Acute Angle-Closure Glaucoma

Acute angle-closure glaucoma (ACG) is secondary to narrowing or closure of the anterior chamber angle, resulting in increased intraocular pressure (IOP), with subsequent damage to the optic nerve.

Pathophysiology: Normally, aqueous humor drains out of the anterior chamber via Schlemm canal in the anterior chamber angle. In ACG, this flow is impeded, and the IOP rises from a normal range of 10 to 21 mm Hg to 50 mm Hg or higher.

Clinical Presentation: ACG presents as an acutely inflamed eye. Nausea and vomiting are common and may be the presenting complaints. Eye pain and headache vary in severity. As the IOP reaches
the 50 to 60 mm Hg range, fluid is forced into the cornea, resulting in corneal edema. Patients report blurred vision and rainbow-colored halos around lights.

Acute Angle-Closure Glaucoma. The cornea is edematous, manifest by the indistinctness of the iris markings and the irregular corneal light reflex. Conjunctival hyperemia is also present.

Clinical findings include:

• tearing, 
• perilimbal injection (“ciliary flush”), 
• a cloudy (“steamy”) cornea, 
• a nonreactive mid-dilated pupil, 
• anterior chamber inflammation, and 
• an increased IOP. 
• Using a penlight or slit-lamp microscopy, the anterior chamber may appear shallow.

Pseudotumor Of The Lung On Chest X ray

X ray chest of a 48 year old woman who presented with generalized weakness is shown below:

Description: Chest X-ray shows an oval soft tissue density which overlays over most of the minor fissure. It is well-defined, no calcification seen and the surrounding lung is clear.

Diagnosed as Pseudotumor.

Comments And Explanation: Loculation within the fissure gives appearance of a tumor and is referred as pseudotumor. The pulmonary pseudotumor is sharply marginated collection of pleural fluid contained either within an interlobar pulmonary fissure or in a subpleural location adjacent to a fissure. Pseudotumors are identified on chest X-rays on their lenticular pattern.
CT chest confirms a loculated effusion within the fissure with Hounsfield value that of a transudate. The pseudotumor resolves with conservative management.
Most occur in the minor (horizontal) fissure and are seen on both the frontal and lateral radiograph; those that occur in the oblique or major fissure may only be seen on the lateral view. Pseudotumors may be erroneously diagnosed as parenchymal lung nodules or masses.

Clinical Discussion: Pseudotumor or vanishing tumor of the lung is an appropriate designation for a

Salivary Gland Tumors

Different types of tumor may occur in the salivary gland and may be benign or malignant. A brief discription of the common tumors occuring in the salivary gland is given here:

1. Pleomorphic Adenoma
The pleomorphic adenoma- mixed salivary gland tumor- is a benign tumor, and the commonest salivary gland tumor. It is most commonly seen in the parotid gland and typically forms a mass in the lateral lobe, which slowly enlarges over many years, women in their forties are most often being affected.

Clinical Features
On palpation the tumor is firm, non tender and smooth or lobulated in texture. initially spherical and encapsulated, it may eventually spread more deeply, with the result that recurrence after resection is common. On oral examination the deep part of the gland may have pushed the tonsil and pillar of the fauces towards the midline.

Histology:

Histologically, it is highly variable in appearance, even within individual tumors. Classically it is biphasic and is characterized by an admixture of polygonal epithelial and spindle-shaped myoepithelial elements in a variable background stroma that may be mucoid, myxoid, cartilaginous or hyaline. Epithelial elements may be arranged in duct-like structures, sheets, clumps and/or interlacing strands and consist of polygonal, spindle or stellate-shaped cells (hence pleiomorphism). Areas of squamous metaplasia and epithelial pearls may be present. The tumor is not enveloped, but it is surrounded by a fibrous pseudocapsule of varying thickness. The tumor extends through normal glandular parenchyma in the form of finger-like pseudopodia, but this is not a sign of malignant transformation.

Pleomorphic adenoma consists of mixed epithelial (left) and mesenchymal cell components (right). The latter often exhibits myxofibrous appearance and in some instances shows chondromatous differentiation.
2. Adenolymphoma (Warthin’s Tumor)
It is a bening tumor and the second most common salivary tumor and is found exclusively in the parotid gland. It usually affects males in their fifties, forming a slow growing, painless swelling over the angle of the jaw, there is a high incidence of bilateral disease.

Infections Causes By Herpes Simplex Virus

Herpes Simplex virus infection may be caused by type I or type II virus and the infection may be primary or recurrent.

Primary Infection
The manifestations of primary Infection includes:

1. Systemic infection: e.g fever, sore throat and lymphadenopathy that may pass unnoticed. If the patient is immunocompromised, then the disease may become life threatening with fever, lymphadenopathy, pneumonitis and hepatitis.

2. Gingivostomatitis: Ulcers filled with yellow slough appear in the mouth.

3. Herpetic Whitlow: A breach in the skin that may be due to any minor trauma allows the virus to enter the finger, causing a vesicle to form. Often this condition is seen in children nurses.

4. Traumatic Herpes: Also known as Herpes gladiatorum. In this condition vesicles develop at any site where herpes simplex virus have been inoculated on the skin by brute force.

5. Eczema Herpeticum: HSV infection superimposed on eczematous skin. Usually seen in children.

Episcleritis - A Brief Introduction

Introduction: Episcleritis is a common and benign inflammation of the episclera, typically affecting young and middle-aged adults. Seventy percent of cases occur in females.

The episclera lies just beneath the bulbar conjunctiva. Its vessels are large, run in a radial direction,
and can be seen beneath the overlying conjunctiva. Episcleral and conjunctival vessels blanch with the use of topical 5% phenylephrine drops, unlike deep episcleral vessels.

Clinical Features: 

• Patients may complain of foreign body sensation, mild tenderness, irritation, mild photophobia, and excessive lacrimation.
• Pain is unusual but can occur, particularly in chroniccases. 
• One-half of cases are bilateral. 
• Eye findings are notable for a localized pink or bright red conjunctival injection, with involvement of the vessels in the superficial episcleral vascular plexus. 
• Visual acuity is normal.

Associated  Conditions: Episcleritis is usually an isolated condition, though it may be associated with a number of systemic diseases, including rheumatoid arthritis, inflammatory bowel disease, lupus, and vasculitis.

Skin Manifestations Of Non Malignant Systemic Diseases

The skin functions as a barrier against potentially harmful physical and chemical agents as well as against different microorganisms. Sometimes different features may be seen that help to differentiate different systemic diseases. 

A brief list of the skin manifestations of non malignant systemic diseases is given here:

1. Erythema

• Collagen disease
• Carcinoid
• Mitral valve disease
• Polycythemia
• Superior vena caval obstruction
• Liver disease
• Hyperviscosity syndrome

                                                  Facies in Primary Polycythemia vera. 

2. Erythema Multiforme

• Fever
• Inflammatory bowel disease
• Rheumatoid arthritis
• Thyrotoxicosis
• Viral Infections

                                               Erythema Multiforme (target skin lesions) 

3. Urtricaria

• Collagen disorders
• Xanthomatoses
• Hereditary angioneurotic edema
• Urtricaria pigmentosa
• Henoch-Schonlein purpura
• Cold aglutinins