Vertebrae Compression Fracture Due to Extra-nodal RDD Case

Vertebrae Compression Fracture Due to Extra-nodal RDD Case INTRODUCTION: RDD was first described by Destombes1 in 1965 as a rare, separate entity of benign self-limiting sinus histiocytosis with massive lymphadenopathy later Rosai and Dorfman2 in 1969, confirmed it as a separate clinic-pathologic entity. Although RDD may occur in any age group, it is most frequently seen in children and young adults. Isolated intracranial disease tend to occur older patients. The disease is more common in males and in individuals of African descent . The most frequent clinical manifestations include fever, night sweats and weight with bilateral massive cervical lymphadenopathy. Mediastinal, inguinal and retroperitoneal nodes may also be involved. RDD is potentially systemic disease and may affect extra nodal sites up to 43% of all RDD patients. The common extra-nodal sites include skin, upper respiratory tract, and bone. Skeletal involvement as a sole manifestation of RDD is extremely rare, occurring in fewer than 2% of all RDD patients and arise most frequently in long b ones such as tibia, femur, humerus, clavicle and bones of the hands. CNS involvement is rare (5%), with 75% of cases involving the brain and 25% involving the spinal canal. Involvement of the CNS without concurrent nodal involvement is rare.3 Laboratory findings are non-specific with leucocytosis, neutrophil, elevation of erythrocyte sedimentation rate (ESR), hypergammaglobulinemia being the most common findings. We present a rare case of vertebrae compression fracture due to extra-nodal RDD without lymphadenopathy later developed metastases to brain. CASE REPORT: A 45 year old lady presented with h/o sudden onset of paraplegia. Work –up was done and spinal mass was found. Later the patient underwent surgical debulking to releave her symptoms. The patient gradually improved. Histopathologically it was diagnosed as RDD. The patient was symptom free for 6 months, then she developed sudden onset of seizures and lower limb weakness. MRI showed multiple cranial and spinal metastasis, following which the patient underwent craniotomy. The patient was further treated with whole brain radiotherapy of 30Gy. There was no improvement of symptoms. The patient eventually expired 6 months following the completion of radiotherapy. Discussion: RDD in its classic form is a benign, self-limiting histiocytic proliferative disorder that is characterized by massive lymphadenopathy. Most patients with RDD are in their second or third decade of life, the mean age of onset of nodal disease is about 20years, with a male-to-female ratio of 1.4:1. It is commonly reported in African-Americans. The etiology of RDD remains unknown; immune system dysfunction and an autoimmune process or viral infection such as Epstein-Barr virus and human herpes virus type 6 have been attributed with the pathogenesis of RDD. The presentation of RDD can be categorised into three sub types: 1) those with only lymph nodes enlargement with sudden increase and spontaneous regression and without any further recurrences; 2) those with immunologic abnormalities at presentation have a more widespread nodal disease and a higher fatality rate4,5 ; 3) those with several extra-nodal site involvement, multi-nodal disease and a protracted clinical course with multiple relapses and remissions for years. In these cases, the severity of disease depends on the type and number of extra-nodal sites.6 Patients who present with or subsequently develop intracranial involvement, become symptomatic at a later mean age (34.9 years), with a strong male predominance.7 Involvement of CNS is rare (5%), with 75% of reported cases involving the brain and 25% involving the spinal canal. Involvement of the CNS in the absence nodal involvement is rare.3 The most common intra cranial presentation is solitary dural based lesion, but multiple intracranial lesions have also been reported. The suprasellar region, cerebral convexity, para sagittal region, cavernous sinus, and petroclival regions are most common locations.7 Only 11 cases of spinal RDD have been reported, of which 10 patients had an extra-medullary tumor. Seven patients presented with epidural lesion, three presented with intra dural lesions.8 Spinal cord compression has been reported in a few patients with spinal involvement causing neurologic deficits.9 Compression fracture due to spinal involvement of RDD has not been reported. CNS RDD is a rare benign histiocytic proliferative disorder, with imaging findings typically showing a meningioma-like, dural-based extra-axial mass lesion, which can be solitary or multiple. Imaging studies typically show an enhancing meningeal-based mass with a variable amount of edema surrounding the lesion. Skeletal involvement of RDD as a sole manifestation is extremely rare, occurs in less than 2% of all RDD patients and involves the long bones such as tibia, femur, humerus, clavicle and bones of the hands or skull, and is usually multiple. Skeletal lesions of RDD are intramedullary osteolytic with either poorly or sharply defined margins. Spinal Rosai-Dorfman disease can be misdiagnosed as meningioma when arising from dura or as metastatic disease of another cause when presenting as vertebral body disease.10 The most common differential diagnosis of a primary bone RDD includes bacterial osteomyelitis, fungal infections such as histoplasmosis and Langerhans cell histiocytosis. Definitive diagnosis requires tissue examination. Microscopically, lymph node enlargement with sinuses containing prominent numbers of histiocytes with phagocytosed lymphocytes. This is a typical picture of RDD. Immunopositivity is expressed by these cells for both CD68 and S-100 protein, and negative for CD1a. RDD has a typical finding in histopathologic studies, that is emperioplesis; a phenomenon of phagocytosis of intact lymphocytes, plasma cells, erythrocytes or neutrophils.11 LCH is a close differential diagnosis both on radiology and histology. Both histiocytes of RDD and LCH are positive for CD68 and S100, but CD1a is positive in LCH. Also Langerhans cell histiocytosis does not exhibit emperioplesis. Treatment in the majority of cases is not indicated as it is a benign and self-limiting.12,13 Therapy is indicated in patients with bulky extra nodal disease with involvement of vital organs or causing life threatening complications.13 Surgical resection or debulking can be considered as an option only when the nodal mass iss compressing airway or intra dural lesion.13 When complete resection cannot be achieved, adjuvant radiosurgery can be give successful partial resection.14 Surgical excision of resectable lesions induced complete remission (CR) in 8 out of 9 patients.13 The role radiotherapy in the treatment has not been established. Various medical alternatives in the management have been tried with limited results. Short term Systemic corticosteroids and prolonged course low dose oral prednisolone has been effectively used in RDD with skin and lymph nodal involvement with respiratory obstruction.15 Steroids tend to alleviate the symptoms and decrease nodal size, recurrences have been reported following withdrawal of steroids. Chemotherapeutic agents have been used without any encouraging results. Combination chemotherapy of low dose MTX and 6-MP, MTX/6MP/vinblastine/6-thioguanine and acyclovir with thalidomide have been tried with limited benefit to patients. It is possible that different patients with RDD may respond to different drugs. Targeted therapy in the form of imatinib, interferon- ÃŽ ±, cladarabine and more recently rituximab has also been in the treatment of RDD.

Proctor reluctantly Essay

This powerful line comes in act 4 when Proctor reluctantly confesses to seeing the devil. He is now passionate about making sure his name doesn’t get put up on the church door. This is the line that starts the incredible build up of emotion and frustration leading to the dramatic climax of the play. Saying it ‘with a cry of his whole soul’ shows how much his name means to him. There isn’t a more emotional way he could say it than with his whole soul. John Proctor would rather give up his life than his name. The exclamation mark at the end and the word ‘cry’ shows he should shout the words with a lot of emotion and passion. I can imagine the actor looking very angry and yelling the line with his arms spread and his fists clenched in rage at the prospect of losing his dignity and reputation. I think when he says the line the other charactors will be silenced and be shocked by his flood of emotion. This abrupt line would surprise the audience and it might make them sympathize with Proctor. In Act 2 John is asked by Hale to repeat the Ten Commandments and remembers all but thou shalt not commit adultery and has to be reminded of it by Elizabeth. It is ironic that Proctor forgets this sin because of the affair he had with Abigail. Adultery was seen as a terrible sin in the Puritan society and adultery was taken very seriously. From Elizabeth’s perspective this would make her feel uncomfortable as she is wounded by her husband’s affair: ‘Proctor (as though a secret arrow had pained his heart): Aye. ‘ The description Miller uses to show how Proctor should say the line is very dramatic and the simplicity of just using the word ‘Aye’ will also have dramatic impact. I can imagine the actor almost whispering the word, dropping his head in shame and with a crack in his voice. This might have the effect of generating sympathy from the audience for both Elizabeth and John. It also adds to the build up of tension creating an expectant atmosphere. Arthur Miller is very good at making the audience feel very involved. One of the ways he does this is by using a technique called dramatic irony. Dramatic irony is when there is contradiction between what a character thinks and what the audience knows to be true. For example in Act 3 Proctor confesses to the court that he had an affair with Abigail. He tells them that Elizabeth knew about the affair and this is why his wife put Abigail out of the house. Danforth sends for Elizabeth and orders that no one is to speak to her and Proctor to turn his back. She is asked about the affair. Not knowing that Procter has confessed and trying to protect Proctor, she lies and denies all knowledge of the affair between John and Abigail. She realizes too late that she should have told the truth and she is led away. During this most tense scene the audience would feel very frustrated with Elizabeth and be willing her to tell the truth. The audience would feel sorry for Elizabeth as she lied to protect Proctor even though it was about his affair, which deeply hurt Elizabeth. At this point in the play I felt desperate for Elizabeth to tell the truth. Arthur Miller uses very powerful stage directions in The Crucible. He uses them for several reasons. One of the reasons is to describe a movement or action of a character. He directs this line at Mary Warren. His wife has just been arrested on suspicion of witchcraft after a poppet is found in her house, which Mary made. This movement prepares us for the dialogue, which is to follow: ‘Proctor (moving menacingly towards her): You will tell the court how that poppet came here and who stuck the needle in. ‘ This shows the mood that Proctor is in. Proctor is furious at Mary and wants to scare her into telling the court. The movement would draw everyone’s attention towards the actor. I think the word ‘menacingly’ would mean that the actor would walk purposely with an edge of threat towards the girl. He would tower over Mary ready for the dialogue. By this point the audience would be anticipating though his actions what would be going to happen next. In Act 4 Proctor is losing control and is confused about his decision of confessing to seeing the devil: ‘(He moves as an animal, and a fury is riding in him, a tantalized search)’. This stage direction would enable the actor to behave in a dramatic, inhuman manner. I can imagine the actor pacing and his eyes searching for answers. It would give the actor the opportunity to take centre stage and exploit this important twist of the play. This would add dramatic tension and a feeling of anticipation of what Proctor was going to do next. I think the actor would pace up and down the stage quickly with his body quite tensed up. I think Arthur Miller was successful in creating tension in The Crucible. He does this through a variety of methods. Firstly his use of dark, forbidding sets. This gives the idea of tension before the scenes have even begun and the characters have started speaking. His use of dramatic dialogue and stage directions build up the tension and help the actors relate to the character and perform the play with more emotion towards the characters. Through dramatic irony he involves the audience and manages to maintain their interest throughout the play. Miller portrays the characters in an intense way. The relationships between them are very close, with the stifling intimacy of their lives adding to the slow build up of hysteria in the play. I found the most dramatic moment in the play was when Proctor confessed to his affair. Elizabeth was then asked if she knew about the affair but she denied all knowledge of this. This was a particularly tense moment because anxiety and frustration was high; the characters along with the audience wanted her to tell the truth, fearing the consequences of a lie. This had the affect of making me feel nervous that something could go wrong and also involved because I knew about Proctor’s confession. I felt that Abigail’s character was especially strong and influential in the play. She was the root of all the troubles. I felt pity for Elizabeth because of Abigail; her affair with Proctor and her accusations about Elizabeth’s involvement in witchcraft destroyed her life. Miller has the ability to pull the audience into the lives of the characters by his use of dramatic devices and theatrical techniques, which maintain interest and participation throughout the play. Miller made me feel nervous and frustrated in The Crucible. He made me feel sympathy, fear and anxiety towards the characters. For example I felt great empathy for Elizabeth Proctor as her husband betrayed her and then she was accused of being a witch. Miller uses the other characters to portray Elizabeth as a cold person but through our knowledge of her as the play progresses we become emotionally involved with her and come to realize what a strong courageous woman she is. With Elizabeth, as with many other characters, Miller allows us to make up our own minds about their honesty and strength as we are drawn into the characters lives and we begin understand the double standards and different tensions that are operating throughout The Crucible.

Presidential Success President Of The United States

The common definition of a president is an officer who is elected or appointed to preside over an organized body of persons as the Chief Executive of the United States. When given this title , Americans expect vast achievements from that individual. Which is judged by their success in the present and the future during their 4 year term. Understandably, some of these expectations include; upholding the Constitution and protecting the natural rights and liberties of the American people . Along with taking speedy actions on problems facing the nation, while having a compelling vision for this country. Presidential success is a large speed bump, a president faces while being in office. That being said, it can only be determined while†¦show more content†¦This was a problem he efficiently and effectively resolved. Another act of example as seen in our history was in 1948, after the World War II ended, the Soviets blocked all routes to West Berlin. In order to weaken their army , which at the time Berlin was divided up. President Harry S. Truman was the president at during this time and found himself in a tight situation. Where he had to pick to either back down and lose the respect of his allies, or stand firm and risk starting a war with the Soviets. Instead, he chose to go around the blockade by sending supplies by air. Within a year, the Soviets ended the blockade.1953) Presidential failure, is just as important as presidential success. This is a determining factor if that candidate should be re-elected if he/she is running for office. A way to evaluate presidential failure can be through ratings in public opinion polls throughout their term. Public opinion polls are vital to guaranteeing democratic governance. They help use see how the public perceive him/her. This concept can be applied vise-versa, where we can also use public opinion polls to measure presidential success. Lastly, we can also evaluate presidential greatness and mediocrity by legisla tive success in applying his/her campaign promises. Throughout their campaign presidents make numerous policy proposals and promises to the American people. The determining factor is how much of those promises are actually

Antwone Fisher Symbolism - 1142 Words

Throughout the two movies, Gus Van Sant and Denzel Washington used both language and stylistic features to present the idea of a personal journey, in particular, through the use of symbolism. In the film, Antwone fisher, Washington uses a symbol of women. The beginning of the film shows how Antwone was mistreated and abused as a child through flashbacks. In this case the symbol of women is used to symbolise worthlessness and insignificance as he is abused and beaten by his foster mother and raped by his foster sister. As the film progresses Antwon meets and becomes romantically involved with a woman, Cheryl, who is also in the navy. With Cheryl by his side Antwone is able to stand up to his foster mother and no longer let her push him†¦show more content†¦Later as his maths skills become more and more evident to the professor, will is offered job opportunities that could set him up for life and insure him of a brighter future. This again symbolises a personal journey for wil l as maths opens a brighter more secure future. By using symbolism as a stylistic feature Gus Van Sant and Denzel Washington are able to successfully present the idea of a personal journey to their intended audiences. Social – language Both Gus Van Sant and Denzel Washington successfully use language to present the idea of the journey in their films however each one uses a different form of language. In Antwone Fisher, Antwone uses body language or violence to shut people out and create a shield between his emotions and the outside world, protecting people from getting to him and hurting him. When Antwone starts seeing a councillor he learns to talk about his feelings and learns to deal with his anger without violence. In the end of the film Antwone is a different man. He is calm and much more happier and open as he has learnt to open up about his feelings and deal with emotions in a constructive way. He learns to talk to people rather than just turning to violence to solve his issues. This shows a social journey as Antwone learns to talk to people about how he feels rather than putting up a wall and using violence to shut people out. Throughout the film of Good Will Hunting, Will is in a very similar