Gian M. Novaro, MD, MS

• Director, Echocardiography
• Department of Cardiology
• Cleveland Clinic Florida
• Weston, Florida

Within each adjustive description presented in Chapters marily one of these many systems or approaches prostate cancer blood in urine generic penegra 50 mg with mastercard. A therapy or technique that works for sectional pieces mens health logo penegra 100 mg with visa, and the appropriate use of any additional pil one patient or problem may not work on a different problem or lows or rolls prostate cancer yahoo answers order penegra now. An integrated approach that incorporates alternative tech described to ensure proper segmental tension mens health vitamin guide quality 100mg penegra. Adjustive tech equipment varieties and Management nique is a psychomotor skill that requires personal development and modification androgen hormone production buy generic penegra 100mg online. Limiting alternatives to one approach may the development of the equipment used by chiropractors and other exclude techniques that fit the physical characteristics of the doc practitioners of manipulation has taken place over time prostate ultrasound generic penegra 50mg with visa. The first chi Although some techniques differ dramatically, most thrust tech ropractic table had a flat, wooden surface atop ornate turned legs. It was not until 1943 that the first pad was designed for chiropractor must have a foundation in these common principles the adjusting table surface. As each spinal region and extremity joint is presented, the A wide range of specialized adjusting tables and equipment unique relationship between regional anatomy, biomechanics, and is now available to enhance patient comfort and adjustive effi adjustive mechanics is discussed (see Chapters 5 and 6). Some equipment is designed for the application of specific delivery of an adjustment. It is an essential component of effec techniques, but most tables may be used with any of the common tive adjustive treatment. Patients placed in awkward positions are apprehensive and to his or her physical attributes, use clean face paper on the head unlikely to relax. Improper selection can leave the doctor at a piece of the adjusting table, and regularly apply a disinfectant to the mechanical disadvantage and in a position of increased risk of table. The average table height for pelvic, lumbar, and thoracic Whenever possible, the doctor should allow the patient to posi adjusting is the distance from the floor to the middle or superior tion himself or herself. The patient should be instructed on how to comfortably assume or modify his or her position on an adjustive bench. If it is necessary to assist a patient, the doctor should ensure A that his or her back is in a stable position and that the patient is B D close to his or her center of gravity. Whenever possible, the doctor C E should use the power available in his or her legs to assist with lifting, pushing, or pulling movements. Adjustive localization and efficiency are products of adjustive leverage, preadjustive tissue resistance, and joint locking. By positioning the joint to be distracted at the apex of secondarily established curves, joint dis Figure 4-37 Specialized tables and equipment are used to enhance traction is increased, and the dysfunctional joint and spinal sec patient comfort and adjusting efficiency. An adjusting bench (Figure 4-38) is a pad ded, nonarticulated, flat table with a face slot. A pelvic bench is very similar to the Figure 4-39 Use of rolls and wedges to modify preadjustive patient standard adjusting bench. The lack of articulated sections limits the ability of adjusting benches to spine are left in an unsupported and unrestricted position. Consequently, this table may be most effec movable head, thoracic, pelvic, and foot pieces to properly accom tive when applied in the treatment of lower thoracic and lum modate the patient in both the prone, side posture, and supine bar extension restrictions. High-low tables tilt from a vertical to patients with large abdomens for whom the prone position is a horizontal position, making it easier for a patient to get on and uncomfortable. Patients beyond the first trimester of pregnancy off the table (see Figure 4-40, B). Elevation tables have the ability may be more comfortable and have less anxiety in the knee-chest to adjust to variable heights for different procedures as well as for position than prone when having P-A thrusts applied to the different-sized doctors (see Figure 4-40, C). When the patient is in the supine position on an articulating the attributes of the knee-chest table are also the features that table, the headrest should be closed and elevated, and all other contribute to its greatest inherent risk for hyperextension injuries. When performing the risk of injury can be minimized by gently developing preten cervical or upper thoracic adjusting, the headpiece may be slightly sion and delivering shallow and nonrecoiling adjustive thrusts. For prone positioning, to achieve a relaxed neutral pos Although cervical, thoracic, and lumbar techniques can be per ture, the footrest, pelvic, and thoracic sections should be elevated formed in the knee-chest position, lower thoracic and lumbar dys slightly, and the headrest should be lowered slightly. The knee-chest table (Figure 4-41) gets its In a predicament, the knee-chest position can be approximated name from the position the patient assumes when on the table. Chapter 4 Principles of Adjustive Technique | 131 4 2 3 1 A Figure 4-41 Knee-chest table. The amount of tension varies depending on the size of the patient, the extent of established preadjustive tension, and the force of the adjustive thrust. The degree of tension established in the drop mechanism should not be ascertained by thrusting against the C patient. Tension should be determined by placing the patient on Figure 4-40 Articulated and hydraulic tables. One position suggests that the degree of adjustive effort and force may be reduced because the drop of the table decreases Some doctors and patients are quite apprehensive about knee the counter-resistance of the table and the patient. In such circumstances, an articulated table may assertion is that the force of the adjustive thrust is enhanced by be used to achieve a similar position. This may be accomplished the counter-reactive force generated across the joint when adjus by slightly raising the pelvic piece and allowing the thoracic piece tive thrusts are maintained through the impact of the drop piece. Mechanical drop pieces are available on any or all drop mechanism and apply multiple light shallow recoil thrusts. Drop mech the thrust is typically terminated before the drop mechanism has anisms allow for the elevation of sectional pieces and the subse completely terminated its drop. In the second approach, resis quent free fall of those sections when sufficient adjustive force tive tension of the drop mechanism is increased to the point at is applied against the patient. The patient should sit with legs comfortably straight action, which makes it difficult to perceive specific joint move ened and hands relaxed on the thighs. The mobile pelvic piece provides a long-lever action that allows the lumbar spine to be positioned in or mobilized in flexion, extension, lateral flexion, or rotation, as well as the combined movement of circumduction. Technique procedures applied to mechanical distraction tables commonly use a manual vertebral contact and either a manual or motorized mobile pelvic section to create distraction. Distraction tables can be used to evaluate spinal mobility, mobilize spinal artic ulations, or assist the doctor in the application of thrust techniques. This motion is produced as the motor ized pelvic section of the table rhythmically depresses toward the floor and back to a neutral position. Additional tension in rotation and lateral flexion can be added by prepositioning the table into the desired direction of rotation or lateral flexion. Some tables also provide the added feature of linear axial distraction, focusing on the long axis of the body (Figure 4-44). When applying motion-assisted procedures for spinal joint dys function, the patient is typically positioned on the table so that B L5 L4 L3 L2 the pelvis is on the pelvic section. Doctors should take caution not to four to fire pumps for one to two additional cycles, with a 30-second rest use excessive flexion with segmental distraction; excessive flexion between. Chapter 4 Principles of Adjustive Technique | 133 thrusts through articulations positioned at end range or in close doctor positioning packed positions places additional tension on the joint capsule Chiropractic is a physically demanding profession associated with and surrounding soft tissues. Core spinal stability and muscular brac ous stressful postures and repetitive movements involving pushing, ing of the involved extremity joints are essential to the applica pulling, twisting, bending, and lifting. Common to determine the prevalence and types of work-related injuries hazardous postures include excessive flexion and twisting of the among a random sample of chiropractors and to identify factors trunk, excessive internal rotation and abduction of the shoulder, associated with these injuries. These injuries were most often related to side posture slouching of the upper back and excessive stress on the posterior manipulation to the lumbar spine. Good body mechanics start by selecting an appropriate table Another critical element in the efficient and effective use of height to maintain a balanced and relaxed stance. The effec ered adjustments and repetitive stress injuries to the upper extrem tive use of body weight (mass) can minimize the effort expended ities. Accommodations to lower tables should be made by can be increased during the adjustment without increasing the bending at the knees and hips and abducting the thighs, not by velocity. Delivering weight and leg strength saves energy for the adjustive thrust and minimizes the workload on the upper extremities. Figure 4-48 illustrates two of the common stances; other modi fications are discussed and illustrated in the regional sections on adjusting. Excessively bony or penetrating contacts A B can prevent an adjustment from succeeding by generating unnec Figure 4-46 a, Illustration of sound body essary splinting and resistance from the patient. Uncomfortable 4-46A, B contacts in the thoracic and lumbar spine may be associated with mechanics and doctor accommodating the table by bending hips and widening his stance and maintaining neutral spinal pos postures involving excessive extension of the wrist or arching of ture. Uncomfortable contacts in the neck are often encoun sively flexing his spine and slouching over the patient. The doctor has dropped his head and upper back into 4-47A, B excessive flexion and has positioned his torso and center of gravity to superior and anterior to his contact point. The points of patient contact and forces necessary to maintain positioning and stabilization are also presented within this cate gory. In the illustrations throughout the text, when thrust ing forces are delineated from stabilization forces, an arrow is used to demonstrate adjustive vectors, and a triangle is used to demon strate stabilization points (Figure 4-50). When accommodating a lower table, the doctor attempts to maintain a neutral spinal posture contacts are to be established on the patient. When possible, they are illustrated in photographs or draw and angled to the torso. This position allows the doctor to efficiently transfer weight intended to be illustrative and clarify the underlying focal point of forward and inferior toward his front foot. Segmental contacts focused at specific bony landmarks cannot be established without contacting overlying or adjacent soft tis than the more padded palmar lateral surface of the finger, is used sues. In this illustration, segmental contacts 3 are illustrated for a spinous push-pull adjustment. Overlying and adjacent soft tissue strucures are obviously also contacted 1 11 vertebra or both vertebrae of the involved motion segment are also effective and in common use. Contacts established on the lower vertebra of the dysfunctional motion segment establish a resisted method; contacts on the superior vertebra establish an assisted Figure 4-49 Contact points on the hand: (1) pisiform; (2) hypoth method; and contacts established on adjacent vertebrae establish enar; (3) metacarpal or knife-edge; (4) digital, used typically with the a counter-resisted method (see Figure 4-51). Assisted and resisted index and middle fingers; (5) distal interphalangeal; (6) proximal inter methods are summarized in Table 4-3. It appears that short-lever prone thoracic adjustments do induce relatively specific effects as compared with side posture lumbar adjustments. If a local focused force is desired, then errors in the placement of adjustive contacts may lead to the localization of adjustive forces adjustments, and adjustments that combine short and long-lever at undesired segmental levels. However, this does not imply that contacts are referred to as semidirect adjustments. What is important is the ability to locate taken on the superior vertebrae of the dysfunctional motion seg contacts in a manner that focuses the adjustive forces and desired ment. Methods that incorporate thrusting contacts on the lower movements in the joints or region to be adjusted. The patient can remain in the neutral position and still have these principles apply. A number of the adjusting methods used by chiropractors of the female doctor and the patient can become an issue. This can easily be avoided if the doctor is simply aware of Explanation of procedures is essential, followed by the questions this potential and positions himself or herself accordingly. The internal mobilization or manipulation of the learn these skills by voluntarily practicing on each other. Therefore, it is impor Superficial tissue traction (pull) is typically applied during the tant to be attentive to procedures that chiropractors may take for establishment of an adjustive contact.

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Obstructive: obstruction of upper airway during sleep with continued respiratory effort; most often associated with obesity or abnormal pharyngeal anatomy 2 man health tonic discount penegra 50mg fast delivery. Central: loss of central respiratory drive leads to cessation of airflow and respiratory effort 3 mens health gift guide order generic penegra from india. Etiology is unknown but may be linked to abnormal feedback control during sleep or decreased sensitivity of upper airway muscles to stimulation man health shop proven penegra 50mg. H/P 5 fatigue man health urban athlon purchase 100 mg penegra otc, excessive daytime sleepiness mens health breakfast recipes generic 50mg penegra otc, snoring androgen hormone in females generic penegra 50mg otc, gasping or choking during sleep, morning headaches or confusion, impaired daytime function because of sleepiness; obesity common, anatomic abnormalities of palate or pharynx may be visible F. Labs 5 Epworth sleepiness scale is useful for predicting likelihood of sleep apnea as cause for daytime somnolence (score. Localized alveolar collapse; common after surgery (especially abdominal) and fever, but the relationship is anesthesia (generally not clinically serious); can also occur in asthmatics, after more likely coincidental than foreign body aspiration, or from mass effect. H/P 5 asymptomatic if mild or slow development; pleuritic chest pain, dyspnea; fever, decreased breath sounds, dullness to percussion over affected area 3. Treatment 5 incentive spirometry, ambulation, and inpatient physical ther If atelectasis lasts. Placement of tube into trachea to maintain airway patency and allow mechanical ventilation during anesthesia and times of respiratory distress 2. Almost all intubations are performed orally (nasal intubation performed for oral surgery, jaw surgery, and in cases when a laryngoscope cannot help to visualize the vocal cords). Laryngoscope inserted into mouth and used to lift jaw and visualize lower phar esophageal placement. Endotracheal tube inserted past vocal cords (direct visualization is important) to depth of 21 to 23 cm (measured at lips). Complications 5 dental injury during placement, placement of tube in esophagus, increased risk of infection 5. Ventilation is assisted respiration that is required during surgery under anesthe sia; it may also be required to maintain patent airway or in cases where the pa tient is not able to breathe without assistance. Inspiration is ventilator driven; expiration occurs through natural recoil of the lungs. Patients are weaned from the ventilator by changing from more patient-independent modes to more patient-dependent modes. Extubation (removal of the tube) can be performed when the patient is capable of breathing independently. H/P 5 nasal congestion, barking cough, dyspnea, inspiratory stridor; fever, mild pharyngeal erythema, lymphadenopathy; respiratory distress in severe cases 4. Caused by Haemophilus influenzae type B (Hib) infection; can also be caused by which prompt intubation is streptococcal or other H. Labs 5 culture from swab of epiglottis can determine causative bacteria (should only be performed if patient is intubated) 6. Radiology 5 neck radiographs show swollen, opacified epiglottis that partially obstructs the airway. Treatment 5 keep child calm; admit for close observation and respiratory Hib vaccine has greatly monitoring; unless airway obstruction is mild, intubate (nasotracheal) to maintain decreased the incidence of airway patency; antibiotics for 7 to 10 days; airway obstruction preventing intuba epiglottitis. Most commonly occurs in winter and spring; usually found in children,2 years of age 3. H/P 5 nasal congestion, cough, respiratory distress; wheezing, fever, tachypnea, crackles, prolonged expiration, hyperresonance to percussion 4. H/P 5 presentation within 2 days of birth; cyanosis, nasal flaring, expiratory grunting, intercostal retractions, respiratory rate. H/P 5 meconium-stained amniotic fluid seen during delivery; cyanosis, intercostal retractions; distended chest, tachypnea 3. Treatment 5 suction nose, mouth, and upper airway at birth; supplemental O2; intubate for worsening respiratory distress; surfactant therapy may be useful for improving respiratory function; consider empiric antibiotic therapy if concerned for development of pneumonia 6. Complications 5 pulmonary hypertension can develop if not promptly treated; in creased risk of developing asthma during childhood F. Autosomal recessive disorder caused by defect in chloride-pumping channel in exocrine glands; ducts of exocrine glands. Presents in childhood and is universally fatal, but proper treatment may allow autosomal recessive disorder survival into 30s and 40s in the United States. Affects both pulmonary (recurrent infections, chronic sinusitis) and gastro intestinal systems (pancreatic enzyme deficiencies, malabsorption) 4. Common agents include Norwalk virus, Coxsackie virus Al, echovirus, and adenovirus; rotavirus is common in children. History and physical (H/P) 5 nausea, vomiting, diarrhea, abdominal pain, myalgias; low-grade fever 4. Labs 5 no fecal white blood cells; viral culture indicates pathogen (usually unnecessary) 5. Inflammatory disease of the liver is most commonly caused by viral infection; it can also result from alcohol or toxins. H/P 5 possibly asymptomatic; malaise, arthralgias, fatigue, nausea, vomiting, right upper quadrant pain; jaundice, scleral icterus, tender hepatomegaly, splenomegaly, lymphadenopathy 6. Dysfunction in sublingual, submandibular, or parotid glands resulting from ductal obstruction or inflammation 2. May be caused by sialolithiasis (ductal stone) in any salivary gland; parotid disease can also be caused by sarcoidosis, infection, or neoplasm 3. H/P 5 enlarged and painful glands; pain worsens during eating; parotid glands may have painless swelling 4. Treatment 5 warm compresses, massage, or lemon drops may help remove ductal stones; antibiotics and hydration for infection; surgery may be required for relief in refractory cases B. Difficulty swallowing because of oropharyngeal or esophageal transport dysfunction or pain with swallowing. Labs 5 manometry measures esophageal pressure and may detect neuromuscular abnormality 6. Idiopathic; most commonly affects persons 25 to 60 years of age neoplasm, and scleroderma. H/P 5 gradually progressive dysphagia of solids and liquids, regurgitation, cough, aspiration, heartburn, weight loss from poor intake 4. Neuromuscular disorder in which nonperistaltic contractions of the esophagus occur Nitrates relieve pain from 2. Treatment 5 calcium channel blockers, nitrates, or tricyclic antidepressants help reduce chest pain and dysphagia E. Risk factors 5 obesity, hiatal hernia, pregnancy, scleroderma semble those of asthma or 3. Symptoms can worsen with consumption of alcohol and fatty foods or with tobacco myocardial infarction. Refractory disease may be treated with Nissen fundoplication or hiatal hernia repair. Squamous cell carcinoma (more common worldwide) or adenocarcinoma (more common in the United States) of esophagus 2. Treatment 5 surgical resection (including total esophagectomy) for early stage disease; radiation and chemotherapy used in nonoperative (advanced) cases or as neoadjuvant therapy to surgery 8. Sliding: gastroesophageal junction and stomach displaced through diaphragm (95% of cases) b. Paraesophageal: stomach protrudes through diaphragm, but gastroesophageal junction remains in normal location 3. Radiology 5 barium swallow shows portion of stomach above diaphragm; chest radiograph may detect hernia without barium swallow if air in stomach is visible above diaphragm 5. Treatment 5 sliding hernias can be treated with reflux control; paraesophageal hernias may need surgical repair. Complications 5 incarceration of stomach in herniation (seen in paraesophageal type) B. Chronic gastritis can occur in either the antrum or fundus of the stomach (see Ta ble 3-6). H/P 5 possibly asymptomatic; epigastric pain, indigestion, nausea, vomiting, hematemesis, melena; symptoms more common for acute form 6. Labs 5 positive urea breath test (detects increase in pH from ammonia-producing bacteria) and positive IgG antibody to Helicobacter pylori with existing infection; ratio of pepsinogen isoenzymes useful to detect autoimmune cause; antral biopsy can detect H. Erosion of gastric and duodenal mucosa secondary to impaired endothelial defenses and increased gastric acidity (see Table 3-7) 2. H/P 5 periodic burning epigastric pain that can change (better or worse) Zollinger-Ellison syndrome (increased gastrin). Surgery is required to repair acute perforations; persistent, non-neoplastic refractory cases may require parietal cell vagotomy or antrectomy. Syndrome secondary to gastrin-producing tumor most frequently located in patients or those with a pre duodenum (70% cases) or pancreas vious ulcer should have an 2. Adenocarcinoma (common) or squamous cell carcinoma (rare; caused by invasion from esophagus) affecting stomach 2. Linitis plastica: all layers of stomach involved; decreased stomach elasticity; poor prognosis 3. H/P 5 weight loss, anorexia, early satiety, vomiting, dysphagia, epigastric pain; enlarged left supraclavicular lymph node. Treatment 5 subtotal gastrectomy for lesions in distal third of stomach, total gas trectomy for lesions in middle or upper stomach or invasive lesions; adjuvant che motherapy and radiation therapy 8. H/P 5 failure to thrive, bloating, and abnormal stools in infants; diarrhea, steatorrhea, weight loss, and bloating in adults; some patients will exhibit depression, anxiety, or arthralgias; associated with Down syndrome; associated with dermatitis herpetiformis d. Treatment 5 removal of gluten from diet (can still eat corn, rice); refractory dis Celiac and tropical sprue ease may require corticosteroids exhibit the same symptoms, 2. Malabsorption syndrome similar to celiac sprue, with possible infectious or toxic responds to removal of gluten from the diet, and tropical etiology sprue occurs in patients who b. Acquired disorder in patients living in tropical areas; can present years after have spent time in the tropics. Treatment 5 folic acid replacement, tetracycline; removal of gluten from diet has no effect 3. H/P 5 diarrhea, abdominal pain, flatulence, and bloating after dairy consumption d. Treatment 5 lactose-restricted or lactose-free diet; adequate dietary protein, fat, calcium, and vitamins; lactase replacement may benefit some patients 4. Malabsorption disorder secondary to Tropheryma whippelii infection and likely immune deficiency (unknown if innate to host or caused by infection); multiple organs involved b. H/P 5 weight loss, joint pain, abdominal pain, diarrhea, dementia, cough, bloat ing, steatorrhea; fever, vision abnormalities, lymphadenopathy, new heart mur mur; severe wasting late in disease course d. Acute diarrhea (,2-week duration) is usually caused by infection (see Figure 3-10). Chronic diarrhea has longer duration of symptoms and may result from malabsorp most common cause of adult tion or motility disorders (see Figure 3-11). Secretory diarrheas are usually hormone mediated or caused by enterotoxic bacteria. Osmotic diarrheas are caused by solute collecting in bowel lumen, leading to increased water in bowel; occur after eating, lessen with fasting c. Inflammatory diarrhea results from an autoimmune inflammatory process or chronic infection. Pediatric diarrhea is most commonly caused by infection, antibiotic use, or related to immunosuppression. Treatment 5 assurance from physician, high-fiber diet, possible psychosocial therapy; antispasmodic, antidepressants, serotonin receptor antagonists have shown use in lessening symptoms D. Disease of small and large bowel, with a constellation of symptoms associated with inflammatory bowel processes, autoimmune reactions, extraintestinal manifestations, and multiple complications 2. Mechanical obstruction of small or large bowel that can lead to vascular compromise 2. Caused by embolus, bowel obstruction, inadequate systemic perfusion, medication, or surgery-induced vascular compromise 3. Of note are the dense line markings where the walls of two dilated loops of bowel are pressed against each other (open arrow) and the dense markings where a dilated loop of bowel is compressed against the cecum (solid arrow) (From Eisenberg, R. H/P 5 acute abdominal pain, bloody diarrhea, vomiting; mild abdominal ischemic colitis; the rectum is tenderness frequently spared because of 5. Radiology 5 barium enema shows diffuse submucosal changes from localized bleeding. Complications 5 high mortality in cases of irreversible damage Abdominal pain for ischemic colitis is less severe than G. Inflammation of appendix with possible infection or perforation is significant and out of pro 2. Caused by lymphoid hyperplasia (children), fibroid bands (adults), or fecaliths portion to examination. H/P 5 dull periumbilical pain followed by nausea, vomiting, and anorexia; pain gradually moves to right lower quadrant and increases; tenderness at McBurney point (1/3 distance from right anterior superior iliac spine to umbilicus), rebound tenderness, psoas sign (psoas pain on passive hip extension), fever, Rovsing sign (right lower quadrant pain with left lower quadrant palpation); perforation pro Always get a b-human duces severe pain and distention with rebound tenderness, rigidity, and guarding chorionic gonadotropin 4. Treatment 5 appendectomy; antibiotics added (covering gram-negatives and an aerobes) for ruptured appendix 7.

The disease affects mainly the skin and has a sudden onset with the occurrence of red medicamentosa prostate cancer metastasis sites generic 100 mg penegra mastercard, Stevens-Johnson syndrome prostate oncology jonesboro order penegra once a day, toxic macules and papules in a symmetrical pattern on epidermal necrolysis prostate 1 plus enlarged cheap penegra 100 mg overnight delivery, pemphigus prostate cancer foods to eat discount penegra line, bullous and ero sive lichen planus prostate 56 buy penegra with amex, cicatricial pemphigoid prostate cancer 3b buy penegra 50mg with mastercard, bullous the palms and soles and less commonly on the face, neck, and trunk. These lesions are small and pemphigoid, primary herpetic gingivostomatitis, may increase in size centrifugally, reaching a and recurrent aphthous ulcers. A histopathologic examina periphery remains erythematous, but the center tion of the lesions is suggestive of the disease. Stevens-Johnson Syndrome extremely painful erosions covered by grayish white or hemorrhagic pseudomembranes (Fig. The lips usually show characteristic bloody severe form of erythema multiforme that predom crusting. The dromal systemic illness (fever, cough, weakness, ocular lesions consist of conjunctivitis, but corneal malaise, sore throat, arthralgias, myalgias, ulceration, anterior uveitis, or panophthalmitis diarrhea, etc. Stevens-Johnson syndrome, widespread erosions covered by hemorrhagic crusting on the lips and tongue. They may be either pathogenesis of the disease still remains unclear, the typical maculopapular eruption of erythema and an underlying immune mechanism seems multiforme, but more commonly are bullous or most probable. The mortality rate of the conjunctivae, and erythema, which begins on untreated patients ranges from 5 to 15%. Diag the face and extremities and rapidly extends to the nosis is based mainly on clinical criteria. In the oral mucosa there is severe inflammation, vesiculation, and Laboratory findings. Histopathologic examination painful widespread erosions, primarily on the lips, is supportive of the diagnosis. Large doses of systemic steroids and Similar lesions may be seen on the eyelids, con antibiotics if considered necessary. A great variety of etiologic factors have been incriminated, but mainly drugs, such as antibiot ics, sulfonamides, sulfones, nonopiate analgesics, nonsteroidal anti-inflammatory agents, and anti epileptic drugs, are thought to be responsible for the disease. Viral, bacterial, and fungal infection, malignant diseases, and radiation have also been 22. Toxic epidermal necrolysis, characteristic detachment of epidermis, resembling scalding. Toxic epidermal necrolysis, severe erosions covered by hemorrhagic crusting on the lips. Pemphigus be involved, but the soft palate, buccal mucosa, and lower lip predominate. Lesions on other Pemphigus is a chronic autoimmune bullous dis mucosal surfaces (conjunctivae, larynx, nose, ease that affects the skin and mucous membranes pharynx, genitals, anus) may eventually develop and has a reasonable prognosis. On the skin, a high incidence in Mediterranean races (Jews, bullae that rupture easily, leaving eroded areas, Greeks, Italians) without, however, usually are seen and exhibit a tendency to enlarge as the exhibiting any familial distribution. When the disease is confined to immunologic criteria, four varieties of pemphigus the oral mucosa, diagnosis usually may be delayed can be recognized: pemphigus vulgaris, pemphi for 6 to 11 months due to the nonspecific nature of gus vegetans, pemphigus foliaceus, and pemphi oral lesions and the low index of suspicion. The differential diagnosis of oral lesions includes cicatricial pemphigoid, bullous pemphigioid, der Pemphigus Vulgaris matitis herpetiformis, erythema multiforme, ero sive and bullous lichen planus, herpetic gingivo Pemphigus vulgaris is the most common form of stomatitis, aphthous ulcers, and amyloidosis. It has been reported that in more than 68% of the Pemphigus Vegetans cases the disease presents initially in the oral cavity, where it may persist for several weeks, Pemphigus vegetans is a rare variant of pemphigus months, or even years before extending to other vulgaris. Clinically, bullae that rapidly rupture leav tical to those of pemphigus vulgaris, but the ing painful erosions are seen (Fig. They denuded areas soon develop hypertrophic granu show little evidence of healing, extend peripher lations. They may occur in any part of the body, ally, and the pain may be so severe that dysphagia but are more common in the intertriginous areas. A characteristic feature Lesions are rare in the mouth, but vegetating of the oral lesions of pemphigus is the presence of lesions may form at the vermilion border and small linear discontinuities of the oral epithelium angles of the lips (Fig. The course and surrounding an active erosion, resulting in epithe prognosis are similar to those of pemphigus vul lial disintegration. Treatment of all forms of pemphigus includes systemic corticosteroids in high doses, Pemphigus foliaceus represents a superficial, less azathioprine, cyclosporine, and cyclophos severe but rare variant of pemphigus. The lesions may spread to involve the entire skin, resembling Pemphigus very rarely affects persons less than 20 a generalized exfoliative dermatitis. It is now well documented that mucosa is rarely affected with small superficial pemphigus vulgaris, foliaceus, and erythematosus erosions (Fig. It has been reported that in 13 of 14 young patients with Pemphigus Erythematosus pemphigus vulgaris (93%) the disease began in the Pemphigus erythematosus is a rare superficial va oral cavity and the female to male ratio was 1. The disease is clinically charac sions are seen, which may persist and exhibit a terized by an erythematous eruption similar to tendency to enlarge (Fig. The clinical and that of lupus erythematosus and by superficial laboratory features of juvenile pemphigus are bullae concomitant with crusted patches, resem similar to those seen in pemphigus of the adults. Sometimes, the differential diagnosis includes other bullous the disease coexists with lupus erythematosus, diseases affecting children, such as herpetic gin myasthenia gravis, and thymoma. The oral givostomatitis, juvenile bullous pemphigoid, mucosa is very rarely affected with small erosions juvenile dermatitis herpetiformis, erythema mul (Fig. Pemphigus erythematosus, characteristic erythema and superficial crusting lesions on the "butterfly" area of the face. Paraneoplastic Pemphigus spaces and along the basement membrane zone are common findings, and circulating "pemphigus Paraneoplastic pemphigus is a rare recently like" antibodies at high titer are also present. All described autoimmune variant of pemphigus reported patients with paraneoplastic pemphigus characterized by skin and mucosal lesions in have had poor prognoses. The differential diagnosis includes other forms of the clinical features of the disease are charac pemphigus, erythema multiforme, cicatricial and terized by a) polymorphous skin lesions often bullous pemphigoid. Helpful laboratory tests include painful, treatment-resistant erosions of the oral histopathologic examination, direct and indirect mucosa and the vermilion border of the lips immunofluorescence. Systemic corticosteroids in association and C3 deposition in epidermal intercellular with the treatment of underlying neoplasm. Cicatricial Pemphigoid involving the gingiva, although ultimately other sites in the oral cavity may be involved. The Cicatricial pemphigoid, or benign mucous mem mucosal lesions are recurrent vesicles or small brane pemphigoid, is a chronic bullous disease of bullae that rupture, leaving a raw eroded surface autoimmune origin that preferentially affects mu that finally heals by scar formation (Fig. Frequently, occurs more frequently in women than in men the disease affects exclusively the gingiva in the (1. The oral mucosa is invariably affected and, in 95% of ocular lesions consist of conjunctivitis, symble the cases, the mouth is the initial site of involve pharon, trichiasis, dryness, and opacity of the ment. The most consistent oral lesions are those cornea frequently leading to complete blindness 208 22. Less commonly, other mucosae the differential diagnosis includes pemphigus vul (genitals, anus, nose, pharynx, esophagus, larynx) garis, bullous pemphigoid, linear IgA disease, are involved (Fig. Skin lesions occur in bullous and erosive lichen planus, dermatitis her about 10 to 20% of the cases and consist of bullae petiformis, erythema multiforme, Stevens-John that usually appear on the scalp, face, and neck son syndrome, and lupus erythematosus. Helpful laboratory tests include histopathologic examination and direct immuno fluorescence of oral mucosa biopsy specimens. Skin Diseases Childhood Cicatricial Pemphigoid Laboratory tests to confirm the diagnosis are direct and indirect immunofluorescence and his Cicatricial pemphigoid is a chronic autoimmune topathologic examination. However, at least eight well-documented cases of cicatricial pem phigoid of childhood have been recorded so far. Five of the patients were girls and three were Bullous Pemphigoid boys, aged 4 to 18 years. All patients except one Bullous pemphigoid is a chronic autoimmune had oral lesions, and in four, desquamative ging mucocutaneous bullous disease that affects ivitis was the cardinal manifestation of the disease women more frequently than men (1. However, well mucosa, eyes, genitalia, anus, and skin are identi documented cases have been described in child cal to those seen in cicatricial pemphigoid of adult hood. Clinically, the cutaneous lesions begin as a the differential diagnosis includes juvenile bul nonspecific generalized rash and ultimately large, lous pemphigoid, juvenile pemphigus, childhood tense bullae develop that rupture, leaving dermatitis herpetiformis, childhood linear IgA denuded areas without a tendency to extend disease, childhood chronic bullous disease, and peripherally. The oral well as direct and indirect immunofluorescent mucosa is affected in about 40% of the cases, tests confirm the diagnosis. Other mucous mem branes, such as the conjunctiva, esophagus, va gina, and anus, may also be affected. Linear Immunoglobulin A Disease the disease has a chronic course with remis Linear IgA disease has been recognized as a new sions and exacerbations and generally a good nosologic entity in the spectrum of chronic bullous prognosis. Linear IgA disease is rare and charac the differential diagnosis includes pemphigus terized by spontaneous bullous eruption on the vulgaris, cicatricial pemphigoid, dermatitis her skin and mucous membranes, and homogeneous petiformis, linear IgA disease, erosive lichen IgA deposits along the dermoepidermal junction planus, and discoid lupus erythematosus. The disease is more common Laboratory tests helpful for the final diagnosis in women than men, with an average age of onset between 40 and 50 years and has been described include histopathologic examination, as well as both in adults and children. Generally, the clinical manifestations of the disease are indistinguishable from those seen in cicatricial pemphigoid. The differential diagnosis includes cicatricial pem phigoid, dermatitis herpetiformis, bullous pem phigoid, and chronic bullous disease of childhood. Childhood cicatricial pemphigoid, small hemorrhagic bulla on the gingiva in a 14-year-old girl. Linear immunoglobulin A disease, erosion on the tongue covered by a whitish pseudo membrane. Dermatitis Herpetiformis mucosa are more frequently involved than the gingiva, lips, and tonsils. Dermatitis herpetiformis, or Duhring-Brocq dis the disease runs a very prolonged course with ease, is a chronic recurrent skin disease charac remissions and exacerbations. In 60 to 70% of the terized by pruritus and a symmetrical papulo cases gluten-sensitive enteropathy coexists. The disease occurs at any age, including includes minor aphthous ulcers, herpetiform childhood, but is more common between 20 and ulcers, erythema multiforme, pemphigus vulgaris, 50 years of age and males are more frequently cicatricial pemphigoid, linear IgA disease, and affected than females. The cause remains unknown, although the oc currence of IgA and C3 deposits in the upper Laboratory tests supporting the diagnosis are his dermis and at the dermoepidermal junction sug topathologic examination and direct immuno gests that immunologic mechanisms may play a fluorescence. Sulfones and sulfapyridines and, in severe burning and pruritus, and small vesicles, certain cases, corticosteroids. Gluten-free diet which group in a herpes-like pattern, involving the may check disease activity. Clinically, the maculopapular lesions are considered as one of the main types of oral lesions (Fig. In addition, erythematous, purpuric, vesicular, and erosive types have been described (Fig. The vesicles appear in a cyclic pattern, rupture rapidly, leaving superficial painful erosions resembling aphthous ulcers. Dermatitis herpetiformis, papules and small vesicles on the skin, grouped in a herpeslike pattern. Dermatitis herpetiformis, intact bulla on the lower lip mucosa and small erosions on the gingiva. Epidermolysis Bullosa Acquisita Lichen Planus Epidermolysis bullosa acquisita is a rare, non Lichen planus is a common, chronic inflammatory inherited, chronic mechanobullous disease with disease of the skin and mucous membranes. Clinically, the disease cause of lichen planus remains unknown, although is characterized by the formation of bullae, mainly recent evidence suggests that immunologic on the skin overlying joints, which are frequently mechanisms may play a role in the pathogenesis. The bullae are the association of lichen planus with autoimmune tense, may contain blood, and heal with scarring. Involvement of the oral mucosa is not equally members of all races and has a cosmopoli frequent. The following diagnostic criteria what more often than men, and the majority of of epidermolysis bullosa acquisita have been pro the patients (about 70%) are between 30 and 60 posed: no family history; adult onset; bullae for years of age. Clinically, the cutaneous lesions mation after mechanical trauma, which heal with appear as small, flat, polygonal, shiny papules scarring, milia, and nail dystrophy; exclusion of all (Fig. Early papules are red, whereas older other bullous diseases; histopathologic, direct and lesions display the characteristic violaceous color. They are distributed in a the differential diagnosis includes pemphigus, symmetrical pattern, more frequently over the cicatricial pemphigoid, bullous pemphigoid, der flexor surfaces of the forearms and wrists, the matitis herpetiformis, linear IgA disease, and por sacral area, the back, and the lateral sides of the phyria cutanea tarda. Clinically, the following forms of oral lichen periphery, papules or lines may be seen (Fig. The reticular form is Frequently, the atrophic and erosive forms, when the most common variant and is characterized by located on the gingiva, may be manifested as small white papules, which may be discrete but desquamative gingivitis (Fig. The second most frequent variant and is characterized bullous form is rare and is characterized by bullae by small or extensive painful erosions with iso formation of variable size, which rupture rapidly lated papules or lines at the periphery (Fig. The bullae the atrophic form is less common and usually the usually arise on a background of papules or striae. The lesions have a smooth red characterized by pigmented papules arranged in a surface and poorly defined borders, and, at the reticular pattern interspersed with whitish lesions 22. This form is due to local melanin Psoriasis overproduction during the acute phase of the dis Psoriasis is a common, chronic, recurrent skin ease. It is most frequent on the skin and should disease of unknown cause, which is characterized not be confused with pigmentation that may by the presence of erythematous, scaly plaques. Oral lichen planus may follow a course of re There is no sex predilection, and the age of onset is usually beyond 25 years, although the disease missions and exacerbations. The disease most fre quently affects the buccal mucosa, tongue, gin may also affect children. Cutaneous lesions are usually located on the extensor surfaces of the giva, and rarely the lips, palate, and floor of the extremities, particularly the elbows and knees, the mouth. The lesions are usually symmetrical and asymptomatic or cause mild discomfort, such as a lumbar area, the scalp, and nails (Fig. Depending on the morphology of the skin lesions, burning sensation, irritation after contact with certain varieties of psoriasis have been recog certain foods, and an unpleasant feeling of rough nized, such as annular, circinate, guttate, nummu ness in the mouth. Rarely, when xerostomia coexists, erythematosus, erythroplakia, erythema mul erythematous and scaly lesions may appear on the tiforme, cicatricial pemphigoid, bullous pem dorsal surface of the tongue.

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