By E. Dolok. University of California, Santa Barbara.

The bacteria proliferate on the endocardium buy 125 mg sinemet medicine glossary, causing r Janeway lesions are small purchase 110mg sinemet visa illness and treatment, flat, erythematous lesions the development of friable vegetations containing bac- on soles and palms, particularly the thenar and hy- teria, fibrin and platelets. The disease process predisposes to the forma- mucosa of pharynx and retinal haemorrhages may tion of thrombus with the potential for emboli. Cytokine be seen (Roth’s spots are haemorrhages with a pale generation causes fever. Afever and a new or changing murmur is endocardi- r Full blood count shows an anaemia with neutrophilia. Urine cultures may be required to identify r Acute bacterial endocarditis presents with fever, new aurinary tract infection, and renal ultrasound may be or changed heart murmurs, vasculitis and infective indicated to demonstrate a renal abscess. Severe acute heart failure may occur due to r Chest X-ray may show heart failure or pulmonary in- chordal rupture or acute valve destruction. General signs: r Malaise, pyrexia, anaemia and splenomegaly, which Complications may be tender. Cerebral emboli may cause infarction or my- disturbance due to the valve lesion(s), e. Chapter 2: Hypertension and vascular diseases 73 Management carditis; this is due to changing patterns of the disease It is important to identify the organism responsible (elderly, drug addicts, prosthetic valves, antibiotic resis- for the endocarditis; however, this should be balanced tance). Once cultures are sent, intravenous antibiotics should be commenced based on the most likely pathogens if there is a high suspicion of Hypertension and vascular bacterial endocarditis. The r When the culture results are known endocarditis World Health Organisation latest guidelines define hy- should be treated with the most appropriate antibi- pertension with three grades of severity that reflect the otics. It is best to have a multidisciplinary approach fact that systolic and diastolic hypertension are indepen- with early microbiological and surgical advice. M > F The timing of surgery is a balance between the desire to eradicatebacteriapriortotheprocedureandtheneedfor early surgery due to the compromised haemodynamic Geography state. Aftersurgeryafullcourseofdrugtreatmentshould Rising prevalence of hypertension in the developing be given to eradicate the organisms. For example, amoxycillin for dental procedures, tension: and amoxycillin and gentamicin for oropharyngeal, gas- Essential hypertension (>90%) r Non-modifiable: Genetic (racial and familial), gender trointestinal or genitourinary procedures. Prognosis r Modifiable: Obesity, alcohol intake, diet (especially Despite advances in treatment, overall mortality is still high salt intake). Complications Hypertension is a major risk factor for cerebrovascular Pathophysiology disease (strokes), heart disease (coronary artery disease, r Hypertension accelerates the age-related process of left ventricular hypertrophy and heart failure) (see Table arteriosclerosis ‘hardening of the arteries’ and predis- 2. Arterioscler- include peripheral vascular disease and dissecting aortic osis, through smooth muscle hypertrophy and intimal aneurysms. In r The chronic increased pressure load on the heart re- severehypertension,retinalhaemorrhages,exudatesand sults in left ventricular hypertrophy and over time this papilloedema are features of malignant hypertension. Saltand r Benign hypertension and small arteries: There is hy- water retention occurs, which can itself worsen hyper- pertrophy of the muscular media, thickening of the tension. In cases of doubt, r Routine investigations must include fasting plasma 24-hour blood pressure recordings may be helpful such glucose, serum total cholesterol and lipid profile, as when ‘white coat’ hypertension is suspected. Management Peripheral arterial disease Treatment is based on the total level of cardiovascular Definition risk and the level of systolic and diastolic blood pressure Peripheralarterialdiseasedescribesaspectrumofpatho- (see Tables 2. Stopping smoking as well as the ac- tions mentioned above will also reduce overall cardio- Age vascular risk. If after 3 months their M > F systolic blood pressure is above 139 or the diastolic above 89, treatment should be started.

Wet beriberi is the high output heart failure caused by thiamine deficiency resulting in Management oedema sinemet 125 mg otc medicine 93 2264. Supplementation with nicotinic acid and treatment of other coexisting deficiencies buy sinemet 125mg on-line medicine clip art. Erythrocyte transketolase activity and blood pyruvate Vitamin B6 (pyridoxine) deficiency are increased. Definition Deficiency of pyridoxine is rarely a primary disorder, but Management it does occur as a secondary disorder. The cardiac failure usually responds rapidly, but Aetiology neuropathies may only partially resolve if they are long- Important sources of Vitamin B6 are similar to those of standing. Deficiency may occur with malabsorp- Niacin deficiency (pellagra) tion such as coeliac disease, dietary lack in alcoholism and drug toxicity especially isoniazid. Definition Niacin (vitamin B3) has two principle forms: nicotinic Pathophysiology acid and nicotinamide. Deficiency of niacin causes pel- Pyridoxine is important in the metabolism of amino lagra. In some rare metabolic disorders, pyridoxine deficiency is as- Aetiology sociated with infantile convulsions and sideroblastic Niacin is found in plants, meat and fish. Clinical features Othercausesincludeincreasedtryptophanconsumption Marginal deficiency may cause stomatitis, glossitis, dry in the carcinoid syndrome, prolonged use of isoniazid lips, irritability and confusion. Deficiency causes men- and Hartnup disease, an autosomal recessive congenital tal confusion, glossitis, dry skin lesions and peripheral disorder with reduced absorption of tryptophan from neuropathy. Management Pathophysiology Oral replacement; however, high doses may cause Nicotinic acid is involved in energy utilisation. Vitamin B12 deficiency It is also used in maintaining skin, especially in sun- exposed areas. Vitamin C deficiency Clinical features Pellagra is due to lack of nicotinic acid, it often occurs Definition as part of a more general nutritional deficiency. Pellagra Vitamin C deficiency causes scurvy, which was first de- presents with dermatitis, diarrhoea and dementia. Chapter 13: Metabolic disorders 513 Aetiology/pathophysiology tably in the brain in Alzheimer’s disease. Genetic factors Occurs in the poor, pregnant or those on a peculiar may be involved in predisposing to the development of diet. Vitamin C fibrillogenesis and amyloidosis: (ascorbic acid) is found in citrus fruits, potatoes, green r Geneticmutationsresultinginproteinswithincreased vegetables and fortified fruit drinks. Clinical features Patients develop listlessness, anorexia, cachexia, gingivi- Clinical features tis, loose teeth, petechial haemorrhages and bleeding. The precursor protein, the tissue distribution and the amount of amyloid deposited affect the clinical presen- Management tation. Deposition in the coronary arteries can lead Vitamin K deficiency to ischaemic heart disease. Amyloidosis r Musculoskeletal system deposition may cause mus- Definition cle pseudohypertrophy, macroglossia, arthropathy, Amyloidosis refers to the extracellular deposition of spondyloarthropathy, bone disease and carpal tunnel fibrils composed of low-molecular-weight proteins, syndrome. This form of deposition is particularly seen many of which circulate as constituents of plasma. At least 21 different protein precursors of amyloid fibrils are now known (see Table 13. Investigations Besides systemic amyloid deposition, organ specific Where possible biopsy and histology is used to con- amyloid may occur in the skin or heart and most no- firm clinical suspicion. Familial amyloidosis Various Autosomal dominant inherited, including familial transthyretin-associated amyloidosis.