Arthritis Australia

By Q. Rasul. Western Baptist College.

A good response to antihistamines would increase the likelihood that the symptoms have an allergic origin order 150 mg bupron sr otc. A prior good response to immunotherapy would strongly implicate an allergic problem buy 150mg bupron sr. Allergic symptoms are often intermittent, and even in those cases in which they are continuous, there may be intermittent exacerbations. A careful history can often narrow the list of suspected allergens responsible for the symptoms of allergic diseases. This facilitates selection of further diagnostic tests and minimizes the amount of testing performed. Awareness of these reactions can prevent unnecessary and expensive allergic evaluations. Some general characteristics of the antigens responsible for allergic illnesses must be appreciated before an adequate clinical history can be obtained or interpreted. Symptoms characteristically produced by common antigens Pollens The grains of pollen from plants are among the most important antigens that cause clinical sensitization. Most plants produce pollen that is rich in protein, and therefore potentially antigenic. Whether a specific pollen regularly causes symptom or not depends on several factors. The pollens that routinely cause illness usually fulfill four criteria: they are produced in large quantities by a plant that is common; they depend primarily on the wind for their dispersal; they are 2 to 60 m in diameter; and the pollen itself is antigenic. Under natural conditions, transfer of the pollen between flowering plants is accomplished chiefly by insects. These pollens are not widely dispersed in the air; therefore, they are rarely clinically significant. Goldenrod, which is popularly considered to cause hay fever, has little significance because its pollen rapidly falls from the air before it can be dispersed widely and reach the hay fever patient. Ragweed plants also grow abundantly in many geographic areas of the United States and Canada. The seasonal occurrence of tree, grass, and weed pollens varies with the geographic location. Even though many factors may alter the total amount of pollen produced in any year, the season of pollination of a plant remains remarkably constant in any one area from year to year. This is because pollen release is determined by length of day, which is so remarkably consistent, year to year. The physician treating allergies must know which windborne pollens are abundant in the area and their seasons of pollination. The role of many of them in producing allergic symptoms is speculative, but some species have been definitely implicated. Because fungi can colonize almost every possible habitat and reproduce spores prolifically, the air is seldom free of spores. However, seasonal or local influences can greatly alter the number of airborne spores. Periods of warm weather with relatively high humidity allow optimal growth of molds. If this period is followed by hot, dry, windy weather, the spores often become airborne in large concentration. A frost may produce a large amount of dying vegetation, but the decreased temperature may reduce the growth rate of fungi. In contrast, spring and fall provide the relative warmth, humidity, and adequate substrate necessary for the growth of fungi. Deep shade may produce high humidity because of water condensing on cool surfaces. High humidity may occur in areas of water seepage such as basements, refrigerator drip trays, or garbage pails. The role of insects, fungi, and mammals as indoor antigens has been definitely established. House dust mites (Dermatophagoides species) are now recognized as the major source of antigen in house dust ( 1,2). Carpeting, bedding, upholstered furniture, and draperies are the main sanctuaries of dust mites in a home. In tropical climates, storage mites such as Lepidus destructor and Blomia tropicalis are important indoor allergens. Dust mite sensitive patients may have perennial symptoms, although these may be somewhat improved outdoors with less humidity or during summer months. They may have a history of sneezing, lacrimation, rhinorrhea, or mild asthma whenever the house is cleaned or the beds are made. In many dust mite sensitive patients, the history is not so obvious, and the presence of perennial symptoms is the only suggestive feature. A child with a positive skin test to cockroaches is more likely to develop asthma.

The initial treatment of this patient involves fluid and salt restriction generic bupron sr 150mg otc, and diuretics to reduce the oedema bupron sr 150 mg online. He should be anticoagulated to reduce the risk of deep vein thrombosis or pul- monary embolus. Definitive treatment is by chemotherapy supervised by the haematologists to suppress the amyloidogenic plasma cell clone. Patients with nephrotic syndrome secondary to amyloidosis usually progress to end-stage renal fail- ure relatively quickly. The man has recently retired, and returned 2 weeks ago from a coach trip to Eastern Europe and Russia. Staphylococcal food poisoning occurs within a few hours and typically presents abruptly and may be severe but short-lived. Campylobacter, Salmonella and Shigella cause more severe symptoms than viral gastroenteritis. The incubation period for giardiasis is typ- ically about 2 weeks, but varies from 3 days to 6 weeks. Giardia lamblia infects the small intestine and causes a watery, yellow, foul-smelling diarrhoea. Symptoms usually improve after 2 3 weeks, but can persist, in some cases causing lactose intolerance. The history should try to distinguish between the small- and large-bowel origin of the diar- rhoea. Large-bowel diarrhoea tends to be maximal in the morning, pain is relieved by defae- cation, and blood and mucus may be present. By contrast diarrhoea of small-bowel origin does not occur at any particular time, and pain is not helped by defaecation. Typically a pale fatty stool without blood or mucus occurs in small-bowel disease. Other pathogens which cause small-bowel diarrhoea include Campylobacter, rotavirus, Cryptosporidia and Strongyloides. If small-bowel-type diarrhoea persists, other non-infective causes of malabsorption should be considered such as tropical sprue, coeliac disease, and chronic pancreatitis. Giardia lamblia occurs worldwide especially in the tropics but also is endemic in Russia, and infection occurs commonly in visitors to St Petersburg. Poor sanitation and untreated water supplies are important factors in transmission. Outbreaks can occur in residents of nursing homes, and giardiasis is a common cause of diarrhoea in homosexuals. If stool samples are negative, cysts can be found on jejunal biopsy or by sampling duodenal fluid by asking the patient to swallow the Enterotest capsule. Ideally a stool sample should be examined 6 weeks after treatment to ensure the parasite has been eradicated. If no infective cause had been found for this man s diarrhoea and weight loss, further inves- tigations would have been necessary to exclude causes such as malignancy or thyrotoxicosis. This has developed over the past 10 days, and she is now breathless after walking 50 yards. About 2 weeks ago she had a flu-like illness with generalized muscle aches and fever. She feels extremely tired and has noticed palpitations in association with her breathlessness. In addition she has some discomfort in her anterior chest which is worse on inspiration. In rural South America acute infection with the proto- zoan Trypanosoma cruzi causes fever, myocarditis and hepatosplenomegaly, and 10 30 years later this can lead to cardiac failure and conduction system defects (Chagas disease). Profound hypocalcaemia, hypophos- phataemia, and hypomagnaesaemia can all cause myocardial depression. Patients usually have a marked sinus tachycardia disproportionate to the slight fever. There may be atrial or, more com- monly, ventricular arrhythmias or signs of conducting system defects. Chest X-ray may be normal if the myocarditis is mild, but if there is cardiac failure there will be cardiomegaly and pulmonary congestion. The differential diagnoses in this case include hypertrophic cardiomyopathy, pericarditis and myocardial ischaemia. Echocardiographic changes may be focal affecting only the right or left ventricle, or global. An endomyocardial biopsy is performed as soon as possible, and will show evidence of myocardial necrosis. Paired serum samples should be taken for antibody titres to Coxsackie B and mumps. Coxsackie virus can be cultured from the throat, stool, blood, myocardium or pericardial fluid. Corticosteroids tend to be used in patients with a short history, a positive endomyocardial biopsy, and the most severe disease.