WordNet

a thin coagulable fluid (similar to plasma but) containing white blood cells (lymphocytes) and chyle; is conveyed to the blood stream by lymphatic vessels
of or relating to or produced by lymph

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リンパ[液]
リンパ[液]の / (人が)不活発な,鈍重な

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2017/07/29 22:47:07」(JST)

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Lymph is the fluid that circulates throughout the lymphatic system. The lymph is formed when the interstitial fluid (the fluid which lies in the interstices of all body tissues)^[1] is collected through lymph capillaries. It is then transported through larger lymphatic vessels to lymph nodes, where it is cleaned by lymphocytes, before emptying ultimately into the right or the left subclavian vein, where it mixes back with the blood.

Since the lymph is derived from the interstitial fluid, its composition continually changes as the blood and the surrounding cells continually exchange substances with the interstitial fluid. It is generally similar to blood plasma, which is the fluid extracellular matrix (ECM) of whole blood. Lymph returns proteins and excess interstitial fluid to the bloodstream. Lymph may pick up bacteria and bring them to lymph nodes, where they are destroyed. Metastatic cancer cells can also be transported via lymph. Lymph also transports fats from the digestive system (beginning in the lacteals) to the blood via chylomicrons.

The word lymph is derived from the name of the ancient Roman deity of fresh water, Lympha.

Composition

Human lymph, obtained after a thoracic duct injury

Lymph has a composition comparable to that of blood plasma, but it may differ slightly. Lymph contains white blood cells. In particular, the lymph that leaves a lymph node is richer in lymphocytes. Likewise, the lymph formed in the human digestive system called chyle is rich in triglycerides (fat), and looks milky white because of its lipid content.

Formation

Formation of interstitial fluid from blood

Blood supplies nutrients and important metabolites to the cells of a tissue and collects back the waste products they produce, which requires exchange of respective constituents between the blood and tissue cells. This exchange is not direct, but instead is effected through an intermediary called interstitial fluid or tissue fluid, the fluid that occupies the spaces between the cells and constitutes their immediate environment. As the blood and the surrounding cells continually add and remove substances from the interstitial fluid, its composition continually changes. Water and solutes can pass between the interstitial fluid and blood via diffusion across gaps in capillary walls called intercellular clefts; thus, the blood and interstitial fluid are in dynamic equilibrium with each other.^[2]

Interstitial fluid forms at the arterial (coming from the heart) end of capillaries because of the higher pressure of blood compared to veins, and most of it returns to its venous ends and venules; the rest (up to 10%) enters the lymph capillaries as lymph.^[3] Thus, lymph when formed is a watery clear liquid with the same composition as the interstitial fluid. However, as it flows through the lymph nodes it comes in contact with blood, and tends to accumulate more cells (particularly, lymphocytes) and proteins.^[4]

Lymphatic circulation

Tubular vessels transport lymph back to the blood, ultimately replacing the volume lost during the formation of the interstitial fluid. These channels are the lymphatic channels, or simply lymphatics.^[5]

Unlike the cardiovascular system, the lymphatic system is not closed and has no central pump, or lymph hearts (which are found in some animals). Lymph transport, therefore, is slow and sporadic. Despite low pressure, lymph movement occurs due to peristalsis (propulsion of the lymph due to alternate contraction and relaxation of smooth muscle tissue), valves, and compression during contraction of adjacent skeletal muscle and arterial pulsation.^[6]

Lymph that enters the lymph vessels from the interstitial spaces usually does not flow backwards along the vessels because of the presence of valves. If excessive hydrostatic pressure develops within the lymph vessels, though, some fluid can leak back into the interstitial spaces and contribute to formation of oedema.

Flow of the lymph in the thoracic duct in an average resting person usually approximates 100ml per hour. Accompanied by another ~25ml per hour in other lymph vessels, total lymph flow in the body is about 4 to 5 liters per day. This can be elevated several folds while exercising. Thus it can be estimated that without lymphatic flow, an average resting person would die within 24 hours. ^[7]

As a growth medium

In 1907 the zoologist Ross Granville Harrison demonstrated the growth of frog nerve cell processes in a medium of clotted lymph. It is made up of lymph nodes and vessels.

In 1913, E. Steinhardt, C. Israeli, and R. A. Lambert grew vaccinia virus in fragments of tissue culture from guinea pig corneal grown in lymph.^[8]

Notes and references

^ Fluid Physiology: 2.1 Fluid Compartments
^ "The Lymphatic System". Human Anatomy (Gray's Anatomy). Retrieved 2012-10-12.
^ Warwick, Roger; Peter L. Williams (1973) [1858]. "Angiology (Chapter 6)". Gray's anatomy. illustrated by Richard E. M. Moore (Thirty-fifth ed.). London: Longman. pp. 588–785. |access-date= requires |url= (help)
^ Sloop, Charles H.; Ladislav Dory; Paul S. Roheim (March 1987). "Interstitial fluid lipoproteins" (PDF). Journal of Lipid Research. 28 (3): 225–237. PMID 3553402. Retrieved 2008-07-07.
^ "Definition of lymphatics". Webster's New World Medical Dictionary. MedicineNet.com. Retrieved 2008-07-06.
^ Shayan, Ramin; Achen, Marc G.; Stacker, Steven A. (2006). "Lymphatic vessels in cancer metastasis: bridging the gaps". Carcinogenesis. 27 (9): 1729–38. PMID 16597644. doi:10.1093/carcin/bgl031.
^ Guyton and Hall Textbook of Medical Physiology. Saunders. 2010. pp. 186, 187. ISBN 978-1416045748.
^ Steinhardt, E; Israeli, C; and Lambert, R.A. (1913) "Studies on the cultivation of the virus of vaccinia" J. Inf Dis. 13, 294–300

UpToDate Contents

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English Journal

Cavitating mesenteric lymph node syndrome: a rare complication of celiac disease.

Rodríguez-Sánchez J, Martín-Dávila F, López-Viedma B, Galván-Fernández MD, Alonso-Lablanca M, Olmedo-Camacho J, García-Rojo M, Rodríguez-Sánchez E.SourceDepartments of Digestive Disease, University General Hospital, Ciudad Real, Spain. joaquinrodriguez@gmail.com
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Significance of the TGF-β1/IL-6 axis in oral cancer.

Chen MF, Wang WH, Lin PY, Lee KD, Chen WC.Source§Department of Pathology, Chang Gung Memorial Hospital, Chiayi, Taiwan.
Clinical science (London, England : 1979).Clin Sci (Lond).2012 May 1;122(10):459-72.
The aim of the present study was to explore specific molecular markers that could lead to new insights into the identification of innovative treatments in oral cancer. The role of TGF-β1 (transforming growth factor-β1) and its predictive power in the prognosis of oral cancer has been identified. H
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Is adjuvant radiotherapy needed after curative resection of extrahepatic biliary tract cancers? A systematic review with a meta-analysis of observational studies.

Bonet Beltrán M, Allal AS, Gich I, Solé JM, Carrió I.SourceRadiation Oncology, Consorci Sanitari de Terrassa, Institut Oncològic del Vallès (CST-HGC-CSPT), Barcelona, Spain; Department of Medicine, Autonomous University of Barcelona, Spain.
Cancer treatment reviews.Cancer Treat Rev.2012 Apr;38(2):111-9. Epub 2011 Jun 8.
BACKGROUND: The role for adjuvant radiotherapy (ART) after curative resection in extrahepatic cholangiocarcinoma remains unclear. Due to the lack of randomized trials, available data comes from single center experiences or data-based population studies with inconclusive results.OBJECTIVE: To assess
PMID 21652148

Japanese Journal

Characterization of the IL-15 niche in primary and secondary lymphoid organs in vivo.

Cui Guangwei,Hara Takahiro,Simmons Szandor,Wagatsuma Keisuke,Abe Akifumi,Miyachi Hitoshi,Kitano Satsuki,Ishii Masaru,Tani-Ichi Shizue,Ikuta Koichi
Proceedings of the National Academy of Sciences of the United States of America, 2014-01-21
… In lymph nodes, IL-15-expressing cells were mainly distributed in the T-cell zone and medulla. … Blood endothelial cells, including all high endothelial venules, also expressed high IL-15 levels in lymph nodes, whereas lymphatic endothelial cells (LECs) lacked IL-15 expression. …
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金沢大学つるま保健学会誌 37(2), 13-21, 2014-01-09
NAID 120005373529

Prognostic factors for survival after first recurrence in breast cancer: a retrospective analysis of 252 recurrent cases at a single institution.

Tsuji Wakako,Teramukai Satoshi,Ueno Masaya,Toi Masakazu,Inamoto Takashi
Breast cancer 21(1), 86-95, 2014-01-01
… Age, clinical stage, pathological stage, axillary lymph node involvement, ER status at the time of diagnosis, progesterone receptor status, human epidermal growth factor receptor 2 status, operative method, adjuvant chemotherapy, adjuvant endocrine therapy, use of trastuzumab after recurrence, site of recurrence, DFI, and time of recurrence were examined for possible influences on survival after the first recurrence. …
NAID 120005372984

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★リンクテーブル★

リンク元	「100Cases 33」「lymphatic」「リンパ」「リンパ液」
拡張検索	「primary central nervous system lymphoma」「splenic marginal zone B-cell lymphoma」

「100Cases 33」

Lymph
	Diagram showing the formation of lymph from interstitial fluid (labeled here as "Tissue fluid"). Note how the tissue fluid is entering the blind ends of lymph capillaries (shown as deep green arrows)
Details
Identifiers
Latin	Lympha
TA	A12.0.00.043
FMA	9671
	Anatomical terminology [edit on Wikidata]

　　[★]

☆case33　頭痛と混乱

■glossary

accompany

vt.

(人)と同行する、(人)に随行する。(もの)に付随する。～と同時に起こる。～に加える(添える、同封する)(with)

slurred n. 不明瞭

強直間代痙攣 tonic-clonic convulsion

　意識消失とともに全身の随意筋に強直痙攣が生じ(強直痙攣期tonic convulsion)、次いで全身の筋の強直と弛緩とが律動的に繰り返される時期(間代痙攣期clonic convulsion)を経て、発作後もうろう状態を呈する一連の発作。

■症例

28歳、女性　黒人　南アフリカ　手術室看護師　ロンドン住在

主訴：頭痛と混乱

現病歴：過去3週間で頭痛が続いており、ひどくなってきた。現在も頭痛が持続しており、頭全体が痛い。友人曰く「過去六ヶ月で体重が10kg減っていて、最近、混乱してきたようだ」。発話は不明瞭。救急室にいる間に強直間代痙攣を起こした。

・診察 examination

やせている。55kg。38.5℃。口腔カンジダ症(oral candidiasis)。リンパ節腫脹無し。心血管、呼吸器系、消化器系正常。痙攣前における神経検査では時間、場所、人の見当識無し。神経局所症状無し(no focal neurological sign)。眼底両側に乳頭浮腫有り。

・検査 investigation

血算：白血球増多

血液生化学：ナトリウム低下

CT：供覧

■キーワード＆着目するポイント

・口腔カンジダ症(oral candidiasis)

・頭痛、精神症状、強直間代痙攣

・眼底両側に乳頭浮腫

・CT 所見

・低ナトリウム血症は二次的なもの

■アプローチ

・口腔カンジダ症(oral candidiasis)　→　細胞免疫低下状態(DM、免疫抑制、AIDSなど) or 常在細菌叢の攪乱(長期の抗菌薬の使用)

　・The occurrence of thrush in a young, otherwise healthy-appearing person should prompt an investigation for underlying HIV infection.(HIM.1254)

　・More commonly, thrush is seen as a nonspecific manifestation of severe debilitating illness.(HIM.1254)

・精神症状、強直間代痙攣　→　一次的、あるいは二次的な脳の疾患がありそう

・頭痛　→　漠然としていて絞れないが、他の症状からして機能性頭痛ではなく症候性頭痛っぽい。

・眼底両側に乳頭浮腫　→　脳圧亢進の徴候　→　原因は・・・脳腫瘍、ことにテント下腫瘍と側頭葉の腫瘍、クモ膜下出血、脳水腫など、そのほか、眼窩内病変、低眼圧などの局所的要因、悪性高血圧、血液疾患、大量出血、肺気腫などの全身的要因 (vindicate本のp342も参考になる)

　・頭痛と脳圧亢進　→　頭蓋内圧占拠性病変、脳炎(IMD.274)

・CT 所見　→　ringformの病変、脳浮腫、脳圧亢進

・低ナトリウム血症　→　脳ヘルニアに続発して起こることがあるらしい。実際には下垂体にトキソプラズマによる病変が形成されることにより起こりうる。

・そのほか出身地、体重減少もHIVを疑わせる点

パターン認識でHIV + 精神症状 + てんかん発作(強直間代痙攣) + 脳圧亢進 + CT 所見 = 一番ありそうなのはToxoplasma gondiiによるトキソプラズマ脳症 cerebral toxoplasosis (トキソプラズマ脳炎 toxoplasmic encephalitis)

■Toxoplasma gondii

　原虫　胞子原虫類

(感染予防学 080521のプリント、CASES p,92、HIM p.1305-)

・疫学：西洋では30-80%の成人がトキソプラズマの感染の既往がある・・・うぇ(CASES)。日本では10%前後(Wikipedia)。

・生活環

　・終宿主：ネコ：ネコの小腸上皮細胞で有性・無性生殖　糞便にオーシストの排泄

　・中間宿主：ヒト.ブタを含むほ乳類と鳥類：無性生殖で増殖、シストの形成

　　　急性期の増殖盛んな急増虫体 tachyzoiteとシスト内の緩増虫体 bradyzoite

・病原、病因 phathogenesis

　・緩増虫体(bradyzoite)、接合子嚢(oocyst)

・感染経路

　1. オーシストの経口摂取

　2. 中間宿主の生肉中のシストの経口摂取

　3. 初感染妊婦からの経胎盤感染。既感染なら胎盤感染しないらしい(HIM.1306)

　(4)移植臓器、輸血。確率は低い(at low rate)(HIM.1306)

・病態

　1. 先天性トキソプラズマ症　congenital toxoplasmosis

　　　①網脈絡膜炎、 ②水頭症、 ③脳内石灰化、 ④精神・運動障害

　2. 後天性トキソプラズマ症　acquired toxoplasmosis

　　(1) 健常者

　　　・多くは不顕性感染。発熱、リンパ節腫脹、皮疹(rash)

　　　・(少数例)筋肉痛、暈疼痛、腹痛、斑状丘疹状皮疹(maculopapular rash)、脳脊髄炎、混乱(HIM.1308)

　　　・(まれ)肺炎、心筋炎、脳症、心膜炎、多発筋炎

　　　・網膜、脈絡叢に瘢痕や、脳に小さい炎症性の病変を残すことあり(CASES)。

　　　・急性感染の症状は数週間で消失　筋肉や中枢神経系に緩増虫体が残存

　　(2)HIV 感染者、臓器移植例、がん化学療法例

　　　シスト内緩増虫体→急増虫体→播種性の多臓器感染

　　　AIDSでは、トキソプラズマ性脳炎が指標疾患 AIDS-defineing illness(CASES)

・治療

　(日本)アセチルスピラマイシン、ファンシダール(感染予防学 080521)

■トキソプラズマ脳炎 toxoplasmic encephalitis、トキソプラズマ脳症 cerebral toxoplasosis

・症状

　発熱、頭痛、混乱ｍ、痙攣、認知の障害、局所神経徴候(不全片麻痺、歯垢、脳神経損傷、視野欠損、感覚喪失)(CASES)

・画像検査

　(CT,MRI)多発性、両側性、ring-enhancing lesion、特に灰白質-白質境界、大脳基底核、脳幹、小脳が冒されやすい(CASES)

・鑑別診断(臨床症状・画像診断の所見で)

　リンパ腫、結核、転移性脳腫瘍(CASES)

・病歴と画像所見からの鑑別診断

　リンパ腫、結核、転移性腫瘍

？

このCTがcerebral toxoplasmosisに特徴的かは不明

□最後に残る疑問

　AIDSでWBC(leukocyte)の数はどうなるんだろう？？？AIDSの初診患者ではWBCが低い人が多いらしいし()、HIVはCD4+ T cellとmacrophageに感染して殺すから、これによってB cellは減るだろうし、CD8+ T cellも若干減少するだろうからWBCは減るんじゃないか？！好中球はAIDSとは関係ない？好中球は他の感染症に反応性に増加している？ちなみに、好酸球は寄生虫(原虫)の感染のために増える傾向にあるらしい(HIMのどこか)。

葉酸拮抗剤である。

サルファ剤と併用され、抗トキソプラズマ薬、抗ニューモシチス・カリニ薬として相乗的に働く。

ST 合剤

SMX-TMP

スルファメトキサゾール・トリメトプリム合剤 sulfamethoxazole and trimethoprim mixture

□AIDSの定義(http://en.wikipedia.org/wiki/CDC_Classification_System_for_HIV_Infection_in_Adults_and_Adolescents)