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100 Cards in this Set
- Front
- Back
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how to memorize autosomal dominants
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ADOMINANT
A-ADPKD D-dystrophic myotonia O-osteogenesis imperfecta/osler M-marfans I-intermitten porphyria N-NF A-Achondroplasia, adenomatous polypsoisis familial N-? T-tuberous sclerosis 6 H's Hypercholesterolemia, huntingtons, hypertrophic obstructive cardiomyopathy, hered SM, hered non polypsosi coli, hereditary hemorragic telangictasia vWD, VHL, PHPTH |
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achondroplasia
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AD, mutation in FGF Rc gene; increase w/ paternal age
imparired proliferation of cartilage at growth plate normal head and spine; short legs/arms; normal GH and IGF-1 no treatment |
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ADPKD
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AD polycystic kidney disease
adult, always bilateral, massive enlargement of kidneys due to multiple large cysts flank pain, hematuria, HTN, porgressive RF, 90% of cases due to mutation in chrom 16 berry aneurysms, MVP infantile form is recessive CYSTS NOT PRESENT AT BIRTH around 20-25 cysts can also be in liver, spleen, pancreas hypertension, IC hemorrage, eventually renal failure small risk RCC, sigmoid diverticular disease 16 letters in polycystic kidney |
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familial adenomatous polypsos
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AD colon becomes colvered w/ polyps after puberty-->progress to colon cancer unless reseted
deletion of chrom 5 APC gene; 100% complete penetrance; 35 y/o (5 letters in poly) |
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familal hypercholesterolemia
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AD hyperlididemia type 2a
elevated LDL due to defective or absent LDL recptor cholesterol=300 heterozygotes; homozygotes have high cholesterol 700_ severe atherosclerotic disease early in life and TENDON XANTHOMAS in achilles tendon, xanthelasmas on the eyelid MI before age 20 ***def in LDL receptors |
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hereditary hemorrhagic telenagictasia
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AD osler weber rendu syndrome; inherited disorder of blood vessels
telangietasia, recurrent epistxis skin discolorations, AV malformations dilated vessels especially in GI TRACT! chronic iron def anemia |
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hereditary spherocytosis
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AD spheroid erythrocytes due to spectrin or ankyrin defect
hemolytic anemia inc MCHC; splenectomy is curative intrinsic defect; extracellular hemolysis-->loss of membrane to spherocyte inc permeability of spherocytes to sodium due to dysfunctional Na/K pump-->inc osmotic fragility rupture in hypotonic salt solutions jaundice inc UCB (indirect), inc Ca bilirubinate gallstones b/c in CB in bile, SM, aplastic crisis in children esp after viral infection (parvo) |
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huntington's disease
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AD
depression, progressive dementia, choreiform movemnts caudate atrophy, ocululomoter abnormalities, parkinson's later, dec levels of GABA and ACh; 20-50 y/o; gene on chrom 4 tirnucleotide repeat disorder CAG hunting 4 food |
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marfan's syndrome
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AD--weak elastic tissue fibrillin MISSENSE MUTATION, CV abnormalities---dilating of ascending aorta-->aortic dissection or aortic regurg, MVP (sudden death), hypermotile joints, eunichoid proportions, arachnodachtyly, dilocation of lens (suspensatory lens is elastic), pectus excavatum (hallow chest ant), cystic medial encrosis of aorta
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MEN syndrome
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AD, 1, 2A, 2B familal tumors of endocrine glands; 2A/2B ret gene
Type I has three Ps which are Parathyroid, Pancreas, and Pituitary Type IIa has two Ps which are Parathyroid, and Pheochromocytoma, medullary Type 2B has One P which is Pheochromocytoma. medullary , mucosal neuromas |
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neurofibromatosis
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NF1/2 AD
cafe au lai spots, enural tumors, lisch nodules (pigmented irin hamrtomas), sk disorders scoliosis, optic pathway gliomas; chrom 17 (17 letters in von recklinhausen's) 2: b/l acoustic schwannomas, juvenile cataracts. NF2 on chrom 22, type 2=22 |
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tuberous sclerosis
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AD
facial lesions adenoma sebaceum, hypopigmented ash leaf spots on skin, cotical and retinal hamartomas, seizure, MENTAL RETARDATION, SEIZURES, rhabdomyomas of heart, astrocyte on vetricles "candle wax", renal cysts and renal angiomylipomas, cardiac rhabdomyomas; inc incidence of astrocytomas incomplete penetrance |
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von HIppel-Lindau disease
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AD
hemangioblastomas of retina/cb/medula; mutiple b/l RCC, pheochromocytoma BILATERAL VHL gene deletion on chrom 3p constitutive expressiove of HIF transcription factor of angiogneic GF VHL 3 words=chrom 3 |
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autosomal recessive diseas
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ABCDEFGHH
A-albinism, ARPKD B-? C-cystic fibrosis D-deaf E-emphysema F-freidricks ataxia (3) G-gauchers, galatosemia, glycogen storage diseases H--hemociderosis, hartnup, homocytinuria, hemochromatosis Mucopolysaccaridosies? PKU, sickle cell, spongolipidoses, THALASSEMIAS von gierke's, mcardles???? wilson's |
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cystic fiborosis
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AR defect in CFTR on chrom 7; Phe 508 deletion
CFR channel actiely secrete Cl in lungs and GI tract and actvely reabsorbs cl from sweat (degraded by golgi). defective Cl channel-->secretion of abnormally thick mucus that plus glungs, pancreas, and liver-->recurrent pulm infections esp PSEUDOMONAS AND STAPH AUREAU AND HI, chronic bronchitis, MCC in US of BRONCHIECTASIS, pancreatic insuff (malabsorp and steatorrhea), meconium ileus in newborns mt causes abnl protein folding -->degrade channel before reaching cell surface heat exaustion, nasal polyps, infertility in males (b/l absense of vas deferens), fat soluble vit def (ADEK), failure to thrive in infancy MC lethal gentic disease of whites inc cl ions in sweat test is diagnosis treat: N-acetylcystein to loosen mucous plus (cleaves disulfide obnes w/oin mucous glycoprotiens) T1DM, rectal prolapse, gall stones |
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x-linked recessive disorders
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Be Wise Fool's GOLD Heeds silly Hope
Bruton's agammaglob, Wiskott's, Fabry's disease, G6PD def, Ocular albinism, lesch-nyhan syndrome, duchenne's (becker's) muscular dystorphy, hunter's Syndrome, Hemophilia A/B |
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duchenne's
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XR frame shift-->deletion of dystorphin-->mm breakdown; weak at pelivc girdle mm and progresses supreriorly
pseudhypertrophy of calf muscles due to fibrofatty replacement of mm; cardiac myopathy gower's maneuver; <5 y/o duchenne's=delted dystorphy; DMD longest known human gene-->inc rate spont mutaiton; dystorphin anchor mm fibers in sk and cardiac mm dx: CPK inc an dmm biopsy INCREASE CK-MM (vs an MI increases CK-MB) |
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becker's
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muscular dystorophy, XR
mutated dystrophin, less severe than duchenee's adolescence inc CPK and mm biopsy |
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fragile X syndrome
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XR, trinucleoid e repeat ( CGG); mental retardation (eXtra large testes, jaw, ears)
long face large mandile everted ears, macroorchidism (testes) at puberty, MVP, autism dx: DNA analysis of repeats FMR1 gene, chromosomal berakage 2nd MC cause of mental retard (Down's #1) |
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Lesch-Nyhnad
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XR; def HGPRF (hpoxanthin guanin phosphoribosytransferase)--salvages purine hypoxanthin and guanin
mental retardation, hyperuricemia, self mutilation, yellow orange sand in diaper, caliculi in kidneys |
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tirnucleotide repeats
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Try hunting for my fried eggs (X)
huntington's CAG, myoTonic dystoprhy CTG, fraGile X syndrome CGG, friedreich's ataxia GAA gentic anticipation (inc w/ age in successive generating, germline expansion in females) |
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down's syndrome
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maternally transmitted, epicanthic folds, flat facial, macroglossia, simian crease, A/V septal defects (cushion), early childhood, inc risk Hirschprong's disease, duodenal atresai; inc risk leukemia ALL, alzheimers at 40; steriliti all males; maternally transmitted
-toe gap, duodendenal atresia, congenital heart disease ***nondisjunction in meiosis 1 47 chrom; robertsonian tranlocation mosaicism no maternal association 46 chrom; 21 (drinking age) MC chrom disorder, MC cuase of congeital mental retardation; abdunant neck skin, cleft palate, pregnacy quad screen--dec AFP, inc HCG, dec estriol, inc inhibin A ultarsound inc nucal tranlucency |
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edwards syndrom
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chrom 18 (election age), MC trisomy
mental retardation, rocker bottom feet, MICROGNATHIA (small jaw), low-set ears, CLENCHED HANDS, prominent occiput, CHD, death w/in 1 year |
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patau's syndrome
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trisomy 13 (pubery)
sever mental retard, rocker-bottom feet, microphthalmia, microcephaly, CLEFT LIP/PALATE, HOLOPROSCENEPHALY (1 eye) cyclops, cystic kidneys, POLYDACTLYL, CHD, death w/in 1 year |
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cri du chat syndrom
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loss of short arm of chrom 5
mental retardation cat like cry, ventricular septal defect 46xx or xy, 5p- looser joints |
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williams syndrome
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long arm chrom 7
elfin facis, mental retardation, hypercalcemia (seizures inc sn to vit D), well dev verbal skills, friendly w/ strangers, CV problesm (stenosis) 7 letters (chrom 7), no social anxiety, no racial bias, prom lower lip WIDE MOUTH SMILE |
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22q11 deletion
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cleft palate, abnormal facies, thymic aplasia (T cell def), cardia defects, hypocalcemia (secondary to paraythyorid aplasia)
CATCH-22--abserrant dev of 3rd/4th pouches DIgeourge syndrome-thymid, parathyroid, and cardiac defect velocardiofacial syndrome--palate, facial and cardiac defects |
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B12 and folate are stored where?
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lliver they are water soluble vitamins
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3 common B vitamins abnormalties
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dermatitis, glossitis diarrhea
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B1
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thiamine TPP, berI, berI
pyruvate DH (glycolysis), a-ketoglutarate DH in TCa, transketolaste (HMP shunt), branched-chain AA DH imparied glucose breakdown-->ATP depletion (glucose infusion can worse), brain and heart are affected first), wernicke korsakoff --confusion, ophthalmoplegia, ataxia + confabulation, personality change, memory loss (permanent), damge to medial dorsal nucleus of thalmus, mammillary bodies dry--polyneurtiis, mm wasting wet berberi--high output cardiac failure (dilated cardiomyopathy), edema WW cause is rice, alcoholics |
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B2
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riboflavin; FADH2 (FAD, fMN) B2=2ATP
FACE problems (f) the C's--cheilosis (mouth), corneal vasculatiozation, glossitis, magenta tongue |
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B3
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niacin (NAD); B3=3ATP
tryptophan-->niacin and serotonin NADP, HAD from tryptophan needs vit B6 glossitis, pellagra (hartnup disease dec trytophan), malignant carcinoid syndrome (inc tryptophan metab) and INH (dec vit B6) 3 D's-diarrhea, dementia, dermatitis (sun exposed Casal's necklace) excess--facial flush (tx hyperlididemai) occurs in corn bakced diet acetyl Coa-->BOHB, malate-->OAA, G6P-->6 phosphogluconate (NADP) in PPP |
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B5
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panththenate; CoA
FA synthase dermatitis, enteritis, alopecia, adreanl insuff |
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B6
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PLP pyridoxine; microcytic anemia
goat milk, chronic alcohol, isoniazid (TB), OCPs-->sideroblastic anemia inc iron-->convulsions peripheral neurop alanine-->pyruvate; OAA-->aspartate ALT/AST, decarbox reactions, glycogen phosphorlyase, cystathione syntehsis, heme synthesis; need niacin --convulsions, hyperirritability, |
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vitamin A
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VISION fat soluble, antioxidant, visual pigments, biot's spot
2nd MCC blind WW, penomonia, renal caliculi, follicular hypercaratosis, papilladema, seizures retinol vit A---Retin-A for wrinkles and achne, epithelial cells (pancreatic, mucus sec), treats measles def--night blind, dry skin excess--arthralgias, fatigue, HA, skin , alopecia, teratogenic (cleft palate, cardiac) |
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vit B12
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coblaamin BLOOD AND CNS
comes only from animal produces so dec in vagans, celiac disease, malnut, pernicious anemia; dec gastric acid pepsin, chron's (term ileal absorp), bact overgrowth, fish tape worm, chronic pancreatitis syn DNA, succinyl coA vit B12-->R factor in salva-->gastric + r factor-->free B12 +IF-->pacreatic enzymes-->vit B12 in IF-->transcobalmin-->liver megaloblastic anemia + neuro (LCT), glossitis, pancytopenia, anemia mm-->succinyl-->heme and gluconeognesis absorped in terminal ileum schilling test homocytein (inc)-->methionin +THF decreases; methymalonyl-coa inc-->succinyl coa decreases |
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fat soluble vit/describe
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A--vision
D-bone cac ca homeostatis E-antiox K-clot |
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folic acid
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DNA synthesis, macrocytic anemia, inc homocystein
def: elderly, goat mlik, alcohol (inhib resorp of monoglut), OCPs (inhib absorp of monoglut), MTX (dihydrofolate reductase), 5fu (thymidylate synthase), phenytoin, TMP, overutilization, green veggies and meat poly--)mon by intest conjugase-->jejunum-->liver folate from fol-iage glossitive neural tube defects |
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S adenosyl methionine
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ATP + methionine-->SAM (transfers methy units the methyl donor man)
regen methionine dependent on Vit B12 and folate required for conversion of NE-->epi |
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biotin
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dermatitis alopecia, LA
propiionyl coa-->methyl malonyl coa raw eggs (avidin) dec pyruvate carboxylate=pyruvate-->OAA; actyl coa carboxylate= acetyl coa-->malonyl; propionyl coa carboxylase=propionyl-->methylmalonyl rare-dermatitis, alopecia, enteitis, caused by antibiotic use or raw eggs ***IT IS A CARBOXYLASE!!! |
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vit c
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ascorbic acid
antioxidant, iron absorb (Fe2+), hydroxyaltion of proline lysine in collagen ysnthesis, dopamine B-hydroxylase dopamine to NE scurvy--swollen gums, bruise, hemarthrosis, anemia, poor wound healing, weak immune |
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vit D
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rickets, ribs
D2-ergocalciferol plants; D3 cholecalciferol in milk and sun; 25-OHD3=stroage as adipose months 1,25OH2D3 calcitrol=active inc intestinal absorption of calcium and phosphate inc bone resoption rickets in children bend bones, osteomalacia in adults; hypocalcemic tetany, excess--hypercalcemia, hypercalciuria, loss of appetitis, stupor, arcoidosis |
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vit E
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causes: hemolytic anemia, peripheral neurop, ataxia
does-->lipid peroxidaiton, antioxidant (protect membranes fro FRs) def--fragile RBCs hemolytic anemia, mm weak, post column and spinocerebellar tract demyelination toxic--dec vit K E=erythrocytes |
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vit K
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carboxylation of lgutamic acid, blood clot, made in intestinal flora
K=koagulation; 2, 7, 9, 10, C, S warfarin=vit K antag; neonates give vit k at birth to prevent hemorrage 1-3 weeks storage neonatal hemorrhage inc PT/PTT normal BT antibiotics cause |
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zinc
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essential for activity of 100 enzymes; zinc fingers formation (trancritpion factor)
delayed wound healing (cofactor in collagenase), hypogonadism, dec adults hair, dysgeusia, anosmia, alcoholic cirrhosis, perioral rash children-growth retard, hypogonad |
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ethanol methanolism
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ehtanol-->acetaladehany by alcohol DH +NAD-->acetate by acetaldehyde DH and NAD
NAD is limiting reagent alcohol DH=zero-oder kinetics fomepizole inhibts alcohol DH, antidots for methanol/ehtylene glycol poisoning disulfiram (antabuse) inhib acetaldehydre DH--> hangover hypoglycemia b/c inc NADH in liver so pyruvate to lactate and OAA to malate inhib gluconeogenesis and stim FA synthesis-->hypoglycemia and heatic fatty change |
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kinase
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uses ATP to add phosphate
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phosphatase
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removes phophate
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phosphylase
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adds phosphate w/o ATP
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dehydrogenase
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oxidizes substrate
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carboxylase
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biotin; add carbon
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RLE of glycolysis
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PFK-1
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RLE of gluconeogensis
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fructose 1,6 bisphosphate
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RLE of TCA cycle
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isocitrate DH
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glycogen synthesis RLE
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glycogen syhtase
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glycogenolysis RLE
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glycogen phosyphorlyase
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HMP shunt RLE
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G6PD
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de nove pyrimidine synthesis RLE
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carbomoyl phosphate synthestase 2
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denovo purine synthesis RLE
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glutamine-PRPP amidotransferase
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urea cycle RLE
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carbamoyl phophate synthetase 1
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FA synthesis RLE
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acetyl-coa carboxylase
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RA oxidation RLE
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carnitine acyltransferase 1
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ketogensis RLE
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HMG-CoA synthease
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Cholesterol synthesis RLE
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HMG-COA reductase
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chromium
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metabolic imparied glucose tolerance, peripheral neuropathy (maintains normal glucose)
coafactor for insulin to bind glucose to adipose and mm |
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copper
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microcytic anemia (ferroxidase cofactor), aortic dissection (weak elastic), poor wound heaing (cofactor lysyl oxidase)
yrosinase melanin synhtesis |
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fluroide
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dental caries
--calcium hydroxypatitie in bone and detth excess: chalky teeth calcification of ligaments; inc risk bone fractures |
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iodide
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thyroid enlargement (goiter), hypothyroidism
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selenium
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mm pain and weakness, dilated cardiomyopahty
***also glutathion peroxidase antioxidant neutralizes peroxides H2O2 used reduced glutathione |
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NAD vs NADP
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catabolic and anabolic (steroid and FA syntheiss reducing)
HMP shunt-NADPH NADPH--anabolic, resp burst, P450, glutathione redutase |
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arsenic
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inhibits lipoic acid in pyruvate dh complex
vominting rice water stools, garlic breath |
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G6PD
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NADPH necessary for glutathione reduced detox FR and peroxides
dec NADPH hemolytic anemia (fava beans, sulfa, primaquine, antitb drugs oxdizing agents) infections can precipitate XR disorder MC; inc malaria resitance HEINZE BODIES--oxidized Hb in RBcs (H-H) bite cells-removal by macs of Hienz be wise GOLD has false hope |
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fructose intolerance
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AR, def in aldolase B
fructose 1 phosphate acuumulates hypophosphatemia available; inhib glycogenolysis and gluconeogenesis --hypoglycemia, jaundice, cirrhosis, vomit tx: dec intake fructose sucrose (glucose + frucose) INCREASE FRUCTOSE 1 PHOSPHATE which is toxic frucose-->F!P-->Glyceraldehyde and DHAP-->G3P-->glycolysis needs frucokinase and aldolase B |
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essential frucosuira and glactokinase def
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fructokinase defect; AR
benign asymp b/c fructose can't end cell of liver frucose in blood/ruine both are bening galactokinase def in in urine maybe cataracts and failure to dev social smile |
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galactosemia
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no galactose 1 phosphate uridyltransferase AR
damge inc glaactitol toxic in lens of eye failure to thrive, jaundice HM, infantile cataracts, mental retardation exclude galactose, lactose (galactose, + glucose) nonsense mutation no enzyme activity galactose in ureine osmotic damage to eye mental retardation, cirrhosis, hypoglycemia, cataracts avoid DAIRY (gallons of milk) GALT (galactose transferase) |
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what has aldose reductase?
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schwann cells, lens retina, kidneys
glucose-->sorbital w/ NADPH aldose reductase and sorbitol DH in liver ovaries seminal vesicles high fructase and glactose can also affect |
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ornithine transcarbomoylase def
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OTC, MC urea cycle disorder
XR; all others are AR excess carbamoyl phosphate-->orotic acid (pyrimidine synthesis) orotic acid in blood and urine dec BUN hyperammonemia |
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pheylketonuria
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dec phenylalanine hydroxylase;
tryosine becomes essential AA; inc phenylalanine excess phenylketones in urine 2-3 days AFTER BIRTH (mat enzyme during fetal life) --mental retard, growth retard, seizures, fair skin, eczema, musty body odor tx--dec phenylalanine in aspartame and inc tyrosine in diet AR!!!! disorder of AROMATIC AA metab---musty body ODOR developmentally delayed; pheotrphy maternal PKU--lack dietary therapy during pregnancy-->infant microcephaly, mental retard, growth retard, congeital heart defects MMMMM--mental retard, microcephaly, mousy odor, melanin derives from tyrosines, dec pig; phy (milk) exposure first |
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alkaptonuria
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homogentisat oxidase def; AR
homogentisat-->maleylacetoacetate black urine (w/ light) and cartialge; degenerative arthritis no dysfjuctnion low protien diet is treatment |
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albinism
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AR, tyrosinase (can't synthesize melanin from tyrosine)
defective tyrosine transports like of migration of neural creast cells inc risk skin cancer ---XR if ocular albinism |
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homocystinuria
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AR
cystathione synthase def (dec Met inc cys and inc B12 and olfate in diet decaffinity of cystathionine synthase for B6 (inc B6 alot) homocystien methytransferase def cystein becomes essential ----->inc homocystien in urine, vessel thrombosis, , knock kneed, mental retardation, osteoporosis, tall stature, kyphosis, lens subluxation downward and inward and atheroslcerosis stroke and MI DVT, PE ---marfanoid TREAT W/ VIT B6 |
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cystinuria
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hereditary defect in renal tubular amino acid transporter for cystein, ronithine, lysine and arginine in the PCT of the kidneys
excess cystine in urine-->cystine kidnye stones (staghorn calculi) AR trreat w/ acetazolamide to alkalinize the urine |
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maple syrup urine disease
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branched chain a-ketoacid DH; inc leucine, valine, isoleukine and their ketoacids; avoid aminoacids (ILV i love vermont maple syrup w/ branches) inc a ketoacids esp Leucine
--metnal retardation, seizrues, feeding problems sweet-smelling urine CNS defects and death --branches of a tree |
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hartnup disease
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AR; defective neutral amino acid transporter on renal and intestinal epithelial cells
tryptophan excretion in urine and dec absorption form gut PELLAGRA b/c no melatonin or niacin |
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glycogen storage diseases
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very poor carbohydrate metabolism
von gierke's disease- G6P pompye disease-a14 glucosidase cori's disease debranch a1,6 glucosidase mc ardle's disease--lgycogen phsphorylase |
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von gierke's disease
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glycogne storage disease
G6-Pase G6P-->glucose-->glycogen glycogenosis, enlarged liver and kidneys, hypoglycemia no response to glucagon or other genesis stim glucose is trapped in cells |
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pompe's disesae
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lysosomal a1,4 glucosidaes (acid maltase) glycogen storage disease
cardiomegaly and styemic findings to early death pump (heart, liver, mm) |
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cori's disease
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debranching enyzme a1,6 glucosidase; glycogen storage disease
mild normal lactase gluconeogensis intact |
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mcardle's disease
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muscle phosphorylase (glycogen to glucose)
inc glycogen in mm mm fatigue no lactic acid inc w/ exercise; Mc=muscle painful mm cramps, myoglobinuria w/ strenuous excersize SK MM!!! |
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fabry's disease
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periipheral nerupathy of hands/feet, angiokeratomas
def in a-glaactosidase A; inc ceramide trihexoside XR; lysosomal storage disease |
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gaucher's disease
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MC, AR, def in B-glucocerebrosidase; inc in glucocerebroside
HSM, aseptic necorsi of femus, bone crises, gaucher's cells (macs like crumpled tissue paper) lysosomal storage disease |
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neimann-pick disease
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dec in sphingomyelinase; inc spingomyelin; AR; lysosomal sorage disease
progressive neurodegeneration, HSM, cherry red spot on macula, foam cells picks nose w/ sphinger |
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tay-sachs disease
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4 base insertion frame shift stop codon, def in hexosamiindidase A; inc GM2 ganglioside
AR, lysosomal storage disease progressive neurodegen, dev delay, cherry red pot on macula (neimann pick too), lysosome w/ onion skin; no HSM (neiman pick) SaX (heX) |
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krabbe' sdisease
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glactocerebrosidase def, inc galactocerebroside;
AR, lysosomal storage disease peripheral neuropathy, dev delay, optic atorphy, globoid cells |
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metachromatic leukodystrophy
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def in arylsulfatase A, inc cerebroside sulfate
AR, lysosomal storage disease central and peirpheral demyelination w/ ataxia and demenia |
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hurler's syndrome
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a-L iduronidase def, inc heparan sulfate and dermatan sulfate
AR, lysosomal storage disease dev delay, gargolylism airway obstruct, corneal clouding (can't see to hurl) |
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hunter's syndrome
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iduronate sulfatase def, heparan sulfate and dermatan sulfate inc
XR, lysosomal storage disease mild hurler's aggreessive behavior no corneal clouding (hunters can see clearly) aim for X |
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osteogenesis imperfecta
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sclera is blue--thinning of sclera from loss of collagen
defect in type 1 collagen multiple pathologic fractures, dec wound healing |
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5-fu
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blocks thymidylate synthase
dUMP-->dTMP blocks folate |
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MTX/TMP
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blocks dihydrofolate reducate
develop folate def |
