September, 2011 | Master Of Medicine

Monthly Archives: September 2011

Phylloides tumour

  • Phylloides tumour is also called serocystic disease of  Broide or cystosarcoma phylloides.
  • The name Cystosarcoma phylloides is a misnomer because,it is not cystic and rarely develops into sarcoma.
  • Phylloides tumour is a benign stromal breast tumour.
  • Seen in older women 40-50yrs,in pre menopausal age group.
  • Contributes <1% of breast tumours.
  • Rapidly growing, firm bosselated surface, resembles a leaf.
  • Treatment is by wide local excision.
  • Chemotherapy and radiotherapy have no role in treatment.

Causes of hyperbilirubinemia in paediatric age group

Unconjugated hyperbilirubinemia

1) Increased production- hemolytic anemia (Hereditary spherocytosis, G6PD deficiency)
ineffective erythropoesis (Thalassemia, Pernicious anemia)
2) Reduced hepatic intake from bilirubin-albumin complex – drug induced
3) Impaired hepatic conjugation
a) Physiological – functionally immature liver
b) Breast milk jaundice - pregnendiol and FFA in breast milk interferes conjugation (in susceptible)
c) Genetic deficiency of UDPG transferase – Crigler-Najjar, Gilberts
d) Hepatocellular dysfunction- Viral or drug induced Hepatitis, Cirrhosis
e) Hypothyroidism
f) Cephalhematoma

Conjugated Hyperbilirubinemia

1) Impaired secretion of conjugated bilirubin into bile – Dubin-Johnson, Rotor’s
2) Impaired bile flow

a) Obstructive jaundice
b) Primary biliary cirrhosis
c) Neonatal cholestasis – extrahepatic biliary atresia/neonatal idiopathic hepatitis
Choledochal cyst,sclerosing cholangitis,Caroli’s disease
d) Metabolic- Tyrosinemia, Wolman disease, Niemann Pick, Galactosemia, Fructosemia

Appearance of Jaundice – Area of infant body to s.bilirubin levels

Head&neck — 5mg/dl
Upper trunk & proximal Upper limb — 10mg/dl
Lower trunk & thigh – 12mg/dl
Legs — 15mg/dl
Palms & sole – >15mg/dl

Causes of jaundice and time of onset

a) within 24 hours

  • Rh incompatibility (most common)
  • Concealed haemorrhage
  • Sepsis
  • Cong. Infections – CMV, Rubella, Syphillis, Toxoplasma
b) appears in 2nd to 3rd day
  • Physiological
  • Crigler najjar
  • Early onset breast milk jaundice
c) from 3rd day to 7th day
  • Bacterial sepsis
  • UTI
  • Polycythemia
  • Cong. Infections
d) after first week -All other caouses other than those mentioned above
Physiological Jaundice (unconjugated bilirubin)
  • After 24 hours
  • progressive rise in s.bilirubin- <5mg/dl per day (no sudden rise)
  • Peaks in 3-5 days, total not more than 15mg/dl
  • Clinical jaundice resolved by 1 week in term infants and 2 week in preterm
  • 2 phases – (phase 1 – lasts 5 days in term (12mg/dl) and 7 days in preterm (15mg/dl); phase 2 – gradual decline to 2mg/dl, which          lasts 2 weeks, before falling to adult values)
Breast milk Jaundice (unconjugated)
  • After 30 hrs, exclusively breast fed infants,
  • May continue way into 3rd month
  • bilirubin may reach 20mg/dl
  • Temprorary intererruption of breast feeding will dramatically bring down bilirubin levels, once within control values restart breast feed.
Crigler Najjar syndrome

Type 1

  • Inheritance –    autosomal recessive
  • LFT    –      normal
  • Liver histology  –    normal
  • Kernicterus –  yes
  • UDPG transferase – absent
  • response to  phenobarbitone-   no response
  • hemolysis –  absent

Type 2

  • inheritance – autosomal dominant
  • LFT –  normal
  • Liver histology- normal
  • Kernicterus-   rare
  • UDPG transferase- reduced
  • response to   phenobarbitone-  decreases bilirubin
  • hemolysis –   absent

Dubin Johnson Syndrome

  1. AR, conjugated hyperbilirubinemia becoz of mutation in canalicular multidrug resistance protein 2(MRP2)
  2. LFT normal; accumulation of black granular pigment in lysosomes of centrilobar hepatocytes
  3. Increased urinary coprophorphyrin but total coprophorphyrin is normal
  4. Gall bladder is not visualised on oral cholecystography

Rotor syndrome

  • AR, congenital conjugated hyperbilirubinemia. decreased biliary excreation
  • Liver is not pigmented, urine as well as total coprophorphyrin will be increased
  • Gall bladder will be visualized

This post was written by my friend Kim George, you can contact him @drkimgeorge@gmail.com

Hodgkins lymphoma classification

There are five subtypes of Hodgkins lymphoma, they are distinguished by their morphology immunophenotype and clinical features.This classification of Hodgkins Lymphoma helps in determining the treatment and provides a rough idea regarding prognosis.

1.Nodular sclerosis

  1. Frequent lacunar cells and occassional Reid Sternberg(RS)cells.
  2. RS cells,CD15+,CD30+,EBV-ve
  3. Stage 1 and 2 diseases most common,frequent mediastinal involvement,affects young adults

2.Mixed cellularity

  1. Frequent mononuclear and diagnostic RS cells
  2. RS cells,CD15+,CD30+,70%EBV+ve.
  3. Biphasic incidence,M>F,>50%present with stage 3 or 4 disease.

3.Lymphocyte rich

  1. Frequent mononuclear and diagnostic RS cells
  2. RS cells,CD15+,CD30+,40%EBV+ve
  3. Uncommon,M>F,seen in older adults.

4.Lymphocyte depletion

  1. Reticular variant,frequent RS cells.
  2. RS cells,CD15+,CD30+,EBV+ve
  3. Uncommon,Older males affected,Advanced disease.

5.Lymphocyte predominance

  1. Lymphocytic Histiocytic(L&H)variant or Popcorn cell variant,reactive Bcells seen.
  2. RS cells,CD15-ve,CD30-ve,CD20+ve,CD45+ve,EBV-ve.
  3. Uncommon,Young males,mediastinal involvement.

Related articles

How events happen in our lives Part 1

Before I started writing this post, I was just wondering how thoughts can change the outcome of every act we are performing. After I started writing, the whole plot became a lot clearer. The story goes like this:

After finishing the MBBS course, qualified as a doctor, the first thing I wanted to do was run Amok! I really enjoyed life for a few months after my House surgeoncy.When I went to Kasargod from my native place(Kottayam) to do rural service, I never had an intention to prepare for PG entrance, my intention was just to complete the rural service and to get the hell out.

Meanwhile all my friends were attending PG coaching classes, I really enjoyed the landscape of the district where I was posted. Four months went by uneventfully, classes had begun, I didn’t even care to join.I was on regular contact with my friends, who were always talking about PG entrance and blah blah. Soon I too was interested, I didn’t know where the interest came from.Maybe I thought about future, but it began influencing me. I joined entrance classes at kottayam all of a sudden.An urge from within asked me to go that way, I obeyed it.

Thoughts influence our life, what we hear, what we see, what we say, everything has something to do with our future.Fortune tellers have a good time, because they follow this rule without knowledge.When a fortune teller predicts your future, what he does is sow some seeds of thought into your mind. The thoughts germinate and grow into big trees and bear fruits. If the seed sown is negative, the fruit will be poisonous, if the seed is a good one, the fruit will be delicious.

Take this another instance. I was planning to return from my workplace which is about 400km from my native place.My brother Justin booked the ticket for me, I got a ticket on the side upper of S4 compartment. Since I am about 6 feet, I knew I couldn’t sleep, with the unavailability of space interfering with positioning of my legs. When I called home, I told mother “Mom I am going to ask the person next to me to trade berths with me”. I forgot this incident but the real surprise came when I boarded the train! When I came in put my luggage on the berth, the lady next to me asked , “can you please take my berth and give y
our berth to me”.I was baffled, I didn’t know how this happened. But now I know how!

Thoughts influence our life a lot, what we think of now materializes tomorrow.Thoughts shape up our world, they bring into our life whatever we want. I may be talking like all those preachers out there, but this fact is true. I have experienced this in my life many times, but didn’t know it was due to my thought on a past date.

Now what I am going to do is shape my future with my thoughts, by nurturing good thoughts, by weeding out negative thoughts.

NB:This post is an old post written by myself, taken from another blog.Please do post your comments

Inspiring quotes to stay focused.

WASHINGTON, DC - JUNE 19:   Clint Dempsey #8 o...

Image by Getty Images via @daylife

There are times when we feel dull,depressed. A year of intense study can deteriorate our health,but maintain your focus, success is within reach and all glory will be yours.

I have compiled 3 quotes which will lighten up your feeling and give you a new energy on the way forward, keep going.

“Action is the real measure of intelligence All achievements, all earned riches, have their beginning in an idea Don’t wait. The time will never be just right”.

“Every person who wins in any undertaking must be willing to cut all sources of retreat. Only by doing so can one be sure of maintaining that state of mind known as a burning desire to win – essential to success Man, alone, has the power to transform his thoughts into physical reality; man, alone, can dream and make his dreams come true”.

“The ladder of success is never crowded at the top. The starting point of all achievement is desire. Keep this constantly in mind. Weak desires bring weak results, just as a small amount of fire makes a small amount of heat”.

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