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Germ Cell Tumors Concept Most consistent lab fnding in Hilus cell tumors is an elevated 17-ketosteroid excretion level unresponsive to cortisone sup- pression order 250 mg trimox visa fungal infection. Teratomas: These are divided into three categories: mature (benign) buy 250mg trimox mastercard antimicrobial kitchen countertops, immature (malignant) purchase 75 mcg synthroid amex, monodermal or highly specialized. Mature (Benign) Teratomas: – Cystic teratomas are usually found in young women during the active repro- ductive years. Most benign teratomas are • Within the wall, it is common to fnd tooth structures and areas of calcifcation. Monodermal or Specialized Teratomas: – The most common of the specialized teratoma are struma ovarii and carcinoid. Interestingly, these thyroidal neoplasms may hyperfunction, causing hyperthyroidism. Primary ovarian carcinoid can be distinguished from metastatic intestinal carcinoid, the latter virtually always bilateral. Immature Malignant Teratomas: – These are rare tumors that differ from benign teratomas in that the component tissue resembles that observed in the fetus or embryo rather than in the adult. A few produce elevated levels of chorionic gonadotropin and may have syncytiotrophoblastic giant cells on These neoplasms are extremely histologic examination. As in the seminoma, the fbrous stroma is infltrated with mature lymphocytes and occasional granulomas. Endodermal Sinus (Yolk Sac) Tumor ture of yolk sac tumor is a – It is the second most common malignant tumor of germ cell origin. Choriocarcinoma – More commonly of placental origin, the choriocarcinoma, similar to the endodermal sinus tumor, is an example of extraembryonic differentiation of malignant germ cells. Concept – Like all choriocarcinomas, they elaborate high levels of chorionic gonadotropins In contrast to choriocarcinomas that are sometimes helpful in establishing the diagnosis or detecting recurrences. Other Germ Cell Tumors arising in the ovary are generally – These include embryonal carcinoma (another highly malignant tumor of unresponsive to chemotherapy primitive embryonal elements, histologically similar to tumors arising in the and are often fatal. Gonadoblastoma is an uncommon tumor thought to be composed of germ cells and sex cord-stroma derivatives. It occurs in individuals with abnormal sexual development and in gonads of indeterminate nature. Eighty per cent of patients are phenotypic females, and 20% are phenotypic males with undescended testicles and female internal secondary organs. On microscopic examination, the tumor consists of nests of a mixture of germ cells and sex cord derivatives resembling immature Sertoli and granulosa cells. Metastatic tumors of ovary • The most common “metastatic” tumors of the ovary are probably derived from tumors of Mullerian origin: the uterus, fallopian tube, contralateral ovary, or pelvic peritoneum. Microscopically, they are characterized by appearance of mucin-secreting signet-ring cells in the tissue of the ovary; when the primary tumor is discovered, the same signet-ring cells are typically found.

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The lef testicular vein drains into the lef • Hematocele tunica vaginalis just above the testis order trimox toronto infection on x ray. But the right testic- Complications Tis is just opposite of the above (Funicular) ular vein opens obliquely into the inferior • Calcifcation variety buy trimox overnight antibiotics for dogs bad breath. Sometimes the lef renal vein may be • Hematocele of from the peritoneal cavity at the deep sandwiched between the abdominal aorta • Hernia of the hydrocele sac-It occurs fol- inguinal ring buy ranitidine canada. So, unlike the congenital or and the trunk of superior mesenteric lowing a tear in the sac which results in funicular variety, it does not disappear when artery which may culminate into varicosi- accumulation of fuid in the subcutaneous the patient lies down. The lef testicular artery may arch over Bilocular Hydrocele the lef testicular vein and this may cause Treatment Here the hydrocele has two communicating compression over it. Jaboulay’s operation (Eversion of sac) is Sometimes hydrocele may be associated with e. Appendix of epididymis (peduncu- Pampiniform plexus of veins (15 – 20) drain- also produces the degeneration cysts, the lated hydatid cyst of Morgagni) – ing the testis and epididymis makes the major degeneration cysts are of two types viz. Tis is a unilocular acquired retention cyst testis or sessile hydatid cyst of Morgagni due to obstruction of the sperm conducting – Tis is a small rounded body attached to Etiology duct of the epididymis. It is usually situated behind the testis Features • A rapid onset varicocele in an elderly and the testis is distinctly separate from the • Solitary cysts are commoner than multi- patient suggests renal cell carcinoma invad- swelling. Clinical Features Small spermatocele does not require any • Tey also contain like multiple cysts the • The patient may have aching or dragging treatment. Big spermatocele requires com- crystal clear fuid and are therefore bril- pain particularly afer prolonged standing. Multiple Cysts • Many a varicocele are asymptomatic and The epididymis and testis are ofen involved Origin found incidentally. The scrotal temperature is believed to be due to dilatation of the usually higher in the presence of varicocele tubules of the epididymis (inferior aberrant Acute Epididymo-orchitis and this may impair spermatogenesis. The condition commonly occurs in associa- Tey are brilliantly transilluminate because tion with infection of the urinary tract such Treatment they contain crystal clear fuid. Asymptomatic varicocele-No treatment like a bunch of tiny grapes, located behind the follow instrumentation of the urinary tract. Tese are cysts in connection with the epidi- following embryonic remnants around the Severe pain in the testes and groin along dymis divided into the following types: epididymis. The paradidymis or organ of Geraldes Culture of urethral discharge and urine can degeneration of the appendages of epidi- which represents the mesonephric reveal the ofending organism. Tis is the common- • Strict bed rest and scrotal support is of the mesonephric tubules and the duct. Elephantiasis is due to obstruction of the • Tere may be vesicular eruptions over the pelvic lymphatics by W. Secondary hydrocele or chylocele in In the tropics, the commonest cause is Causes of Lymphangitis the tunica vaginalis. Eosinophilia 5 to 15 percent in early cases, ofen due to a hematogenous spread than products from dead worms, undergo- no such fnding in late cases.

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Onchocerciasis is seen exclusively in Africa and also be taken cheap trimox 500mg fast delivery bacteria in florida waters, wherever possible cheap 500mg trimox with visa antibiotics for sinus infection for adults, of visual field and near South America and trachoma in trophical regions order cardizem master card. For visual field comparisons, patients with field children, genetic factors are the major cause of blindness of vision less than 10° but more than 5° around central in the west, while xerophthalmia and measles are fixation should be placed in category 3 while those with responsible for more than 50 percent of childhood blindness in Asia and Africa. The National Program for Control of Blindness in The first comprehensive survey was undertaken by India defines blindness in the following manner. Of these Vision < 6/18-6/60 in better eye : Low vision Vision < 6/60-3/60 in the better eye : Economic blindness 3. The major Vision < 3/60 in the better eye : Social blindness causes of blindness in this survey are shown in Table 21. The main blinding diseases have specific epidemio- Causes Percentage of blind logical characteristics which, if properly assessed, may Cataract 81. In developing Moderate 1 to 49 Gujarat, Haryana, Kerala, Bihar, Karnataka, Andhra Pradesh, Assam countries, the onset is much earlier, usually after the age High 1. Very high > 2 Madhya Pradesh, Rajasthan, J and K Sex: Women are more commonly affected but men have been observed to be 1. The causes enumerated in this related to poor nutritional status, use of cheap fuel survey are shown in Table 21. Similarly, low of blindness in India are follows: literacy levels also predispose to increased risk of • Increase in population cataract. The literacy effect may also be due to other • Increased life expectancy underlying socioeconomic factors. This was done in Sivagana district tional crisis and the type of fuel used for cooking have (Tamil Nadu) and Bharatpur district (Rajasthan). In these areas the active inflammatory stage of trachoma starts during infancy, with gradual Xerophthalmia is a major cause of blindness in the pre- conjunctival scarring during school age and school age group (0 to 5 years) and is commonly adolescence. Twenty-three countries in inverted eyelids, does not appear until the fourth the world have the highest risk of vitamin A deficiency. Cross-sectional prevalence surveys in Asia Over the years, blinding trachoma has declined in indicate that 0. Females suffer more from trachoma and also blindness and Bitot’s spots occur more frequently in males, the incidence of active corneal lesions is similar have a higher risk of blinding trachoma. Nutritional blindness is mostly aggregated Environmental risk factors are very important for in lower socioeconomic strata. Related to the availability of water is the Glaucoma frequency of face washing; the less the frequency of face This disease may manifest in several forms but mainly washing, the more is the frequency of trachomatous as angle closure glaucoma with sudden intense pain and afflictions. The etiology of this disorder remains characteristic optic disc changes and visual field losses. The risk of macular degeneration increases In India, prevalence of glaucoma has been reported to with age, especially after the fifth decade. Blinding trachoma is a disease of rural areas, urban Onchocerciasis slums and shanty towns where environmental sanitation is poor, overcrowding is rampant and personal hygiene Endemic onchocerciasis occurs in tropical Africa, is poor.

The etiological agents include exposure to ionizing radiations as X rays buy generic trimox 500mg on-line antibiotics prior to surgery, chemical like benzene generic 500 mg trimox free shipping antibiotic resistance veterinary medicine, genetic disorders like Down syndrome generic meldonium 250mg with mastercard, ataxia telangiectasia and acquire disorders like paroxysmal nocturnal hemoglobinuria and aplastic anemia. In the pre-T-cell type, there is presence of mediastinal mass due to thymus involvement which can compress either the vessels or airways in the region. Uncommonly, some patients may show pancytopenia with few or no blast cells in peripheral blood which is called as aleukemic leukemia. However, diagnosis is made in this condition by the presence of >20% blasts in the bone marrow. Biochemical investigations It include elevated serum uric acid and phosphate levels accompanied by hypocalcemia (because of hyperphoshatemia). So, trans retinoic acid provided from external source is benefcial in these patients. It has been linked to the exposure to radiation, benzene, alkylating agents and some chromosomal abnormalities. Juvenile myelomonocytic leu- Bone marrow fndings kemiaQ is a childhood myelo- dysplastic syndrome. It is the Cells affected Features seen commonest leukemia seen in Erythroid cells Ringed sideroblastsQ (Iron laden mitochondria in erythroblasts) with increased children suffering from neurof- iron stores bromatosis-1Q. Megaloblasts, nuclear budding, intranuclear bridging, irregular nuclei Megakaryocytes Pawn ball megakaryocytesQ (Megakaryocytes with multiple separate nuclei) Neutrophils Dohle bodiesQ (toxic granulations) are seen, Pseudo-Pelger-Huet cellsQ (Neutrophils with two nuclear lobes) are also seen Peripheral blood shows the presence of Pseudo-Pelger-Huet cells, giant platelets, macrocytes, poikilocytes and monocytosis. Clinical features are seen in only 50% patients including weakness, infection and hemorrhage due to pancytopenia. Characteristically, there is presence of splenomegalyQ caused by infltration of leukemic cells as well as extramedullary hematopoiesis. Leukocytic infltration and hypercellularity can cause sternal tenderness whereas leukostasis can cause priapism, venous thrombosis and visual disturbances. Bone marrow It is 100% cellular in these patients (in normal individuals, the marrow is 50% cellular and 50% fat is present). The erythroid precursors are decreased (due to replacement by myeloid precursors) The Neutrophil Alkaline Phos- whereas abnormal megakaryocytes are commonly seen. Chronic phase • Lasting for about 3-6 years having <10% blasts in the blood or bone marrow. Accelerated phase • Aggressive phase lasting for few months showing increased anemia and thrombocytopenia. It is characterized by presence of skin rash, absence of Philadelphia chromosome, increased levels of HbF and a poor prognosis. These are responsible for suppression of the proliferation of normal lymphocytes and bone marrow cells.

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