Mark Corson

By T. Mirzo. Colgate University.

Mucosal lesions that appear similar to those caused Lesions associated with hypovitaminosis A in galli- by hypovitaminosis A have been described on the naceous birds first appear in the pharynx and are palate of pigeons and are referred to as sialoliths (see largely confined to the mucous glands and their Color 13) cheap seroflo 250mcg fast delivery. The epithelium is replaced by a stratified substrate mixed with cellular debris are clinically squamous epithelium that occludes the ducts of the recognized in approximately one percent of pigeons discount seroflo 250mcg otc. Fish bones may lodge in the pharynx or Foreign Bodies proximal part of the esophagus causing dysphagia order seroflo 250 mcg otc. A thorough oropharyngeal examination and Stomatitis radiographs may reveal the foreign body. Stomatitis in birds has been associated with the consumption of hot foods, ingestion of oil and inges- A string looped around the base of the tongue and tion of caustic substances. Beak ne- can become lodged around the tongue, causing avas- crosis has been described in pigeons and gallinaceous cular necrosis. The bird’s feathers were in poor condition, and the bird appeared to be hungry but would eat reluctantly. On physical examination, the defect in the palatine area of the beak appeared to contain a foreign body. The splinter was removed and the wound was accumulate in the damaged tissues and create a nidus for secon- debrided and flushed. In this Umbrella Cockatoo, days of presentation, and it began topreen normally within a week. The grad- Lacerations of the Tongue ual accumulation of fine particles of food along the Lacerations of the tongue have been encountered in inner edge of the lower beak leads to secondary infec- psittacine birds and may be due to mate-induced tion and necrosis of the beak. Feeding pelleted ra- trauma, automutilation during the excitement phase tions prevents the problem. The tongue of turkey of post-anesthetic recovery or gnawing on sharp ob- poults fed a finely ground mash may be curled back- jects. The tongue is highly vascular and bleeds pro- ward by an accumulation of food on the floor of the fusely if damaged. Many trichotecenes, notably T toxin, can cause caus-2 tic injury to the alimentary mucosa. Yellow erosive Glossitis Gelatinosa Circumscripta and exudative plaques with underlying ulcers lo- A gelatinous mass may be found on the dorsal aspect cated near the salivary duct openings on the palate, of the tongue in five- to twelve-week-old ducklings tongue and buccal floor are characteristic lesions. The precise etiology is undetermined, Thick crusts of exudate may accumulate along the 103 but a multi-deficient diet has been suggested. Experimental transmission occurs by inocu- lation of tissue suspensions and by direct contact. Moist, slick mucosal membranes have been described 31,49,101 Anatomy and Physiology in pheasants with Newcastle disease virus and in chronic cholera. The esophagus lies immediately under the skin and to the right of the trachea (see Color 13). From a clinical per- spective, the anatomy of the avian esophagus allows for easy introduc- tion of instruments or endoscopes for foreign body removal from the esophagus, crop and proventriculus. In most birds, the esophagus is di- vided by the crop or ingluvies (some birds do not have a crop) into a cervi- cal and a thoracic component. In Galliformes and Falconiformes, the crop forms a ventral enlarge- ment of the esophagus at the tho- racic inlet. In canaries and ducks, the crop is absent, but there is a spindle- shaped swelling of the esophagus at the thoracic inlet. Mucous glands are located in the lamina propria, and are numerous in the thoracic esophagus. The structure of the crop resembles that of the esophagus, except that the mucous glands are restricted to an area adjacent to the esophagus. The function of the crop is to store food when the ventriculus is full (Figure 19. When the ventriculus is empty, food can bypass the crop and move directly into the proventriculus. The entire length of the esophagus can be used to store food in species that do not have a crop (eg, penguins and gulls). The esophagus and crop produce mucus, which softens and moisturizes the food in preparation for mechanical and chemical digestion lower in the gastrointestinal tract. Initial stages of carbohydrate digestion (mediated by salivary amy- lase) may occur in the crop of some species. The bird was in overall good having a large cervical component and two thoracic condition and would regurgitate when handled by either of the components. The bird would flick its head when it regurgitated, causing vomitus to land on the head feathers giving and the muscular crop is the main site for the me- them a stiff, displaced appearance. Adult pigeons of both genders produce a secretion called crop milk that is regurgitated and fed to the tation or vomiting. Other accompanied by a rapid flick of the beak, which fre- food items gradually replace the crop milk as the quently deposits vomitus on top of the bird’s head babies mature. A history of recent drug administra- crop milk, which consists of desquamated cells of the tion, assisted feeding, poor hygiene or access to toxic proliferated stratified squamous epithelium of the compounds may suggest an etiology for esophageal crop. Wetting of the feathers finches may also produce some secretions that are will help in visualizing lacerations, discolorations or regurgitated and fed to neonates. Hypermotility or hypomotility Penguin feeds its chicks a fluid produced by may occur with crop disorders. Regurgitation is a common courtship be- The esophagus and crop are thin-walled structures havior in some psittacine birds, particularly budgeri- that are difficult to palpate unless abnormally thick- gars, cockatiels and macaws. The crop can be palpated when it species (eg, pigeon, Great Bustard, ostrich, Sage is full of food, fluid, air or abnormal masses. An Grouse) have inflatable esophageal diverticula that enlarged crop with a dough-like consistency that fails act as resonating chambers or display devices.

Both acute bronchitis and pneumonia are characterized by the development of a cough with or without the production of mucus trusted seroflo 250 mcg. Acute bronchitis often occurs during the course of an acute viral illness such as the common cold or influenza proven seroflo 250mcg. Although pneumonia may occur in healthy individuals seroflo 250mcg generic, it is usually seen in those who are immune- compromised, particularly drug and alcohol abusers, individuals with chronic lung diseases, and those on chemotherapy and other drugs that suppress the immune system. Hospital-acquired pneumonia is also a serious problem and carries with it a high mortality rate. Acute pneumonia is still the seventh- leading cause of death in the United States. In individuals who are not taking drugs to suppress their immune system or who are suffering from diseases associated with impaired immunity, pneumonia most often follows a viral infection (especially influenza) or an insult to the host defense mechanisms: cigarette smoke and other noxious fumes, impairment of consciousness (which depresses the gag reflex, allowing aspiration), cancer, or hospitalization (being hospitalized for any purpose increases the risk of developing pneumonia). A chest X-ray clears up the diagnosis, but an X-ray should not be done every time someone has a cough. In patients with an acute cough, the following findings suggest the need for a chest X-ray: (1) heart rate greater than 100 beats per minute, (2) respiratory rate greater than 24 breaths per minute, (3) body temperature above 100. Typically when a person has pneumonia there are characteristic chest sounds: • Rales (a bubbling or crackling sound) heard on one side of the chest or while the patient is lying down • Rhonchi (abnormal rumblings indicating the presence of thick fluid). Viral Pneumonia Viral pneumonia is most often caused by adenovirus, influenza virus, parainfluenza virus, or respiratory syncytial virus. Viral pneumonia is responsible for about 30% of cases of pneumonia and will often develop as a complication of an upper respiratory infection caused by one of the viruses. People who are at risk for more serious viral pneumonia include those with impaired immune function (e. Clinical Summary for Viral Pneumonia • People who are at risk for more serious viral pneumonia are often immunocompromised. Clinical Summary for Mycoplasmal Pneumonia • Most commonly occurs in children or young adults. Pneumococcal Pneumonia Pneumococcal pneumonia (due to Streptococcus pneumoniae) is the most common bacterial pneumonia and the most common cause of pneumonia requiring hospitalization. Unfortunately, antibiotics are becoming less effective, as there has been an increase in resistant strains of bacteria. Clinical Summary for Pneumococcal Pneumonia • Pneumonia is usually preceded by upper respiratory tract infection. Therapeutic Considerations The natural approach to bronchitis and pneumonia involves three primary goals: (1) stimulation of normal processes that promote the expectoration (removal) of mucus; (2) thinning the mucus to aid expectoration; and (3) enhancement of immune function. Bacterial pneumonia can be quite serious, and any individual with symptoms suggestive of pneumonia should consult a physician immediately, as antibiotics may be required. Nor are they useful in bronchitis, as demonstrated in more than a dozen double-blind studies over the past 30 years. According to the guidelines of the American College of Chest Physicians, “The widespread use of antibiotics for the treatment of acute bronchitis is not justified, and vigorous efforts to curtail their use should be encouraged. The risks include overgrowth of Candida albicans, disruption of normal gut microflora, and the possibility of developing antibiotic-resistant strains of bacteria. Many doctors persist in prescribing antibiotics for acute bronchitis, despite the scientific facts, because of their own misconceptions—such as that a fever is a sign antibiotics are required, or that antibiotics are required to prevent progression to pneumonia. They may also prescribe antibiotics because of pressure from patients who mistakenly believe antibiotics are necessary. Because impaired cough reflexes have been thought to play a role in recurrent bronchitis and pneumonia, it seems reasonable that these botanicals would be useful in helping to relieve this condition and prevent recurrences. Some expectorants are also cough suppressants; however, Lobelia inflata, a commonly used expectorant, actually helps promote the cough reflex. Other commonly used expectorants include Glycyrrhiza glabra (licorice), Pelargonium sidoides (South African geranium), Hedera helix (ivy), and wild cherry bark. South African Geranium (Pelargonium sidoides) Pelargonium sidoides is a medicinal plant in the geranium family that is native to South Africa. Its common name, umckaloaba, is a close approximation of a Zulu word that means “severe cough” and is a testimony to its effect in bronchitis. Extracts from the underground parts of the plant (rhizomes and tubers) have been shown to have a number of effects beneficial in upper respiratory tract infections, particularly bronchitis. In another study, 742 children with acute bronchitis showed a drop of at least 80% in the severity of symptoms within two weeks of therapy, and over 88% of the treating physicians rated the treatment as “successful. Similar results were seen in a study of 400 children with acute bronchitis using the same dosage assessment. In 2007, more than 80% of herbal expectorants prescribed in Germany, totaling nearly 2 million prescriptions, included ivy extract. Ivy leaf contains saponins that show expectorant, mucolytic, spasmolytic, bronchodilatory, and antibacterial effects. The mucolytic and expectorant action of ivy is due to the saponins alpha-hederin and hederacoside C, the latter of which is metabolized to alpha-hederin when ingested. Patients were randomly assigned to an 11-day treatment with either thyme-ivy combination syrup (5. In the thymeivy combination group, a 50% reduction in coughing fits was reached two days earlier compared with the placebo group. Treatment was well tolerated, with no difference in the frequency or severity of side effects between the thyme- ivy combination and placebo groups. Guaifenesin (also known as glycerol guiacolate) is a derivative of a compound originally isolated from beech wood.

Accidental contact with a cigarette tends to leave a more superficial 250mcg seroflo with amex, irregular area of erythema with a tail generic 250mcg seroflo with amex. Nonaccidential Injury in Children 169 • Electrical burns—small cheap 250 mcg seroflo otc, deeply penetrating burns with an entry and exit wound with possible necrosis of underlying tissues. Differential Diagnosis of Thermal Injuries • Accidental burns—appropriate history and presentation. Skeletal Injury Historically, skeletal injury played a major role in the recognition of child abuse (25,26). In 1946, Caffey (27) described six patients presenting with 170 Thomas chronic subdural hematoma in which 23 unexplained fractures of the long bones were found. Caffey concluded that the fractures were traumatic in ori- gin and introduced the concept of inflicted injury. Fractures in infants and children resulting from falls of under 3 ft are relatively uncommon. Research evidence suggests that 1% of children falling less than 3 ft may sustain a simple linear skull fracture (29). Accidental fractures in infants and toddlers do occur, usually as a result of falls, often from a height, but they can occasionally occur in long bones of ambulant children from twisting, running, and falling. Fractures cause pain and distress and are often accompanied by nonuse of the affected body part and local swelling. Other features of skeletal injury suggestive of abuse include the following: • Absence of an appropriate history. Precise dating of fractures cannot be achieved, although ranges of frac- ture ages are available. Advice from an experienced pediatric radiologist should be sought to assist with dating injuries, to obtain further radiological or other imaging views, and to exclude other causes of skeletal abnormality. Detecting occult injury is particularly important in the younger child and infant and recommended indications for a skeletal survey include the follow- ing (17,25,28,32): • Any child younger than 2 years when there is a suspicion of physical abuse. Differential Diagnosis of Skeletal Injury • Accidental injury—appropriate, consistent history, and prompt presentation. Intracranial Injury There is a high incidence of mortality and morbidity after inflicted head injury, and it is the most common cause of traumatic death in infancy (34). It has been generally accepted from research evidence that serious or fatal injury from accidental injury, other than that sustained in road traffic accidents or falls from major heights, is rare in children under 2 years and that simple skull fractures in accidental trauma have a low risk of intracranial sequelae (26). The mechanism of brain injury is considered to be a whiplash motion of acceleration and deceleration, coupled with a rotational force, during a shak- ing episode of an infant, where the head is unsupported. Shaking alone may lead to brain injury, although in many instances there may be other forms of head trauma, including impact injuries (35,36). Impact may be against a hard surface, leading to external injury and an associated skull fracture, or against a soft surface, with no associated external injury. Hypoxia may also lead to brain injury from impairment of ventilation during chest squeezing, suffoca- tion, or strangulation (26). Retinal hemorrhages are strongly suggestive of abuse when accompanied by intracranial injuries and in the absence of a confirmed history of severe accidental injury. Unilateral or bilateral retinal hemorrhages are present in 75– 90% of cases of shaken baby syndrome (36). Retinal hemorrhages can also be found after severe closed chest injury, asphyxia, coagulation disorders, carbon monoxide poisoning, acute hypertension, sepsis, meningitis, and normal birth (usually disappearing by 2 weeks, rarely persisting to 6 weeks). When shaking injuries are suspected, retinal examination is essential and should include di- rect and indirect ophthalmoscopy preferably by an ophthalmologist. Subhyaloid hemorrhages and local retinal detachment occur earliest, are often peripheral, and are found only by indirect ophthalmology. When intraocular injury is present, subdural hemorrhage is likely, and the presence of retinal detachment and multiple hemorrhages may indicate additional cerebral lacerations or in- tracerebral hemorrhages (35). Children with acute intracranial injury may present with fits, lethargy, irritability, apnea, unconsciousness and signs of shock, a tense fontanelle, increasing head circumference, and low hemoglobin. Children with chronic subdural hematomas may present with poor feeding, failure to thrive, vom- Nonaccidential Injury in Children 173 iting, increasing head circumference, and fits. The presentation may suggest sepsis, meningitis, encephalitis, or toxic or metabolic bone disease. The find- ings of retinal hemorrhages, other signs of abuse, and blood-stained cere- brospinal fluid may assist with the differential diagnosis. Milder forms of shaking may go undetected or present with nonspecific signs that may be minimized by physicians or attributed to a viral illness (36). Injuries arise mainly from blunt trauma (punching, kicking, trampling, or stamping) or sudden acceleration/deceleration injuries (swinging or throw- ing a child into a solid object) and include contusion, laceration, and rupture of solid or hollow viscera. Fabricated or Induced Illness The fabrication or induction of illness in children by a caregiver is referred to by several different terms, most commonly Munchausen syndrome by proxy, factitious illness by proxy or illness induction syndrome. In the United States, the term pediatric condition falsification is being adopted by the American 174 Thomas Professional Society on the Abuse of Children. The American Psychiatric Association’s Diagnostic and Statistical Manual has proposed using the term factitious disorder by proxy for a psychiatric diagnosis applicable to the fabri- cator (40). Fabricated or induced illness is a persistent fabrication of a child’s ill- ness either simulated or produced by the child’s parent or caretaker. There are three main ways of the caregiver fabricating or inducing illness in a child: • Fabrication of signs and symptoms. This form of child abuse is uncommon but severe and carries a high mortality and morbidity.