By M. Faesul. Geneva College.

Although such treatments can be safely administered by experienced ophthalmologists and are associated with few complications (infections 40 mg lasix for sale, hemor- rhage) lasix 100 mg without prescription, disadvantages remain. Weekly intravitreal injections of ganciclovir or fos- carnet, or pellet implantation (Vitrasert, must be replaced every 6–9 months) do not protect from infection of the contralateral eye or from extraocular manifesta- tions (Martin 1999). The same is true for fomivirsen (Vitravene), an antisense- oligonucleotide for intravitreal injection, which is astonishingly effective even with multiresistant CMV strains (Perry 1999). These local treatments have become less important since ART and valganciclovir and some have been taken off the market. Treatment/prophylaxis of CMV retinitis (daily doses, if not otherwise specified) Acute therapy Duration: always at least three weeks Treatment of choice Valganciclovir Valganciclovir (Valcyte) 2 tbl. Therefore, the most important method for prevention in patients with CD4 counts below 200 cells/µl is still fundoscopy every three months. With good immune recon- stitution, intervals between examinations can be extended. It is important to perform a fundoscopy in severely immunocompromised patients prior to starting ART. This allows detection of smaller lesions, which may later present with severe inflamma- tion during the course of immune reconstitution. Secondary prophylaxis: After approximately three weeks of acute therapy, but at the earliest with scar formation of lesions, a reduced dose secondary prophylaxis (maintenance therapy) should begin, preferably with oral valganciclovir (Lalezari 2002). However, the drug is not only very expensive but also just as myelotoxic as ganciclovir infusions. Discontinuation of secondary prophylaxis as quickly as possible is desirable (Tural 1998, Jouan 2001), but it also requires strict ophthalmologic monitoring. According to US guidelines, discontinuation should occur at the earliest after six months of maintenance therapy and with an immune reconstitution above 100–150 CD4 T cells/µl. However, we have successfully stopped ganciclovir at lower CD4 counts, if both HIV and CMV PCR in blood were below detection.

Treatment is simple by contraceptives purchase 100mg lasix otc, preferably the oral contraceptive making a cruciate order lasix 40 mg overnight delivery, a circular or elliptical incision in pill to prevent osteoporosis. It is important to talk the hymen and large amounts of chocolate-colored openly and repeatedly with the patient and if she fluid will come out5. Prophylactic antibiotics should allows, together with her partner, and counsel the be given before surgery. After evacuation of blood, couple on the low chances for pregnancy. These the edges of the hymen are excised to maintain an patients tend to visit a lot of different doctors and adequate opening5. Absence of uterus or endometrium In the Mayer–Rokitansky–Küster–Hauser syn- Disorders of uterus and outflow tract drome there is no apparent vagina and the uterus is usually absent. Girls with this syndrome have Imperforate hymen normal growth and development and present with An imperforate hymen or vaginal septum is a rare primary amenorrhea. The progestational challenge cause of primary amenorrhea. Besides amenorrhea test and the combined oral contraceptive pill will it presents with cyclical abdominal pain and an cause no withdrawal bleeding. On examination of abdominal swelling sometimes in combination the vulva there is no vagina or a very shallow in- with acute urinary retention. In most cases abdominal ultrasound will is the vagina or uterus filled with blood (hemato- be able to establish the absence of a uterus. Examination of the vulva girls will never be able to become pregnant. The usually reveals a blue imperforate hymen bulging patient herself can create a vagina by using vaginal 87 GYNECOLOGY FOR LESS-RESOURCED LOCATIONS Table 1 Etiology of amenorrhea Disorders of uterus and vagina Congenital (Müllerian abnormalities) Imperforate hymen, transverse vaginal septum, vaginal agenesis/aplasia (Mayer– Rokitansky–Küster–Hauser syndrome, androgen insensitivity syndrome), cervical agenesis Acquired Asherman’s syndrome, cervical stenosis Disorders of ovary Gonadal dysgenesis Turner syndrome (45 X, mosaics), Swyer syndrome (46 XY), Perrault syndrome (with neurosensory deafness) Premature ovarian failure Idiopathic, injury (mumps, radiation, chemotherapy) Disorders of the pituitary Pituitary tumors Prolactinomas, other hormone-secreting tumors Hyperprolactinemia Hypothyroidism, psychotropic drugs, breastfeeding Sheehan’s syndrome Disorders of the central nervous system Kallmann’s syndrome Isolated gonadotropin deficiency (not able to smell, renal agenesis, neurological symptoms) Dysfunctional Nutrition-related (malnutrition, severe weight loss, eating disorder), exercise, stress Use of medication Anti-epileptics, hormonal contraception, antipsychotic drugs Chronic diseases HIV/AIDS, tuberculosis, malnutrition, sickle cell disease, liver cirrhosis, chronic kidney disease, cancer, major psychiatric disorders Tumors Craniopharyngioma Infections Tuberculosis, syphilis, encephalitis/meningitis, sarcoidosis Other Polycystic ovary syndrome Other endocrine gland disorders Hypo- and hyperthyroidism, ovarian tumors, adrenal hyperplasia, Cushing syndrome dilators with increasing diameters.

In case of treatment failure 100 mg lasix with amex, photochemotherapy can be insti- tuted (local = bath or cream PUVA buy lasix 40mg, or systemic PUVA). Systemic therapy is used addi- tionally in patients with severe psoriasis or topical treatment refractory clinical course. Also generalized or exudative eruptions are usually treated systemically. Methotrexate, cyclosporine, fumaric acid esters and retinoids are systemic treatment options (DDG 2011). Interactions with ART as well as adverse events and immune suppressive effects of the systemic psoriasis therapy have to be considered. Fumaric acid esters reduce the CD4 and CD8 T cell counts and long term therapy in HIV-neg- ative psoriasis patients was associated with higher incidences of Kaposi sarcomas (Philipp 2013). Biologicals can modulate the inflammation cascade by reducing the secretion and the effects of pro-inflammatory cytokines like TNF-alpha. Adalimumab, etanercept, infliximab and ustekinumab are highly effective additional or alterna- tive treatment options for patients with severe and therapy refractory psoriasis (DDG 2011). Before TNF-alpha blocker are initiated tuberculosis, hepatitis B infection and other clinically relevant opportunistic infections have to be diagnostically excluded. Etanercept and infliximab do not increase the viral load in HIV+ patients (Bartke 2004, Ting 2006, Sellam 2007, Morar 2010). Although the total number of cases is rare a higher incidence of progressive multifocal leukoencephalopathy has been observed in HIV+ patients during treatment with biologicals (Bharat 2012). Interactions of the mentioned antipsoriatics with antiretroviral agents are unknown. Reiter’s syndrome: Reiter’s syndrome is regarded as a variant of psoriasis in patients who carry HLA-B*27. This rare chronic-relapsing disease mainly affects young men, the incidence being higher than in the general population (0.

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