ECG Interpretations

Clinical history 

A 60 year old man with long standing hypertension

A 75 year old asymptomatic woman with a long standing hypertension

An 83 year old man with a recently implanted pacemaker.He has a history of heavy smoking

A 75 year old man with a history of palpitations

A 21 year old man with end stage renal disease

A 34 year old man with Down's syndrome who complains of chest pain

A 65 year old woman taking digoxin for congestive heart failure

A 79 year old man with chronic dyspnea. He is heavy smoker

A 52 year old man with chest pain and hypotension

A 16 year old healthy female with atypical chest pain

An asymptomatic 70 year old man who has been treated with a calcium channel blocking agent for a history of angina

Progressive Supranuclear Palsy

Important points

Males > Females 60/70 year of age

Atypical parkinsonism

• Lack of resting tremor

Tau pathology (''Tauopathy'')

• Risk factors: head trauma,vascular disease, drugs

• Prognosis: death in 5-10 years

• Treatment: L-Dopa

Opportunistic and Deep Mycoses

Coccidioides immitis  (Southwest USA)

• Located in desert soil
• Characteristic structures
• In the environment:  Arthroconidia
• In the body:  Sphereules are pathognomonic

Blastomyces dermatitidis  (north central and southeast USA)

• Associated with water

Lymphocutaneous Sporotrichosis

Mucocutaneous mycoses:  candida and dermatophytosis (get inflammatory response)

• Candida albicans
• Primary cutaneous candidiasis
• Mucocutaneous candidiasis

Candidiasis

• Wide range of infections
• Candida albicans is the most virulent species
• Candida spp. are common organisms of the skin, GI and UG tracts.
• Candidiasis is a disease of compromised hosts.

Mucocutaneous (T CELL IMPAIRMENT)

• Systems affected:
• GI tract, skin, vagina
• Onychomycosis
• Keratitis
• Symptoms:  Odynophagia, stridor, etc.
• Diagnosis: white pseudomembranous plaques with hyphae, pseudohyphae, and budding yeast.
• Groups at risk
• HIV patients
• Diabetics
• Pregnancy
• Age
• Antibiotics
• Steroids

Chronic mucocutaneous candidiasis – autoimmune polyendocrinopathy candidosis ectodermal dystrophy

• Inherited disorder of CMI to candida along with polyendocrinopathies
• Intractable candida infection of the mucocutaneous areas
• Concurrent adrenal insufficiency and hypoparathyroidism
• Type I diabetes
• Hypothryroidism
• Hypogonadism
• Ectodermal dystrophy

Deeply invasive candidiasis (think CANCER)

• Systems affected/ symptoms and signs:
• Candidemia
• Endocarditis – organism is sticky
• Hepatosplenomegaly
• Acute, shocklike syndrome
• Renal dysfunction

At risk groups:  

• Altered barriers
• Neutropenia
• Transplant
• Hemodialysis
• Pathogenesis
• Adherence and colonization
• Penetration through mucosal barriers and angioinvasions/access through catheters
• Hematogenous spread
• Replication yields necrosis +/- abscess with budding yeast and hyphae
• Look at the fundus!  Candida goes to the eyes!

Virulence factors of Candida

• Surface receptors
• Cell wall is an immune modulator
• Hydrolytic enzymes – e.g. acid protease, phospholipase
• Host mimicry – e.g. C3D receptor
• Dimorphism – makes it hardy!
• Germ tube + species.

Superficial:  

• Fungus confined to the stratum corneum or distal portions of hair
• Tinea versicolor:  Malassezia furfur
• Pigmentation changes due to fungal effect on melanocytes
• Can cause folliculitis
• Can cause fungemia in neonates with indwelling vascular catheters receiving total nutrition with lipids.
• Malassezia furfur is a lipophilic yeast and it requires fatty acids to grow.

Microscopic morphology of Aspergillus

Medical Mycology

• Microscopic morphology of Aspergillus fumigatus showing typical columnar, uniseriate conidial heads. Conidiophores are short, smooth-walled and have conical shaped terminal vesicles, which support a single row of phialides on the upper two thirds of the vesicle.

• Microscopic morphology of Aspergillus fumigatus showing typical columnar, uniseriate conidial heads. Conidiophores are short, smooth-walled and have conical shaped terminal vesicles, which support a single row of phialides on the upper two thirds of the vesicle.

• Microscopic morphology of Aspergillus niger showing large, globose, dark brown conidial heads, which become radiate, tending to split into several loose columns with age. Conidiophores are smooth-walled, hyaline or turning dark towards the vesicle. Conidial heads are biseriate with the phialides born on brown, often septate metulae. Conidia are globose to subglobose, dark brown to black and rough-walled 

• Microscopic morphology of Aspergillus flavus. Conidial heads are typically radiate, later splitting to form loose columns, biseriate but having some heads with phialides borne directly on the vesicle. Conidiophores are hyaline and coarsely roughened, often more noticeable near the vesicle. Conidia are globose to subglobose, pale green and conspicuously echinulate. Some strains produce brownish sclerotia. 

• Microscopic morphology of Aspergillus nidulans. Conidial heads are short columnar and biseriate. Conidiophores are usually short, brownish and smooth-walled. Conidia are globose and rough-walled.

• Grocott's methenamine silver GMS stained tissue section of lung showing fungal balls of hyphae of Aspergillus fumigatus in lung tissue, note conidial heads forming in an alveolus

• Grocott's methenamine silver GMS stained tissue section of lung showing fungal balls of hyphae of Aspergillus fumigatus

• Asperilloma found at post-mortem in the lung of a child with leukemia.  Note fungus ball occupying cavity

Vascular Pathology

Large vessels vasculitis

Medium vessels vasculitis

Small vessels vasculitis