Fw: Autoimmune and collagen vascular symptoms

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----- Original Message ----- From: Kathi

Sent: Monday, October 28, 2002 8:57 AM

Subject: Autoimmune and collagen vascular symptoms

This is by no means a way to diagnose yourself, nor is it complete; Leaving out Raynaud's, Sjogren's, and Sicca, because we are all most aware of them already, it is intended to help you identify your symptoms to help you in communicating with your doctor......... I also have found that it is BEST not to even mention silicone initially. Let them run their tests, you will need them anyway and when they start to scratch their heads, inform them...."I don't know if this makes a difference or not, but I did have or do have implants" This saves their false pride and egos and allows them to become the ones who want to investigate this. It has not failed me since I began this, they love being the detective, then you can start taking information that you just recently located. Kathi images: Clinical Example: CREST syndrome with scleroderma, telangiectasias and subcutaneous calcification http://www.eatonhand.com/img/14522.htm 'Localized Scleroderma' http://www.dermis.net/bilddb/diagnose/englisch/i701000.htm Scleroderma in the Oesophagus http://www.gastrolab.net/ng007.htm Scleroderma 4-613 http://www.google.com/search?hl=en & lr= & ie=ISO-8859-1 & q=scleroderma+image Scleroderma and Dermatomyositis http://140.251.5.102/CUMC_PathNotes/Immunopathology/622.GIF 'Raynaud's Syndrome' http://www.dermis.net/doia/diagnose.asp?zugr=d & lang=e & diagnr=443000 & topic=t Sclerodactyly http://www.dermis.net/doia/diagnose.asp?zugr=d & lang=e & diagnr=710110 & topic=t Scleroderma and Calcinosis http://www.brisbio.ac.uk/ROADS/cgi-bin/tempbyhand.pl?database=BRISBIO+IMAGES & query=BRISBIO-3927 LIVEDO RETICULARIS http://dermatlas.med.jhmi.edu/derm/ Lupus http://dermatlas.med.jhmi.edu/derm/ lumps, bumps and nodules http://dermatlas.med.jhmi.edu/derm/result.cfm?BodySite=0 & Pigmentation=0 & Diagnosis=0 & Category=4 & AgeSelect=default & Author=0 & keywords= & ImageName=Enter+Image+Name collegan vascular http://dermatlas.med.jhmi.edu/derm/result.cfm nails http://dermatlas.med.jhmi.edu/derm/result.cfm photo sensitivity http://dermatlas.med.jhmi.edu/derm/ descriptions: note: Scleroderma can cause malabsorption, which is difficulty in the digestion or absorption of nutrients from food substances. Irritable Bowel Syndrome can cause constipation, diarrhea Temple University School of Medicine. In Scleroderma, the symptoms are similar to IBS, however there is a thinning of the intestinal wall which causes impaired neuromuscular problems. Interstitial Lung Diseases Sarcoidosis, idiopathic pulmonary fibrosis (IPF), and pulmonary fibrosis associated with connective tissue diseases have an unknown etiology The insidious onset of breathlessness or cough is common, as are other nonspecific findings such as fatigue, arthralgias, and myalgias. arthritis, myositis (muscle tenderness, weakness), photosensitivity, visual problems, or Raynaud's phenomenon suggests a systemic process, such as collagen vascular disease, vasculitis, or sarcoidosis. The physical examination usually reveals resting tachypnea and bibasilar rales. Cardiac test results may be normal, but a thorough search for signs of left ventricular dysfunction and mitral valve disease (both common in the elderly) should be made. Signs of pulmonary hypertension (right-sided gallops or heaves, accentuated pulmonary component of the second heart sound) may occur late in any of the ILDs. Digital clubbing is common in IPF, collagen vascular disease-related ILD, and asbestosis but is uncommon in hypersensitivity pneumonitis, silicosis, sarcoidosis, and idiopathic bronchiolitis obliterans with organizing pneumonia (BOOP). A thorough inspection of mucosal surfaces, skin, and joints may give clues to systemic processes. The chest x-ray may provide the earliest evidence of ILD by showing reticular or nodular opacities with reduced lung volume. Other abnormalities indicative of ILD include alveolar or ground-glass opacities, septal Kerley B lines, pleural involvement, and mediastinal or hilar adenopathy. High-resolution CT (HRCT) of the chest may show distinctive patterns of various ILDs. HRCT is significantly more sensitive and specific than chest x-ray for diagnosing and assessing the extent of ILD. Pulmonary function tests often reveal a restrictive pattern of lung dysfunction. The ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) is normal or increased because of increased elastic recoil of the stiff lung parenchyma. Several ILDs (eg, chronic sarcoidosis, chronic hypersensitivity pneumonitis, advanced pulmonary histiocytosis X) cause airway obstruction and normal or increased volumes secondary to air trapping and hyperinflation. Lung compliance is increased in ILD. The diffusing capacity for carbon monoxide (Dlco) is generally reduced, even when corrected for alveolar volume and Hb. Arterial blood gases obtained at rest may be normal early in ILD; hypoxemia and mild hypocarbia are common as the disease progresses. Routine blood and serologic tests are often unremarkable. Abnormal results of hepatocellular injury tests and high serum calcium levels are clues to the diagnosis of sarcoidosis or metastatic malignancy with pulmonary lymphangitic spread. Renal insufficiency or microscopic hematuria raises the possibility of Wegener's granulomatosis, Goodpasture's syndrome, systemic lupus erythematosus, or systematic necrotizing vasculitis. However, these conditions rarely present in the elderly. Low titers of antinuclear antibodies and rheumatoid factor are nonspecific findings in a number of ILDs, especially IPF. High titers of antinuclear antibodies suggest collagen vascular disease. http://www.merck.com/pubs/mm_geriatrics/sec10/ch80.htm SLE The term lupus means "wolflike" and refers to the characteristic butterfly rash that is seen over the cheekbones and gives the face a wolflike appearance. The rash is not always present, but when it is, it strongly suggests the likelihood of lupus. A variety of rashes almost anywhere on the body is another common finding in lupus. Many systemic lupus erythematosus patients also have Raynaud's syndrome, a blanching of the hands and feet on exposure to the cold, which disappears after warming. The various combinations of symptoms differ from patient to patient and from time to time during the evolution of the disease. Thus, a lupus patient may initially seek treatment for an emotional disturbance and, years later, develop arthritis and a characteristic rash. Or another may first consult a kidney specialist or a cardiologist. A false-positive blood test for syphilis, detected during a premarital physical examination, may be the first marker of lupus, preceding other manifestations by years (see box "The Anti-cardiolipin Syndrome"). Other symptoms may include severe fatigue, low-grade fever, hair loss, oral ulcers, swollen glands, appetite loss, nausea and vomiting, or other gastrointestinal disturbances THE ANTICARDIOLIPIN SYNDROME Some lupus patients have an antibody to a substance called cardiolipin, which causes a false-positive result in the blood test for syphilis. Consequently, lupus sufferers may be repeatedly treated with penicillin in the erroneous belief that they have a venereal disease. (In some cases, a false-positive test for syphilis may be the first manifestation of lupus.) It has been shown that the anticardiolipin antibody can be present for unknown reasons, as well as in association with other connective tissue diseases, and need not be restricted only to lupus patients. The presence of anticardiolipin antibody is associated with a tendency to increased blood clot formation. This tendency may cause strokes or heart attacks in young people, recurrent phlebitis, multi-infarct dementia (a form of senile dementia due to multiple small strokes), and recurrent miscarriage. The test for anticardiolipin antibody is now routinely performed in anyone suffering these problems, and is particularly important for women who recurrently miscarry. The antibody is believed to cause miscarriage by stimulating thrombosis of the small veins in the placenta. Anticardiolipin syndrome is treated with anticoagulant drugs, generally either low-dose aspirin or the Coumadin-type of anticoagulants, depending on the severity of the clinical manifestation and the duration for which the anticoagulation would have to be maintained. Pregnant women are given lowdose aspirin or, occasionally, heparin, since Coumadin would threaten the health of the fetus. http://cpmcnet.columbia.edu/texts/guide/hmg25_0009.html SCLERODERMA Scleroderma, also known as progressive systemic sclerosis, is a disorder characterized by excessive buildup of fibrous connective tissue. Initially scleroderma, which means thickening (sclero) of the skin (derma), was thought to involve only the skin. Recently, however, it has been recognized that vital internal organs also may be the targets of increased collagen deposits. Hence, the term progressive systemic sclerosis (PSS) is more accurate and will be used here except in situations involving only the skin, which will be referred to as scleroderma. In progressive systemic sclerosis, there often is an associated arthritis even though the joints are not the main targets of the disease. In addition to mild joint inflammation, there are changes in the tissues around the joints due to deposition of excessive amounts of connective tissue, resulting in reduced mobility. With the progressive thickening and tightening of the skin about the fingers, motion becomes increasingly restricted. Larger joints such as the elbows and knees also may be involved. Thickening of the skin may occur anywhere in the body, especially in the face. Scleroderma is usually chronic and progresses over a period of many years; however, there may be periods when the disease seems to be static. Occasionally, it may go into remission, either in certain localized areas or throughout the body. When this occurs, the skin appears to be perfectly normal, as though it had never been attacked by scleroderma. Hair growth and sweating generally stop as the hair follicles and sweat glands are destroyed. Often the patient may experience intense itching as normal skin structures are replaced by excessive collagen. The superficial layers of the skin atrophy or shrink as their blood supply is decreased due to the strangulating effect on blood vessels of the dense new collagen in the underlying layers. The blood vessels themselves become narrowed. If the hands are affected, as they often are, tightening of the skin over the fingers results in a similar physical narrowing of the tiny blood vessels vital to their nourishment, and skin ulceration may develop on the fingertips and over the joints and bony prominences. These ulcers, which are usually painful and often become infected, are very difficult to treat and greatly interfere with the use of the hand. With progressive loss of blood supply, more distant tissues such as the ends of the fingers are unable to obtain adequate oxygen via the circulation and may gradually become shortened. When the disease attacks internal organs, it may be life-threatening. In the lung, for example, progressive sclerosis may cause an increase in connective tissue in the delicate air sacs, a condition called pulmonary fibrosis. The normal process of oxygen transfer from the inhaled air to the blood is progressively blocked. As a result, blood is deprived of its normal oxygen content, leading to shortness of breath, which is often further aggravated by restriction in chest wall movement because of thickening of skin over the chest. If the heart is affected, there may be a replacement of the pericardium, the membrane surrounding the heart, by increased fibrous tissue. This can encase the heart in a progressively tightening "shell" that restricts the normal pulsation and pumping of blood. More commonly, the actual heart muscle fibers themselves are replaced with ineffective scar tissue, leading to progressive heart failure. In the gastrointestinal tract, progressive systemic sclerosis may cause difficulty in swallowing, malabsorption of digested food into the circulation, or severe constipation and possible intestinal obstruction, depending upon the structures that are affected. The kidney is still another vital organ progressive systemic sclerosis may attack, sometimes leading to a severe form of hypertension. http://cpmcnet.columbia.edu/texts/guide/hmg25_0009.html DERMATOMYOSITIS AND POLYMYOSITIS Dermatomyositis and polymyositis are connective tissue diseases in which arthritis is present but plays only a minor role compared to involvement of the muscles. The two disorders are very similar except that dermato-myositis involves the skin as well as the muscle, while polymyositis involves only muscles. Both have some features in common with rheumatoid arthritis, lupus, and progressive systemic sclerosis. The symptoms usually wax and wane in severity, but in some instances the disease progresses rapidly. The major manifestation of polymyositis is inflammation, leading to destruction of muscle and increasing muscular weakness. As the disease progresses, the muscle tissue is replaced by functionless scar tissue. Muscles of the shoulders, arms, pelvis, and thighs are the most frequent targets, but the reasons for this are unknown. As the disease spreads, other muscles may become involved. For example, the diaphragm and chest wall muscles, which are needed for breathing, may be attacked. The pharyngeal muscles, which are needed for swallowing, can be weakened to the point where swallowing solid foods becomes impossible. Heart muscle is still another potential target. This is particularly note-worthy because of the many similarities between the heart muscle fibers and those of the voluntary muscles, which move the limbs. When heart muscle is involved, there may be disturbances in the heart rhythm that require drug therapy. Involvement of the skin is a major manifestation of dermatomyositis. There is a characteristic purplish rash, found mostly on the face and upper chest, although it may occur anywhere on the body. Associated with this rash, patients will often have swelling around the eyes, especially upon arising in the morning. There also may be scaly, reddened eruptions over the small joints of the fingers, sometimes over the eye-lids, and occasionally on the shoulders or upper back. Dermatomyositis and polymyositis are connective tissue diseases in which arthritis is present but plays only a minor role compared to involvement of the muscles. The two disorders are very similar except that dermato-myositis involves the skin as well as the muscle, while polymyositis involves only muscles. Both have some features in common with rheumatoid arthritis, lupus, and progressive systemic sclerosis. The symptoms usually wax and wane in severity, but in some instances the disease progresses rapidly. The major manifestation of polymyositis is inflammation, leading to destruction of muscle and increasing muscular weakness. As the disease progresses, the muscle tissue is replaced by functionless scar tissue. Muscles of the shoulders, arms, pelvis, and thighs are the most frequent targets, but the reasons for this are unknown. As the disease spreads, other muscles may become involved. For example, the diaphragm and chest wall muscles, which are needed for breathing, may be attacked. The pharyngeal muscles, which are needed for swallowing, can be weakened to the point where swallowing solid foods becomes impossible. Heart muscle is still another potential target. This is particularly note-worthy because of the many similarities between the heart muscle fibers and those of the voluntary muscles, which move the limbs. When heart muscle is involved, there may be disturbances in the heart rhythm that require drug therapy. Involvement of the skin is a major manifestation of dermatomyositis. There is a characteristic purplish rash, found mostly on the face and upper chest, although it may occur anywhere on the body. Associated with this rash, patients will often have swelling around the eyes, especially upon arising in the morning. There also may be scaly, reddened eruptions over the small joints of the fingers, sometimes over the eye-lids, and occasionally on the shoulders or upper back. http://cpmcnet.columbia.edu/texts/guide/hmg25_0009.html Sarcoidosis , an idiopathic disorder characterized by noncaseating granulomas, has an incidence of 11 cases per 100,000 population in the United States.[1] Sarcoidosis can affect one or many organs, including the lungs, lymph nodes, eyes, skin, heart, liver, and nervous system. According to most reports, the nervous system is affected in about 5 percent of patients with sarcoidosis.[1-4] Sharma and Sharma,[5] however, report that 10 percent of patients with sarcoidosis have nervous system involvement, and the finding of subclinical neurosarcoidosis is even greater. The case described below illustrates the importance of recognizing that facial numbness might be a manifestation of sarcoidosis. http://www.medscape.com/viewarticle/417859_print VASCULITIS Vasculitis is an inflammation of the blood vessels—both the arteries and the veins. Inflammation of a blood vessel, particularly a small artery, can cause a narrowing of its lumen (internal diameter). If the vessel completely closes, the tissue normally nourished by the diseased artery will die or be severely damaged. Diseases in this category are relatively rare and comprise some of the most baffling and poorly understood disorders in medicine. Polyarteritis nodosa and systemic necrotizing vasculitis are among the better defined examples. Very often, the diagnosis remains unsuspected for long periods because of the variable way in which these disorders behave. Persons presenting with vasculitis, particularly when the disease involves widespread areas in the body, may be extremely ill with a generally poor prognosis. One type of vasculitis, which affects older people, involves inflammation of the cranial or temporal arteries, the vessels that serve a portion of the facial, jaw, and tongue muscles, the scalp, and most important, the retina. Cranial arteritis is the most common cause of sudden blindness in the elderly. Usually only one eye is involved, but sometimes it occurs in both. Cranial arteritis is often associated with a syndrome of severe muscle pain and stiffness called polymyalgia rheumatica. This illness is also largely confined to the elderly. It is almost always associated with a very high sedimentation rate, a measure of the amount of inflammation. Poly-myalgia may occur without cranial arteritis, but because of the association, arteritis should always be suspected in cases of polymyalgia. Another form of vasculitis is called Wegener's granulomatosis. This is an extremely rare disorder that attacks the lungs, the nasal sinuses, and the kidney in a progressively destructive process. People with generalized or systemic vasculitis will often have paralysis of a foot or a wrist as a result of loss of blood supply to the peripheral nerve serving that limb. The blood vessels of the lung may also be affected, resulting in symptoms like those of asthma. The development of asthma relatively late in life is very unusual, and may signify vasculitis. The skin is another common site for vasculitis of all types. It shows up as areas of hemorrhage and death of superficial skin tissue due to loss of circulation. Another type of vasculitis, known as Takayasu's disease, occurs almost exclusively in young women. The inflammation is largely restricted to the branches of the great artery that leaves the heart (the aorta). It has also been called "pulseless" disease, for the diseased arteries may be so narrowed that a pulse cannot even be detected at the wrist. Women with this disease will very frequently have symptoms of dizziness, light-headedness, weakness, and difficulty in using the arms, due to muscle pain from even slight physical effort. This is a direct result of lack of oxygen to the muscles, as the narrowed arteries are unable to deliver the increased amount of blood required during muscular effort. http://cpmcnet.columbia.edu/texts/guide/hmg25_0009.html congestive heart failure Dyspnea on exertion is a well-recognized symptom of congestive heart failure (CHF) but is nonspecific in that it can also result from pulmonary diseases, obesity, anxiety, and other conditions Hypertension Metabolic disorder Thyroid disease Vitamin deficiency Diabetes mellitus Infection Toxin exposure Cobalt Chemotherapeutic agents Alcohol Cocaine Infiltrative disease Cardiac amyloidosis Hemochromatosis Other Neuromuscular disease Collagen vascular disease Valvular heart disease Peripartum cardiomyopathy High-output heart failure Arteriovenous fistula Severe anemia Paget's disease Idiopathic Chronic viral myocardial infection? Autoimmune mechanisms? Genetic factors? http://www.postgradmed.com/issues/1997/01_97/bales.htm other more common symptoms: ACUTE URTICARIA/ANGIOEDEMA A recent episode of urticaria/angioedema lasting less than 6 weeks is characterized as acute, while lesions recurring for more than six weeks are termed chronic. In acute urticaria/angioedema, the etiology may be readily apparent to both the patient and the physician. For example, the patient who presents with acute urticaria after drug administration, insect sting, or repetitive physical triggers will often note an association. The longer the urticaria persists the more difficult it is to determine a specific etiology. Urticaria should be considered when the patient presents with pruritic (and sometimes painful or burning), erythematous, circumscribed (or coalescent) wheals. Urticarial lesions commonly involve the extremities and trunk but may appear on any part of the body. In contrast to urticaria, angioedema presents as deeper subcutaneous swelling. Less circumscribed than the lesions of urticaria, angioedema has a predilection to areas of loose connective tissue such as the face or mucous membranes involving the lips or tongue. If angioedema involves the upper respiratory tract, life-threatening obstruction of the laryngeal airway may occur. Hereditary or acquired angioedema associated with C1 esterase inhibitor deficiency are particularly prone to this presentation, although other forms of angioedema can present either with laryngeal or glossopharyngeal edema causing hoarseness and difficulty in swallowing. Urticarial lesions are defined as chronic if manifestations persist or recur beyond six weeks. Persistent symptoms may be daily or episodic. Diurnal patterns are often reported but these are highly variable from patient to patient. It is not possible to predict the duration of chronic urticaria/angioedema. Spontaneous remissions often occur within 12 months but many patients continue to have symptoms at least periodically for years. Conditions that can masquerade as urticaria include erythema multiforme minor, nonspecific maculopapular exanthemata, mast cell releasibility syndromes such as urticaria pigmentosa and urticarial vasculitis. The skin lesions of urticarial vasculitis differ from urticaria in that they are palpable, purpuric, and persist 24 hours or longer. Resolution of these lesions is prolonged and they often leave residual pigmented changes in the skin. If skin lesions have the appearance of urticarial vasculitis, a skin biopsy should be performed. Routine histopathology reveals the presence of leukocytoclastic vasculitis while immunofluorescence may demonstrate the presence of fibrinogen, various immunoglobulins, and complement within the vascular lesions. Systemic collagen vascular diseases should also be considered in the differential diagnosis of urticarial vasculitis. Treatment of this condition may require various anti-inflammatory agents such as glucocorticosteroids, colchicine, dapsone, hydroychloroquine, or other cytotoxic agents. http://www.jcaai.org/Param/Urticaria/executive_summary.htm Delirium Multiple acute illnesses can precipitate delirium: systemic disease outside the central nervous system (metabolic, infectious, endocrine, cardiorespiratory, and paraneoplastic syndromes); primary intracranial disease (infectious, degenerative dementia, collagen vascular, mass lesion, trauma, and stroke); exogenous toxic agents including some medications; withdrawal from drugs; depression; and epilepsy. In the elderly, the most common associated conditions are the use of psychotropic drugs, particularly those with anticholinergic properties, urinary tract infections, and the presence of an underlying dementing illness in combination with an acute illness. Rather than a single cause, most patients have two or more coexisting problems. http://www.lincoln.edu/aging/ce-del.html Fever of undetermined origin Unexplained fevers that continue for more than three weeks are referred to as fever of undetermined origin (FUO). FUO is classically identified by the following elements: A temperature higher than 101°F (38.3°C) on several occasions A fever that lasts longer than three weeks Failure to find the underlying cause(s) of the fever, despite one week of inpatient investigation or three outpatient visits Collagen vascular disease, which encompasses widespread damaging changes in connective tissue, can also cause FUO. Polymyalgia rheumatica and giant-cell arteritis are two especially common causes in the elderly. Lupus sarcoidosis is a common cause in middle-aged women. The primary symptom of FUO is a temperature higher than 101°F (38.3°C) on several occasions that lasts longer than three weeks. Additional symptoms may be dependent on the underlying cause of the FUO. For example, lower extremity weakness, back pain, and a history of urinary tract infection may indicate that FUO is caused by osteomyelitis--especially in patients with prosthetic devices. An accompanying heart murmur may indicate that infective endocarditis is the cause of FUO. http://praxis.md/bhg/bhg.asp?chapter=BHG01ID02 & section=report VERTIGO Dizziness is a common complaint and too often the symptom is attributed to an "inner ear problem." Numerous cochleovestibular, neurologic, cardiovascular, metabolic, ocular, and systemic diseases are capable of eliciting the sensation of dizziness; the ear, however, is responsible for only 50-60 percent of the known causes of dizziness http://www.bcm.tmc.edu/oto/studs/vertigo.html Pericarditis Acute pericarditis is an inflammation of the pericardium, the saclike membrane that encloses the heart. Pericarditis can be triggered by many, very different medical conditions Rheumatic diseases (rheumatoid arthritis, scleroderma and polyarteritis nodosa) and collagen vascular diseases (especially systemic lupus erythematosus, or SLE) also can cause acute pericarditis http://www.intelihealth.com/IH/ihtIH/WSIHW000/9339/24458/284782.html?d=dmtHealthAZ VENOUS LEG ULCERS The classical presentation of a venous leg ulcer is an irregularly-shaped partial thickness wound with well-defined borders, surrounded by erythematous or hyperpigmented indurated skin (acute or chronic lipodermatosclerosis). A yellow-white exudate is commonly observed. Venous ulcers vary in size and location, but are usually found on the distal medial aspect of the lower leg ("gaiter" area). A lateral venous ulcer may be associated with short saphenous insufficiency. Varicose veins are often present in the venous ulcer patient. Typically there are telangiectatic veins of the medial ankle, so-called corona phlebectatica, indicative of chronic venous insufficiency. Edema of the ankle area is common, although in some patients the skin is brown, thickened and the ankle circumference is actually narrowed. Other etiologies must be considered. Metabolic, neuropathic, neoplastic, vasculitic, infectious, hematologic and collagen vascular diseases should be considered. However, if arterial insufficiency is ruled out and the patient has normal pinprick sensation in the face of a typical appearing venous ulcer, then a venous etiology will be found in about 95% of cases. http://www.phlebology.org/syllabus11.htm IDIOPATHIC (IMMUNOLOGIC) THROMBOCYTOPENIC PURPURA Physical examination is normal except for petechiae, purpura, and mucosal bleeding, which may be minimal or extensive. Peripheral blood is normal except for reduced platelet numbers. Bone marrow examination reveals normal or possibly increased numbers of megakaryocytes in an otherwise normal marrow. http://www.merck.com/pubs/mmanual/section11/chapter133/133b.htm Emphysema What is the difference between cigarette smoking induced and other causes? Cigarette smoking leads to neutrophil activation and retention in the lung parenchyma. A number of neutrophil-derived and macrophage-derived enzymes known as proteinases and elastases (ie, proteolytic enzymes) can destroy various components of the extracellular matrix of the lung and cause emphysema. In addition, neutrophils produce serine proteinases. Macrophages synthesize various metalloproteinases and cysteine proteinases. Other causes; Normally, the locally synthesized plasma proteinase inhibitors, especially AAT, permeate the lung tissue and prevent proteolytic enzymes from digesting structural proteins of the lungs. Lung destruction results from an excess of proteinase release in the lungs, a reduction in the antiproteinase defense within the lung, or a combination of both increased proteinase burden and decreased proteinase inhibitor capacity. Therefore, emphysema is the product of an imbalance between the proteinases and antiproteinases in favor of proteinases. AAT is a glycoprotein member of the serine protease inhibitor family that is synthesized in the liver and is secreted into the blood stream. The main purpose of this 394–amino acid, single-chain protein is to neutralize neutrophil elastase in the lung interstitium and to protect the lung parenchyma from elastolytic breakdown. Severe AAT deficiency predisposes to unopposed elastolysis with clinical sequela of early onset of panacinar emphysema Immune deficiency syndromes Apical and cortical bullous lung damage occurs in patients who have autoimmune deficiency syndrome and Pneumocystis carinii infection. Reversible pneumatoceles are observed in 10-20% of patients with this infection. Human immunodeficiency virus (HIV) infection is associated with development of emphysemalike disease, to which malnutrition, direct cytotoxicity, and enhanced cytokine or elastase release contribute. Vasculitis syndrome Hypocomplementemic vasculitis urticaria syndrome (HVUS) may be associated with obstructive lung disease. Other symptoms Angioedema Nondeforming arthritis Sinusitis Conjunctivitis Pericarditis http://www.emedicine.com/MED/topic654.html http://216.239.53.100/search?q=cache:MLWYqLnIlJYC:alice.ucdavis.edu/IMD/420C/ILDy2k.pdf+physical+signs+of+collagen+vascular%27 & hl=en & ie=UTF-8 Diverticulitis Diverticulosis is defined as the condition of having diverticula. Diverticulitis is defined as an inflammation of one or more diverticula. Diverticula are small mucosal pockets in the wall of the colon that conceivably fill with stagnant fecal material or undigested food particles. Obstruction of the neck of the diverticulum may result in the distention of the diverticulum secondary to mucus secretion and overgrowth of normal colonic bacteria. The thin-walled diverticulum, consisting solely of mucosa, is susceptible to vascular compromise and, therefore, is at risk for microperforation or macroperforation. Infection subsequently may extend through the wall of the colon into the peridiverticular tissue and cause peridiverticulitis. Inflammation is frequently mild, and the pericolic fat and mesentery can wall-off a small perforation. However, the walled-off infection can progress to localized abscess formation. Less commonly, rupture of the abscess may occur with generalized peritonitis. If adjacent organs are involved, fistulae can develop. The most common is a colovesicular fistula (colon to urinary bladder). This is observed almost exclusively in men and in women following hysterectomy, probably because of the interposition of the uterus between the sigmoid colon and the urinary bladder. Colovaginal and colocutaneous fistulae are much less common. http://www.emedicine.com/med/topic578.htm Chemical Sensitivity Chemical sensitivity is an abnormal state of health characterized by intensified and adverse responses to components found in food, air, water, or physical surroundings of the patient’s environment (Hileman, 1991). The provoked symptoms or signs may be chronic, relapsing, or multisystem and are triggered by levels of exposure that are generally well tolerated by most people. The diagnosis is suspected on the basis of history and physical examination, and the condition may be confirmed by removing the offending agents and rechallenging patients under properly controlled conditions. The clearing or improvement of symptoms or signs by removing the suspected substances and the recurrence or worsening after specific, low-level challenge is highly indicative of environmental hypersensitivity and, in this context, chemical sensitivity. This definition is very similar to that proposed by Ashford and (1989) in their report to the State of New Jersey and in their subsequent book (Ashford and , 1991). http://www.aehf.com/articles/history_of_cs.html swallowing disorders Autoimmune - Scleroderma, Lupus Neurologic - CNS disease: bulbar paralysis, botulism, multiple sclerosis, polio, amyotrophic lateral sclerosis etc. Myasthenia gravis, other myopathies Esophageal Dysphagia: Autoimmune - Collagen vascular diseases, Crohn's disease Vascular Esophageal varices http://icarus.med.utoronto.ca/carr/manual/swallow.html signs of inflammation Inflammation is a vascular and cellular response to trauma. Its purpose is to initiate the healing of the injured tissue The body’s attempt to dispose of micro-organisms, foreign material and dying tissues so that tissue repair can occur An inflammatory response may result from external or internal factors (infection) Protects to the body by localizing and removing the injuring agent Signs of Swelling Redness (Rubor) Swelling (Tumor) Pain (Bolar) Warmth (Calor) Loss ROM Signs of Inflammation (Cardinal Signs) Redness (Rubor): Caused by blood vessel dilation (the arterioles) Chemical mediators promote the vessel dilation (contained in the capillary walls or endothelium resulting in immediate response) Histamine Seritonin Bradykinins Prostaglandins Signs of Inflammation Cont. Swelling (tumor) Edema fluid varies with the stage of inflammation initially vessel permeability is only slightly altered and no cells or protein escapes and the fluid is mainly water and dissolved electrolytes (transudate): like synovial fluid As capillary permeability increases and plasma proteins escape the extravascular fluid becomes cloudy and more viscous. This is called exudate (contains a large amount of leukocytes (called pus) Causes of Edema/Swelling- bleeding from torn vessels cell death due to anoxia, allows fluid leakage (permeability increases) increased proteins raise extracellular osmotic pressure, drawing fluids from the capillaries Chemicals alter cell permeability to proteins and fluid Gravity may increase swelling (Capillary filtration pressures) Edema/Swelling To cease hemorrhage/swelling/edema Must reverse the condition pressure gradient vessel repair Pain (bolar) Results from irritation of nerve ending by physical or chemical factors Physical trauma may irritate pain receptors Chemical mediators release when cell damage occurs sensitize pain receptors Trauma may result in cell anoxia because of interference with blood flow due to capillary damage Signs of Inflammation Cont. Warmth (calor) The result of chemical activity and increased blood flow in the injured area. Loss of Function May occur due to pain causing reflex guarding or muscle spasm, spasm decreases metabolic activity and constricts blood flow which causes more pain due to ischemia; thus the pain cycle http://216.239.53.100/search?q=cache:iWle6--m4v0C:www.sjsu.edu/depts/hup/gradath/inflam1.ppt+physical+signs+of+collagen+vascular%27 & hl=en & ie=UTF-8 Classic Migraines periodic headaches separated by symptom-free intervals and associated with at least 3 of the following criteria: abdominal pain, nausea/vomiting aura (motor, sensory, visual) family history sleep relief unilateral pulsatile (throbbing) 1. Aura 1. Sensory perioral paresthesia, numbness of hands & feet 2. Visual blurring, distortion, fortification spectra, homonymous hemianopsia, photopsia (flashes of bright light), scintillating scotomata (dark or blind spots), tunnel vision 2. Common Migraines rare nausea/vomiting (N/V) no aura family history sleep relief bifrontal or temporal variable quality 3. Complicated Migraines 1. Basilar Artery brain stem signs: ataxia, blurred vision, diplopia occipital HA, scotoma, tinnitis, vertigo altered consciousness, dilated pupils, generalized seizure, ptosis 2. Hemiplegic aphasia, alternating hemiplegia, unilateral sensory or motor signs (i.e., numbness) 3. Ophthalmoplegic 3rd nerve palsy ipsilateral to headache 4. Migraine Variants 1. Acute Confusional State confusion, disorientation, hyperactivity, lethargy, memory disturbances, unresponsiveness, vomiting defects of sensorium - touch & pain 2. Benign Paroxysmal Vertigo (BPV) ataxia, horizontal nystagmus, nausea and vomiting abnormal vestibular function (abn.ice water caloric test) 3. Cyclic Vomiting recurrent vomiting, dehydration, electrolyte abnormalities later abdominal pain, diarrhea, fever http://www.icondata.com/health/pedbase/files/MIGRAINE.HTM Tic: sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization http://www.mend.net/tic/tic2a.html Pulmonary

Pulmonary Hypertension Associated with Disorders of the Respiratory System and/or Hypoxemia Chronic Obstructive Pulmonary Disease Interstitial Lung Disease Sleep Disordered Breathing Alveolar Hypoventilation Disorders Chronic Exposure to High Altitude Neonatal Lung Disease Alveolar-Capillary Dysplasia Other

Pulmonary Hypertension due to Chronic Thrombotic and/or Embolic Disease

Thromboembolic Obstruction of Proximal Pulmonary Arteries Obstruction of Distal Pulmonary Arteries Pulmonary embolism (Thrombus, Tumor, OVA and/or parasites, Foreign Material) In-situ Thrombosis Sickle Cell Disease Pulmonary Hypertension due to Disorders Directly Affecting the Pulmonary Vasculature

Inflammatory Schistosomiasis Sarcoidosis Other Pulmonary Capillary Hemangiomatosis http://www.phcentral.org/medical/nomenclature.html