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Clinical Findings
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A Symptoms and Signs
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Keratoconjunctivitis sicca results from inadequate tear production caused by lymphocyte and plasma cell infiltration of the lacrimal glands Ocular symptoms are usually mild Burning, itching, and the sensation of having a foreign body or a grain of sand in the eye occur commonly For some patients, the initial manifestation is the inability to tolerate wearing contact lenses Many patients with more severe ocular dryness notice ropy secretions across their eyes, especially in the morning Photophobia may signal corneal ulceration resulting from severe dryness For most patients, symptoms of dryness of the mouth (xerostomia) dominate those of dry eyes Patients frequently complain of a cotton mouth sensation and difficulty swallowing foods, especially dry foods like crackers, unless they are washed down with liquids The persistent oral dryness causes most patients to carry water bottles or other liquid dispensers from which they sip constantly A few patients have such severe xerostomia that they have difficulty speaking Persistent xerostomia results often in rampant dental carries; carries at the gum line strongly suggest Sj gren s syndrome Some patients are most troubled by loss of taste and smell Parotid enlargement, which may be chronic or relapsing, develops in one-third of patients Desiccation may involve the nose, throat, larynx, bronchi, vagina, and skin Systemic manifestations include dysphagia, vasculitis, pleuritis, obstructive lung disease (in the absence of smoking), neuropsychiatric dysfunction (most commonly peripheral neuropathies), and pancreatitis; they may be related to the associated diseases noted above Renal tubular acidosis (type I, distal) occurs in 20% of patients Chronic interstitial nephritis, which may result in impaired renal function, may be seen A glomerular lesion is rarely observed but may occur secondary to associated cryoglobulinemia
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B Laboratory Findings
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Laboratory findings include mild anemia, leukopenia, and eosinophilia Polyclonal hypergammaglobulinemia, rheumatoid factor positivity (70%), and antinuclear antibodies (95%) are all common findings Antibodies against the cytoplasmic antigens SS-A and SS-B (also called Ro and La, respectively) are often present in Sj gren s syndrome and tend to correlate with the presence of extraglandular manifestations (Tables 20 10 and 19 2) Thyroid-associated autoimmunity is a common finding among patients with Sj gren s syndrome Useful ocular diagnostic tests include the Schirmer test, which measures the quantity of tears secreted Lip biopsy, a simple procedure, is the only specific diagnostic technique and has minimal risk; if lymphoid foci are seen in accessory salivary glands, the diagnosis is confirmed Biopsy of the parotid gland should be reserved for patients with atypical presentations such as unilateral gland enlargement
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RHABDOMYOLYSIS
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ESSENTIALS OF DIAGNOSIS
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Associated with crush injuries to muscle, prolonged immobility, drug toxicities, hypothermia, and other causes Massive acute elevations of muscle enzymes that peak quickly and usually resolve within days once the inciting injury has been identified and removed
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Defined strictly, rhabdomyolysis is necrosis of skeletal muscle and may be encountered in a wide variety of clinical settings, alone or in concert with other disorders of muscle When the term rhabdomyolysis is used without being otherwise defined, healthcare providers ordinarily think of the syndrome of crush injury to muscle, associated
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Treatment & Prognosis
Treatment is symptomatic and supportive Artificial tears applied frequently will relieve ocular symptoms and avert further desiccation The mouth should be kept well lubri-
Arthritis & Musculoskeletal Disorders
with myoglobinuria, renal insufficiency, markedly elevated creatine kinase levels and, frequently, multiorgan failure as a consequence of other complications of the trauma Renal insufficiency in myoglobinuria is caused by tubular injury resulting from excessive quantities of filtered myoglobin (See Acute Tubular Necrosis in 22) This complication is nearly always associated with hypovolemia Experimental models of severe rhabdomyolysis in which blood volume and pressure are maintained ordinarily are not associated with acute tubular necrosis From a practical point of view, however, many patients who suffer crush injuries are indeed volume-contracted, and oliguric renal failure is encountered routinely In addition to crush injuries, prolonged immobility, particularly after drug overdose or intoxication and commonly associated with exposure hypothermia, may be associated with rhabdomyolysis Often there is little evidence for muscle injury on external examination of these patients and specifically, neither myalgia nor myopathy presents The clue to muscle necrosis in such individuals may be a urinary dipstick testing positive for blood in the absence of red cells in the sediment This false-positive finding is due to myoglobinuria, which results in a positive reading for blood Such an abnormality is investigated by serum creatine kinase determination Other studies elevated in rhabdomyolysis include ALT and lactate dehydrogenase (LDH) and once again, these studies may be obtained for other reasons, such as suspected liver disease or hemolysis When disproportionately elevated, it is prudent to establish that they are not of muscle origin by confirming them with creatine kinase determination A number of other causes of rhabdomyolysis are encountered Statins, agents used commonly to treat hyperlipidemia, are common offenders (see above) The presence of compromised renal and hepatic function, diabetes, and hypothyroidism as well as concomitant use of other medications all increase the risk of rhabdomyolysis in those patients taking statins Both acute alcohol intoxication and even intramuscular injections may cause some elevation of creatine kinase
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