Glossary

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A

AAN

American Academy of Neurology.

Adverse event (AE)

any untoward medical occurrences that may present during treatment with a pharmaceutical product but which do not necessarily have a causal relationship with the treatment. Also referred to as adverse side events or side effects (SEs).

AE

adverse event.

ALS

amyotropic lateral sclerosis (also called Lou Gerhig’s disease).

American Academy of Neurology (AAN)

professional association of neurologists based in the United States.

Alopecia

absence or loss of hair.

Amplitude

largeness; extent; breadth or range.

Amyotropic lateral sclerosis (ALS)

a fatal degenerative disease involving the corticobulbar, corticospinal and spinal motor neurons, manifested by progressive weakness and wasting of muscles innervated by the affected neurons.

Anaphylaxis

an induced systemic or generalized sensitivity; at times, the term is used for anaphylactic shock. The condition may be fatal if asphyxiation or cardiovascular collapse occurs. SYN: anaphylactic reaction.

Anemia

a condition in which the number of red blood cells are less than normal.

Angiotensin

a family of peptides with vasoconstrictive activity.

Anorexia

diminished appetite; an aversion to food.

Antibody

immunoglobulin molecule produced by B-lymphoid cells that combine specifically with animmunogen or antigen.

Antigen

any substance that, as a result of coming in contact with appropriate cells, induces a state of sensitivity or immune responsiveness and that reacts in a demonstrable way with antibodies or immune cells of the sensitized subject in vivo or in vitro.

Antinuclear

having an affinity for or reacting with the cell nucleus.

Areflexia

an absence of reflexes.

Aseptic meningitis

the name given to a mild form of meningitis, most cases of which are caused by viruses.

Asthenia

weakness or disability.

Asymmetric

lack of symmetry; disproportion between two parts which are normally alike.

Ataxia

Failure of muscular coordination; irregularity of muscular action.

Atypical

not typical; irregular; not conformable to the type; in microbiology, applied specifically to strains of an unusual type.

Autoantibody

an antibody directed against a self antigen, i.e., against a normal tissue constituent. An antibody (immunoglobulin) formed in response to, and reacting against, one of the individual’s own normal antigenic endogenous body constituents.

Autoimmune

describes cells and antibodies arising from and directed against the individual’s own tissues, as in autoimmune disease.

Axon

the single process of a nerve cell that under normal circumstances conducts nervous impulses away from a cell body and its remaining processes (dendrites).

Axonal

pertaining to an axon; most often used to describe the type of underlying nerve pathology responsible for generalized polyneuropathies.

Axonal degeneration

deterioration or loss of function of the axonal process.

Azathioprine

an immunosuppressant agent.

Azoospermia

Absence of living spermatozoa in the semen; failure of spermatogenesis.

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B

BBB

blood brain barrier.

B cells

one of a population of functionally diverse cells that contain basophilic granules and secrete hormones.

Biopsy

the process of removing tissue from patients for diagnostic examination.

Blood brain barrier (BBB)

a selective mechanism opposing the passage of most ions and high molecular weight compounds from the blood to brain tissue located in a continuous layer of endothelial cells connected by tight junctions.

Borrelia burgdorferi

the responsible bacterial species causing Lyme disease in humans. Lyme disease is a subacute inflammatory disorder transmitted by deer ticks or western black-legged ticks.

Brachial plexus

a major nerve plexus formed of the ventral primary rami of the fifth cervical to first thoracic spinal nerves for innervation of the upper limbs.

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C

C reactive protein (CRP)

a beta-globulin found in the serum of various people with certain inflammatory, degenerative, and neoplastic diseases.

Campylobacter jejuni

a thermophilic bacterial species that causes an acute gastroenteritis of sudden onset with constitutional symptoms (malaise, myalgias, arthralgia, and headache) and cramping abdominal pain in humans; it has been associated with a demyelinating sequelae, which can present with ascending paralysis.

Carcinogenic

causing cancer.

Cardiac arrhythmia

loss or abnormality of the rhythm of the heart; denoting an irregularity of the heartbeat.

Castleman’s disease

a benign giant lymph node hyperplasia.

Cauda equina

the bundle of spinal nerve roots arising from the lumbosacral enlargement and medullary cone and running through the lumbar cistern (subarachnoid space) within the vertebral canal below the first lumbar vertebra; it comprises the roots of all the spinal nerves below the first lumbar vertebra.

CBC

complete blood count.

Cellular

pertaining to cells.

Central nervous system (CNS)

the brain and the spinal cord.

Cerebrospinal fluid (CSF)

a fluid largely secreted by the choroids plexuses of the ventricles of the brain, filling the ventricles and the subarachnoid cavities of the brain and spinal cord.

Cervical

pertaining to the neck.

Charcot-Marie-Tooth disease type 1 (CMT1)

peroneal muscular atrophy.

Chemokines

several groups composed of usually 8-10 kD polypeptide cytokines that are chemokinetic and chemotactic, stimulating leukocyte movement and attraction.

Chronic inflammatory demyelinating polyneuropathy (CID)

an uncommon, acquired, demyelinating sensorimotor polyneuropathy clinically characterized by insidious onset, slow evolution (either steady progression or stepwise), and chronic course.

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP)

 another name for chronic inflammatory demyelinating polyneuropathy.

CIDP

chronic inflammatory demyelinating polyneuropathy or chronic inflammatory demyelinating polyradiculoneuropathy.

Citrate-induced hypocalcemia

an abnormally low level of calcium in the circulating blood caused by citric acid.

Clonal

pertaining to a clone, a colony or group of organisms (or an individual organism), or a colony of cells derived from a single organism or cell by asexual reproduction, all having identical genetic constitutions.

CMAP

compound muscle action potential.

CMT1

Charcot-Marie-Tooth disease type 1.

CNS

central nervous system.

Collagen vascular disease

a group of generalized diseases affecting connective tissue and frequently characterized by fibrinoid necrosis or vasculitis; in some diseases, autoimmunization, particularly antinuclear antibodies, have been shown and circulating immune complexes are found.

Complement

Ehrlich’s term for the thermolabile substance, normally present in serum, that is destructive to certain bacteria and other cells sensitized by a specific complement-fixing antibody.

Complete blood count (CBC)

a combination of the following determinations; red blood cell count, white blood cell count, erythrocyte indices, hematocrit, differential blood count, and sometimes platelet count.

Compound muscle action potential (CMAP)

capable of doing or being, although not yet in the course of doing or being.

Concomitant

to accompany. Commonly used to signify two (or more) diseases or disorders present in a patient at the same time.

Conduction block

blocking (or stopping) the action of conduction, which is transmitting or conveying certain forms of energy, such as heat, sound, or electricity from one point to another without evident movement in the conducting body.

Conduction velocity

The speed with which conduction occurs.

Corticosteroids

a steroid produced by the adrenal cortex (i.e., adrenal corticoid); a corticoid containing a steroid.

Co-stimulatory

the natural ligand for the T-cell antigen CD28; mediating T- and B-cell adhesion. CD80 is expressed on activated B-cells and gamma-interferon-stimulated monocytes. The binding of CD80 to CD28 and CTLA-4 provides a co-stimulatory signal to T-cells and leads to greatly upregulated lymphokine production.

Criteria

standards or rules for judging; plural of criterion.

Cryoglobulins

a serum globulin (invariably an immunoglobulin) that precipitates at low temperature (e.g., 4° C) and redissolves at 37° C. Classified as Type I, Type II or Type III.

CSF

cerebrospinal fluid.

Cushingoid features

resembling the features associated with Cushing’s syndrome, such as rapidly developing adiposity of face, neck and trunk, kyphosis caused by osteoporosis of the spine, hypertension, diabetes, amenorrhea, hypertrichosis (in females), impotency (in males), dusty complexion with purple markings (striae), polycythemia, pain in the abdomen and back, and muscular wasting and weakness.

Cyclophosphamide

an immunosuppressant agent.

Cyclosporin

an immunosuppressant agent.

Cytokinesis

changes occurring in the cytoplasm of the cell outside the nucleus during cell division.

Cytotoxic

detrimental or destructive to cells.

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D

DADS

distal acquired demyelinating symmetrical (neuropathy).

Deep tendon reflex (DTR)

SYN myotatic reflex. Tonic contraction of the muscles in response to a stretching force, due to stimulation of muscle proprioceptors.

Degeneration

deterioration; a worsening of physical qualities; a retrogressive pathological change in cells or tissues in consequence of which their functions are often impaired or destroyed.

Diabetes mellitus

a chronic metabolic disorder is which the use of carbohydrate is impaired and that of lipid and protein is enhanced. Caused by an absolute or relative deficiency of insulin.

Diagnosis

the determination of the nature of a disease, injury, or congenital defect.

Diphenhydramine

SYN diphenhydramine hydrochloride. An H2 antihistaminic with anticholinergics and sedative properties.

Diphtheria

a specific infectious disease due to the bacterium Corynebacterium diphtheriae and its highly potent toxin.

Distal

situated away from the center of the body, or from the point of origin; specifically applied to the extremity or distant part of a limb or organ.

Distal acquired myelinating sensory neuropathy (DAMS)

a sensory neuropathy.

Distal latency

a period of apparent inactivity between the time the stimulus is presented and the moment a response occurs.

DTRs

deep tendon reflexes.

Dysproteinemias

an abnormality in plasma proteins, usually in immunoglobulins.

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E

Edema

an accumulation of an excessive amount of watery fluid in cells or intercellular tissues.

EFNS

European Federation of Neurological Societies.

Electrodiagnostic

the use of electrical devices in the diagnosis of pathological conditions.

Electrolyte imbalance

a lack of balance between electrolytes.

Electrophysiology

the branch of science concerned with electrical phenomena that are associated with physiologic processes. Electrical phenomena are prominent in neurons and effectors.

Endoneurial

pertaining to the innermost connective tissue supportive structure of nerve trunks, surrounding individual myelinated and unmyelinated nerve fibers.

Epitope

the simplest form of an antigenic determination on a complex antigen molecule, which can combine with antibody or T cell receptor.

Etanercept

an immunosuppressant agent

European Federation of Neurological Societies (EFNS)

A professional organization, based in Europe, composed of various neurological societies. Joined with the Peripheral Nervous Society to issue diagnostic guidelines in 2005.

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F

Fc receptors

receptors present on a variety of cells for the Fc fragment of immunoglobulins. These receptors recognize immunoglobulins of the IgG and IgE classes.

F-wave latency

a period of apparent inactivity between the time the stimulus is presented and the moment a response occurs.

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G

Gadonlinium

the paramagnetic properties of this element are used in contrast media for MRI studies.

Ganglioside

a glycosphingolipid chemical similar to cerebrosides but containing one or more sialic acid residues; found primarily in nerve tissue, spleen, and thymus.

GBS

Guillain-Barre syndrome.

Glaucoma

a disease of the eye characterized by increased intraocular pressure, excavation, and atrophy of the optic nerve; produces defects in the field of vision and eventually blindness.

Glucocorticoid

any steroidlike compound capable of significantly influencing intermediary metabolism such as promotion of hepatic glycogen deposition, and of exerting a clinically useful anti-inflammatory effect.

Glycolipids

lipids that contains D-glucose.

Glycoprotein

one of a group of proteins containing covalently linked carbohydrates, among which the most important are the mucins, mucoid, and amyloid.

 

Guidelines

clinical practice guidelines. A formal statement about a definite task of function in clinical practice, such as a desirable diagnostic tests or the optimal treatment regimen for a specific diagnosis; generally based on the best available evidence , e.g., randomized controlled trials that have been assessed by a Cochrane collaborating group.

Guillain-Barre syndrome (GBS)

an acute, immune-mediated disorder of the peripheral nerves, spinal roots, and cranial nerves, commonly presenting as a rapidly progressive areflexive relatively symmetric ascending weakness of the limb, truncal, respiratory, pharyngeal, and facial musculature, with variable sensory and autonomic dysfunction. 

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H

Hemodynamic

relating to the physical aspects of the blood circulation.

Hepatitis

inflammation of the liver, due to viral infections but sometimes to toxic agents.

Hepatoxicity

the capacity of a drug, chemical or other exposure to produce injury to the liver.

Histocompatability

a state of immunologic similarity of tissues that permits successful homograft transplantation.

HIV infection

human immunodeficiency virus infection, a human T-cell lymphotropic virus type III. HIV-1 infects only humans and chimpanzees and is more virulent than HIV-2, which is more closely related to Simian or monkey viruses, found in West Africa, and not as widespread as HIV-1.

Humoral

relating to a humor in any sense. A humor is any clear liquid or semi-fluid hyaline anatomic substance.

Hypertropic

relating to hypertrophy, a general increase in bulk of a part or organ, not due to tumor formation.

Hyporeflexia

a condition is which reflexes are weakened. Reduction in deep tendon reflexes may be generalized, regional, or focal.

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I

Ichthyosis

congenital disorder of keratinization characterized by noninflammatory dryness and scaling of the skin.

Idiopathic

denoting a disease of unknown cause or origin.

Idiotype

a collection of idiotopes within the variable region than confers on an immunoglobulin molecule an antigenic specificity and is frequently a unique attribute of a given antibody in a given animal. It is the product of a limited number of B lymphocyte clones; also found on the T-cell receptor.

IGIV

intravenous immunoglobulin. Also IVIG and IVIG.

Immunofixation

the condition of being firmly attached or set.

Immunoglobulin

one of a class of structurally related proteins.

Immunoinflammatory

inflammation within the immune system.

Immunomodulatory

capable of modifying or regulating one or more immune functions.

Immunopathology

the study of diseases or conditions resulting from immune reactions.

Immunosuppressant

a pharmacological agent that induces immunosuppression (cyclosporine, corticosteroids). Immunosuppressants prevent or interface with the development of immunologic response.

INCAT

Inflammatory Neuropathy Cause and Treatment group, a collaborating force of International neurologists.

Inflammatory Neuropathy Cause and Treatment

full name of INCAT which offers diagnostic criteria and scales for assessment.

Infusion

the introduction of fluid other than blood, e.g. saline solution, into a vein.

Interferon

a class of small protein and glycoprotein cytokines produced by T cells, fibroblasts, and other cells in response to viral infection and other biologic and synthetic stimuli.

Interferon-alpha

an immunosuppressant agent.

Interferon-beta 1a

an immunosuppressant agent.

Interlukine

a cytokine, derived primarily from mononuclear phagocytes, which enhances the proliferation of T-helper cells and the growth and differentiation of B cells.

IVIG

intravenous immunoglobulin. Also used are IVIG or IGIV.

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J

Joint Task Force

shortened term used on this Web site for references from the Joint Task Force of the European Federation of Neurological Societies (EFNS) and the Peripheral Nerve Society (PNS) which issued joint diagnostic and treatment criteria for CIDP.

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L

Leukocyte

a type of cell formed in the myelopoietic, lymphoid, and reticular portions of the reticuloendothelial system in various parts of the body.

Leukocytosis

an abnormally large number of leukocytes, as observed in acute infections, inflammation, hemorrhage, or other conditions.

Leukopenia

the antithesis of leukocytosis; any situation in which the total number of leukocytes in the circulating blood is less than normal.

Lewis-Sumner Syndrome

also known as MADSAM (multifocal, asymmetric demyelinating sensory and motor) neuropathy.

Lipopolysaccharide (LPS)

a compound or complex of lipid and carbohydrate.

LLN

lower limit of normal.

Lumbosacral

relating to the lumbar vertebrae and the sacrum.

Lyme disease

a subacute inflammatory disorder transmitted by deer or western black-legged ticks.

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M

Macrophage

any mononuclear, actively phagocytic cell arising from monocytic stem cells in bone marrow; these cells are widely distributed throughout the body and vary in morphology and motility.

MADSAM

multifocal acquired sensory and motor neuropathy; also called Lewis-Sumner Syndrome.

Magnetic resonance imaging (MRI)

a diagnostic radiologic modality using nuclear magnetic resonance technology.

Median nerve

formed by the union of medial and lateral roots from the medial and lateral cords of the brachial plexus. It supplies most the muscles in the anterior compartment of the forearm. The median nerve is most commonly injured through compression in carpal tunnel syndrome, resulting in a loss of ability to oppose the thumb and loss of sensation over the radial portion of the hand.

Meta-analysis

the process of using statistical methods to combine the results of different studies.

Metabolic

relating to metabolism.

Metalloproteinases

a family of protein-hydrolizing endopeptidases that contain zinc ions as part of the active structure.

Methotrexate

an immunosuppressant agent.

Methylprednisolone

a prednisone agent.

MGUS

monoclonal gammopathy of unknown significance.

Migraine

a familial recurrent syndrome characterized usually by unilateral head pain, accompanied by various focal disturbances of the nervous system.

MMN

multifocal motor neuropathy.

Monoclonal gammopathy

one of a group of disorders due to a proliferation of a single clone of lymphoid or plasma cells and characterized by the presence of monoclonal immunoglobulin in serum or urine.

Monophasic

occurring in or marked by only one phase or stage.

MRC

Medical Research Council.

MRI

magnetic resonance imaging.

MS

multiple sclerosis.

Multifocal

relating to or arising from many foci.

Multiple sclerosis (MS)

a common demyelinating disorder of the central nervous system, causing patches of sclerosis (plaques) in the brain and spinal cord.

Myalgia

muscle pain.

Mycobacterium leprae

a bacterial species that causes Hansen disease (leprosy).

Mycophenolate mofetil

an immunosuppressant agent.

Myelin sheath

the lipoproteinaceous envelope surrounding most axons.

Myelinated

having a myelin sheath.

Myosin

a globular protein present in muscle and nonmuscle cells that has an ATPase activity.

Neoplasia

the pathological process that results in the formation and growth of a neoplasm.

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N

Nerve biopsy

used as a diagnostic evaluation for CIDP; used to document inflammation, demyelination, vasculitis, and hereditary disorders.

Neutropenia

the presence of abnormally small numbers of neutrophils in the circulating blood.

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O

ODSS

overall disability sum score, an impairment assessment.

Oligoclonal

a deficiency in a clone.

Onion-bulb formations

abnormal formations that resemble and are shaped similar to an onion bulb.

Optic neuritis

inflammation of the optic nerve; affecting either the part of the nerve within the eyeball or the nerve portion behind the eyeball.

Opthalmoplegia

paralysis of one or more of the optical muscles.

Osteopenia

decreased calcification or density of bone.

Osteoporosis

reduction in the quantity of bone or atrophy of skeletal tissue; an age-related disorder characterized by decreased bone mass and loss of normal skeletal microarchitecture, leading to increased susceptibility to fractures.

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P

Pancytopenia

pronounced reduction in the number of erythrocytes, all types of leukocytes, and the blood platelets in the circulating blood.

Paraprotein

a monoclonal immunoglobulin of blood plasma, observed electrophoretically as an intense band of γ, β, or α regions, due to an isolated increase in a single immunoglobulin type as a result of a clone of plasma cells arising from the abnormal rapid multiplication of a single cell. The finding of a paraprotein in a person’s serum indicates the presence of a proliferating clone of immunoglobulin-producing cells and may be seen in a variety of malignant, benign, or nonneoplastic diseases.

Pathogenesis

the pathological, physiological, or biochemical mechanism resulting in the development a disease or morbid process. 

Pathologic

pertaining to pathology; either morbidity or disease.

PE

plasma exchange.

Peripheral

pertaining to or situated at or near the periphery; situated away from a center or a central structure.

Peripheral Nerve Society (PNS)

professional society of neurologists involved in study and treatment of the peripheral nerve and the peripheral nervous system.

Peripheral nervous system (PNS)

the peripheral part of the nervous system, external to the brain and spinal cord from their roots to their peripheral terminations.

Perivascular inflammation

inflammation surrounding a blood or lymph vessel.

Peroneal nerve

sural communicating branch of common fibular nerve.

Phagocytes

cells that ingests bacteria, foreign particles, and other cells. They ingest and kill microbes, present antigen to lymphocytes, scavenge degenerating material, and release mediators.

Plasma exchange (PE)

Also referred to as plasmapheresis. Removal of plasma and replacement with various fluids, e.g., fresh frozen plasma, plasma protein fractions (PPF), albumin preparations, dextran solutions, and saline. Used in treatment of autoimmune diseases, immune complex diseases, diseases of excess plasma factors, and other conditions.

Plasmapheresis

another name for plasma exchange.

PNS

peripheral nervous system. Also Peripheral Nerve Society.

POEMS syndrome

an acronym for a condition characterized by polyneuropathy, or organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes.

Polyneuropathy

a disease process involving a number of peripheral nerves. A nontraumatic generalized disorder of peripheral nerves affecting the distal fibers most severely, with proximal shading and typically symmetrically; most often affects motor and sensory fibers almost equally, but can involve either one, either solely or very disproportionately; classified as axon degenerating or demyelinating.

Prednisolone

a dehydrogenated analogue of cortisol with the same actions and uses.

Prednisone

a dehydrogenated analogue of cortisol with the same actions and uses. Must be converted to prednisolone before becoming active.

Pressure palsy

SYN Pressure paralysis. Paralysis due to compression of a nerve, nerve trunk, plexus, or spinal cord.

Proprioception

a sense or perception, usually at a subconscious level, of the movement and position of the body and especially its limbs, independent of vision.

Proximal

nearest the trunk or point of origin, said of part of a limb, of an artery or of a nerve.

Pseudotumor cerebri

a disorder, most commonly seen in obese young women, characterized by headache, blurred vision, and visual obstructions resulting from increased intracranial hypertension; if untreated, occasionally results in permanent visual loss.

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Q

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R

Remyelination

the restoration of the myelin sheath.

Renal insufficiency

defective function of the kidneys with accumulation of waste products, particularly nitrogenous) in the blood.

Retinitis pigmentosa

a progressive retinal degeneration characterized by bilateral nyctalopia, constricted visual fields, electroretinogram abnormalities, and pigmentary infiltration of the inner retinal layers.

Rituximab

an immunosuppressant agent

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S

Sacroidosis

inflammation in the sacral region.

Schwann cells

cells of the ectodermal (neural crest) origin that compose a continuous envelope around each nerve fiber of the peripheral nerves.

Sensitivity

in clinical pathology and medical screening, the proportion of affected patients who give a positive test result for the disease that the test is intended to reveal.

Sensory ataxia

an ataxia (inability to coordinate muscle activity during voluntary movement) due to impairment of position sense caused by lesions located at some point along the central or peripheral sensory pathways.

Serum

a clear watery fluid. The fluid portion of the blood obtained after removal of the fibrin clot and blood cells, distinguished from the plasma in circulating blood.

Specificity

the condition or state of having a fixed relation to a single cause or to a definite result.

Sphincture disturbance

a disturbance of the sphincter muscle that encircles a duct, tube or orifice in such a way that its contraction constricts the lumen or orifice.

Striae

dusty complexion with purple markings.

Subperoneal

situated beneath or deep into the peroneal nerve.

Sural nerve

formed by the union of the medial sural nerve, cutaneous from the tibial nerve and the peroneal nerve, usually about the middle of the calf although this location is highly variable.

Symmetric

equality or correspondence in the form of parts around the center of an axis, at the extremities, or poles, or on the opposite sides of the body.

Systemic lupus erythematosus

an inflammatory connective tissue disease with variable features frequently including fever, weakness and fatigue, joint pains or arthritis resembling rheumatoid arthritis, diffuse skin lesions on face, neck, and upper extremities.

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T

Tachycardia

rapid beating of the heart, conventionally applied to rates over 90 beats per minute.

T cells

T lymphocytes.

Thrombocytopenia

a condition in which an abnormally small number of platelets is present in the circulating blood.

Thromboembolism

an obstruction or occlusion caused by a blood clot.

Thrombosis

a clot formed from the constituents of blood.

Thyroid disease

disease of the thyroid gland.

Tibial nerve

one of the two major divisions of the sciatic nerve, it courses down the back of the leg to terminate at the medial lateral nerve in the foot.

TNF

tumor necrosis factor.

Transcription

the transfer of genetic code information from one kind of neucleic acid to another.

Tremor

repetitive, often regular, oscillatory movements caused by alternate, or synchronous, but irregular contraction of opposing muscle groups; usually involuntary.

Trypanosoma cruzi

a species of asexual digenetic protozoan flagellates that causes South American trypanosomiasis and is endemic in Mexico and various countries of Central and South America.

Tumor necrosis factor

SYN cachectin. A cytokine that is produced by CD4 and CD8 T cells after exposure to an antigen.

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U

ULN

upper limits of normal.

Ulnar nerve

a nerve that arises from the medial cord of the brachial plexus conveying fibers mainly from the C8 and T1 nerves. It passes down the arm to the hand.

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V

Vasculitis

inflammation of a blood vessel.

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W

Waldenström’s macroglobulinemia

a disease, occurring in the elderly, characterized by the proliferation of cells resembling lymphocytes or plasma cells in the bone marrow. The spleen, liver, or lymph nodes are often enlarged with frequent purpura or mucosal bleeding.

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X

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Y

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Z

Zenith

highest point or peak.

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