Histologically, changes are often nonspecific and consistent with a chronic dermatitis, but lichenoid features can be seen [1,3]. Infections can occur in apparently healthy individuals, but it is a particular problem in severely immunocompromised patients in the endemic area. Obesity may decrease treatment responsiveness and appears to be one of the main reasons for the development of premature cardiovascular disease [10,13,14]. The minimal depth dose characteristics that may be achieved avoid the irradiation of subcutaneous structures, which would occur if Xray therapy that is absorbed exponentially was used. Agar 1 is a caseinbased, vitaminfree control; agar 2 is supplemented with inositol, agar 3 with thiamine and inositol, and agar 4 with thiamine alone. Alternatively, there may be ulceration, the condition resem bling a form of pyoderma gangrenosum. The differential diagnosis of psoriasis includes seborrhoeic dermatitis, atopic eczema, dermatophytosis, drug eruption and mycosis fungoides. These changes lead to a wedgeshaped infarctlike lesion with a large central zone of coagulation necrosis surrounded by inflammation extending from the superficial to the deep dermis, and sometimes into the subcutaneous tissues. The median time from onset of symptoms to diagnosis was 86 days in the largest series [1] available. Squamous cell and basal cell carcinoma in transplant patients (see Chapter 146) Skin tumours developing after organ transplant are known to have more aggressive characteristics and carry a poorer prognosis [47]. Histopathological changes of Paederus dermatitis include intraepidermal and subepidermal blistering, epidermal necrosis and acantholysis [28]. Unlike animal cells, however, their cells are enclosed by a rigid cell wall containing varying amounts of chitin, a polymer of Nacetyl glucosamine and glucans. Causative organisms the measles virus is a morbillivirus, of the Paramyxoviridae family. The lesions are smaller than the typical lesions of guttate psoriasis and may be either grouped, or diffuse [1,2]. Disease course and prognosis the illness is usually mild with spontaneous recovery. For culture, the hairs must be surface sterilized, and this may be done by immersion in 70% alcohol. Migratory birds have been implicated in the spread of diseases to new regions [6]. Intravenous treatment with pentavalent antimonials results in a number of common adverse reactions and side effects including hepatic, pancreatic, musculoskeletal and cardiac toxicity. From these sources, they are implanted subcutaneously, usually after a penetrating injury [3,4]. Pathophysiology the infection follows traumatic implantation of organisms from the environment. For instance, 1 week of topical terbinafine was found to be more effective than 4 weeks of clotrimazole in tinea pedis. Ice packs should be applied, and the injection of local anaesthetic without vasoconstrictors around the sting site will help to reduce the pain. Some fungi can completely switch their form of growth depending on the environmental conditions. The components responsible for probing the skin and piercing a blood vessel are a group of stylets, which are kept withdrawn within the head unless the insect is feeding. Differential diagnosis the diagnosis may be confused in localized infections by secondary bacterial infection [461], and by lesions in preexisting blistering skin disorders, but typical vesicles or subsequent erosions, generally confined to eczematous or inflamed areas, should be sought, especially if there is a poor response to antibacterial Clinical variants When developing from a primary infection, there is more likely to be malaise, high fever and lymphopenia. Debris from under the nail is a fruitful source of material, which may be scraped out using the flat end of a dental probe. Differential diagnosis Erythema dyschromicum perstans (ashy dermatosis) clinically resembles pinta, and pityriasis alba, vitiligo, atrophic lichen planus and tuberculoid leprosy also have to be considered in the differential diagnosis.
The disease occurs in all socioeconomic groups; however, it does occur more commonly when people are living in crowded conditions. The condition does not appear to show a significant geographical variation in distribution. Even if there is no Presentation the initial bite is usually not felt because of the anaesthetic contained in the saliva of bedbugs. These organisms occupy the lymphatic system in humans, and can lead to the disease elephantiasis. Similarly, worsening of asthma, and urticaria in an atopic research laboratory worker, on exposure to grasshoppers, has been described [5]. Changes in normal flora, including an increase in the num ber of subjects carrying Gramnegative organisms, may occur in seriously ill patients, apparently to an extent that cannot be accounted for by the treatment they are receiving [28]. Like genital primary lesions, extragenital sores are accompanied by regional adenitis. Although most patients do not have any symptoms after the first bites, reactions may occur 10 days later [22]. Dry skin should be treated by soaking in water, followed by rub bing with emulsifying ointment or petrolatum. Likewise, there are many causes of eye disease in endemic countries which may cause signs that in isolation mimic leprosy, especially trachoma, in which trichiasis and entropion follow scar ring of the lids, and onchocerciasis, which causes uveitis and its complications. African patients with blastomycosis have a higher frequency of skin and bone involvement [2]. The vaccine can also be considered in those receiving immune suppression at a lower level (prednisolone 20 mg/day, azathioprine 3 mg/kg/day, methotrexate 0. When surgical reexcision is inappropriate, it may thus be reasonable, particulary in the elderly, merely to observe and to offer adjuvant radiotherapy only for clinical recurrence. The vulva is particularly likely to be invaded in the infant with amoebic dysentery. However, the flashlamp may be more painful than laser treatment and several treatments may be required. In any community, the number of individuals who react strongly to tuberculin relates to the prevalence of active tuberculosis. Introduction and general description Melioidosis is a systemic infection which can result in the develop ment of skin lesions such as abscesses. As ringworm fungi can frequently be isolated from the environment, when there are cases of ringworm of the scalp, and from clothing after laundering, it is highly likely that patients whose infection has been eradicated may be reinfected from these sources. Light between 600 and 1200 nm has been described as an optical window into the skin because it is subject to low scattering in addition to being well absorbed by endogenous chromophores. The lesions can occur all over the body but are most frequently found on the trunk, thighs, buttocks and genitalia [4]. Scrapings from the affected skin may show bacteria and fine filaments if stained with Gram or Giemsa or even with simple potassium hydroxide clearance. The significance of the isolation of Pseudomonas from nonspecific lesions must be care fully evaluated on the clinical findings. As with the identification of Candida species, commercial kits are widely used to identify Cryptococcus neoformans. Introduction and general description Marburg disease was first observed in Marburg and Frankfurt in Germany and in Yugoslavia in 1967 when 30 infections, seven of which were fatal, followed the importation of a consignment of African green monkeys (Ceropithecus aethiops) from Uganda [33,34]. Differential diagnosis the appearance of the typical verrucous lesions is typical although other conditions such as disseminated deep mycoses should be considered.
Spherules may be seen within the cytoplasm of histiocytes and in giant cells of the foreignbody type. They arise following embolism of ova from adults, which are localized in abnormal sites, such as the paravertebral plexus [5]. Conjunctival papillomas Human papillomavirus of the lowrisk mucosal type is frequently detected in conjunctival papillomas [251] with rare detection of highrisk types [252]. Both may show the central black haemor rhagic crust and the zone of oedema and erythema. Acute pemphigus foliaceus can mimic subacute generalized pustular psoriasis, but histological and immunofluorescence testing will distinguish between them. There are no controlled studies on the use of methotrexate with adalimumab in psoriatic arthritis but registry studies suggest that no additional efficacy is achieved by the addition of methotrexate [21]. Some, possibly 15% of patients, fail to respond to these drugs, and there is a strong clinical impression that results are much better in younger patients in whom faster linear nail growth and relative absence of coexisting ischaemic or traumatic dystrophy are probably important factors. Involvement of the perianal skin may present as pruritus ani, of which erythrasma is an uncommon cause. The organism selectively destroys those tissues within its own viable temperature range [35]; muscle is usually spared, perhaps because of its higher temperature. The tissue effect of this may therefore be very similar to a continuous wave laser beam. In a laser this is, more precisely, a narrow band in a Gaussian distribution around a characteristic wavelength. The extent of the erythroderma and the warty plaques varies greatly, and either may predominate. The hyphae within the hair are fewer in number than in other endothrix infections and do not break up into a mass of arthroconidia but run intact through the hair, forming tunnels within its structure. The other less commonly involved species produce their own characteristic types of hair invasion. The percentage incidence varies greatly with different populations but, as nasal carriers sometimes disseminate large numbers of organisms, their detection and treatment are most important in the control of staphylococcal and streptococcal infections. Some form of injury is mandatory for the initiation of the infection, as the tubercle bacillus cannot penetrate the normal intact skin or mucosal barrier. Lichen striatus Definition and nomenclature Lichen striatus is a distinctive, usually selflimiting and asymptomatic inflammatory dermatosis characterized by pink or red papules in a linear distribution that develop in the lines of Blaschko. Occupational allergy in laboratory workers caused by the African migratory grasshopper Locusta migratoria. Differential diagnosis Part 3: InfectIons & InfestatIons Hand warts Conditions that may be confused with hand warts include epidermal naevus, Bowen disease, actinic keratosis and callus. Collective measures are also important: house walls should be constructed with smooth coating to inhibit access of scorpions and doorways of houses should be checked and cleaned regularly. This evidence is not confined to cases with clinically apparent preceding herpetic lesions. The addition of immunosuppressive therapy can suppress this reaction and will improve the chance of clearance of the immunedriven disease [60]. This may not arouse any suspi cions, but the fetus may be aborted or the infant may be stillborn or premature. Cancer There are reports of an association between various cancers and psoriasis, although some of the studies are of low methodological quality with insufficient accounting for potential confounding variables. The use of telaprivir increases the chance of a cutaneous adverse reaction to over 50% [63].
There are few data at present on the use of posaconazole and voriconazole in dermatophytosis. After remission, the optimal length of maintenance therapy is unknown and will be adapted to each patient. Transmission is also prevented by repellents and pyrethroidimpregnated mosquito netting. Bed linens and clothes should be systematically decontaminated, and this action suffices for some physicians. Paronychia, caused either by bacteria or Candida, usually affects the nail plate proximally and laterally, while the free edge is often spared, at least initially. Microfilarial counts remain very low for 6 months, then rise slowly but do not reach pretreatment levels within 1 year. Several products including lavender and teatree oils are marketed for the treatment of head lice and are in wide use. Bedbug infestation is confirmed by the identification of the insect, not requiring the assistance of an entomologist in most cases. This has led to recent major advances in our understanding of their biology, epidemiology and clinical presentations, and the issue of diagnostic and treatment guidelines from both the American and British thoracic societies [8,9]. An acral pattern of purpuric lesions, amounting to papularpruritic gloves and socks syndrome (see p. Other forms of cutaneous tuberculosis, such as lupus vulgaris, tuberculous gumma, papulonecrotic tuberculid [9] and tuberculosis verrucosa cutis, may coexist [1,10]. Joint injections with corticosteroids can provide symptomatic relief but there is little evidence that they prevent bone remodelling and fibrosis. Management [2] There is no consensus concerning the management of latrodectism as evidence to support therapies is scarce, and there are no controlled trials. Demodex folliculorum and topical treatment: acaricidal action evaluated by standardized skin surface biopsy. Microscopy: the dominant form of conidiation is sympodial with the conidia confined to the upper part of Differential diagnosis the disease must be differentiated from blastomycosis (by the absence of a sharp border containing minute abscesses) and also the absence of pulmonary lesions, cutaneous tuberculosis, leishmaniasis, syphilis and yaws. The explanation for the hyperpigmentation seen in fairskinned subjects remains obscure, although electron microscopy reveals abnormally large melanosomes in hyperpigmented lesions, and smaller than normal Age In both tropical and temperate zones the condition is rare in childhood but becomes more common in the late teens, with a peak in the early twenties. Investigations As with all mycobacterial disease, the diagnosis requires a high index of suspicion. There is also a report of the damaging effect of Anthrenus larvae on paraffinembedded tissue specimens, especially the sectioned surface of hyperkeratotic lesions [42]. Clinical variants Isolated lesions on the genitalia, particularly the penis, may occur [3,4,5,6]. Production of pyrogenic exotoxin by groups of streptococci: association with Group A. In the acute phase, the presence of fever, leukocytosis and elevated inflammatory markers may lead to a mistaken diagnosis of systemic infection, sometimes leading to a counterproductive discontinuation of immunosuppressive treatment. Sex Adult male agricultural workers are most often affected, but the condition has occasionally been reported in children. Part 3: InfectIons & InfestatIons epidemiology One of the major features of the infection is the clustering of cases, often associated with exposure to organisms in the environment such as watercooling systems, showers and humidifiers. This section is therefore concerned with ringworm of the palmar skin and with infections beginning under rings.
The clinical picture is very variable and purely or predominantly bullous lesions have been reported. There is lobular proliferation of small blood vessels that con tain swollen endothelial cells. This association is highest in young sexually active women [296], in whom infection may be transient. The septa that are formed usually cut off sporing structures and old parts of the mycelium, and are complete, so that damage to any part of the hypha will result in the death of the whole aseptate length. Apart from transferrin, the presence of persistent Candida infection has, on some occasions, led to the inhibition of Tcell function; an effect demonstrable with other leukocytes in vitro, and that was reversed by antiCandida therapy [19]. This is probably the most morphologically variable dermatophyte species and several distinct colonial forms are regularly isolated. A fourfold or greater rise in titre between acute and convalescent sera is taken as diagnostic. Tick paralysis is an ascending flaccid paralysis probably caused by a neurotoxin injected by the feeding tick [34,35]. A protein, the thaumetopoein, has been isolated from pine processionary caterpillar hairs [18,19]. This in turn leads to a reduction in innate immunity and results in the inability of atopics to react to the load of staphylo cocci. Granulomas vary in appearance and are influenced by the virulence of the organism and the immune status of the patient. Fluctuant glands may be aspirated, but should not be incised as chronic drainage may occur. Clearly, some information may be obtained from the clinical picture, the presence or absence of fluorescence, Tinea faciei 32. The face and chest are first affected by the rash, which generally spreads over the next few days after delivery. The initial invasion of the hyponychium shows through a relatively normal dorsal nail plate. Staphylococcus aureus may occasionally be grown from pustules and rarely from blood cultures. On histology, often performed on specimens from fineneedle aspiration, granulomas are seen with fat necrosis but acidfast bacilli are rarely found. The observation of families over a period of years showed that the same phage type may be responsible for irregular episodes of infection between long inter vals of clinical quiescence [4]. Here, they may later start to multiply and cause severe destructive lesions, known as espundia (Portuguese: a sponge) [14]. Pregnancy and neonatal complications may include premature rupture of the membranes, premature delivery and acute chorioamnionitis and ophthalmia neonatorum. Acute lesions include erythematous macules, papules or nodules, tissue necrosis and ulcers. These occur mainly on the floor of the mouth and histologically many of the prickle cells in the epidermis are vacuolated. Seborrhoeic dermatitis is commoner in seropositive than in seronegative homosexual men, and among infected patients it is more prevalent and has an earlier onset in homosexual and bisexual people compared with intravenous drug users [1]. Although massive singledose therapy and intermittent dose regimens (25 mg/kg twice a week) have had some success, conventional continuous daily therapy (10 mg/kg) is advisable in general. Since then more extensive genomic data has been amassed and this has helped to define divergent species and strains of Staphylococcus through identification of their Streptococci 26.
Partridge berry (Wintergreen). Dulcolax.
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In a recent study from Nepal tuberculosis verrucous cutis had a higher incidence (44%) than other types of cutaneous tuberculosis [16]. Microscopy: large clavate macroconidia with a rounded apical end and up to six cells are rapidly formed. The pustular dermatitis atrophi cans of the legs [4], described as accounting for 0. Some ixodids use one host for larval, nymphal and adult stages (onehost ticks), whereas others require two or, more usually, three separate hosts. Disease course and prognosis Early treatment improves the prognosis and reduces onward transmission. Usually, yeasts are not present under the nail fold, suggesting that the changes are caused by Neoscytalidium alone. Skin of the scrotum and penile shaft may be affected by psoriasis but the glans penis is the most frequently affected part. Histopathology There is an infiltrate of inflammatory cells including T lymphocytes, dendritic cells, eosinophils and mast cells in the dermis [1]. Grown at a higher temperature, characteristic long chains of chlamydoconidia are observed. In those for whom immunosuppressive treatment is being considered, for example pretransplantation or for skin or rheumatic conditions, vaccination can be administered at least 2 weeks prior to commencing immunosuppression. The need to provide a single name for a single species becomes obvious, particularly when so many synonyms have been proposed for one and the same organism. Preventive methods include avoidance of highrisk areas and the use of insect repellent on both clothing and skin. Vaccination with vaccinia virus gives 85% protection and it is postulated that the increasing number of cases in the Congo Basin reflects the cessation of smallpox vaccination in 1980 [17]. Management First line General supportive measures with fluid balance and blood transfusions. Introduction and general description the human diseases associated with these organisms are trench fever due to B. The development of effective, adaptive immunity halts bacterial progression and individuals do not shed bacteria. Investigations Diagnosis is made by extracting the worm from the lesion, or by identifying it in an excised specimen [1]. A raised mean corpuscular volume on full blood count tests is expected and in contrast to when this occurs in patients on methotrexate therapy, it is not a cause for concern. In such patients, the glabrous skin is commonly affected by the development of similar yellowish crusts. The clinical differential diagnosis includes acute allergic or irritant contact dermatitis, thermal burns, chemical burns, herpes zoster, herpes simplex and bullous impetigo [17,21]. In other cases, changes are more superficial, with red, smooth, glazed areas and the loss of papillae. A maculopapular or petechial rash over the face, arms and thorax may be seen in whiteskinned individuals but is not reported in black Africans. Under battle con ditions, soreness and pain have been reported in severe cases [1,6]. Both itraconazole and terbinafine are now licensed in a few countries for use in children, and are alternatives for certain infections such as those caused by Trichophyton species, although there are fewer data and, in some cases (particularly with Infection control [35,36] It is of considerable importance with scalp ringworm to discover the species involved. Environmental factors Socioeconomic and behavioural factors and patterns of sexual mixing affect the risk of infection. Third line If symptoms of herpes B virus disease develop, treatment is with intravenous aciclovir, 12. A rare clinical form has been described in children with eczema: varicelliform vesicles or pustules are succeeded by diphtheritic ulcers. It can be challenging to differentiate histologically from eosinophilic folliculitis but immunohistochemistry may be helpful [11]. In the hypopig mented lesions of the tertiary stage, there is epidermal atrophy and loss of melanin in the basal layer.
Management There have been no comparative trials of treatment regimens for infections with M. Perianal warts, especially in men who have sex with men, may be florid and refractory to treatment [377]. In grain handlers, they are usually on the forearms and neck, but they may be profuse around the waist and in the groin area. Serological reactions, such as the complementfixation test, agglutination test and intracutaneous test, are of doubtful value. Treatment is indicated if gonorrhoea is diagnosed or on epi demiological grounds if there is a history of contact with a person known to be infected. Mortality varies with the infecting strain from <1 to 10% and occurs typically in the oliguric phase. Cat and dog fleas are readily identified, but if unfamiliar species are encountered, the help of an entomologist with an interest in Siphonaptera should be sought. Following mass treatment campaigns in the 1950s and 1960s, the incidence of the endemic treponematoses was greatly reduced [3,7], but these diseases have not been totally eradicated. In older children and adults, clinical infections occur mainly in patients with debilitating diseases. The mode of action of topical tar therapy is incompletely understood but clearance of psoriasis with the Goeckerman regimen is associated with decreased serum levels of inflammatory cytokines [2]. In the opportunistic systemic mycoses, serology is also useful but may be more difficult to interpret. Clinical features [1] History Benign forms of the disease, which heal by calcification, are indistinguishable on Xray from tuberculosis. Cutaneous botryomyco sis caused by Staphylococcus aureus in a patient with diabetes. The Triatominae are largely confined to the western hemisphere, with the majority of species being distributed in North, Central and South America. The differential diagnosis of tungiasis includes myiasis, verruca vulgaris, ingrowing toe nail, acute paronychia, mycotic granuloma, malignant melanoma, and arthropod bites Bees, wasps and ants (hymenoptera) 34. The injection of lignocaine (lidocaine) underneath the nodule may be sufficient to push the larva out [63], and Loong et al. Longterm studies have suggested that the efficacy of Fumaderm continues to improve beyond 16 weeks with one large study of 984 patients reporting good responses in up to 80% of patients [12]. However, there are still regular outbreaks of infection in countries from northern South America, West Africa, SouthEast Africa and the West Pacific. When symptoms do appear, they resemble infectious mononucleosis with fever, lymphocytosis and mildly deranged liver function, although lymphadenopathy and splenomegaly are not usually striking. Several components of the immune response contribute to pathology but the details are not clear and much of the work has been undertaken in murine models. Disease course and prognosis Chronic infections are recognized regularly both in the skin and associated with disease in the central nervous system and joints. Not all groups working in this field have confirmed the presence of these viruses in patients with pityriasis rosea and the strength of the association continues to be debated [109,110]. Thus, on present incomplete information, both sexual and nonsexual routes are significant in the transmission of childhood anogenital warts [224]. Responses were generally sustained in a 52week open label extension to the trial [5]. A therapeutic trial of specific antituberculous therapy is usually decisive in doubtful cases. The distinction between generalized pustular psoriasis and pustular lesions in reactive arthritis is probably academic.
In severe cases, larger purpuric lesions may occur, including extensive ecchymoses and necrotic ulcera tion, particularly in dependent areas and under pressure sites, and are associated with a high mortality [5,6]. Differential diagnosis the significance of this condition lies in the fact that it must be differentiated from other types of leukoplakia as, although the affected areas may undergo malignant change [14,15], it may eventually clear with prolonged antiCandida therapy. There is an important role for variations in Tolllike receptor signalling in determining levels of colonization particu larly for potential pathogens such as Staph. Colony: the short surface mycelium is white to pale buff with regular, deep, radial grooves. Presentation the effects on the baby range in severity and may be due to disseminated disease, affecting multiple organs but predominantly central nervous system, or limited to the skin, eyes and Varicellazoster virus infections 25. Electron microscopy of keratinocytes of the lesion will show the characteristic brickshaped enveloped poxvirus [150]. The micropapular varieties of syphilis can be confused with keratosis pilaris, lichen scrofulosorum, trichophytide and lichen planopilaris. The frequency of mild subclinical nocardiosis is unknown, but since the organism is known to cause fatal infections in humans, the demonstration of N. New proposals include testing a common 6month regimen of dapsone, clofazimine and rifampicin for all patients [119]. Whatever method is used, the ability to find fungi on direct examination of samples is largely a matter of practice. Scrub typhus [1,10] Definition the infective agent of scrub typhus, Orientia tsutsugamushi (previously Rickettsia tsutsugamushi), is conveyed to humans from its natural rodent reservoir by the bites of the mites, Trombicula akamushi and T. Eruptive pseudoangiomatosislike lesions have also been reported as a response to arthropod bites [27,28]. Calcipotriol (50 g/g) ointment has also been shown to be effective and safe in children when administered in amounts up to 45 g/week/m2 [14]. Ribavirin has no effect on filoviruses, so the only treatment available is supportive. In addition, botryomycosis has been recorded in a patient with follicular mucinosis [7]. This is obviously very important to some patients, but others are content to accept a poorer cosmetic outcome in exchange for fewer hospital visits (Table 24. Perinatal and neonatal infections arise as a result of exposure to infectious cervical secretions in the birth canal or from infected breast milk. Periorbital cellulitis is similar to that in other sites; however, orbital cellulitis, usually secondary to sinusitis, involves the major sinus pathogens such as Streptococcus pneumoniae, other streptococci, S. The conspicuous macular eruption on the fourth day is the result of the cellmediated immunity response against this material. The macular hyperpigmentation involves chiefly the face, neck and upper limbs, although it can be more widespread, and varies from slate grey to brownish black. Unfortunately, the problems with thalidomide mean that it is unavailable in several leprosy endemic countries despite its undoubted value. In one case report an individual who presented with an isolated skin ulcer subsequently developed acute respiratory distress syndrome secondary to pulmonary involvement [3]. Associated diseases A significant prevalence of autoimmune thyroid disease and the presence of thyroid antibodies have been found in association with palmoplantar pustulosis [1]. The fluoroqui nolones pefloxacin and ofloxacin have a remarkable degree of bac tericidal activity, with 22 daily doses killing 99. Previously, these beams have usually not been suitable for the treatment of skin cancers because of their greater penetration and skin sparing properties, but that has changed in the last few years, with advances in beam delivery technology, although megavoltage beams are still only used for a small minority of skin cancer patients and in particular clinical situations. When commercial grade venom became available, several potent allergenic proteins were identified [9,24]. There has been a recent resurgence of interest in the use of maggots (usually those of the greenbottle, Lucilia sericata) for wound debridement, an added bonus of which is their ingestion of meticillinresistant Staphylococcus aureus [22]. Moderate or severe epithelial dysplasia on oral biopsy should probably be regarded as an increased risk for subsequent cancer development [19]. It seemed likely that staphylococci, perhaps introduced by hand or from perineal skin, found appropriate conditions for growth in the medium of the menstrual blood, facilitated in some way by the tampon.
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