Friedreich’s Ataxia

Friedreich’s ataxia is an inherited genetic disorder of chromosome 9. It is a slowly progressive disorder of the nervous system and muscles, and results in the inability to control voluntary muscles (ataxia). It is inherited in an autosomal recessive manner, meaning that a child must inherit a copy of the defective gene from each parent in order to develop the disorder. Friedreich’s ataxia affects both males and females. About 1 in 90 people of European ancestry carries the gene for the disorder.

Symptoms

The symptoms of Friedreich’s ataxia usually begin between the ages of 5 and 15 years old, but it may start as early as infancy or as late as 30 years old. Typical symptoms include:
 

• muscle weakness in the legs, unsteadiness when standing, and difficulty walking
• loss of coordination (ataxia) in the arms and legs
• loss of sensations of touch and pressure in the arms and legs
• changes in vision, involuntary movements of the eye (nystagmus)
• difficulty speaking
• curvature of the spine (scoliosis) 

 
In addition, the individual with Freidreich ataxia is at risk of developing:

• weakening of heart muscle and enlargement of the heart (hypertrophic cardiomyopathy), chest pains, shortness of breath, abnormal heart rhythm
• diabetes 

Diagnosis

Diagnosis of Friedreich’s ataxia is based on the symptoms the individual is experiencing. Usually the earliest sign is weakness in the legs and unsteady standing or walking. A test of the electrical activity of muscles (electromyogram) may be done. A genetic test for the defect on chromosome 9 may also be done.

Treatment

There is at present no way to cure or reverse Friedreich’s ataxia. Treatment therefore focuses on the symptoms the person is having. Assistive devices for walking and standing may be used. Generally, about 15 to 20 years after diagnosis a wheelchair will be needed. Orthopedic surgery to correct scoliosis may be performed. Physical and occupational therapy can help maintain muscle strength and range of motion of the joints. Speech therapy can help with speaking and swallowing problems. Diabetes is treated with daily insulin.

Sources:
- "NINDS Friedreich's Ataxia Information Page." Disorders. 13 Feb 2007. National Organization for Neurological Disorders and Stroke. 28 Feb 2007 .
- "What is Friedreich's Ataxia?." FARA. Friedreich's Ataxia Research Alliance. 28 Feb 2007 .
- "Fact Sheet: Friedreich's Ataxia." MDA USA Specific Information. 11 Apr 2003. MDA USA. 28 Feb 2007 .

Credit : About.com

Regards,

Stroke

 Image taken from http://www.beliefnet.com/


A stroke is a disorder in which the arteries to the brain become blocked or rupture, resulting in death of brain tissue.

 A stroke is a cerebrovascular disorder, so called because it affects the brain (cerebro-) and the blood vessels (vascular).

In western countries, strokes are the 3rd most common cause of death and the 2nd most common cause of disabling neurologic damage after Alzheimer's  disease. In the US, over 600,000 people have a stroke and about 160,000 die of stroke each year. Strokes are much more common among older people that among younger adults, usually because the disorders that lead to strokes  progress overtime. Over 2/3 of all stokes occur in people older than 65 years old. Slightly more than 60% of deaths due to stroke occur in women, possibly because women are on average older when the stroke occurs. Blacks are more likely than whites to have a stroke and to die of it.

There are two types of strokes: ischemic and hemorrhagic. 

About 80%  of strokes are ischemic-due to blocked artery. Brain cells, thus deprived of their blood supply, do not receive enough oxygen and glucose which are carried by blood.

A transient ischemic attack (TIA), sometimes called a mini stroke, is often an warning sign of and impending ischemic stroke. TIAs are caused by an inadequate blood supply to part of the brain  but only for a brief time. Because of the blood supply is restored quickly, brain tissue does not die, as it does in a stroke.

The other 20% if strokes are hemorrhagic-due to bleeding in or around the brain. In this type of stroke, a blood vessel ruptures, interfering with normal blood flow and allowing blood to leak into brain tissue. Blood that comes into direct contact with brain tissue irritates the tissue and can cause scarring, leading to seizures.

The major risk factors for both types of stroke are;

1. atherosclerosis (the narrowing or blockage of arteries by patchy deposits of fatty material in the walls of arteries),
2. high BP,
3. diabetes and
4. smoking.

Atherosclerosis is more important risk factor for ischemic stroke, and high BP is  a more important risk factor for hemorrhagic stroke.

Other risk factor for hemorrhagic stroke include,

1. use of anticoagulants,
2. cocaine,
3. amphetamines,
4. aneurysms in the arteries within the skull,
5. arteriovenous malformation; and
6. vasculitis.

The incidence of strokes has decline in recent decades, mainly because people are more  aware of the importance of controlling high BP and high cholesterol levels. Controlling these factors reduces the risk of atherosclerosis.

Image taken from http://news.bbc.co.uk/

Symptoms

The effects of a stroke or TIA vary depending on the precise location of the blockage or bleeding in the brain. Each area of the brain is supplied by specific arteries. For example, if an artery supplying the area of the brain that control the left leg's muscle movements is blocked, the leg becomes weak or paralyzed.

If the area of the brain that senses touch in the right arm is damaged, sensation in the right arm is lost. Because early treatment can help loss of function and sensation, everyone should know what the early symptoms of stroke are. People who have such a symptom should see a doctor immediately, even if the symptom does not cause pain or if it goes away quickly. Starting treatment within 3 to 6 hours can help prevent the more severe consequences of a stroke.

The most common early symptoms of an ischemic stroke are;

1. sudden weakness or paralysis of the face and leg on one side of the body;
2. slurred speech;
3. sudden confusion with difficulty speaking or understanding speech;
4. sudden dimness or loss of vision, particularly in one eye;
5. loss of balance and coordination, leading to falls;
6. sudden severe headache; and
7. abnormal sensations or loss of sensation in an arm or a leg or one side of the body.

Symptoms of TIA usually disappear within minutes and rarely last more than 1 or 2 hours.

Symptoms of hemorrhagic stroke are largely the same as those of an ischemic stroke but may also include;

1. sudden severe headache,
2. nausea and vomiting,
3. temporary or persistent loss of consciousness, and
4. very high blood pressure.

In both types of stroke, an abnormal pattern of breathing can occur. Slow, irregular breathing may be caused by herniation of the brain. Herniation may develop when very high pressure within the skull forces the brain downward in the skull and distorts the respiratory center in the lower part of the brain stem.

In most people who have had a ischemic stroke, the loss of function caused y a stroke is usually greatest immediately after the stroke occurs. However, in about 15 to 20%, the stroke is progressive, causing greatest loss of function after a day or two. In people who have had a hemorrhagic stroke, loss of function usually occurs progressively over minutes to hours.

One days to months, some function is usually regained because even though some brain cells die, others are only damaged and may recover. Also, certain areas of the brain can sometimes switch to the functions previously performed by the damaged part-a characteristic called plasticity.

However, the early effects of stroke, including paralysis, can become permanent. Muscle may become permanently spastic and stiff, and painful muscle spasm may occur. Walking, swallowing, physically saying words clearly, and performing daily activities may remain difficult.

Problems with memory, thinking, attention, or learning may persist.The person may be unable to recognize parts of the body and may be unaware of the stroke's effects.

The person may continue to be unable to control emotions and to feel depressed. The peripheral field of vision may be reduced, and hearing may be partially lost. Dizziness and vertigo may be continuing problems. Control of bowel or bladder function may be permanently impaired.

Certain factors suggest that the outcome of a stroke is likely to be poor. Strokes that cause unconsciousness or that affect a large part of the left side of the brain are particularly grave. In adults who have had an ischemic stroke, neurologic losses that remain after 6 months are likely to be permanent, although children continue to improve slowly for many months. Older people fare less well than younger people who already have other serious disorders (such as dementia, recovery is more limited.

If a hemorrhagic stroke is not massive and pressure within the brain is not very high, outcome is likely to be better after than that after an ischemic stroke.

Blood (in a hemorrhagic stroke) does not damage brain tissue to the extent that an inadequate supply of oxygen (in and ischemic stroke) does. People who have had a hemorrhagic stroke may continue to improve for many months, even years.

Prevention
 

Preventing strokes is preferable to treating them. The main preventive strategy is managing the major risk factors.

High blood pressure and diabetes should be controlled; cholesterol levels should be measured and, if high, lowered to reduce the risk of atherosclerosis.

Other recommendations include stopping smoking, not using amphetamines or cocaine, consuming alcohol only in moderation, exercising regularly, and, if overweight, losing weight.

Taking an anti platelet drug, such as aspirin, reduces the risk of stroke (and heart attack). Anti platelet drugs reduce the tendency of platelets to clump and to promote clot formation, a common cause of stroke.

Aspirin, one of the most effective anti platelet drugs, is usually prescribed as 1/2 of an adult's tablet or 1 children's tablet (which is 1/4 of an adult's tablet) a day.

Dipyridamole is sometimes prescribed, but for most people, it is not effective unless it is taken with aspirin. Taking aspirin with dipyridamole is more effective than taking aspirin alone.

Ticlopidine or clopidogrel (other anti platelet drugs) may be given to the people who cannot tolerate or have not responded to aspirin.

People who have had TIAs or strokes due to blood clots originating in the heart may be given warfarin, an anticoagulant.

Rehabilitation

 Image taken from http://graphics8.nytimes.com/

Intensive rehabilitation can help many people overcome disabilities after a stroke. The exercises and training of rehabilitation help develop the plasticity of the brain (the ability of one area to shift to different functions) and teach the person new ways to use muscles unaffected by the stroke to compensate for losses in function.

The goals of rehabilitation are to regain as much normal function as possible, to maintain and improve physical condition, and to help people relearn old skills and learn new ones as needed.

Success depends on the area of the brain damaged and the person's general physical condition, functional and cognitive abilities before the stroke, social situation, learning ability, and attitude. Patience and perseverance are crucial.

Gastroesophageal Reflux Disease (GERD)

  Image taken from http://www.rush.edu/ 

In GastroEsophageal Reflux Disease (GERD), stomach acid and enzymes flow backward from the stomach into the esophagus, causing inflammation and pain in the esophagus.

The stomach lining protects the stomach from effects of its own acid. Because the esophagus lacks a similar protective lining, stomach acid and enzymes that flow backward (reflux) into the esophagus routinely cause symptoms and in some cases damage.

Acid and enzymes reflux when the lower esophageal sphincter, the ring-shaped muscle that normally prevents the contents of the stomach from flowing back into the esophagus is not functioning properly.

When a person is standing or sitting, gravity helps to prevent the reflux of stomach contents into the esophagus. This explains why reflux can worsen when a person is lying down.

Smoking and certain foods, such as chocolate, interfere with the sphincter muscle, making reflux more likely. Reflux is also more likely to occur after soon after meals, when the volume and acidity of contents in the stomach are higher.

Alcohol and coffee also stimulate acid production.

Delayed emptying of the stomach (for example due to diabetes or use of opioids) can also worsen reflux.

 

 

Symptoms and Complication

 Image taken from http://www.thehealthword.com/

 

Heartburn (a burning pain behind the sternum) is the most obvious symptoms of GERD. Sometimes the pain even extends to the neck, throat, and face. Heartburn may be accompanied by regurgitation, in which the stomach contents reach the mouth.

Inflammation of the esophagus (esophagitis) may cause bleeding that is usually slight but can be massive. The blood may be vomited up or may pass through the digestive tract, resulting in the passage of dark, tarry stools (melena) or bright red blood, if the bleeding is brisk enough.

Esophageal ulcers, which are open sores on the lining of the esophagus, can result from repeated reflux. They can cause pain that is usually located behind the sternum or just below it, similar to the location of heartburn.

Narrowing (stricture) of the esophagus from reflux makes swallowing solid foods increasingly more difficult. narrowing of the airways can cause shortness of breath and wheezing.

Other symptoms of GERD include chest pain, sore throat, hoarseness of voice, excessive salivation, a sensation of a lump in the throat (globus sensation), and inflammation of the sinuses (sinusitis)

With prolonged irritation of the lower part of the esophagus from repeated reflux, the cells lining the esophagus may change (resulting in a condition called Barett's esophagus). Changes may occur even in the absence of symptoms. These abnormal cells are precancerous and progress to cancer rarely.

 

 

Diagnosis

The symptoms point to the diagnosis, and treatment can be started without detailed diagnostic testing. Specific testing is usually reserved for situations in which the diagnosis is not clear or treatment has failed to control symptoms.

Examination of the esophagus using and endoscope of the lower esophageal sphincter, and esophageal pH tests are sometimes needed to help confirm the diagnosis and check for complications.

Endoscopy may confirm the diagnosis if the doctor finds that the person has esophagitis or Barrett's esophagus. Endoscopy also helps to exclude the presence of esophageal cancer.

X-rays taken after a person drinks a barium solution and then lies on an incline with the head lower than the feet may show reflux of the barium from the stomach into the esophagus. A doctor may press on the abdomen to increase the like hood of reflux. The x-rays taken after the barium is swallowed also can reveal esophageal ulcers or a narrowed esophagus.

Pressure measurements at the lower esophageal sphincter indicate the strength of the sphincter and can distinguish a normal sphincter from a poorly functioning one. The information gained from this test helps the doctor decide whether surgery is an appropriate treatment.

Some doctors believe that the best test for GERD is esophageal pH testing. In this test, a thin, flexible tube with a sensor probe on the tip is paced through the nose an into the lower esophagus. The other end of this tube is attached to a monitor that the person wears on his belt. The monitor records the acid levels in the esophagus, usually for 24 hours. Besides determining how much reflux is occurring, this test identifies much the relationship between symptoms and reflux and is particularly helpful for people with symptoms that are not typical for reflux.

The esophageal pH test is needed for all people being considered for surgery for GERD. 

 

 

Prevention and Treatment

Several measures may be taken to relieve GERD.

Raising the head of the bed about 6 inches can prevent acid from flowing into the esophagus as a person sleeps.

Specific foods (for example, fats an chocolate) should be avoided, as should smoking and certain drugs (for example, anticholinergic, certain antidepressants, calcium channel blockers, and nitrates), all of which increase the tendency of the lower esophageal sphincter to leak.

A doctor may prescribe a cholinergic drug (for example, bethanechol or metoclopramide) to make the lower sphincter close more tightly.

Coffee, alcohol, and other substances that strongly stimulate the stomach to produce acid or that delay stomach emptying should be avoided as well.

Many of the drugs used to treat gastritis and peptic ulcers also help prevent and treat GERD.

Antacids taken at bedtime, for example, are helpful. Antacids can usually relieve the pain of esophageal ulcers by reducing the amount of acid that reaches the esophagus.

However, proton pump inhibitors, the most powerful drugs for reducing acid production, are usually the most effective treatment for GERD, because even small amount of acid can cause significant symptoms. Healing requires drugs that reduce stomach acid over a 4 to 12 week period. The ulcers heal slowly, tend to recur, and, when chronic and severe, can leaved a narrowed esophagus after healing.

Esophageal narrowing is treated with drug therapy and repeated dilation, which may be performed using balloons or progressively larger dilators. If dilation is successful narrowing does not seriously limit what a person can eat.

Barrett's esophagus may or may not disappear when treatment relieves symptoms. Therefore, people with Barrett's esophagus are asked to undergo an endoscopic examination every 2 to 3 years to ensure that it is not progressing to cancer.

Surgery is an option for people whose symptoms are unresponsive to drug therapy or for people with esophagitis that persists even after symptoms are relieved. In addition, surgery may be the preferred treatment for people who do not like the prospect of having to take drugs for many years. A minimally invasive procedure performed through a laparoscope is available. However, 20 to 30% of people who undergo this procedure experience side effects, most commonly difficulty swallowing and a sensation of bloating or abdominal discomfort after eating.

Barrett's esophagus

Barrett's esophagus is a condition in which abnormal cells develop on the inner lining of the lower part of the gullet (esophagus). The esophagus is the muscular tube that carries food from the mouth to the stomach.

Barrett's esophagus is not in itself a cancerous condition, but over a period of time it can occasionally lead to cancer developing in the lower part of the esophagus. A cancer happens when cells in the affected area continue to grow and reproduce and become increasingly abnormal.

Diagram of comparison between normal esophagus and Barrett's esophagus

Normal

Barrett's esophagus

  Images taken from www.barrettsinfo.com/

Development of Barret's esophagus

 

Barrett’s oesophagus occurs when the acidic stomach contents are continuously refluxed onto the lining of the oesophagus, causing changes to the structure of the tissue. Over time, your body replaces the normal cells lining the oesophagus with cells of a different type. This new type of cell secretes mucus which makes it more resistant to the acid coming up from the stomach. The presence of these cells in the oesophagus is known as Barrett’s oesophagus or Barrett’s metaplasia.

Sign and symtoms

Barrett's esophagus itself does not cause symptoms. The acid reflux that causes Barrett's esophagus results in symptoms of heartburn. Rarely, Barrett's esophagus can progress to cancer of the esophagus, the symptoms of which may be difficulty swallowing or weight loss

 

 

Diagnosis

Diagnosis of the condition usually requires taking a sample of tissue by endoscopy. Doctors insert a lighted, flexible tube (endoscope) with a camera on its tip through the mouth and into the esophagus. Patients are given a local anesthetic or sedated for the procedure. During endoscopy, doctors may remove tissue samples (biopsies) of potentially abnormal areas for examination under a microscope.

Barrett's esophagus without dysplasia (cancerous changes) — If, at the first endoscopy all biopsies are without dysplasia, a second examination is recommended in one year. This is done to make sure that a very small cancer (also known as a prevalent cancer) was not missed at the first endoscopy. For those without dysplasia at the second examination, follow-up endoscopy is recommended in three to five years.

Barrett's esophagus with low-grade dysplasia — follow-up endoscopy is recommended every six months for a year, than every 12 months. Low grade dysplasia, by itself, is usually not lethal. Follow up is to make sure a serious finding is not missed.

Barrett's esophagus with high-grade dysplasia — If two pathologists agree that biopsies show high grade dysplasia, then intervention is usually suggested. The standard of care treatment is esophagus resection surgery or minimally invasive treatment such asphotodynamic therapy. In cases where the high grade dysplasia is only found in one small bump, an experimental option, endoscopic mucosal resection, may be possible. If a patient is not a good candidate for surgery, the doctor may opt to increase acid suppression medications and repeat an endoscopic examination in three months

 

Treatment

Barrett's esophagus usually is treated with medicines called proton pump inhibitors (one brand name: Nexium). These medicines reduce the amount of acid in your stomach. In some cases, surgery is used to keep stomach acid out of the esophagus. Your doctor may recommend that you make some lifestyle changes, such as quitting smoking if you smoke, exercising, losing weight, and avoiding foods that make your heartburn worse.

Hemorrhagic Stroke (Pathology of Nervous System)

 Image taken from www.merck.com

A hemorrhagic stroke is damage to brain tissue resulting from bleeding inside the skull.

• There are two main types of hemorrhagic strokes: intracerebral hemorrhage and subarachnoid hemorrhage.
• Intracerebral hemorrhage occur within the brain while subarachnoid hemorrhage occur within a space between pia and arachnoid mater of the tissue covering the brain (meninges).
• Bleeding inside the skull can also result in epidural and subdural hematomas, which are usually caused by a head injury and cause different symptoms.

Intracerebral Hemorrhage  

 

An intracerebral hemorrhage is bleeding within the brain.

•  Intracerebral hemorrhage accounts for about 10% of all strokes but for a much higher  percentage of death due to stroke.
• Among people older than 60, intracerebral hemorrhage is more common than subarachnoid hemorrhage.
• Causes of intracerebral hemorrhage include high blood pressure and in older people, fragile blood vessels.
• Bleeding disorders and use of anticoagulants increase the risk of dying from an intracerebral hemorrhage.

Symptoms and Diagnosis

 Image taken from  uwmedicine.washington.edu

• An intracerebral hemorrhage begin abruptly. In about half of the people, it begins with a severe headache.
• Neurologic symptoms develop and steadily worsen. They include weakness, paralysis, numbness, loss of speech or vision, and confusion.
• Symptoms worsen as the hemorrhage expands. Nausea, vomiting, seizures, and loss of consciousness are common and may occur within seconds to minutes.
• Doctor can often diagnose intracerebral hemorrhages on the basic of symptoms and the results of a physical examination.
• However, CT or MRI scan is usually performed when a stroke is suspected. Both procedures can help doctors distinguish a hemorrhagic stroke from an ischemic stroke. The procedures can also detect how much brain tissue has been damaged and whether pressure is increased in other areas of the brain.
• A lumbar puncture (LP)  is not usually performed. LP cab cause herniation of the brain, a life threatening disorder.

Treatment and Prognosis.

• Treatment of hemorrhagic stroke differs from that of an ischemic stroke.
• Anticoagulants, thrombolytic drugs, and anti-platelet drugs (such as aspirin) are not given, and surgery may save the person's life.
• The goal of surgery is to remove blood that has accumulated in the brain and to relieve the resulting increased pressure.
• Stroke due to intracerebral hemorrhage is more dangerous that ischemic stroke. The stroke is usually large and catastrophic, especially in people who have chronic high blood pressure.
• More than have of the people who have large hemorrhages die within a few days. Those who survive usually recover consciousness and some bran function as the body absorbs the leaked blood.
• Ever after surgery, many people continue to have some neurologic symptoms. The symptoms may include weakness, paralysis, loss of sensation on one side of the body, or difficulty understanding and using language (aphasia).
• However, people with small hemorrhages recover to a remarkable degree.

Subarachnoid Hemorrhage

Image taken from uwmedicine.washington.edu

A subarachnoid hemorrhage is sudden bleeding into the space (subarachnoid space) between the inner layer (pia mater) and middle layer (arachnoid mater) of the meninges.

• Usually, the cause is the sudden rupture of an aneurysm in a cerebral artery or blood vessel (atriovenous) malformation of the arteries or veins in or around the brain.
• An aneurysm  may rupture because of the pressure  of blood inside the artery; hemorrhage and stroke may result.
• An arteriovenous malformation may be present at birth, but it is identified only if symptoms develop, it may cause bleeding, usually during adolescence or young adulthood, and sudden collapse, stroke, and death may result.
• Rarely, atherosclerosis or a bacterial infection damage a blood vessel, causing it to rupture. Ruptures can occur in people of any age of 25 and 50. A subarachnoid hemorrhage can also result from a head injury.
• A subarachnoid hemorrhage is the only one type of stroke more common among women than among men.

Symptoms and Diagnosis

 Image taken from  uwmedicine.washington.edu

• Before rupturing, aneurysms that cause subarachnoid hemorrhages usually produce no symptoms. However, aneurysm sometimes press on a nerve or leak small amounts of blood before a major rupture, thereby producing warning signs, such as headache, facial pain, double vision, or other visual problems.
• The warning signs can occur minutes to weeks before the rupture. People should always report such symptoms to a doctor immediately, because steps may be taken to prevent a massive hemorrhage.
• A rupture usually produces a sudden, severe headache, often followed by a brief loss of consciousness. Some people remain in a coma, but more people wake up, feeling confused and sleepy.
• Blood and cerebrospinal fluid around the brain irritate the layers of tissue covering the brain (meninges), producing dizziness.
• Frequent fluctuations in the heart rate and in the breathing rate often occur, sometimes accompanied by seizures. Within hours or even minutes, people may again become sleepy and confused.
• About 25% of people have neurologic symptoms, usually paralysis on one side of the body.
• A subarachnoid hemorrhage can usually be diagnosed by CT scan, which pinpoints the site of bleeding.
• LP if necessary can detect any blood in the CSF.
• Cerebral angiography is usually performed within 72 hours to confirm the diagnosis and to identify the site of the aneurysm or arteriovenous malformation causing the bleeding, so that surgery can be performed.

An angiogram shows a left-sided aneurysm

Image taken from www.thecni.org

Treatment and Prognosis

• People who may have had a subarachnoid hemorrhage are hospitalized immediately and instructed to avoid exertion.
• Analgesics such as opioids (but not  aspirin or other NSAID)  are given to control the severe headaches.
• Occasionally, a drainage tube may be placed in the brain to relieve pressure.
• Nimodipine, a calcium channel blocker, is usually given to prevent spasm of an artery. This drug  helps prevent late spasm and ischemic stroke.
• For people who have an aneurysm, surgery that isolates, blocks off, or supports the walls of the weak artery reduce the risk of fatal bleeding later. These procedures are difficult, and regardless of which one is used, the risk of death is high, especially for people whoa are in a stupor or coma.
• The best time for surgery is somewhat controversial and must be decided based on the person's situation.
• Most neurosurgeon  recommend operating within 3 days of the start of symptoms, before the brain becomes swollen and inflamed.
• Delaying in operation 10 or more days reduces the risk of surgery, but bleeding is more likely to recur in the longer interim.
• A common procedure is placement of a metal clip across the aneurysm, which prevents blood from entering  the aneurysm and thus eliminates the risk of rupture. People who have clips remains on place permanently. 
• People who had clips placed years ago cannot undergo MRI: newer clips are not affected by the magnetic forces.
• An alternative procedure, called neuroendovascular surgery, involves the insertion of coiled wires into the aneurysm. The coils are placed using a catheter inserted into an artery and threaded to the aneurysm. Thus, this procedure does not require that the skull be opened.  By slowing blood flow, the coils promote clot formation, which seals of the aneurysm.
• About 35% if people who have a subarachnoid hemorrhage due to an aneurysm die during the first episode because of extensive brain damage.
• Another 15% die within  a few weeks because of subsequent bleeding.
• People who survive for 6 months but who do not have surgery for the aneurysm may have a 3% chance of another rupture each year.
• The outlook is better when the cause is an arteriovenous malformation. Occasionally, the hemorrhage is caused by a small defect that is not detected by cerebral angiography becayse it has already sealed itself off. In such cases, the outlook is very good.
• Many people recover most or all mental and physical function after a subarachnoid hemorrhage.
• However, neurologic symptoms, such as weakness, paralysis, loss of sensation on one side of the body, or difficulty in understanding and using language (aphases) sometimes persist.
  

Hydrocephalus (Pathophysiology of NS)

Image taken from www.lucinafoundation.org/. 

Copyright of Lucina Foundation. All right reserved 

• The fluid surrounding the brain (cerebrospinal fluid, CSF) is produced in spaces within the brain called ventricles. The fluid must be drain to a different area, where it is absorbed into the blood. When the fluid cannot drain, hydrocephalus (water in the brain) develops.
• Hydrocephalus often increases the pressure in the ventricles, which compresses the brain. 
• Many conditions, such as a birth defect, bleeding within the brain, or brain tumours can block drainage and cause hydrocephalus.
• An abnormally large head my be a symptom of hydrocephalus. The infant usually fails to develop normally.
• CT scan, ultrasound, or MRI scan of the head reveals the diagnosis as well as the degree of brain compression.
• The goal of treatment is to keep pressure normal within the brain. A permanent alternate drainage path (shunt) for CSF decrease the pressure and volume of the fluid inside the brain.
• A doctor places the shunt in the ventricles in the brain and runs it under the skin from the head to another site, usually the abdomen (ventriculoperitoneal shunt). The shunt contains a valve that allows fluid to leave the brain if the pressure  becomes too high.
• Although a few children can eventually do without the shunt as they get older, shunts are rarely removed.
• If needed, pressure within the brain can often be temporarily reduced with drugs (such as acetazolamide or furosemide) or repeated lumbar puncture until a shunt is placed.
• Some children with hydrocephalus develop normal intelligence. Others are mentally retarded or have learning disabilities.

Heart Defects (Pathophysiology of CVS)

• One of 120 babies is born with a heart defect. Some are severe, but many are not. Defects may involve abnormal formation of the heart's walls or valves or of the blood vessels that enter or leave the heart.
• Before birth, a fetus uses oxygen obtained from the mother's blood through the placenta. The fetus does not breathe. Also, the path by which blood circulates through the heart and lungs is  different in fetus. After birth, a newborn must obtain oxygen using his own lungs.Therefore, many changes occur in the heart and blood vessels soon after birth.
• Before birth, blood that has not yet traveled to the lungs (venous blood) mixes with blood that has already traveled to the lungs (arterial blood). Such mixing occurs in the foramen ovale, a hole between the right and left atria and ductus arteriosus, a blood vessel connecting the pulmonary artery and the aorta. In the fetus, both venous and arterial blood contain oxygen, so mixing arterial and venous blood does not affect how much oxygen gets pumped to the body. After birth, arterial blood and venous blood do not normally mix. The foramen ovale and ductus arteriosus normally close within days to a couple of weeks after birth.
• Two general processes account for most of the symptoms resulting from heart defects. One is that blood flow gets altered or rerouted(shunting). Another is that not enough gets pumped to the body, usually because of a blockage.
• Shunting can cause oxygen-poor blood to mix with oxygen-rich blood that is pumped to the body tissues (right to left shunt). The more oxygen-poor blood that flows to the body, the more blue the body appears, particularly the skin and lips. Many heart defects are characterized by a bluish discoloration of the skin (cyanosis); cyanosis indicates that not enough oxygen-rich blood is reaching the tissues where it is needed.
• In heart failure, blood also backs up, often in the lungs. Heart failure can also develop when the heart pumps too weakly or when blood is blocked from flowing to the baby's body.
• Blockages may develop in the valves of the heart or in the blood vessels leading away from the heart. Blood may be impeded from flowing to the lungs because of narrowing of the pulmonary valve (pulmonary valves stenosis) or narrowing within the pulmonary artery itself (pulmonary valve stenosis). Blood may be impeded from flowing through the aorta to the body because of narrowing of the aortic valve (aortic valve stenosis) or blockage within the aorta itself (coarctation of the aorta).

Symptoms and Diagnosis

•  Often, heart defects produce few or no symptoms and are  not detectable even during a physical examination of the child. Some mild defects produce symptoms only later in life. 
• However, many heart defect do result in symptoms during childhood. 
• Because oxygen-rich blood is necessary for normal growth, development, and activity, infants and children with heart defects may fail to grow or gain weight normally. They may not be able to exercise fully.
• In more severe cases, cyanosis may develop, and breathing or eating may be difficult.
• Abnormal blood flow through the heart usually produce murmur sound that can be heard using a stethoscope; however, the vast majority of heart murmurs that occur during childhood are not caused by heart defects and are not indicative of any heart problems.
• Heart failure makes the heart beat rapidly and often causes fluid to collect in the lungs or liver.
• Many heart defects can be diagnosed before birth using ultrasound. After birth, heart defects are suspected when symptoms develop or when particular heart murmurs are heard.
• Diagnosing heart defects in children involves the same techniques used for diagnosing heart problems in adults. A doctor may be able to diagnose the defect after asking the family specific questions and performing a physical examination, ECG, and a chest x-ray. Ultrasound (echochardiography) is used to diagnose almost all of the specific defects. Cardiac catheterization often can show small abnormalities that are not detected with echocardiography or can further illuminate the details of the abnormality.

Treatment

      

Comparison of angioplasty and valvuloplasty

Images taken from http://www.know-heart-diseases.com and http://www.cardiosmart.org/

• Many significant heart defects are effectively corrected using open-heart surgery. When to perform the operation depends on the specific, its defect, its symptoms, and severity. For example, it may be better to postpone surgery until the child is a little older. However, severe symptoms resulting from a heart defects are most effectively relieved with immediate surgery.
• A narrowing can sometimes be relieved by passing a thin tube (catheter) through a blood vessel in the arm or leg into the narrowed area. A balloon attached to the catheter is inflated and widens the narrowing, usually in a valve (a procedure called balloon valvuloplasty) or blood vessel (a procedure known as balloon angioplasty). These balloon procedures spare the child from general anesthesia and open heart surgery. However, a balloon procedures are not usually as effective as surgery.
• If the aorta or pulmonary artery is severely blocked, a temporary shunt can sometime be created to keep an adequate amount of blood  flowing. A shunt can be created with a catheter balloon (for example, between the right and left atria - balloon septostomy).
• Drug prostaglandin E1 (alprostadil) can be given to keep the ductus arteriosus open, shunting blood between the aorta and pulmonary artery. 
• In rarer cases, when no other treatment helps, a heart transplant is performed, but the lack of donor hearts limits the availability of this procedue.
•  Most children who have significant heart defects are at increased risk for developing life-threatening bacterial infections of the heart and its valves (endocarditis). They need to take antibiotics before certain treatments and procedures.

Patent Ductus Arteriosus 

 Fetal echocardiogram of the ductus arteriosus (Courtesy of Drs. J. Moodley and Y. Shah)

Image taken from www.sahha.gov.mt/

•  In patent ductus arteriosus, the blood vessel connecting the pulmonary artery and the aorta (ductus arteriosus) fails to close as it usually does within the the first 2 weeks after birth.
• A left-to-right shunt causes extra blood flow, and pressure in the lungs may damage the lung tissue.
• Premature newborns are especially susceptible to patent ductus arteriosus and lung damage.
• Most often, the defect causes no symptoms. When symptoms do occur, they are usually difficulty breathing or cyanosis, which may be present at birth or not for several weeks after birth.
• When the infant has no symptoms, doctors most often suspect the defect when they hear a heart murmur.
• Use of indomethacin, a drug that inhibits the production of prostaglandins, closes the defect in 80% of infants. Indomethacin is most effective if given in the first 10 days after birth and is more effective in premature newborns that in full-term newborns. 
•  If the defect does not close after several doses of indomethacin, it is closed surgically.

Atrial and Ventricular Septal Defects

 

Image taken from www.nmtmedical.com/

• Atrial and ventricular septal defects are holes in the septum that separate the heart into left and right sides.
• Atrial septal defects are located between the atria while ventricular septal defects are located between the ventricles.
• These holes typically cause left-to-right shunting of blood. 
• Many atrial septal defects close by themselves, especially in the first year of life; many ventricular septal defects close within the first 2 years.
• Infants and most older children with atrial septal defects have no symptoms.
• In more severe case, children may develop heart murmurs, fatigue, and difficulty in breathing.
• The symptoms caused by atrial septal defects increase as the person ages. For example, heart failure may develop during middle age.
• Ventricular septal defects can vary from  small holes, which may cause a heart mumur but no symptoms and usually close by themselves, to larger holes that cause symptoms in infants.
• Significant ventricular septal defects usually cause more severe symptoms that atrial septal defects, because there is more shunting of blood.
• Because of the way lungs develop, shunting increases during the first 6 weeks after birth. Usually the murmur becomes louder, and symptoms, typically rapid breathing, sweating, and difficulty feeding, worsen.
• Mild symptoms of ventricular septal defect may be treated with diuretics (such as furosemide) or drugs that decrease resistance to the flow of blood to the body (such as captopril).
• If atrial and ventricular septal defects are large or cause symptoms, they are closed by surgery.

Rhinitis (Pathology of Respiratory System)

 

Rhinitis is inflammation and swelling of the mucous membrane of the nose, characterised by a runny nose and stuffiness and usually caused by the common cold or and an allergy.

The nose is the most commonly infected part of the upper airways. Rhinitis may be acute or chronic. Acute rhinitis commonly results from viral infections but may also be a result of allergies or other causes. Chronic rhinitis usually occurs with chronic sinusitis (chronic rhinosinusitis).

Viral Rhinitis

• Acute viral rhinitis (the common cold) can be caused by a variety of viruses
• Symptoms consists of runny nose, congestion, post nasal drip, cough, and a  low-grade fever.
• Stuffiness can be relieved by taking phenylephrine as a nasal spray or pseudphedrine by mouth. These drugs, available by over the counter, cause the blood vessels of the nasal mucous membrane to constrict. Nasal spray should only be used for only 3 or 4 days because  after that period of time, when the effects of the drugs wear off, the mucous membrane often swells even more that before. This phenomena is called as rebound congestion.
• Antihistamines help  control runny nose but cause drowsiness and other problems, especially in older people.
• Antibiotics are not effective for acute viral rhinitis.

Allergic Rhinitis

• Allergic rhinitis is caused by a reaction of the body's immune system to an enviromental trigger. The most common environmental triggers include dust, molds, pollens, grasses, trees, and animals.
• Symptoms include sneezing, runny nose, stuffiness, and itchy, watery eyes.
• A doctor may diagnose  allergic rhinitis based on a person's history of symptoms. Often, the person has a family history of allergies.More detailed information may be obtained using blood tests or skin testing.
• Avoiding the substance that triggers the allergy prevents symptoms but is often not possible.
• Nasal corticosteroid sprays decrease nasal inflammation caused by many sources and are relatively safe for long-term use.
• Antihistamine help prevent the allergy reaction and thus symptoms.
• Antihistamines dry the mucous membrane of the nose but many of them also cause sleepiness and other problems, especially in older  people.
• Never ones require a prescription but do not have these side effects.
• Allergy shots (desensitization) help to build long therm tolerance to specific  environmental triggers, but they may take months  or years to become fully effective.
• Antibiotic do not relieve the symptoms of allergic rhinitis.

Atrophic Rhinitis

• Atrophic rhinitis is a form of chronic rhinitis in which  the mucous membrane thins (atropies) and hardens, causing the nasal passages to widen and dry out.
• The cells normally found in the mucous membrane of the nose - cells that secrete mucus and have hairlike projections to move dirt particles out - are replaced by cells like those normally found in the skin.
• The disorder can develop in someone who had sinus surgery in which a significant amount of intranasal structures and mucous membranes were removed. 
• A prolong bacterial infection of the lining of the nose is also a factor.
• Crust form inside  the nose, and an offensive odour develops.
• A person may have recurring severe nosebleeds and can lose his sense of smell (anosmia).
• Treatment is aimed at reducing the crusting, elimination the odour, and reducing infections. 
• Topical antibiotics, such as bacitracin applied  inside the nose, kill bacteria.
• Estrogens and vitamins A and D sprayed into the nose or taken by mouth may reduce crusting by promoting mucosal secretions.
• Other antibiotics, given by mouth or intravenously, may also be helpful.
• Surgery to narrow the nasal passages may reduce crusting became the decreased airflow prevents drying if the thinned mucous membrane

Vasomotor Rhinitis

• Vasomotor rhinitis is a form of chronic rhinitis.
• Nasal stuffiness, sneezing, and a runny nose - common allergic symptoms - occur when allergies do not appear to be present.
• In some people, the nose reacts strongly to irritants, perfumes, and pollution.
• The disorder comes and goes but is worsened by dry air.
• The swollen mucous membrane varies fro bright red to purple.
• Sometimes, people also have slight inflammation of the sinuses.
• When persistent, endoscopy of the nose or CT scan of the sinus is not significant.
• Treatment is aimed at relieving symptoms.
• Avoiding smoke and irritants and using a humidified central heating system or vaporizer to increase humidity may be beneficial.
  

Related article :

1. Sinusitis
   

Headaches (Patophysiology of NS)

Headache is defined as pain or discomfort in the head that is located above the eyes or the ears, behind the head (occipital), or in the back of the upper neck.

Headaches are a very common medical problem and a common cause of disability among men and women. Headaches interfere with the ability to work and to perform daily tasks. Some people have frequent headaches; other people hardly ever have them.

Classification of headache are;

• Primary (idiopathic) headache, includes;
  

1. Tension-type of headache
   
2. Migraine (with or without aura)
   
3. Combination of headache
4. Cluster headache
   

• Secondary headache caused by underlying disease

Causes

• Although headaches can be painful and distressing, they rarely indicate a serious condition. Most headaches - tension type, migraine, and cluster headaches - are not caused by another identifiable disorder. Tension type headaches are the most common.
• Less commonly, headaches result from another disorder. Usually, the disorder is not serious. Disorders that cause headaches are often minor or temporary ones that affect the eyes, nose, throat, sinuses, teeth, jaws, ears, or neck.
• Rarely, headaches are caused by a serious disorder. Such disorder include a head injury, stroke, bulge in the wall of an artery supplying the brain (cerebral aneurysm), brain infection (brain abscess, meningitis, and encephalitis), and blood vessel (arteriovenous)malformation near the brain. Infections such as tuberculosis may affect the brain and cause headaches. Disorders that increase pressure within the skull can cause headaches by putting pressure on the brain. Examples area brain tumor, bleeding (hemorrhage), an accumulation of blood (hematoma), and pseudotumor cerebri, in which pressure within the skull increases but ni cause can be identified.
• Other serious diseases that may cause headache include very high blood pressure, which may produce a throbbing sensation in the head. (However, high BP does not usually cause headache.) Lung disorders (such as emphysema) that reduce the oxygen supply to the brain may cause headaches, as may sleep apnea, which temporarily increases levels of carbon dioxide in the blood. Inflammation of large arteries (temporal arteritis), usually in the neck and head, may cause headaches. Temporal arteritis affects older people primarily. Severe cases of influenza and high fever may cause headaches. Lyme disease in its early stages commonly causes headaches.
• Headaches commonly result from withdrawal of caffeine, withdrawal of analgesics after long-term use, and use of certain drugs that widen blood vessels (such as nitroglycerin).

Diagnosis

• Usually, doctors can determine the type or cause of headaches on the basis of the person's medical history, the characteristics of the headache, and results of a physical examinations.
• Characteristics of the headache include its frequency, duration, location, severity, and associated symptoms.
• The following characteristics may indicate that a serious disorder is the cause of headaches, and prompt medical attention is required.

1. Frequent headaches in a person who rarely has headaches,
2. Mild headaches that become severe,
3. headaches that awaken a person from sleep,
4. Any change in the pattern or nature of headaches,
5. Headaches associated with symptoms such as a fever and a stiff neck, changes in sensation, or vision, weakness, loss of coordination, or fainting.
   

• For example, a severe headache with a fever and a stiff neck suggests meningitis - a life threatening infection of the layers of tissue covering the brain and spinal cord (meninges). A headache that occurs suddenly and that is more severe that any others the person has experienced suggests a subarachnoid hemorrhage - often due to ruptured aneurysm.
• When doctors suspect a serious disorder, additional diagnostic procedures are usually performed. If meningitis is suspected, a spinal tap (lumbar puncture) is performed immediately. A spinal tap may also be performed if doctors suspect a ruptured aneurysm. Occasionally, blood tests are performed to check for a disorder such as Lyme disease. The erythrocyte sedimentation rate (ESR - the rate at which RBC settle down to the bottom of a test tube containing blood) may be determined to check for temporal arteritis. A high ESR suggests inflammation.
  
• If doctors suspect a tumor, stroke, hemorrhage, or another structural brain disorder, CT or MRI scan of the head is performed.
  

Tension-Type Headaches
Tension type headache is usually mild to moderate, band-like pain that affects the whole head.

The cause of tension-type headaches is not well understood but may be related to a lower-than normal threshold for pain. Stress clearly understood, and it is not the only explanation for the symptoms.

There are two classification of tension type headache;

1. Episodic type headache - tension type headache that occur fewer than 15 days per month.
2. Chronic type headache - occurs more than 15 days per month for at least 6 months.
   

Symptoms and Diagnosis

• The pain is usually mild to moderate, although it may be severe.
  
• It feels like tightening of a band around the head, making whole head ache. The pain may last 30 minutes to 1 week.
  
• Unlike a migraine headache, a tension-type headache is not associated with nausea and vomiting and is not made worse by physical activity, light, sounds, or smells.
  
• Tension-type headaches typically start several hours after waking and rarely awaken a person from sleep.
• The diagnosis is based on the person's description of the headache and the results of a physical examination.
• No specific procedures can confirm the diagnosis.
• Rarely, CT or MRI scan of the head is performed to rule out other disorders that may be causing the headache, particularly if headaches have developed recently.

Treatment

• For most mild to moderate tension-type headaches, almost any over-the counter analgesic, such as aspirin, acetaminophen, or ibuprofen can provide fast, temporarily relief.
• Massaging the affected area may help relieve the pain.
• Severe headaches may require stronger, prescription analgesics, some of which contains opioid (narcotics), such as codeine or oxycodone.
• For some people, caffeine, an ingredient of some headache preparations, enhances the effect of analgesics.
• However, overuse of analgesics or caffeine can lead to chronic daily headaches. Such headaches. called rebound headaches, occur when a dose of an analgesic is missed or late or when caffeine intake is reduced or stopped.

Migraine Headaches

A migraine headache is throbbing, moderate to severe pain, usually on one side of the head that is worsened by physical activity, light sounds, or smells and that is associated with nausea and vomiting.

• Although migraines can start at any age, they usually begin between the ages of 10 and 40.
• In most people, migraines recur periodically, but they usually become significantly less severe or resolve entirely after age 50 or 60.
• Migraines are 3 times more common among women that among men.
• Migraines tend to run in families; more than half of the people who have migraines have close relatives who also have them.
• The cause of migraines is not well understood. According to one theory, migraines occur when arteries to the brain become constrict and then dilate; dilation is thought to activate nearby pain receptors.
• However this theory is too simple to explain the complex changes in blood flow that occur in the brain during a migraine. Furthermore, a series of changes in the nerve cells of the brain occur before the changes in the blood flow.
• A rare subtype of migraine called familial hemiplegic migraine is associated with a genetic defect on chromosomes 1 and 19. The role of genes in the more common forms of migraine is under study.
• Estrogen, the main female hormone, appears to trigger migraines, a possibly explaining why migraines are more common among women.
• During puberty, migraines become much more commons among girls than among boys.
• Some women have migraines just before, during, or just after menstrual periods.
• As menopause approaches (when estrogen level fluctuating), migraines become particularly difficult to control. Oral contraceptives (which control estrogen) and estrogen replacement therapy often make migraines worse.
• Insomnia, changes in barometric pressure, and hunger may also trigger migraines.
• There are two types of migraine;

1. Migraine with aura (classic)
   
2. Migraine without aura (common)
   

Symptoms and Diagnosis

• In a migraine, throbbing pain is typically felt on one side of the head. The pain may be moderate but is often severe and incapacitating.
• Physical activity, light, sounds, or smells may make the headache worse.
• Headache is often accompanied by nausea, sometimes with vomiting.
• A migraine attack often involves more than a headache. It may include a prodrome, an aura, an a postdrome.
• The prodrome is a change in mood or behavior, which can precede the rest of the migraine by 24 hours.
• People may become depressed, elated, irritable, or restlessness.
• Nausea or loss of appetite may also occur.
• About 25% of people experience an aura. The aura involves temporary, reversible disturbances in vision, sensation, balance, movement, or speech.
• Commonly, people see jagged, shimmering, or flashing flashing lights.
• Less commonly, people experience tingling sensations, loss of balance, weakness in an arm or a leg, or difficulty talking.
• The aura occurs within the hour before the migraine and ends as the migraine begins.
• About 25% of people experience a postdrome, which involves changes in mood and behavior after the migraine.
• Migraines attacks may occur frequently for a long period of time but then may disappear for many weeks, month, or even years.
• Migraines are diagnosed on the basics of symptoms. No procedure can confirm the diagnosis.
  
• If headaches have developed recently or if the pattern of symptoms has changed, CT or MRI scan of the head is performed to exclude other disorder.

Prevention &  Treatment

 

• Treatment of migraine headaches involves three types of drugs; drugs to prevent migraines, drug to stop (abort) a migraine as it beginning, and drugs to relive pain.
• People who have more than one migraine a week often benefit from taking drugs every day to prevent migraine attacks.
• Beta blockers, such as propanolol, are often given first.
• Calcium channel blockers, antidepressants, and some anticonvulsants, particularly divalproex, are also effective.
• The choice of a preventive drug is based on the side effects of the drug and another disorders present. For example, if weight gain could cause problems, divalproex is usually not prescribed. If the person is has depression, a tricyclic antidepressant such as nortriptyline may be prescribed.
• To abort a migraine as it is beginning, most doctors prefer a relatively new group of drugs called triptans (5-hydroxytryptophan [5-HT] agonist). Triptans specifically target the receptors that stimulate the nerves supplying the the cerebral blood vessels. Thus, triptans may reverse the dilatation of these blood vessels which contributes to a migraine.
• As soon as people sense a migraine attack is beginning, they take one of these drigs to stop the attack from the processing.
  
• Other drugs used to abort migraines, such as ergotamine, are sometimes used, but they are not as safe or as effective as triptans. Because triptans and ergotamine cause blood vessels to constrict, they are not recommended for people who have angina or other heart disease or for people who have prodromal symptoms that resemble those of stroke (because constriction of arteries may trigger a stroke).
• For less severe migraines, analgesics alone or analgesics that contain caffeine can be useful. They can be taken as needed during a migraine, with or instead of a triptan.
• As for tension-type headaches, overuse of analgesics or caffeine can make the migraine worse.
  
• For more severe migraines, opioids may be needed.
  

Better Migraine Treatment

Mouth Sores (Pathology of GI System)

Mouth Sores Mouth sores vary in appearance and size. Some may be raised, usually filled with fluid (in which case it is called as a vesicle or bulla); others may be ulcers. An ulcer is a hole that forms in the lining of the mouth when the top forms in the lining of the mouth, when the top layer of cells breaks down and the underlying tissue shows through. An ulcer appears white because of the dead cells and food debris inside the hole. Sores can affect any part of the mouth, inside and outside. Canker sores/aphthous ulcers and cold sores are perhaps the most well know, but there are many other types and causes of mouth sores. Any sore that lasts for 10 days or more must be examined by a dentist or doctor to ensure that it is not cancerous or precancerous.


Canker Sores (aphthous ulcers) Aphthous ulcers are small, painful sores inside the mouth

• Aphthous ulcers are very common. The cause is unknown, but stress seem to play a role - for example, a BMS student may get aphthous ulcers during final exam week.
  
• Aphthous ulcer appears as a round white spot with a red border. The ulcer almost always forms on soft, loose tissue on the inside of the lip or cheek; on the tongue, the floor of the mouth, or soft palate; or in the throat.
• Small aphthous ulcers (less than 1/2 inch in diameter) often appear in clusters of two or three; generally, they disappear by themselves within 10 days and do not leave scars.
  
• Larger ulcers are less common, they are irregularly shaped, can take many weeks to heal, and frequently leave scars.
• People with AIDS often have large ulcers that persist for weeks.
• Many people who get aphthous ulcers get them repeatedly - often several times a year.

Symptoms and Diagnosis

• The main symptoms of aphthous ulcers is pain - far more than would be expected from something so small.
• The pain, which lasts 4 to 7 days, worsens if the tongue or food rubs the sore or if hot or spicy foods are eaten.
  
• Severe ulcers can cause fever, swollen lymph nodes in the neck, and a generally run-down feeling.
• A doctor or dentist identifies aphthous ulcers by its appearance and the pain it causes.

Symptoms and Diagnosis

• Treatment consists of relieving the pain until the sore heals by itself.
• An anesthetic such as dyclonine or lidocaine may be used as a mouth rinse.
• However, because these mouth rinses numb the mouth and throat and thus may make swallowing difficult, children using them should be watched to ensure that they do not choke on their food.
  
• Lidocaine in a thicker preparation (viscous lidocaine) can also be swabbed directly on the aphthous ulcers.
  
• A protective coating gel of carboxymethylcellulose, often combine with a corticosteroid (such as triamcinolone or betamethasone), may be applied to protect the ulcers and temporarily relieve pain.
• Finally, for the most severe cases, a corticosteroid may be prescribed as a dexamthasone mouth rinse or, rarely, as predisone tablets taken by mouth.
• However, before prescribing as corticosteroid, a doctor ensures that the person does not also have oral herpes simplex infection, which can be further spread by corticosteroid given in gel form , so the side effects may be a concern.

Oral Herpes Simplex/Cold Sores

Infection of the mouth with herpes simplex virus causes recurring sore (often called cold sores), in which small fluid-filled sore develop on the skin, lips, or mouth in single or multiple clusters.

• The 1st eruption of sores due to infection with oral herpes simplex virus is called primary herpes. It is usually contracted in childhood. Primary herpes may be mild or severe, but it often affects large areas of the mouth and always the gums.
  
• Any subsequent eruption of the sores is called secondary herpes. Secondary herpes is a reactivation of the virus rather than a new infection.
  
• There are at least two forms of herpes simplex virus. In the past, herpes simplex virus type I only caused sores above the waist, and type 2 only below the waist (genital herpes). Click here to more detail on types of herpes simplex virus.
  
• Now however, either type can cause sores anywhere on the body because of sexual behavior etc. Herpes simplex 2 tends to be more severe than type I.
• Typically, a previously uninfected child acquires the virus from contact with an adult who has a cold sore. In rare cases, a person first acquires herpes simplex virus in adulthood, also after contact with someone with a cold sore.
• A person is capable of spreading the infection (contagious) from the time the tingling sensation that proceeds the development of a sore (the prodorome) is experienced to the time at which the sore has completely crusted over. It is unknown whether herpes can be spread by sharing a glass or touching something that an infected person has touched.

Symptoms

• When primary herpes is acquired in childhood, the infection causes gum inflammation and extensive mouth soreness. Fever, swollen lymph nodes in the neck, and general discomfort may develop.
• A child may be cranky and cry continually. However, many cases are mild and go unrecognized. Parents often mistake the problem for teething or another illness. In more severe cases, small blisters form in the child's mouth. These blisters may not be noticed because they rupture within a day or two, leaving many ulcers. The ulcers may occur anywhere in the mouth but always include the gums. Though the child get better in a week to 10 days, the herpes simplex virus never leaves the body.
• When a primary herpes is acquired in adulthood, symptoms are usually more severe and include multiple rapidly developing painful sores on the gums an other parts of the mouth.
• Unlike primary herpes, which causes widespread mouth soreness, the flare-ups of secondary herpes usually produce a single raw, weeping open sore on the outer lip that later crusts over before healing within 2 or 3 weeks. The sore is sometimes called a cold sore or fever blister. Less commonly, a cluster of blisters (vesicles) forms on the roof of the mouth. These small blisters run together and quickly break down into a sore. There is no crusting stage.
• Flare-ups are commonly triggered by sunburn on the lips, certain foods, anxiety, a cold (hence the name 'cold sore'), fever, or anything that lowers the body's resistance to infection. Certain dental procedures can cause a flare-up as well; if a cold sore already exists, dental visits should be postponed until the sore heals.
• Although merely a painful annoyance for most people, flare-ups of oral herpes simplex infection can be life-threatening for a person with an impaired immune system. Impairment of the immune system can be caused by diseases (such as AIDS), chemotherapy, radiation therapy, or a bone marrow transplant. In such people, large, persistent sores in the mouth can interfere with eating; spreading of the virus to the brain can be fatal.

Treatment

• Treatment for primary herpes aims to relieve the pain so that the person can sleep, eat, and drink comfortably. Pain may keep a child from eating and drinking, which, combined with a fever, can quickly lead to dehydration. Thus, a child should drink as much fluids as possible. An adult or older child can use a prescribed anesthetic mouth rinse such as lidocaine to reduce pain. A mouth rinse containing baking soda may also be soothing.
• Treatment for secondary herpes works best when started before the sore erupts - as soon as the person has the sensation (the prodorome) that an attack is starting. Taking vitamin C (1,000 to 2,000 milligrams per day) during the prodrome may make the attack less severe. A doctor may prescribe penciclovir cream or amlexanox paste, which is applied during the prodorome to shorten the duration and severity of the outbreak. The virus itself cannot be permanently eliminated.
• Protecting the lips from direct sunlight by wearing a wide-brimmed hat or by using lip balm containing sunscreen can reduce the possibility of of a flare-up. Also, a person should avoid activities and food that are know to cause flare-ups. Anyone who suffers frequent, severe flare-ups may try taking lysine (available at food stores) indefinitely.
  
• Levaisole, available by prescription, is another drug that seems to reduce recurrences.
• For people with severe herpes simplex and for people with and impaired immune system, acylovir or penciclovir capsules may be prescribed to prevent or limit the severity of the infection. Corticosteroids are not used for herpes simplex because they may allow the infection to spread.