What is the diagnosis???

35 years old female suffering from recurrent painless nonitchy swelling for last 5 years. No h/o respiratory distress. No family history of such lesions. She is a known Hypertensive and for that she is on Telmisertan 40 mg/day. Patient has been treated with Levocetirizine 10mg twice a day for six months and Monteleukast 10 mg at night for six months, but no relief. Only responding to short courses of systematic Steroid 2 mg /kg with tapering dose. 1). Diagnosis 2). D/D 3). Investigations 4). Management. Please give your answers in chronological order.

SARCOIDOSIS. Sarcoidosis is a multi system inflammatory disorder of unknown etiology that predominantly affects the lungs and intra thoracic lymph nodes. Sarcoidosis is manifested by the presence of non caseating granulomas ( NCG's ) in affected organs. It is characterised by a seemingly exaggerated immune response against a difficult - to - discern antigen. SIGNS AND SYMPTOMS. The presentation of sarcoidosis depends on the extent and severity of organ involvement. *Asymptomatic. *Systematic complaints like fever and anorexia. *PULMONARY MANIFESTATION Dyspnea on exertion. Cough. Chest pain Hemoptysis. Pulmonary findings on physical examination can be Usually normal. Crepitus. External oxygen desaturation. LOFGREN SYNDROME. Fever,bilateral hilarious lymphadenopathy and polyarthralgias. DERMATOLOGICAL MANIFESTATION. *-Erythema nodosum. *A lower extremity panniculitis with painful erythematous nodules. *Lupus permit ( the most specific associated cutaneous lesion ) *Violaceous rash on cheeks and nose ( common ) *Maculopapular plaques ( uncommon ) OCULAR MANIFESTATION. *Anterior or posterior granulomatous uveitis. *Conjunctival lesions and scleral plaques. If untreated can lead to blindness. OTHER POSSIBLE MANIFESTATION. *Osseous involvement. *Heart failure from cardiomyopathy. *Heart block and sudden death. *Lymphocytic meningitis. *Cranial nerve palsies and hypothalamic / pituitary dysfunction. DIAGNOSIS. *Chest X-RAY central to the evaluation. *High resolution CT identifies active alveolitis versus fibrosis. *Gallium scans. *Pulmonary function tests and carbon monoxide diffusion capacity test of the lungs( DLCO ) for carbon monoxide is used routinely in evaluation and follow up. An isolated decrease in DLCO is the most common abnormality. *Cardiopulmonary exercise testing is a sensitive test for identifying and quantifying the extent of pulmonary involvement.I t also suggests cardiac involvement that otherwise is not evident. IMPAIRED HEART RATE RECOVERY DURING THE FIRST MINUTE FOLLOWING EXERCISE HAS BEEN SHOWN TO BE AN INDEPENDENT PREDICTOR FOR CARDIOVASCULAR AND ALL CAUSE MORTALITY. DIAGNOSIS REQUIRES BIOPSY IN MOST CASES.ENDOBRONCHIAL BIOPSY VIA BRONCHOSCOPY IS OFTEN DONE.THE CENTRAL HISTOLOGICAL FINDING IS THE PRESENCE OF NON CASEATING GRANULOMAS WITH SPECIAL STAINS NEGATIVE FOR FUNGUS AND MYCOBACTERIA. *Hypercalcemia. *Hypercalcuria. *Elevated alkaline phosphatase level. *Elevated angiotensin converting enzyme level. STAGING OF SARCOIDOSIS. STAGE O : Normal chest radiographic findings. STAGE I. : Bilateral hilar lymphadenopathy. STAGE II : Bilateral hilar lymphadenopathy and infiltrates. STAGE III : Infiltrates alone. STAGE IV : fibrosis. TREATMENT. Most patients do not require therapy and their condition improves spontaneously. Markers for poor prognosis are Advanced chest radiography stage. Extra pulmonary disease Evidence of pulmonary hypertension. Most patients require symptomatic treatment with NSAID 's for treatment of arthralgias. Treatment for patients with pulmonary involvement. *Asymptomatic patients do not require treatment. *In patients with minimal symptoms,serial re evaluation is prudent *Treatment is indicated for patients with severe symptoms. *Corticosteroid are helpful. *For extra pulmonary sarcoidosis involving heart,liver,eyes,kidney and central nervous system , corticosteroid therapy is indicated. *Topical steroids are useful for ocular disease. Common indications for non - corticosteroid are *Steroid resistant disease. *Intolerable adverse effects of steroids. Non corticosteroid agents are METHOTREXATE CHLOROQUINE and HYDROCHLOROQUINE used for cutaneous lesion,hypercalcemia,neurologic sarcoidosis and bone lesions. CHLOROQUINE is useful for Acute and maintenance treatment of chronic pulmonary sarcoidosis. CYCLOPHOSPHAMIDE is used in refractory sarcoidosis. AZATHIOPRINE is best used as a steroid sparing agent. CHLORAMBUCIL is beneficial in patients with progressive disease unresponsive to steroids. CYCLOSPORINE is of limited benefit in skin sarcoidosis or in progressive sarcoidosis resistant to conventional therapy. INFLIXIMAB & THALIDOMIDE are used for refractory sarcoidosis. FOR PATIENTS WITH ADVANCED PULMONARY FIBROSIS FROM SARCOIDOSIS,LUNG TRANSPLANTATION REMAINS THE ONLY HOPE FOR LONG TERM SURVIVAL. LONG TERM MONITORING. *Monitor pulmonary function and chest radiography every 6 months. *Assess for progression or resolution. *Determine if previously uninvolved organs have become affected. *Annual slit lamp examination and ECG are recommended.

1.Describe the findings 2.what could be the aggravating factor. 3.diagnosis and differential diagnosis.

ABC OF : NAIL DISORDERS. ( I ). MAY BE USEFUL. *** ANONYCHIA is the absence of nails, an anomaly, which may be the result of a congenital ectodermal defect, ichthyosis, severe infection, severe allergic contact dermatitis, self-inflicted trauma, Raynaud phenomenon, lichen planus, epidermolysis bullosa, or severe exfoliative diseases....... *** PSORIASIS can also affect the fingernails and toenails, leading to thick fingernails with pitting, ridges in the nails, nail lifting away from the nail bed, and irregular contour of the nail....... *** LICHEN PLANUS of the nails can cause brittle or split nails, and the affected nails may have ridges running lengthwise....... *** FUNGAL nail infections are common infections of the fingernails or toenails that can cause the nail to become discolored, thick, and more likely to crack and break. Infections are more common in toenails than fingernails.....by some dermatophytes, Candida (Monilia) species, etc....... The technical name for a fungal nail infection is “ONYCHOMYCOSIS.”....... *** SPOON-SHAPED or spooning fingernails refers to a concavity in the fingernail itself, resulting in a depression in the nail that gives an appearance of a spoon shape to the entire nail. This growth disturbance in the nail is known as KOILONYCHIA....... In particular, koilonychias is associated with IRON DEFICIENCY. *** Fingernails are made by living skin cells....... So a skin condition such as eczema may lead to fingernail ridges. Skin dryness can also cause these ridges. If the body is low in protein, calcium, zinc.......or vitamin A, a deficiency can sometimes be revealed by ridges in the fingernails. ** HORIZONTAL RIDGES run from side to side on nails and are often referred to as BEAU'S LINES may be a sign of previous injury, underlying health conditions, or in rare cases, arsenic poisoning....... Horizontal ridges can be caused by trauma to the nail and may be deep or discolored. The can also indicate malnutrition, psoriasis or a thyroid problem....... ** VERTICAL RIDGES are usually harmless and a consequence of ageing.......nail injury, or trauma, or underlying medical conditions....... *** The ECTODERMAL DYSPLASIAS (EDs) are genetic disorders affecting the development or function of the teeth, hair, nails and sweat glands....... ** ED is not a single disorder, but a group of closely related conditions of which more than 150 different syndromes have been identified....... *** Nail CLUBBING, also known as digital clubbing, is a deformity of the finger or toe nails associated with a number of diseases, mostly of the heart and lungs. ... Hippocrates was probably the first to document clubbing as a sign of disease, and the phenomenon is therefore occasionally called "Hippocratic fingers"..... ** Lung cancer is the most common cause of clubbing. Clubbing often occurs in heart and lung diseases that reduce the amount of oxygen in the blood. ... Heart defects that are present at birth (congenital) Chronic lung infections that occur in people with bronchiectasis, cystic fibrosis, or lung abscess....... *** While the NAIL BITING and picking seems to be such a common problem, the psychological and medical research does not agree on the exact motivation for the action. However, it suggests that nail biting can be the result of STRESS, VARIOUS MEDICAL DISORDERS, LEARNED BEHAVIORS, OR JUST PLAIN HABIT....... *** SPLINTER HEMORRHAGES : They run in the direction of nail growth. They are named splinter hemorrhages because they look like a splinter under the fingernail. The hemorrhages may be caused by tiny clots that damage the small capillaries under the nails. Splinter hemorrhages can occur with infection of the heart valves (endocarditis)....... *** YELLOW TOENAILS in an infection by a fungus that attacks the nails..... or, in some cases, they may be a sign of skin cancer. The fungal infection is caused most often by dermatophytes, which eat keratin to grow....... One of the MOST COMMON CAUSES of YELLOW NAILS is a FUNGAL INFECTION. As the infection worsens, the nail bed may retract, and nails may thicken and crumble. In rare cases, yellow nails can indicate a more serious condition such as SEVERE THYROID DISEASE, LUNG DISEASE, DIABETES or PSORIASIS....... *** WHILE NAILS ( LEUKONYCHIA ) : CAUSES : Iron deficiency anemia. Cirrhosis of liver. Kidney disease. Heart failure. Diabetes. Problems with the digestion of proteins. An excessive loss of proteins in the intestines. zinc deficiency........etc....... *** RED NAILS :- CAUSES : LUPUS patients get quirky, angular blood vessels in their nail folds. PSORIASIS starts in the nails up to 10 percent of the time and CAUSES SPLITTING and PITTING of the nail bed. HEART DISEASE can turn the nail beds red....... ** If the NAIL BED is RED, it could be caused by a high content of fatty acids and cholesterol, due to an excess of dairy products, sugar and salt in the diet. This can lead to an underactive liver and blocked arteries....... To keep the system healthy by replacing refined foods with wholegrain rice and bread, and flush out the system with plenty of fresh vegetables and at least five glasses of water a day....... *** HALF PINK and HALF WHITE nails can be a sign of kidney disease....... *** BRITTLE NAILS :- CAUSES : AGING. CHEMICAL/TOXIN EXPOSURE. LONG-TERM USE OF NAIL POLISH AND POLISH REMOVE. LOW HUMIDITY ENVIRONMENT. MALNUTRITION. NAIL-PATELLA SYNDROME. PROLONGED EXPOSURE TO WATER. TRAUMA. ** B complex vitamins (especially biotin), calcium, and zinc have all been implicated. There are other medical conditions which can cause brittle nails such as ANEMIA (low blood count), THYROID DISORDERS, and skin disorders such as LICHEN PLANUS and PSORIASIS. ** ONYCHOSCHIZIA includes splitting, brittle, soft or thin nails. Onychoschizia is MORE COMMON IN WOMEN. Only VERY RARELY are INTERNAL DISEASE or VITAMIN DEFICIENCIES the reason (IRON DEFICIENCY is the MOST COMMON).......

Friends today I am discussing about Vitiligo or leucoderma. Vitiligo also called as 'leucoderma' is an autoimmune disorder wherein the immune system of the body attacks the healthy cells and, in turn, starts affecting the body. The condition is characterised by white patches on the skin that develops as a result of melanocytes within the skin. These are the cells that are responsible for the skin pigment melanin that gives colour to your skin. The white patches appear when the melanocytes die off. The condition is called vitiligo, or leucoderma, or white leprosy. Symptoms Usually pale and white spots, patchy areas of depigmented skin appear. This is generally found in those body parts that face sun exposure. It usually occurs on hands, wrist and facial areas. If a white pigmentation already exists on your skin & you get hurt all of a sudden thereby developing similar white patches on the skin, then you should immediately visit a doctor. Remember that the patches are painless and it does not even cause any sensation of itching. But, with the sun's exposure, it may cause irritation and even sometimes a burning sensation. Myths VS Facts Myth 1: Vitiligo is an outcome of the wrong combination of foods, for instance, milk consumption shortly after eating fish can bring on the disorder. Fact: Factually, vitiligo has no link with the diet. It is irrational to deprive patients of the sour foods like lemon, curd, tomatoes, and pickles in the hope of declining the possibility of the disease. Myth 2: People with vitiligo disorder are lesser in their mental or physical proficiencies. Fact: Vitiligo is limited entirely to the skin. It has no relationship with or does not influence or affect any other organs. Myth 3: Vitiligo is a kind of leprosy and is communicable. Fact: Vitiligo is in no way linked to leprosy. It is not infectious or contagious and, hence, cannot pass on from one person to another. Myth 4: Vitiligo is connected to serious skin diseases, such as skin cancer and albinism. Fact: There are transparent dissimilarities among each of these syndromes, not any of them are linked to Vitiligo. Myth 5: Vitiligo is untreatable Fact: Medications like steroids, Ultraviolet A, immunomodulator drugs and the newer narrowband Ultraviolet B are accessible, along with several surgical options. Treatments There is no doubt that the treatment is tough and slow and not all patients respond equally. However, it is important to treat the stigma than the syndrome. Suction Blister Epidermal Grafting: With the use of vacuum, the skin is segregated into the ones with the white patches and the other normal skin. The skin with the colour pigment is placed over the white patches. Melanocyte Epidermal Cell Suspensions: Here, the white patches are covered without any cut. The skin pigment from the normal part of the body is taken out and converted into a liquid form and inserted into the white skin area. Melanocyte Culture: After conducting skin biopsy, a small part of the skin is cultured in a specialised lab, which is then grafted on the affected area. Platelet Rich Plasma: After extracting plasma from the blood, it is treated and injected into the area with white patches. Plasma has stem cells that help in developing new cells in the body. This technique is natural and does not have any side-effects. askdrshah Vitiligo/homeopathic medicines case photos/ Vitiligo is caused by immunological, hormonal and genetic factors. Vitiligo/homeopathic medicines case photos/ Parents of children with Vitiligo should not panic. Vitiligo/homeopathic medicines case photos/ Timely administered homeopathy treatment for your child’s vitiligo will help long-term management. Vitiligo/homeopathic medicines case photos/ Parents have to understand that some varieties of Vitiligo are treatable; some are controllable while some are not treatable. Vitiligo/homeopathic medicines case photos/ External treatment of Vitiligo with Corticosteroid or any immunosuppressive medicine is likely to increase it eventually /homeopathic medicines case photos/ Did you know that Homeopathy cures many Chronic diseases? READ MORE.../homeopathic medicines case photos/ Dr Shah's breakthrough research in animal model: Homeopathy is as effective as pain-killers READ MORE.../homeopathic medicines case photos/ Welcome to World's oldest homeopathy website READ MORE.../homeopathic medicines case photos/ Dr Rajesh Shah and his team have answered over million queries from patients across the globe READ MORE.../homeopathic medicines case photos/ Are you deprived of the homeopathy advantage? READ MORE.../homeopathic medicines case photos/ Over 2000 case-studies of patients for you to study READ MORE.../homeopathic medicines case photos/ Life Force Homeopathy symbolizes READ MORE.../homeopathic medicines case photos/ Meet the doctor who has treated patients from highest number of countries /homeopathic medicines case photos/ Dr Shah’s research based molecules have US, Europe, Australia, Asia patents READ MORE.../homeopathic medicines case photos/ Research for revolution in the treatment of chronic diseases READ MORE.../homeopathic medicines case photos/ Check hundreds of case-studies of patients from across the world READ MORE.../homeopathic medicines case photos/ Are you depriving yourself of the benefits of homeopathy? /homeopathic medicines case photos/ Dr. Rajesh Shah has treated patients from every state and city in the United States, from every European, Asian and African country. /homeopathic medicines case photos/ Dr Shah’s patients are pan-India, /homeopathic medicines case photos/ Dr. Shah has pioneered Online homeopathic practice since 1995. /homeopathic medicines case photos/ “I have a rare privilege of treating all kinds of Americans from every corner of the US, including the past President’s family, Hollywood stars, scientists, university professors, and the like.” HomeDiseasesVitiligoHomeopathic Remedies for Vitiligo Homeopathic Remedies for Vitiligo There are about thirty odd homeopathic medicines, which might get indicated for the treatment of vitiligo, depending on individual patient’s parameters, in terms of: Nature and extent of vitiligoProbable causes of vitiligoGenetic factors indicated by family history of certain diseases (e.g., autoimmune diseases, tuberculosis, cancer, hormonal disorders, etc.)Emotional make up of the patient: Patient’s reactive and behavior pattern, some prominent emotions, the impact of emotional circumstances, etc.Physical factors such as thermal sensitivity, natural preference for food, etc. Some of the commonly used remedies have been described in brief here. It must be noted that the description offered herewith is neither complete nor exclusive; as there is flexibility on the part of a qualified homeopath to make prescription based on one’s clinical judgment. Besides some of the following ingredients, the product contains Dr Shah's international Patented, Research-based, highly effective medicines. Dr Shah's patented molecules Kali CarbonicumSiliceaArsenicum Sulfuratum FlavumSyphillinumNitricum acidumCarcinosinHydrocotyle AsiaticaNatrum MuriaticumPhosphorus The following photos simply demonstrate how homeopathic medicines stimulate re-pigmentation. Please click photos to enlarge. Vitiligo on hands (Re-pigmentation demonstrated with research-based molecules at Life Force.) Kali Carbonicum: Potassium carbonate undergoes the process of potentization to evolve into a powerful deep acting homeopathic remedy called Kali Carb. Kali carb is a polychrest drug i.e. having effects on multiple organs and systems in the body. It has a broad sphere of action and is useful for a wide range of diseases. Kali Carbonicum positively influences lungs, digestive system, heart, liver, kidney, female reproductive system, skin, etc. Kali Carbonicum does wonders in cases of asthma, bronchitis, tuberculosis, pneumonia, hydrothorax, etc. It is one of the commonly used remedies for vitiligo, warts, eczema, urticaria, hair loss, trigeminal neuralgia, sciatica and low backache, hypothyroidism, heavy menstrual bleeding, etc. It is also useful for complaints of digestive system like acidity, piles, jaundice, gastritis, etc. On the mental sphere, it tackles anxiety states very efficiently and is used for the treatment of the effects of stress on the body. Silicea (Silica): It is one of the splendid acts of homeopathy that substances labeled as inert can also be used effectively to treat a large variety of disorders. Silica is the example of one such substance, which is chemically inert in its natural form, but after undergoing the process of potentization it gets transformed into a wonderful, deep acting remedy. Silica is in a true sense called as polychrest remedy as it has a broad spectrum of action, useful for a wide range of disease processes. In fact, this remedy has helped Homeopaths world over to treat so-called surgical conditions gently without requiring a knife. This drug is prepared from the metal Silica (Si), sand. It is a popular remedy for those vitiligo patients who are sensitive to cold wind (breeze, air-conditioners, winter); who tend to sweat on palms and soles; have typically offensive foot-sweat; have lean-thin physical body structure, and may additionally have a tendency to have easy pus formation after injury. Arsenicum Sulfuratum Flavum: This is one of the specific remedies used for the treatment of vitiligo in homeopathy. It has discoloration of the skin in blotches that are pale or white in color. It is also a good remedy for eczematous lesions which are moist and have intense itching with corrosive discharge. Pyoderma and urticaria also find a solution to this drug. Its sphere of action also extends to catarrhal affections and asthmatic states. A deep acting drug which has been known to give good results in Leucoderma (vitiligo). Syphillinum: Syphilinum belongs to a group of homeopathic drugs called as Nosodes which are prepared from disease products or diseased tissues. The remedy prescribed does not contain the original drug substance in the material form but it contains only the dynamic curative powers of that substance. This is achieved through the process of potentization in homeopathy. Syphillinum is a deep acting, polychrest remedy affecting multiple systems of the body. It positively influences the mind, sensorium, skin, gastrointestinal tract, genito-urinary system, nerves, bones, etc. It is a very helpful remedy to combat hereditary syphilitic tendencies in patients. Syphillinum is frequently used in the homeopathic treatment of vitiligo, recurrent abscesses, osteomyelitis, trigeminal neuralgia, alcohol dependence, rheumatic complaints, etc. It's a useful drug to combat diseases that are destructive in nature and are deep-seated. Nitricum acidum: As the name suggests, this drug is prepared from nitric acid. It must be remembered that the remedy does not contain the original drug substance in its material form but it contains only the dynamic powers of the drug which are released after it undergoes the process of potentization. Nitricum acidum is a deep acting, constitutional remedy which positively influences the gastrointestinal tract, nerves, glands, skin, bones, etc. Its one of the commonly used drugs for vitiligo, warts, ulcers, fissures, gastritis, hemorrhoids, bony and rheumatic affections, malignancy, cachexia, etc. Carcinosin: It's the beauty of the homeopathic system of medicine to be able to use not only plants, animal products, and minerals but also certain disease products and diseased tissue for curing various ailments of patients. These are called as Nosodes. Here is a remedy prepared from the material derived from the carcinoma of the breast. It must be borne in mind that the actual medicine does not contain any part of the original substance in the material form. Only the dynamic powers of the original drug substance are present in the final medicine. Carcinosin is a deep acting constitutional drug having many indications and a very broad spectrum of action. It is useful for a wide range of disease processes, all of them cannot be described here, but a few of them are discussed here. It positively influences mind, lungs, heart, eyes, skin, bones and joints, nerves, etc. It is one of the commonly used remedies for diseases like vitiligo (Leucoderma), urticaria, lichen planus, styes and chalazion, hair loss, asthma, insomnia, trigeminal neuralgia, etc. Homeopathy believes that the genetic predisposition or inherent susceptibility is usually the root cause of a wide range of diseases and Carcinosin in one such remedy which is used to combat these genetic tendencies effectively. Hydrocotyle Asiatica: This is a remedy that is prepared from the plant called Indian Pennywort. The tincture from the whole fresh plant is used for the preparation of this remedy. After undergoing the process of Potentization, the curative powers of this remedy are brought forth. This is one of the very good remedies for vitiligo. It is supposed to stimulate the process of pigmentation. It is also beneficial for other skin problems such as psoriasis, lupus, leprosy, acne and other disorders of the skin in which there is much exfoliation of the skin. This medicine is often prescribed in combination with a constitutional medicine or other deeper acting medicine to get the best effect. Natrum Muriaticum: Natrum Muriaticum is an interesting example of homeopathic medicine prepared from a common food substance, the common salt, sodium chloride. As a rule, the common salt undergoes a special procedure called potentization, whereby its inner healing power is activated to make it available for healing. Constitutionally, this medicine has a broad spectrum of action and is useful for a wide range of disease processes affecting the skin, gastrointestinal organs, nose, lungs, kidney, metabolism, muscles, head, hormonal system, etc. It is one of the commonly used remedies for hair loss, fissures-in-ano, urticaria, migraine, eczema, lichen planus, vitiligo, asthma, etc. Natrum muriaticum is frequently prescribed in cases of vitiligo and is one of the very good remedies for the same. Phosphorus: This is a wonderful remedy prepared by the potentization of inorganic phosphorus. After undergoing the process of potentization, the latent healing powers of this drug are brought to the surface and it proves to be a wonderful remedy capable of curing a wide range of diseases. Phosphorus predominantly acts on the skin, gastrointestinal tract, hepatobiliary system, blood, kidneys, bones, lungs, nervous tissue, etc. It is frequently used in the homeopathic treatment of vitiligo (Leucoderma), hair loss, nephrotic syndrome, hepatitis, cirrhosis, hemorrhagic tendencies, respiratory infections, osteomyelitis, paralytic symptoms, etc. Few of its common skin symptoms are Loss of pigmentation in spots, white discoloration of the skin. It is also used for skin disorders where the patient has much itching and burning of the skin; in urticaria, psoriasis. It is also a good drug for hemorrhagic spots occurring on the skin at various places.