Baló-like Lesion With Psoriasis and Autoimmune Thyroiditis

Balà ³-like Lesion With Psoriasis and Autoimmune Thyroiditis BALÓ-LIKE LESION ASSOCIATED WITH PSORIASIS AND CHRONIC AUTOIMMUNE THYROIDITIS Authors: Corina Roman-Filip1, Aurelian Ungureanu2, Ileana Prăvariu3 Abstract Variants of multiple sclerosis are seldom encountered in clinical practice, sometimes with reserved prognosis or possibly serious disability. These pathologies are characterized by atypical demyelinating lesions such as Balà ³-type lesions or tumefactive lesions. The mechanism behind these lesions still remains a debate, since genetic and immune factors are incriminated. We present a case of multiple sclerosis variant with remarkably good outcome in association with autoimmune thyroiditis and psoriasis. This concomitant process questions the possibility of shared immune pathogenesis regarding the activation of T helper 17 cells lineage and mitochondrial oxidative stress. The imagistic appearance of the found lesions raises discussions on a possible radiologic diagnosis. Keywords: Balà ³-type lesions; tumefactive lesions; psoriasis; autoimmune thyroiditis; T helper 17 cells; Introduction Pathologist Jà ³zsef Balà ³ described a particular form of demyelinating disease, leukoencephalitis periaxialis concentrica, classically named Balà ³Ã¢â‚¬â„¢s concentric sclerosis (BCS). Nowadays, this is defined as a variant of multiple sclerosis. The intensive use of magnetic resonance showed an increasing number of different types of demyelinating lesions. Some of these are specific, but a large variety is under debate regarding the classification. Tumefactive demyelinating lesions (pseudotumoral) can sometimes present a degree of concentricity and can be easily mistaken for a genuine Balà ³ lesion, or at least a Balà ³-like demyelinating lesion. Historically, the variants of multiple sclerosis were regarded as serious disabling inflammatory damages of the central nervous system, but recent works have demonstrated that the course of the disease may be more variable, at least regarding BCS. Imagistic studies can lead to a better appreciation on the prognosis of BCS and its ass ociation with other types of demyelinating lesions [1]. The pathological mechanism behind it still remains a debate, although one can find similarities with multiple sclerosis (MS) and even overlapping lesions of these conditions. Case report We present the case of a 40-year-old woman admitted for mild incoordination of the left arm and speech impairment. The patient’s medical history is positive for psoriasis (since 2002) and autoimmune thyroiditis under treatment with levothyroxine 50 ug/day (since 2010). Magnetic resonance imaging (MRI) studies revealed FLAIR and T2 weighted inhomogeneous hyperintense lesions with concentric enhanced and non-enhanced lesions on T1 with gadolinium contrast (fig 1ab). The lesion was characterized as atypical demyelinating with 22.5/21.6 mm in size, with late concentric enhancement and without mass effect. Additionally, two demyelinating periventricular enhancing lesions were found (fig 1def). A biochemistry panel, antinuclear antibodies, anti-ds DNA antibodies, ANCA antibodies, anti Ro antibodies and anti-Borrelia antibodies were negative. Slight pleocytosis (16 cells/mm3 with 75% monocytes) was detected in the cerebrospinal fluid together with present oligoclonal bands and normal proteins. Serum myelin oligodendrocyte glycoprotein antibodies, myelin basic protein antibodies, IgG anti-aquaporin 4 antibodies were negative. Moreover, a high serum titre of anti-thyroperoxidase antibodies (60.73 IU/mL – normal Discussion The association of the pathologies described may seem incidental. However, strong research evidence shows the implication of Thelper17 cells (Th17) and Interleukin 17 (Il17) in the autoimmune pathways of MS, autoimmune endocrinopathy and psoriasis [2,3]. BCS type lesions and MS lesions may both be present simultaneously in the same patient, and Balà ³-like lesions may change over time into the classic appearance of MS lesions [4]. The lesions are characteristic, with rings of demyelination, surrounded by partial demyelinated regions, reflecting the concentricity within the lesion. The lesion type is classified as MS pattern III with oligodendrocyte loss, microglial activation and loss of myelin-associated glycoprotein [4]. Studies of 7 Tesla MRI support the microvascular pathology associated to inflammation, which seems to be consistent with pattern III lesions [5]. These studies are sustained by identifying Notch 3 mutation in a patient with BCS phenotype and a family history of No tch 3 mutation carriers and CADASIL. Mitochondrial respiratory chain disturbance and the expression of some molecules probably tend to precondition hypoxic tissue to inflammation, such as mitochondrial heat shock protein 70 [6]. Furthermore, new cellular biology studies of cancer found that hsp70 can mediate the Th17 differentiation [1]. We consider that the simultaneity with the autoimmune endocrinopathy and psoriasis may be more than incidental and raises the hypothesis of probable linkage of the proinflammatory and autoimmune role of Th17 cells lineage with mitochondrial oxidative stress. Compliance with Ethical Standards Conflict of Interest: The authors declare that they have no conflict of interest Informed consent was obtained from all individual participants included in the study Fig. 1 a. T1 gadolinium sequence showing a frontal demyelinating lesion with concentric enhancing rings (arrow); b. T2 weighted image with concentric rings of demyelination and myelinated regions (arrow); c. DWI sequence with diffusion restriction in the active lesion; d. T1 gadolinium enhancement of periventricular lesion (arrowhead); e. Enhancing periventricular lesion in the occipital lobe (arrowhead); f. Coronal T2 small demyelinating lesion (arrowhead) with enhancement on T1 (not shown) Fig. 2 a. T1 gadolinium sequence showing a significant improvement six months later (arrow); b. T2 weighted image showing the demyelinating lesion markedly decreased (arrow); c. DWI; d, e, f. Improvement of demyelinating lesions References Hardy TA,Miller DH (2014) Balà ³s concentric sclerosis. Lancet Neurol 13(7):740-6. doi: 10.1016/S1474-4422(14)70052-3. Kottke T, Sanchez-Perez L, Diaz RM, Thompson J, Chong H, Harrington K, Calderwood SK, Pulido J, Georgopoulos N, Selby P, Melcher A, Vile R (2007) Induction of hsp70-Mediated Th17 Autoimmunity Can Be Exploited as Immunotherapy for Metastatic Prostate Cancer. Cancer Res 67(24):11970-11979. Bossowski A, Moniuszko M, Dabrowska M, Rusak M, Jeznach M, Bodzenta-Ã…Â ukaszyk A, Bossowska A (2013) Role of Th17 cells and IL-17, IL-23 cytokines in pathogenesis of autoimmune thyroid disease in children. Thyroid Research 6(Suppl 2):A8.doi:10.1186/1756-6614-6-S2-A8. Stadelmann C, Ludwin S, Tabira T, Guseo A, Lucchinetti CF, Leel-Ossy L, Ordinario AT, Brà ¼ck W, Lassmann H (2005) Tissue preconditioning may explain concentric lesions in Balà ³s type of multiple sclerosis. Brain 128(Pt 5):979-87. doi:10.1093/brain/awh457. Berghoff M, Schlamann MU, Maderwald S, Grams AE, Kaps M, Ladd ME, Gizewski ER (2013) 7 Tesla MRI demonstrates vascular pathology in Balos concentric sclerosis. Mult Scler 19(1):120-122. doi: 10.1177/1352458512445302. Chitnis T, Hollmann TJ (2012) CADASIL mutation and Balo concentric sclerosis: a link between demyelination and ischemia? Neurology 78(3):221-3. doi: 10.1212/WNL.0b013e31823fcd3c.

Cry, the Beloved Country

Literary Elements by Paton In the last chapter of the novel Cry, The Beloved Country the author Alan Paton uses symbols, repetition, and tone shows disparity and hope in the main character, Kumalo in order to describe how the black men of south Africa must be able to adapt to their situations, or they may not make it out with their sanity. Throughout the passage in chapter 36, Paton often used tone to depict the stages of emotions Kumalo experienced while thinking about his son’s fate. Kumalo questions himself â€Å" Would [Absolam] be awake, would he be able to sleep, this night before the morning?He cried out, My son† (310). In this sentence, Kumalo wonders how his son will face his death the next morning and feels the same pain Absolam does. The anguish and concern Kumalo felt shows his way of coping with the terrible fate to meet his son the following morning. Kumalo not only worries about how his son is coping with his inevitable death, but cries out in desperation as if Absolam will be able to hear him and be comforted. In addition, in the final moments of the book, Kumalo looks â€Å"at the faint steady lightening in the east† (312). Kumalo is no longer afraid of his son’s future, embraces it and is at peace.His son’s execution placed Kumalo in a dark place where he was not familiar with, but at when dawn came and the sun rose the thing he feared was finally here and he accepted it so he could move on and his son could rest in peace. The tone in this sentence had a tone of hopefulness, as opposed to the tone of the rest of the passage that had a tone of despair and grief because the referral to the sun displayed optimism and feelings of not wanting to dwell in the past. However, Paton uses the tone shift in this passage to show Kumalo’s acceptance and adaption to reality and the things he could not change.Paton often used repetitive words relating to the darkness, light, and about the sun rising and setting. Thes e words all described how each village had to accept their situation before they could truly be at peace with themselves and the lives they live. For example, â€Å"The great valley of Umzimkulu is still in darkness, but the light will come there. â€Å" (312). In a literal interpretation, this simply describes how the sun slowly rises and shines on all the villages, but in the context of this passage, Paton depicts the darkness and the negativity some people of South Africa are stuck in.And as the sunlight shines over them, they will become rejuvenated and realize the beauty in living one more day despite the conditions they live in. In addition, Kumalo thought to himself that â€Å"The sun would rise soon after five, and it was then it was done† (310). The indication of the sun rising represents the end of the darkness of the night and then end of Kumalo’s dark thoughts throughout the night. Not only does it mean the end of Kumalo’s suffering, it means that the sun rise will end his son’s life by execution.It is also a metaphor for renewal throughout, the moment he feared most is over and done with and he can now rest easy. Furthermore, Paton’s use of tone in this passage also illustrates how Kumalo persisted through his darkest times and he eventually was able to pull through and hope his son the best, or the capability to acclimate to any situation. Paton illustrates ultimate hope and renewal at the end of the passage with the usage of symbols of the sun and the titihoya bird. For example, Kumalo professes that â€Å" when that dawn will come, of our emancipation, from the fear of bondage and the bondage of fear, why, that is a secret. (312). The dawn for Kumalo shows his son is freed from his life of sin and can now peacefully travel to the next world without worry. Not only is Absolam freed, Kumalo is free himself from the fear of his son further sinning and for his well being, as he is in God’s hands now. In addition, Kumalo says â€Å" Yes, it is the dawn that has come. The titihoya wakes from sleep, and goes about his work of forlorn crying. † (311). The bird the sun are intertwined, as the bird only wakes with the sun, and Kumalo and Absolam’s fate are forever connected no matter how far away they are from each other.Despite the grief Kumalo experiences, his usage of light and birds displays his acceptance of the future for himself and the end of his son’s. Kumalo’s adaptation to a terrible event in his life displays his ability to be optimistic and not live in the past. Overall, Kumalo went through a series of emotions and feelings that at the time seemed impossible to cope with. And with Paton’s usage of tone, symbols, and repetition, he showed Kumalo was greatly in tune with nature and his spiritual self. His adaption to reality geared himself to serenity when he let destiny lead the way.

Essay on Internet - 480 Words

How to use Internet as a management resource? Introduction: Internet is a global network, connecting thousands of host servers worldwide. The United States Department of Defense established it in the beginning of the 1960 ¡Ã‚ ¯s. Today, there are now 10 to 20 million people using an Internet comprised of more than 30,000 networks spread out over 78 nations all over the world. Now the Internet has become a great electronic gateway that provides instant access to global news and information. The databases, documents, files, and programs that are  ¡Ã‚ °sitting ¡Ã‚ ± on Internet computers contain a tremendous amount of information. You can search for and find up-to-the-minute stock market activity, weather reports, music, recipe; you can make†¦show more content†¦At last, we will briefly discuss some risks for using Internet. Implementing Internet as a management resources: Search external information to compete in the business world Approach specific knowledge and experts to increase management skill Use internet as a tool to improve management performance Risks: The very fundamental purpose of Internet is to provide an open information framework with few access barriers to information. There are several potential risks associated with the implementation of Internet in the organization. So managers should pay attention to it and avoid it. Security Internet is a completely open system. Any user is able to access any information interconnected via the information superhighway. Computer quot;Virusesquot; and quot;Wormsquot;. Computer Viruses and Worms are known for causing harm to computer systems. Information Overload and Redundancies. Conclusion: How to successful use Internet as a management resource are more than a management buzzword and a textbook definition. It is a new way of managing organizations towards a more complex and competitive future. Furthermore, more and more managers have realized that Internet is not only a communication tools and information resource. In fact, managers have promoted how to use Internet to their strategy plan. Internet has proven very successful in providing information andShow MoreRelatedInternet Privacy And The Internet954 Words   |  4 Pagesunauthorized information by computer, but they actually make the internet a safer place. With the growth of the internet comes the growth of hackers and internet privacy. New laws that would increase internet privacy and, limit hackers would halt the internets growth and development. Since the year 2000, the internet has grown enormously we can all agree and with this growth comes a growth of internet users. 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Justice And Injustice Of Plato s The Republic - 1502 Words

Short Essay: Justice and Injustice in Plato’s The Republic In Plato’s The Republic, Socrates expresses his belief that in order for a state and its people to be functioning at their best, every citizen ought to do what they have the most character for, or what they are most qualified to do. Whether it is craftsmanship, guarding the city, playing music, or healing the sick, Socrates thinks that everyone should make his or her living doing one thing that they are skilled at, and one thing only. In order to ensure that only the best guardians are guarding the state, and only the most fit to rule become rulers, and so on, Socrates proposes the myth of the metals. He says to Glaucon that such an â€Å"audacious fiction† is necessary to convince the people that their livelihoods are beyond their choice and out of their control. 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