Pemphigus of the oral cavity and extremities of the Coxsackie virus . Diagnostics and treatment

Pemphigus of the oral cavity and extremities is a viral disease that can affect humans and some animals and is manifested by a characteristic clinical picture. 

The disease is common throughout the world. 

• In the United States, epidemics occur every three years. In temperate climates, the peak incidence occurs in late summer and early autumn. 

• Pemphigus of the mouth and extremities is mild, but may be more severe in infants and young children. • No racial or sex differences were found. Most cases occur in children under 10 years of age. 

• Pemphigus of the mouth and extremities is usually caused by enteroviruses , in particular Coxsackie viruses . Epidemic infections are caused by the A16 coxsackie virus or enterovirus 712. There are sporadic cases caused by other types of coxsackie virus .

• Infections caused by the coxsackie virus are highly infectious . The infection is transmitted by airborne droplets or by direct contact with the patient’s feces. During epidemics, the virus is transmitted from child to child and from mother to fetus. 

• The incubation period is on average 3-6 days. First, the virus is implanted into the mucous membrane of the gastrointestinal tract, and then within 24 hours enters the lymph nodes. Rapidly developing viremia with spread to the oral mucosa and skin. Usually by day 7, a neutralizing response from antibodies is formed, and the virus is eliminated from the body. 

• If pemphigus of the mouth and extremities is caused by enteroviruses , it can lead to myocarditis, pneumonia, meningoencephalitis and even death. 

• Infection in the first trimester of pregnancy can cause spontaneous miscarriage or fetal growth retardation. The first sign of oral and extremity pemphigus is the prodromal period, which usually lasts 12 to 36 hours and includes the typical common symptoms of viral infection with anorexia, abdominal pain and oral pain. The lesions are present for 5 to 10 days and resolve spontaneously after 5-7 days. Each lesion initially forms as an erythematous papule 2-10 mm in diameter, from which a gray oval vesicle arises, located parallel to the skin tension lines along the longitudinal axis. The lesions in the oral cavity appear as erythematous spots and develop into vesicles on the erythematous base (2-3 mm in diameter), and then quickly ulcerate. The vesicles are painful and may interfere with food intake. In some cases, the cervical and submandibular lymph nodes are enlarged.

Skin lesions occur on the hands, feet and / or buttocks, while lesions in the oral cavity can be located on the hard palate, cheek mucosa, gums and / or tongue. No laboratory tests are required. Differential diagnosis of pemphigus

• Aphthous stomatitis manifests itself as single or multiple ulcers in the mouth without skin rashes. 

• Chickenpox is characterized by clusters of vesicular foci that are common throughout the body. 

• Erythema multiforme appears as target-like lesions throughout the body, which also affect the skin of the palms and feet. 

• Herpes simplex is characterized by painful recurrent ulceration of the lips or genitals without simultaneous lesions on the hands and feet, with the exception of herpetic felon on the hand.


Treatment for pemphigus

• Oral lesions are usually not as painful as in herpetic gingivostomatitis . If the patient does experience severe oral pain that interferes with food intake, local anesthetics, such as viscous 2% lidocaine prescription or over-the-counter topical benzocaine 20% Orabase , may be prescribed to treat painful oral ulcers. Also helpful is a combined solution of aluminum and magnesium hydroxide (liquid antacid) and 2% viscous lidocaine , which is used several times a day to rinse the mouth as needed to relieve pain. 

• Acetaminophen or nonsteroidal anti-inflammatory / selective cyclooxygenase inhibitors are used to control fever , and analgesics are used to treat arthralgias. Aspirin should not be used to prevent Reye’s syndrome in viral infections in children under 12 years of age. 

• There is one report of enterovirus- induced pemphigus of the mouth and extremities in an immunodeficient state, symptoms and lesions resolved quickly with oral acyclovir. Recommendations for pemphigus patients. Parents of young children should be on the lookout for signs of dehydration due to poor fluid intake due to oral pain. When symptoms subside, the patient can attend school, but care must be taken to wash hands thoroughly to prevent transmission. If you have any neurological symptoms, you should see a doctor immediately. A clinical example of pemphigus. A four-year-old boy with a low fever and focal lesions of the hands and feet was taken to a free clinic for homeless families. The mother said that two more children in the temporary residence center have similar rashes. Further examination revealed foci in the child’s mouth. The mother was reassured by the message that the pemphigus of the oral cavity and extremities resolved on its own. Treatment includes drinking plenty of fluids and, if necessary, antipyretic drugs.

Algorithm for the management of patients with artificial heart valve

ACC / ANA recommend warfarin therapy for patients with mechanical prostheses . For patients with an AK prosthesis, such as a two-lobed mechanical prosthesis and a Medtronic Hall prosthesis , INR targets range from 2 to 3, and for patients with a Starr-Edwards or rotary disk prosthesis, they range from 2.5 to 3.5. The same values ​​are indicated for the replacement of a MK with a mechanical prosthesis. Patients for whom warfarin is contraindicated should be prescribed aspirin at a dose of 75 to 325 mg / day . Low-dose aspirin (75 to 100 mg / day ) is recommended in addition to warfarin for all patients with mechanical prostheses and patients with biological prostheses and AF, previous history of thromboembolism, LV dysfunction, or hypercoagulability . For those patients for whom aspirin is not indicated, clopidogrel may be considered . a) Adjunctive therapy. Receiving antithrombotic drugs patients with mechanical valves can sometimes temporarily stop extracardiac in connection with surgical interventions or invasive procedures, dental manipulations. In patients at low risk of thrombosis, warfarin may be discontinued 48-72 hours before the procedure and resumed no more than 24 hours after it. The ACC / AHA guidelines indicate that in patients with a two-lobed mechanical AV prosthesis, if there are no factors predisposing to thrombosis, heparin is usually not necessary. Adjuvant anticoagulant therapy is recommended for individuals at increased risk of thrombosis, including those with mechanical MV, TC, or AK prostheses who have RFs such as AF, recent thrombosis or embolism, LV dysfunction, old-generation thrombogenic artificial valve, and patients with a predisposition to thrombosis . who have not previously received therapy. Ancillary therapy consists of intravenous administration of unfractionated heparin (class I), but subcutaneous administration of it or low molecular weight heparin (class IIb ) is possible . b) Artificial valve thrombosis. In case of thrombosis of the artificial valve of the left side of the heart in a patient with moderate or severe symptoms of HF (NYHA FC III-IV) or with a large thrombus, urgent surgery should be performed. Fibrinolytic therapy may be considered in patients with less severe symptoms, small thrombus size, or when surgery presents a high risk or lack of prerequisites. c) Postoperative management of the patient. After implantation of an artificial valve on the left side of the heart, asymptomatic patients should be examined 2-4 weeks after discharge, and then once a year. Annual echocardiography in the absence of changes in clinical status is not indicated. To reduce the risk of cardiovascular events, all patients should receive primary and secondary prevention. Patients who do not improve with valve replacement or who experience deterioration in valve function should be evaluated to determine the cause. Patients with postoperative LV systolic dysfunction should receive standard drug therapy for systolic HF even in the absence of symptoms.

Skin is a sense organ. Sensitive skin function.

Receptors of various types of sensitivity differ in their structure: pain receptors are free nerve endings. Other types of irritation are perceived by encapsulated nerve endings (pressure – Meissner’s and Vater-Pacini’s little bodies ; temperature – Krause’s flasks and Ruffini’s little bodies , etc.). The skin is an extensive receptor field. No other organ has such a rich sensory innervation. Obviously, this can be explained by the fact that the epithelial formations of the skin and the central nervous system have a single source of development – ectoderm. Receptors on the skin surface are unevenly distributed. It is estimated that there are 2 heat points, 12 cold points, 25 tactile points and 150 pain points per 1 cm2 of skin. Extensive and complex information flows through the receptors of the skin. In any area of ​​the skin, there is a complex complex of several receptive fields, each of which is associated with many separate receptors, combined into a specific anatomical and functional complex. The most common sensation and symptom in dermatology is itching, which can occur with a variety of dermatological conditions or without a clinically apparent skin disorder. Itching and pain are carried along myelin – free C-fibers formed by dendrites of pseudo-unipolar neurons. The axons of these neurons enter the posterior horn of the spinal cord, switch to the second neurons, the axons of which move to the opposite side and, as part of the spinothalamic tract, rise to the thalamus.

Then the impulse goes to the sensory zone of the posterior central gyrus of the cerebral cortex. Securing the spinothalamic tract relieves pain and itching ( anterolateral hemihordotomy ). Various peripheral mediators stimulate C-fibers and cause itching. These include histamine, trypsin, protease, peptides ( bradykinin , vasoactive intestinal peptides, substance P – all possible histamine releasers ) and bile salts. Prostaglandins are modulators of pruritus rather than primary mediators, lowering the threshold for pruritus caused by both histamine and pain. Central modulators of pruritus, such as systemic morphine, induce pruritus by relieving pain by acting on central opiate receptors. Generalized pruritus in the absence of primary skin disease can be an important sign of internal disease. Diseases as diverse as uremia, cholelithiasis , lymphomas and myeloproliferative diseases, thyrotoxicosis, diabetes, carcinoma, deficiency anemias of various origins, and mental disorders can cause severe itching. An important cause of itching is mental stress. Some patients with psychogenic pruritus believe that itching is caused by invisible parasites in the skin. Such patients are combed until excoriation and pruriginous papules develop in areas easily accessible to the patient (limbs, skull, upper back). Dry skin (xerosis) is a common cause of itching in other individuals. Certain medications (aspirin, opiates) can cause itching without a visible rash. Patients with polycythemia vera have a unique type of itching, namely itching that begins with sudden changes in temperature, especially when leaving a warm bath. Itching is prickly in nature and lasts from several minutes to several hours.

Esophageal cancer treatments and their effectiveness

For tumors of the middle third of the esophagus, radiation therapy is increasingly used as the main treatment, sometimes in combination with surgery. Some surgeons believe that surgery is easier and that long-term results are better with preoperative radiation. Technically, preoperative and radical radiation therapy for tumors in the middle third of the esophagus is easier than for tumors in the upper third of the esophagus. As in the case of tumors of the upper third of the esophagus, currently synchronous chemotherapy and radiation therapy is widely used for the middle third of the esophagus; In our center, the standard of treatment is now a combination of mitomycin C and 5-FU. For cancers of the lower third of the esophagus, surgery is often preferred, and the reconstruction, usually performed with a mobilized stomach, is less difficult. In cancer of the lower third of the esophagus, there is a risk that the stomach will be affected by a tumor and not be suitable for reconstruction. For inoperable tumors, radiation therapy may be helpful. Complications in the treatment of tumors of all departments can be difficult or even severe, both in the case of radiation therapy and during surgery. Radiation therapy is often accompanied by radiation inflammation of the esophagus (esophagitis), which requires treatment with alkaline or aspirin-containing suspensions for local action on the inflamed esophageal mucosa. Possible later complications include radiation damage to the spinal cord and lungs, leading to radiation pulmonitis and sometimes shortness of breath, cough, and decreased respiratory capacity, but these are rare in everyday practice. Fibrosis and scarring of the esophagus lead to stricture, which may require dilatation to keep the esophagus open. Despite the above facts, most patients tolerate this treatment surprisingly well, even with chemotherapy. Surgical complications include esophageal stricture and anastomotic leakage, resulting in mediastinitis, pulmonitis and sepsis, sometimes leading to patient death. In patients with high-grade dysplasia in Barrett’s esophagus, the use of photodynamic therapy has proven promising. While data have been collected for a small number of patients, this treatment is already recognized by the National Institute of Clinical Arts (NICE) as suitable in some cases.

Palliative treatment for esophageal cancer Palliative treatment for esophageal cancer can be very beneficial with Celestine or other permanent prosthesis, radiation therapy or laser treatment (or both), or sometimes bypass surgery, without attempting to remove the primary tumor, but with the creation of an alternative channel. For patients who cannot undergo radical surgery and radiation therapy, palliative treatment should always be considered, especially in cases of severe dysphagia. Moderate doses of radiation can lead to marked clinical improvement. In experienced hands, conducting a Celestine or expandable esophageal tube with metal mesh is a relatively safe and effective procedure that can be combined with radiation therapy. Common problems with tube insertion include movement of the tube, gastroesophageal fistula (sometimes associated with stomach contents entering the lungs), chest pain, and discomfort. Complications with palliative radiation are minimal because low doses are used: 30 Gy treatment is usually beneficial over a 2-week period if dysphagia is not total and high doses are rarely needed. Intoesophageal brachytherapy is widely used at our center , offering a simple and fast alternative. Since the early 1990s, the role of laser therapy, which can be used in combination with radiation therapy, has become increasingly important. At the same time, the ability to swallow is immediately restored, sometimes even after the first session, and the procedure can be easily repeated. For patients with an unresectable tumor, such treatment is the best and least traumatic method for temporary relief. An interesting addition to the use of laser therapy was the idea of ​​phototherapy. At the same time, before the start of laser therapy, the patient receives phthalocyamine derivatives , which are captured mainly by the tumor, which increases the selectivity of treatment.

local_offerevent_note December 4, 2020

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