Anemia (Disorder of Hematopoietic System) - Probably the most common effect of nutritional deficiency. Any factor that decreases hematopoiesis can cause an anemia.

A. Iron deficiency - Widely recognized as the most important cause of anemia, It is indicated that ½ of all pregnant women and infants are affected, as are ~13% of all adult women.

1. Dietary factors - Availability of iron from different food sources and mixtures.
2. Malabsorption – One third of patients with inflammatory bowel disease (IBD) have recurrent anemia and 30% or more of patients who have had partial gastrectomy will develop iron deficiency anemia.
3. Blood loss - Menses, gastrointestinal bleeding 
4. Increased demand - Pregnancy, growth in children.
5. Congenital - Atransferrinemia
6. Importance of multiple factors.
7. Pathophysiology - Initially iron is mobilized from reticuloendothelial stores and increased intestinal absorption occurs. Total iron stores are depleted, serum iron levels fall. In severe cases in peripheral blood, the red cells become smaller (microcytic) and their hemoglobin content is reduced (hypochromic).  

B. Megaloblastic anemias- Characterized by the presence of abnormal WBCs and RBCs. In severe cases, megaloblasts (abnormal red cell precursors) may be present. These anemias are a consequence of disordered DNA synthesis.
1. Folate deficiency - Can be caused by:
a. Dietary deficiency
b. Malabsorption (celiac disease)
c. Increased demand (pregnancy & lactation)
d. Drugs - methotrexate, anticonvulsants, oral contraceptives, alcoholism.
e. Liver disease

2. Cobalamin (vitamin B12) deficiency - Almost always a secondary disorder that can  be caused by:

a. Intrinsic factor deficiency (pernicious anemia due to autoimmune destruction of the gastric mucosa)

b. Malabsorption

3. Pyridoxine (vitamin B6) deficiency- most commonly associated with alcoholism.

C. Other factors known to be frequently associated with anemia would include protein-calorie malnutrition, vitamin C deficiency, and pyridoxine deficiency (usually associated with alcoholism).

D. Other anemias not particularly associated with nutritional disease would include hemolytic anemia
(decreased red cell life span) and aplastic anemia (failure of marrow to produce new cells).  

Infections caused by gonorrhea

1.  Acute urethritis.  Mostly in males.  Generally self-limiting.  Dysuria and purulent discharge.

2.  Endocervical infection.  Purulent vaginal discharge, abnormal menses, pelvic pain.  Often co-infection with other STD’s.  Some women are asymptomatic.

3.  Pelvic Inflammatory Disease (PID).  Consequence of ascending endocervical infection.  Causes salpingitis, endometriosis, bilateral abdominal pain, discharge, fever.  May lead to sterility, chronic pain, and ectopic pregnancy because of loss of fallopian cilia.

4.  Anorectal inflammation.  Mostly in homosexual men.  Pain, itching, discharge from anus.

5.  Dermatitis/arthritis.  Occurs after bacteremia.  Skin will have papules on an erythematous base which develop into necrotic pustules.  Asymmetric joint pain.  These infections are susceptible to penicillin.

6.  Neonatal infections.  Ophthalmia neonatorum is a conjunctival infection from going through infected vagina.  After one year of age, suspect child abuse.

Malignant Diseases of Skin
 
1. Bowen's disease refers to a carcinoma in situ on sun-exposed skin or on the vulva, glans a penis, or oral mucosa which has an association, in some cases, with a visceral malignancy.
2. Skin cancers associated with ultraviolet light damage include basal cell carcinoma, squamous cell carcinoma, and malignant melanoma.
3. A basal cell carcinoma is the MC malignant tumor of the skin and occurs on sunexposed, hair-bearing surfaces.
 - Locally aggressive, infiltrating cancers arising from the basal cell layer of the epidermis and infiltrate the underlying superficial dermis.
 - they do not metastasize
 - BCC are commonly located on the face on the inner aspect of the nose, around the orbit and the upper lip where they appear as raised nodules containing a central crater with a pearly-colored skin surface and vascular channels.
 - microscopically, they have cords of basophilic staining cells originating from the basal cell layer infiltrating the dermis.
 - they commonly recur if they are not totally excised, because they are frequently multifocal. 
- the basal cell nevus syndrome is an autosomal-dominant disorder characterized by the development of basal cell carcinomas early in life with associated abnormalities of bone, skin, nervous system, eyes, and reproductive system. 

Pulmonary embolism

A pulmonary embolism (thromboembolism) occurs when a blood clot, generally a venous thrombus, becomes dislodged from its site of formation and embolizes to the arterial blood supply of one of the lungs.

Clinical presentation

Signs of PE are sudden-onset dyspnea (shortness of breath, 73%), tachypnea (rapid breathing, 70%), chest pain of "pleuritic" nature (worsened by breathing, 66%), cough (37%), hemoptysis (coughing up blood, 13%), and in severe cases, cyanosis, tachycardia (rapid heart rate), hypotension, shock, loss of consciousness, and death. Although most cases have no clinical evidence of deep venous thrombosis in the legs, findings that indicate this may aid in the diagnosis.

Diagnosis

The gold standard for diagnosing pulmonary embolism (PE) is pulmonary angiography

An electrocardiogram may show signs of right heart strain or acute cor pulmonale in cases of large PEs

In massive PE, dysfunction of the right side of the heart can be seen on echocardiography, an indication that the pulmonary artery is severely obstructed and the heart is unable to match the pressure.

Treatment

Acutely, supportive treatments, such as oxygen or analgesia

In most cases, anticoagulant therapy is the mainstay of treatment. Heparin or low molecular weight heparins are administered initially, while warfarin therapy is given

POLYCYTHEMIA

 It is an increase in number of RC per unit volume of blood (Hb more than 1.9.5 gms% and 18 gms% for women)
 
Causes :

True polycythemia.
- Idiopathic Polythemia vera.

- Secondary to :

    o    Hypoxia of high altitude , heart disease, chronic lung disease etc.
    o    Erythopoietin  oversecretion as in renal diseases , tumours of liver, kidney and adrenal etc.
    o    Compensatory in haemogIobinopathies
    
- Relative polycythemia due to reduction in plasma volume as in dehydration or in redistribution off fluids

Polycythemia vera: It is a myeloprolifeative disorder, usually terminating in myelosclerosis.

Features: are due to hypervolaemic circulation and tendency to tbrombosis and haemorrhage 

    -Headaches, dizziness and cardiovascular accidents.
    -Hypertension.
    -Peripheral vascular thrombosis.
    -GIT bleeding. retinal haemorrhage.
    -Gout.
    -Pruritus.

Blood Finding

-Increased Hb. PCV and RBC count.
-Leucocytosis with high alkaline  phosphatase.
-Platelets increased.

Marrow picture Hypercellular with  increase in precursors of all series 
Course Chronic course ending in myelosclerosis or acute  leukaemia.
 

Seborrheic keratosis
1. A round, brown-colored, flat wart.
2. Most often seen in middle-aged to older adults.
3. A benign lesion.