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Bray and Gallagher androgen hormone pdf order 60 ml rogaine 5 mastercard, who analyzed eight cases of the latter type prostate 5lx 120 softgels rogaine 5 60 ml line, concluded that the critical lesion was a bilateral destruction of the ventromedial regions of the hypothalamus prostate 8 formula generic rogaine 5 60 ml otc. Most of the reported cases of this type have been due to tumors, particularly craniopharyngioma, and some to trauma, inflammatory disease, and hydrocephalus (Suzuki et al). In a case that was subject to clinicopathologic correlation, Reeves and Plum found that a hamartoma had destroyed the medial eminence and the ventromedial nuclei bilaterally but spared the lateral hypothalamus. Hyperphagia and rage reactions were the main clinical features; the associated polydipsia and polyuria were due to extension of the tumor to the anterior hypothalamus. It is evident that in only a tiny fraction of persons can obesity be traced to a hypothalamic lesion. Of overriding importance are genetic factors, such as the number of lipocytes that one inherits and their ability to store fat. A rare disorder of infants has been described under the title of diencephalic syndrome. Progressive and ultimately fatal emaciation (failure to thrive), despite normal or near-normal food intake, in an otherwise alert and cheerful infant is the main clinical feature. The lesion has usually proved to be a low-grade astrocytoma of the anterior hypothalamus or optic nerve (Burr et al). Extrahypothalamic parts of the brain, if diseased, may also be associated with increased food-seeking behavior, food ingestion, and weight gain. Examples are involvement of limbic structures, as in the Kluver-Bucy syndrome (page 448) and basal frontal lobe Ё lesions leading to gluttony. Anorexia Nervosa and Bulimia the special syndromes called anorexia nervosa and bulimia have been difficult to classify and are mentioned in this chapter only because they are associated with Pituitary Insufficiency Loss of function of the anterior pituitary gland may result from disease of the pituitary itself or from hypothalamic disease. In either event, it leads to a number of clinical abnormalities, each predicated on the deficiency of one or more hormones that depend on the pituitary trophic factors described earlier. The condition of panhypopituitarism represents the more serious illness in that it requires supplementation with multiple hormones. Hypopituitarism may have its onset in childhood, either as an inherited process that affects individual or multiple hormones or as a secondary process due to a destructive lesion of the pituitary or the hypothalamus from tumor. Later in life the causes vary, but the most common are pituitary surgery, infarct of the gland from a rapidly growing adenoma (pituitary apoplexy, page 577), involutional changes that occur at the end of pregnancy (Sheehan syndrome), cranial irradiation for cerebral tumors other than those in the pituitary fossa, lymphocytic hypophysitis, and granulomatous and neoplastic invasion. The clinical features of pituitary failure vary, but impairments of thyroid function tend to be more prominent than those of adrenal failure. The neurologic accompaniments of pituitary failure depend on the underlying cause; Lamberts and colleagues have reviewed the endocrinologic aspects. These usually occur not in isolation but in various combinations, comprising a number of rare but well-characterized syndromes. Precocious Puberty this term refers to the abnormally early onset of androgen secretion and spermatogenesis in boys and of estrogen secretion and cyclic ovarian secretion in girls. It is associated with the premature development of secondary sexual characteristics. The occurrence of precocious puberty always calls for a neurologic as well as an endocrine investigation. In the male, one searches for evidence of a teratoma of the pineal gland or mediastinum or an androgenic tumor of the testes or adrenals. In the female with early development of secondary sexual characteristics and menstruation, one seeks other evidence of hypothalamic disease as well as an estrogen-secreting ovarian tumor. In all likelihood, these alterations are not the result of a primary dysfunction of hypothalamic nuclei but are secondary to the extreme weight loss, which is the primary feature of the disease. However, a causal link between these idiopathic diseases and hypothalamic dysfunction has been suggested by the rare patients with anorexia nervosa who were later found to have hypothalamic tumors (Bhanji and Mattingly, Berek et al, and Lewin et al). Anorexia nervosa and bulimia are probably best regarded as disorders of behavior, in this case an obsession with thinness; they are therefore discussed with the psychiatric disorders (see page 1304). Many patients with the more severe forms of mental retardation are subnormal in height and weight, but the explanation for this has not been ascertained.
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The maternal infection may be so mild that it is passed off as minor; but even when it is evident androgen hormone metabolism cheap rogaine 5 60 ml with visa, the fetus is spared in about 50 percent of cases man health daily tip us images buy rogaine 5 60 ml visa. In the nervous system of abortuses (the abortion performed because of proven maternal rubella in the first trimester) man health tonic generic rogaine 5 60 ml visa, R. Adams found no visible lesions by light microscopy, even though the virus had been isolated from the brain by Enders. At this period of development there is no inflammatory reaction because of the absence of polymorphonuclear leukocytes, lymphocytes, and other mononuclear cells in the fetus. At birth the brain is usually of normal size, and there may be no discernible lesions. In a few, a mild meningeal infiltration of lymphocytes as well as a few zones of necrosis and vasculitis with later calcification of vessels are seen, as are small hemorrhages, presumably related to the thrombocytopenia. Smallness of the brain and delay in myelination have been observed in children dying at 1 to 2 years of age. A delayed progressive rubella encephalitis in childhood is also known and is described on page 651. Our colleagues have had two cases, studied in serial sections by Yakovlev, that survived 5 to 6 years. Since there is no treatment for the active infection, the obvious approach to the problem of congenital rubella infection is to make sure that every woman has been vaccinated against rubella or has antibodies as a result of infection prior to pregnancy. The widespread use of rubella vaccine has reduced the chance of major outbreaks, but sporadic infections continue to be seen, and outbreaks of epidemic proportions continue to occur in developing countries. Congenital Cytomegalovirus Infection For many years it was known that in the tissues of some infants who died in the first weeks and months of life there were swollen cells containing intranuclear and cytoplasmic inclusions. In 1956 and 1957, three different laboratories isolated what has come to be called the human cytomegalovirus (see Weller). Although cervicitis is common, the virus is probably transmitted to the fetus transplacentally. Infection of the fetus usually occurs in the first trimester of pregnancy, sometimes later, by way of an inapparent maternal viremia and infection of the placenta. However, only a small proportion of women known to harbor the virus give birth to infants with active infection. The likelihood of the fetus being infected is much greater if the seronegative mother becomes infected for the first time during pregnancy. Early infection of the fetus may result in a malformation of the cerebrum; later, there is only inflammatory necrosis in parts of the normally formed brain. In the low-birth-weight or full-term infant, the clinical picture is one of jaundice, petechiae, hematemesis, melena, direct hyperbilirubinemia, thrombocytopenia, hepatosplenomegaly, microcephaly, mental defect, and convulsions. Disseminated inflammatory foci have been observed in the cerebrum, brainstem, and retinae. The mononuclear histiocytes (microglial cells) contain inclusion bodies; some astrocytes are similarly affected. There is no way of identifying the infected fetus prior to birth or to prevent inapparent infections in the pregnant woman. Moreover, some infected infants (with viruria) may appear normal at birth but develop neural deafness and mental retardation several years later. Viral replication in infected organs continues after the first year and health workers are at risk. The difficulties in prenatal diagnosis of maternal infection preclude planned abortion. Routine serologic testing should be done on every young woman of childbearing age. Until an effective vaccine becomes available, pregnancy should be avoided if a sexual partner is infected. There may also be vascular lesions, with infarction or hemorrhage and lymphoid neoplasia. To date there is little that one can do for these children, but this may be changing with the current use of three-drug antiretroviral therapy, as described in Chap.
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Another early-life hereditary retinal degeneration prostate cancer untreated purchase rogaine 5 60 ml with amex, characterized by massive central retinal lesions prostate cancer juice cure buy rogaine 5 60 ml cheap, is the autosomal recessive Stargardt form of juvenile tapetoretinal degeneration androgen hormone excess order rogaine 5 60 ml overnight delivery. Like retinitis pigmentosa, Stargardt disease may be accompanied by progressive spastic paraparesis or ataxia. Nonpigmentary retinal degeneration is a familiar feature of a number of other rare syndromes and diseases, such as neuronal ceroid lipofuscinosis, Bassen-Kornzweig disease, Refsum disease, BattenMayou disease, and others (see Chap. If these drugs are administered in high dosages for protracted periods, the patient should be tested frequently for defects in visual fields and color vision. Among the drugs used to treat neurologic disease, vigabatrin is notable for causing retinal degeneration and a concentric restriction of the visual fields in almost half of the patients. Retinal degeneration may also occur in patients with an oatcell carcinoma of the lung as a so-called paraneoplastic illness (see Chap. Antiretinal ganglion cell antibodies, presumably produced by the tumor cells, have been demonstrated in the serum of such patients by several investigators (Grunwald et al; Kornguth et al; Jacobson et al). Certain lysosomal diseases of infancy and early childhood are characterized by an abnormal accumulation of undegraded proteins, polysaccharides, and lipids in cerebral neurons as well as in the macula and other parts of the retina (hence the terms storage diseases and cerebromacular degenerations). Corneal clouding, cherry-red spot and graying of the retina, and later optic atrophy are the observed ocular abnormalities. In some of these retinal diseases, minimal changes in the pigment epithelium or other layers of the retina that reduce visual acuity may not be readily detected by ophthalmoscopy. In these circumstances, it is helpful to estimate the time required for recovery of visual acuity following light stimulation (macular photostress test). This test consists of shining a strong light through the pupil of an affected eye for 10 s and measuring the time necessary for the acuity to return to the pretest level (normally 50 s or less). With macular lesions, recovery time is prolonged, but with lesions of the optic nerve, it is not affected. This phenomenon may be observed in the eye on the side of a carotid occlusion, in essence an ischemic retinopathy. Retinal diseases reduce or abolish the electrical activity generated by the outer layers of the retina, and this can be measured in the electroretinogram. As macular degeneration begins to disturb vision, the straight lines on the Amsler grid are observed by the patient to be distorted. Examination discloses central scotomata and an alteration of the retina around the macula. Central vision is at first distorted, then gradually diminishes, impairing reading, but these patients can still get about because of retained peripheral vision. The two most common types of macular degeneration are an atrophic "dry" type, which is a true pigmentary degeneration causing gradual visual loss, and an exudative "wet" type, which is the result of choroidal vascularization and secondary macular damage. Diabetic Retinopathy Although not strictly speaking a problem taken up by neurologists, this is such an important cause of reduced vision and blindness that the basic facts should be known to all physicians. The earliest changes are of microaneurysms and tiny intraretinal hemorrhages; these are present in almost all diabetics who have had type 1 disease for more than 20 years. Subsequently, there is a more threatening proliferative retinopathy that consists of the formation of new blood vessels and consequent leakage of proteins and blood. The proliferative feature occurs in half of type 1 diabetics and 10 percent of those who have had type 2 disease for 15 to 20 years. The new vessels can grow into the vitreous and hemorrhage and may cause traction on the retina, which results in detachment. Elevated levels of vascular endothelial growth factor have been shown to be the cause of retinal neovascularization in diabetic retinopathy. Papilledema and Raised Intracranial Pressure Of the various abnormalities of the optic disc, papilledema or optic disc swelling has the greatest neurologic implication, for it signifies the presence of increased intracranial pressure. Mild papilledema with hyperemia of the disc and slight blurring of the disc margins. Chronic papilledema with beginning optic atrophy, in which the disc stands out like a champagne cork. The hemorrhages and exudates have been absorbed, leaving a glistening residue around the disc.
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