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In leukemia (B) erectile dysfunction 17 purchase viagra super active 25 mg on line, the marrow fat and normal hematopoietic cells have been replaced by leukemic cells protein shakes erectile dysfunction order viagra super active visa. The granulocytes are usually neutrophils, but it is not uncommon to find increased numbers of basophils and eosinophils. In the bone marrow, general myeloproliferation is present, involving not only the granulocyte series but also erythroid cells and megakaryocytes. Acceleration typically is accompanied by further cytogenetic changes, including extra copies of the Ph1 chromosome. The bone marrow is infiltrated by similar cells, but normal hematopoietic elements remain until an advanced stage of the disease. Treatment & Prognosis Combination chemotherapy, using several anticancer agents simultaneously in various combinations, has improved the prognosis of patients with acute leukemias dramatically. However, chemotherapy does increase the duration of survival in comparison with nontreated cases. Paradoxically, treatment has little effect on the survival rate of chronic leukemias. Many of these patients survive many years after diagnosis of disease without treatment, and their overall course and outcome does not seem to be altered by therapy. Recently, acute leukemias have been treated more aggressively with the intention of destroying all the hematopoietic cells in the marrow, including leukemic cells, followed by rescue of the patient by bone marrow transplantation (see Chapter 10). The transplant consists either of matched heterologous marrow or of autologous marrow taken prior to therapy and purged of leukemic cells by in vitro treatment with monoclonal antibodies. Hemorrhage and infection are major causes of death of patients with leukemia, occurring as a direct effect of the leukemia or as a complication of cytotoxic therapy or failed transplantation. The first three conditions listed have already been discussed and are quite well defined. While all may show some clinical overlap, the last three are most difficult to distinguish and to diagnose. Clonal chromosomal translocations or partial deletions (chromosomes 7 and 13) are found in 50% or more of cases. Aspiration of marrow is often unsuccessful because of extensive fibrosis of the bone marrow (myelofibrosis). The peripheral blood typically shows leukoeryothroblastic anemia with neutrophil leukocytosis and a marked shift to the left. As marrow fibrosis progresses, extramedullary hematopoiesis may cause massive enlargement of the spleen and liver. Some cases are associated with other myeloproliferative disorders, especially polycythemia rubra vera. The neoplastic cell is medium-sized, with an ovoid nucleus, a fine chromatin pattern, and inconspicuous nucleoli (see Table 29-7). The abundant cytoplasm has a frayed cell membrane (on electron microscopy, the cell membrane shows hairy processes, hence the name). Electron microscopy also reveals the presence in the cytoplasm of a specific spiral organelle (lamellar ribosomal complex). The cytoplasm contains tartrate-resistant acid phosphatase, the demonstration of which is of diagnostic value. Patients present commonly with anemia, neutropenia and thrombocytopenia, and splenomegaly, the last often massive. The disease responds poorly to chemotherapy and has a relatively poor prognosis, with median survival approximately 2-3 years after diagnosis. Platelet function is often abnormal, however, and patients may present either with excessive bleeding or with occlusion of small vessels (focal ischemia, visual loss, neurologic symptoms). Peripheral blood shows numerous platelets, many of abnormal shape, plus leukocytosis. The bone marrow is often fibrotic, emphasizing the close relationship of this disorder with myelofibrosis. Patients are typically elderly, and the disease generally progresses to marrow failure. Myelodysplastic Disorders (Refractory Anemias) this category includes several related and ill-understood conditions. Some cases follow a history of cytotoxic therapy; others are associated with severe vitamin B12 or folate deficiency.

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Amebic colitis erectile dysfunction caused by hernia buy viagra super active in united states online, showing typical flask-shaped ulcers with maximal involvement of the submucosa impotence when trying to conceive cheap generic viagra super active uk. The mucosal surface-as seen at colonoscopy- shows multiple ulcers separated by healthy-appearing mucosa which is, however, undermined by the submucosal abscesses. Confluence of mucosal ulcers results in large areas of denuded mucosa covered by a necrotic base. Hemorrhage and toxic megacolon may also occur with severe infection, and venous spread to the liver may occur (Chapter 42). Clinically, patients with amebic colitis present with bloody and mucous diarrhea accompanied by low-grade fever. The diagnosis is made by the finding of trophozoites of E histolytica in the stools or in a biopsy specimen. Giardia attaches itself to the surface of the small intestinal mucosal cells by its ventral sucker. In heavy infections, a large part of the mucosal surface area may be occupied by parasites, causing mechanical interference with absorption. Giardiasis also causes partial villous atrophy, which contributes to malabsorption. Clinically, infected individuals develop cramping abdominal pain, with diarrhea and steatorrhea due to malabsorption. Crypto sporidium and Isospora species may rarely infect healthy individuals, causing a mild self-limited acute diarrhea. High-magnification photograph of the edge of an ulcer, showing trophozoites of Entamoeba histolytica. They are minute organisms that are best seen by electron microscopy and silverstained sections. Intestinal helminthiasis is extremely common in underdeveloped countries and has been estimated as afflicting about 25% of the world population. In many of these diseases, the worm lives in the lumen without causing major symptoms; in others, significant clinical manifestations occur (Table 40-4). Cryptosporidium is present in large numbers, usually attached to the surface of the epithelial cell. The diagnosis is established by identifying the organism in stool smears stained with acid-fast stains. Cryptosporidium is 2-4 (Jin in diameter, round, and seen only in acid-fast stained smears. They are recognized as distinct entities with distinct clinical and pathologic features (Table 40-5). These cases are characterized as indeterminate idiopathic inflammatory bowel disease. However, there are so many differences that it is probably best to regard them as two diseases until their cause (or causes) is determined. The diagnosis of idiopathic inflammatory bowel disease is suspected clinically (chronic or recurrent diarrhea) and confirmed by colonoscopy and biopsy. The mucosal features of idiopathic inflammatory bowel disease on histology include distortion of crypt architecture, crypt destruction and loss, and a marked increase in lymphocytes and plasma cells in the lamina propria. These changes distinguish idiopathic inflammatory bowel disease from acute infectious colitides and from other causes of chronic colitis such as collagenous disease (where the crypts are normal and there is a layer of collagen under the epithelial basement membrane), ischemia, and radiation injury. In other cases, the differentiation is made on clinical and radiologic grounds (see Table 40-5). There is no inheritance pattern, and the familial tendency is likely to be the result of a shared, common environment. Sites of Involvement: Combined ileal (most commonly terminal ileum) and colonie disease is most common (50%). Involvement of the oral cavity, larynx, esophagus, stomach, and perineum are rare. Perianal disease occurs in both ileal and colonie disease and is not dependent on the presence of rectal involvement. The mucosa shows diffuse hyperemia, acute inflammation, and shallow, aphthous ulceration. In involved ileal segments, the mesenteric fat creeps from the mesentery to surround the bowel wall (creeping fat).

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During diastole erectile dysfunction lexapro order viagra super active 25mg mastercard, regurgitant blood flows back across the mitral valve www.erectile dysfunction treatment purchase viagra super active 25mg otc, producing a third heart sound and a diastolic flow murmur. Left ventricular volume is greatly increased, because it is the sum of the cardiac output plus the regurgitant flow; the left ventricle is thus dilated and hypertrophied. The left atrium, which accepts both the pulmonary venous return and regurgitant flow, is also dilated in chronic cases. Regurgitation of blood from left ventricle to left atrium during systole causes dilation and increased pressure in the left atrium. This results in pulmonary venous congestion, pulmonary vascular changes, and pulmonary arterial hypertension, leading to right ventricular hypertrophy. The left ventricle, which must pump out the cardiac output plus the regurgitant flow, undergoes dilation and muscular hypertrophy. Mitral regurgitation, showing pressure changes in the left side of the heart and aorta and abnormal heart sounds in a typical case. Note the marked rise of left atrial pressure during systole owing to regurgitation of blood across the incompetent mitral valve. Acute mitral valve regurgitation, as occurs with valve perforation or papillary muscle rupture, produces pulmonary edema and acute left heart failure with little left atrial dilation. Congenital bicuspid aortic valves may undergo progressive fibrosis and calcification; this is now believed to be the cause of more than 50% of cases of aortic stenosis. Congenital narrowing of the left ventricular outflow tract above or below the aortic valve produces the same functional defect as aortic stenosis. Hypertrophic cardiomyopathy may also produce obstruction of the left ventricular outflow tract. Decreased flow of blood through the aortic valve causes decreased cardiac output, hypotension, and syncopal (fainting) attacks, myocardial ischemia, and angina (decreased coronary artery perfusion). The systemic blood pressure is decreased, and this results in soft closure of the aortic valve (soft S2). The peripheral pulse is typically of low amplitude, with the pulse wave rising slowly and being sustained owing to the prolonged left ventricular ejection. The left ventricle develops increased systolic pressure to overcome the resistance at the aortic orifice and undergoes hypertrophy. Increased oxygen demand by the myocardium aggravates the tendency to myocardial ischemia. Aortic stenosis, showing pressure changes in the left side of the heart and aorta and abnormal heart sounds in a typical case. Note the pressure gradient between the aorta and left ventricle during systole owing to the stenosis of the aortic valve orifice. In most of these cases, there is associated mitral valve disease as well as aortic stenosis. Syphilis was once a common cause of isolated aortic regurgitation but now accounts for less than 10% of cases. Aortic regurgitation in syphilis is caused by dilation of the aortic root and valve ring due to aortitis. Ankylosing spondylitis, which also involves the root of the aorta, is an important, although uncommon, cause (5% of cases) of isolated aortic regurgitation. Rupture of the aortic valve may occur as a complication of blunt chest trauma and infective endocarditis. Myxomatous degeneration of the aortic valve due to accumulation of mucopolysaccharides, similar to that seen in mitral valve prolapse syndrome, is being recognized as a possible cause of aortic regurgitation. The pressure gradient across the valve is greatest in early diastole, and it is in this phase that the murmur is loudest (decrescendo murmur). Regurgitation of blood from the aorta in diastole causes decreased diastolic blood pressure, sometimes to zero (which is the ventricular diastolic pressure). At the same time, the systolic pressure is elevated as a result of increased cardiac output (normal volume plus regurgitant volume).

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The difficulty is greatest on expiration; small airways tend to collapse as intrathoracic pressure rises cost of erectile dysfunction injections buy viagra super active 50 mg on-line. Fluid in the parenchyma or alveoli (as in left heart failure and pulmonary edema) produces decreased compliance and vital capacity impotence blood pressure medication generic 50mg viagra super active free shipping. Collapse and consolidation of lung parenchyma (as in pneumonia) reduce the vital capacity. Diffuse pulmonary fibrosis: decreases compliance and produces diffusion abnormalities. Hypoxemia and hypercapnia stimulate the respiratory center, increasing the ventilatory rate. Painful lesions of chest or pleura (pleurisy and trauma) or restrictive chest diseases produce limited expansion. Fluid or air (especially under pressure) in the pleural cavity, as in pleural effusion or pneumothorax, reduces expansion of the lung. Pulmonary embolism and infarction produce perfusion defects and destruction of lung tissue. It usually involves one lobe, which is enlarged and composed of abnormal cystic cavities lined by bronchiolar and columnar mucinous epithelium. The cystic mass may compress adjacent normal lung and displace the mediastinum, interfering with normal cardiac and lung function. Respiratory distress syndrome is also seen in babies born to diabetic mothers and occurs with a higher incidence in children delivered by cesarean section. Despite major improvements in the care of these infants, respiratory distress syndrome still accounts for about 7000 neonatal deaths every year in the United States. Respiratory distress syndrome occurs in 60% of babies born after less than 28 weeks of gestation, 40% of those born between 28 and 32 weeks, 20% of those born between 32 and 36 weeks, and less than 5% of those born after more than 36 weeks of gestation. Surfactant reduces surface tension, decreasing the amount of pressure required to open the alveoli. In the immediate neonatal period, surfactant is important in maintaining expansion of the lung after the first few breaths. In surfactant deficiency, the alveoli collapse after initial expansion, causing failure of oxygenation, hypoxemia, alveolar damage, protein exudation, and alveolar hemorrhage. Respiratory distress syndrome has a mortality rate of about 25% even when treated with positive-pressure ventilation and exogenous surfactant aerosols. In babies with a birth weight of less than 1000 g, the mortality rate is over 50%. Grossly, the involved lung shows inadequate expansion and is heavy and purple as a result of fluid exudation and hemorrhage. It must be made clear that hyaline membranes are a nonspecific response to any type of acute alveolar damage; a simi- Note that anxiety and exercise produce temporary dyspnea in physiologically normal individuals. Occasionally, an additional segment of lung develops from an abnormal accessory lung bud. The bronchi in this sequestered segment may not communicate with the normal bronchial tree, causing accumulation of mucus secretion followed by infection with abscess formation, parenchymal fibrosis, and bronchial dilation. Patients usually present with a mass in the lung, commonly in the left lower lobe or, more rarely, with accessory lung tissue in the mediastinum. The cyst is lined by respiratory epithelium and frequently has cartilage in its wall. Some degree of pneumonia is present at autopsy in the majority of autopsies of patients who have died of chronic disease, and in many of these cases the pneumonia contributes significantly to death. Many types of pulmonary infections caused by a variety of agents are recognized (Table 34-4). Neonatal respiratory distress syndrome, showing marked alveolar collapse and hyaline membranes. Babies that survive severe respiratory distress syndrome-particularly if oxygen has been used in therapy-may progress to chronic lung disease with fibrosis, called bronchopulmonary dysplasia.

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Clinical Features & Diagnosis Patients with acute air space pneumonia present with an acute onset of fever can you get erectile dysfunction pills over the counter order viagra super active 50mg without prescription, dyspnea erectile dysfunction options order 50 mg viagra super active mastercard, and cough that is commonly productive of purulent, rust-colored sputum. Chest pain, a pleural friction rub, and effusion are present if there is pleural involvement. When secondary pneumonia occurs in chronically ill patients, these symptoms may not be obvious. Chest x-ray to confirm an alveolar pattern of pneumonia is essential to differentiate air space pneumonia from interstitial pneumonia. Chest x-ray may also differentiate between lobar and bronchopneumonic patterns, which provides insight to the etiologic agent. Specimens that may provide a positive test (either by direct examination of a gramstained smear or culture) are sputum and blood (Table 34-5). Special staining of sputum smears using acid-fast stains (mycobacteria) and immunofluorescence (Legionella) may be indicated in some cases. In patients who do not produce sputum, induction of secretions with ultrasonic nebulization of water or saline is sometimes effective. In patients with pleural effusions, thoracentesis provides pleural fluid for culture. Bronchoscopy and bronchoalveolar lavage to obtain a specimen for culture may be indicated in seriously ill patients when no other specimen is readily available. In patients with acute pneumonia, antibiotic therapy must be started before the etiologic agent has been identified. The specific antibiotics used will depend on clinical assessment of the agent most likely to be present. This will depend on epidemiologic data (Table 34-4) and the results of a gram-stained smear of a sample of any obtained specimen. The antibiotic regimen should cover the range of possible organisms that may be involved. Disturbances of Ventilation and Perfusion: Air space pneumonia interferes with gas exchange in the involved area of the lung. Note the small pale areas of patchy consolidation around bronchioles throughout the lung. In most cases, vital capacity is reduced, but respiratory failure occurs only with extensive disease involving both lungs. Pleural Involvement: Spread of infection to the pleura, with acute inflammation and effusion, commonly accompanies air space pneumonia. Rarely, pleural inflammation becomes progressive and does not resolve, leading to loculation and accumulation of pus (empyema). Bacteremia: Bacteremia is the most serious complication of pneumococcal pneumonia. Bacteremia may also lead to pneumococcal infections elsewhere in the body, most commonly meningitis and endocarditis. Suppuration (Abscess Formation): Suppuration is associated with liquefactive necrosis of alveoli leading to areas of destroyed lung replaced by pus. Suppuration is associated with virulent pyogenic bacteria such as S aureus, gram-negative bacilli, and type 3 pneumococci. In patients who recover, areas of suppuration heal by fibrous scarring because the destroyed alveoli cannot regenerate. Necrotizing Bacterial Pneumonia: this is a rare complication characterized by extremely severe necrosis of the lung associated with a rapidly progressive disease with a high mortality rate. It is seen with etiologic agents such as Yersinia pestis (pneumonic plague) and Bacillus anthracis (anthrax), which are rare causes of pneumonia. An acute necrotizing pneumonia may also occur in immunodeficient and malnourished patients secondary to more common pathogens such as L pneumophila and M tuberculosis. Most cases of interstitial pneumonia are community-acquired; very few are hospital-acquired. Acute interstitial pneumonias are sometimes called atypical pneumonias because the typical features of air space pneumonia are not present in a patient presenting with clinical features of acute pneumonia. Etiology Mycoplasma pneumoniae is the most common cause of sporadic cases of interstitial pneumonia. Most of the other agents causing acute interstitial by [University of Melbourne 128.

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In carcinoma in situ erectile dysfunction age 30 buy generic viagra super active 100mg, biopsy reveals that maturation is totally lacking how to cure erectile dysfunction at young age discount viagra super active express, and most of the cytologic changes of carcinoma are present except invasion through the basement membrane. Dysplasias are reversible lesions, but the more severe the degree of dysplasia the less the tendency to reverse. The median time for carcinoma to develop is 7 years for mild dysplasia and 1 year for severe dysplasia. This observation has led to the recommendation that routine cervical Pap smears should be performed in all women at least once every 3 years after two initial examinations 1 year apart have proved negative. The mortality rate from cervical carcinoma has been falling, partly due to early detection of premalignant epithelial dysplasia by routine cytologic screening of cervical smears (Pap smears); many cases are detected and treated in the preinvasive stage. In contrast to carcinoma, dysplasia of the cervical epithelium remains common and appears to be occurring in younger women. Etiology Considerable evidence suggests that carcinoma of the cervix is caused by a sexually transmitted carcinogenic agent, probably viral (Table 53-3). The risk of developing carcinoma increases with early onset of sexual activity, frequency of coitus, and greater number of sexual partners. It is common in multiparous women who have married early and in prostitutes but vanishingly rare in nuns. In general, cervical carcinoma tends to affect the lower socioeconomic stratum of society. Cervical carcinoma is uncommon in Jewish and Moslem women, leading to a theory that male circumcision reduces the incidence of cervical cancer in women. It has been shown recently that there is a threefold increase in the incidence of cervical cancer among the sexual partners of men who have been married previously to women with carcinoma of the cervix. Squamous epithelial dysplasia and carcinoma of the cervix, showing criteria used to grade dysplasia. Dysplasia affects cervical surface epithelium as well as extending down into endocervical glands (gland duct involvement). The significance of gland duct involvement is the same as that of dysplasia of the surface epithelium. Changes in the mucosa on inspection are minimal, but some lesions may be recognized by means of the magnified image provided at colposcopy (eg, abnormal vascular pattern, thickening, and white coloration). Colposcopy and biopsy should be performed in all patients in whom dysplasia of any grade is found on routine cervical cytologic examination (see Table 53-2). The Schiller test, which consists of painting the cervix with aqueous iodine, is helpful in locating areas of dysplasia, since dysplastic epithelium lacks glycogen and will appear as a pale area whereas normal epithelium stains dark brown with iodine. Microinvasive carcinoma so defined is rarely associated with metastases, and local surgical excision is curative. It should be recognized that the submucosa of the cervix within this 5-mm zone below the basement membrane does contain lymphatics and blood vessels, and metastases are a hypothetical possibility. Microscopically, there are three different types: (1) large cell, nonkeratinizing squamous carcinoma-the most common type, with the best prognosis; (2) keratinizing squamous carcinoma-next most common, with an intermediate prognosis; and (3) small cell carcinoma-rare, with a poor prognosis. Invasive cervical carcinoma is manifested as abnormal uterine bleeding (commonly irregular and excessive menstrual bleeding or postmenopausal bleeding) or vaginal discharge. Obstruction of the cervical canal may cause blood to accumulate in the uterine cavity and result in infection (pyometron). Colposcopy permits direct visualization and biopsy to make a definitive histologic diagnosis. Extension to the pelvic side wall or involvement of the lower third of the vagina or the presence of hydronephrosis from ureteral involvement (35%). Its upper part is derived from the miillerian duct, its lower part from the urogenital sinus. The vagina normally contains no glands but exudes fluid throughout the epithelium. The vagina is effectively evaluated by direct examination using a speculum, which also permits taking of biopsies from abnormal areas. Squamous carcinoma of the cervix involving the squamocolumnar junction and most of the endo cervical canal. The tumor is mainly to the left of the displaced endocervical canal in this figure.

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Dysplasia commonly involves the region of the squamocolumnar junction and the endocervical canal that has undergone squamous metaplasia erectile dysfunction at the age of 21 buy 25 mg viagra super active amex. The cytologic changes include increased nuclear size erectile dysfunction in your 20s purchase 25mg viagra super active visa, increased nuclear:cytoplasmic ratio, hyperchromatism, abnormal chromatin distribution, and nuclear membrane abnormalities. These cytologic changes on a Pap smear correlate accurately with the degree of abnormal maturation of the epithelium in a subsequent cervical biopsy specimen. Treatment is a combination of surgery and radiation therapy, depending on the extent of disease. It arises in the endocervical glands, presenting as a mass in the endocervical canal. Microscopically, endocervical adenocarcinoma is usually a well-differentiated lesion, often with a pap- Before puberty, pyogenic bacterial infection of the vagina may occur. After puberty, the vaginal mucosa is protected by the low pH produced by the commensal Doderlein bacillus (Lactobacillus acidophilus), and vaginitis is relatively rare during the reproductive years. Non-sexually transmitted vaginitis may be caused by Gardnerella vaginalis, Trichomonas vaginalis, and Candida albicans. Atrophic vaginitis is a specific form of acute inflammation that occurs in postmenopausal women when the vaginal mucosa undergoes extreme atrophy as a result of estrogen withdrawal. They occur in the anterolateral wall of the vagina and are lined by cuboidal or columnar epithelium. In most cases, there is no visible lesion, and the condition is of little significance clinically except for its yet uncertain relationship to clear cell adenocarcinoma of the vagina (see below). If vaginal adenosis is the precursor lesion for clear cell adenocarcinoma, the risk is small. Grossly, vaginal carcinoma presents as a polypoid, fungating, exophytic mass or as an ulcerative, infiltrative tumor. Microscopically, it has the typical appearance of a squamous carcinoma, with keratinization and formation of epithelial pearls. Tumors in the upper two thirds drain similarly to cervical cancer; tumors in the lower third, similarly to vulvar cancer. Furuncles are common, and erysipelas and severe necrotizing vulvitis have been reported. All of the sexually transmitted diseases may produce lesions in the vulva (Chapter 54). Staphylococcus aureus, Streptococcus pyogenes, Neisseria gonorrhoeae, and Escherichia coli are the common organisms. Acute bartholinitis presents as a painful, tender, erythematous swelling in the inferior part of the labium majus. Leukoplakia may be due to a variety of different conditions, including vulvar dystrophies, chronic dermatitis, psoriasis, and carcinoma in situ. There are two main types of vulvar dystrophy: lichen sclerosus and hyperplastic dystrophy. Microscopically, it is composed of clear cells arranged in a tubuloglandular pattern. Treatment with surgery and radiation is effective, with a 5-year survival rate of 80%. It occurs in the first 5 years of life and appears as a large, lobulated tumor mass (Gk botryoides, like a bunch of grapes) that frequently protrudes at the vaginal orifice. Lichen sclerosus is a chronic, progressive disease usually occurring in postmenopausal women. Sclerosis and shrinkage of the dermis causes the vulva to be smooth, glazed, and parchment-like. Microscopically, lichen sclerosus is characterized by thinning of the epidermis, with a relatively prominent stratum corneum, flattened rete pegs, and some basal layer degeneration. The condition was formerly called lichen sclerosus et atrophicus, but true atrophy is not present.

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These tumors appear as slowly growing yellowish masses that may resemble a chalazion erectile dysfunction drug types purchase viagra super active 25 mg fast delivery. Progression causes erosion of the lid margin or conjunctiva and the appearance of a large lobulated mass depression and erectile dysfunction causes buy viagra super active 100mg low price. Microscopically, the tumor forms large invasive nests and sheets of cells with abundant cytoplasm. The diagnostic feature is the presence of large cells with vacuolated cytoplasm that contain lipid (demonstrable with lipid stains on frozen sections). Like other adenocarcinomas, meibomian gland carcinoma may spread laterally in pagetoid fashion into the epidermis of the eyelid. Meibomian gland carcinoma is important to distinguish from squamous and basal cell carcinoma because it has a more aggressive biologic behavior. This is the most common neoplasm of the eyelids and the most common location for basal cell carcinoma. Pathology & Clinical Features Acute bacterial conjunctivitis is characterized by pain, hyperemia appearing as vascular injection (red eye), and a purulent discharge in which numerous neutrophils are present. Ophthalmia neonatorum results from infection of the fetus with Neisseria gonorrhoeae during delivery through the birth canal. Ulceration occurs in severe cases, and when this involves the cornea visual impairment may occur. Neisseria gonorrhoeae (ophthalmia neonatorum) in babies born to mothers with active gonococcal cervicitis. Viral Especially severe in herpes simplex keratitis; occasionally herpes zoster, adenoviruses. Trauma, foreign bodies the conjunctiva is lined by a thin, transparent, nonkeratinizing stratified squamous epithelium in which are found scattered mucous cells. Diagnosis the diagnosis of conjunctivitis can be made clinically based on the presence of conjunctival injection and discharge. Keratitis is diagnosed by examination; invisible epithelial lesions may be outlined by fluorescein staining. The etiologic agent is identified by culture and microscopic examination of conjunctival discharge and scrapings from corneal lesions. Amebic trophozoites are present, often in large numbers, in Acanthamoeba keratoconjunctivitis. It is characterized clinically by acute inflammation with pain, red eye, and discharge and histologically by accumulation of lymphocytes in the conjunctiva. It is caused by chlamydiae, which may be demonstrated as cytoplasmic inclusions in infected cells in the exudate. The disease is transmitted via contaminated hands, shared towels, and infection of the fetus during delivery through an infected birth canal. It is self-limited, with recovery occurring in all cases after a few days of discomfort. Trachoma is a much more serious chlamydial infection in which there is long-term destruction of the cornea, leading to blindness in cases that are not treated early. The acute conjunctival inflammation progresses to a chronic phase in which there may be epithelial hyperplasia, lymphocytic infiltration, and pannus formation-the last an inflamed mass of granulation tissue that replaces the superficial layers of the cornea and results in blindness. Trachoma is the most common cause of blindness in underdeveloped tropical countries. Epidemics of keratoconjunctivitis caused by amebae of the species Acanthamoeba have been traced to the use of contaminated contact lens cleaning fluids. Allergic conjunctivitis- also called vernal ("spring") conjunctivitis-is typically seasonal in occurrence due to pollens in the environment and is associated with hay fever. Histologically, it shows goblet cell hyperplasia and infiltration by lymphocytes and eosinophils. Phlyctenular conjunctivitis is a delayed hypersensitivity response to antigens of bacteria such as Mycobacterium tuberculosis and Staphylococcus aureus. It is characterized by an elevated, hard, red tri- Pinguecula is a common degenerative disease caused by ultraviolet solar radiation and is similar to solar-induced changes in the skin, with epithelial atrophy, degeneration of collagen, and hyalinization of elastic tissue (see Chapter 61). The incidence of secondary infection, ulceration, and epithelial dysplasia is low.