The eye and systemic disease

This article describes various ocular manifestations of certain systemic diseases. The most common are given herein, but in addition several less common conditions are detailed because of the life-threatening nature of the underlying cause. Emergency physicians need to be aware of these conditions in order to be prepared for possible presentations in the Emergency Department.     

Smoking and inflammatory bowel disease: a meta-analysis

OBJECTIVE: To assess whether there is a true effect of smoking on the 2 most prevalent forms of inflammatory bowel disease (IBD): Crohn disease (CD) and ulcerative colitis (UC). METHODS: For this meta-analysis, we searched multiple health care databases, including MEDLINE and EMBASE (January 1980 to January 2006), to examine the relationship between smoking and IBD. Keywords searched included smoking, Inflammatory bowel disease, Crohn's disease, and ulcerative colitis. Data were abstracted using predefined inclusion and exclusion criteria. An odds ratio (OR) was recalculated for each study using the random-effects model, and a combined OR was calculated. RESULTS: A total of 245 articles were obtained through an electronic search of health care databases. Thirteen studies examined the relationship between UC and smoking, whereas 9 examined the relationship between CD and smoking. We found evidence of an association between current smoking and CD (OR, 1.76; 95% confidence interval [CI], 1.40-2.22) and former smoking and UC (OR, 1.79; 95% CI, 1.37-2.34). Current smoking had a protective effect on the development of UC when compared with controls (OR, 0.58; 95% CI, 0.45-0.75). CONCLUSION: This is the first meta-analysis, to our knowledge, to evaluate the relationship between smoking and IBD using accepted quality standards for meta-analysis reporting. Our meta-analyses confirm that smoking is an important environmental factor in IBD with differing effects in UC and CD. By using predefined inclusion criteria and testing for homogeneity, the current analysis provides an estimate of the effect of smoking on both these forms of IBD.     

Nasal manifestations of systemic disease

The spectrum of systemic diseases that can involve the nose extends from bacterial and fungal infections to connective tissue disorders. Nasal involvement may be minor and merely an annoyance to the patient, as in systemic lupus erythematosus, or it may pose the risk of life-threatening complications, as in mucormycosis. Although the diagnosis is often readily apparent from characteristic nasal lesions or other systemic manifestations, nasal biopsy may be necessary to positively identify the cause, as in Wegener's granulomatosis. With prompt identification and treatment, nasal involvement in many disorders can be halted before further damage and destruction occur.     

Oral manifestations of systemic disease

Careful examination of the oral cavity may reveal findings indicative of an underlying systemic condition, and allow for early diagnosis and treatment. Examination should include evaluation for mucosal changes, periodontal inflammation and bleeding, and general condition of the teeth. Oral findings of anemia may include mucosal pallor, atrophic glossitis, and candidiasis. Oral ulceration may be found in patients with lupus erythematosus, pemphigus vulgaris, or Crohn disease. Additional oral manifestations of lupus erythematosus may include honeycomb plaques (silvery white, scarred plaques); raised keratotic plaques (verrucous lupus erythematosus); and nonspecific erythema, purpura, petechiae, and cheilitis. Additional oral findings in patients with Crohn disease may include diffuse mucosal swelling, cobblestone mucosa, and localized mucogingivitis. Diffuse melanin pigmentation may be an early manifestation of Addison disease. Severe periodontal inflammation or bleeding should prompt investigation of conditions such as diabetes mellitus, human immunodeficiency virus infection, thrombocytopenia, and leukemia. In patients with gastroesophageal reflux disease, bulimia, or anorexia, exposure of tooth enamel to acidic gastric contents may cause irreversible dental erosion. Severe erosion may require dental restorative treatment. In patients with pemphigus vulgaris, thrombocytopenia, or Crohn disease, oral changes may be the first sign of disease.     

Oral manifestations of systemic disease

Many systemic diseases have associated oral symptoms. Occasionally, patients with these diseases present with lesions that occur primarily in the mouth. Although few systemic diseases have strictly pathognomonic lesions of the oral mucosa, a careful examination of the oral cavity can often lend important clues to making a diagnosis.     

Cutaneous signs of systemic disease

In this article we have discussed briefly some of the important diseases in which a thorough skin examination is of help in evaluation and diagnosis of patients in an emergency department. Changes in the skin, for instance, may be the first clue of an internal malignancy. Disorders associated with gastrointestinal bleeding, endocrine abnormalities, and/or epilepsy can have prominent cutaneous manifestations. Thus, an awareness of the unusual findings is of value to the emergency medicine physician.     

Dermatomyositis as a systemic disease

Dermatomyositis is a classic example of a disease that has both cutaneous and systemic manifestations. The skin and muscle disease are described as well as the possible systemic manifestations including overlap syndromes, joint symptoms, pulmonary disease, and other internal organ involvement. The association with pregnancy is also discussed.     

Ophthalmologic complications of systemic disease

The human eye, as an organ, can offer critical clues to the presence of systemic disease. This article discusses the various ophthalmologic manifestations of systemic disease that can be evident on examination by an emergency department provider, as well as some findings that can be discerned with specialty consultation. The following topics are reviewed with respect to potential ocular signs and complications: syphilis, herpes zoster, Lyme disease, acquired immunodeficiency syndrome, Reiter's syndrome, Kawasaki's disease, temporal arteritis, endocarditis, hypertension, and diabetes mellitus. Indications for emergent ophthalmologic consultation are also emphasized.