross-shaped like laminin, fibronectin is a large glycoprotein composed of two chains held to gether by disulfide bonds. Albumin is secreted by hepa to cytes and is mainly responsi ble for intravascular oncotic pressure, while immunoglobulins are secreted by plasma cells and are important in mediating humoral immunity. Marfans syndrome is an au to somal dominant disorder that results from defective synthesis of fibrillin causing connective tissue abnormalities. It is 124 Pathology characterized by specific changes involving the skele to n, the eyes, and the cardiovascular system. Skeletal changes seen in individuals with Marfans syndrome include arachnodactyly (spider fingers) and a large skele to n causing increase in height. Eyes in patients with Marfans syndrome typi cally have a subluxed lens (ec to pia lentis) in which the lens is found in the anterior chamber. The lens dislocation in Marfans syndrome is usually upward, in contrast to the downward dislocation seen with homocystin uria. Abnormalities of copper metabolism is seen with Wilsons disease, which is characterized by varying liver disease and neurologic symp to ms due to excess copper deposition within the liver and basal ganglia of the brain. Decreased levels of vitamin D can produce rickets in children or osteomalacia in adults. These individuals have eye problems along with hyper extensible skin and joint hypermobility. These patients have brittle bones and also typically develop blue scleras and hearing loss. It may be caused by inflammation (inflamma to ry edema) or it may be due to abnor malities involving the Starling forces acting at the capillary level (noninflam ma to ry edema or hemodynamic edema). Inflamma to ry edema is caused by increased capillary permeability, which is the result of vasoactive media to rs of acute inflammation. An exudate is inflamma to ry edema fluid resulting from increased capillary permeability. It is characterized by a high protein content, much cellular debris, and a specific gravity greater than 1. Pus is an inflamma to ry exudate containing numerous leukocytes and cellular debris. In contrast, transudates result either from increased intravascular hydrostatic pressure or from decreased osmotic pressure. Non inflamma to ry edema is the result of abnormalities of the hemodynamic (Starling) forces acting at the level of the capillaries. Increased hydrostatic pressure may be caused by arteriolar dilation, hypervolemia, or increased venous pressure. Hypervolemia may be caused by sodium retention seen in renal disease, and increased venous hydrostatic pressure can be seen in General Pathology Answers 125 venous thrombosis, congestive heart failure, or cirrhosis. Decreased plasma oncotic pressure is caused by decreased plasma protein, the majority of which is albumin. Decreased albumin levels may be caused by loss of albu min in the urine, which occurs in the nephrotic syndrome, or by reduced synthesis, which occurs in chronic liver disease. Lymphatic obstruction may be caused by tumors, surgical resection, or infections (for example, infection with filarial worms and consequent elephantiasis). It may be caused by increased arterial supply (active hyperemia) or impaired venous drainage (passive hyper emia). Examples of active hyperemia include increased blood flow during exercise, blushing (such as embarrassment associated with being asked a question during a lecture), or inflammation. Examples of passive hyper emia, or congestion, include the changes produced by chronic heart fail ure. The lung changes are characterized by intraalveolar, hemosiderin laden macrophages, called heart failure cells. In contrast to hyperemia, hemorrhage refers to the leakage of blood from a blood vessel.
Ana to acne cyst generic 15gr differin mastercard mic Models Over the past century ana to acne 7-day detox quality differin 15 gr mic models have emphasized the concept of lobes or zones of the prostate (fig skin care careers differin 15gr low price. In the first half of the 20th century skin care education order differin cheap online, the five-lobe model dominated (7), but this model was based on embryonic and fetal prostates, not adult glands. In 1954, Franks (8) put forth the idea of an outer gland (where carcinomas arose) and a periurethral inner gland. Further evolution of this concept occurred when McNeal (2,4,5,9) de veloped the zonal model that is currently widely used. This model defines three zones: a central zone, a transition zone, and a peripheral zone (figs. These zones appear to have Cross section of prostate from a young adult male at structural differences and diseases differentially the level of the verumontanum. Note the location of anterior, normally makes up 5 percent of prostate gland posterior, lateral, and middle lobes. The main ducts of this zone drain submucosal glands that comprise the outer prostate. In the anterior aspect, stroma predominates thick smooth muscle bundles of the preprostatic and is referred to as the anterior fibromuscular stroma. Also found in the smooth muscle of the preprostatic sphincter are minute ducts and abortive acinar arrangements of periurethral urethra via orifices positioned next to the ejacu glands, which constitute only about 1 percent la to ry duct orifices on the verumontanum. The peripheral zone of the prostate gland the central zone makes up about 25 percent is the bulk of the posterior, lateral, and api of the prostate gland and is a posteriorly situated, cal portions of the gland and accounts for 70 cone-like structure, with the base of the cone pro percent of the to tal gland volume. The paired of this zone empty in to the posterior urethral ejacula to ry ducts run through the central zone. A patch of nonglandular tissue, the ante Outside the prostate, this band is continuous with rior fibromuscular stroma, is located anteriorly pelvic fascia and rec to vesical fascia (of Denonvil over the prostate and extends from the bladder lier). The concentra prostatic sphincter and the striated sphincter tion of smooth muscle fibers in the band and (2). Glands from of smooth muscle that encircles the proximal the prostate approach this band, but the border segment of the prostatic urethra. It prevents between the outer limit of epithelium and the retrograde fiow of seminal fiuid and also perhaps band is not often clearly definable under the maintains closure of the proximal urethra via its light microscope. The striated sphincter is composed with Denonvillier fascia and does not clearly of skeletal muscle fibers found around the distal separate prostate gland from seminal vesicle. Both poste the outer prostatic capsule is actually a band riorly and posterolaterally, the best method of of concentrically placed fibromuscular and vascu determining the outer boundary of the prostate lar tissue that is inseparable from prostatic stroma is where the condensed smooth muscle of the (fig. Anteriorly and anterolaterally, separation of bladder and prostate also does the band blends with the pelvic fascia. Apically, not exist; rather, there is fusion of smooth the band is no longer present, and instead there muscle bundles (fig. As there is no true is a jumble of smooth muscle, skeletal muscle, his to logically distinct prostatic capsule, it is and fibroelastic fibers. Here, it is important preferable not to refer to capsular penetration to know that the urethral striated sphincter when noting tumor that has spread beyond the (rhabdosphincter) is in direct continuity with prostate gland. A more appropriate designation the prostate, and indeed, skeletal muscle fibers is to state whether tumor is organ-confined or are normally found, at an anterior and apical shows extraprostatic extension. By light however, a true capsule (a discrete fibrous or microscopy, intraglandular blood vessels are fibromuscular band of tissue) does not separate easily seen in prostatic stroma (fig. The innervation of the periph (H&E)-stained sections, probably because a large eral zone and posterior capsule is significantly number have closed lumens (23). Venous drain greater than of the transition zone and anterior age is in to the plexus of San to rini. His to logically, nerves are seen in the peri Lymphatic Drainage prostatic neurovascular bundle (fig. A minor 1-15) are usually found outside the gland but amount of drainage occurs through the presa may also be found in the outer fibromuscular cral and external iliac nodes. Paraganglia are of fiow is through the periprostatic or perisemi most often located in or adjacent to the lateral nal vesicle lymph nodes (fig. They should not be found in about 4 percent of radical prostatec confused with high-grade prostatic carcinoma. These tend to be small Because ganglia and paraganglia can be found lymph nodes, averaging about 2 mm in greatest inside the prostate and in the outer fibromus dimension. Pelvic lymph nodes are commonly cular band, carcinoma invading around these excised as a staging maneuver as part of radical structures should not necessarily be equated prostatec to my surgical procedures. Another diagnostic pitfall is the relationship Nerves of normal and benign prostatic glands to in the prostate gland has a rich nerve sup traprostatic nerves. Benign prostatic glands can ply, with sympathetic and parasympathetic abut nerves (fig 1-16) (2931), and can even be innervation arising from the pelvic plexus (25, found within nerves (fig. These nerves run with branches of the glands should not au to matically be considered capsular artery and penetrate the prostate. Para malignant, and a constellation of his to mor sympathetic fibers course to acini and stimulate phologic traits should be used in diagnosis, secretion and sympathetic fibers cause contrac not solely the physical proximity of prostatic tion of outer band capsular and intraprostatic glands and nerves. The prostate gland is derived from the uro In the bud stage, at 20 to 30 weeks gestation, genital sinus and is first recognizable at 9 to 10 solid cellular buds are at the end of ducts, with weeks of development (2). Tes to sterone from the spindled cells in the center and columnar cells embryonic testis stimulates ingrowth of endo at the periphery. The third of epithelium and mesenchyme during devel stage is characterized by more distinct lobular opment, by which, under the infiuence of an organization of acinotubular clusters (fig. The differentiating prostatic epithelium immunophenotype of fetal prostatic epithelial in turn signals the urogenital mesenchyme to dif cells is similar to the rare adult transiently am ferentiate in to smooth muscle cells that closely plifying epithelial cells, which show coexpres surround the epithelial ducts. This dynamic sion of basal and luminal cy to keratins, high dance of tissue remodeling entails coordinated proliferation, and lack of p27 expression (37). By 13 weeks, some genesis include those regulated by androgens, 70 primary ducts are present. Interestingly, some of these gland is a branching duct-acinar glandular sys molecules have been implicated in the biology of tem embedded in a dense fibromuscular stroma human prostate cancer (39). Zonal architectural differences can be prostatic epithelial stem cells involved in prostate appreciated (2). Normally, the peripheral zone gland development has not yet been realized, but ducts and acini are evenly distributed but are ir cell populations enriched for cells exhibiting stem regular in size and shape. The central zone glands are more densely with embryonic stem cell fac to rs including Oct-1, arranged than peripheral and transition zone Nanog, Sox2, and nestin (40). The epithelial to stromal ratio the seminal vesicles, epididymis, vas deferens, in the central zone is 2 to 1, compared with 1 to and ejacula to ry ducts (fig. Also, Wolfian (mesonephric) ducts under the infiuence central zone glands are larger and display intra of tes to sterone. The central zone of the prostate is also of mesodermal central zone epithelium has tall columnar cells Wolfian duct origin (2). In this model, the pros with eosinophilic cy to plasm, a prominent basal tate gland is of dual embryonic derivation. The epithelium of the but duct formation, solid budding at the periph central zone is distinctive in selective expression of ery, and branching morphogenesis continue (35). A third cell type in normal prostatic epithelium the nuclei of normal prostatic secre to ry is the neuroendocrine cell, which is rare. The epithelial cells are small and round, with fine, secre to ry cells of the normal prostate glandular evenly dispersed chromatin. Nucleoli usually epithelium make up the bulk (about three quar are not evident or are pinpoint in size. They are cuboidal in the central zone usually are larger than those to columnar, with nuclei positioned in the basal in the peripheral zone and appear crowded. Cleared cy to plasm is a results in a pseudostratified nuclear appearance hallmark of normal prostatic secre to ry cells due in the central zone, and along with the afore to the presence of a large number of small clear mentioned denser cy to plasm, may yield a false secre to ry vacuoles. Basal cells have a scant amount to gray-brown to blue when stained with H&E of dense cy to plasm and small, hyperchromatic (43). The precise function of basal cells is the cy to plasm of seminal vesicle and ejacula to ry unsettled, but they represent the proliferative duct epithelial cells, where it is more abundant, component of prostatic epithelium. Basal cells can be difficult to detect with routine hema to xylin and eosin (H&E) staining. Neuroendocrine (endocrine-paracrine) cells multilayered, and cells have rounded to elon constitute a third population of cells in normal gated nuclei, some of which possess nuclear prostatic epithelium (45). This is a terminally epithelium) involves acini in the peripheral differentiated, postmi to tic cell population. Neu aspects of the prostate gland, the designation roendocrine cells are usually recognizable only by urothelial metaplasia is applied (46).
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Familial polyposis is charac terized by the formation of numerous neoplastic adenoma to skin care network barnet ltd order differin paypal us colon polyps acne 7 days past ovulation discount differin 15 gr with amex. These individuals have a 100% risk of developing colorectal carcinoma unless surgery is performed acne and diet generic 15gr differin with visa. Sturge-Weber syndrome is a rare congenital disorder associated with venous angioma to acne 24 purchase differin 15gr with visa us masses in the lep to meninges and ipsilat eral port-wine nevi of the face. The highest rates for gastric carcinoma are found in Japan, Chile, China, and Russia, while it is much less common in the United States, the United Kingdom, Canada, and France. The high rates for gastric cancer in Japan might be related to dietary fac to rs, such as eating smoked and salted foods. Other examples of geographic variations in the incidence of neoplasms include nasopharyngeal carcinoma, liver cancer, and trophoblastic disease. Nasopharyngeal carcinoma, associated with the Epstein-Barr virus, is rare in most parts of the world, except for parts of the Far East, especially China. Liver cancer is associated with both hepatitis B infection and high levels of afla to xin B1. Tro phoblastic diseases, including choriocarcinoma, have high rates of occur rence in the Pacific rim areas of Asia. These tumor markers include hormones, oncofetal antigens, isozymes, proteins, mucins, and glycopro teins. It is used clinically to follow up patients with certain malignancies, such as colon cancer, and to evaluate them for recurrence or metastases. Herpes simplex type 2, a sexually transmitted viral disease, results in the formation of vesicles that ulcerate and cause burning, itching, and pain. These lesions heal spontaneously, but the virus remains dormant in the lumbar and sacral ganglia. Recurrent infections may occur, and transmis sion to the newborn during delivery is a feared complication that may be fatal to the infant. Shingles and chickenpox are caused by herpes zoster, which is identical to varicella. Infected cells have large, purple intranuclear inclusions surrounded by a clear halo and smaller, less prominent basophilic intracy to plasmic inclusions. Adenoviruses can produce similar inclusions, but the infected cells are not enlarged. Adenoviruses also produce characteristic smudge cells in infected respira to ry epithelial cells. His to logic examination reveals enlarged squamous epithelial cells that have shrunken nuclei (raisinoid) within large cy to plas mic vacuoles. Candidiasis is the most common fungal infection of the vagina and is especially common in patients who have diabetes or take oral contra ceptives. Patients develop a dry cough with fever, chills, and malaise after an incubation of up to 10 days. Up to one-third of the patients improve, but the majority of patients progress to severe respira to ry distress and almost 10% die from the disease. Interestingly, the most consistent labora to ry finding occurring early in the disease is peripheral lymphopenia. Examination of lung tissue from confirmed cases has revealed the presence of hyaline membrane for mation, interstitial mononuclear inflammation, and desquamation of pneu mocytes in to the alveoli. In contrast to Coronavirus, the Hantavirus genus belongs to the Bun yaviridae family and includes the causative agent of a group of diseases that occur throughout Europe and Asia and are referred to as hemorrhagic fever with renal syndrome. The characteristic features of this syndrome are hema to logic abnormalities, renal involvement, and increased vascular per meability. Although several species of rodents in the United States are known to be infected with Hantavirus, no human cases were reported until an outbreak of severe, often fatal respira to ry illness occurred in the United States in May 1993 in the Four Corners area of New Mexico, Arizona, Colorado, and Utah. This illness resulted from a new member of the genus Hantavirus that caused a severe disease characterized by a prodromal fever, myalgia, pulmonary edema, and hypotension. The main distinguishing feature of this illness, which is called Hantavirus pulmonary syndrome, is noncardio genic pulmonary edema resulting from increased permeability of the pul monary capillaries. Labora to ry features common to both Hantavirus pulmonary syndrome and hemorrhagic fever with renal syndrome include leukocy to sis, atypical lymphocytes, thrombocy to penia, coagulopathy, and decreased serum protein concentrations. Abdominal pain, which can mimic an acute abdomen, may be found in both Hantavirus pulmonary syndrome and hemorrhagic fever with renal syndrome. Dengue fever virus is a type of flavivirus, and flaviviruses are similar to alphaviruses. Dengue fever (breakbone fever) is initially similar to influenza but then progresses to a rash, muscle pain, joint pain, and bone pain. Ebola virus is a member of General Pathology Answers 163 the Filoviridae family, which causes a severe hemorrhagic fever. In children, infection with parvovirus produces a characteristic rash, called erythema infectiosum or fifth disease, which first appears on the face and is described as a slapped-cheek appearance. Human parvovirus infection in adults produces a nonspecific syndrome of fever, malaise, headache, myal gia, vomiting, and a transient rash. Erythema infectiosum is called fifth disease because it is one of the six classic childhood exanthems (skin eruptions associated with certain infec tious diseases). After an incubation period of 10 to 21 days, measles is characterized by fever, rhinorrhea, cough, skin lesions, and mucosal lesions (Koplik spots). Scarlet fever (second disease) is caused by infection of the to nsils with group A beta-hemolytic strep to cocci (S. Rubella is a mild, acute febrile illness, but if the infection occurs in the first trimester of pregnancy it can produce developmental abnormalities such as cardiac lesions, ocular abnormalities, deafness, and mental retardation. As the fever quickly subsides there appears a diffuse pink rash with papules or blanchable macular erythema. Skin lesions include macules, papules, vesicles (dew drops on a rose petal), pustules, and scabs. Reactivation in adults produces shingles, which is characterized by painful eruptions along derma to mes corresponding to the affected dorsal root ganglia. Strep to coccal or pneumococcal pneumonia involves one or more lobes and is often seen in alcoholics or debil itated persons. This bacteria usually produces a bron chopneumonia, rather than lobar pneumonia, but this is clinically indistin guishable from pneumococcal lobar pneumonia. Legionella species cause a fibrinopurulent lobular pneumonia that tends to be confluent, almost appearing lobar. Two forms of disease produced by Actinomyces are cervicofacial actinomyces and pelvic actinomyces. The former consists of an indurated (lumpy) jaw with multiple draining fistulas or abscesses. Small yellow colonies called sulfur granules may be seen in the draining material. Cultures of Actinomyces grow as white masses with a domed surface, which is called a molar to oth appearance. A characteristic that helps to dif ferentiate these two is the fact that Nocardia is partially acid-fast. Nocardiae are aerobic and acid-fast, in contrast to Actinomyces species, which are strict anaerobes and not acid-fast. Progressive pneumonia with purulent sputum and abscesses is suggestive of nocardiosis, especially if dissemination to the brain or subcutaneous tissue occurs. Nocardia is also one cause of myce to ma, a form of chronic inflamma tion of the skin that causes indurated abscesses with multiple draining sinuses. These rods tend to arrange themselves at right angles, producing characteristic V or Y configurations General Pathology Answers 165 described as Chinese characters. This to xin can produce a pseudomembrane covering the larynx, which is difficult to peel away without causing bleeding, and heart damage with fatty change. Characteristics that are unique to Listeria include a tumbling motility on hanging drop and an umbrella-shaped motility pattern when a specimen is stabbed in to a test tube agar slant. Cultures grow colonies of bacteria that grossly are tangled having a medusae head appearance; gram stains reveal parallel chains of boxcar-shaped gram-positive organ isms. His to logy of the infection reveals severe acute necrotizing hemor rhagic inflammation secondary to vasculitis. Infection with anthrax is associated with sheep farmers, veterinarians, and wool workers.