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Is Ketoacidosis Hereditary

Severe Diabetic Ketoacidosis In A Newly Diagnosed Child With Type 2 Diabetes Mellitus: A Case Report

Severe Diabetic Ketoacidosis In A Newly Diagnosed Child With Type 2 Diabetes Mellitus: A Case Report

Abdulmoein E Al-Agha1* and Mohammed A Al-Agha2 1Department of Pediatric Endocrinology, King Abdul-Aziz University Hospital, Saudi Arabia 2Faculty of Medicine, King Abdul-Aziz University, Saudi Arabia Citation: Abdulmoein E Al-Agha1, Mohammed A Al-Agha (2017) Severe Diabetic ketoacidosis in a Newly Diagnosed Child with Type 2 Diabetes Mellitus: A Case Report. J Diabetes Metab 8:724. doi:10.4172/2155-6156.1000724 Copyright: © 2017 Al-Agha AE, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Visit for more related articles at Journal of Diabetes & Metabolism Abstract Background: Diabetes ketoacidosis (DKA) is an acute complication of both type 1 and type 2 diabetes mellitus (DM). DKA is characterized by the presence of hyperglycemia, ketosis, ketonuria, and metabolic acidosis. Cerebral edema is a rare but rather a serious complication of DKA. Case presentation: An obese 12-year-old, Egyptian boy, previously medically free, presented to the emergency room (ER) of King Abdulaziz university hospital, with two weeks' histories of dizziness, shortness of breath, polyuria, polydipsia & nocturia. His symptoms were deteriorating with a change in sensorial and cognitive functions at the time of presentation. He was diagnosed with type 2 DM based upon clinical background, namely the presence of obesity (weight+7.57 Standard Deviation Score (SDS), height+1.4 SDS, and body mass index (BMI) of 34.77 kg/m2 (+3.97SDS) together with the presence of Acanthosis nigricans and biochemically based on, normal level of serum insulin, normal serum level of connecting peptide and negative autoantibodies. H Continue reading >>

If You Have Gallstones Is Removing The Gallbladder Required?

If You Have Gallstones Is Removing The Gallbladder Required?

A2A: Cholecystectomy (removal of the gallbladder) is not indicated in most patients with asymptomatic (silent) gallstones, because only 2-3% of these patients go on to become symptomatic each year. For an accurate determination of the indications for elective cholecystectomy, the risk posed by the operation (with individual patient age comorbid factors taken into account) must be weighed against the risk of complications and death if the operation is not done. Updated: Apr 14, 2016 Author: Douglas M Heuman, MD, FACP, FACG, AGAF; Chief Editor: BS Anand, MD Practice Essentials Cholelithiasis involves the presence of gallstones (see the image below), which are concretions that form in the biliary tract, usually in the gallbladder. Choledocholithiasis refers to the presence of 1 or more gallstones in the common bile duct (CBD). Treatment of gallstones depends on the stage of disease. Magnetic resonance cholangiopancreatography (MRCP) showing 5 gallstones in the common bile duct (arrows). In this image, bile in the duct appears white; stones appear as dark-filling defects. Similar images can be obtained by taking plain radiographs after injection of radiocontrast material in the common bile duct, either endoscopically (endoscopic retrograde cholangiography) or percutaneously under fluoroscopic guidance (percutaneous transhepatic cholangiography), but these approaches are more invasive. Signs and symptoms Gallstone disease may be thought of as having the following 4 stages: Lithogenic state, in which conditions favor gallstone formation Asymptomatic gallstones Symptomatic gallstones, characterized by episodes of biliary colic Complicated cholelithiasis Symptoms and complications result from effects occurring within the gallbladder or from stones that escape the gallbladder to Continue reading >>

Type 1 Diabetes

Type 1 Diabetes

Type 1 diabetes is a disorder characterized by abnormally high blood sugar levels. In this form of diabetes, specialized cells in the pancreas called beta cells stop producing insulin. Insulin controls how much glucose (a type of sugar) is passed from the blood into cells for conversion to energy. Lack of insulin results in the inability to use glucose for energy or to control the amount of sugar in the blood. Type 1 diabetes can occur at any age; however, it usually develops by early adulthood, most often starting in adolescence. The first signs and symptoms of the disorder are caused by high blood sugar and may include frequent urination (polyuria), excessive thirst (polydipsia), fatigue, blurred vision, tingling or loss of feeling in the hands and feet, and weight loss. These symptoms may recur during the course of the disorder if blood sugar is not well controlled by insulin replacement therapy. Improper control can also cause blood sugar levels to become too low (hypoglycemia). This may occur when the body's needs change, such as during exercise or if eating is delayed. Hypoglycemia can cause headache, dizziness, hunger, shaking, sweating, weakness, and agitation. Uncontrolled type 1 diabetes can lead to a life-threatening complication called diabetic ketoacidosis. Without insulin, cells cannot take in glucose. A lack of glucose in cells prompts the liver to try to compensate by releasing more glucose into the blood, and blood sugar can become extremely high. The cells, unable to use the glucose in the blood for energy, respond by using fats instead. Breaking down fats to obtain energy produces waste products called ketones, which can build up to toxic levels in people with type 1 diabetes, resulting in diabetic ketoacidosis. Affected individuals may begin breathin Continue reading >>

Diabetes In Dogs: Symptoms, Causes, & Treatment

Diabetes In Dogs: Symptoms, Causes, & Treatment

Diabetes is a chronic disease that can affect dogs and cats and other animals (including apes, pigs, and horses) as well as humans. Although diabetes can’t be cured, it can be managed very successfully. Diabetes mellitus, or “sugar diabetes,” is the type of diabetes seen most often in dogs. It is a metabolism disorder. Metabolism refers to how the body converts food to energy. To understand what diabetes is, it helps to understand some of this process. The conversion of food nutrients into energy to power the body’s cells involves an ongoing interplay of two things: • Glucose: essential fuel for the body’s cells. When food is digested, the body breaks down some of the nutrients into glucose, a type of sugar that is a vital source of energy for certain body cells and organs. The glucose is absorbed from the intestines into the blood, which then transports the glucose throughout the body. • Insulin: in charge of fuel delivery. Meanwhile, an important organ next to the stomach called the pancreas releases the hormone insulin into the body. Insulin acts as a “gatekeeper” that tells cells to grab glucose and other nutrients out of the bloodstream and use them as fuel. What is diabetes? With diabetes, the glucose-insulin connection isn’t working as it should. Diabetes occurs in dogs in two forms: • Insulin-deficiency diabetes—This is when the dog’s body isn’t producing enough insulin. This happens when the pancreas is damaged or otherwise not functioning properly. Dogs with this type of diabetes need daily shots to replace the missing insulin. This is the most common type of diabetes in dogs. • Insulin-resistance diabetes—This is when the pancreas is producing some insulin, but the dog’s body isn’t utilizing the insulin as it should. The ce Continue reading >>

Diabetes With Ketone Bodies In Dogs

Diabetes With Ketone Bodies In Dogs

Diabetes Mellitus with Ketoacidosis in Dogs Diabetes is a medical condition in which the body cannot absorb sufficient glucose, thus causing a rise the blood sugar levels. The term “ketoacidosis,” meanwhile, refers to a condition in which levels of acid abnormally increased in the blood due to presence of “ketone bodies”. In diabetes with ketoacidosis, ketoacidosis immediately follows diabetes. It should be considered a dire emergency, one in which immediate treatment is required to save the life of the animal. This condition typically affects older dogs as well as females. In addition, miniature poodles and dachshunds are predisposed to diabetes with ketoacidosis. Symptoms and Types Weakness Lethargy Depression Lack of appetite (anorexia) Muscle wasting Rough hair coat Dehydration Dandruff Sweet breath odor Causes Although the ketoacidosis is ultimately brought on by the dog's insulin dependency due to diabetes mellitus, underlying factors include stress, surgery, and infections of the skin, respiratory, and urinary tract systems. Concurrent diseases such as heart failure, kidney failure, asthma, cancer may also lead to this type of condition. Diagnosis You will need to give a thorough history of your dog’s health, including the onset and nature of the symptoms, to your veterinarian. He or she will then perform a complete physical examination, as well as a biochemistry profile and complete blood count (CBC). The most consistent finding in patients with diabetes is higher than normal levels of glucose in the blood. If infection is present, white blood cell count will also high. Other findings may include: high liver enzymes, high blood cholesterol levels, accumulation in the blood of nitrogenous waste products (urea) that are usually excreted in the urine (azo Continue reading >>

How To Identify And Manage Diabetic Ketoacidosis In Adults

How To Identify And Manage Diabetic Ketoacidosis In Adults

By Natasha Jacques, BSc, MRPharmS, and Sally James, MSc, MRPharmS In short Diabetic ketoacidosis (DKA) is a condition in which a lack of insulin leads to hyperglycaemia, ketosis and metabolic acidosis. The symptoms of DKA include thirst, polyuria, confusion, fatigue and nausea. Treatment of DKA centres around the administration of intravenous fluids (including potassium) and infusions of soluble insulin. Natasha Jacques is principal pharmacist for diabetes at Heart of England NHS Foundation Trust and Sally James is divisional pharmacist for medicine at Royal Liverpool and Broadgreen University Hospital NHS Trust. Both authors are committee members of the United Kingdom Clinical Pharmacy Association diabetes group. Call for Practice tools Useful clinical skills are described in this Clinical Pharmacist series. Comments on this or other articles are welcomed in the form of personal feedback to the editor or correspondence to Clinical Pharmacist. Pharmacists who have ideas for the series or wish to write an article are invited to contact the editor. Email: [email protected] Telephone: +44 (0)20 7572 2425 Continue reading >>

: Diabetic Ketoacidosis

: Diabetic Ketoacidosis

While many diabetic patients may have some level of ketosis the term "diabetic ketoacidotic" refers to animals that are not only ketotic but also clinically unwell because of the degree of their diabetic ketoacidosis. Usually a diabetic patient that is unwell, either because of intercurrent disease or due to the endogenous toxaemia that results from marked ketosis, will be inappetent making standard subcutaneous insulin therapy difficult. In these cases parenteral fluids and insulin either as a continuous intravenous infusion or repeated intramuscular injections can be a very effective means of short-term management. In the author's opinion, as long as there is a volumetric pump available a continuous intravenous insulin infusion is the simplest and least labour intensive means for treatment of these patients. Managing the "Ketoacidotic Diabetic" Parenteral Fluid Therapy Inappetent diabetics usually require total parenteral hydration and, by virtue of their poorly controlled diabetes, have relatively high fluid maintenance requirements. Consequently flowing intravenous fluids at around 150 ml/kg/24 hr generally will provide some replacement and adequate maintenance. The optimum fluid composition is 0.45% NaCl with 30-40 mmol/l of KCl or a mixture of approximately 20 mmol/L of KCl and 20 mmol/L of KPO4 added. While one aim is to rehydrate the patient the other must be to provide some measure of diabetic control, or at least inhibit ongoing peripheral lipolysis and hence to start to reduce the potential for ketoacidosis. Insulin Therapy When insulin therapy is being considered to treat clinically significant ketoacidosis the choice is continuous intravenous insulin therapy or repetitive intramuscular insulin injections. In both situations the insulin should be in a solubl Continue reading >>

Diagnosis And Classification Of Diabetes

Diagnosis And Classification Of Diabetes

Diagnosis and Classification of Diabetes is a topic covered in the Johns Hopkins Diabetes Guide. Official website of the Johns Hopkins Antibiotic (ABX), HIV, Diabetes, and Psychiatry Guides, powered by Unbound Medicine. Johns Hopkins Guide App for iOS, iPhone, iPad, and Android included. Explore these free sample topics: -- The first section of this topic is shown below -- Diabetes is classified as type 1 (formerly called juvenile-onset or insulin-dependent diabetes mellitus), type 2 (formerly called adult-onset or non-insulin dependent diabetes mellitus), gestational or other specific types. Type 1 diabetes: complete or almost complete insulin deficiency, usually caused by autoimmunity. Clinical features: younger onset (usually but not always before 30 years old), normal body weight, usually no family history of diabetes, insulin treatment required immediately or within about a year, positive GAD, IA2 and/or islet cell antibodies, susceptibility to ketoacidosis and unstable blood glucose levels. Type 1b or idiopathic diabetes: an unusual form of phenotypic type 1 diabetes with almost complete insulin deficiency, a strong hereditary component, and no evidence of autoimmunity. Reported mainly in Africa and Asia. Latent autoimmune diabetes of adulthood (LADA): a form of type 1 diabetes with adult onset, slowly progressive, eventual insulin requirement but may respond to oral agents initially, usually no ketoacidosis on presentation, positive GAD, IA2 and/or islet cell antibodies. Type 2 diabetes: insulin resistance with preserved endogenous insulin secretion but inadequate to overcome the resistance. About 90-95% of all diabetes, more common type in ethnic minorities. Clinical features: older onset (often >35 years old, though recently occurring more often in youth), over Continue reading >>

Diabetic Ketoacidosis In Dogs

Diabetic Ketoacidosis In Dogs

My dog is diabetic. He has been doing pretty well overall, but recently he became really ill. He stopped eating well, started drinking lots of water, and got really weak. His veterinarian said that he had a condition called “ketoacidosis,” and he had to spend several days in the hospital. I’m not sure I understand this disorder. Diabetic ketoacidosis is a medical emergency that occurs when there is not enough insulin in the body to control blood sugar (glucose) levels. The body can’t use glucose properly without insulin, so blood glucose levels get very high, and the body creates ketone bodies as an emergency fuel source. When these are broken down, it creates byproducts that cause the body’s acid/base balance to shift, and the body becomes more acidic (acidosis), and it can’t maintain appropriate fluid balance. The electrolyte (mineral) balance becomes disrupted which can lead to abnormal heart rhythms and abnormal muscle function. If left untreated, diabetic ketoacidosis is fatal. How could this disorder have happened? If a diabetic dog undergoes a stress event of some kind, the body secretes stress hormones that interfere with appropriate insulin activity. Examples of stress events that can lead to diabetic ketoacidosis include infection, inflammation, and heart disease. What are the signs of diabetic ketoacidosis? The signs of diabetic ketoacidosis include: Excessive thirst/drinking Increased urination Lethargy Weakness Vomiting Increased respiratory rate Decreased appetite Weight loss (unplanned) with muscle wasting Dehydration Unkempt haircoat These same clinical signs can occur with other medical conditions, so it is important for your veterinarian to perform appropriate diagnostic tests to determine if diabetic ketoacidosis in truly the issue at hand Continue reading >>

Treatment And Complications Of Diabetic Ketoacidosis In Children And Adolescents

Treatment And Complications Of Diabetic Ketoacidosis In Children And Adolescents

INTRODUCTION Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes mellitus (T1DM), with a case fatality rate ranging from 0.15 percent to 0.31 percent [1-3]. DKA also can occur in children with type 2 DM (T2DM); this presentation is most common among youth of African-American descent [4-8]. (See "Classification of diabetes mellitus and genetic diabetic syndromes".) The management of DKA in children will be reviewed here (table 1). There is limited experience in the management and outcomes of DKA in children with T2DM, although the same principles should apply. The clinical manifestations and diagnosis of DKA in children and the pathogenesis of DKA are discussed elsewhere. (See "Clinical features and diagnosis of diabetic ketoacidosis in children and adolescents" and "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Epidemiology and pathogenesis".) DEFINITION Diabetic ketoacidosis – A consensus statement from the International Society for Pediatric and Adolescent Diabetes (ISPAD) in 2014 defined the following biochemical criteria for the diagnosis of diabetic ketoacidosis (DKA) [9]: Hyperglycemia – Blood glucose of >200 mg/dL (11 mmol/L) AND Metabolic acidosis – Venous pH <7.3 or a plasma bicarbonate <15 mEq/L (15 mmol/L) AND Continue reading >>

Diabetic Ketoacidosis (dka)

Diabetic Ketoacidosis (dka)

Diabetic Ketoacidosis (DKA) Diabetic ketoacidosis (DKA) occurs when the body does not have enough insulin. Insulin is what breaks down sugar into energy. When insulin is not present to break down sugars, our body begins to break down fat. Fat break down produces ketones which spill into the urine and cause glucose build up in the blood, thus acidifying the body. Because sugar is not entering into our body’s cells for energy breakdown, the sugar is being processed by the kidneys and excreted through the urine; as a result, we become dehydrated and our blood becomes even more acidic. This leads to sickness and hospitalization if not treated. If a person’s blood sugar is over 240, they should start checking their blood for ketones. If you have diabetes, or love someone who does, being aware of warning signs of diabetic ketoacidosis (DKA) can help save a life. Early Symptoms of DKA: High blood glucose level, usually > 300 High volume to ketones present in blood or urine Frequent urination or thirst that lasts for a day or more Dry skin and mouth Rapid shallow breathing Abdominal pain (especially in children) Muscle stiffness or aches Flushed face As DKA Worsens: Decreases alertness, confusion – brain is dehydrating Deep, labored, and gasping breathing Headache Breath that smells fruity or like fingernail polish remover Nausea and/or vomiting Abdomen may be tender and hurt if touched Decreased consciousness, coma, death If you think you might have DKA, test for ketones. If ketones are present, call your health care provider right away. To treat high blood sugar, hydrate with water or sugar free, caffeine free drinks. Sugar free popsicles and snacks are also good alternatives. Always call the doctor if vomiting goes on for more than two hours. Symptoms can go from mild Continue reading >>

What You Should Know About Diabetic Ketoacidosis

What You Should Know About Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a buildup of acids in your blood. It can happen when your blood sugar is too high for too long. It could be life-threatening, but it usually takes many hours to become that serious. You can treat it and prevent it, too. It usually happens because your body doesn't have enough insulin. Your cells can't use the sugar in your blood for energy, so they use fat for fuel instead. Burning fat makes acids called ketones and, if the process goes on for a while, they could build up in your blood. That excess can change the chemical balance of your blood and throw off your entire system. People with type 1 diabetes are at risk for ketoacidosis, since their bodies don't make any insulin. Your ketones can also go up when you miss a meal, you're sick or stressed, or you have an insulin reaction. DKA can happen to people with type 2 diabetes, but it's rare. If you have type 2, especially when you're older, you're more likely to have a condition with some similar symptoms called HHNS (hyperosmolar hyperglycemic nonketotic syndrome). It can lead to severe dehydration. Test your ketones when your blood sugar is over 240 mg/dL or you have symptoms of high blood sugar, such as dry mouth, feeling really thirsty, or peeing a lot. You can check your levels with a urine test strip. Some glucose meters measure ketones, too. Try to bring your blood sugar down, and check your ketones again in 30 minutes. Call your doctor or go to the emergency room right away if that doesn't work, if you have any of the symptoms below and your ketones aren't normal, or if you have more than one symptom. You've been throwing up for more than 2 hours. You feel queasy or your belly hurts. Your breath smells fruity. You're tired, confused, or woozy. You're having a hard time breathing. Continue reading >>

Diabetes And Genetics

Diabetes And Genetics

Tweet Genetics play a strong role in the chances of developing both type 1 and type 2 diabetes. Other factors include environment and lifestyle. Diabetes is an increasingly common chronic condition affecting millions of people in the UK alone. Diabetes and genetic risk The risk of developing diabetes is affected by whether your parents or siblings have diabetes. The likelihood of developing type 1 diabetes or type 2 diabetes differ, as you can see below. Type 1 diabetes and genetics - average risks Mother with diabetes increases risk of diabetes by 2% Father with diabetes increases risk of diabetes by 8% Both parents with diabetes increases risk by 30% Brother or sister with diabetes increases risk by 10% Non-identical twin with diabetes increases risk by 15% Identical twin with diabetes increases risk by 40% Type 2 diabetes and genetics - average risks If either mother of father has diabetes increases risk of diabetes by 15% If both mother and father have diabetes increases risk by 75% If non-identical twin has diabetes increases risk by 10% If identical twin has diabetes increases risk by 90% Some other forms of diabetes may be directly inherited, including maturity onset diabetes in the young (MODY) and diabetes due to mitochondrial DNA mutation. However, neither type 1 or type 2 diabetes may be entirely genetically determined. Experts believe that environmental factors act as either ‘initators’ or ‘accelerators.’ Several genes are known as susceptibility genes, meaning that if an individual is carrying this gene they face greater risk of developing diabetes. Similarly, other genes provide greater immune tolerance for non-diabetics. My family have type 2 diabetes, will I get it? Type 2 diabetes is, in part, inherited. First degree relatives of individuals wit Continue reading >>

New Insights Into The Management Of Diabetic Ketoacidosis - Wsava2009 - Vin

New Insights Into The Management Of Diabetic Ketoacidosis - Wsava2009 - Vin

The diagnosis of diabetic ketoacidosis (DKA) in the ill-appearing diabetic dog is usually straightforward. Dogs with DKA usually present with dramatic clinical manifestations, such as anorexia, vomiting, and lethargy. Within such a setting, detection of ketonuria can rapidly confirm the suspicion of DKA, but it has few implications in the subsequent approach. One can estimate ketonemia by applying a drop of serum or plasma on the appropriate reagent of the urine test strip, but this test only detects acetoacetate and is a semiquantitative test. The measurement of plasma beta-hydroxybutyrate (β-OHB) on admission can provide additional information. Based on a previous study, dogs with plasma β-OHB >2.0 mmol/L should receive ambulatory monitoring and treatment, until the results of additional tests. If plasma β-OHB is >3.8 mmol/L the diagnosis of DKA is confirmed and intensive care is warranted.1 Coincidentally, a recent study in human beings with DKA, suggested that the same cutoff value of plasma β-OHB should be used for the diagnosis of DKA, using a portable meter (MediSense Optium, Abbott Laboratories).2 This device has been validated for the use in dogs.3 Evaluation of blood gases and pH is still needed. In a study of our group (unpublished data), mixed acid-base disorders were common, chiefly high anion gap acidosis and concurrent respiratory alkalosis, and hyperchloremic acidosis with moderated to marked increases in serum B-OHB. The implications of these findings are unknown, but in human patients with DKA, both conditions can possibly slower the recovery from metabolic acidosis. Because respiratory alkalosis is the expected physiologic response to metabolic acidosis, this mixed acid-base disorder may be difficult to recognize clinically, and the diagnosis can Continue reading >>

1,138 Possible Causes For Diabetic Ketoacidosis + Lip Edema + Prerenal Azotemia + Swelling Of The Dorsum Of A Hand In Usa

1,138 Possible Causes For Diabetic Ketoacidosis + Lip Edema + Prerenal Azotemia + Swelling Of The Dorsum Of A Hand In Usa

Amelogenesis Imperfecta Type 1G with Nephrocalcinosis lip edema diabetic ketoacidosis […] of a hand Septicemia Prerenal Azotemia Malaise amelogenesis imperfecta type 1g with nephrocalcinosis swelling of the dorsum of a hand Angioedema Prerenal Azotemia Malaise[symptoma.com] swelling of the dorsum of a hand Sarcoidosis Prerenal Azotemia Malaise amelogenesis imperfecta type 1g with nephrocalcinosis swelling of the dorsum of a hand Fever, arthralgia[symptoma.com] Acute Gastroenteritis Prerenal Azotemia Malaise amelogenesis imperfecta type 1g with nephrocalcinosis swelling of the dorsum of a hand AG is characterized by a sudden onset[symptoma.com] List represents a sample of symptoms, diseases, and other queries. Updated weekly. Hungry Bones Syndrome Altitude Sickness Cavernous Sinus Thrombosis Posterior Subcapsular Cataract Cellulitis Splenic Infarction Megaloblastic Anemia Islet Cell Tumor Chronic Phase of Chronic Myeloid Leukemia Penile Fracture Tuberous Sclerosis Primary Sclerosing Cholangitis Odynophagia, unilateral throat pain Costovertebral Angle Tenderness Dyspepsia Tenesmus Oliguria Scrotal Ulcer Choledochal Cyst Anal Fistula Essential Hypertension Enthesitis-Related Arthritis Glioblastoma Multiforme Leiomyosarcoma Brain Neoplasm Hyperventilation Wolff-Parkinson-White Syndrome Ethmoid Sinusitis Dementia with Lewy Bodies Infarction vaginal discharge, weight loss hemoglobin decreased, typhoid fever Fever, Polyserositis Hyponatremia, Ileus Burning Sensation Autoamputation of Digits Bradycardia Reduced Fetal Movement Calcaneal Spur Arteriovenous Malformation Berry Aneurysm Arachnoiditis Lateral Medullary Syndrome Myiasis Cryptogenic Organizing Pneumonia Hereditary Motor and Sensory Neuropathies Cheilitis Clonus, Hyperreflexia, muscle hypotonia Absent Triceps Reflex C Continue reading >>

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