UI Pathology Faculty List 2013-14

UNIVERSITY OF ILLINOIS
COLLEGE OF MEDICINE
AT
URBANA-CHAMPAIGN

PATHOLOGY - VOLUME II

2013 2014

PATHOLOGY TEACHING FACULTY LIST

William Albers, MD
Department of Pediatrics
420 N.E. Glen Oak, Suite 304
Peoria, IL 61603
Phone: (309) 655-3453
Farah Gaudier, MD
Dept. of Pathology
Carle Physician Group
Farah.Gaudier@carle.com

Ramesh Ramanathan, MD
rramanathan1913@gmail.com
Jerome Anderson, MD
Department of Pathology
McDonough District Hosp.
McComb, IL 61455
Phone: (309) 837-2368
jdanderson@mdh.org

Nasser Gayed, MD
190 Medical Sciences Bldg
506 South Mathews Avenue
Urbana, IL 61801
Nasser.Gayed@med.va.gov

Michael Schneider, MD
Dept. of Pediatrics/Genetics
Brett Bartlett, MD
Dept. of Pathology
SBL Health Centre
Mattoon IL 61938
BBartlett@sblhs.org

Nicole Howell, MD
Dept. of Pathology
Carle Physician group
Nicole.Howell@carle.com

William Scott, MD, MPH
Clinical Assistant Professor
Occupational Medicine

Frank Bellafiore, MD
Dept. of Pathology
602 West University Avenue
Urbana, IL 61801
Frank.Bellafiore@carle.com
Zheng George Liu, MD
Dept. of Pathology
Carle Clinical Association
602 West University Avenue
Urbana, IL 61801
George.Liu@carle.com

Richard Tapping, PhD
Associate Professor
Dept. of Microbiology
tapping@illinois.edu

Allan Campbell, MD
Dept. of Pathology
UICOM Peoria, IL
allancampbellmd@
gmail.com
Naveen Manchanda, MD
Indiana Univ. Sch. of Medicine
Dept. of Hematology/Oncology
525 Barnhill Drive
Indianapolis, IN 46202
nmanchan@iupui.edu

Teaching Assistant
Brent Beenders, PhD
beenders@life.illinois.edu
Gregory Freund, MD
Head, Dept. of Pathology
190 Medical Sciences Building
Urbana, IL 61801
freun@illinois.edu

Steve Nandkumar, MD
Pathology Course Director
249 Medical Sciences Building
Urbana, IL 61801
snandkum@illinois.edu

Pathology Office
Ms. Jackie Newman
(217) 244 2265
jknewman@illinois.edu

HYPERTENSION

Steve Nandkumar, MD

Pathology M-2 Hypertension

1

HYPERTENSION

Blood Pressure = Cardiac Output x Peripheral Resistance

Pressure = Force per unit area

Force exerted by blood against any unit area of the vessel wall

Measured in mms of Hg (sometimes cms of H
2
0)
1.36 cm of H
2
0 = 1 mm of Hg

Resistance is the impediment to blood flow in a vessel. This depends on:

1. Diameter of vessel
2. Viscosity of blood

REGULATION OF NORMAL BLOOD PRESSURE

I. CARDIAC OUTPUT

A. Cardiac Factors (e.g., heart rate, contractility)
B. Blood Volume
Sodium homeostasis
Mineralocorticocoids
Atriopeptides

II. PERIPHERAL RESISTANCE

PR is predominantly determined at the level of arterioles (size of lumen, thickness of wall)

Normal vascular tone depends on a balance between vasoconstricting and vasodilating influences

A. Neural Factors
Constrictors Dilators
!-adrenergic "-adrenergic

B. Humoral Factors
Constrictors Dilators
Angiotensin II Prostaglandins
Catecholamines Kinins
Thromboxane NO (nitric oxide)
Leukotrienes EDRF (endothelial-derived, relaxing factor)
Endothelin

C. Local Factors
Metabolic products (lactic acid, H ions, adenosine)
Hypoxia
Autoregulation (! flow causes vasoconstriction)


2

III. KIDNEY AND BLOOD PRESSURE

N
a
homeostasis
Kidney influences
Peripheral resistance

A. Renin Angiotensin System

B. KIDNEY produces vasodilators, e.g., prostaglandins, kinins, NO, PA Factor

C. ! GFR (glomerular filtration rate) due to ! blood volume causes
" N
a
reabsorption by proximal tubules

D. Natriuretic peptides cause:
1. Vasodilation
2. Inhibit N
a
reabsorption in tubules " natriuresis (N
a
loss in urine)

Natriuretic peptides or factors, e.g., ANF counteract volume expansion/aldosterone action.


3

BP in an individual is a complex trait determined by the interaction of multiple genetic,
environmental and demographic factors; age, gender, BMI, diet (Na intake) race,
obesity,smoking, stress etc., affect BP.

TYPES OF HTN (Systolic- sustained SBP > 139 and Diastolic sustained DBP > 89)

Essential or primary HTN (95%) Secondary HTN (5%)
1. Renal 2-3%
2. Endocrine < 1%
3. Cardiovascular
4. Neurologic
5. Miscellaneous 0.2%

NOTE: Most cases of HTN, when adequately treated and controlled, are compatible with a long life.
They are usually asymptomatic until cardiac or cerebrovascular problems supervene. This
group is called Benign Hypertension.

Malignant or accelerated HTN. Occurs in normotensive people or in those with benign
HTN; 5% of HTN cases with rapidly rising blood pressure (200/120 mm or more), renal
failure, retinal hemorrhage and exudates, papilledema . Most cases if left untreated will die
within one or two years.

PATHOGENESIS OF ESSENTIAL HTN

A. Genetic Factors
1. Essential HTN is a polygenic and heterogeneous disorder in which the combined effect
of mutations or polymorphisms at several gene loci influence BP, e.g., RAA system
genes/receptor locus etc.
2. Single-gene disorders (rare)
a. Gene defect in enzymes involved in aldosterone metabolism
b. Mutations in proteins that affect N
a
reabsorption, e.g., epithelial N
a
channel
protein (Liddle syndrome increased Na reabsorption leads to HTN). NaCl co-
transporter (Gitelman syndrome decreased Na reabsorption leads to
hypotension).

Joint National Committee on prevention, detection, evaluation, and treatment of high
blood pressure.

4

B. Environmental Factors
Geographic factors, stress, smoking, obesity, physical inactivity, increased salt consumption
all contribute to HTN.

MECHANISMS

TWO MECHANISMS ARE PROPOSED:

A. Defective Renal Na Homeostasis

! serum Na and hence ! fluid volume (! cardiac output)

! PR due to autoregulation

HTN

The HTN allows kidneys to excrete more N
a
thus leading to Na homeostasis (resetting of
pressure natriuresis).

NOTE: SODIUM INTAKE/BLOOD LEVELS AFFECT BLOOD PRESSURE
! N
a
"

HTN

B. Vasoconstriction and Vascular Hypertrophy
Both cause increased peripheral resistance and hence, HTN.

Vasoconstrictor influences
1. Local
2. Humoral
3. Neural
4. Genetic abnormal N
a
/C
a
transport across smooth muscle cell membrane; ! C
a
in cells
with increased contraction " vascular changes

Decreased N
a
excretion

5

Vascular Hypertrophy
Structural changes may precede vasoconstriction. Defective intracellular signaling in
smooth muscle cells affects cell cycle genes and ion fluxes causing structural changes and
vasoconstriction.

MORPHOLOGY OF BLOOD VESSEL CHANGES IN HTN

1. Hyaline arteriolosclerosis Common in BENIGN NEPHROSLCEROSIS
A homogeneous, pink, hyaline thickening of arteriolar walls with luminal narrowing.
E.g., HTN/DM/aging. Endothelial damage " leakage of plasma components into
subintimal tissue; increased extracellular matrix production by smooth muscle cells "
hyaline arteriolosclerosis (luminal narrowing causes ischemia).
2. Hyperplastic arteriolosclerosis
Seen as onionskin, concentric, laminated thickening of vessel wall with progressive
narrowing of lumen, e.g., malignant or severe HTN. (Diastolic BP > 120).

E.M. shows:
a. Smooth muscle cell proliferation
b. Thickening and reduplication of basement membrane

The above changes may progress to NECROTIZING ARTERIOLITIS (fibrinoid,
acute necrosis of vessel wall).

COMPLICATIONS OF HTN

1. Coronary heart disease/AS NOTE: 50% cases die due to # 1 and 3.
2. CVA (cerebrovascular accidents)
3. Cardiac failure 33% cases die due to # 2.
4. Renal failure
5. Aortic dissection
6. Retinopathy

HYPERTENSIVE HEART DISEASE HHD

I. SYSTEMIC (LEFT SIDED) HHD

HTN (pressure overload) " concentric hypertrophy of LV wall " cardiomegaly (size and weight
increase). Thickness of wall leads to stiffness and impaired diastolic filling with subsequent left
atrial enlargement.

Microscopic changes:
1. Transverse diameter of myocyte !
2. Nuclear variation/enlargement
3. Interstitial fibrosis


6

Systemic HHD may be:
a. Compensated: Patients are asymptomatic
Diagnosis made by EKG or echocardiogram (evidence of LV hypertrophy)
b. Decompensated: There is evidence of cardiac failure, atrial fibrillation, cardiac enlargement,
etc.

Course:
1. Normal longevity (with treatment)
2. Complications of HTN, including sudden death.

II. PULMONARY (RIGHT SIDED) HHD (Cor Pulmonale)

This entity is characterized by:
1. R.V. hypertrophy and dilatation
2. Cardiac failure due to pulmonary HTN.

Causes:
1. Diseases of pulmonary parenchyma
2. Diseases of pulmonary vessels
3. Disorders of chest movement

COR PULMONALE may be
1. Acute, e.g., pulmonary embolism
2. Chronic, e.g., emphysema

Morphologic Changes:
Similar to those described in systemic HHD.

NOTE: THE MOST COMMON CAUSE OF RIGHT HEART FAILURE IS LEFT HEART
FAILURE, DUE TO ANY CAUSE. Cor Pulmonale is usually diagnosed in the absence of
diseases of the left side of the heart and/or congenital heart disease.

Revised: 07-31-09

ANEURYSMS

Steve Nandkumar, MD

Pathology M-2 Aneurysms

1

ANEURYSMS

Definition: Localized abnormal dilation of a blood vessel or wall of the heart.

TYPES OF ANEURYSMS:

1. True Aneurysm
Aneurysm is bounded by arterial wall components or wall of the heart.

2. False or Pseudo Aneurysm
Break in vessel wall with escape of blood to outside forming a hematoma that communicates with
the intravascular space (pulsating hematoma).

3. Dissecting Aneurysm (Arterial Dissection)
Blood enters the wall of an artery forming a hematoma between its layers.

CAUSES OF ANEURYSMS
Congenital
Trauma
AS
Mycotic (infections) e.g., aortic aneurysm with salmonella infection
Syphilis
Others (vasculitis)

I. ATHEROSCLEROTIC ANEURYSMS
AS can lead to aneurysm formation due to wall damage.

Sites:
1. Abdominal aorta (AAA Abdominal aortic aneurysm)
2. Arch of aorta
3. Descending aorta
4. Common iliacs

Gross:
Fusiform or saccular forms, 15 to 25 cm long
occur below renal arteries and above aortic bifurcation
AS induced changes, ulceration, thrombus formation

Micro
Same changes as seen in AS.

Pathogenesis:
1. AS induced damage causes aneurysm.
2. Genetic defects in connective tissue synthesis and degradation. MMPs (matrix
metalloproteinases) in macrophages degrade extracellular matrix (collagen). T
H
2 cells
produce IL-4 and IL-10 that cause MMP synthesis. TIMPs (tissue inhibitors of
metalloproteinases) inhibit such degradation.


2

3. MMP > TIMP = wall damage " aneurysms
4. Hypertension may contribute to aneurysm formation (50% of cases)

NOTE:
a. Marfans syndrome - defective Fibrillin synthesis affects vessel wall integrity
b. Loeys Dietz syndrome - TGF beta receptor mutation affects elastin, collagen 1 and III
synthesis
c. Ehlers Danlos syndrome collagen III synthesis is defective
d. Scurvy defective collagen synthesis due to Vit C deficiency

Clinical Features:
More common in men ( incidence < 5% in males > 60)
Smokers

Presentation/Consequences:

1. Abdominal mass asymptomatic, (discovered incidentally; may be pulsatile)
2. Rupture " hemorrhage
3. Obstruction " vessel orifice blocked " ischemic damage to organs supplied by renal, iliac
spinal and mesenteric arteries.
4. Embolism (from thrombus)
5. Pressure on surrounding tissue, e.g., ureters, vertebrae

Course: Risk of Rupture is proportional to Size of Aneurysm

Aneurysms # 5 cm size must be treated.

Mortality for unruptured aneurysm = 5%
Ruptured aneurysm = 50%

NOTE: Inflammatory AAA = abdominal aortic aneurysm with periaortic fibrosis and inflammation
(lymphocytes, macrophages, plasma cells, giant cells seen).

II. SYPHILITIC ANEURYSM (LEUTIC ANEURYSM)

Cause:
Treponema Pallidum

Obliterative endarteritis affects vasa vasorum in tertiary syphilis. Luminal narrowing causes
ischemic damage of the media of the vessel wall (aorta) with destruction of elastic fibers. Fibrosis
follows yielding aneurysm (mainly thoracic aorta).

Morphology:
1. Syphilitic aortitis
2. Tree barking of aorta " contraction of fibrous scars causes wrinkling of aortic intima
3. Aortic valve ring dilatation " valve incompetence
4. Massive left ventricular enlargement (cor bovinum cows heart)


3

Clinical Features:
1. Respiratory difficulties (pressure on bronchi, lungs)
2. Dysphagia " swallowing difficulty (pressure on esophagus)
3. Cough " pressure on recurrent laryngeal nerve
4. Pain " due to erosion of ribs/vertebrae
5. Cardiac problems " aortic valve incompetence, myocardial ischemia, cardiac failure
6. Rupture

NOTE: CARDIAC FAILURE DUE TO VALVE INCOMPETENCE IS THE MOST
COMMON CAUSE OF DEATH.

III. AORTIC DISSECTION

Definition: Dissection of blood between and along the laminar planes of the media forming a
hematoma within aortic wall.

Types (based on pathogenesis):

Spontaneous Antecedent HTN Connective tissue disorder, e.g., Marfans
90% in men 40-60 years Younger men

Other causes: Pregnancy (exact cause is unknown)
Iatrogenic (use of arterial catheters)

Morphology:
Spontaneous intimal tear, horizontal or oblique, 1 to 5 cm long
Occurs within 10 cm of aortic valve
Dissection/hematoma spreads between middle and outer thirds of aortic wall
Rupture outside with massive hemorrhage/death
Rupture into original lumen of aorta to form a new false channel (double-barreled aorta) with
endothelialization.

Microscopic:

Medial cystic degeneration is frequent

Occurs in Marfans Elastic tissue fragmentation and loss with cleft-like spaces (cysts)
Syndrome seen in the wall; filled by extracellular matrix
.
Connective tissue NO NECROSIS OR INFLAMMATION
Disorder

Occurs in HTN Mild fragmentation of elastic tissue to medial degeneration
(non-specific changes)

CLASSIFICATION OF DISSECTION
Depends on the level of aortic involvement

Type A (proximal)
Involves ascending aorta only or entire length of aorta

4

Type B (distal)
Involves aorta DISTAL to the subclavian artery; ASCENDING AORTA IS NOT INVOLVED.
Clinical Features

1. Sudden, severe chest pain/back pain
2. Sudden death/RUPTURE
3. MI/cardiac tamponade
4. Aortic valve insufficiency
5. Occlusion of vessel orifices by dissection
6. Compression of spinal vessels (myelitis)

Treatment

Timely detection and treatment with antihypertensive drugs and surgical repair of aortic wall yield
a salvage rate of 65-75%.

NOTE: RUPTURE OF DISSECTION OUTWARD (into pleural, peritoneal, pericardial
cavities) IS THE MOST COMMON CAUSE OF DEATH.

Revised: 07/31/09

1

VALVULAR HEART DISEASE

Rheumatic Fever
Rheumatic Heart Disease
Congestive Heart Failure (CHF)

Steve Nandkumar, MD

Pathology M-2 Valvular Heart Disease

1


2

VALVES

(Thin, translucent, avascular, membranous structures)

Atrioventricular valves tricuspid
mitral

Semilunar valves aortic
pulmonary
Valve Structure
1. Zona spongiosa central core of loose connective tissue
(Acts as a shock absorber)
2. Zona fibrosa layer of dense collagenous tissue
(Provides mechanical integrity)
3. Zona ventricularis layer rich in elastin
4. Surface endothelium layer that is exposed to blood
5. Interstitial cells scattered throughout the valve; produce collagen

Terminology
Valve leaflets or cusps constituent members of a valve
Valve ring or annulus outer edge or ring of the valve orifice where the leaflets
are attached
Valve edge or margin thin edge of a valve
Valve coaptation valve cusps coming together during valve closure
Lunula an area of overlap of the valve cusps beneath/near the
edge
Commissure valve orifice/opening
Nodule of Arantius small nodule in the center of the free cusp of the aortic
valve; helps in valve closure

NOTE: The pulmonary and aortic cusps are attached to the annulus (an area of thickening in
the pulmonary trunk base and aortic root respectively ).

The AV valves (tricuspid and mitral) at their free edge are attached to delicate strands
of chordae tendineae, which in turn are attached to papillary muscles which are
contiguous with ventricular wall muscle. All these structures constitute, the tensor
valve apparatus (whose integrity is important for valve function).

The valve cusps, during diastole (closed phase), are stretched by an area 40 50%
larger than during systole (open phase).


3

VALVULAR HEART DISEASE

Definition: Disorders or dysfunction of the valves constitute valvular heart disease.

1. What are the cardiac valves?
They are:

2. Define valve stenosis.
Failure of a valve to open completely is called stenosis. Hence, forward blood flow is impeded,
(e.g., aortic stenosis.)

3. Define valve incompetence.
Incompetence (insufficiency, regurgitation) is failure of a valve to close completely. Hence, back
flow is allowed, (e.g., aortic incompetence.)

A valve can be both stenotic and incompetent. Stenotic valves are usually also incompetent
(because a valve that fails to open completely, also fails to close completely).

Valve stenosis is due to primary valve cusp abnormality and is almost always due to a chronic
process. Incompetence is due to valve cusp damage or distortion of supporting structures such as
valve ring (annulus) chordae tendineae, papillary muscles, etc. It may be acute (e.g., valve
perforation) or chronic.

4. What are the effects of valve dysfunction?
The effects are abnormal blood flow; abnormal pressure; work load changes
Work = flow x pressure
Increased work leads to chamber dilatation and hypertrophy.

Thus in stenosis:
Chamber Proximal Chamber Distal
Flow Normal or # #
Pressure $ #
Work $ Normal

In Incompetence:

Chamber Proximal Chamber Distal
Flow $ $
Pressure $ Normal or $
Work $ $

Tricuspid valve
Pulmonary valve
% Right side
Mitral valve
Aortic valve
% Left side

4

Other effects are:
Cardiac failure < Right
Left

Jet flow & pseudo valves or plaques (areas of thickening and fibrosis owing to impact of
blood flowing through a narrow orifice)
Turbulence & murmurs

CARDIAC FAILURE

1. What is cardiac failure?
It is the inability of the heart to pump blood so as to meet the metabolic requirements of the tissues.
Often called congestive heart failure (CHF), there is impaired cardiac function and circulatory
congestion.

2. What are the causes of cardiac failure?
Congenital
Cardiac
There are many causes: Acquired
Non-cardiac

Based on cardiac dysfunction, the causes are as follows:
SYSTOLIC FAILURE DIASTOLIC FAILURE
1. Ischemic heart disease Massive LV hypertrophy
2. HTN Myocardial fibrosis
3. Valvular heart disease Amyloidosis
4. Myocarditis Constrictive pericarditis
5. Cardiomyopathy (DCM) Cardiomyopathy (others)

3. What are the types of cardiac failure?
There are 2 types:

A. SYSTOLIC FAILURE (DYSFUNCTION)
There is progressive deterioration of myocardial contractile function; associated with
pressure or volume overload.

B. DIASTOLIC FAILURE (DYSFUNCTION) (40 60% of cases)
There is inability of the heart chamber to relax, expand, and fill up with adequate blood
during diastole.

NOTE: CHF is characterized by: 1. Diminished cardiac output (forward failure), and 2. Damming
back of blood in venous system (backward failure).

4. Discuss morphologic changes and clinical effects of left-sided cardiac failure.

A. HEART
Changes seen depend on the underlying cause
1. LV hypertrophy and dilation EXCEPT IN MITRAL VALVE STENOSIS. Size and
weight of heart increase.

5

2. Myocyte hypertrophy and fibrosis
3. Secondary enlargement of left atrium
4. Atrial fibrillation (arrhythmia); thrombus formation; thromboembolism occur

B. LUNGS
There is PULMONARY CONGESTION AND EDEMA
1. Increased cardiac pressure is transmitted retrogradely to pulmonary veins, capillaries,
and arteries. There is increased perivascular and interstitial transudation, edematous
widening of alveolar septal walls and fluid accumulation in alveolar lumen (EDEMA).
Hemoglobin from damaged red blood cells are phagocytosed by macrophages, and
converted to hemosiderin. Such cells are called hemosiderinophages or heart-failure
cells.
2. Patients develop dyspnea (SOB), orthopnea, and PND (paroxysmal nocturnal
dyspnea).Cough is common.

C. KIDNEYS
Decreased cardiac output reduced renal perfusion

Protective renal Blood volume Na and Activation of RAA
mechanism and interstitial H
2
0 retention System
fluid increase

If this mechanism FAILS, renal azotemia and uremia (renal failure) can occur

D. BRAIN
Cerebral hypoxia and encephalopathy may occur:
There is irritability, restlessness, loss of attention span, stupor, coma

5. Discuss the morphological changes and clinical effects of right-sided cardiac failure.

IMPORTANT: RIGHT SIDED CARDIAC FAILURE IS MOST OFTEN
SECONDARY TO LEFT-SIDED HEART FAILURE.

A. HEART
Pure right-sided failure (COR PULMONALE) may be due to pulmonary embolism, pulmonary
hypertension, pulmonary vascular diseases, etc.
There is right ventricular and atrial dilatation and hypertrophy.

B. LUNGS
Underlying pathology seen, (e.g., thrombus, vascular changes, etc.)
PULM-CONGESTION AND EDEMA ARE MINIMAL!

C. LIVER/PORTAL SYSTEM
Damming of fluid and increased pressure via the vena cava cause
Passive congestion of liver
Congestive hepatomegaly
Fatty change, centrilobular necrosis
Cardiac cirrhosis (liver fibrosis in chronic cases)
Congestive splenomegaly (spleen enlarged, weight increases)
Edema of bowel causes loss of appetite, absorption problems
ASCITES (abnormal fluid transudate in peritoneal cavity)

6

D. KIDNEY/BRAIN
Similar to those of left-sided failure

E. PLEURAL SPACE " Fluid accumulation causes EFFUSION
PERICARDIAL SPACE " Pericardial EFFUSION

F. SUBCUTANEOUS TISSUE
1. Dependent portions of the body are edermatous, e.g., ankle, pedal, sacral edema.
2. Anasarca
Massive, generalized, edema

6. What is the major difference between the clinical features of left and right-sided heart
failure?
Left-side failure Right-side failure
Pulmonary congestion/edema Systemic/portal system venous congestion and related features
Less respiratory features (depends on cause)

PULMONARY FEATURES PULMONARY FEATURES
ARE PROMINENT LESS PROMINENT

7. What is compensated heart failure?
When the heart fails, an adaptive mechanism kicks in to maintain cardiac function. This
mechanism involves:
1. Frank-Starling hypothesis
Pressure or volume overload causes muscle stretch which enhances
contractility/cardiac function
2. Myocardial structural changes
Augmented muscle mass (hypertrophy) enhances contractility.
3. Activation of neurohumoral system
Nor epinephrine release (adrenergic cardiac function)
Activation of RAA system
Natriuretic peptide release
Thus, blood pressure and perfusion of vital organs are maintained. The patients failure is
compensated.

8. What is decompensated heart failure?
With chronicity and persistence of the underlying cause, the adaptive mechanism is
OVERCOME due to molecular/genetic/biochemical/structural/ functional abnormalities of the
cardiac muscle (ventricular remodeling). There is now progressive cardiac dysfunction and
circulatory congestion with attendant symptoms and signs.
Treatment (medical, surgical, etc.) of the underlying cause will help.

9. What is refractory cardiac failure? Home work


7

RHEUMATIC FEVER/RHEUMATIC HEART DISEASE

CASE HISTORY

A ten-year-old girl complains of cough, sore throat, and fever. She is treated with antibiotics and sent
home.

Six weeks later, she returns with complains of multiple joint pains, fever, and tiredness. On physical
examination of the chest (auscultation), there seems to be a murmur in the mitral valve area. She is
admitted to the hospital and treated with analgesics, antibiotics, and bed rest.

Lab tests reveal: E.S.R. 89 mm at the end of the first hour (normal 0-15 mm)
( ESR = Erythrocyte sedimentation rate)

WBC count 13,800/cmm (normal 5-10k).
E.K.G. non-specific ST-T wave changes

Questions:

1. What is your diagnosis?

2. What do you know about the etiology of this disease?

3. What complications would you expect in this case?


8

RHEUMATIC FEVER/RHEUMATIC HEART DISEASE
Rheuma = flux
Rheumatic = suffering from rheumatism
Rheumatism = various conditions associated with joints or
musculoskeletal system

1. Define rheumatic fever (RF).
Rheumatic fever is an acute, recurrent, post-infectious immune-mediated inflammatory
disease.
Occurs between 5-15 years; occasionally in middle life.

2. Define rheumatic heart disease.
Inflammatory changes affecting the heart, in a case of RF, constitute rheumatic heart disease.

3. What does the term post-infectious mean?
It means that RF generally follows sore throat (pharyngitis, tonsillitis) caused by group A
beta-hemolytic streptococcus, (rheumatogenic strains serotypes 1, 3, 5, 6, 18, etc.). The
incidence of RF is about 3% following such infections.

4. What does the term immune mediated mean?
One to five weeks following streptococcal infection.
Antibodies to streptococci are formed. These antibodies cross react with human tissue
antigens in various organs causing inflammation. Thus,
anti-streptococcal antibodies + tissue ( glycoprotein) antigens & RF lesions
CD4 T lymphocytes are activated, release cytokines and cause tissus damage.
Alternately, streptococcal infection somehow initiates an AUTOIMMUNE REACTION,
causing RF lesions.
Genetic susceptibility influences this hypersensitivity reaction.

5. What are the RF lesions?
During the ACUTE stage of the disease, the characteristic lesions are called Aschoff
bodies. These are granulomata with a focus of fibrinoid (fibrin like) necrosis, surrounded
by lymphocytes, plasma cells, macrophages, and special histocytes called Aschoff or
Anitschkow cells (caterpillar cells). These cells have abundant cytoplasm and central round
to ovoid nuclei with the nuclear chromatin looking like a caterpillar. Aschoff giant cells may
be seen.
Plasma Cells
Thus:

Aschoff body & Histocytes Lymphocyte
(Sterile lesion, (Aschoff cells) Macrophages
organisms not present)

Fibrinoid Necrosis

During the CHRONIC or HEALING STAGE, there is neovascularization of the avascular valve,
the lesions are replaced by fibrous scar (fibrosis), and may be difficult to identify. Calcification
may follow.


9

6. What happens in Rheumatic Heart Disease?
In acute or early stages, Aschoff bodies are formed in:
Pericardium & pericarditis (bread and butter typeheals without sequelae)
Endocardium & endocarditis
Valve & valvulitis
Myocardium & myocarditis
Endocarditis & valve vegetations called verruca. Small, 12 mm, friable wart-like
lesions seen along valve cusps. These are due to fibrin deposits and
DO NOT cause problems.
MacCallum
plaques & flat, irregular, plaque-like subendocardial thickenings seen in the left
atrium owing to jet lesions seen in valve incompetence.
Myocarditis & MAY CAUSE:
Cardiac arrhythmia
Emboli
Cardiac failure
Valve ring dilatation causing value incompetence
Sudden death

MYOCARDITIS IS HENCE, THE MOST SERIOUS CARDIAC
PROBLEM IN ACUTE RF

During the chronic stage, valve damage caused by fibrosis leads to scarring and
shrinkage of valves, commissural fusion, and shortening and fusion of Chordae
tendineae. The valves become (1) stenotic and (2) incompetent. Left side valves are
more affected than right side. These changes occur over several years (2025 years)
and follow recurrent attacks of RF. Cardiac decompensation follows and leads to
congestive heart failure.

7. What are Jones criteria for diagnosing RF?
These are:
Major Minor
Carditis (3575%) Fever
Arthritis (90%) Arthralgia
Subcutaneous nodules
Erythema marginatum

1060%
Tachycardia
$ ESR
Rheumatic chorea (Sydenhams) Prolonged PR interval seen on EKG
*( St. Vitus dance) Previous history of RF
St. Vitus patron saint of
dancers, singers, artists
Previous "-strep infections

If two major criteria or
one major and two minor are present

Then diagnosis is R.F.

The serologic lab tests useful are: Antistreptokinase (ASK)
Antistreptolysin O (ASO)
Antihyaluronidase
Anti DNAse B

These are antibodies and elevated serum titers may be helpful.

10

8. What are the complications of RF?
They are:
Acute Chronic
Myocarditis Valve dysfunction (stenosis/incompetence)
# Embolism
Sudden death Infective endocarditis
Cardiac failure/arrhythmias

9. What is the prognosis in RF?
Most acute lesions resolve completely. Only 1% of patients die from RF.
Recurrent streptococcal infections may cause repeated attacks of RHD with cumulative
damage.
Thirty percent of children may die within 10 years after the initial attack. Chronic valve
disease causes cardiac failure.
Most patients are given prophylactic antibiotic treatment. Surgical valve repair and
replacement are done in chronic valvular diseases.

10. What are the complications of artificial valves?
Mechanical types from non-physiologic biomaterial
Artificial valves
Tissue valves (bioprosthesis from pig, bovine or human valves)
Treated with glutaraldehyde and mounted on a prosthetic frame
60% of valve recipients develop problems within 10 years postoperatively.

The complications are:
Structural deterioration (wear and tear, calcification, fracture, etc.)
Thrombosis/thromboembolism, (especially with mechanical valves)
Bleeding associated with anticoagulation therapy
Infection (endocarditis), e.g., valve ring abscess. Common organisms are S. aureus,
S. epidermitis, and Streptococci, fungus, etc.
Non structural dysfunction, e.g., hemolytic anemia due to shearing forces, obstruction to
blood flow, etc.

NOTE: RF Licks the joints, but bites the heart
ESR Erythrocyte sedimentation rate
R. Chorea CNS involvement causing purposeless, jerky, involuntary movements of
head and upper extremities.

MITRAL VALVE PROLAPSE
(Floppy Valve Syndrome, Barlows Syndrome, Myxomatous Degeneration of the Valve)

1. What is mitral valve prolapse?
It is a condition where one or more leaflets of the mitral valve prolapse into the left atrium
during ventricular systole (also called ballooning or hooding of the valve)


11

2. Why does the valve prolapse?
A normal valve is composed of zona fibrosa and zona spongiosa in a ratio of 1:1.
In valve prolapse, the spongiosa is much thicker than the fibrosa which is attenuated. So the
valve, although thick, is weak and hence flops back into the left atrium.
A developmental anomaly affecting connective tissue as seen in Ehlerss-Danlos Syndrome
or Marfans syndrome, may be the cause for this change (known as myxomatous change
there is mucoid or myxomatous deposition). Gene defects ( eg. Fibrillin 1 in Marfans) may
dysregulate TGF beta functions leading to abnormal ECM ( collagen) synthesis.

3. What are other changes seen in this condition?
Annular dilation is characteristic
The chordae tendineae may become thin, elongated, and rupture.
Tricuspid valve change (2040%)
Pulmonary valve change (5%)
Commissural fusion is absent
Thrombi may form; focal calcification seen at the base of the valve leaflet.

4. What are the clinical features?
More common in females between 2040 years (3% of the U.S. population).
Patients may be asymptomatic.
Midsystolic click and murmurs may be heard (during routine physical exam) owing to the
tensing or snapping of the valve or chorda tendineae.
Echocardiogram can diagnose valve prolapse.
Occasional patients may have fatigue, chest pain, dyspnea, anxiety reactions, depression, etc.

5. What are the complications? Seen in 3% of cases. They are:
Mitral insufficiency
Embolism causing strokes/infarcts
Infective endocarditis
Cardiac arrhythmias
Cardiac failure
Sudden death (uncommon)

6. What is the prognosis?
It is generally good.
A careful follow-up with echocardiogram is recommended.
Should there be evidence of valve incompetence or risk for complications, valve replacement
must be undertaken.

CALCIFIC AORTIC VALVE STENOSIS

Congenital
This condition may be:
Acquired, e.g., rheumatic heart disease

Ninety percent of the cases are due to age-related degenerative calcification of either a
congenital bicuspid valve (1% of cases) or a normal one. There is NO commissural fusion.
Calcific deposits within the cusps, distort the valve causing valve stenosis (functional area is
decreased).
Features of aortic stenosis, as discussed in the earlier section, are applicable to this disease.

12

CASE HISTORY ( Case MA 50-79)

A 56-year-old Caucasian male was admitted with chronic fever of unknown origin (FUO).

History revealed that the patient has had fever for the past five weeks and associated weakness and
fatigue. There was no hemoptysis, hematemesis, chest pain, weight loss, dyspnea, or fainting spells.

Family history was non-contributory.

Personal habits: the patient denied smoking or alcohol consumption.

Examination
The patient was alert, oriented, but appeared pale.

Vital signs
Pulse: 130/min and regular
Temp: 102F
B.P.: 120/80 mm of Hg.
Res. Rate: 24/min

CVS: A faint systolic murmur was heard. This appeared to change over the next few days.

RS, AS, and CNS were all not contributory

Lab tests
Hb: 8.2 gm%
Hct: 25%
WBC: 13,100/cmm
Urine: Rbcs +++
BUN: 50 mg%
S. creatinine: 2.6 mg%

Chest X-ray
Bilateral pleural effusions
Changes of moderate congestion

Blood culture
Gram-negative coccobacilli

The patient was treated with antibiotics and antipyretics. He developed dyspnea and personality changes
five days after admission and died following a sudden cardiac arrest.


13

INFECTIVE ENDOCARDITIS

Definition: Inflammation of the heart valves or the mural endocardium, caused by microbiologic
organisms. Aorta, aneurysmal sacs and prosthetic devices can also become infected.

itis = inflammation

1. What are these organisms?
They are:
Streptococcus viridans (5060%)
Staphylococcus aureus (1020%) & common in IV drug abusers
Staph. epidermidis & most common organism causing prosthetic valve
endocarditis
Streptococcus pneumoniae
Gram-negative bacilli
Fungi (Candida, aspergillus)
*HACEK group of commensals in the oral cavity
Enterococci
Culture negative endocarditis (10%)

2. Why are cultures negative for organisms?
Prior antibiotic treatment
Technical difficulties in isolating organisms
Organisms are safely embedded in the vegetations and, hence not released into the blood.

3. What is the source of microorganisms?
The source of infection may be:
(Hidden) Covert Overt (Obvious)
Transient bacteremia Any infection in the body
from oral cavity, gut, etc. IV drug abuse
Minor (trivial) injuries Surgical procedures (i.e., catheterization)
Dental work

4. Why do these organisms tend to localize in the heart valves?
Because of:
Nonbacterial thrombotic endocarditis sterile platelet fibrin plugs form or deposit on the
valve surface and allow organisms to gain a foothold.
Agglutinating antibodies they cause bacterial clumping allowing attachment to vegetations
Adhesion factors on the organisms or endocardium. Fibronectin a component of the
endocardium has surface receptors for bacteria.

5. What are the risk factors for endocarditis?
They are:
Congenital heart disease
Acquired valvular disease (rheumatic heart disease)
Mitral valve prolapse
Artificial valves
IV drug abuse
Indwelling catheters.

*HACEK Hemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella

14

Immunocompromised states (HIV)/immunosuppressed conditions
Diabetes mellitus
Alcoholism
Malignancy

Sometimes even a normal heart may be infected by a virulent organism.

6. What are the differences between acute and subacute endocarditis?
They are:
Acute Endocarditis Subacute Endocarditis
Acute, sudden onset Slow insidious
Lasts for days to weeks Weeks to months
Highly virulent organism Low virulence
Staph. aureus Strep. Viridans
Normal heart Damaged heart
Vegetations are aggressive causing Tendency to heal less destructive
erosion and destruction Granulation tissue, fibrosis, calcification present
Poor prognosis Good prognosis

7 What are vegetations?
They are large, irregular, friable, bulky masses (like warts) seen on the valve cusps. They
contain fibrin, inflammatory cells, and microbial organisms. They are produced following
inflammation, tissue damage, and destruction caused by organisms. Any valve may be
affected, but the mitral and aortic valves more so (85% cases). IV drug abuse leads to
tricuspid valve endocarditis.
With treatment, vegetations become sterilized and heal by fibrosis and fibrocalcification.

8. What are the clinical features of endocarditis?
They are:
Fever (FUO, fever of unknown origin)
Fatigue, weakness, weight loss
Heart murmurs, cardiac failure
Embolic manifestations
Roth spots (retinal hemorrhages)
Janeway lesions (painless, erythematous lesions occur on palms and soles)
Osler nodes painful, subcutaneous nodules, occur in toes and fingers
Subungual ( nail bed ) hemorrhages

9. What are the complications seen in endocarditis?
They are:
Cardiac
Valve stenosis or incompetence
Myocardial abscess with perforation
Pericarditis/abscess
Artificial valve dehiscence
Cardiac failure

Embolic
Causing septic infarcts or metastatic abscesses to the brain, spleen, kidney, lungs, etc.


15

Renal
Embolic infarcts
Abscesses
Focal glomerulonephritis
Diffuse glomerulonephritis

10. What are the diagnostic criteria for IE?
See Table 12-8.

11. What is the management of IE?
MANAGEMENT OF IE

prophylactic
1. Antibiotics
therapeutic

emergency
2. Surgery
elective

The overall 5-year survival rate is 50-90%.

NONBACTERIAL THROMBOTIC ENDOCARDITIS
(MARANTIC ENDOCARDITIS)

Definition: This disease is characterized by deposition of small vegetations (masses) of fibrin, platelets,
and other blood elements on valve leaflets.

They are:
STERILE, small and nondestructive
Usually seen singly or multiply on previously normal valves
NOT associated with inflammation, more a bland thrombus
May embolize as they are loosely attached
May provide a nidus for bacterial implantation
Associated with a HYPERCOAGULABLE state leading to blood coagulation (DIC)
This condition is seen in patients with burns, cancer, sepsis, pulmonary thrombosis, indwelling
catheters in the heart, leukemias, and mucin-producing tumors of ovary, pancreas, and GI tract.
Occasionally, healthy persons may also have NBTE.


16

LIBMAN-SACKS DISEASE

Definition: Endocarditis of systemic lupus erythematosus, a connective tissue disease, may reveal small,
sterile, vegetations on either or both sides of a valve cusp.

Associated valvulitis (valve inflammation) may lead to healing, fibrosis, and valve deformity.
Figure 12-22. Diagrammatic comparison of the lesions in the four major forms of vegetative endocarditis. The
rheumatic fever phase of RHD (rheumatic heart disease) is marked by a row of warty, small vegetations along the
lines of closure of the valve leaflets. IE (infective endocarditis) is characterized by large irregular masses on the
valve cusps that can extend onto the chordae (see Fig. 12-20). NBTE (nonbacterial thrombotic endocarditis)
typically exhibits small, bland vegetations, usually attached at the line of closure. One or many may be present
(see Fig. 12-23). SLE (Libman-Sacks endocarditis) has small or medium-sized vegetations on either or both sides of
the valve leaflets.

CARCINOID HEART DISEASE

Definition: Carcinoid tumors originate from neural crest cells that are capable of taking up amine
precursors and causing decarboxylation (APUD amine precursor uptake and decarboxylation). These
tumors (called APUDOMAS) produce serotonin, kallikrein, histamine, bradykinin, prostaglandins, and
tachykinins (neuropeptide K and substance P), and may cause right heart valve and endocardial
plaque-like lesions (contain smooth muscle fibers, sparse collagen, and acid mucopolysaccharide rich-
matrix) and subsequent fibrosis (i.e., stenosis). Cardiac lesions occur in 50% of patients with carcinoid
syndrome. Serotonin and its urinary metabolite 5HIAA (hydroxy indole acetic acid) may correlate with
the severity of the disease.

The left side of the heart is protected as these bioactive products are (1) metabolized by the liver;
(2) inactivated by the monoamine oxidase system in the pulmonary vascular endothelium.

1. Can the left side of the heart be affected?
Yes, in case of:
Right to left shunts (blood flow from right to left side of the heart)
Lung and ovarian carcinoids
Ergotamine Rx for migraine
Fenfluramine-phentermine (Fen-Phen, appetite suppressant drug used in Rx for obesity)

What is Carcinoid syndrome?
8emember SCAL
Revised: 8/9/11

MYOCARDIAL DISEASES AND TUMORS

Steve Nandkumar, MD

MYOCARDITIS

1. What is myocarditis?
Myocarditis is inflammation of the myocardium (i.e., heart muscle).

NOTE: Inflammation is the primary event causing subsequent tissue damage. Contrast this with MI,
where inflammatory cells are present secondary to ischemic injury.

2. What causes myocarditis?
The causes are:
Infections Immune-mediated Unknown ( Idiopathic)

VIRUS Drug hypersensitivity Sarcoidosis
Bacteria Postviral Giant cell myocarditis
Chlamydia Collagen-vascular disease
Rickettsia
Fungi Post streptococcal ( RF)
Protozoa Transplant rejection
Parasite

NOTE: Chagas disease & T. cruzi protozoa causes trypanosomiasis (South America)

3. Give a brief summary of viral myocarditis.
The most common viruses, causing myocarditis, are Coxsackie A and B and other
enteroviruses; CMV, influenza, HIV, etc. are less common; they affect infants,
pregnant women, and immune compromised people. Patients may suffer from a
flu-like disease without cardiac problems or may develop sudden cardiac failure,
arrhythmia, or death. Features may also mimic those of acute MI.

The diagnosis is by:
Serologic titers
Endomyocardial biopsy (this procedure is risky!) and documenting viral DNA or RNA
by polymerase chain reaction

Most cases of viral myocarditis heal without sequelae.
Occasional cases may result in dilated cardiomyopathy (DCM).

4. How do viruses cause myocarditis?
By:
Direct cytotoxicity
Through T-cell mediated immune injury

5. What is Fiedlers or Giant cell myocarditis?
It is a type of myocarditis of UNKNOWN CAUSE, characterized by the presence of
many multinucleated giant cells along with lymphocytes, plasma cells, eosinophils,
and macrophages with extensive foci of necrosis. The giant cells originate from
a) macrophage or b) myocytes; the prognosis is usually poor
Treatment Cardiac transplantation (disease may recur in 25% of cases)

6. What are the tissue changes seen in myocarditis?
They are:
1. FOCAL, PATCHY, myofiber necrosis or damage
2. Inflammatory cells such as:
Neutrophils (usually signify bacteria)
Lymphocytes, macrophages (interstitial, signify viral disease)
Eosinophils (signify hypersensitivity drug reactions)
Healing occurs; either complete resolution or progressive fibrosis.

7. Compare and contrast myocarditis and cardiomyopathy.
Myocarditis Cardiomyopathy
Acute onset Slow, insidious onset
Cardiac failure generally resolves Protracted, downhill course
Inflammatory changes are seen Usually/mostly not seen

CARDIOMYOPATHY
Cardio = heart
Myo = muscle
Pathy (pathos) = suffering

Definition: Heart muscle disease characterized by deterioration of myocardial function leading to
congestive heart failure, arrhythmias, and death.

1 Classification: Based on WHO (World Health Organization) guidelines, cardiomyopathy is of 2
types.
EXTRINSIC The primary pathology is outside the myocardium and involves ischemic,
valvular, hypertensive, inflammatory, pericardial or congenital causes.
INTRINSIC The primary pathology is in the myocardium. It may be due to
IDIOPATHIC or other causes (genetic, alcohol, etc.) MOST CASES OF
CARDIOMYOPATHY PRESENT AS A SLOWLY PROGRESSIVE, REFRACTORY
CHF

2. What are the types of cardiomyopathy?
There are three types: 1. Dilated or congestive (90% of cases)
2. Hypertrophic
3. Restrictive (least common)

3. Describe dilated cardiomyopathy (DCM).
Progressive four chamber dilatation and hypertrophy of the heart with SYSTOLIC
DYSFUNCTION resulting in CHF.
Causes
Genetic Non-genetic
(30-40%) 1. Viral
2. Alcohol related ( 10 20%)
3. Pregnancy associated
4. Idiopathic
Genetic influences
Familial occurrence in 25-35% of cases
Autosomal dominant form is the most common

X-linked DCM is associated with Dystrophin gene mutation. (Dystrophin is a Cytoskeletal
protein).
Other genetic mutations in SARCOMERE, CYTOSKELETON, NUCLEAR ENVELOPE
and MITOCHONDRIA
Regardless of etiology, there is SYSTOLIC DYSFUNCTION with a LOW LV
EJECTION FRACTION (less than 40%, normal is 50-65%). THERE IS DEFECTIVE
FORCE GENERATION AND TRANSMISSION; ALSO MYOCYTE SIGNALING.

Morphology
The hypocontracting heart is enlarged, dilated, flabby, hypertrophic, and weighs 2-3 times
that of normal (i.e., 600-900 gm). Muscle hypertrophy is neutralized by dilatation.
Dilatation can also cause stretching of the valve ring leading to valve incompetence.
Thrombi may form leading to embolization.
MICROSCOPIC CHANGES ARE NON-SPECIFIC. Attenuated or hypertrophic muscle
fibers, replacement fibrosis (interstitial and replacement scars) due to ischemic injury can
occur.

Clinical Features
can occur at any age, but common in the 20-50 age groups. Patients develop CHF,
arrhythmias, valve incompetence, thromboembolism, etc.

Prognosis
50% of patients die within 2 years (5 year survival rate is 25%).

Cause of death
Cardiac failure
Arrhythmia/sudden death

Treatment
Cardiac transplantation; ventricular assist device.

4. Describe Hypertrophic Cardiomyopathy (HCM)
Also known as Asymmetric Septal Hypertrophy (ASH) or Idiopathic Hypertrophic Subaortic
Stenosis (IHSS) or Hypertrophic Obstructive Cardiomyopathy (HOCM).
MOST COMMON CAUSE OF SUDDEN UNEXPLAINED DEATH IN YOUNG
ATHLETES.

Pathogenesis
100% of cases are genetic involving MUTATIONS IN SARCOMERE

THERE IS DEFECTIVE FORCE GENERATION AND FORCE TRANSFER

Mutations in "-myosin heavy chain genes on chromosome 14 (35%), Troponin T (15%) and
Myosin binding protein C (15%) are the most common.
Most cases are familial with an autosomal dominant pattern of transmission.

Morphology
Enlarged, hypertrophic, hyper contracting heart. Hypertrophy may be symmetric (LV thickness =
septal thickness) 10% of cases or may be asymmetric (septum:LV wall thickness is greater than 1:3
to 1:5). Chamber size is reduced (banana heart)

Subaortic septal thickening, bulging can obstruct the aortic valve orifice (30% of cases) "
functional aortic stenosis.
Thickening of anterior mitral leaflet and mural plaque formation in LV outflow tract.

Microscopic
Myocardial DISARRAY and DISORGANIZATION, i.e., myocardial fibres are
haphazardly arranged.
Myocyte hypertrophy (> 40 m thick, normal = 15m).
Interstitial and replacement fibrosis.

Clinical Features
Sarcomere mutations " impaired contractile function " compensatory hypertrophy (due to growth
factors) and fibrosis due to ischemic damage.

Chamber size reduced " poor compliance " less diastolic filling NOTE: L.V. pressure is
# high. WHY?
Low cardiac Diminished stroke
$ Output $ Volume

THUS THERE IS DIASTOLIC FAILURE. Systolic function is normal (ejection fraction is
50-80%).
There is syncope, angina, dyspnea and cardiac murmur.
Cardiac failure, thromboembolism, infective endocarditis, arrhythmia and sudden death can occur.

Treatment:
Drugs that can increase relaxation of ventricles ( beta blockers)
Surgical myectomy & thinning septal wall or myectomy ( excision)
Alcohol infusion into myocardium (causes infarction)

CHF

5. Describe restrictive cardiomyopathy.
This form of cardiomyopathy is characterized by an enlarged, dilated heart. There is
DIASTOLIC DYSFUNCTION as diastolic relaxation and chamber filling are reduced due
to poor ventricular compliance. Systolic function is unaffected. The LV ejection fraction is
45-90%.

This disease may be:
Idiopathic
Associated with amyloidosis, sarcoidosis, storage diseases, radiation fibrosis, etc.
Overall 10 year survival rate = 10%

Other examples are:

A. ENDOMYOCARDIAL FIBROSIS

Cause unknown
Seen in tropical African countries
Present in children/young adults
Fibrosis of the endocardium and subendocardium restricts ventricular volume and
compliance; diastolic filling is reduced, hence cardiac failure
Mural thrombi are seen ( organization of thrombus and fibrosis may be the cause)

B. LOEFFLERS ENDOMYOCARDITIS

Seen in Africa but not confined to any geographic areas
_ Exact cause is unknown; chromosomal abnormalities involving PDGFR
Alpha and Beta genes occur leading to Tyrosine Kinase activity
Associated with eosinophilic leucocytosis, eosinophilic leukemia
Fibrosis of endo and myocardium with associated thrombi formation
Eosinophilic proteins, such as major basic protein, cause toxic damage, necrosis,
scarring, and thrombus formation with subsequent organization
Rapid downhill course with poor prognosis

R
x
: Endomyocardial stripping of the fibrotic layer may be helpful.
Tyrosine kinase inhibitors help

C. ENDOCARDIAL FIBROELASTOSIS

Exact cause is unknown
Seen in infants and young children ( under 2 years)
There is focal or diffuse cartilage-like thickening of the mural endocardium of cardiac
chambers owing to fibrosis and elastosis
Associated with congenital cardiac anomaly, such as aortic valve obstruction in 1/3
cases
May cause cardiac failure and death (esp. the diffuse type)

NEOPLASTIC HEART DISEASE

Tumors of the heart may be:
Primary Secondary (Metastatic Occurs in 5% of all cases)
Uncommon e.g. Cancer of lung
Cancer of breast
Melanoma
Leukemia
Lymphoma

Primary tumors of the heart may be:

Benign (80-90% of tumors) Malignant
Myxoma
Lipoma
Papillary fibroelastoma Angiosarcoma
Rhabdomyoma Rhabdomyosarcoma
Fibroma

Only two tumors will be considered:

Myxomas
Most common tumor derived from primitive mesenchymal cells
Occurs in young adults/females
Maybe sporadic or familial. Ten percent of patients have Carneys syndrome (familial,
autosomal dominant, cardiac and extra cardiac myxoma, spotty skin pigmentation, and
endocrine overactivity)
Ninety percent occur in the left atrium (L:R = 4:1)
Arise from the fossa ovalis area
May be sessile or pedunculated; globular hard masses or soft, villous, gelatinous lesions
May cause VALVE OBSTRUCTION/EMBOLISM; IL-6 production may cause fever,
malaise, etc.
Stellate or globular myxoma cells (LEPIDIC CELLS) seen in mucopolysaccharide ground
substance
Also present are smooth muscle cells, endothelial cells and undifferentiated cells.
PECULIAR STRUCTURES resembling poorly formed glands or vessels are characteristic.
Diagnosis by echocardiogram; also screen relatives 50% of kindreds have mutations on
chromosome 17( PRKAR1 protein kinase receptor A1 gene mutation), 2p16, etc.
Good prognosis following surgical removal (30% die due to cerebral embolism)

Rhabdomyomas
Are HAMARTOMAS rather than true neoplasms
Common in infants and children
Usually cause obstruction of valve orifice or cardiac chambers
Tumor contains spider cells
Associated with tuberous sclerosis

NOTE: Spider cells are polygonal with glycogen-laden vacuoles separated by cytoplasmic strands
extending from a centrally placed nucleus to the outer plasma membrane.

ARTERIOSCLEROSIS

Steve Nandkumar, MD

(Based on Dr. Jean OMorchoes Notes)

Pathology M-2 Atherosclerosis

1

ARTERIOSCLEROSIS

Definition: Thickening, hardening, and loss of elasticity of arterial wall.

Three types of arteriosclerosis:
1. Atherosclerosis (AS)
2. Monckeberg medial calcific sclerosis
3. Arteriolosclerosis

Atherosclerosis (AS)
Athera greek for gruel; sclerosis = hardening

Sites/Vessels affected by AS
1. Lower abdominal aorta
2. Coronaries
3. Popliteal arteries
4. Internal carotids
5. Vessels of Circle of Willis (brain)

Lesions
Are most common around:
1. OSTIA (origin) of major branches
2. Bifurcation sites

Lesions Seen in AS
Types Gross Microscopic
1. Fatty Streak Yellow flat spots Lipid containing foam cells,
1 mm- 1 cm size T-lymphocytes, extracellular lipid

NOTE: Fatty streaks may be precursors of plaques. Not all such lesions develop into plaques or
advanced lesions.

2. Plaques Focal patchy raised 1. Superficial fibrous cap
yellow, white lesions containing smooth muscle
0.3-1.5 cm size; cells and extracellular
eccentric, can become matrix.
diffuse, decrease lumen size. 2. Side of the cap (shoulder)
contains T cells, macrophages,
smooth muscle cells
3. central necrotic core
containing lipids
(cholesterol, cholesterol
esters) chol. clefts, foam
cells, fibrin, plasma
proteins, cell debris
4. new blood vessels

NOTE: Foam cells are lipid laden 1. Macrophages
2. Smooth muscle cells


2

3. Complicated/ Plaques show: Changes seen in #2 plus
Advanced hemorrhage, calcification,
Plaque 1. Erosion thrombosis, organization,
2. Ulceration lumen reduction, etc.
3. Rupture
4. Hemorrhage
5. Calcification
6. Thrombosis
(embolism occurs)
Risk Factors of AS

Major Minor

1. Age 1. Physical inactivity
2. Gender Non-modifable 2. Obesity
3. Genetics/family 3. Diet
4. Hyperlipidemia 4. Alcohol
5. Hypertension 5. Stress
6. Cigarette smoking 6. Estrogen lack in elderly
7. Diabetes 7. Homocysteine

Pathogenesis of AS

Hypotheses for AS include:
1. Reaction/response to injury
2. Monoclonal/oligoclonal
3. Infection

I. REACTION TO INJURY HYPOTHESIS

A. Chronic Endothelial Injury caused by hemodynamic factors and hyperlipidemia; other
factors are hypertension, homocysteine, smoking, toxins, viruses, and immune reactions.

AS protected sites AS prone sites
Artheroprotective genes Artheroprone genes
Superoxide dismutase present Superoxide dismutase absent
Smooth laminar blood flow disturbed, turbulent flow

B. Endothelial Dysfunction/Damage There is increased endothelial permeability and
expression of cell adhesion molecules. Increased monocyte, T lymphocyte adherence, and
emigration due to chemokines. Macrophages and T cells interact, produce cytokines and
induce a chronic inflammatory state. Macrophages oxidize and engulf LDL (foam cells).

C. Smooth muscle migration into intima, lipids are engulfed (foam cells). Cytokines and growth
factors cause smooth muscle proliferation.

D. Cell proliferation, extra-cellular matrix (collagen) deposition along with lipids " Atheroma
forms


3

II. MONOCLONAL/OLIGOCLONAL HYPOTHESIS

Clonal patches of cells exist in normal and AS lesional areas. Such clones may become active and
proliferate due to exogenous chemicals, oncogenic viruses etc. (simulates benign neoplastic
growth!), leading to atheroma formation.

III. INFECTION

Chlamydiae and viruses (CMV) may contribute to AS. Infection of a vessel wall can cause
inflammation, damage and subsequently AS lesions, due to cytokines.

COMPLICATIONS OF AS

1. Heart Coronary arteriosclerosis
Coronary Artery Disease (CAD)
Angina Pectoris; Myocardial
Infarction; Sudden Death;
Chronic Ischemic Heart Disease
2. Brain C. V. A/Stroke (Infraction)
Ischemic Encephalopathy
3. LxLremlLles (P. V. D) Peripheral Vascular
Disease/Gangrene
4. AorLa Aneurysm
3. kldneys Nephrosclerosis (Arteriosclerosis) Renal Dysfunction
6. Cl 1racL Mesenteric Occlusion/Bowel
Infarction


4

ARTERIOSCLEROSIS
(sclerosis = thickening/scarring)

This is a generic term referring to thickening, hardening, and loss of elasticity. It includes
atherosclerosis, Mnckebergs medial calcific sclerosis, arteriolosclerosis, and hypertensive
arteriosclerosis. Because atherosclerosis is the most common and important form of arteriosclerosis, the
terms are often used interchangeably.

ATHEROSCLEROSIS (AS) (athero = porridge)
AS primarily affects the intima of large elastic and medium muscular arteries in descending order of
frequency: lower abdominal aorta, coronaries, popliteals, descending thoracic aorta, internal
carotids, circle of Willis. However, atherosclerosis is always more or less generalized. About 50% of
all deaths in the United States are attributable to AS, but since the late 1960s a decrease in prevalence of
deaths due to coronary artery disease and cerebrovascular disease has been reported.

I. RISK FACTORS

A. Age: This is a major risk factor, but environmental and genetic factors are also involved.

B. Sex: This is a major risk factor. Male predominance at all ages until 7585 years. It is
suggested that the higher levels of circulating estrogen and HDL in the premenopausal female
are protective. However, it has recently been suggested that it is the loss of iron that protects
women during the reproductive years. The rate increases in women who smoke cigarettes,
have diabetes mellitus, or hypertension.

C. Genetic: it is suggested that genetic factors affect other risk factors.

D. Hyperlipidemia: This is a major risk factor, e.g., diabetes mellitus, myxedema,
nephrosis, xanthomatosis, familial hypercholesterolemia.
1. Hypercholesterolemia: this is a major risk factor, and the risk rises significantly over
200 mg/dl. LDL is the richest in cholesterol.
2. Hypertriglyceridemia: especially VLDL.
3. HDL, on the other hand, is inversely related to the risk. (However, a recent article
from Finland has shown that with HDL values over 1.75 mmol/l the mortality from
coronary heart disease increases.)
4. Lp(a), Lipoprotein a a heterogeneous lipoprotein (apolipoprotein a plus apoB-100
particles). High plasma levels of Lp(a) are an increased risk for AS.
5. Diet low cholesterol and low ratio of saturated to polyunsaturated fats lower plasma
cholesterol.

There is evidence that the reduction of total cholesterol or low density lipoprotein cholesterol, with
or without increase in HDL cholesterol, results in slowing of progression of lesions and regression
of existing lesions. The lowering of cholesterol and LDL can be produced in a variety of ways
(drugs, e.g., niacin, lovastatin, colestipol; partial ileal bypass or diet). However, in a different
study, the lowering of serum cholesterol did not affect overall survival.

Currently, it is recommended that everyone 20 years of age or older should undergo cholesterol
screening. Patients with a history of coronary heart disease or other atherosclerotic disease should
lower their cholesterol level to 100 mg/dl or lower.


5

E. Hypertension: This is a major risk factor and is particularly associated with stroke.

F. Cigarette smoking: This is a major risk factor with an unequivocal relationship with
coronary and aortic atherosclerosis. Males who smoke one or more packs/day have a
70200% greater death rate from IHD (ischemic heart disease) and an increased likelihood of
developing ischemia of the legs.

G. Diabetes mellitus: This is a major risk factor as it causes an increased level of blood
cholesterol, hypertension, obesity, and decreased levels of HDL. This condition is also
strongly linked to ischemia of the legs.

H. Homocysteine (HC), Elevated levels of HC, an amino acid, increases the risk of AS (MI and
Stroke). HC elevation can cause endothelial cell damage.

I. There are a number of soft risk factors. These include obesity, physical inactivity,
hyperglycemia, hyperuricemia, high carbohydrate intake, type A personality, alcohol
and coffee (controversial). Hard water, stress, and nonatherosclerotic cardiac abnormalities
have not been fully established as risk factors.

N.B. Combinations of risk factors are the main trouble makers.

TABLE 20-3. Hyperlipidemic Disorders

1
On standing, the plasma normally clears. Chylomicrons are large particles and tend to stay on the surface without
precipitating, producing a creamy supernatant. This is a simple test to detect lipoprotein abnormalities.
VLDL = very low density lipoproteins (high content of triglyceride).
LDL = low-density lipoproteins (high content of cholesterol).
N = normal serum level; normal levels are defined statistically for men and women, separately for different age groups.

Type

Elevated
Lipoprotein

Serum

Plasma on
Standing
1

Familial Disease
(Inherited)

Secondary

cholesterol

Triglyceride

I

Chylomicrons

N

$

Creamy

Lipoprotein lipase
deficiency (autosomal
recessive)

. . .

IIa

LDL

$

N

Clear

Familial hyper-
cholesterolemia (autosomal
dominant; varies)

Hypothyroidi
sm, nephrotic
syndrome,
dietary,
diabetes
mellitus

IIb

LDL plus
VLDL

$

$

Usually
Clear

Familial mixed
lipoproteinemia (autosomal
dominant; varies)

III

Beta-VLDL

$

$

Turbid

Familial dysbetali-
poproteinemia (autosomal
recessive)

Obstructive
jaundice

IV

VLDL

N

$

Clear or
turbid

Familial triglyceridemia
(variable)

Diabetes
mellitus,
alcoholism,
dietary

V

Chylomicrons
plus VLDL

N

$

Creamy

Very rare

. . .

6

FIGURE 12-6. Pathways for receptor-mediated metabolism of lipoproteins carrying endogenous and
exogenous cholesterol. HDL = high-density lipoprotein; LCAT = lecithin-cholesterol acyltransferase;
LDL = low-density lipoprotein; IDL = intermediate-density lipoprotein; VLDL = very-low-density
lipoprotein. The distinction between exogenous and endogenous cholesterol applies to the immediate source
of the cholesterol in plasma lipoproteins. After the exogenous cholesterol has been delivered to the liver and
has been secreted in VLDL, it is considered endogenous cholesterol. Note that HDL is the lipoprotein that
removes cholesterol from extrahepatic cells. (From Goldstein, J.L., et al.: Defective lipoprotein receptors
and atherosclerosis. N. Engl. J. Med. 309:288, 1983. Reprinted, by permission, from The New England
Journal of Medicine.)

FIGURE 4-11. Schematic illustration of LDL metabolism and the role of liver in its synthesis and clearance.
Lipolysis of VLDL lipoprotein lipase in the capillaries releases triglycerides that are then stored in fat cells and used
as a source of energy in skeletal muscles.

7

II. PLAQUE MORPHOLOGY

The morphology is related to disturbances in blood flow.

A. Diffuse Intimal Thickening: This is age-related and occurs in arteries particularly prone to
the development of atherosclerosis. However, the intimal thickening is not clearly related
to advanced atherosclerosis.

B. Fatty Dots and Streaks: These begin during the first year of life and are referred to as
juvenile fatty streaks, and are uncommon in older individuals. Black races have more
extensive lesions and females have more extensive lesions than males. The dots and streaks
consist of lipid deposits in the intima (foam cells and fat cells). However, the relationship to
atherosclerosis remains uncertain.

C. Gelatinous Lesions: These are foci of intimal edema. Again, the relationship to
atherosclerosis is uncertain.

D. Fibrous Plaque: (Atherosclerotic, atheromatous, fibrolipid, fibrofatty)

The fibrous plaque is the hallmark of atherosclerosis. It arises in the intima and may extend into
the media. Morphologically it is raised, pearly white to grey, smooth, few mms to > 1 cm in
diameter, and usually elongated in the long axis of the artery. It may encroach upon the lumen. A
yellow central core may or may not be present. The core consists of cholesterol, debris, foam
cells, and fibrin, etc. The plaque is covered by a fibrous cap.

Complicated fibrous plaques is the term used to describe the following changes:
(i) calcification of the cap and core producing, an eggshell brittleness, (ii) ulceration and
thrombosis, particularly in calcified plaques. Emboli may arise from these plaques, and occlusion
may occur, (iii) hemorrhage, which is common in advanced plaques and in those in the coronary
arteries, (iv) rupture is the most common cause of myocardial and cerebral infarcts,
(v) aneurysmal dilatation, which especially occurs in elastic arteries.

III. PATHOGENESIS

The exact mechanism is unknown. Current theories involve smooth muscle, endothelium,
platelets, and lipoproteins.

Smooth muscle migrates and proliferates and multiple factors play a role, e.g., PDGF (platelet
derived growth factor), macrophage factor, FGF (fibroblast growth factor), EGF (epidermal
growth factor), TGF# (transforming growth factor %) and inhibiting factors which include
prostaglandins, fatty acids, oxidative derivatives of cholesterol, HDL, heparin, estrogens, and
thrombocytopenia.

Smooth muscle cells have receptors for LDL and become foam cells. Injury to the endothelial
cells also plays an important role. Denuded or dysfunctioning endothelium permits platelets
and monocytes to adhere to the collagen and allows lipoproteins access to the wall. These
stimulate smooth muscle migration and proliferation. The monocytes have B-VLDL and modified
LDL receptors and they become foam cells.

Platelets adhere, aggregate, and release PDGF, and PGs.


8

Lipoproteins. Chylomicrons are formed of dietary triglycerides. VLDLs are endogenous
triglycerides. IDLs are formed from VLDL. LDLs are formed from VLDL and are bound by
fibroblasts, smooth muscle, lymphocytes, and endothelial cells and are taken up avidly by
macrophages. The lipoproteins may increase the rate of penetration of lipids into the vessel wall.

Lp(a) is a variant of LDL, and the level correlates with an increased risk of coronary artery disease.

HDLs are antiatherogenic, transport cholesterol to the liver and compete with LDL for cellular
binding.

The role of lipoproteins in atherosclerosis is not fully understood. It is suggested that they may
increase the permeability of endothelial cells and they may increase the replication and
adhesion of monocytes. Oxidized lipoproteins (from macrophages) cause injury to the
endothelium and smooth muscle, they are responsible for foam cell formation, and they
attract monocytes and inhibit the mobility of activated macrophages.

Current theories of the pathogenesis of atherosclerosis:

A. Reaction to Injury Hypothesis (see FIGURE 12-16).

FIGURE 12-16. Schematic diagram of a hypothetical sequence of events and cellular interactions in
atherosclerosis. Hyperlipidemia, as well as other risk factors, is thought to cause endothelial injury resulting in
adhesion of platelets and monocytes and release of PDGF (and other growth factors), which lead to smooth muscle
migration and proliferation. Smooth muscle cells produce large amounts of collagen, elastin, and proteoglycans, and
these form part of the atheromatous plaque. Foam cells of atheromatous plaques are derived both from macrophages
and from smooth muscle cells; from macrophages via the &-VLDL receptor and LDL modifications recognized by
scavenger receptors (such as oxidized LDL); and from smooth muscle cells by less certain mechanisms.
Extracellular lipid is derived from insudation from the lumen, particularly in the presence of hypercholesterolemia,
and also from degenerating foam cells. Cholesterol accumulation in the plaque should be viewed as reflecting
imbalance between influx and efflux, and it is possible that HDL is the molecule that helps clear the cholesterol
from these accumulations. The diagram also depicts other postulated mechanisms for smooth muscle proliferation,
bypassing primary endothelial injury: the action of mutagens, loss of growth control, and direct smooth muscle
injury (such as by oxidized LDL). PG = Proteoglycan. (From Cotran, R.S., and Munro, J.M.:

9

It should be noted that macrophages also synthesize and secrete a number of factors, e.g., IL-I and
TNF (tumor necrosis factor) which cause increased adherence to the endothelium by leukocytes,
chemotactic factors for leukocytes, toxic oxygen species which oxidize LDL, and PDGF and
TGF beta (growth inhibitor). The presence of hyperlipidemia results in the decreased synthesis of
PGI
2
.

B. Monoclonal (Mutagenic) Hypothesis.
This hypothesis states that a single, genetically transformed smooth muscle cell produces the
plaque. Mutagenic agents in this process include endogenous or environmental chemicals,
radiation, some viruses, cigarette smoke, and metabolic products of cholesterol.

IV. COMPLICATIONS

By itself atherosclerosis causes little trouble but the complications give rise to problems. For
example, ulceration and hemorrhage may lead to thrombosis and embolization with consequent
ischemia. Calcification and aneurysmal dilation are other complications.

It is believed that it is the nature of the plaque that determines the risk of acute cardiovascular
events. Dangerous plaques have a lipid rich core with surrounding inflammation and a thin friable
overlying fibrous cap. However, such plaques usually appear innocuous on angiography. On the
other hand, a stable plaque has a thicker fibrous cap without a large inflamed lipid core.

FIGURE 20-6. Complications of atherosclerosis.
C Calcification
U Ulceration
T Thrombosis
E Embolism
H Hemorrhage
A - Aneurysm

10

V. CLINICAL EFFECTS OF AS

FIGURE 20-6. Complications of atherosclerosis.

A. Arteriolosclerosis
1. Hyaline. This is a common type. It is associated with hypertension, increasing age,
and diabetes mellitus. Microscopically in the subendothelial tissues, a homogeneous,
glassy, pink material (H & E) is deposited. It starts focally and spreads around the
vessel with a narrowing of the lumen. In the cerebral arterioles there is a progressive
fibrosis of the media and adventitia. This form of arteriolosclerosis is a major
characteristic of nephrosclerosis.
2. Hyperplastic arteriolosclerosis is associated with hypertension, anoxia, and immune
damage. Microscopically there is intimal thickening, hypertrophy and hyperplasia of
smooth muscle, and thickening and duplication of the basement membrane giving an
onion skin-like appearance, luminal narrowing, fibrinoid deposits, and necrosis
(necrotizing arteriolitis). The pathogenesis is unclear possibly the entry of plasma
proteins through damaged endothelium.

FIGURE 20-7. Clinical effects of atherosclerosis related to the major arteries involved.

11

B. Hypertensive Arteriosclerosis
Clinically, hypertension is classified as: primary or essential, for which the etiology is
unknown and secondary which is caused by some underlying disorder. Both primary and
secondary types may follow one of two courses: chronic (benign) or accelerated (malignant).
Arteries of all sizes are involved. The changes in the large and medium arteries are the same
no matter whether chronic or accelerated. The changes in small arteries and arterioles differ
according to the type of hypertension.

1. Large and medium arteries. There is intimal and medial hypertrophy (involving both
smooth muscle and elastic tissue). Eventually collagenization of the intima and media
occurs. There is decreased resilience in the vessels which become tortuous and dilated.
2. Small arteries and arterioles. In benign hypertension there is hyaline
arterio/arteriolar sclerosis. In malignant hypertension there is thickening and
hyalinization of the intima (hyperplastic arteriolosclerosis). Arterioles (especially
renal) undergo fibrinoid necrosis, fibrin thrombi form, and there is narrowing of the
lumina.

In fibrinoid necrosis there are areas of cell death combined with the deposition of a fibrin-like
material. It occurs in arteries and arterioles. Neutrophils, masses of fibrin, immunoglobulins,
and other plasma proteins accumulate in the walls of the vessels and then undergo necrosis.

C. Mnckebergs Medial Calcific Sclerosis
This is an age-related condition and it is rare < 50 years. It is a degenerative process
affecting medium and small arteries. It has little or no clinical significance. The etiology is
unknown and in fact it is probably not a disease process. The femoral, tibial, radial, and
ulnar arteries and those of the genital tracts are particularly affected. Microscopically there is
calcification of the media and sometimes osseous metaplasia. The vessels feel hard and may
be dilated. Because of the calcification they can be seen on x-ray.
Revised 06/28/06 Reformatted 07/21/08

ISCHEMIC HEART DISEASE

Steve Nandkumar, MD

Pathology M-2 Ischemic Heart Disease

1


A heart disease that occurs as a result of myocardial ischemia an imbalance between supply
(perfusion) and demand of the heart for oxygenated blood.

Coronary artery disease (CAD) or coronary heart disease (CHD) is due to atherosclerotic arterial
narrowing or obstruction causing ischemia (90% cases).

AS lesions (erosions, ulceration, fissuring, rupture or thrombosis) constitute changes called disruption or
acute plaque changes.

IHD

There are 4 clinical syndromes.

1. Myocardial Infarction
2. Angina Pectoris
3. Chronic IHD with heart failure
4. Sudden cardiac death

PATHOGENESIS OF IHD

I. ROLE OF FIXED CORONARY OBSTRUCTION

75% reduction of vessel lumen of one or more major epicardial vessels.
E.g., LAD, LCX, RCA and their secondary branches.

II. ROLE OF ACUTE PLAQUE CHANGE

A. Disruption of a Partially Stenosing Plaque
B. Hemorrhage into Plaque
C. Rupture/Fissuring
D. Erosion/Ulceration
E. Thrombosis

Factors causing Plaque Disruption/Acute Changes
1. Stress ! adrenergic response ! systemic hypertension ! local vasospasm
!
Ischemia due to acute plaque changes
2. Plaque composition/tendency to rupture
3. The MOST DANGEROUS LESIONS are those that cause MODERATE STENOSIS OF
VESSELS (50-75% occlusion)
As opposed to SEVERELY STENOTIC lesions, the moderate ones
a. are more prone to rupture ( vulnerable plaque)
b. have more mechanical stress in the walls
c. have less collateral circulation


2

III. ROLE OF CORONARY THROMBUS/EMBOLISM PLAQUE DISRUTPION

Plaque disruption
Platelets fibrinogen

Thrombus formation

Growth signals smooth muscle proliferation

Embolism
Increases AS
IV. ROLE OF VASOCONSTRICTION

Adrenergic agonists, platelet products, NO !, endothelin ", mast cell mediators ! all cause
vasoconstriction ! ischemia.

V. ROLE OF INFLAMMATION

ACUTE CORONARY SYNDROMES

I. ANGINA PECTORIS Recurrent, paroxysmal attacks of chest pain or discomfort caused by
transient myocardial ischemia. There is no tissue necrosis.

There are 3 subtypes:

A. Stable Angina (Typical Angina) Most common
Chronic stenosing coronary AS (>75%) causes a reduction of perfusion to a critical level.
Plaque changes are absent.
" demand due to physical activity, emotional stress, etc. causes ischemia of myocardium.

REST ( !demand) RELIEVE ANGINA
NITROGLYCERIN (vasodilator)

B. Prinzmetal Angina - uncommon angina that occurs at REST and is due to vasospasm.
Transmural ischemia ! ST segment elevation noted. Usually unrelated to physical activity,
heart rate or BP.

Prompt response to NITROGLYCERIN
CALCIUM CHANNEL BLOCKERS

C. Unstable Angina (Crescendo Angina) Chest pain occurs with increasing frequency, at
rest, tends to be of most prolonged duration and is precipitated with less effort

Caused by: Plaque disruption with thrombosis/embolization
Vasospasm

This is a harbinger of a subsequent acute MI and is hence called preinfarction angina.

3

II. MYOCARDIAL INFARCTION (MI) (HEART ATTACK)

There are 2 types:

Transmural Subendocardial
(full thickness involvement) (involvement of inner 1/3 or ')
Chronic AS, acute plaque changes, Stenosing AS seen
obstructive thrombosis present Plaque changes, thrombosis
ABSENT (Lysis of thrombus)

Risk factors for MI ! same as those for AS.

Pathogenesis:
90% cases ! coronary AS ! Plaque disruption ! thrombus formation/occlusion
In 10% cases without thrombosis ! vasospasm, embolism, vasculitis, unexplained cause.

Myocardial response

A. Biochemical !aerobic glycolysis
"anaerobic glycolysis ! ATP " lactic acid
B. Functional
reversible changes (upto ' hour)
Ischemia causes
irreversible changes (necrosis)
When ischemia lasts between
Loss of contractile function 20-40 minutes ! microvascular
! injury follows.
Heart failure/arrhythmias Apoptosis occurs.

MYOCARDIAL SALVAGE IS TIME DEPENDENT. Early diagnosis and Rx can
minimize infarct size.

C. Morphologic
The type, number and severity of blood vessels involved by AS, presence of collateral
vessels, vasospasm, etc. affect the infarct location and size.

Subendocardial infarct ! wavefront progression/extension of infarct ! transmural infarct.

Pale zone (initial)
1. Gross changes !
Hyperemic area ! granulation tissue ! scar
2. Microscopic changes
Coagulative necrosis
Wavy fibers
Myocytolysis
Acute inflammation (2-3 days)
Macrophages remove necrotic tissue (5-10 days)
Vascularized granulation tissue (2-4 weeks)
Scar tissue (4-6 weeks)

4

3. Reperfusion injury

Alleviation of coronary occlusion (by medical or surgical means) within 3-4 hours after
onset of symptoms is CRITICAL (to prevent further myocardial damage). The
myocardium at- risk is thus saved.

Contraction band necrosis
Stunned myocardium (ventricular dysfunction)

Clinical Features

Chest pain/discomfort
Fever
Tachycardia, B.P. (
Dyspnea
Silent MI asymptomatic, Dx (diagnosis) by ECG
Q wave changes (10-15% cases) e.g., DM, elderly patients.

Lab Tests
Cardiac enzymes CK/CK-MB
Troponins
Other studies

COMPLICATIONS of MI
1. Contractile dysfunction L.V. failure, pulmonary edema, ! B.P.
pump failure (cardiogenic shock) " deaths
2. Arrhythmias associated with sudden deaths
3. Rupture of myocardium (3-7 days)

free wall I.V. septum papillary muscle

hemopericardium L to R shunt valve incompetence
and CARDIAC
TAMPONADE (fatal)

4. Pericarditis (2-3 days) / Dressler syndrome (2-10 weeks)
5. Mural thrombus/embolism
6. Ventricular aneurysm (LATE complication ABOUT 2 MONTHS OR MORE)
7. Progressive late heart failure

III. CHRONIC ISCHEMIC HEART DISEASE (ISCHEMIC CARDIOMYOPATHY)

Severe CAD with obstruction diffuse myocardial dysfunction chronic ischemic damage
-+ progressive heart failure


5

A. Gross Changes
Enlarged, heavy heart with LV hypertrophy
scars/patchy fibrosis
coronary artery AS, stenosing/occlusive
B. Microscopic Changes
Myocardial hypertrophy
vacuolization of muscle cells
scars
CAD

IV. SUDDEN CARDIAC DEATH

Unexpected death from a cardiac cause within 1 hour after onset of symptoms/or no symptoms.

Cause is ALWAYS CARDIAC ARRHYTHMIA!

Injury to conduction Electrical irritation of
pathway damaged myocardium

Morphology

IMP 1. Severe AS with > 75% stenosis of vessels ] 90% cases
acute plaque changes/disruption

2. Non AS related cause ] 10% cases
e.g., valve stenosis or prolapse
myocarditis
cardiomyopathy
conduction pathway abnormalities
Pulmonary-HTN/Congenital coronary artery abnormalities

Also noted are healed MI (40% cases) and subendocardial vacuolization of cells.


6


I. REVIEW OF NORMAL GROSS ANATOMY AND HISTOLOGY OF THE HEART

Special reference to the structure and distribution of the coronary arteries and to the light and
electron microscopic structure of cardiac muscle.

II. PATHOLOGY GENERAL

A. Review the processes of adaptation with special reference to the heart. There is evidence
that hypertrophy of the left ventricle in the athlete and the patient with hypertension is not the
same. It has been shown that in hypertension there is increased fibrosis as well as increased
size of myocytes.

B. Review the processes of cell injury with special reference to cardiac muscle. Particularly
think about ischemia, starting at the molecular level within 1530 seconds, mitochondrial
aerobic respiration stops and anaerobic glycolysis starts.

III. ISCHEMIC HEART DISEASE (IHD)

A. General
1. IHD is a generic term for a group of closely related syndromes caused by an imbalance
between supply and demand for oxygen. Most cases are due to narrowing or
obstruction of a coronary artery and are often referred to as coronary heart
disease (CHD) or coronary artery disease (CAD).
2. Causes of decreased oxygen supply: (a) increased demand outpaces supply,
(b) decreased transport in blood, and (c) decreased coronary blood flow which
accounts for > 90% of cases (AS, thrombosis, vasospasm, platelet aggregation).
3. Ischemic syndromes are: (a) angina pectoris, (b) myocardial infarction (MI),
(c) chronic ischemic heart disease, and (d) sudden cardiac death.
There is often a long prodrome (decades) of silent, slowly progressive coronary
atherosclerosis
4. Epidemiology
IHD is the leading cause of death in the U.S. and other industrialized nations. It
accounts for about 80% of all cases of cardiac mortality. However, the death rate has
fallen since the late 60s (by about 50%) partly due to changes in lifestyles,
prevention of major risk factors for atherosclerosis, and improved early diagnosis and
therapy.

There has been considerable debate in recent years with regard to whether women receive
the same aggressive care as do men for ischemic heart disease. I refer those of you who
wish further information to a review article in the NEJM, Vol. 334, No. 20, May 16, 1996,
p. 1311: The Evaluation of Chest Pain in Women by Pamela S. Douglas, M.D., and
Geoffrey S. Ginsburg, M.D., Ph.D.


7

5. Pathogenesis
There is decreased coronary perfusion caused by:
a. Coronary atherosclerosis. This exists in > 90% of patients with the
IHD syndrome. A 75% or greater reduction of the cross-sectional area of at
least one major subepicardial artery (fixed chronic obstruction) is necessary to
block the augmented flow needed for a moderate increase in myocardial demand.
Usually 2 or all 3 major epicardial vessels are involved. The major sites at
which the stenosing plaques occur are the first 2 cm of the LAD and the LC
and the proximal and distal one-thirds of the RC. Sometimes major
secondary branches are also involved. Slowly developing occlusions usually
lead to compensatory collateral vessel development (a protective mechanism).
There is usually a good correlation between the extent and severity of
atherosclerosis and acute plaque events and the ischemic syndromes or their
severity.
Acute plaque events depend on:
(1) Intrinsic factors
Physicochemical nature of the plaque (vulnerable plaque)
(2) Extrinsic factor
Adrenergic stimulation
HTN
Vasospasm
Platelet reactivity increase

NOTE: 1) Partially stenotic vessel (50-70% occlusion) + acute plaque events thrombosis

Sudden death COMPLETE OCCLUSION
or acute transmural MI

2) Partially stenotic vessel + acute plaque events thrombosis INCOMPLETE
OCCLUSION

1. Unstable angina
2. Subendocardial
infarction
3. Sudden death

Nitric oxide is released continuously from the endothelium to assist in the
maintenance of vascular tone and in the prevention of the adhesion of platelets
and leukocytes. The release of NO is increased in the following situations:
aggregation of platelets, serotonin, thrombin, and %
2
adrenergic receptor agonists
and shear and stress forces.

In atherosclerosis, the release of NO is impaired. This would leave the
endothelinI (released from the endothelium) unopposed " vasoconstriction
with lumen narrowing.
b. Platelet aggregation within the coronary system. The aggregation occurs
following rupture of a plaque and the subsequent exposure of collagen. The
platelets adhere, aggregate, and become activated. This may be followed by the


8

formation of thrombi, microemboli, and vasospasm of the vessel. Thrombus
activated growth related signals can cause smooth muscle proliferation and
more AS.
c. Vasospasm (vasoconstriction) may occur over the plaques and may cause
rupture or fissuring of the plaques followed by platelet aggregation, etc. The
cause of the vasospasm is believed to be due to adrenergic agonists, mediators
released from inflammatory cells, the action of platelet products, and increased
endothelin (low NO).
d. Role of inflammation. Atherogenesis depends on the interaction of endothelial
cells, leucocytes, T-cells and macrophages. Cytokines formed promote AS.
Macrophage produced matrix metalloproteinases can cause collagen digestion
and plaque rupture " ischemic events.
CRP C reactive protein
Aspirin use
e. Nonatherosclerotic coronary disease. The narrowing of the coronary vessels in
this type of IHD are due to the following: emboli, arteritis, cocaine, and trauma.
f. Hemodynamic derangements. These include a fall in blood pressure, increased
pressure in the right atrium and coronary sinus, and left-sided heart failure.

FIGURE 23-2. Causes and clinical consequences of ischemic heart disease.

How do they help?

9

B. Ischemic Syndromes

Acute Coronary Syndromes
Unstable Angina
Acute MI
Sudden cardiac death

1. Angina pectoris (AP)
AP refers to paroxysmal recurrent attacks of substernal or precordial discomfort
or pain caused by transient (15 seconds-15 minutes) myocardial ischemia.
There is often evidence of previous MI(s) with interstitial fibrosis and myocyte
atrophy. Varying combinations of fixed stenoses, vasospasm, platelet
aggregation, and increased myocardial demand play a role.
Three overlapping patterns of AP are encountered. Patients may manifest
one or all of the three either concurrently or at different times.
a. Stable or typical. This is the most common type and there is
involvement of the subendocardial region of the left ventricle and EKG
shows ST depression. The condition is usually provoked by emotion,
exertion, and tachycardia. Pathogenesis chronic stenosing
atherosclerosis of the vessels is found with perfusion of the myocardium
decreased to a critical level. Rest (decreased demand) and NG
(nitroglycerin) help relieve the pain.
b. Prinzmetals. This type of AP occurs at rest usually unrelated to heart
rate, blood pressure or physical activity and is due to vasospasm. The
EKG shows ST elevation. Pathogenesis is unknown but the patients may
have significant atherosclerosis. The theories put forward to explain
Prinzmetals angina are hypercontractility of a segment of a major
epicardial trunk and abnormal infiltrates of mast cells within the adventitia
which secrete vasoconstrictors, e.g., XA
2
.
NG and calcium channel blockers (vasodilators) help relieve discomfort.
c. Unstable or crescendo (preinfarction angina or acute coronary
insufficiency). This type of AP occurs with increasing frequency in the
patient and progressively less effort is required to initiate it. In fact, it
often occurs at rest and the period of pain becomes increasingly prolonged.
A very important aspect of unstable AP is that it forewarns of an MI. The
pathogenesis is that of progressive atherosclerosis with fissures, ulcers, or
rupture of the plaques and platelet aggregation with thrombosis
embolization and vasospasm. The lesions involve a branch of the artery
rather than the main trunk.

2. Myocardial infarction (MI)
a. Acute myocardial infarction (AMI)
Acute myocardial infarction is the most important form of IHD in
industrialized nations and is the leading cause of death in the U.S. There
are about 1.5 million MIs/annum in the U.S., and they are the most frequent
cause of death (500,000/annum) in men over age 35 and women over 65 in
the U.S. The North American male has a 1 in 5 chance of an MI or of
dying suddenly from an AMI < 65 years. Heart attacks were recognized as
a public health problem only in this century, and it is predicted that they
will lose this notoriety early in the next. This is because of our greatly
increased understanding of the pathogenesis of atherosclerosis and the

10

favorable results of three major clinical trials of the therapeutic value of the
drugs called statins. Statins inhibit 3-hydroxy-3-methyl glutaryl CoA
reductase, a key enzyme of cholesterol synthesis. The statins slow
cholesterol production and enhance receptor-mediated removal of LDL
from the plasma.
b. The incidence of MI is directly related to the incidence of atherosclerosis.
MI can occur at any age and the frequency increases with age. There is
not any difference in incidence between black and white races. It is
greater in males than in females who are protected against MI in their
reproductive years. With increasing age and declining estrogen levels, the
incidence of CAD and MI increase (most common cause of death in
elderly women).
c. Risk factors include cigarettes (directly related to the number per day and
also includes passive smoking), personality (controversial) and in fact
anything that is a risk factor for atherosclerosis.
Cigarette smoke is related to damage to the endothelium, coronary
vasospasm, platelet aggregation, CO production, and increased viscosity
and increased fibrinogen and cholesterol levels. It has also been shown
that smoking causes reduction in the aorta flexibility and elasticity as well
as causing the left ventricle to pump more furiously. The oxygen
demand of the ventricle is increased but the ability of the coronary arteries
to supply oxygen to the heart muscle is decreased because of the stiffened
aorta. It is estimated that passive smokers have a 30% increase in the risk
of death from ischemic heart disease or MI. (Environmental tobacco
smoke is composed of mainstream smoke exhaled by the smoker and
sidestream smoke emitted from a lit cigarette. Sidestream smoke appears
to be more dangerous than mainstream.)
d. Two types of MI are described with differing morphology and clinical
significance.
(1) Transmural is most common and most serious of the two types.
There is ischemic necrosis of all or nearly all of the ventricular
wall. The area of ischemia is at least 2.5 cm in its greatest
diameter. Severe atherosclerosis, acute plaque changes and
thrombosis are present in the vessels.
It has been shown experimentally that ischemic and irreversible
damage begins first and is greatest in the subendocardial zone
presumably because the microcirculation is compressed by the
ventricular muscle contraction. However, usually a thin rim of
subendocardial tissue (about 0.1 mm) is preserved because of direct
imbibition of nutrients and 0
2
diffusion from the blood in the
ventricle.
(2) Subendocardial (nontransmural). In this type the ischemic necrosis
is limited to the inner or at most $ of the ventricular wall.
Atherosclerosis without thrombosis of at least three vessels but
not usually major vessels is noted. One explanation is that there is
extreme coronary hypoperfusion due to a decreased blood pressure
in the presence of a compromised coronary blood flow.

Occasionally, AS with acute plaque events and thrombosis followed
by lysis of thrombus (before necrosis spreads across the wall) can be
seen.

11

An MI may start as subendocardial and extend in a wave front
across the wall.
e. Pathogenesis
(1) Transmural 90% of the cases are associated with an occlusive
thrombus over an ulcerated or fissured stenotic plaque. Platelet
aggregation/activation and vasospasm also contribute. NO release
will be decreased in atherosclerosis, but the aggregation of platelets
will encourage NO release. An increased myocardial demand
worsens the situation. Sequence of events: 1) A sudden change in
the morphology of the stenosing atheroma, e.g., hemorrhage, ulcer,
or fissure. What causes the sudden change? 2) Platelets
adhere/aggregate/activate with platelet emboli or thrombosis and
release of tissue thromboplastin which causes coagulation;
3) platelets release thromboxane, serotonin, platelet factors 3 and 4
with coagulation, vasospasm occurs, and there is increased size of
the thrombus; 4) occlusion by the thrombus causes the AMI. Some
thrombi clear spontaneously by lysis and/or relaxation of the spasm.
It should be noted that 10% of transmural MIs are not related to
atherosclerotic thrombosis. Vasospasm, emboli, arteritis,
amyloidosis, hemoglobinopathies, and cocaine have all been
suggested as the precipitating cause in this 10% of cases.

As mentioned in the section on blood vessels, it appears that there
are dangerous plaques with a thin friable fibrous cap overlying a
large lipid core with intense surrounding inflammation. The stable
plaque has a thicker fibrous cap without a large inflamed lipid core.
The dangerous plaques appear innocuous on angiography.

Collaterals determine the degree of ischemia and the rates of
myofiber death in the different areas.

A window exists between the onset of ischemia and irreversible
injury. This window is very relevant to the methods of therapy
currently available and some cells may be salvaged even though
they may not function for 12 days.

The ultimate size of the infarct and the amount of viable
myocardium, after acute coronary occlusion, depend on the
duration, extent, and severity of ischemia (coronary artery events),
and the extent of collaterals. The metabolic demands of the
myocardium also play a role. The infarct may be surrounded by
reversibly injured myofibers and patches of necrosis.
(2) Subendocardial there is advanced atherosclerosis, often without
critical stenosis and it is possible that the thrombus initiates the
process, but is spontaneously lysed. At autopsy, total occlusion of a
major vessel or a branch is uncommon. It is possible that diffuse
atherosclerosis, combined with reduced flow, critical insufficiency
caused by increased demand, and vasospasm or platelet aggregation,
are the precipitating events leading to the MI. In other words, a
lowered blood pressure in the presence of a compromised coronary
blood supply.

12

In Disease at the Cellular Level, the effect of hypoxia on
myocardial cells was discussed and the following points are relevant
here: myocardial cells exposed to hypoxia protect themselves by
(a) the cells closely regulate the concentration of intracellular Ca
2+

by regulating Ca
2+
influx via slow Ca channels. The local acidosis
rapidly reversibly inhibits the channels so that there is a decreased
Ca
2+
influx which leads to a decreased force of contraction and thus
the cells are protected, and (b) the decreased ATP affects the
K channels so that there is an increased K
+
outflow. Therefore,
overall there is a decreased action potential, decreased Ca
2+
influx,
and a conservation of ATP.
f. Morphology
(1) Transmural the left ventricle and septum are involved and in
1530% of cases the right ventricle is also involved. However, the
right ventricle alone is rare. In 510% of cases, the atria also are
involved, but atrial involvement alone is very rare. The size of the
infarct is 2.510 cm in the longest diameter and it may involve the
entire circumference of the left ventricle. Severe stenosing
atherosclerosis and thrombosis is seen in the vessels. There is
usually a single infarct, but several of varying ages may be
encountered.
Collaterals occasionally prevent development of an MI in spite of
thrombus formation. The presence of collaterals may occasionally
result in a single infarct in spite of multiple severe stenoses or
thromboses and occasionally because of the collaterals there is
infarction at a distance from the thrombosis.

Which type of individual would be the most likely to have
well-developed collaterals?

Stuttering infarct refers to the extension of an infarct to produce
lesions of varying age. The situation is due to retrograde propagation of
a thrombus, proximal vasospasm, impaired contractility, the formation
of platelet/fibrin emboli, and arrhythmias.

The progressive sequence of macroscopic changes depend upon the
length of survival of the patient, < 612 hours macroscopic changes are
inapparent or the muscle is slightly paler than normal. In the first 3
6 hours if the tissue slices are immersed in a solution of
triphenyltetrazolium chloride (TTC) the infarcted area is pale due to
loss of dehydrogenase enzymes and the surrounding normal
myocardium is red/brown. Similarly, if the tissue is immersed in
succinate dehydrogenase, the infarcted area remains white. In 1824
hours the area appears pale or red/blue (trapped blood). In 24 hours a
more sharply defined, yellow, softened area is noted. In 7-10 days the
area is surrounded by a hyperemic, moist, narrow zone. During the
following weeks the necrotic muscle is replaced by scar tissue.

Histopathology coagulative necrosis and fibrosis are the major
changes. It may be possible to see a WAVINESS of the myofibers at
the edge of the infarct within the first 30 minutes. At the LM level
subtle changes can be detected in 48 hours and include edema and
stretched wavy myofibers at the border of the infarct, lipid droplets, and

13

vacuoles (MYOCYTOLYSIS) in the viable muscle cells at the margins
of the infarct, and a narrow rim of preserved subendocardial
myocardium. Severe stenosing atherosclerosis is present in the vessels.
At the EM level, changes in the mitochondria can be detected within the
first 30 minutes (Table 13-2).

TABLE 13-1. Time Sequence of Changes in Acutely Ischemic Myocardial Cells

Beginning depletion of ATP
Loss of contractility
50% depletion of ATP
Irreversible cell injury

Almost immediate
12 minutes
10 minutes
2040 minutes

Vessel
Frequency of Critical
Narrowing (and
possible thrombosis)

Typical Lesions

Left anterior
Descending
40-50% Anterior wall left ventricle near
apex,anterior 2/3 I-V septum
LAD also supplies '
of anterior wall of
right ventricle

Right coronary
Artery
30-40% Posterior wall left ventricle,
posterior 1/3 I-V septum
Right coronary also supplies
remaining ' of the anterior
wall of the right ventricle
Left circumflex 15-20% Lateral wall left ventricle


14

TABLE 13-2. Sequence of Changes in Myocardial Infarction

Time

Electron
Microscope

Histochemistry

Light Microscope

Gross Changes
0' hr Reversible injury
Mitochondrial
swelling; distortion
of cristae; matrix
densities;
relaxation of
myofibrils
# Dehydrogenases
# Oxidases
# Phosphorylases
# Glycogen
# K and $ Na
+

and Ca
++

? Waviness of fibers at
border

12 hr Irreversible injury
Sarcolemmal
disruption:
mitochondrial
amorphous
densities

412 hr Margination of
nuclear chromatin

Beginning coagulation
necrosis; edema;
hemorrhage; beginning
neutrophilic infiltrate

1824 hr

Continuing coagulation
necrosis; Pallor (pyknosis
of nuclei, shrunken
eosinophilic cytoplasm),
marginal contraction band
necrosis
Pallor
2472 hr

Total coagulative necrosis
with loss of nuclei and
striations; heavy interstitial
infiltrate of neutrophils
Pallor, sometimes
Hyperemia
37 days

Beginning disintegration of
dead myofibers and
resorption of sarcoplasm by
macrophages; onset of
marginal fibrovascular
response
Hyperemic
border, central
yellow- brown
softening
10 days Well-developed necrotic
changes; prominent
fibrovascular reaction
in margins
Maximally
yellow and soft
vascularized
margins,
red-brown and
depressed
7th wk Scarring complete


15


16

(2) Subendocardial The morphologic changes are qualitatively
similar to those seen in transmural infarction. The inner of the left
ventricular wall is involved. The lesions may be multifocal, cover
an arc of the circumference, or totally encircle the ventricle.
Time wise the changes are also similar to transmural except gross
changes may not be as sharply defined.
The major complication is the formation of mural thrombi. Other
complications are rare.

REPERFUSION CHANGES
Restoration of coronary flow (reperfusion) by medical and/or surgical means is
necessary for tissue perfusion so that the ischemic myocardium can be salvaged before
permanent loss (necrosis). Reperfusion limits infarct size and preserves structural and
functional integrity of the myocardium at risk.

NOTE: REPERFUSION WITHIN 3-4 HOURS FOLLOWING ONSET OF
SYMPTOMS IS CRITICAL. 1) Thrombolysis by t-PA (tissue
Plasminogen Activator) or streptokinase is by activation of fibrinolytic
system). The underlying AS/plaque remains unchanged. 2) PTCA-
percutaneous transluminal coronary angioplasty and CABG-coronary
artery bypass-graft surgery remove thrombus and treat underlying CAD.

REPERFUSION CHANGES SEEN ARE:
1. Hemorrhage, due to leaky blood vessels at the injured site.
2. Contraction band necrosis: Dark, eosinophilic, transverse bands spanning the
muscle fibers. Reperfusion Ca ion influx act on dead/dying muscle
cell membrane exaggerated contraction of myofibrils
CONTRACTION BANDS.
3. Reperfusion injury: There is some new cell damage due to
a. generation of 0
2
free radicals.
b. apoptosis of cells.
Microvascular injury
Perfusions can cause endothelial damage, swelling and occlusion of vessels. So
there is no-reflow. Muscle damage worsens.

OTHER ISCHEMIC EFFECTS:
Hibernation
Persistent ischemia with chronic depressed function in a myocardial tissue
leads to hibernating muscle.
Stunning
Myocardial stunning or ventricular dysfunction may occur with reperfusion
owing to biochemical and functional changes of injured muscle fibers.
Pre-conditioning
Short lived ischemia may be protective-the myocardium is protected against
greater subsequent ischemic insult mechanism is unknown.

g. Complications of MI:
The complications depend on the size and site of infarction along with the extent of
wall damage and are as follows:

17

(1) Contractile dysfunction: Myocardial damage/dysfunction leads to heart
(ventricular) failure hypotension-pulmonary congestion and edema. PUMP
FAILURE (cardiogenic shock) occurs in 10-15% of cases with greater than 40% LV
wall damage. The mortality rate is 70%.
(2) Cardiac arrhythmias: Myocardial irritability and conduction pathway damage
can lead to bradycardia, tachycardia, fibrillation, etc. Sudden death can occur.
(3) Cardiac rupture: Most frequent between days 3-7, 1-5% incidence
(a) Free L.V. wall hemopericardium cardiac tamponade
occasionally a false aneurysm can occur with pericardial adhesions.
(b) I.V. Septum L to R shunt
(c) Papillary muscle ruptures (uncommon) A.V. valve incompetence.
(4) Infarct extension and expansion.
(5) Mural thrombus and thrombo-embolism.
(6) Pericarditis occurs 2-3 days following an infarct.Dressler syndrome( 2-10 weeks)
(7) Progressive late cardiac failure.
(8) Ventricular aneurysm: Following a large infarct, reparative fibrosis (scar
tissue) replaces myocardium. This bulges during systole to form an aneurysm
with associated thrombus formation, arrhythmia and heart failure. It occurs
WEEKS TO MONTHS AFTER A MYOCARTDIAL INFARCTION.
h. Clinical Diagnosis:
(1) Symptoms
The onset is sudden, with a devastating, severe, radiating pain. This is
accompanied by sweating, nausea, vomiting, and breathlessness. However, the
symptoms may be less specific and in 1015% of cases the patient is
ASYMPTOMATIC. Such silient MIs are common in the elderly and in those
with diabetes mellitus.
(2) ECG
Changes are usually evident from the onset. Because ECG changes occur very
early (several hours before elevated enzyme levels appear) the decision to institute
thrombolytic therapy is made on the ECG changes. With the advent of more rapid
enzyme assays this scenario might change. However, they may be nondiagnostic
so that a substantial number of patients may not receive the therapy. Because of
this some centers do not rely on EKG changes before deciding to commence
thrombolytic therapy.
(3) Cardiac biomarkers
Are more sensitive and reliable than ECG. LDH (lactic dehydrogenase) is
elevated. The elevation begins in 24 hours, peaks in 36 days, and returns to the
baseline at the end of the second week. CK (creatine kinase) is elevated. The
elevation begins in 48 hours, peaks early or in several days, and returns to the
baseline in 4 days. The elevation of CK-MB (isoenzyme) is quite specific
(although skeletal muscle injury also causes elevated levels of CK-MB and this is
important to remember if a patient has undergone recent surgery). Recently a rapid
assay (6 minutes, with high voltage electrophoresis) for CK-MB isoenzymes has
been reported that can detect MI within 6 hours of onset if symptoms with a much
higher specificity than the conventional CK-MB assay performed within the first
6 hours.
Other serum biochemical markers are under investigation. The troponins (cTn)
have gained attention as the gold standard in detecting myocardial injury,
(troponin I, C and T complex regulates the calcium-mediated interaction between
actin and myosin). They are absent from the serum of healthy subjects and are,
therefore, able to detect minor myocardial-cell injuries. A rapid assay

18

(20 minutes) for bedside determinations of cardiac troponin T has been
developed. It has several advantages over CK-MB testing (persists longer in the
circulation than CK-MB; can be differentiated from skeletal muscle isoforms). It
has been reported that cTnI is more specific than cTnT and is the troponin of
choice. The advent of cTnI has eliminated the need to measure LD and LD
isoenzymes.
(4) Echocardiography and Radioisotopes
i. Therapy:
(1) Thrombolytic, to produce reperfusion, e.g., I-V streptokinase (SK), tissue
plasminogen activator (t-PA), anisoylated plasminogen streptokinase activator
complex (APSAC). It has been shown in one clinical study that accelerated t-PA
(rapid I-V perfusion of t-PA over 1' hours with _ of the dose in the first 30
minutesthe conventional time is 3 hours) plus I-V heparin gives the best
survival. An even faster t-PA regimen is now under investigation the so-called
double bolus approachwhich may be even more effective. In the first 46
hours with thrombolytic therapy, a 25% reduction in mortality has been reported.
If the therapy can be administered in the first hour, there may be a reduction in
mortality up to 50%. The three drugs cited above are being compared by the
Third International Study of Infarct Survival. There is considerable controversy
regarding the efficacy and side effects of the thrombolytic drugs, especially in
view of the fact that t-PA costs $2,200 per dose 10X that of streptokinase.
However, thrombolytic therapy is regarded as the treatment of choice for AMI in
most clinical settings. Following early reperfusion the irreversibly injured
myocytes may show contraction band necrosis (seen at the LM level as deeply
eosinophilic bands running across the fibers), and reversibly injured cells may
recover. However, the rapid influx of Ca
++
and release of oxygen free radicals
may cause more irreversible damage.
(2) Percutaneous transluminal coronary angioplasty (PTCA) involves dilating a
balloon in the stenosed area causing plaque compression and fracture with
hemorrhagic dissection or aneurysmal dilatation. This technique is used to treat
an increasing number of patients with stable or unstable angina or AMI. Thirty
percent of the vessels following angioplasty restenose.
(3) Bypass grafts from the saphenous vein or internal mammary artery may be
employed. Venous grafts in 5 to 10 years develop intimal thickening and
atherosclerosis. A recent editorial in the NEJM states there is now
incontrovertible evidence that for patients with severe diffuse coronary
atherosclerosis who are candidates for myocardial revascularization,
internal-mammary-artery grafting to the left anterior descending coronary artery
is the single most important determinant of survival and event-free survival.
Minimally invasive techniques are required without need for a sternotomy or
heart-lung bypass and a final quote from the same article states open-chest
coronary bypass and coronary angioplasty both may be eclipsed by a minimally
invasive technique that safely provides new and biologically better arteries.
(4) Atherectomy is used to remove plaques.
(5) Intracoronary laser therapy is also used to remove plaques and may be used
alone or in combination with PTCA.
j. Outcome of AMI:
(1) Sudden cardiac death (SCD) occurs in 25% of cases. About 250,000 cases die
within 1 hour of onset BEFORE REACHING THE HOSPITAL.
(2) In-hospital patients with an uncomplicated course account for 1020% of cases;
complications develop in 8090% of cases, e.g., arrythmias (7595%) which

19

may result in SCD, left ventricular dysfunction (60%) which may lead to
cardiogenic shock, cardiogenic shock (10%), rupture (15%), and
thromboembolism which is an important in-hospital cause of death. Sudden
cardiac death occurs at the rate of about 1,000 per day in the U.S. with an annual
death toll of 300,000 to 400,000.
Prognosis is difficult to assess because there are many variables. The overall
total mortality rate is about 10-13%. With prompt diagnosis and aggressive
treatment, it is about 7%.
Prevention is a most important aspect of MI; primary prevention is for people
who have never had an MI. The aim is to control hypercholesterolemia,
hypertension, and cigarettes. Secondary prevention is for patients who have
recovered from an MI. The aim is the same as for primary control plus
&-blockers, antiplatelet agents, and anticoagulants.
(3) Sudden cardiac death (SCD)
Unexpected death from cardiac causes within 1 hour (some say 24 hours) of
the onset of acute symptoms or without symptoms. Most of the patients are
adults with AS caused IHD, but sometimes they have aortic valve stenosis or
hereditary or acquired abnormalities. In young patients the condition is rare and
is associated with myocarditis, conduction abnormalities mitral valve prolapse,
and hypertrophic cardiomyopathy. 8090% of the patients have coronary
atherosclerosis with > 75% stenosis of one major vessel. 4060% of the cases
show acute coronary changes (thrombosis, fissures, etc.), and < 25% have a
new MI. Death is from cardiac arrhythmia, due to myocardial irritation or
electrical dysfunction (conduction pathway damage or ion channel pathway
mutation).
(4) Chronic ischemic heart disease (CIHD) (ischemic cardiomyopathy, or
coronary cardiomyopathy)
(a) This controversial entity is seen in elderly patients. There is progressive
ischemic damage of the myocardium and usually a history of angina or
prior MIs. Occasionally the condition is silent. Many of the patients die
from congestive heart failure.
(b) Morphology. There is diffuse myocardial brown atrophy, diffuse
patchy foci of fibrous tissue, or healed scars of MIs, interstitial
fibrosis, and myocytolysis. The coronaries show stenosing
atherosclerosis with/without total occlusion.
(c) Diagnosis is from the atherosclerotic narrowing of the coronaries,
atrophy of the myofibers, spotty myocytolysis, and diffuse small scars.
(d) Clinically the diagnosis is made by the insidious onset of congestive
heart failure in patients with a history of angina or MI, ECG changes,
and the presence of murmurs.
(5) Silent myocardial ischemia
This term is used to describe the 10% of middle-aged men in the U.S. who have
asymptomatic, but active, coronary artery disease, other patients who have silent
disease after an MI and others who have a combination of silent ischemia and
angina. The pathophysiology is unclear.
Revised: 07/21/10

CONGENITAL HEART DISEASES

William Albers, MD
Pathology M-2 Congenital Heart Disease Lecture 1

1

INTRODUCTION TO CONGENITAL HEART DISEASE
William H. Albers, MD

I. DEFINITION:
Defect present at birth

II. INCIDENCE
8-10/1,000 live births
Recurrence risk 2%
Risk for parents with CHD - 10%

III. ETIOLOGY
Multifactoral
Chromosomal
Autosomal
Drugs
Viral
Idiopathic = 90%

IV. PERINATAL CIRCULATION
Key points
A. 3 shunts ductus venosus, foramen ovale and ductus arteriosus
B. Pulmonary resistance > systemic
C. Flow promotes growth
D. Important factors in postnatal

V. ADJUSTMENT
A. First breath " # pulmonary vascular resistance
B. Prostaglandins, bradykinin
C. Increased oxygen

VI. CLASSIFICATION
A. Acyanotic
1. Left to right shunts
2. Obstructions
B. Cyanotic
1. Obstruction to pulmonary blood flow with right to left shunt
2. Transposition of great arteries
3. Mixing lesions

VII. CLINICAL PROBLEMS
We will discuss as many as possible. Students should review syllabus and problems before class
session.


2

CONGENITAL HEART DISEASE SEGMENT
CARDIOVASCULAR ORGAN SEGMENT

LECTURE 1

INTRODUCTION TO CONGENITAL HEART DISEASE

Objective 1 Understand general principles of cardiac development and fetal circulation and how
these effect post-natal circulatory adjustments.

Objective 2 Identify the three major cardiac segments

Objective 3 Describe the major differences in the fetal and adult circulations and define the roles of
the foramen ovale, the ductus venosus and the ductus arteriosus.

Objective 4 Describe the changes in pulmonary vascular resistance after birth.

Objective 5 List normal values for pressure and oxygen saturation in each cardiac chamber and
describe methods for measuring cardiac output and vascular resistance

References
Adams, Emanouilides, and Riemenschneider Moss Heart Disease in Infants, Children and Adolescents
4
th
ed., Williams and Wilkins, 1989.

Embryology and Development pp. 2-14
Etiologic Factors pp. 15-23
Fetal and Perinatal Circulation pp. 24-33
Cardiac Output Hemodynamics and Shunts pp. 136-144

Lecture Notes

History Congenital heart disease (CHD) is defined as heart disease present at birth. The formal study
of CHD began in the early 1930s with the work of Dr. Helen Taussig, who was able to classify certain
groups of findings into clinical diagnoses. In 1938, Dr. Robert Gross successfully repaired a patent
ductus arteriosus to open the era of surgical correction of CHD. Cardiac catheterization was developed in
the 1940s, leading to more accurate diagnosis. Open heart surgery was pioneered by Dr. Gibbon (1953)
and Dr. Lillehei (1954) who did the first atrial septal defect and Tetralogy of Fallot, respectively. The
incidence of CHD is approximately 1% or about 35,000 infants per year. Of these, 10,000 infants have
critical or life-threatening CHD. In 1960, 90% of these infants died. Today 90% survive.

Early diagnosis and treatment of serious CHD is lifesaving and all physicians caring for children should
have some familiarity with the presenting signs and symptoms of CHD. Equally important for our current
purposes, these experiments of nature offer an important lesson in cardiovascular physiology and
hemodynamics. The student who understands the physiology of the basic congenital lesions will have a
better understanding of circulatory dynamics which will carry over into the study of many other fields.


3

Classification For our purposes, the common lesions are divided into Acyanotic and Cyanotic CHD.
Acyanotic lesions include Left to Right shunts and obstructive lesions. The most common L-R shunts are
Atrial Septal Defect (ASD), Ventricular Septal Defect (VSD), and Patent Ductus Arteriosus (PDA).
Common obstructive lesions are Aortic Stenosis (AS), Pulmonary Stenosis (PS), and Coarctation of the
Aorta (Coa). The common cyanotic lesions are Tetralogy of Fallot (TOF), Transposition of the Great
Arteries (TGA), and Tricuspid Atresia (TA). There are many other less common and more complex
lesions, but we will concentrate on these nine conditions, which make up 90% of CHD.

Etiology In 90% of cases a specific etiology is not apparent. In these cases the theory of multifactorial
inheritance is used to explain the etiology. This theory will be discussed in the lecture. In 10%, specific
factors may be identified as causally related to CHD. These include chromosomal defects, intrauterine
infection, drug exposure, radiation, and autosomal inheritance. Most CHD is not hereditary. The
incidence of repeat CHD in the same parentage is 2%.

Embryology and Development The heart develops during the 5
th
-8
th
week of gestation. The heart
forms from blood islands (mesoderm). The earliest structure is a straight tube (Figure 1). Each segment
of the tube is destined to develop into a specific portion of the fully developed heart and great vessels.
Looping of the tube as it grows normally leads to the normal relationships of ventricles and great arteries.
Errors in looping may lead to malpositions of the heart, e.g., dextrocardia, or to complex anomalies. It is
useful to remember that the heart develops in three separate segments, the atria, the ventricles, and the
great arteries.


4

Consequences of CHD These depend on the severity and specific lesion. However the general
problems caused by CHD are:

1. Cyanosis Chronic cyanosis leads to growth failure, central nervous system complications,
hematologic disorders and reduced stamina.
2. Congestive Heart Failure Large L-R shunts and severe obstructive lesions may lead to CHF, the
manifestations of which are different in infants and young children from those seen in adults.
3. Chronic Arrhythmias Lesions causing pressure overload or volume overload may lead to
dysrhythmias, some of which are life-threatening.
4. Growth Failure
5. Pulmonary Vascular Obstructive Disease Large L-R shunts and lesions causing elevated
pulmonary artery pressure may permanently damage to pulmonary arterioles and permanent
pulmonary hypertension. When this is caused by a systemic-pulmonary communication, this is
called Eisenmengers Syndrome.
6. Infective Endocarditis Most congenital lesions predispose to bacterial endocarditis. This is a
serious cause of morbidity and mortality in patients with CHD.
7. Psychosocial Even patients who have been successfully treated for CHD may suffer serious
psychosocial problems. Securing employment or health or life insurance is often difficult.
Families experience severe financial hardships caring for these children. Many children experience
difficulty in school or have emotional problems relating to their chronic handicap. Early treatment
does ameliorate these problems, but does not totally eliminate them.

The Perinatal Circulation


5

Students should be familiar with the fetal circulation (FIGURE 2). The presence of connections between
the two sides of the circulation, (foramen ovale and ductus arteriosus), allow the fetus to survive even in
the presence of severe cardiac anomalies. One ventricle is sufficient to maintain satisfactory circulation
to the fetal organs. Pulmonary vascular resistance is high in the fetus because of arteriolar constriction
and lack of aeration of the lungs. The lungs receive only 5% of the total cardiac output prior to birth. The
pulmonary arterioles develop gradually increasing medial hypertrophy as gestation progresses. The
number of pulmonary units also increases, especially in the last trimester.

The changes after birth are critically important and should be thoroughly understood by the student.

1. With the first breath, the lungs expand, pulmonary resistance drops rapidly and pulmonary blood
flow increases.
2. As left atrial return increases, LA pressure rises and the foramen ovale is functionally closed,
leading to fully oxygenated blood leaving the LV.
3. Increased in arterial pO
2
leads to further decrease in pulmonary resistance. This is also augmented
by vasoactive substances such as bradykinin released in the lung.
4. As flow to the placenta stops, systemic resistance increases.
5. The ductua arteriosus constricts in response to increased arterial pO
2
.
6. Remember the following responses of the pulmonary and systemic vessels:

Physiological Parameter Pulmonary Systemic

Increase pO
2

Decrease pO
2

Acidosis
Prostaglandins

Dilate
Constrict
Constrict
Dilate

Constrict
Dilate
Dilate
Dilate

The ductus arteriosus acts as a systemic vessel in this regard.

Answer the Following Questions Regarding The Perinatal Circulation.

1. Why is CHD infrequently associated with intrauterine death?

2. Why do premature infants develop symptoms from a VSD sooner than full-term infants?

3. Why do many heart murmurs not appear until several weeks of age despite the presence of large
L-R communications present at birth?

4. Why should women not use aspirin during pregnancy?

5. What would be the effect of closure of the foramen ovale at 12 weeks gestation?


6

Normal Hemodynamics
Intracardiac pressures and oxygen measurements are routinely measured during cardiac catheterization
and often monitored continuously at the bedside in ICUs. The student MUST be familiar with normal
values and their interpretation (FIGURE 3).

Pressures Intravascular pressures are measured by electronic transducers which are connected to
catheters introduced into the various chambers and connected to the transducer through a column of water
or saline. The student should already be familiar with venous, atrial, ventricular, and arterial wave forms.
Practice by drawing each, and labeling A wave, V wave, systolic arteri.


1


LECTURE 2

PHYSICAL EXAMINATION AND PATHOPHYSIOLOGIC
CORRELATION

There is close correlation between physical findings in the examination of the cardiovascular system and
actual physiologic events. These correlations are especially apparent in the study of patients with CHD.
A careful and systematic PE is the cornerstone of the evaluation of any patient with CV disease.

A systematic examination utilizes the 4 cardinal techniques of physical diagnosis, Inspection, Palpation,
Percussion, and Auscultation. The best examination will be obtained by performing these segments
individually, while considering at each step the observations one seeks to make.

Inspection Each patient should be inspected for cyanosis, clubbing, redness of the digits and peripheral
perfusion. Certain syndromes are associated with CHD and facial and other dysmorphic features should
be analyzed. Inspection of the chest for bulges and neck veins is also done.

Palpation Pulses should be felt in all 4 extremities and recorded. Bounding pulses suggest wide pulse
pressure, due to aortic runoff or low peripheral resistance. Weak pulses suggest low cardiac output,
narrow pulse pressure (e.g., aortic stenosis) or regional obstruction if not symmetrical (e.g., coarctation).
The precordial impulse should be felt for RV, LV, or combined hyperactivity. Hyperactive impulse at the
upper left sternal border suggests increased pulmonary blood flow or high cardiac output.

Percussion This technique is not as useful as in the pulmonary examination, but may occasionally give
you an idea of cardiac size.

Auscultation This yields the most information in most patients, but must be done systematically to
obtain maximal benefit. Students should concentrate on doing each examination the same way each time.
Listen to each sound independently, while asking yourself questions concerning the findings. (Where is
this sound loudest, softest, is it split, etc.). Ignore other parts of the examination until you have
satisfactorily evaluated each sound sequentially at each of the 4 sites of auscultation. (Remember that the
4 precordial sites of auscultation are critical, but auscultation in the back and in the axillae is also a part of
the CV examination).

S
1
First Heart Sound Due to closure of atrioventricular valves, mitral before tricuspid.
Loud S
1
= mitral stenosis, short P-R interval, large L-R shunt
Soft S
1
= Long P-R interval

S
2
Second Heart Sound Due to closure of semilunar valves, aortic before pulmonary.
Loud S
2
= systemic or pulmonary hypertension
Soft S
2
= stenosis or low peripheral resistance or low diastolic pressure in the respective great artery
Normal splittingwider in inspiration than expiration
Wide splitting = Right bundle branch block (RBBB), pulmonary stenosis, or L-R shunt


2

Wide fixed splitting (no respiratory variation) = ASD
Paradoxical splitting = LBBB, WPW, severe aortic stenosis

S
3
Third Heart Sound Due to rapid filling of ventricles
Normally heard in most children
Loud S
3
gallop = CHF

S
4
Fourth Heart Sound Due to atrial contraction against high diastolic ventricular pressure
Always abnormal
Stiff ventricle, hypertension, or high RA pressure

Ejection Clicks Due to large great artery or semilunar valve stenosis
Simultaneous with opening of semilunar valve
Aortic click is constant
Pulmonary click loudest in expiration

Heart Murmurs
Murmurs are the most common reason for referral to the pediatric cardiologist. They are vibrations in the
blood with frequencies between 50 and 1000 cps. Murmurs are due to turbulent flow. Turbulence is
measured by the Reynolds number and is directly related to Velocity of flow and inversely related to
Viscosity of the blood. Since velocity is inversely related to diameter of the tube through which the blood
flows, murmurs are found over areas of stenosis, valvular regurgitation, or when there is a pressure drop
as seen in flow from the systemic directly to the pulmonary or venous circulation.

Classification of Murmurs
Timing Murmurs may be systolic, diastolic, or continuous. Systolic murmurs may be
pansystolic (regurgitant) or ejection. Diastolic murmurs may be regurgitant (due to semilunar
valve regurgitation) or rumbling (produced by abnormal flow across the AV valves). Continuous
murmurs originate outside the heart and are due to continuous flow from high pressure bed
(e.g., systemic circulation) to low pressure bed (e.g., pulmonary or systemic venous bed).
Intensity loudness rated on a scale of 1-6
Organic Murmur is due to abnormality of heart or vascular system
Normal (Often called Functional Murmur). See below.

Classification of Normal (Functional) Murmurs
Normal murmurs may be heard at any age, but are very common in children. At five years of age, as
many as 40% of children may be found to have a murmur at least grade 2 in intensity. These are more
common in children because of small chest wall, higher cardiac output, and lower hematocrit. There are
three major types of functional murmur:
Pulmonary Ejection Murmur Caused by turbulent flow across the RV outflow tract. This
murmur is made louder by fever, anemia, or anxiety (anything causing higher CO).
Vibratory Ejection Murmur Probably originates in left ventricle. Exact cause not known.
Called musical or twang-string murmur. Also called Stills murmur. May be grade 3 in
intensity.
Venous Hum Due to turbulent flow in the neck veins. Continuous bruit which disappears with
rotation of head or assuming the supine position.

Other less common normal murmurs are the carotid bruit, the mammary soufle (heard in lactating women
over the breast), and the soft ejection murmur heard over the lungs in premature infants due to relatively
small pulmonary arteries.

3

Diagnostic Modalities
History General history plus specific questioning about:
Cyanosisresting
Blueness during exercise
Fatigue
Nocturnal dyspnea
Orthopnea
Failure to thrive or poor growth
Family history of congenital heart disease
Volume per feed
Dyspnic while sucking
Perspires profusely
Exhausted sleeping after feeds
Requires frequent feeds

Physical Examination
Growth and development
Length average and weight decreased
Tachypnea
Liver enlargement
Spleen enlargement
Rales
Peripheral edema
Cyanosis
Clubbing
Cardiac rate note normals for age:
Newborn = 70-190
Infant = 80-160
6 years = 75-115
10 years = 70-110
Adult = 50-95
Character of the pulses
Blood pressure varies by age
Normal (after 1 year of age) can be approximated by:
Systolic Blood Pressure = 80 + (age in years X 2)
Diastolic Blood Pressure = 2/3 of systolic pressure
Cardiac examination
Visual
Palpation
Auscultation


4

Heart Murmurs
Heart murmurs are classified according to their grade, location in the cardiac cycle, point of maximal
intensity and the area of their radiation, and the quality of their pitch.

Grade of Murmurs
Grade I Soft heard only with difficulty
Grade II Easily heard
Grade III Loud but without a palpable thrill on the chest wall
Grade IV Loud with a palpable thrill
Grade V Heard with only one edge of the stethoscope on the chest
Grade VI Heard without the stethoscope touching the chest.

Cardiac Cycle Classification of Murmurs
Systolic Murmurs Murmurs heard between the first heart sound (S
1
) and the second heart sound (S
2
).

Systolic Ejection Murmur (SEM) There is a silent interval between S
1
and the onset of the murmur.
It then crescendos to a maximum intensity and decrescendos to end before the S
2
heart sound. These
murmurs arise in stenotic aortic or pulmonary valve areas and must overcome the pressure in such vessels
before the flow rate is great enough to produce a murmur.

Holosystolic Murmur Also called pansystolic murmurs. These are the result of immediate flow from
a high pressure area to a low flow area and are heard through our systole. Areas of such pressure
differentials are from a ventricle to an atrium or from the left ventricle to the right ventricle.

End Systolic Murmur Also called late systolic murmurs. These murmurs are caused by prolapse of
the mitral valve toward the end of systole, allowing regurgitation of blood into the left atrium.

Diastolic Murmurs Murmurs heard between the second heart sound (S
2
) and the first heart sound (S
1
).

Early Diastolic murmur Murmurs beginning with S
2
are due to back flow through incompetent
outflow tract valves and are generated by pressure in the aorta or pulmonary vessels. They rarely can e
heard beyond mid diastole. Characteristically they are high pitched blowing murmurs.


5

Mid Diastolic Murmur These murmurs are the result of turbulent flow over the mitral or tricuspid
valves during the atrial filling phase of diastole. They are due to either an actual or relative (increased
volume over normal sized valves) flow across these valves. These are usually very low pitched rumbling
murmurs.

Late Diastolic Murmur These are the result of end diastolic filling into a ventricle with decreased
compliance, as occurs in ventricular hypertrophy. These may sound more like a click than a distinct
murmur.

Continuous Murmurs Continuous murmurs continue through S
2
. They begin in at least systole and
continue in early diastole. A typical continuous murmur is that of a PDA. The systolic component is due
to increased flow across a relatively stenotic pulmonary valve and the diastolic component is generated by
the flow through the ductus from the aorta to the pulmonary vessel at the beginning of diastole.

Typical Points of Maximal Intensity of Murmurs
Aortic area: 2
nd
right intercostal space (ICS)
Pulmonary area: 2
nd
left intercostal space
Mitral area: The cardiac apex
Tricuspid area: Left lower sternal border (LSB)

Typical Qualities of Murmurs
Blowing: High Pitched This sound can be simulated by holding the stethoscope in the palm and
stroking the back of the hand with the pad of a finger

Harsh: Medium Pitched This sound can be simulated by holding the stethoscope in the palm and
scratching the back of the hand with a fingernail

Rumbling: Low Pitched This is the sound of a bowling ball rumbling down a gutter


1


LECTURE 3

LEFT TO RIGHT SHUNTS

Objective Understand natural history, anatomy, and physiology of common left to right shunts: Patent
Ductus Arteriosus, Atrial Septal Defect, and Ventricular Septal Defect.

Learning Tasks:

For each lesion:
1. Identify which ventricle is overloaded
2. Determine whether shunt occurs during diastole or systole or both.
3. Describe natural history of each lesion, especially regarding:
a. Infective endocarditis
b. Congestive heart failure
c. Pulmonary hypertension and pulmonary vascular disease
4. Describe expected changes in intracardiac 02 saturation and pressures

References:
PDA Adams pp. 209-222
VDS Adams pp. 182-207
ASD Adams pp. 170-180

Self-Learning Exercises
Problems 1, 2, and 3 - (Appendix B - See Appendix C for solutions)

Lecture Notes
The three lesions included in this lecture are among the most common CHD lesions. Ventricular septal
defect makes up to 25% of all CHD and is the most common cause of CHF in infancy. PDA is the most
important cause of CV morbidity in the prematurely born infant. ASD is the most commonly overlooked
congenital heart defect and may not be diagnosed until adulthood, in some cases. Numerous other less
common and more complex lesions are associated with L-R shunt and increased pulmonary blood flow,
but these are beyond the scope of this presentation.

Atrial Septal Defect
Anatomy There are three types of ASD; secundum, primum and sinus venosus
ADS Secundum Defect of the Fossa Ovalis located in the central portion of the septum
ASD Primum Defect in the lower portion of the septum usually associated with cleft in
the mitral valve. A type of Endocardial Cushion Defect.
Sinus Venosus ASD Defect high in septum at level of SVC entrance. Associated with
anomalous return of right pulmonary veins into RA or SVC.

Physiology Large ASD results in equal pressures in left and right atrium. Shunting occurs primarily in
diastole when AV valves are open. Direction of shunt depends on COMPLIANCE of the two ventricles.
Since the RV is usually more compliant than LV the shunt is usually L-R. If the RV is stiff or
hypertrophied (e.g., due to Pulmonary Stenosis) the shunt may be R-L

2

Clinical Findings Hyperactive precordium, widely split S
2
which does not vary with respirations.
Systolic ejection murmur and diastolic rumble along LSB. (Why?)

Natural History Small defects usually not diagnosed. May close spontaneously. Even large defects
are usually asymptomatic in infancy and childhood. Right ventricular dilatation and eventual failure in
adulthood. Atrial arrhythmias common in later years. Pulmonary vascular disease rare before third
decade. Infective endocarditis rare. Life expectancy untreated about 40 years.

Treatment All but small defects should be repaired by surgery before school age.

Ventricular Septal Defect

Anatomy Four types: Sub-pulmonary, Sub-aortic (perimembranous), inlet (sub-tricuspid) and
muscular. The latter may be multiple (the septum looks like swiss cheese.

Physiology Shunting increases early in life as PVR reduces and PA pressure drops. Large defects cause
equalization of RV and LV pressures and pulmonary hypertension early. These infants are symptomatic
with failure to gain weight and respiratory problems. (Why is this so different from large ASD?) The
shunt occurs in systole and both ventricles are subjected to volume overload. Small defects result in
small shunts, mild LV volume overload, and usually no symptoms.

Clinical Findings Hyperactive precordium and upper sternal border. Loud S
2
. Loud systolic murmur
with thrill. Large defects also have diastolic rumble? (Why?)

Natural History Spontaneous closure in 30-40% even large defects. Ten percent develop pulmonic
stenosis (acquired Tetralogy of Fallot). All lesions subject to Infective Endocarditis (IE). Small lesions
(Qp:Qs < 1.5:1) usually asymptomatic and may lead normal lives. Large lesions (Qp:Qs > 2.5:1)
symptomatic as infants. Pulmonary vascular disease may occur early in life in large defects and later in
life in moderate defects.

Treatment Small lesions may not require treatment. Moderate defects repaired electively and large
defects should be closed in infancy to prevent complications.

Patent Ductus Arteriosus
The PDA is present in the normal fetus and usually closes in 1-2 days after birth. Circulating
prostaglandins, hypoxia, and acidosis contribute to opening the ductus in newborn and premature infants.
Prostaglandin synthetase inhibitors such as indomethacin promote closure of the ductus in newborns.
After one month, the ductus is usually not affected pharmacologically.

Physiology As pulmonary vascular resistance drops, shunting may occur from aorta to pulmonary
artery. This occurs in both systole and diastole (continuous). Only large defects result in pulmonary
hypertension. The left ventricle is overloaded.

Clinical Findings Hyperactive precordium, bounding pulses (Why?). Continuous murmur at upper
left sternal border.

Natural History Similar to VSD if untreated.

Treatment If symptomatic, surgical ligation. In premature infants under one month of age,
indomethacin may be effective. If still patent by one year, even small lesions should be closed. Risk of
surgery very small. Results in true cure.

1


LECTURE 4

LEFT-SIDED OBSTRUCTIONS

Objective Understand the natural history, anatomy, and physiology of congenital aortic stenosis and
coarctation of the aorta.

Learning Tasks:

For both lesions:
1. Understand the effects of pressure overload of the left ventricle
2. Describe the effects of each on coronary flow dynamics
3. Describe natural history and two important complications
4. Identify major clinical findings

References:
Coarctation Adams pp. 243-253
Aortic Stenosis Adams pp. 224-234

Self-Learning Exercises:
Problems 4 and 6 (Answers in Appendix)

Lecture Notes:

Aortic Stenosis The physiology and clinical findings in aortic stenosis will be discussed later in the
segment on valvular heart disease and not be discussed to any extent in this lecture. However, the student
should understand the effects of LV outflow obstruction and the various anatomical causes. Congenital
AS may be valvar, supra-valvar, or discrete sub-valvar. Hypertrophic subaortic stenosis (IHSS) may
occur in young children, but is covered in another section of this curriculum.

Coarctation of the Aorta

Anatomy This lesion usually consists of discrete narrowing of the aorta in the distal arch at or about
the site of origin of the ductus arteriosus and just distal to the origin of the left subclavian artery. It is
sometimes associated with tubular hypoplasia of the aortic isthmus. The narrowing may be a long
segment of aorta in some cases. Rarely the narrowing is between the carotids. Occasionally it is
associated with anomalous origin of the right subclavian from the descending thoracic aorta. Consider
the physical findings in the latter two instances. Abdominal coarctation is another rare anatomical
variation.

Physiology Obstruction to flow of blood from ascending aorta to descending aorta requires higher
pressures in the left ventricle and upper extremities than in the lower half of the body (a pressure
gradient is present). If the narrowing is severe, LV failure might occur acutely in infancy. This usually
occurs when the ductus arteriosus closes. If the narrowing develops gradually, the child may be totally

2

asymptomatic as the LV has time to hypertrophy and collateral vessels develop. The primary collaterals
are intercostal vessels, the internal mammary arteries, and the long thoracica artery.

Clinical Findings The most important sign of coarctation of the aorta is a difference in strength of the
pulses between the upper and lower extremities. This may be appreciated by careful simultaneous
palpation of the brachial and femoral pulses. Blood pressures will reflect the difference between upper
and lower extremities. Murmurs may or may not be present, but if so, are usually loudest in the back
between the scapulae (one reason why auscultation of the back is always considered a part of the CV
examination). Clinical presentation ranges from severe CHF and shock in infants to an entirely
asymptomatic school age child and physical findings very accordingly. If collaterals have developed,
chest x-ray may show rib notching.

Natural History Those infants presenting early usually have associated lesions (VSD, AS, or complex
disease) and mortality is high. Children with isolated coarctation who are asymptomatic may not be
detected for many years if pulses are not examined or blood pressure measured. Patients with untreated
coarctation may develop severe systemic hypertension. The mechanism of hypertension is complex and
you are encouraged to study this further in the text. At least two mechanisms are operative: mechanical
and humoral. Even after successful repair hypertension may persist and require medical treatment. Other
complications are development of aortic regurgitation, aneurysm of the ascending aorta and rupture of the
descending aorta. Infective endocarditis is a life-long risk. Eighty percent of patients have bicuspid
aortic valve. The average life expectancy of untreated coarctation of the aorta is 25 years.

Treatment Surgical repair of all but the milder cases is recommended. In some cases balloon
arterioplasty may be an option. Even after repair, patients should be followed into adulthood for
development of hypertension, recurrence of coarctation, aortic aneurysm or aortic valvular disease.


1


LECTURE 5

PULMONARY AND TRICUSPID VALVE DISEASE

Objectives Describe the anatomy, physiology, clinical findings of pulmonic stenosis, congenital
tricuspid regurgitation, and Ebsteins Disease.

Learning Tasks:
1. Identify the ventricle which is overloaded and distinguish between pressure overload and volume
overload.
2. Describe changes in S
2
and ejection sounds heard in P.S.
3. Discuss pressure gradients and relationship to flow.

References:
Pulmonary Stenosis Adams pp. 308-320
Tricuspid Disease Adams pp. 361-369

Self-Learning Exercise:
Problem 5 Appendix B

Lecture Notes:

Pulmonary Stenosis

Anatomy The most common site of obstruction is at the valve level. The pulmonary valve is thickened
and commissures are fused. Occasionally no normal features are distinguishable and the valve is a thick
cartilaginous disc (dysplastic valve). Obstruction may also be infundibular. This consists of abnormal
muscle bands below the valve in the body of the RV. In these cases the pressure below the valve will be
lower than in the body of the RV (so called two chambered RV). Stenosis may be supravalvar. Here
there may be a discrete narrowing of the main or branch pulmonary arteries or the obstruction may be
long and tubular. Pulmonary artery stenosis is quite variable anatomically.

Physiology The primary abnormality is a pressure gradient from right ventricle to the pulmonary artery
distal to the obstruction. The RV hypertrophies to compensate and moderate degrees of stenosis are well
tolerated without symptoms. Pressures in the RV which are higher than LV pressure indicate severe
obstruction and eventually may lead to RV failure or arrhythmias. Contrary to your initial thought these
patients have NORMAL pulmonary blood until the RV fails (the ventricle maintains cardiac output at the
expense of a high RV pressure). There is NO CYANOSIS unless an atrial septal defect or patent foramen
ovale is present. With severe PS and ADS, the RV compliance decreases and a R-L shunt may occur
leading to cyanosis.

Clinical Findings Except in the most severe cases, patients are asymptomatic and appear healthy. S
2
is
widely split but does show respiratory variation. There is a click when stenosis is valvar. The click is
loudest in expiration. The murmur is loudest at the upper left sternal border, radiates to the left clavicle
and is a long systolic ejection type murmur. If the stenosis is infundibular no click is present. If the

2

stenosis involves the pulmonary arteries, the murmur is heard in the chest and back equally well.
Electrocardiogram shows RVH. The degree of RVH by ECG correlates well with severity of PS.

Natural History Mild lesions are well tolerated and need no treatment. Moderate stenosis produces no
symptoms until mid adulthood when RV failure and arrhythmias may occur. Severe stenosis may present
with cyanosis due to a R-L atrial shunt and should be treated urgently. IE is uncommon except with
IV drug use.

Treatment Valvar PS is now treated by balloon valvoplasty in the cardiac cath lab. Mild forms do not
require treatment.

Tricuspid Valve Disease

Ebsteins Anomaly of the tricuspid valve is a downward displacement of the TV into the body of the RV,
causing tricuspid stenosis and/or tricuspid regurgitation. This is an esoteric problem which you may wish
to read about briefly.

Tricuspid regurgitation in the newborn results from intrauterine anoxia and RV hypertension. It is treated
by attempting to remove the cause of pulmonary hypertension and CHF. The clinical findings of severe
tricuspid regurgitation include large pulsatile liver, distention of neck veins, fluid accumulation
peripherally, and low cardiac output.


1


LECTURE 6

CYANOSIS AND CYANOTIC CONGENITAL HEART DISEASE

Objectives Describe the natural history, anatomy, physiology, and clinical presentations of Tetralogy
of Fallot (TOF) and Transposition of the Great Arteries (TGA).

Learning Tasks:
1. Define cyanosis and describe compensatory mechanisms developed in patients with chronic
hypoxemia.
2. Describe the relationship between oxygen saturation, clinical cyanosis, and hemoglobin
concentration in a patient with chronic hypoxemia.
3. Explain the mechanism of cyanosis in Tetralogy and Transposition
4. Describe hypercyanotic spells in TOF and explain the physiologic mechanism.

References:
Tetralogy Adams pp. 273-287
Transposition Adams pp. 371-384
Complications of cyanosis pp. 389

Self-Learning Exercise:
Problems 7 and 8 Appendix B

Lecture Notes:
Congenital lesions associated with chronic arterial desaturation present at earlier age and carry more
morbidity and higher mortality than acyanotic lesions. Many anomalies may produce cyanosis. Our
purpose in these sessions is to illustrate the basic mechanisms which cause arterial desaturation and the
mechanisms the body uses to adjust to chronic cyanosis. The two lesions mentioned, TOF and TGA are
the most common lesions producing cyanosis and are used as models to explain the underlying
pathophysiology, which is what the student should emphasize.

Causes of Cyanosis Clinical cyanosis appears when blood in the capillary bed contains 5 Gm of
reduced Hgb/DL. This may be due to arterial desaturation from pulmonary or cardiac disease, or from
increased extraction of O
2
in the peripheral circulation. Acrocyanosis should be distinguished from
central cyanosis.

There are two basic cardiac mechanisms of cyanosis: A right to left shunt and abnormal anatomic
connections of the arteries or veins. TOF is an example of the former and TGA the latter. There are
two requirements for a right to left shunt:

1. Some obstruction to right-sided output, and;
2. A communication between the systemic and pulmonary circulations.


2

Definition: Before proceeding, the student should review the meaning of the following terms:
Oxygen saturation Oxygen content
Oxygen consumption Oxygen capacity
pO
2
Clinical cyanosis

The student should also understand the relationships of systemic and pulmonary blood flow and the
definition of left to right and right to left shunts.

COMPENSATORY MECHANISMS TO CHRONIC HYPOXEMIA

Oxygen delivery to the tissues is maintained in patients with chronic desaturation by the following
mechanisms:
Polycythemia Increased hemoglobin levels increases O
2
content
Increased RBC organic phosphates (2,3-DPG) Effects easier release of O
2
at the tissue level
Increased extraction of O
2
at the capillary level (mixed venous O
2
content is lower)

COMPLICATIONS OF CHRONIC HYPOXEMIA

Children with cyanotic heart disease are subject to the following:
Slow growth
Decreased exercise tolerance
Possible learning disability
Central nervous system complications (CVA in young patients, brain abscess in older)
Clubbing of the digits
Complications of pregnancy in females

EXAMPLES OF CYANOTIC CONGENITAL HEART DISEASE

Tetralogy of Fallot
TOF is the most common cause of cyanotic heart disease. The four components are: VSD, pulmonic
stenosis, RVH, and overriding aorta. Physiologically the important components are VSD and PS.

Anatomy The VSD is always large and subaortic, high in the membranous portion of the septum. The
aorta straddles the septum leading to overriding. The pulmonary obstruction is usually infundibular due
to muscular hypertrophy and hypoplasia of the infundibulum. Valvar stenosis may also be present.
Twenty-five percent of patients have right-aortic arch.

Physiology Because of a large interventricular communication, blood may flow R-L or L-R depending
on the degree of pulmonary stenosis. The degree of arterial desaturation depends on the severity of the
pulmonary stenosis. Sudden increases in pulmonary stenosis caused by infundibular spasm lead to acute
reduction in pulmonary blood flow, increase in right to left shunt, and increased arterial hypoxemia. This
is called a hypercyanotic spell. The mechanism of cyanotic spells is fundamental to the understanding of
this and other lesions with R-L shunts, and must be well understood by the student.

Clinical Findings Children with tetralogy are cyanotic and cyanosis increases with exercise. They may
squat with exertion (squatting increases systemic resistance and improves venous return, both of which
increase pulmonary blood flow). The second heart sound is single (because of a very soft P2). The
murmur is systolic at the upper left sternal border. The intensity and duration of the murmur are inversely
proportional to the severity of the pulmonic stenosis. Can you explain that?

3

Natural History Patients may be severely cyanotic at birth or acyanotic, depending on the severity of
outflow tract obstruction. Most patients live into adulthood with the availability of palliative and
corrective surgery. All are subject to the complications of cyanosis, as well as IE. Hypercyanotic spells
are life-threatening and an indication for immediate surgery

Treatment In the past, palliation could be achieved by a shunt between the systemic circuit and the
pulmonary artery. The classical Blalock-Taussig shunt is a connection between the subclavian artery and
the pulmonary artery. This palliation often lasts for years, but today most tetralogy patients are treated
with complete repair done near one year of age. There is no satisfactory medical treatment. Patients with
TOP do not go into CHF so digitalization is never necessary.

Transposition of Great Arteries
This is the most common cause of cardiac cyanosis in the newborn infant. TGA was once fatal in 95% of
cases before one month of age. Today over 90% of infants survive and can lead normal lives.

Anatomy In simple TGA, the aorta arises anteriorly from the right ventricle and the pulmonary artery
posteriorly from the LV. For survival some connection between the systemic and pulmonary circuits is
necessary (patent foramen, PDA or VSD). The right ventricle becomes hypertrophied and the LV wall is
quite thin after the first month of life. Associated defects are sometimes present (pulmonic stenosis,
VSD, coarctation of aorta).

Physiology Pulmonary venous return rich in oxygen returns to the lungs and systemic venous return
returns to the aorta. The only oxygenated blood reaching the systemic circulation comes through one of
the above mentioned systemic-pulmonary connections. In 1965, Dr. Rashkind developed the technique of
balloon atrial septostomy. This procedure creates a large ASD without thoracotomy, allowing
bidirectional mixing at the atrial level and permitting survival until other treatment can be attempted.

Clinical Findings These infants present with deep cyanosis shortly after birth. Cyanosis is
unresponsive to oxygen administration (Why?). There is no murmur usually. The ECG and x-ray of the
chest are usually normal for age.

Natural History Death within a few hours without palliation.

Treatment Today patients are treated surgically by switching the arteries to their normal positions.
Infants having survived the arterial switch procedure apparently have a normal life expectancy. Can you
name two anatomical problems which might interfere with successful arterial switch surgery?

THE NEWBORN INFANT WITH CYANOSIS (BLUE BABY)

The differential diagnosis of the infant presenting with cyanosis shortly after birth includes congenital
cardiac disease, pulmonary disease, and peripheral cyanosis due to polycythemia. The latter condition
can be excluded by physical exam (primarily acrocyanosis) and measurement of the hematocrit (> 65%
abnormally high).

Distinguishing cyanosis due to pulmonary disease from CHD is sometimes difficult:

Physical Diagnosis clues-abnormal breath sounds, rales, bowel sounds in chest suggest pulmonary
disease or diaphragmatic hernia: Heart murmurs often not present in severe heart anomalies, but
suggestive of CHD if present.


4

Hyperoxia Test When breathing 100% O
2
infants with pulmonary problems will show significant rise
in arterial pO
2
. Since desaturation in CHD is due to R-L shunting, increasing pulmonary venous O
2
will
usually not change the arterial pO
2
significantly when cyanosis is due to CHD.

Chest X-Ray When pulmonary disease is present, the x-ray is usually abnormal. With cardiac disease
the x-ray may help in diagnosis. In TGA, the pulmonary markings are normal and the heart size is
normal. In lesions associated with obstruction to pulmonary blood flow (Tetralogy, Tricuspid Atresia,
pulmonary atresia) pulmonary vascular markings are severely diminished (black lung fields). The heart
size and shape may or may not be abnormal.

Infants with normal x-ray and no response to O
2
should be considered as having life-threatening CHD.
Since many of the responsible lesions may be aided by a L-R shunt through the PDA. Prostaglandins
should be started immediately and the infant transferred to a tertiary pediatric cardiac center.

Pathology M-2 Congenital Heart Disease Appendix A

1

APPENDIX A

The following eight problems and questions constitute the self-learning exercises referred to in the
syllabus. You will benefit most from the class sessions by reviewing these problems before the class and
then attempting to answer each question again after the sessions. Answers are in Appendix B. Refer to
the answers only after you have attempted to answer each question yourself.

Problem 1

History:
A 5-year-old girl is discovered to have a heart murmur on a
routine school examination. She has no symptoms.

Physical Examination:
No cyanosis
Femoral pulses good
Cardiac impulse RV hyperactivity
S
1
loud. Single
S
2
normal intensity widely split no respiratory variation
Grade 2 systolic ejection murmur at left upper sternal border

Chest X-Ray:
Moderate cardiac enlargement increased pulmonary vascularity

ECG:
Right ventricular enlargement.

Cardiac Cath Findings*
Site Oxygen Saturation Pressure
Superior vena cava (SVC) 76 mean 4
Right Atrium (RA) 92 mean 4
Right Ventricle (RV) 92 20/3
Pulmonary Artery (PA) 91 20/10
Left Atrium (LA) 97 mean 5
Left Ventricle (LV) 97 110/5
Aorta (AO) 97 110/60

Oxygen consumption = 140 cc/min/m2
Oxygen capacity = 180 cc/L
See Nadas, p. 126 for normal valves


2

Questions:

1. Diagram the defect.

2. Is there a shunt? If so, where?

3. Why does the splitting of S2 not vary with respirations?

4. Which ventricle is overloaded?

5. What is the cause of the systolic murmur?

6. What is the cause of the diastolic murmur?

7. Why is the left atrial pressure similar to right atrial pressure?

8. Calculate pulmonary blood flow, systemic blood flow and Qp:Qs ratio.


3

Problem 2

History:
A 6-week old infant presents with tachypnea, poor feeding,
and poor weight gain. No murmur was present at birth. A
murmur was heard at four weeks of age on a routine well child
exam. Birth weight was 7 pounds 5 ounces.

Weight 8 pounds 10 ounces
Thin child
No cyanosis
Moderate retraction
Pulse Rate: 60
Respiratory Rate: 48
Blood Pressure: 80/50
Femoral pulses are good
Cardiac impulse right and left hyperactivity
S
1
loud and single, S
2
loud, narrowly split
S
4
harsh pansystolic murmur heard over entire precordium
Thrill at 4
th
left intercostal space

Chest X-Ray:
Moderate cardiac enlargement, increased pulmonary
Vascularity

ECG
RVH and LVH

Cardiac Cath Findings Age 6 weeks

Site O
2
Saturation Pressure
SVC 59 M 8
RA 58 M 8
RV 85 65/9
PA 88 60/20
LV 96 LA M = 16
AO 96 LV 75/10
AO 90/42

Questions:

1. Diagram the defect.



4

3. Why was no murmur heard at birth?

4. Which ventricle(s) is/are overloaded?

5. Why is there no cyanosis?

6. Untreated, the prognosis is _______________________________

7. Which of the following are risks for this patient?

A. Congestive heart failure
B. Infective endocarditis
C. Early coronary disease
D. Mental subnormality
E. Pulmonary vascular obstruction
F. Early polycythemia and clubbing.

Problem 3

History:
A 7-day-old infant was born at 33 weeks gestation weighing
3 pounds, 13 ounces. On day two, respiratory distress required
ventilatory support. On day six, a murmur was heard. On day seven,
the baby showed signs of congestive heart failure with a large heart,
congested lungs, and a large liver.

Acyanotic
Hyperactive precordial impulse
Pulses bounding
Grade 3 systolic murmur third upper sternal border


5

Questions:

1. Diagram the lesion.


3. Explain why the pulses are bounding.

4. Why is this baby showing cardiac symptoms earlier than in Case 2?

5. How might one treat the patient medically?

Problem 4

History:
A 10-year-old boy is seen for a routine examination. You find a
blood pressure of 135/95 in the right arm and 130/95 in the
left arm. What would you do next?

The cardiac examination reveals no significant murmurs, but a
bruit is heard in the left side of the chest posteriorly.

Acyanotic
Hyperactive precordial impulse
Pulses bounding
Grade 3 systolic murmur third-upper sternal border

Chest X-ray:
Normal cardiac shape and lung fields.

ECG:
Normal


6

Questions:

1. Diagram the lesion

2. Your diagnosis?

3. Why should this patient have surgery? He has no symptoms and has a normal electrocardiogram.
4. What is the average life expectancy of this lesion?

5. Explain the hypertension.

Problem 5

History:
A 5-month-old boy has had a murmur since birth. He is larger
than average and has no symptoms.

Normal color
Normal pulses
Cardiac impulse RV
Thrill at upper left sternal border
S
1
normal. S
2
normal wide split
Ejection click at left sternal border
Grade 4 systolic ejection murmur at upper left sternal border

Chest X-Ray:
Normal

ECG
Right ventricular hypertrophy


7

Cardiac Cath Findings:

Site O
2
Saturation Pressure
SVC 59 M 4 a-12 v-5
RA 63 M 4
RV 63 160/10
PA 63 14/8 m-10
LV 95 90/5
AO 92 90/50
PV 99 m-6
LA 90 m-6

Questions:


2. What causes the murmur?

3. What causes the click?

4. What does he have no symptoms?

5. Why is the x-ray normal?


7. Why is he not cyanotic?

8. Pulmonary blood flow is (less than, more than, the same as) systemic blood flow?

8

Problem 6

History:
A 9-year-old boy has had a heart murmur since birth. He has
complained of left precordial chest pain made worse by
vigorous exercise.

Blood pressure: 100/70
Acyanotic
S
1
and S
2
normal
Systolic click at apex
Thrill at suprasternal notch
Grade 3 harsh ejection murmur upper-right sternal border

Chest X-Ray:
Normal

ECG:
Right ventricular hypertrophy

Cardiac Cath Findings:

Site O
2
Saturation Pressure
SVC 59 M 4 a-12 v-5
RA 63 M 4
RV 63 160/10
PA 63 14/8 m-10
LV 95 90/5
AO 92 90/50
PV 99 m-6
LA 90 m-6

Questions:


2. Explain the chest pain

3. Name three complications associated with this lesion.


9

Problem 7

History:
A patient presents at 3 months of age with the findings of a
moderately large VSD. Cardiac cath confirms the presence of a
large sub-aortic VSD. The baby remains asymptomatic.

Two years later, however, you see him and there is mild cyanosis of
the lips. The murmur is somewhat shorter and more prominent at
the left-upper sternal border.

Chest X-Ray:
Shows normal heart size with decreased pulmonary vascularity

ECG:
Shows pure RVH

Cardiac Cath Findings at age 3 months

Site O
2
Saturation Pressure
SVC 74 4
RA 75 4
RV 86 50/5
PA 87 52/20
LV 98 100/8
AO 97 100/65
PV 99 m-6
LA 90 m-6

Questions:

1. Diagram lesion

2. Is there a shunt? If so, in which direction?

3. At what site?

4. What has happened between the two catheterizations?


10

5. At age 2, does he show symptoms? If so, what would you expect?

The patient above was doing well until, at the age of 3 years, he suddenly was found very cyanotic, very
irritable, anxious, sweating with marked hypernea. Examination revealed tachycardia and deep cyanosis.
No murmur was heard.

7. Why is he more cyanotic?

8. Why is there no murmur?

9. If it were in your power to alter this patients cardiac physiology,

Problem 8

History:
A 12-hour-old term infant is noted by the nurse to be dusky

Weight: 8 lbs
Moderately cyanotic infant
Mild subcostal retractions
Pulse Rate: 160
Respiratory Rate: 60
Femoral pulses palpable.
Liver not enlarged
S
1
and S
2
loud and single
No murmur

Chest X-Ray:
Normal heart size. No thymic shadow seen. Pulmonary
vascularity normal.

ABGs PO
2
, PCO
2
34, pH 7.38

ECG:
Normal


11

Questions:

1. What things suggest a cardiac cause of cyanosis?

2. What might you do to confirm your suspicion of cardiac disease?

3. Why is no murmur present?

4. Why is this baby not underdeveloped?

5. After appropriate treatment, the arterial oxygen saturation was 64%. Name 2 mechanisms by which
the body compensated for chronic hypoxemia.

6. Name 4 late complications of chronic hypoxemia.

M-2 Pathology Congenital Heart Disease Appendix A - Answers

1

APPENDIX A

ANSWERS TO CLINICAL PROBLEMS

Problem 1

1. This patient has a large atrial septal defect. See diagram.

2. There is a large left to right shunt
3. At the atrial level (large increase in O2 sat from SVC to RA)
4. During inspiration, systemic venous return increases and pulmonary venous return decreases. The
opposite occurs in expiration. In atrial septal defect the same occurs, but the presence or a large ASD
allows equalization of pressure and volume at all times. Thus the shunt decreases in inspiration and
increases in expiration, meaning the pulmonary blood flow remains the same in inspiration as in
expiration.

2

5. The right ventricle
6. The systolic murmur is due to increased flow across the right ventricular outflow tract from the L-R
shunt. (A poor term for this is relative pulmonary stenosis).
7. By the same explanation, the diastolic rumble is due to increased flow across the tricuspid valve, which
is the usual size. (NOTE: Neither murmur is caused by low across the defect.)
8. A large communication between two chambers results in equalization of pressures.
9. Calculations:

Pulmonary blood flow = Oxygen consumption/Pulm A-V Differences
= 140 cc/min/M
2
/(PV Content PA Content)

PA content = PA Sat X O
2
Capacity = 91% x 180 cc/L = 164 cc/L
PV content = PV Sat x O
2
Capacity = 97% x 180 = 175 cc/L

PBF = 140 cc/min/M
2
/(175-164)cc/L = 140/11 = 12.7 L/min./M
2

Systemic Blood Flow = Oxygen Consumption/Systemic A-V Difference
Systemic A-V Difference = Aorta context-mixed venous (SVC) content
Aorta content = 180 x 97% = 175
SVC content = 180 x 76% = 137

SBF = 140 cc/min/M
2
/(175-137) cc/L = 140/38 = 3.7 L/min/M
2

Qp:Qs ratio = 12.7/3.7 = 3.4:1


3

Problem 2

1. Large ventricular septal defect. See diagram.

2. There is a large left to right shunt at the ventricular level.
3. The pulmonary resistance at birth is elevated to near systemic levels. Blood flows where resistance
is least so the increased PVR prevents significant shunting, hence no flow across the defect and no
murmur.
4. Both ventricles are overloaded.
5. The pulmonary resistance is lower than systemic resistance so the shunt is entirely left to right and
there is no right to left shunt.
6. The baby will be chronically ill with CHF for some time. There is a 30-40% chance of closure or
reduction in size of the VSD. Five percent will develop pulmonary vascular disease by one year.
Ten percent will develop pulmonic stenosis.
7. a., b., e.

4

Problem 3

1. The infant has a patent ductus arteriosus. See diagram.

2. There is a left to right shunt from aorta to pulmonary artery. (Even without catherization data, the
large heart and increased pulmonary vascular markings indicate the shunt).
3. There is a wide pulse pressure due to continuous runoff from aorta to pulmonary artery, (i.e., low
aortic diastolic pressure).
4. The muscular media of the pulmonary arterioles develop increasing thickness as gestation
progresses. Infants born prematurely will have lower pulmonary resistance than term infants.
Thus, PVR drops sooner in premature infants and if systemic-pulmonary connections exist, earlier
left to right shunting will occur in these infants.
5. Indomethacin to inhibit prostaglandin synthetase and reduced PGE levels which contribute to
maintaining the PDA. If hypoxia and acidosis are present, treatment of these may also help to
narrow the PDA. (Remember that the pharmacologic manipulation of the ductus is usually not
effective after one month of age).

5

Problem 4

1. This patient has coarctation of the aorta. See diagram.
2. Same as 1.

3. The natural history of coarctation includes permanent hypertension, aortic aneurysm, and eventually
left ventricular failure.
4. Twenty-five years
5. Hypertension is partially due to mechanical obstruction of the aortic arch. High upper extremity
pressure is required to perfuse the lower segment of the body through the narrow aorta and/or
collaterals. The renin-angiotensin system is also involved since the kidneys are potentially
underperfused and eventually a steady state exists in which the resistance in the lower portion of the
body is increased to maintain perfusion in that region.


6

Problem 5

1. This patient has severe pulmonic stenosis. See diagram.

2. The murmur is due to turbulent flow across the stenotic valve.
3. The click is due to sudden deceleration of the column of blood under the pulmonary valve which
domes during systole.
4. The cardiac output remains normal because the RV is able to generate enough pressure to maintain
normal flow to the body.
5. The heart is not enlarged because no chamber is dilated (only hypertrophied). Even though there is
a small right to left shunt at atrial level, the pulmonary vascular markings would probably be nearly
normal.
6. There is a small R-L shunt from RA to LA because of thick non-compliant RV. (Note drop in
saturation from PV to LA).
7. Clinical cyanosis is usually not perceived until the arterial saturation drops below 86-88%.
8. Somewhere less than.

7

Problem 6

1. Diagnosis is aortic stenosis. See diagram.

2. Chest pain on exertion is seen with severe AS. This is due to myocardial ischemia caused by low
diastolic perfusion pressure compared to myocardial pressure. Shorter diastole due to tachycardia
leads to further decrease in myocardial perfusion.
3. Infective endocarditis, LV failure, sudden death or other arrhythmias, aortic regurgitation.

Pressure gradient in patient with aortic stenosis. Note the left ventricular pressure of approximately
180 mm. of mercury, and the aortic pressure on pull-back of approximately 100 mm of mercury.

8

Problem 7

1. This is acquired tetralogy of Fallot. See diagram

2. There is mainly a right to left shunt. (The increase from 75-79%, SVC to PA may represent a small
L-R shunt, but remember the method is only accurate to within 3 or 4 %.
3. Same as 2.
4. From RV through VSD into LV and Aorta.
5. Infundibular pulmonic stenosis has developed.
6. Child may tire easily and become cyanotic with exertion. The narrow infundibulum limits
pulmonary blood flow and the heart can not respond to the demand for increased PBF. He may
squat when exerting to increase venous return and increase systemic resistance, both of which can
force more blood into the pulmonary artery.
7. This is a hypercyanotic spell due to sudden increase in RV obstruction, or decrease in peripheral
vascular resistance.
8. The murmur in tetralogy is due to flow across the stenotic RV outflow tract, not R-L flow through
the VSD. Since there is very little flow across the infundibulum during the spell, there is no
murmur.
9. a. Increase peripheral resistance to force more blood from left to right (knee-chest position; alpha
adrenergic drug such as phenylephrine). b. Increase volume of return to the RV (morphine, bolus
of i.v. fluid), or c. Reduce the stenosis by decreasing muscular spasm of the infundibulum, (beta
blocker, morphine).


9

Problem 8

1. This is probably TGA. Normal X-ray makes lung disease unlikely. Not much dyspnea. See
diagram

2. Observe response to 100% oxygen (pO
2
would rise only slightly if CHD).
3. There is no obstruction to cause turbulence.
4. Fetus received adequate oxygenated blood because placenta did the oxygenation and ductus
arteriosus and foramen ovale provided ample access of blood to the systemic circulation.
5. a. Increased peripheral extraction, b. Increased release of O
2
at tissue level due to increase in 2,3
DPG.
6. a. Cerebro-vascular accident, b. Brain abscess, c. slow growth, d. polycythemia, e. possible
learning disorder, f. clubbing


10

Congenital Syndromes Associated with Congenital Heart Disease

Syndrome

Trisomy 13

Trisomy 18

Trisomy 21

Turner Syndrome

Williams Syndrome

Noonan Syndrome

Holt-Oram Syndrome

Marfan Syndrome

Asplenia Syndrome

Polysplenia Syndrome

Congenital Rubella

Glycogen Storage Disease

DiGeorge Syndrome

CHARGE Association

Coloboma
Heart Lesion
Atresia of Choanae
Retardation
Genital Anomalies
Ear Anomalies
VATER Association
Vertebral Anomalies
Anal Anomalies
Trachero-
Esophageal Anomalies
Radial and Renal
anomalies
Heart Lesion

VSD, ASD, PDA

VSD, ASD, PDA

Endocardial cushion defect

Coaractation of the aorta, aortic stenosis

Supravalvular aortic stenosis

Pulmonary valve stenosis, aortic valve stenosis

AST, VSD

Mitral valve prolapse, aortic valve regurgitation, dilated and dissecting aorta

Complex cyanotic heart lesions, anomalous pulmonary venous return,
dextrocardia, single ventricle, single AV valve

Pulmonary atresia, dextrocardia, single ventricle, azygos continuation of
inferior vena cava

PDA, peripheral pulmonic stenosis

Hypertrophic cardiomyopathy

Aortic arch anomalies, tetralogy of Fallot, pulmonary atresia, transposition
of great vessels, truncus arteriosis

Tetralogy of Fallot, endocardial cushion defects, VSD, ASD

VSD


11

Surgical Procedures for Selected CHD Lesions

Palliative Procedures

Procedure

Anatomy Involved

Result

Indicated for

Blalock-Taussig Shunt

Subclavian artery to
ipsilateral pulmonary
artery

Increased pulmonary
blood flow

Tetralogy of Fallot
pulmonary valve atresia
Waterston Shunt Aorta to right
pulmonary artery

Increased pulmonary
blood flow

Tetralogy of Fallot
pulmonary valve atresia
tricuspid atresia
Rashkind Procedure Balloon aria septostomy

Increased atrial mixing Transposition of great
arteries
Tricuspid atresia
Blalock-Hanlon
Procedure
Operative atrial
septostomy

Increased atrial mixing Transposition of great
arteries
Balloon Angioplasty Valves and vessels

Dilation of
valves/vessels

Pulmonary valve
stenosis aortic valve
stenosis
Pulmonary Artery
Banding
Pulmonary artery Decreased pulmonary
blood flow
VSD
Endocardial cushing
effect single ventricle

Corrective Procedures

Fontan Procedure

Right atrium to
pulmonary artery
anastomosis

Atrium functions as
right ventricle

Tricuspid atresia,
single ventricle,
and pulmonary atresia
Mustard Procedure Intra-atrial baffle

RV remains systemic
arteries ventricle
Transposition of great
Norwood Procedure A complex two stage
procedure
Hypoplastic left heart

END

VASCULITIS, VEINS, LYMPHATICS,
AND VASCULAR TUMORS

Steve Nandkumar, MD
Pathology M-2 Vasculitis, Veins, Lymphatics, and Vascular Tumors

1

VASCULITIS
Inflammation of a vessel is called vasculitis.
Artery = arteritis
Capillary = capillaritis
Vein = phlebitis

CAUSE
1. Infections
2. Immunologic
a. Immune complex mediated
b. ANCA mediated
c. Direct antibody mediated
d. Cell-mediated immune reaction
3. Unknown
Trauma, toxins, radiation, etc., can cause vasculitis.

CLASSIFICATION OF VASCULITIS

TABLE 11-4 Classification of Vasculitis Based on Pathogenesis

Direct Infection
Bacterial (e.g.,, Neisseria)
Rickettsial (e.g., Rocky Mountain spotted fever)
Spirochetal (e.g., syphilis)
Fungal (e.g., aspergillosis, mucormycosis)
Viral (e.g., herpes zoster-varicella)

Immunologic
Immune complex-mediated
Infection-induced (e.g., hepatitis B and C virus)
Henoch-Schnlein, purpura
SLE and rheumatoid arthritis
Drug-induced
Cryoglobulinemia
Serum sickness
Antineutrophil cytoplasmic antibody (ANCA)-mediated
Wegener granulomatosis
Microscopic polyangiitis (microscopic polyarteritis)
Churg-Strauss syndrome
Direct antibody mediated
Goodpasture syndrome (anti-GBM antibodies)
Kawasaki disease (anti-endothelial antibodies)
Cell-mediated
Organ allograft rejection
Inflammatory bowel disease
Paraneoplastic vasculitis

Unknown
Giant cell (temporal) arteritis
Takayasu arteritis
Polyarteritis nodosa ()classic polyarteritis nodosa)

GBM, glomerular basement membrane; SLE, systemic lupus erythematosus. Data from Jennette JC, Falk RJ:
Update on the pathobiology of vasculitis. In Schoen FJ, Gimbrone MA (eds); Cardiovascular Pathology:
Clinicopathologic Corrections and Pathogenetic Mechanisms. Baltimore, Williams & Wilkins, 1995, p. 156

2

Pathogenesis
Immune complex mediated diseases, hypersensitivity reaction to drugs, infection associated vasculitis
(immune mediated) all occur.

ANCA Mediated Vasculitis
Antineutrophil cytoplasmic antibodies are antibodies that react with antigens (enzymes) present in the
primary or azurophilic granules of neutrophils and lysosomes of monocytes and endothelial cells.

Based on IF (immunofluorescent microscopy) there are 2 types of ANCAs:

1. Anti- PR3 (c-ANCA) cytoplasmic ANCA
acts against proteinase 3 (PR-3) present in neutrophil

2. Anti- MPO (p-ANCA) perinuclear ANCA
- acts against MPO (myeloperoxidase); also lactoferrin, elastase,
lactoperoxidase, lysozyme, cathepsin G. azurocidin, etc.

C. ANCA P. ANCA
Wegeners 90% < 10%
Microscopic polyarteritis 30% 60%
CSS rare 50-80%
PAN maybe maybe

ANCAs are associated with vasculitis. Possible causative hypothesis infection/inflammation " cytokines
(TNF, GM-CSF) and endotoxins " expression of Ags (PR3, MPO) on neutrophil surface " antibodies
(ANCA) formed " neutrophil degranulation " damage to endothelial cells and tissues.

NOTE: 1. ANCAs are helpful but not specific or diagnostic. They may be present in
inflammatory bowel disease, chronic active hepatitis, etc.
2. Negative ANCAs do not exclude vasculitis.
3. ANCAs are not used as a screening test
4. ANCAs may represent an epiphenomenon/autoimmune induced, etc. following tissue
damage.
5. Neither a diagnosis of vasculitis nor a treatment decision should be based solely on a
positive ANCA test result.
6. Vasculitis may present with anemia, leucocytosis, eosinophilia,
leukopenia/thrombocytopenia, hypoalbuminemia, elevated gammaglobulins, and
decreased complement levels.

I. GIANT CELL ARTERITIS (TEMPORAL ARTERITIS)

An acute and chronic inflammation of large, medium-sized and small arteries, often
granulomatous.

The most common vasculitis, may affect the aorta (giant cell aortitis), its major branches and
arteries in the head vertebral, ophthalmic, temporal arteries.

Morphology
Gross short segments of arteries are affected.
nodular thickenings with reduction of the lumen and thrombosis.

3

Microscopic
a. Granulomatous pattern ( 75% cases) showing
fragmentation of internal elastic lamina.
acute and chronic inflammation Giant cells (Langhans type and foreign
body type).
b. Non-granulomatous pattern ( 25% cases) showing
nonspecific acute and chronic inflammation with neutrophils, lymphocytes,
eosinophils, macrophages.
giant cells are absent.
fibrinoid necrosis noted.

Inflammation causes thrombosis with subsequent organization and healing (repair) " narrow
fibrous, nodular cord of artery.

Pathogenesis
Exact cause unknown
Probably a T-cell mediated immune reaction against elastin; IL-1, IL-2, IL-6, IFN are involved.
Association with HLA-DR present
Humoral immune reaction with anti-endothelial antibodies formation noted.

Clinical Features
Incidence 7-32 cases/100,000 population/year
More common > 50 years; # > ); in Scandinavian people of Nordic descent
Constitutional symptoms (fever, fatigue, weight loss)
Severe, unilateral pain or headache along the course of a tender, nodular, temporal artery
Ocular features (50% cases) diplopia, vision loss (transient or permanent)
Myocardial ischemia, GI and neurologic changes may occur
Polymyalgia rheumatica present

Diagnosis
Temporal artery (2-3 cm segment) biopsy of thickened, nodular area.
ESR (erythrocyte sedimentation rate) elevated

NOTE: The disease may be focal and segmental. Hence the ENTIRE SEGMENT OF ARTERY must
be examined microscopically.

In 1/3 of cases there may be a NEGATIVE BIOPSY (No changes seen). Even if there is
absence of morphologic confirmation, IF CLINICAL FEATURES ARE PRESENT,
START R
x
WITH ANTI-INFLAMMATORY DRUGS/STEROIDS/ANTI-TNF DRUGS!
Response to R
x
is very good.

II. TAKAYASU ARTERITIS (PULSELESS DISEASE) (AORTIC ARCH SYNDROME)

An acute and chronic inflammation, often granulomatous, of medium and large arteries.

AORTIC ARCH AND ITS BRANCHES ARE AFFECTED eventually leading to fibrous
thickening and narrowing or obliteration of lumen (at the origin of vessels or distally). This
DIMINISHES blood supply to the distal areas (hence pulselessness if extremities are involved).


4

Morphology
Fibrous thickening and luminal narrowing or obliteration can affect
1. Aortic arch (most common)
2. Distal aorta, branches, pulmonary artery (1/2 cases)
3. Renal and coronaries

Microscopic
Changes seen are similar to those of giant cell arteritis!
Intimal wrinkling and thickening
Inflammation (chronic type) of media with granuloma
Patchy necrosis of media
Adventitial mononuclear inflammation with perivascular cuffing of vaso vasorum

Pathogenesis
Unknown; perhaps immune mediated
Association with HLA A24-B52 DR-2 (mainly in Japanese)

Clinical Features
Incidence 1-2 cases/million. Occurs in young women < 40 years as apposed to giant cell arteritis
occurring in older age groups.
a. Cranial vessels neurologic disturbances, dizziness, hemiparesis, etc.
b. Ocular vessels visual defects, retinal hemorrhages, blindness
c. renal vessels HTN (50% cases)
d. Coronaries MI
e. Root of aorta aortic valve incompetence
f. Arch of aorta/branches weak pulse, hypotension in upper extremities with coldness and
numbness
g. Distal aorta claudication of legs
h. Pulmonary vessels pulmonary HTN, cor pulmonale

Investigation
Aortic arch angiogram may show marked narrowing or luminal obliteration of the vessel branches
"ESR, " Igs, anemia

Course
Quite variable. Some cases rapid progression

Show progress with a quiescent
stage in 1-2 years; chronic relapses may follow

Spontaneous remission

Medical steroids
R
x
methotraxate

Surgery (angioplasty correcting stenotic vessels)

5

III. POLYARTERITIS NODOSA (P.A.N.), CLASSIC TYPE

A systemic vasculitis, affecting small and medium-sized arteries,

Arterioles, capillaries and venules are not involved. PULMONARY VESSELS ARE
SPARED!

Morphology
1. Lesions are sharply SEGMENTAL (involves only a portion of the vessel {circumference}).
2. Inflammation causes local nodularity and aneurysmal dilation or even rupture.
3. Compromised blood supply may cause ischemia, infarction, hemorrhage, atrophy, ulceration,
etc. in the affected organ.
4. Renal, cardiac, hepatic, G.I., pancreatic, cerebral, cutaneous vessels are involved.

Microscopic Changes
1. Fibrinoid necrosis of the inner half of the vessel wall.
2. Necrotizing transmural inflammation of the vessel wall that is segmental.
3. All stages of inflammation (acute, subacute and chronic including reparative changes) are
present in the same vessel or in different vessels.

Acute and chronic inflammation followed by repair causes luminal narrowing and thrombosis
leading to nodularity and eventual fibrotic obliteration of the affected vessel.

Clinical Features
Usually occurs in young adults (also children and older adults).
Constitutional features, e.g., weakness, malaise, fever, weight loss
Organ involvement
1. Renal (60%) HTN, renal failure
2. Musculoskeletal (64%) arthralgia, myalgia, arthritis
3. Peripheral nervous system (51%) neuropathy, neuritis
4. G.I. (44%) pain, nausea, vomiting, bleeding, perforation, infarction
5. Skin (43%) purpuras, rash, ulcers, etc.

NOTE: RENAL INVOLVEMENT IS THE MAJOR CAUSE OF DEATH.
GLOMERULONEPHRITIS IS RARE! (because arterioles are normal)

Lab Investigations
1. Tissue biopsy (of skin, muscle, nerve, testis)
2. Angiographic studies (show occlusions, or aneurysms in 50% of cases)
3. HBV surface antigen positive (30% of cases); HBsAg and HBsAb immune complexes
seen
4. Anemia, leucocytosis, " ESR

NOTE: Per Robbins, PAN has little association with ANCA

Course Disease is fatal, if untreated

Acute fulminant {5-year survival rate = 10-20%}
Course
Protracted with intermittent flare-ups


6

R
x

Treat HTN (if present)
Drugs steroids and cyclophosphamide
Antiviral compounds, interferon, plasma exchange
Remission rate is 90%; relapse 10%

IV. MICROSCOPIC POLYANGIITIS OR POLYARTERITIS (HYPERSENSITIVITY OR
LEUKOCYTOCLASTIC VASCULITIS)

1. Unlike classic PAN, this vasculitis affects arterioles, capillaries and venules (rarely arteries).
2. All inflammatory changes (lesions) tend to be of the same age.
3. p-ANCA present in the majority of cases (80%)
4. Necrotizing glomerulonephritis (90% cases) and pulmonary capillaritis are common.

Leukocytoclastic Vasculitis occurs in microscopic polyarteritis.
Cutaneous vasculitis affecting small vessels of the skin is predominant. LCV may be idiopathic in
30% of cases or secondary in 70% of cases. Secondary LCV is associated with systemic diseases
or due to antigens (exogenous or endogenous), e.g., drugs( aspirin, Thiazides), infections ( Staph.
Strep. Viral hepatitis, TB etc.).

Microscopic Changes
1. Post-capillary venules are affected.
2. Leukocytoclasia presence of fragmented neutrophils as they follow (involve) the vessel
wall in acute stage (nuclear debris appears in and around vessels).
3. Mononuclear cells seen in subacute and chronic stages.
4. Extravasated rbcs seen (purpura).

Lesions occur as Purpuras. There are few or no immune deposits (PAUCI-IMMUNE).

Clinical Features
More common in men than women; usually about 50 years of age
Similar to those of classic PAN; also renal, lung, and skin manifestations present.

Treatment
R
x
as for PAN
Remove cause or offending Ag
For cutaneous vasculitis
Steroids

Five-year survival rate is 74%; relapse rate is about 30%

V. CHURG-STRAUSS SYNDROME (ALLERGIC GRANULOMATOSIS AND ANGIITIS)

Features incidence 1-3 cases/million; f:m = 12:1; occurs about 50 years
1. Allergic Rhinitis
2. Bronchial Asthma
3. Eosinophilia (80% cases); count is > 1,000/microlitre
4. Vasculitis with Intra and Extra Vascular Granulomata with Eosinophils
5. P-ANCA is Positive (50% cases)


7

This disease is a hypersensitivity phenomenon (cause allergen) affecting vessels (such as arteries,
veins, venules, capillaries) in the lungs, heart, spleen, kidneys, GI, nerves and skin.
Treatment
1. Steroids
2. Cyclophosphamide

Five-year survival > 50% (about 72% of cases)
If untreated, the 5-year survival rate is 25%. Cause of death is pulmonary or cardiac disease
(myocarditis or coronary arteritis).

VI. KAWASAKI SYNDROME (MUCOCUTANEOUS LYMPH NODE SYNDROME)

This is a vasculitis of small, medium, and large arteries with involvement of
1. Skin Erythema of palms and soles; rash with desquamation
2. Mucous membranes Conjunctival and oral erythema and erosions
3. Lymph Nodes cervical lymphadenopathy
4. Fever is also present.

Morphology
Fibrinoid necrosis, segmental transmural inflammation with necrosis, etc. are similar to those of
PAN.
Subsides spontaneously
Acute phase
Subsides with R
x

ACUTE CORONARY VASCULITIS CAN CAUSE ANEURYSM FORMATION,
THROMBOSIS AND LEAD TO MI.

Pathogenesis
Infectious agent (viral) " activation of T-cells and macrophages " cytokine release " polyclonal
B cell activity " auto Abs to endothelial and smooth muscle cells " vasculitis.

Clinical Features
Occurs in infants and young children (80% under 4 years old)
Common cause of acquired heart disease in U.S. children
20% cases develop cardiovascular sequelae (aneurysm, rupture, MI, sudden death).
Death due to coronary vasculitis occurs in 1% of cases

Course
A self-limiting disease with very good prognosis.

R
x
Aspirin for several weeks
I.V. gamma globulin

VII. WEGENER GRANULOMATOSIS

This disease is characterized by a triad of
1. Focal necrotizing or granulomatous vasculitis affecting arteries, arterioles, capillaries and
venules mainly in the lungs and upper airways.
2. Acute necrotizing granulomata of the respiratory tract (lungs, sinuses, ENT areas).

8

3. Glomerulonephritis (focal or crescentic).
Limited Wegener = Respiratory involvement
Kidneys are unaffected
Pathogenesis
This is probably a hypersensitivity disease either immune complex or cell mediated.

The Ag is not known (infective or environmental)

c-ANCA IS POSITIVE IN 90% OF CASES

Morphology
NECROTIZING GRANULOMATOUS VASCULITIS
Inflammation/necrosis of vessels similar to PAN
Granulomata with necrotic areas surrounded by lymphocytes, plasma cells, macrophages,
giant cells.

LESIONS RESEMBLE TUBERCLES! RULE OUT TB OR FUNGI BY SPECIAL STAINS;
ALSO CONSIDER MALIGNANT LYMPHOMAS! (Lymphomatoid granulomatosis)

Lesions undergo healing (fibrosis and organization)
Sinusitis and ulcers in the ENT area also occur

Focal necrotizing GN hematuria, proteinuria
In Kidneys
Crescentic GN renal failure

Clinical Features
More common in men than women; incidence 3 per 1000,000 population
Age about 40 years

Lung pneumonitis with nodular cavitary infiltrates (95%); alveolar hemorrhage
sinuses chronic sinusitis (90%)
Nasopharynx ulcers (75%)

Renal GN, proteinuria, HTN, renal failure (80%)
Eye, skin, cardiac, CNS involvement can also occur.

Lab Investigations
1. Biopsy (lung, renal)
2. c-ANCA test titres reflect disease activity
3. Leucocytosis, " ESR, anemia, " IgG, " platelet count

Course
If untreated, 80% cases die in one year.

R
x
Steroids Complete remission in 75% cases
Cyclophosphamide
Antibacterial drugs

There may be a relapse in 50% cases


9

VIII. THROMBOANGIITIS OBLITERANS (BUERGER DISEASE)

A segmental, thrombosing, acute and chronic inflammation of small andmedium-sized
arteries principally the tibial and radial arteries.

Veins and nerves of the extremities may be secondarily affected

Morphology
Segmental, thrombosing vasculitis of small and medium-sized arteries; veins and
nerves may be affected.
MAINLY VESSELS OF THE EXTREMITIES ARE INVOLVED

Microscopic
Acute and chronic inflammation of the vessel wall
Thrombosis of the lumen with organization/recanalization
Microabscess formation (pmns and giant cells)
Inflammation extends to veins, nerves with encasement in fibrous tissue

Pathogenesis
STRONG ASSOCIATION WITH CIGARETTE SMOKING!

Direct endothelial cell cytoxicity
Tobacco products
Hypersensitivity affecting endothelial cells causing damage

Association with HLA-A9 and HLA-B5
More common in India, Israel, Japan than in U.S.
(geographic or genetic influences)

Clinical Features
More common in ) than #
< 35 years of age

VASCULAR INSUFFICIENCY DUE TO THROMBOSIS CAUSES
1. Raynaud phenomenon
2. Instep claudication (exercise induced pain in the instep area)
PAIN OCCURS ALSO AT REST! due to nerve involvement (unlike AS where pain
is absent at rest).
3. Chronic ulcers of fingers, toes, feet and even gangrene
4. Migratory superficial thrombophlebitis

Treatment
1. STOP SMOKING! Good response in early stages of the disease
2. Surgery (arterial bypass, amputation, etc.)


10

IX. RAYNAUDS PHENOMENON

Paroxysmal pallor or cyarosis of the digits of hands and feet, tip of nose or ears occurs due to
vasoconstriction of digital arterioles and AV shunts.

Upon exposure to cold/subject to emotional stress, etc., the following events occur:
1. PALLOR (WHITE COLOR) Usually due to vascular ischemia caused by vasospasm of
digital arteries.
2. CYANOSIS (BLUE COLOR) Capillaries and venules dilate, blood stagnates and
becomes deoxygenated.
3. RUBOR (RED COLOR) Upon rewarming, vasospasm resolves, blood flows into
vasodilated areas; this reactive hyperemia causes a bright red color to the digits.

The above Triphasic color response is often associated with cold, numbness, paresthesia of the
digits; tips of the nose and ears may be affected.

Pathogenesis
An exaggerated central or local vasomotor response to cold or emotion causes intense vasospasm
of local small arteries/arterioles.

Primary or idiopathic
Raynauds Phenomenon may be
Secondary to other diseases

PRIMARY RAYNAUDS PHENOMENON
Also known as Raynauds Disease, it has the following features:
Prevalence 3-5% of population
# : ) = 5 : 1, usually occurs 15-20 years of age (in young healthy women)
Positive family history in 25% of cases
NO KNOWN UNDERLYING DISEASE OR CAUSE
Organic changes in vessels are rare
Intimal proliferation/proliferative endarteritis occur in late stages

Spontaneous remission (15%)
Benign
course Progression (30%)

SECONDARY RAYNAUDS PHENOMENON
This is due to ARTERIAL INSUFFICIENCY caused by diseases such as SLE, SS, AS or
Buergers disease.

Patients are > 30 years, suffer more severe episodes and have skin lesions (ulcers, gangrene, etc.)

Treatment
1. Avoid exposure to cold; dress warmly
2. Avoid smoking
3. Drugs/surgery for underlying cause


11

APPROACH TO VASCULITIC DISORDERS

Clinical Features Biopsy

Lab Investigations Angiographic studies

I. ROUTINE TESTS
a. Chemistry CMP Results depend
b. CBC on the organs
ESR " involved
c. Urinalysis
d. Culture studies for microbes
e. Serologic studies (for HCV, HBV, CMV, etc.)

II. SPECIAL TESTS FOR ANTIBODIES
a. ANCA antineutrophilic cytoplasmic antibodies
b. Anti-GBM antibodies, e.g., Goodpastures syndrome
c. Anti-endothelial antibodies, e.g., Kawasakis disease
d. Anti-hepatitis antibodies, e.g., PAN
e. Anti-nuclear antibodies (ANA), e.g., SLE
f. SSA, SSB, e.g., Sjogrens disease
g. Rheumatoid factor, e.g., rheumatoid arthritis
h. Anti-C1q antibodies, e.g., hypocomplementemic urticarial vasculitis
i. Mixed cryoglobulins, e.g., cryoglobulinemia

VASCULITIS

12

VEINS

I. NORMAL STRUCTURE

Review and compare to arterial counterparts thinner walls, less well-demarcated tunicae, scant
elastic tissue and less muscle in the media, and the presence of valves.

II. AGE CHANGES

Intima a fibromuscular layer develops, becomes hyalinized, and may calcify. Rarely does a
narrowing of the lumen follow.

III. PATHOLOGY

Clinical: There are a few important points to remember, e.g., pathological processes in veins
predispose to thromboembolism, stasis is not uncommon in veins, and collaterals may develop.

90% of diseases of veins are varicosities and phlebothromboses.

A. Varicosities
1. Varicose veins (vvs) Vvs most commonly involve superficial vessels of the
lower extremities long saphenous and its tributaries. More than 20 x 10
6
people
in the U.S. have vvs of the legs. Most patients are over 50 years and the female:male
= 3-6:1. In women they are rare before puberty and are often first noted during
pregnancy. Hereditary factors and increased intraluminal pressure play a major
role. Obesity, age, scars, posture, thromboses, neoplasms, and an abnormality in the
structure of the vessel wall are also involved in the etiology. Gross: the veins become
tortuous, elongated, dilated, nodular.
Microscopic: media degeneration of tissue; and thrombosis; variation in thickness
of the vessel wall due to hypertrophy, and fibrosis; valves become deformed.
Sequelae: skin changes include edema, stasis dermatitis, cellulitis, and erosion.
Thrombophlebitis may also develop. There is not any evidence that varicose veins
on their own cause deep vein thrombosis. However, older patients and those with
bilateral phlebitis may be at increased risk of developing deep vein thrombosis.
2. Esophageal varices The distal esophagus is the commonest site to be involved.
The causes include obstruction of portal vein, hepatic cirrhosis, SVC obstruction,
portal vein thrombosis, hepatic vein thrombosis, pylephlebitis (inflammation of the
portal vein), or neoplasm. Sequelae: rupture of the varices with possible massive
hemorrhage.
3. Hemorrhoids External: There is involvement of the inferior plexus which is
below the dentate line and drains into the internal iliacs. The hemorrhoids are covered
by stratified squamous epithelium. Internal involves the internal plexus which is
above the dentate line and drains into the portal vein. The overlying epithelium is
columnar. Etiology involves heredity, erect posture, and obstructed venous return.
Complications include thrombosis, ulcers, and hemorrhage, and infection.
4. Varicoceles The pampiniform plexus is involved and the condition may be: (a)
primary or idiopathic common on the left side and (b) secondary or
symptomatic on the left or right side and due to increased pressure in or on the cord
veins.

13

B. PHLEBOTHROMBOSIS AND THROMBOPHLEBITIS
(venous thrombosis)
These terms are used synonymously. The condition starts as phlebothrombosis and the
thrombus causes inflammation of the wall leading to thrombophlebitis. Pathogenesis
involves the vessel wall (endothelial damage), blood, and blood flow (stasis) = Virchows
triad.

Clinical: There is an association with estrogen therapy, cardiac disease, postoperative stasis,
inactivity, and immobilization. The initial site is usually the calf thrombi develop in the
sinuses of valves and they may lyse, or organize, cause obstruction, produce emboli, or
extend into larger veins with a greater risk of thromboembolism. After several hours
inflammation and repair (possible resolution) follow. The first manifestation may be an
embolic episode.

1. Superficial thrombophlebitis
This includes varicose veins in legs. I-V fluid lines in the arms. The condition is
aseptic.
2. Thrombophlebitis migrans These are recurrent episodes of thrombosis in the
veins of extremities and viscera. Malignant tumors are often present and should be
looked for. Buergers disease, connective tissue disorders, and blood disorders are
also accompanying conditions.
3. Phlegma alba dolens (white, painful leg or milk leg) There is massive swelling
of the leg, usually the left. Causes include iliofemoral thrombosis or blockage of
local lymphatics and the condition may be seen in the third trimester of pregnancy,
postpartum, or following extensive pelvic surgery. Pulmonary embolism may
occur.
4. Phlegmasia cerulea dolens There is massive iliofemoral thrombosis in this serious
condition. Massive swelling of a leg occurs with a blue skin, and bullae or gangrene.
5. Superior vena caval syndrome (SVC) SVC is due to external compression by a
malignant tumor (bronchogenic or lymphoma). Dilatation of the veins of the upper
thorax and neck develop with edema of the neck, face, and upper torso.
CNS symptoms may also develop.
6. Inferior vena caval syndrome Causes of this condition include thrombosis from
the femoral and iliac veins, compression, invasion, or direct intraluminal extension
of renal cell carcinoma or heptacellular carcinoma. Less often there may be external
compression from neoplasms, pregnancy, aneurysms, or ascites. There is swelling,
edema, and dilation of superficial veins of the lower extremities. Venous collaterals
of the lower abdomen become prominent.
7. Thrombosis of hepatic veins (Budd-Chiari syndrome) There is thrombosis of the
major hepatic veins and often the adjacent IVC, congestion, and portal hypertension.
The cause is found in two-thirds of cases, e.g., neoplasm, birth control pills, pregnancy,
abscess, etc.
Gross: nutmeg liver.
icroscopic: centrilobular and panlobular necrosis of the liver with hemorrhage and
fibrosis.
8. Portal vein obstruction Extrahepatic caused by thrombosis, compression,
congenital atresia, or inflammation and b) intrahepatic caused most commonly by
cirrhosis of the liver.


14

9. Aortocoronary vein bypass grafts Fibromuscular intimal proliferation with
narrowing or occlusion of the veins may develop and thrombosis may follow.
Atherosclerosis is uncommon and only occurs years later.

LYMPHATICS

I. NORMAL STRUCTURE
Review

II. PATHOLOGY

A. LYMPHANGITIS
Superficial lymphatics are involved. The inflammation is caused by pyogenic bacteria.
Painful red streaks spread up the limb to lymph nodes (lymphadenitis). Microscopic:
dilated vessels with coagulated lymph, leukocytes, cell debris. There is a surrounding
inflammation and possibly abscesses and cellulitis. Chronic lymphangitis predisposes
to lymphedema.

B. LYMPHEDEMA (abnormal accumulation of interstitial fluid)
1. Primary (idiopathic)
a. Congenital
(1) Familial hereditary (Milroys disease): there is an autosomal
dominant trait. The condition affects males and is present from birth.
The lower limbs are involved with dilated vessels with incompetent
valves.
Nonfamilial (simple) is also present from birth. Part or all of one
extremity becomes swollen. The condition may be associated with
Turners syndrome. The etiology is unknown.
(2) Lymphedema praecox This very uncommon condition occurs in
females, 10-25 years of age. It starts in the feet or ankles and spreads.
The etiology is unknown.
b. Secondary (obstructive)
Obstruction by malignant neoplasms, surgical removal, postradiation
fibrosis, filariasis, and interstitial fibrosis are causes. There is enlargement of
the area with peau dorange skin, ulcers, and brawny induration. The
obstructed vessels may rupture into a body cavity.

C. TUMORS
1. Benign
a. Lymphangioma
(1) Simple: subcutaneous head, neck and axilla. Gross: slightly elevated
or pedunculated swelling, 1-2 cm in diameter. Microscopic: masses of
small lymphatic channels are seen. Lymphangiomyoma: abundant
smooth muscle develops in the vessels.
(2) Cavernous (cystic hygroma): These occur in the neck or axilla.
Occasionally they reach diameters up to 15 cm. Microscopic: cavernous
lymphatic channels.


15

2. Malignant Lymphangiosarcoma

This is a rare neoplasm caused by prolonged obstruction with edema and radical
surgery for carcinoma of the breast. There is a 10-year latent period. Gross:
multiple subcutaneous nodules which coalesce. Microscopic: channels lined by
anaplastic endothelial cells.

VASCULAR TUMORS

I. HEMANGIOMA
Angiomas (hemangiomas) are:
Benign
Localized to head or neck, skin, extremities
1/3 occur in the liver

A. Capillary Hemangioma
Can occur anywhere
Strawberry (juvenile) hemangioma of the skin is quite common in newborns, may be
Multiple, grow rapidly then fade and regress by age 7 (75-90% of cases)
Composed of thin-walled capillaries
B. Cavernous Hemangioma
Can occur anywhere; involves deep structures
Composed of large cavenous vascular spaces
Do not regress; may cause pressure symptoms of rupture " bleeding
Associated with von Hippel-Lindau syndrome
Requires surgical excision
C. Pyogenic Granuloma
Is a lobular, polypoid hemangioma
Occurs following TRAUMA in skin, gingival, oral mucosa
Associated with ulceration, edema, acute and chronic inflammation granulation tissue
Granuloma gravidarum occurs in 1% pregnant women and regresses after delivery
R
x
surgical excision

II. GLOMUS TUMOR
Glomus body is a specialized arteriovenous anastomosis involved in thermoregulation
Glomus tumor (glomangiomas) is benign and originates from the glomus body
Occurs as a PAINFUL mass in the distal parts of digits
Composed of nests and masses of glomus cells arranged around blood vessels (branching
vascular channels)
R
x
by surgical excision

REACTIVE VASCULAR PROLIFERATION

BACILLARY ANGIOMATOSIS
A vascular, tumor-like proliferation seen in skin, bone, brain and other organs
It is an opportunistic infection of immunocompromised persons due to a gram-negative
bacillus-Bartonella henselae and B. Quintana (involves cat and cat flea in former and louse in
the latter)
Presents as round nodules in subcutaneous tissue

16

Microscopically shows proliferating capillaries with epithelioid endothelial cells, nuclear
atypism, mitoses; surrounding stroma shows pmns, nuclear debris and purplish granular
material (bacteria)
Diagnosis: 1. Tissue exam
2. PCR
R
x
antibiotics (erythromycin)

III. KAPOSI SARCOMA (KS)
A low-grade malignant tumor usually occurring in immune compromised patients (HIV)
Caused by human herpes virus 8 (HHV-8) also called KS-associated herpes virus (Kshv)
transmitted by sexual and nonsexual routes
KS virus disrupts control of cell proliferation and prevents apoptosis of endothelial cells
through p53 inhibitors and a viral homologue of cyclin D.

There are four forms of Kaposi Sarcoma
1. Chronic (European or Classic) K.S.
90% of cases occur in older men of Eastern European (Jews) or Mediterranean descent;
uncommon in U.S.
Not associated with HIV; homosexuals at increased risk.
Occurs as multiple skin plaques or nodules on arms/legs; viscera, mucosa in 10% cases.
Usually asymptomatic; lesions are localized and persistent with relapse and remissions.
2. Lymphadenopathic (African or Endemic) K.S.
Common in Bantu (S. African) children
Common in C. Africa (HIV positive or negative)
Skin lesions are sparse; Lymphadenopathy seen
Very aggressive disease
3. Transplant (immunosuppression) Associated
Occurs in post-transplant, immunosuppressed K.S. patients
50% of cases lymph nodes, viscera, mucosa involved; skin lesions are absent
Lesions may regress when immunosuppressive R
x
is reduced
Condition is aggressive and fatal
4. AIDS Associated K.S.
Seen in 1% of AIDS Rx cases (formerly in 33% of cases, mainly homosexuals)
Widely disseminated lesions with GI and lymph node involvement
Patients die due to opportunistic infections rather than K.S.

MORPHOLOGY OF K.S.
There are 3 stages

PATCH PLAQUE NODULE

Reddish purple, single or
multiple macules occur in
legs or feet

Large, violaceous raised plaques

Nodules seen
Micro. Dilated, angular
blood vessels with
surrounding lymphocytes,
monocytes, plasma cells
Looks like granulation
tissue
Dilated, jagged vascular channels
lined by plump spindle cells which
also occur in perivascular areas;
mitoses and inflammatory cells and
pink hyaline globules seen
Sheets of neoplastic, plump, spindle
cells with nitosees +++
Small slitlike spaces and vessels
with rbcs and hyaline globules
inflammatory cells +++


17

CLINICAL COURSE AND TREATMENT
Most primary lesions in chronic KS are asymptomatic; surgical excision is sufficient.
For multiple lesions " radiation Rx
Disseminated disease " chemotherapy
Treat AIDS; interferon alpha/angiogenesis inhibitors are helpful

IV. HEMANGIO ENDOTHELIOMA
Soft tissue tumors of vascular origin with plump, cuboidal cells resembling epithelial cells

R
x
is by excision
Recurrence 40% of cases
Metastasize 20-30% of cases
Death 15% of cases

V. ANGIOSARCOMA (Hemangiosarcoma)
A malignant endothelial neoplasm
Occurs in the elderly
Involves skin, soft tissue, breast, liver
Associated with radiation, arsenic, thorotrast (dye) and PVC (polyvinyl chloride)
Tumors are composed of well-differentiated endothelial cells in vascular channels to plump,
anaplastic atypical, spindle cells undifferentiated; vessels not seen

Diagnosis
Excision biopsy tissue positive for CD31, CD34, vWF (immunostains) indicating endothelial origin

Rx: Excision
Prognosis very poor (few live for 5 years)

VI. HEMANGIOPERICYTOMA
Tumor originates from vascular pericytes
Occurs in middle-aged women
Site pelvic retroperitoneum/lower limbs
Micro: Thin walled, branching (stag-horn) vessels

Prognosis
Benign course 67%
*Malignant 33%

*denoted by necrosis
mitoses
nuclear atypism/pleomorphism
large size of tumor
Revised: 10-23-12

PULMONARY LECTURES

(Krishnarao Tangella, MD)

Dr. F. Gaudier may use these notes;
Her ppts. will be available on the web
Pathology M-2 Pulmonary Lectures

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1

PULMONARY INFECTIONS

(Modified from previous notes)

Steve Nandkumar, MD
Pathology M-2 Pulmonary Infections

1

LUNGS AND UPPER RESPIRATORY TRACT INFECTIOUS DISEASES

Respiratory tract infections are common causes of morbidity and mortality in the United States. The only
other conditions that bring more people to the hospital each year are pregnancy and heart disease.
According to the CDC, nearly 90,000 people in the United States die from pneumonia each year. It is the
fifth leading cause of death. At the international level, acute respiratory infection ranks as the third most
common cause of death in children under 5 years of age and is responsible for 3.5 million deaths
annually.

An account of respiratory infections that focuses only on the death toll does not give a complete picture of
their effects. Respiratory diseases remain a major cause of days lost at work or school. Walking
pneumonia, a bacterial lung disease that is rarely fatal, causes young people to miss weeks of school or
work. Influenza is such a common cause of lost days at work and lost productivity that many employers
offer free influenza vaccinations to employees. And, of course, the common cold (whose name says it all)
continues to disrupt lives and complicate schedules. There is no question that respiratory diseases remain
major public health and economic problems in both developed and developing countries.

FUNCTION AND STRUCTURE OF THE RESPIRATORY TRACT

The primary function of the respiratory tract is the exchange of gases between the environment and the
blood. This process occurs in three steps. The first is ventilation, which is the flow of air through the
conducting air passages into the alveoli. The second step is perfusion, the movement of arterial blood
into capillary beds of the alveoli. The third step is diffusion, the exchange of gases between the air spaces
in the alveoli and the capillaries.

The upper respiratory tract, composed of the nasal cavity and pharynx, is responsible for filtering out
foreign particles and humidifying and adjusting the temperature of inspired air. The upper and lower
parts of the respiratory tract are connected by the larynx. The trachea leads from the base of the larynx
into the chest and ends by dividing into the primary bronchi. The bronchi continue to divide
dichotomously becoming smaller and more thin-walled as they move from the hilum outward to the
periphery (see FIGURE 1 on next page). The histology also changes gradually.

The bronchi are lined by pseudostratified columnar ciliated epithelium with goblet cells, serous cells, and
short pyramidal basal cells interspersed. The basement membrane rests on the lamina propria, which
contains elastic fibers and aggregates of the mucosa associated lymphoid tissue (MALT). The lamina
propria merges into the submucosa made up of loose connective tissue with mixed serous and mucous
glands. This is surrounded by C-shaped hyaline cartilage.

As the bronchi branch into bronchioles, the epithelium gets shorter but it still consists of a mixture of
ciliated columnar cells and goblet cells. The number of goblet cells decreases, as does the surrounding
cartilage. A new type of cell, a nonciliated secretory cell called the Clara cell appears. Although the
MALT is still present, the cells are much more diffuse. Many mast cells are located in this area.


2

FIGURE 1. Major features of the lower respiratory tract

Bronchioles divide into terminal bronchioles, which have no goblet cells. The respiratory portion of the
tract begins at the end of the terminal bronchioles. This portion is called the acinus or terminal
respiratory unit. Acini comprise respiratory bronchioles, alveolar ducts, and alveolar sacs. The proximal
part of the respiratory bronchiole has ciliated cells, but these are replaced by Clara cells distally. The
alveoli are thin-walled polyhedral sacs that are delineated by interalveolar walls or septa. The walls have
a sandwich-like construction with epithelial cells on both sides and loose connective tissue in the middle
(the interstitium). The interstitium contains capillaries, elastic fibers, fibroblasts, fibers, occasional mast
cells, and supporting basement membranes. Small openings (pores of Kohn) allow some air as well as
bacteria and exudate to pass from one alveolus to another. The alveolar lining cells are called
pneumocytes and occur as two types. Type I pneumocytes are flat cells that cover most of the alveolar
surface. The cuboidal type II pneumocytes have microvilli on their surfaces. They produce surfactant
and are the main cells involved in tissue repair. A major host defense, the alveolar macrophage, is found
in the alveoli.

The visceral pleura, consisting of mesothelial cells, surrounds the lung and is continuous with the lining
of the chest wall (parietal pleura). The lung has two blood supplies. One is the bronchial arteriolar
branch, which provides nutrients to the lung. The other, the pulmonary artery and its network of
capillaries, is responsible for gas exchange.


3

DEFENSES OF THE RESPIRATORY TRACT

Each day we take in about 10,000 liters of air with many noxious components not the least among which
are microorganisms. Whether or not inhaled particles make it to the lung depends in large part on their
size. Particles 10m or larger usually are trapped in the nasal passages or upper airways. Particles in the
5-10m range tend to be trapped in the trachea and bronchi. The smaller particles (1-5m) can make the
entire trip to the terminal bronchioles and alveoli. There are two levels of defense those that prevent
microbes from entering the lung and those designed to eliminate microorganisms that get past the first
line of defense and enter the lung.

An important protection of the lung is the resident microbiota of the oral cavity and nasopharynx. The
resident microbiota inhibits colonization by pathogens. A pathogen that can colonize the mouth or
nasopharynx has a better chance of causing infection than one that cannot, because high numbers of the
pathogen are present and are constantly being inhaled. This increases the likelihood that the pathogen
will eventually succeed in bypassing the defenses of the upper airway and be in a position to take
advantage of a transient breach of host defenses. Most pulmonary pathogens come from the oral flora
because healthy people transiently carry common pulmonary pathogens at various times during the year.
Other defenses important in keeping the lung free of pathogens are described below.

The sneeze reflex will eliminate particles that land on the nonciliated epithelium at the front part of the
nasal passage. However, particles that are deposited in mucus layers further back are carried by the
ciliated epithelium to the oropharynx then swallowed or expectorated. The cough reflex of the larynx is
also an important defense. Particles trapped in mucus lining the trachea and bronchi are swept up and out
by the mucociliary elevator. Another important defense in this area may be secretory IgA if the person
has encountered that particular microbe in the past. High levels of complement are present in nasal
secretions.

Damage to the mucociliary apparatus is seen in cigarette smokers and as a result of viral infections.
Stroke, alcohol consumption, drug abuse, anesthesia, and even normal sleep interfere with proper closure
of the epiglottis, and with cough and sneezing reflexes. This may result in aspiration of infectious
particles.

Diseases or conditions that interfere with normal function of the immune system, for example, HIV
infection, chemotherapy, immunosuppression to treat autoimmune disease or to prevent rejection of organ
grafts, extremes of age, and other systemic illness, increase the possibility of infection by microorganisms
that are nonpathogenic under normal conditions (opportunists).

Exposure to a particularly virulent organism or exposure to a large number of organisms may overcome
the normal defenses even in a healthy person.

Although the alveolar lining fluid contains free fatty acids, cytokines, immunoglobulins, and bactericidal
proteins, the primary defense of the lower airways is the alveolar macrophage. The alveolar macrophages
have two roles. Some of them may phagocytose and directly kill invading pathogens. Others may
process and present microbial antigens to the lymphatic system and elicit an immune response. The
macrophage defense also is responsible for many of the symptoms associated with pneumonia.


4

TYPES OF LUNG DISEASES

Bronchitis: Bronchitis is an inflammation of mucus membranes of the bronchial tube. It may be acute or
chronic. For this lecture we are concerned only with acute bronchitis because microbes do not typically
cause chronic bronchitis.

Etiology: The most common causes of acute bronchitis are viruses (rhinovirus, coronavirus, influenza
viruses, and adenovirus). Some bacterial species are also capable of causing the disease, e.g., Bordetella
pertussis, Mycoplasma pneumoniae, and Chlamydophila (formerly Chlamydia) pneumoniae.

Pathological features: Bronchitis is characterized by edema of the mucus membrane, increased
bronchial secretions, submucosal inflammation, and loss of mucociliary function. The disease is usually
self-limited unless it is complicated by secondary bacterial infection.

Acute pneumonia: Acute pneumonia occurs in two forms. One is airspace pneumonia and the other is
interstitial pneumonia (also called primary atypical pneumonia). Airspace pneumonia is an inflammation
of the lung parenchyma characterized by consolidation of the affected part, the alveolar spaces being
filled with exudate, inflammatory cells, and fibrin. There are three different methods of classifying
airspace pneumonia.

(1) Pathological classification: Pathological classification divides pneumonias into two groups
according to the macroscopic anatomic distribution of the disease.

(a) Bronchopneumonia: Infection starts in the bronchi and spreads to the alveoli. These areas
become consolidated and eventually may involve entire lobes of the lung. More than one
lobe may be involved.
(b) Lobar pneumonia: Causative organisms enter the distal airspaces and spread through the
alveoli to cause acute inflammation throughout the entire lobe. Infections of this type are
usually confined to a single lobe.

Although in theory these are easy to understand, clinically it may be difficult to differentiate between the
two types.

(2) Microbiological (or etiological) classification: This type of classification is self-explanatory.
Pneumonias are classified according to the type of microbe causing the disease bacterial, viral,
fungal, or parasitic.

(3) Clinical classification: Clinical classification is based on the environment in which the pneumonia
is contracted community acquired, hospital acquired (nosocomial), diseases of the
immunosuppressed patient, and interstitial pneumonia. See TABLE 1 on next page for organisms
commonly causing the different clinical types of pneumonia.


5

TABLE 1. Organisms that commonly cause the different clinical types of pneumonia.

Community-acquired
pneumonia

Hospital-acquired
pneumonia (nosocomial)

Pneumonia in
immunocompromised
hosts

Interstitial
pneumonia

Streptococcus pneumoniae

Legionella pneumophila

Mycoplasma pneumoniae

Staphylococcus aureus

Klebsiella pneumoniae

Haemophilus influenzae

Moraxella catarrhalis

Viruses: influenza,
adenovirus, respiratory
syncytial virus

Gram-negative bacteria
(often resident microbiota
of colon)

Staphylococcus aureus

Streptococcus
pneumoniae

Streptococcus pyogenes

Aspergillus spp.

Candida spp.

Pneumocystis jirovecki

Cytomegalovirus

Mycobacterium avium-
intracellulare

Cryptococcus
neoformans

Legionella pneumophila
Mycoplasma
pneumoniae

Chlamydophila
pneumoniae

Coxiella burnetti
(Q fever)

Viruses

AIRSPACE PNEUMONIA

Airspace pneumonia may be either primary or secondary. Primary pneumonia occurs in previously
healthy people. The microbes that cause primary pneumonia are highly virulent. The most common
cause is Streptococcus pneumoniae. Other microbial species that can cause primary pneumonia are
Staphylococcus aureus, Klebsiella pneumoniae, Legionella pneumophila, Haemophilus influenzae, and
various viruses. Primary pneumonia is usually a lobar type of pneumonia.

Secondary pneumonia occurs in patients who are compromised in some way. Examples of susceptible
people are AIDS patients, patients on chemotherapy or other immunosuppressive therapy, smokers,
people who have had a viral infection, those with bronchial obstructions, and any other conditions in
which some host defense is impaired. The causative agents may be either highly virulent or opportunists.
Secondary pneumonia is usually seen as a patchy bronchopneumonia.

Features of lobar pneumonia: Classic descriptions of lobar pneumonia divide the progression into four
stages. The macroscopic features mirror the sequence of events occurring as a result of acute
inflammation.

Congestion: Cut surface of the lung is red. The lung is heavy because of vascular congestion and
accumulation of fluid in the alveolar spaces. A few polymorphonuclear leukocytes are present in the
alveoli. At this stage of the inflammation, bacteria may be visible in the alveolar spaces.


6

Red hepatization: At this stage the lung is solid and feels firm, the cut surface resembles the cut surface
of liver. These features are a result of increased congestion, abundant polymorphonuclear leukocytes and
fibrin, and red blood cells. Infection is usually controlled at this stage.

Gray hepatization: At this stage the cut surface of the lung is somewhat dry. It is gray-brown because
there is breakdown of the red blood cells that are mixed with neutrophils and fibrin. This is the beginning
of the healing stage.

Resolution: At this stage the inflammatory exudate undergoes progressive enzymatic digestion. Some of
the cellular debris is removed by the macrophages, some of it is coughed up and the fluid is reabsorbed.
Organization by ingrowing fibroblasts occurs. Small areas of scarring may occur on the pleural surface if
the inflammatory response extends to the pleura.

In this era of liberal use of antibiotics, the four stages are generally not clearly identifiable.

COMPLICATIONS OF PNEUMONIA: Disturbances of ventilation and perfusion

Necrotizing bacterial pneumonia and lung abscess

Empyema: spread of the infection to the pleura; the pleura is covered with fibrin and pus.
Organization of the pneumonia may result in fibrosis or scarring.

Bacteremia: Bacteria may be disseminated by the bloodstream to distant sites such as the pericardium,
heart valves, brain, kidney, spleen, joints, etc.

DIAGNOSIS: Diagnosis requires correlating the patients history, a physical examination, X-ray
findings, and laboratory tests.

Pertinent history should include the following: (1) clinical setting in which the pneumonia occurred;
(2) defects in the host immune system that may predispose to a particular type of infection; and (3)
history of exposure to a specific pathogen. This information provides clues to the possible infectious
agent responsible for the pneumonia.

Clinical features include fever, chills, productive cough, hemoptysis, dyspnea, chest pain (pleural
involvement) and other general signs of infection such as increased pulse rate, respiration rate, etc.

A chest x-ray will show areas of consolidation and may help differentiate between lobar pneumonia
(confluent areas) and bronchopneumonia (patchy areas).

Laboratory tests are required for a definitive diagnosis. The following tests should be done:

(1) A sputum smear with gram-stain will show a predominance of either gram-positive or gram-
negative bacteria.

(2) Sputum culture: This procedure will give a definitive diagnosis. However, it takes one to two
days to finalize the identification of the bacteria. Also, it is not unusual for any bacteria to grow
from a sputum specimen even though they can be seen in the gram-stained slide.

(3) Blood culture: Blood cultures are positive in 20 to 30% of the cases of bacterial pneumonia.

(4) Urinary antigen testing, CBC, Blood gas studies are helpful.

7

SUMMARY OF BACTERIA THAT COMMONLY CAUSE PNEUMONIA

Streptococcus pneumoniae: As indicated previously, Streptococcus pneumoniae is the most common
cause of community-acquired pneumonia. Although lobar pneumonia is typical, bronchopneumonia may
also occur. S. pneumoniae commonly colonizes the upper respiratory tract of up to 20% of the
population.

Complications of pneumococcal pneumonia include meningitis, bacteremia, endocarditis, arthritis,
peritonitis, empyema, and lung abscess.

Diagnosis: Gram-positive, lancet-shaped diplococci in sputum. Organism has a capsule. Blood cultures
are often positive.

Haemophilus influenzae: A gram-negative organism, it exists in 2 forms encapsulated (5%) and
unencapsulated (95%). The encapsulated form produces an antibiotic HAEMOCIN that kills the
unencapsulated forms.

The organisms spreads/survives by
1. pili on the surface adhere to the respiratory epithelium.
2. factors that disorganize ciliary beating.
3. protease degrading IgA in respiratory secretions.
4. capsule prevents opsonization by complement and phagocytosis by host cells.

It causes acute community acquired pneumonia/bronchopneumonia, meningitis and pink eye
(conjunctivitis) in young children, acute exacerbation of COPD, etc. H. influenzae pneumonia following
viral infections in children has a high mortality rate.

Moraxella catarrhalis: Moraxella catarrhalis is part of the resident microbiota of the oropharynx. It is
usually acquired by inhalation of respiratory droplets. It causes bronchopneumonia especially in older
adults with COPD, and otitis media in children. The disease resembles that caused by H. influenzae and
S. pneumoniae.

Rare complications of M. catarrhalis pneumonia include pleural effusion and bacteremia.

Diagnosis: Gram-negative diplococci. They can be cultivated on blood agar or chocolate agar. Most of
the bacteria isolated from clinical specimens produce &-lactamase, but they are susceptible to most other
classes of antibiotics.

Staphylococcus aureus:. Staphylococcus aureus causes bronchopneumonia. It is commonly isolated as a
cause of pneumonia after viral infections, as a nosocomial infection, in patients with COPD and IV drug
abusers, and in immunocompromised patients.

Complications of S. aureus pneumonia are multiple abscesses and endocarditis specifically in IV drug
abusers. Infection is associated with a mortality rate of 30 to 40%. As many as 15 to 30% of the adult
population may be carriers. Antibiotic resistance is common.
Diagnosis: Gram-positive cocci that grow in clusters. S. aureus grows readily on most general laboratory
media. The coagulase test helps in further identification.


8

Klebsiella pneumoniae. Klebsiella pneumoniae can colonize the oropharynx in certain circumstances
and generally causes infection when aspirated. Typically upper lobe lobar or bronchopneumonia is seen.
K. pneumoniae infections are more common in the debilitated, alcoholics, and the malnourished
population. It is the most frequent cause of gram-negative bacterial pneumonia.

Complications are abscesses, fibrosis, and bronchiectasis. The morality rate may be as high as 20 to 25%.

Diagnosis: Gram-negative rods with thick capsule. Culture of blood, transtracheal aspirate, and pleural
fluid is diagnostic.

Legionella pneumophila: It causes sporadic or epidemic pneumonia (Legionnaires disease), and
Pontiac fever, a self-limited URTI.

The mode of transmission is either inhalation of aerosolized organisms or aspiration of contaminated
drinking water (present in water cooling towers and pipes).

The pre-disposing conditions include cardiac, renal, immunologic, hematologic and post organ transplant
status.

Diagnosis: Culture is useful; antigen detection in urine and positive fluorescent antibody test (FAT) on
sputum samples are commonly used.

Pseudomonas aeruginosa: Pseudomonas aeruginosa causes diffuse bronchopneumonia. It is a common
cause of nosocomial infections and occurs in patients who are immunocompromised or those who have
cystic fibrosis. It invades blood vessels and hence spreads outside the lungs. The mortality rate is high.

Diagnosis: Gram stain shows gram-negative rods. The bacteria grow readily on laboratory media.
Culture of the organism and metabolic tests are definitive.

Aspiration pneumonia: Aspiration pneumonias are seen in debilitated patients and patients with stroke,
drug overdose, alcoholism, etc. These conditions interfere with proper cough reflex and closure of the
epiglottis. Aspiration of gastric contents with gastric acid leads to acid-induced necrosis and
superimposed infection with mixed bacterial flora. Abscesses are very common. The mortality rate is
high.


9

COMMUNITY-ACQUIRED ATYPICAL PNEUMONIAS

It is defined as acute, febrile, respiratory disease characterized by patchy inflammatory changes in the
lungs, largely CONFINED TO THE ALVEOLAR SEPTA AND INTERSTITIUM (formerly called
interstitial pneumonia).

It is considered atypical because of
1. moderate amounts of sputum
2. absence of physical findings of consolidation
3. only moderate elevation of WBC count
4. lack of alveolar exudate

Causative organisms Viruses
Mycoplasma pneumoniae Influenza Type A, B
Chlamydiae pneumoniae RSV, Rubeola
Coxiella burnetti (Q fever) Varicella
Adeno and Rhino viruses
MPV (Human Meta pneumovirus)

Pathogenesis: Seen in extremes of age, malnutrition, alcoholics, and debilitating illnesses. Organisms
attach to URT epithelium followed by necrosis and inflammation. Spread to alveoli with interstitial
inflammation occurs. Alveolar spaces may be filled with fluid (mimics pneumonia on x-rays). Bacterial
infections may follow due to loss of mucociliary clearance.

Morphology: Red blue congested areas with patchy or lobar involvement.

Microscopic: Alveolar septal INTERSITIAL INFLAMMATION AND EDEMA
Mononuclear cells, lymphocytes, plasma cells seen
Neutrophils may be seen
Alveolar spaces are free or may show proteinaceous material and cells

Superimposed bacterial infection may cause bronchitis, bronchiolitis, and pneumonia.

Clinical features: Features are those of chest cold or URTI. Fever, headache, muscle ache, leg pain.
Physical signs are scanty.

Course: Sporadic cases recover; Most cases heal. Severe cases may develop DAD with hyaline
membrane formation. Epidemic forms may be severe with great mortality.

INFLUENZA VIRAL INFECTIONS

Influenza Virus A, B, C ( single stranded RNA virus)
Lipid bilayer envelope contains hemagglutinin and neuraminidase which determine viral subtype (H
1
, H
2
,
H
3
, N
1
or N
2
). Host antibodies against these are helpful. Cytotoxic T cells kill virus infected cells and
cytokine mediated macrophage protein helps clear the virus.

Type A Occurs in humans, pigs, horses, and birds.
- Lpldemlcs occur Lhrough muLaLlons of P and n LhaL allow vlrus Lo escape anLlbody
("#$%&%'(#)*'#+ ,$#-()

10

Pandemics occur when both H and N are replaced through recombination of RNA segments
with those of animal viruses " a new virus is formed (VIRAL ANTIGENIC SHIFT).

Types B and C
Occur in children
No antigenic drift or shift
- May cause viral myocarditis ( rare), Reyes syndrome ( following aspirin use).

Avian Influenza
primarily in birds
antigenic type H5N1 can be fatal to humans. It is acquired due to close contact with
birds. The viral H protein is cleaved by host proteases and the virus enters the cells and
becomes widespread. Patients can develop pneumonia.

Inflammatory response in the host tissues can lead to URTI, tonsillitis, laryngo
tracheobronchitis, bronchiolitis and focal atalectasis. Organization of inflammatory exudate
and subsequent fibrosis can cause obliterative bronchiolitis/lung scarring and damage.

Human Metapneumovirus (MPV)
A paramyxovirus occurs in children, elderly and immunocompromised patients, leading to
URTI,
bronchiolitis and pneumonia.
Reinfections are common
Reverse transcriptase PCR is diagnostic

SARS (Severe Acute Respiratory Syndrome)
Caused by a corona virus, it was transmitted to humans by contact with masked palm civets that
are eaten in China. Subsequent human spread occurred due to respiratory droplet infection and perhaps
from feces.

Clinical Features: incubation period 2-10 days
Fever, chills, malaise, myalgia, dry cough
dyspnea, tachypnea, other features of pleurisy, pneumonia

Diagnosis: Viral antibodies (after about 4 weeks), PCR ( viral Ag detection in resp. secretions, blood,
feces), virus in pneumocytes by EM.

Course: With supportive treatment :
Improvement/resolution " 33% of cases
Progression in rest (then resolution)
Death in 10% of cases due to DAD.

Mycoplasma pneumonia
A free living organism, 125-300 nm in size, facultative anaerobe.
Common in 5-20 year olds; spread by close contact; epidemics occur in late summer and early fall;
severe pneumonia occurs; 50% of patients develop (IgM antibodies) cold agglutinins against rbc I
group antigens, leading to agglutination at or below 4C.


11

LUNG ABSCESS

Lung abscess is defined as a circumscribed collection of pus appearing in an acute or chronic
localized infection and associated with destruction and necrosis. Microorganisms most likely to
cause lung abscess are aerobic and anaerobic streptococci, Staphylococcus aureus, gram-negative
organisms, and anaerobic organisms commonly found in the oral cavity.

PATHOGENESIS

Aspiration: Aspiration of oral contents and gastric contents occurs when the cough reflex is not
optimal. Conditions that interfere with normal functioning of the cough reflex are stroke, coma,
debilitated condition, and drug and alcohol abuse. Aspiration of gastric contents causes acid
necrosis of the tissue, foreign body giant cell reaction to the food particles, and bacterial infection.

Complication of pneumonia: Lung abscess is seen as a complication of bacterial and fungal
pneumonia or as a focus of secondary infection following viral pneumonia.

Septic emboli: Septic emboli from distant sites of infection may be carried with the bloodstream
and lodge into lungs as well as into other organs and result in abscess. These types of lung
abscesses may be bilateral and multiple abscesses may occur.

Post obstruction: Tumor mass may obstruct the bronchial lumen. Distal to the site of obstruction,
bronchial secretions are pooled and provide a site for infection.

Miscellaneous: Miscellaneous causes of lung abscess include traumatic injury, rupture of the
esophagus, etc.

Cryptogenic lung abscess: cases where cause is unknown.

Macroscopic Features: Macroscopic examination shows single or multiple generally well-
defined cavitary areas with a soft, necrotic center and occasionally a fibrotic wall.

Microscopic Features: (Suppurative destruction of tissue within cavitary area):
Microscopically the contents consist of abundant neutrophils, cellular debris, fibrin, and
occasionally microorganisms or foreign material. If the abscess cavity communicates with a
bronchus, part of the inflammatory and necrotic debris is drained and an air fluid level is visible on
chest x-ray.

Clinical feature: Similar to those of pneumonia, bronchiectasis etc. It is important to rule out a
malignancy in older people with lung abscesses (occurs in 10-15% of cases).

Complications:

Hemorrhage
Empyema
Brain abscess / meningitis
Amyloidosis


12

CHRONIC PNEUMONIA

Tuberculosis

Epidemiology: Tuberculosis is a common infectious disease and a leading cause of death in developing
countries. It is less common in the United States, is associated with HIV infections and occurs in
immigrants from countries where TB is highly prevalent.
Poverty, crowding, chronic debilitating illnesses, D.M., chronic lung disease, chronic renal failure,
malnutrition, alcoholism, hematolymphoid malignancies, immunosuppressed states such as HIV all
increase the risk of acquiring TB.

Etiology: Mycobacterium tuberculosis hominis is usually found in humans (reservoirs) with active
pulmonary disease. Inhalation of airborne organisms in aerosols generated from expectoration/secretions
from infected persons leads to lung infection. Oropharyngeal and intestinal TB by drinking milk
contaminated with M. bovis is uncommon nowadays due to pasteurization.

Pathogenesis: In unexposed immunocompetent person Acquisition of organisms

Host immune response

Cell mediated
immunity/hypersensitivity

Resistance tissue destruction

Sequence of events: During first 3 weeks
1. Mycobacterial cell wall mannose-glycolipid is recognized by alveolar macrophage mannose
receptors and other complement receptors. Organisms enter macrophage endosomes and cause
endosomal manipulation (lack of acid pH, maturation arrest, ineffective phagolysosome
formation). Bacilli proliferate in the airways/lungs with resulting bacteremia and spread to other
sites. MOST PERSONS ARE ASYMPTOMATIC OR HAVE A MILD FLU-LIKE ILLNESS.
2. Genetic makeup
Polymorphisms of NRAMP1 (natural resistance associated macrophage protein 1) gene lead to
ineffective microbial killing due to poor immune response.
(NRAMP is found in endosomes and lysosomes and acts as a transmembrane ion transport protein).

Three weeks after exposure (CELL MEDIATED IMMUNITY occurs).

3. Alveolar macrophages present mycobacterial antigen with HLA-MHCIIs help to CD 4 + T cells in
lymph nodes.IL-12 is secreted by macrophages; T
H
1 cells are generated and secrete IFN-*.
4. IFN-* activates macrophages. These produce
a. TNF " recruitment of monocytes " formation of granuloma.
b. nitric oxide " free radicals " oxidative destruction of mycobacteria.
c. Reactive O
2
species " antibacterial activity
5. Defective macrophage, T
H
1 function, or cytokine production lead to poor CM immune response,
poor granuloma formation and disease progression.

13

PRIMARY TB

This occurs in PREVIOUSLY UNEXPOSED, UNSENSITIZED PERSON.

Morphology: Bacilli implant in areas of maximal airflow in the lung (LOWER PART OF UPPER
LOBE AND UPPER PART OF LOWER LOBE CLOSE TO PLEURA). An inflammatory, necrotic
area of consolidation, 1 to 1.5 cm gray-white lesion called GHON LESION (FOCUS) develops. There
is caseation necrosis; organisms spread to regional lymph nodes. This PARENEHYMAL LESION
AND NODE INVOLVEMENT IS CALLED GHON COMPLEX. Eventually this area undergoes
fibrosis and calcification (RANKE COMPLEX). Cell mediated immunity controls infection in 95% of
cases. Sometimes the organisms may spread to other sites, but no lesions develop.

Microscopic Features:
1. Non-caseating granulomata
2. Caseating granulomata Epithelioid granulomata with central necrosis, with surrounding
lymphocytes, mononuclear cells and Langhans multinucleated giant cells and fibroblasts.

NOTE: The organisms can be demonstrated by acid fast stain, in areas of necrosis. However,
anaerobiosis, low pH and increased fatty acids retard bacterial growth in such areas.

Course/complications:
1. Following scarring/healing (95% cases) the organisms remain viable for life. REACTIVATION
can occur when the hosts defence is compromised.
2. Progressive primary tuberculosis: Elderly people, malnourished, immunocompromised persons,
and Inuit Indians, etc., develop this disease ( 5 % cases). Lack of immune response results in the
absence of caseating granuloma. The clinical features resemble acute pneumonia with lobar
consolidation, hilar adenopathy, and pleural effusion. Spread by lymphatic or vascular means can
cause meningitis or miliary TB.

SECONDARY OR REACTIVATION TB

Also called post-primary TB, it occurs in PREVIOUSLY SENSITIZED HOST. It may occur in 3 ways

1. Reactivation of primary infection (< 5% cases). Occurs after years when resistance is decreased.
2. Progression of primary infection
3. Exogenous reinfection with new bacilli (due to diminished resistance).

Morphology: LESIONS are localized to the apex of one or both lobes due to high 02 tension in these
areas. HILAR ADENOPATHY IS LESS PROMINENT. CAVITATION OCCURS. This leads to
erosion of airways, expectoration and hence spread of bacilli.
gray-white, yellow lesions, 2 cm size, subpleural site
caseating granulomata with bacilli seen
Normal resolution/ healing
fibrocalcific lesions in late stages
Following therapy


14

The disease may spread along several pathways:

1. Progressive pulmonary TB: Expanding CAVITARY lesions with erosion into bronchi and
subsequent spread. Healing by fibrosis due to treatment occurs.
2. Miliary pulmonary TB: Dissemination by lymphatics/vessels leads to multiple, small, 2mm areas
of consolidation in the lungs. These lesions may coalesce and give rise to diffuse consolidation.
3. Pleural effusions, empyema, or obliterative fibrosing pleuritis (usually seen in progressive
pulmonary TB).
4. Endobronchial, endotracheal, laryngeal TB due to airway spread occur.
5. Miliary systemic TB It involves liver, spleen, kidney, adrenals, bone, meninges.
6. Isolated organ TB Single organ involvement may be a manifestation of TB, e.g., Potts disease of
vertebrae ( cold abscess in paraspinal area ), intestinal TB, cervical lymphadenopathy called
SCROFULA.

Clinical Course:
A. Systemic symptoms due to cytokines. Low grade fever, anorexia, weight loss, malaise, weakness,
night sweats.
B. Localized symptoms: Lungs " cough, chest pain, hemoptysis;
other organs may be involved.

Diagnosis:
a. Documenting acid fast bacilli in sputum/tissue by AFB stains, fluorescent auramine-rhodamine
b. Routine culture slow
c. Radiometric assays
d. PCR-assay (detect as few as 10 organisms)
e. Skin test: Tuberculin skin (Mantoux) test Intra cutaneous injection of purified, protein,
derivative of tubercle bacilli (Myco-tuberculosis) leads to a visible and palpable induration in 48-72
hours. A positive test signifies T-CELL MEDIATED IMMUNITY (DELAYED
HYPERSENSITIVITY) TO MYCOBACTERIAL ANTIGENS. False-positive reactions are
seen in infections with atypical mycobacteria and following BCG vaccination. False negative
reactions occur in malnutrition, viral infections, sarcoidosis, immune suppression, Hodgkins
lymphoma and overwhelming active TB.
f. IGRA Interferon gamma release assays use an objective measurement of interferon gamma
production by peripheral mononuclear cells exposed to peptides designed to simulate MTB Ags.
They are used in detecting latent TB infection.
g. Clinical features, imaging studies etc. are helpful.

TB AND HIV

1. HIV with mild immune suppression (CD4 count > 300 cells/cmm)
a. apical disease with cavitation
b. extrapulmonary spread 10-15% of cases

2. HIV with severe immunosuppression (CD4 count < 200 cells/cmm)
a. lower and middle lobe consolidation, hilar adenopathy and NO CAVITATION.
b. extra pulmonary spread 50% of cases.

3. In HIV patients, there is higher tissue bacillary load, but increased frequency of sputum smear
negativity for AFB as compared with HIV negative persons. WHY?

15

ATYPICAL OR NON-TUBERCULOUS MYCOBACTERIAL DISEASE

Organisms: Mycobacterium avium intracellulare (M. avium complex)

NOTE: M. kansasii (Common in soil, dust,
M. abscessus water, and domestic animals)

They can mimic TB by presenting as a localized pulmonary disease (upper lobe cavitation) in smokers
and alcoholics. COPD, cystic fibrosis, etc., are other risk factors. In immunosuppressed persons (HIV
positive), there is a disseminated disease, with diarrhea and malabsorption. M. avium complex usually
occurs in AIDS when the CD4 count is below 60 cells/cmm. Granulomata are absent. Foamy histocytes
with atypical mycobacteria are seen. Liver, spleen, and lymph nodes are affected and enlarged.

CHRONIC FUNGAL PNEUMONIA

Fungal pneumonias are usually caused by dimorphic fungi (they grow as hyphae that produce spores at
environmental temperatures, but grow as yeasts (spherule or ellipses) at body temperatures in the tissues).
They can mimic tuberculosis.

A. HISTOPLASMOSIS

Causative fungus Histoplasma capsulatum
Oval budding yeasts 2-5 + in size
Common areas Ohio and Mississippi river valleys; also Caribbean

Pathogenesis: Inhalation of dust particles from soil contaminated with bird or bat droppings
containing infectious spores (microconidia)

Convert to yeast forms in 2-3 days after reaching lungs (alveoli)

Opsonized by antibody and taken up by macrophages; Heat shock protein
60 on fungus is identified by beta 2 integrins on macrophages leading to
phagocytosis. Lysis of some host cells occurs.

T-cell immune reaction, production of IFN-* activating macrophage
killing of yeast, macrophages produce TNF which recruits/activates other
macrophages " death of yeasts.

Morphology

a. Immunocompetent hosts " epithelioid cell granulomata with coagulative necrosis,
consolidation, and cavitation. Healing occurs by fibrosis and concentric calcification
(laminated granulomata with tree bark appearance seen as calcific lesions on chest x-rays).


16

b. Immunocompromised hosts " epithelioid granulomata are NOT seen. Focal aggregates of
macrophages containing yeasts are seen in various tissues/organs.

Clinical Features
Self-limited flu-like disease presents with latent lung involvement/ coin lesion on imaging
studies ( concentric laminar calcification)
chronic progressive lung disease involving apical areas; cough, fever, night sweats present.
localized lesions in lymph nodes, adrenals, liver, meninges, etc.
disseminated disease (immuno compromised hosts).

Diagnosis:
Identification of organisms in tissue (special stains PAS, GMS)
Serologic tests (detect Ag and Abs 2 - 6 weeks after infection)

B. BLASTOMYCOSIS

Causative organism blastomyces dermatitidis round, broad based budding yeasts, 5-15 + size.

Common areas Central and SE United States
Canada, Mexico, Africa, India, Middle East

Pathogenesis: Similar to that of histoplasmosis

Morphology: Suppurative granulomata with thick, double contoured cell walled fungi and
multiple nuclei.

Clinical Features
a. Pulmonary form associated with fever, chills, night sweats, chest/abdominal pain, cough,
weight loss, anorexia
Imaging studies:
consolidation
infiltrate (multilobar, perihilar or miliary)
nodular lesions
b. Disseminated form
c. Cutaneous form ( rare)
Lesions on skin mimic squamous cell carcinoma

Diagnosis:
Morphologic id and culture
serologic tests
skin tests (40% false positive due to other fungi)

Course:
spontaneous resolution, persistence or progression

C. COCCIDIOIDOMYCOSIS

Causative fungus C. Immitis
thick walled, non-budding spherules, 20-60 + in diameter, filled
with endospores


17

Common location SW/Western US (San Joaquin valley disease)

Pathogenesis: Inhalation of spores causes alveolar infection. Macrophages ingest organisms
(arthroconidia) which prevent fusion of phagosomes and lysosomes increasing resistance to killing.
A delayed type hypersensitivity reaction develops.

Morphology: Granulomatous/pyogenic/or mixed lesions seen

Clinical features:
Asymptomatic
Lung lesions (10% of cases) fever, cough, chest pain, erythema nodosum, erythema
multiforme (San Joaquin Valley fever complex)
Disseminated form (1%) involves skin, spleen, brain, meninges,bone, liver,lymph nodes etc.

Diagnosis:
ID of organisms/cultures
serologic tests; SKIN TEST 80% POSITIVE
DNA probe tests

PNEUMONIA IN THE IMMUNOCOMPROMISED HOST

Immunocompromised or immunosuppressed states (HIV, malignancy, radiation therapy, chemotherapy,
organ transplantation) can predispose to the development of pulmonary infection (pulmonary infiltrate
with or without fever). Such opportunistic pneumonias may be caused by bacteria, virus and fungi.

OPPORTUNISTIC INFECTIONS

A. CYTOMEGALOVIRUS (CMV) INFECTION
Member of herpes virus family

Transmission
Congenital CMV transplacental spread to fetus from infected mother.
Perinatal CMV spread through vaginal or cervical secretions at birth, via milk during breast
feeding.
School children salivary spread
Venereal, fecal, oral, respiratory spread.

Iatrogenic blood transfusion, organ transplantation

Morphology: Affected cells (epithelial, endothelial, neurons, alveolar macrophages renal
tubular/glomerular endothelial) are ENLARGED (CYTOMEGALY), 40 + size, CELLULAR
NUCLEAR PLEOMORPHISM NOTED.
NUCLEI WITH BASOPHILIC INCLUSION SURROUNDED BY A HALO (OWLS
EYE)
BASOPHILIC INCLUSIONS IN CYTOPLASM


18

CMV Mononucleosis
In healthy children and adults, the disease is asymptomatic. 50-100% of adults in the world
are seropositive (with antibodies in serum).
Cytomegalic inclusion disease (CID) in neonates and an IM (infectious mononucleosis) type
disease occur in immune competent adults. Most individuals recover from the disease and
are seropositive for life. The virus remains LATENT in lymphocytes and monocytes.

CMV in Immune Compromised State occurs in
1. Recipients of organ transplants due to
a. reactivation of host CMV following treatment
b. donor CMV (from seropositive donors)
2. Allogeneic BMT due to reactivation of latent CMV in the recipient who is immune-suppressed
by drugs/GVHD).
3. AIDS due to reactivation of CMV or sexual transmission.

Pneumonitis Interstitial mononuclear infiltration with necrosis, CMV inclusions in
cells/ARDS
Colitis Intestinal necrosis, ulceration, diarrhea
*Retinitis Most common form of opportunistic disease

Diagnosis 1d of organisms in fluids/tissues
Culture
Serologic tests
PCR

B. PNEUMOCYSTIS INFECTION
Causative fungus P. jiroveci

Almost all persons are exposed to Pneumocystis, but the infection remains latent. Reactivation
occurs in immune incompetent/suppressed states, severe malnutrition and AIDS.

Intersitial Pneumonitis occurs with Pneumocystis infection.
Intra-alveolar pink, foamy exudate (cotton-candy exudate)
Septal thickening and edema with mononuclear infiltrate
SPECIAL STAINS DEMONSTRATE CUP OR BOAT SHAPED CYST WALLS 5-8 %
SIZE IN THE EXUDATE
SPUTUM STAINS (GIEMSA OR METHYLENE BLUE) SHOW TROPHOZOITES,
4 % SIZE WITH LONG FILOPODIA (50% OF CASES)

Clinical Features: Respiratory symptoms cough, dyspnea
Fever, hypoxia
Bilateral peri hilar / basilar infiltrates

Diagnosis: ID organism in fluids/tissue (bronchio alveolar lavage or biopsy)
Immunofluoroscence Ab studies
PCR assays

Course: Early treatment " recovery is good
Relapses are common; treat underlying immune deficiency condition (e.g. HIV)


19

C. CANDIDIASIS

Causative fungus Candida Albicans
A normal inhabitant of oral cavity, GI tract, vagina

Morphology: Blastoconidia " yeast like forms
Pseudohyphae " budding yeasts joined end to end at constrictions
True hyphae

Organisms are seen on H and E stain; also PAS and GMS

Clinical Syndromes

1. Oral cavity infection of mucosa (thrush)
Grey-white, dirty, pseudomembranes composed of organisms and inflammatory debris
covering mucous membrane
subjacent stromal inflammation present
common in HIV, newborns following antibiotic/steroid use, pregnancy, chronic
debilitating diseases.
2. Candida vaginitis
Occurs in women who are pregnant, on oral contraceptive pills, or diabetic
associated with intense itching and thick curd like discharge
3. Candida esophagitis
Resembles oral thrush
occurs in AIDS and patients with hematolymphoid malignancies
4. Cutaneous candidiasis
affects nail, nail folds, hair follicles, webs of fingers/toes, penis, diaper rash in infants
5. Chronic mucocutaneous candidiasis
associated with T-cell defects
affects many organs
6. Disseminated Candidiasis

D. CRYPTOCOCCOSIS

Causative fungus cryptococcus neoformans
occurs in AIDS, hematolymphoid malignancies, sarcoidosis, SLE, steroid therapy etc.

PATHOGENESIS
Organism evades host defences by the following:
1. Polysaccharide capsule : It inhibits phagocytosis by macrophages, recruitment of
other inflammatory cells, and inhibits neutrophil migration.
2. Laccase production that synthesizes melanin- like pigment that is anti-oxidant.
3. Serine proteinase that cleaves fibronectin and basement membrane proteins so that
there is tissue invasion.

Morphology: 5-10 + yeast with thick, gelatinous capsule

It is seen as a halo surrounding the fungus on H and E stain.
Special stains such as PAS/India ink are helpful ( fungus seen as halo in black background)
No pseudohyphae or true hyphae


20

Clinical Features: Acquired by inhalation of fungi from soil or bird ( pigeon) droppings.
Organisms proliferate in lung, CNS and then disseminate to other organs.
In immunocompetent patients " granulomata seen in lung ( coin lesion)
In immunocompromised patients " organisms with minimal or no inflammatory response
Meningeal and gray matter involvement occurs in Robin Virchow spaces producing SOAP
BUBBLE LESIONS ( organisms sitting in a bubble like space).
Disseminated lesions occur in liver, spleen, skin, adrenals,bone etc.

.
E. ASPERGILLOSIS eg. A.Fumigatus, Aspergillus Niger

Inhaled conidia convert to yeast forms in lung. Sometimes macrophages kill conidia and neutrophils
destroy hyphae due to free radical damage.
Morphology 5 10 micron fungi with septate hyphae branching at acute angles ( 40 degrees)
fruiting bodies seen
SUPPURATIVE, GRANULOMATOUS LESIONS WITH VASCULAR INVASION
SEEN; NECROSIS/INFARCTION/HEMORRHAGE OCCUR

Clinical Features: Occurs in immunocompromised hosts.

1. Invasive Aspergillosis: Sinusitis,lungs (necrotizing pneumonia) and cerebral aspergillosis
(usually fatal) occur.
2. Allergic bronchopulmonary aspergillosis: Asthmatic patients develop a type I
hypersensitivity response to the fungi. Eosinophilia and IgE antibodies are present
3. Aspergilloma: Fungal colonization of lung cavities (as seen in TB, cysts etc.) can result in a
FUNGUS BALL occluding the cavity. Hemoptysis and infections occur.

F. MUCORMYCOSIS ( ZYGOMYCOSIS)

Morphology:

non-septate hyphae, 6 50 micron wide, branching at right angles
lesions are similar to those of aspergillosis

Clinical Features:
1. Pulmonary form: localized cavitary or diffuse miliary forms ! pneumonia
2. Rhinocerebral form: involvement of nasal cavity/sinuses with spread to orbit, brain, and
other head and neck structures. Vessels involved with thrombosis and infarction.
Meningoencephalitis occurs.
Other lesions in GI tract are sometimes noted.

NOTE: Special stains for fungus PAS Periodic Acid Schiff ( fungus stains pink)
GMS Gomori Methanamine Silver ( fungus stains black)

Revised 9/5/12.

URINALYSIS

Steve Nandkumar, M.D.

(FOR SELF-STUDY)

Reading Assignment: See handout and A Handbook of Routine Urinalysis, by Sister Laurine
Graff, available in the MSB Library.

PPT ON WEB.

Objectives: See College Guidelines
Pathology M-2 Urinalysis

1

URINALYSIS

Analysis of urine is a simple, economical test that provides a lot of information especially if one knows what to
EXPECT.

IT HELPS IN
1. Diagnosis and management of renal diseases
2. Diagnosis and management of extra-renal diseases

A good urine sample depends upon proper collecting procedure

Proper collecting procedure includes cleansing the external genitalia, before urine collection. In females,
vaginal secretions may contaminate the sample.

COLLECTION SOURCE
1. Mid-stream urine sample
2. Urethral catheterization sample
3. Ureteric catheterization sample
4. Supra-pubic bladder aspiration sample

TIME
1. The first morning specimen is good as it is a concentrated sample.
2. Routine random samples are also acceptable.
3. Timed samples (2, 12, or 24-hour collection samples) are useful in assaying metabolites, hormones, and
steroids.

AMOUNT
5-15 ml (usually)

Examination is preferably done within 1/2-1 hour. Samples may be refrigerated up to 4 hours and then
examined. PRESERVATIVES such as formalin, Na-fluoride are helpful.

URINE EXAMINATION

I. DIPSTICK (REAGENT STRIP) URINALYSIS
Commonly used for screening purposes

II. ROUTINE URINALYSIS
Consists of gross and microscopic (sediment) exam.

III. SPECIALIZED URINE EXAM
A. Cytopathology
B. Immunohistochemistry
C. Molecular diagnostics
D. DNA ploidy and cell cycle analysis
E. Microbiologic studies

NOTE: Automated instrument urinalysis for routine studies is available.


2

Urine Examination

Gross Microscopic
(Physicochemical) (Urine Sediment)

GROSS EXAMINATION

1. Color UROCHROME

Usually pale yellow due to: UROBILIN

UROERYTHRIN
Concentrated (in dehydrated state) " deep yellow
Dilute (in hydrated state) " pale yellow
Drugs, chemicals, other compounds can affect the color.

Red Urine Yellow or Green Dark Brown or
Brown Black
1. Hematuria Bilirubinuria Methhemoglobinuria
2. Hemoglobinuria e.g, Obstructive Alkaptonuria
3. Myoglobinuria Jaundice Melanin
4. Porphyria
5. Menstrual blood

2. Odor
Ammonia smell
Certain metabolic disorders such as PKU (phenylketonuria) have peculiar odor.

3. Clarity (Character) Urine is normally clear
Turbidity may be caused by proteins, mucus, cells, crystals, etc.

LIPIDURIA Lipids in Urine
1. Free form (globules)
2. Oval fat bodies
These are macrophages and/or renal tubular cells that contain lipids (cholesterol or
triglycerides), e.g., nephrotic syndrome. Cholesterol causes the Maltese cross appearance
under polarized light. Triglycerides are detected by fat stains (Sudan III or Oil Red O)

Chyluria
Lymph in urine following rupture of lymphatics, (due to obstruction caused by tumor, filariasis, etc).

4. Amount (daily volume)
Normal = 1,500-2,000 ml/24 hours (varies from 600-1,200 ml)

Polyuria over 2,000 ml/24 hours, e.g., D. Mellitus, D. Insipidus, diuretics, chronic renal failure
Oliguria less than 500 ml/24 hours, e.g., dehydration, acute renal failure
Anuria virtually no or suppressed urine
Nocturia more than 500 ml at night (normal day to night ratio is 2:1)
5. Specific Gravity
It reflects the density of the specimen (degree of concentration or dilution of urine)
Normal = 1.016-1.022 (1.004-1.035)
Hyposthenuria low Sp. Gr. Urine ( < 1.007).
Isosthenuria Sp. Gr. of urine is low and fixed at 1.010.

3

Urea (20%), NaCl (25%), sulfates and phosphates contribute most of the Sp. Gr. of normal urine.
Sp. Gr. of ' 1.023 indicates normal concentrating mechanism of kidney.

6. Osmolality
Normal = 500-850 mOsm/kg of water
It indicates the number of solute particles per unit of solution. Measurements of plasma and urine
osmolalities are helpful. In dehydration, normal kidney can produce urine osmolality of 800-1400
(3 times that of plasmas). In diuresis, it may be about 40.

7. pH
Normal around 6.0 (varies between 4.6-8)
In vegetarian, it may be alkaline

Acid urine
High protein diet, cranberries
Respiratory or metabolic acidosis

Alkaline urine
Citrus fruits, drugs, renal tubular acidosis, respiratory and metabolic alkalosis.

8. Other substances routinely examined are:
Sugar
Ketone
Blood
Bilirubin
Urobilinogen
Nitrites
Proteins

NOTE: Leucocytes contain Esterases. In urinary tract infections, the enzyme level is high, (a positive
leucocyte esterase test) along with leukocyturia (pyuria).

Uropathogenic bacteria reduce nitrate to nitrite. Detection of nitrite is indicative of urinary tract
infection. This can be correlated with culture studies.

Abnormal substances such as porphyrins may be present in urine. Detection may involve specialized
procedures.

URINE SEDIMENT (Microscopic)
Subdued light and sedistain are normally used.

1. Cells
a. RBCs normal 0-1 rbc/hpf
b. WBCs normal 2-5 wbc/hpf
c. Renal tubular epithelial cells
d. Transitional epithelial cells
e. Squamous epithelial cells
f. Other, e.g., malignant cells

2. Casts
A cast is a protein that has precipitated and subsequently undergone gel transformation. IT IS
FORMED ONLY IN THE TUBULES (NEPHRON). Tamm-Horsfall protein, a glycoprotein
produced by the distal tubules/loop of Henle, forms the substrate in a cast.

4

Casts are of many types, e.g.
a. Hyaline (Basic cast normal 0 to 2 per low power field)
b. Granular (Granular proteins embedded in a hyaline cast)
c. Waxy (Degenerating cast. It now appears waxy)
d. Cellular (cells embedded in a hyaline cast)
e. Broad (Waxy casts ! Broad casts; 2 to 6 times the width of normal cast;
known as Renal Failure casts; indicate poor prognosis as seen in CRF).

Conditions that pre-dispose to cast formation
a. Increased proteins
b. Increased solutes
c. Decreased pH
d. Urine stasis or obstruction

Cylindruria increase number of casts in urine
RBC cast is associated with glomerulonephritis (glomerular damage)
WBC cast is associated with tubulointerstitial disease (pyelonephritis)

Cylindroids disintegrating casts (frayed casts with tails and tapering ends)

3. Crystals
Precipitation of urinary salts due to changes in pH, temperature and concentration normally seen in

Acid pH Alkaline pH
1. Amorphous and crystalline urates 1. Amorphous phospates
2. Uric acid 2. Calcium carbonates
3. Ca oxalate 3. Triple Po
4
, Magnesium,
ammonium phosphate MAP
crystals
4. Ammonium biurate
Abnormal crystals
Leucine
seen in liver damage
Tyrosine
Drugs, e.g., ampicillin, sulfa
Cystine, seen in cystinuria
Others too numerous to mention

A PHYSICIAN MUST BE CATCHING WHEN THE KIDNEYS ARE PITCHING.

MISCELLANEOUS TESTS

I. BLADDER CANCER TESTS
A. BTA bladder tumor Ag
B. NMP-22 Nuclear matrix protein

II. MONOCLONAL Ab ASSAY FOR OSTEOPOROSIS, BONE DISEASE, ETC. IT DETECTS
FREE URINARY PYRIDINIUM CROSS-LINKS

5


6

THE KIDNEY


Pathology M-2 The Kidney
1

THE KIDNEY

A. Introduction

B. Anatomy and Histology

C. Physiology/Functions

D. Diagnosis of Renal Disease

1. Urinalysis, proteinuria, renal function tests

2. Organ imaging

3. Clinical presentation
a. Nephritis vs. nephrotic

b. Asymptomatic urinary abnormality

c. Infection

d. Acute renal failure

e. Chronic renal failure

f. Tubulointerstitial diseases

g. Calculi

h. Tumors

E. Diagnostic Approaches

1. Clinical Fx

2. Histopathologic examination

a. Light microscopy

b. Immunofluorescence

c. Electron microscopy

3. Pathogenesis and Etiology

2

]

3

GLOSSARY OF TERMS

Proteinuria Abnormal amount of proteins in urine

Hematuria Blood (gross and/or microscopic) in urine

Dysuria Painful micturition

Pyuria Pus cells (WBCs) in urine

Lipiduria Lipids (neutral fats, cholesterol, etc.) in urine

Azotemia GFR (
BUN, S creatinine !

Uremia Renal failure, azotemia along with multi-system manifestations
(G1, CVS, skin, hematologic, etc.)

Diminished renal reserve GFR is about 50% of normal; BUN, S. creatinine are normal patient is
asymptomatic

Renal insufficiency GFR is 20-50% of normal; azotemia, anemia, HTN, polyuria, and nocturia
present

Renal failure GFR < 20-25% of normal; uremia present

ESRD or ESKD End stage renal or kidney disease
GFR < 5% of normal; uremia (terminal stage)

HISTOLOGIC TERMS USED IN GLOMERULONEPHRITIS

1. Diffuse: abnormal changes affecting all the glomeruli examined
2. Focal: abnormal changes affecting some of the glomeruli examined (other glomeruli are spared!)
3. Global: applied to a single glomerulus; the entire glomerulus is affected by the abnormal changes
4. Segmental: applied to a single glomerulus; only a part or segment or lobule of the glomerulus is affected
(other lobules are spared)
5. Mesangial: abnormal changes are predominantly seen in the mesangium

4

CLINICAL PATHOLOGIC CORRELATIONS

THE NEPHROLOGIST AND THE NEPHROPATHOLOGIST

The nephrologist performs a renal biopsy because he/she recognizes that clinical and functional findings,
without renal biopsy, do not always present a true picture of the patients renal status. Pure morphological
classification on the other hand without clinical correlation, produces an incomplete statement of renal status.

APPROACH TO CLASSIFICATION

The kidney reacts in a limited number of ways to a number of injurious agents and the clinical manifestations
corresponding to these reactions are also limited.

The study of renal tissue involves:
1. Light microscopy (LM)
2. Immunofluorescence (IF)
3. Electron microscopy (EM)

Structures to look at in any kidney biopsy/section:
a. Glomeruli
b. Tubules
c. Interstitium
d. Vessels

GLOMERULAR DISEASES

Glomerulonephritis = Inflammation of the glomeruli
Glomerulopathy = Abnormal glomerular changes without a cellular inflammatory component

GLOMERULAR DISEASES

There are three types:
1. Primary glomerulonephritis or nephropathy: Kidney is the only or predominant organ involved.
2. Secondary (Systemic) glomerular diseases: Glomerular injury associated with or part of other diseases, e.g.,
HTN, SLE, and DM
3. Hereditary disorders: e.g., Fabry disease, Alport syndrome

CLINICAL MANIFESTATIONS

These are:
1. Acute nephritic syndrome
2. Acute renal failure
3. Nephrotic syndrome
4. Chronic renal failure
5. Asymptomatic hematuria or proteinuria (sub-nephrotic)

NOTE: EXCLUDE MAJOR SYSTEMIC DISORDERS BEFORE CONSIDERING
PRIMARY GLOMERULOPATHY!
5

The major four systemic disorders are:
1. DM
2. SLE
3. Vasculitis
4. Amyloidosis

HISTOLOGIC CHANGES

!" $%&'()'**+*,(-.%
Mesangial
1. Cellular proliferation Endothelial
Epithelial
2. White blood cell infiltration, e.g., pmns, lymphocytes, monocytes, macrophages
3. Crescent formation due to fibrin deposition and proliferation of epithelial cells and WBCs.

/" /,0'1'2. 3'14(,2' 56-)7'2-28
Normal GBM = 300400 nm (thickness)

Increased BM synthesis and deposition or accumulation of electron dense material in the BM cause
increased THICKNESS!

(Substances deposited are immune complexes, fibrin, amyloid, cryoglobulins, proteins, etc.)

Above changes are seen in LM as thickening of capillary wall (best seen with special stain PAS)

9" $%,*-2-:,.-;2 ,2< =)*'(;0-0
LM = accumulation of homogeneous, eosinophilic, acellular material in the glomerulus (hyalinosis)

EM = ! BM
! Mesangial matrix
! Plasma protein deposition

Glomerular structure is obliterated " sclerosis.

>" ?.6'( 96,28'0
Glomerular thrombosis
Fibrin or lipid accumulation

HISTOLOGIC CHANGES ARE FURTHER SUBDIVIDED INTO:

DIFFUSE, FOCAL, GLOBAL, SEGMENTAL, MESANGIAL

PATHOGENESIS OF GLOMERULAR INJURY

I. CIRCULATING IMMUNE COMPLEX NEPHRITIS
Circulating immune complexes are TRAPPED in the glomeruli. A type III hypersensitivity reaction
occurs causing glomerular injury (innocent bystander!)
Endogenous, e.g., DNA (SLE), tumors
Ag may be:
Exogenous, e.g., Infections: Bacteria
Virus
Unknown Parasites
6

Immune complexes bind complement and cause damage. With time, these complexes are degraded by
phagocytic neutrophils, monocytes and mesangial cells and inflammation subsides. Repeated exposure to
Ags can cause recurrence and chronic injury.

Glomerular localization of immune complexes is due to:

A. Physicochemical Properties
1. Molecular charge
Cations CROSS GBM " Subepithelial location
Ions with neutral charge " Mesangial location
Anions " Subendothelial location; excluded from GBM (NOT nephritogenic)
2. Size of molecules
Large immune complexes are cleared by the RE system and hence not nephritogenic

B. Local Hemodynamic Factors

II. IN SITU IMMUNE COMPLEX NEPHRITIS
Antibodies react directly with GLOMERULAR Ag!

Intrinsic or fixed Planted
(from circulation)
AGAINST FIXED ANTIGENS:

A. Anti-GBM Nephritis
Abs bind to Ags that are normal component of the GBM.
Ag = component of NC1 (non collagenous domain) of !3 chain of collagen type IV
Egs. RPGN; Goodpastures syndrome
Experimental counterpart is MASUGI NEPHRITIS (nephrotoxic nephritis)
I.F. shows homogenous diffuse, LINEAR pattern of deposition

B. Heymann Nephritis
Heymann nephritis occurs in experimental animals.
Tubular cell brush border Ag injected, causes Ab formation
Ab binds to Ag in the base of visceral epithelial cells. This is called Megalin Ag.

Megalin Ag = Homologous to LDL receptor protein
+
RAP (receptor associated protein)

Cross reaction with brush border Ag is seen!

IN HUMANS, membranous GN is a similar disease. The Ag is a homolog of the Megalin
complex.

AGAINST PLANTED ANTIGENS:

Abs against planted antigens
Abs react with Ags that are planted or deposited via circulation
Ags are NON-GLOMERULAR!
They may be cations, DNA, aggregated Igs, immune complexes, bacterial, viral or parasitic
products and drugs.
I.F. usually shows a coarse or granular pattern of deposition
NOTE: Anti GBM disease and membranous GN are AUTOIMMUNE DISEASES!
7

@@@" 9A5?5?B@9 !C5@/?>@D=
Antibodies react with glomerular Ag, cause cytotoxic injury and disease.

E.g.s. Antimesangial Ab " Mesangiolysis and mesangial cell proliferation
Antiendothelial Ab " Vascular damage and thrombosis
Antivisceral cells Ab " Proteinuria

@E" 9DFFG3D>@!5D> @33HCD IF?3DJHF?CDK$J@5@=
Activated macrophages or sensitized T cells can cause glomerular injury
Egs, Experimental crescentic GN

E" !95@E!5@?C ?L !F5DJC!5@ED 9?3KFD3DC5 K!5$M!A
Complement activation, independent of immune complex, may cause glomerular injury.
e.g., MPGN II.

VI. EPITHELIAL CELL INJURY
Besides Ab, toxins, cytokines and other unknown factors can damage visceral epithelial cells causing
detachment and loss of adhesive interactions with the BM leading to proteinuria.

MEDIATORS OF GLOMERULAR INJURY
Cells and molecules are involved in glomerular inflammation.

A. Cells
Neutrophils
Macrophages, lymphocytes, NK cells
Platelets
Mesangial cells

B. Soluble Mediators
Complements
Eicosanoids, NO, endothelin
Cytokines
Chemokines
Coagulation factors

PROGRESSION OF GLOMERULAR DISEASES
Any renal disease causing ( GFR to 3050% of normal can lead to ESRD if left unchecked.

HISTOLOGIC CHANGES NOTED
1. Focal Segmental Glomerulosclerosis (Ablation nephropathy)
2. Tubulointerstitial Damage
These changes can worsen the disease process. However, treatment targeted at these changes
can be helpful in managing the renal disease.
e.g., ACE-inhibitors for ( intracapillary HTN, anti-inflammatory compounds, etc.

8

L.M.
NEPHRITIC SYNDROME

DEFINITION
A group of diseases characterized by inflammation of the glomeruli with the following clinical features:

1. Hematuria (gross or microscopic), RBC casts in urine
2. Oliguria
3. HTN
4. Azotemia
5. Proteinuria may occur but are not as severe
6. Edema as in Nephrotic Syndrome

Acute Nephritic Syndrome may be:
1. Primary
2. Secondary, e.g., SLE, PAN

PRIMARY NEPHRITIC SYNDROME There are two types

I. ACUTE PROLIFERATIVE GLOMERULONEPHRITIS (POST INFECTIOUS GN)
This is an IMMUNE COMPLEX DISEASE.

Antigen may be: 1. Exogenous, e.g., post infection

2. Endogenous, e.g., SLE

PATHOGENESIS

*Nephritogenic strains of group A "-hemolytic streptococci (90% of cases M type 1, 2, 4, 12, 18, 25, 49,
55, 57, 60) cause URTI or skin infections (impetigo)
Streptococcal Ag 1. Endostreptosin (cytoplasmic)
2. Cationic proteinases (NSAP nephritis strain associated protein)
3. Nephritis associated strep. plasmin receptor protein( NAP1r)
4. Streptococcal pyogenic exotoxin B and its zymogen form

Anti-Streptococcal Abs 1. ASO Antistreptolysin
2. Anti hyaluronidase
3. Antistreptokinase
4. Anti-DNA ase B
5. Anti NAD ase

Ag + Ab " IMMUNE COMPLEXES ARE FORMED, FIX COMPLEMENT AND CAUSE
NEPHRITIS.

*NOTE: Rheumatogenic strains of streptococci 1, 3, 5, 6, 18, etc. rarely cause nephritis.

MORPHOLOGY

1. Diffuse involvement of glomeruli that are enlarged and hypercellular.
Hypercellularity is due to: a. Proliferation of epithelial, endothelial, and
mesangial cells.
b. Infiltration by PMNs and monocytes.
bacterial
viral
parasitic
streptococcus
non-streptococcus
Remember: 1,2,3, and 4
constitute HOHA!
9

I. F.
E.M.
2. Thrombosis/thrombonecrosis of capillaries with FIBRIN deposition in capillary lumen and
mesangium.
3. RBC casts in tubules, interstitial edema and inflammation.

IgG, IgM and C
3
seen as granular deposits in mesangium and along GBM (lumpy-bumpy
appearance).

SUBEPITHELIAL ELECTRON DENSE DEPOSITS SEEN AS HUMPS

Deposits may be subendothelial or intramembranous; they are usually catabolized in 1-2 months. (Overall
this is a disease of LUMPS, BUMPS, and HUMPS).

CLINICAL COURSE Epidemic and Sporadic forms occur.

In CHILDREN and ADULTS, 14 weeks following URTI (sore throat) or skin infection, there may be
fever, malaise, nausea, vomiting, anorexia, periorbital edema and HOHA!
Lab findings Elevated Decreased
BUN
Creatinine
Cryoglobulins
Antibodies to Strep

PROGNOSIS IN CHILDREN IN ADULTS
1. Following Rx, complete recovery in 95% of cases 60-80% of cases
2. RPGN develops in < 1% occasional cases
3. CGN develops in 1-2% CGN in 15-40% cases over 10-12 years

II. RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS (RPGN)
(also called Crescentic glomerulonephritis)

A disease characterized by severe glomerular injury leading to a rapid and progressive loss of renal
function. If untreated, death occurs due to renal failure within weeks to months.

HISTOLOGIC HALLMARK

Presence of CRESCENTS in most glomeruli. These are crescent-like structures composed of
proliferating parietal epithelial cells, monocytes/macrophages/T lymphocytes/ pmns/giant cells and
FIBRIN. Cytokines such as TNF, IFN gamma, IL-1 etc. are involved. Crescents lead to sclerosis of
glomeruli.

CLASSIFICATION

RPGN may be idiopathic (50% of cases) or non-idiopathic (50% associated with another disease).
Based on immunologic findings the accompanying table indicates three types of RPGN

Complements
10

I. F.
I. F.

ANCA = antineutrophil cytoplasmic antibody

A. Type I RPGN
This is an ANTI-GBM disease

IgG and C3 seen as linear, smooth deposits in GBM

Goodpasture Syndrome

Renal failure + lung hemorrhage

Ag is NC1 of !3 chain of collagen type IV; anti GBM antibodies cross react with pulmonary
alveolar BM and cause the syndrome.
Trigger for Ab formation is unknown. Drugs, viruses, cancers, smoking, hydrocarbon solvents
(paints, dyes, etc.,) may play a role.

There is a genetic predisposition and association with HLA-DRB1.

Rx: Plasma exchange (plasmapheresis) to remove circulating antibodies is quite helpful.

B. Type II RPGN
This is an IMMUNE COMPLEX MEDIATED disease, whatever the cause.

Immune complexes deposited in a granular pattern.

Rx: Treat underlying cause. Plasmapheresis is NOT HELPFUL.

JKIC N ;O 9,0'0
Type I
!"#$ &&
Type III
Idiopathic
Non-idiopathic
25
12
25
44
50
44
TABLE 14-3. CRESCENTIC GLOMERULONEPHRITIS (CrGN)

Type I CrGN (Anti-GBM)
Idiopathic
Goodpasture syndrome

Type II CrGN (Immune Complex)
Idiopathic
Systemic lupus erythematosus
Postinfectious
Henoch-Schnlein purpura

5%&' @@@ 9(IC PK,+)-G-11+2'Q !C9!G!00;)-,.'<
Idiopathic
Wegener granulomatosis
Microscopic polyarteritis
11

E.M.

C. Type III RPGN considered as part of systemic vasculitis
PAUCI-IMMUNE LACK OF ANTI-GBM ANTIBODIES OR IMMUNE COMPLEXES BY IF AND
EM.

ANCA (p-ANCA or c-ANCA) is positive (in 90% of idiopathic cases)

Morphology of RPGN
L.M. features are as mentioned earlier.

Wrinkling of B.M. with focal disruptions and ruptures
Occasional cases may show sub-epithelial humps

Antibodies Serum Complement
NOTE: Type I RPGN anti-BM Abs normal
Type II RPGN ANA/anti-streptococcal decreased
Type III RPGN ANCA normal

CLINICAL FEATURES
Features of nephritic syndrome present. In Goodpastures syndrome there is renal failure along
with hemoptysis and pulmonary hemorrhage.

Serum testing for Anti-GBM antibodies, ANA and ANCA may be helpful.

COURSE
There is usually a rapid, progressive renal failure. Hence Rx must be prompt.
(Crescents in # 80% glomeruli " poor prognosis)

Rx: Plasma exchange
Steroids/Cytotoxic drugs
Chronic dialysis or transplantation.

Overall survival rate is 85-90%.

NEPHROTIC SYNDROME

This is a disease characterized by the following features:
1. Massive proteinuria # 3.5 gm/24 hours of urine
2. Hypoalbuminemia; plasma albumin < 3.0 gm%; normal 3.5-5.0 gm %
Normal albumin: globulin = 2:1. In N.S. the ratio is reversed.
3. Generalized edema (anasarca)
4. Hyperlipidemia
5. Lipiduria
GLOMERULAR BASEMENT MEMBRANE (GBM) DAMAGE allows increased permeability to
plasma proteins and hence proteinuria.
a. Highly selective proteinuria " involves low molecular weight protein (albumin 70,000 Transferrin
76,000).
b. Poorly selective proteinuria " involves high molecular weight protein such as globulin + albumin
Proteinuria (albuminuria) leads to hypoalbuminemia. There is also increased renal catabolism of
albumin.

12

Edema occurs due to: 1. Hypoalbuminemia and decreased colloid osmotic pressure in blood vessels
2. Increased retention of Na and H
2
0 by the kidney
. Decreased plasma volume and GFR leading to ! ADH ! aldosterone and (
ANP " all allow fluid retention in tissues (pleural effusion, ascites)

Hyperlipidemia: ! cholesterol, triglycerides, LDL, VLDL, L
p
(a), apoprotein
( HDL

Due to: 1. increased hepatic synthesis of lipoproteins.
2. decreased catabolism.
3. abnormal transport of circulating lipids.
Lipiduria: Due to lipoprotein loss in urine. Seen as free fat globules or oval fat bodies in urine.

OTHER ASSOCIATED FEATURES IN N.S.
1. Predisposition to infections (Staph; Pneumo) due to loss of Ig and complement factors in urine.
2. Thrombotic/thromboembolic complications due to loss of anticoagulant factors (antithrombin III)
and anti plasmin activity

This hypercoagulable state leads to renal vein thrombosis.

CAUSES OF N.S.

I. MEMBRANOUS GLOMERULOPATHY

Idiopathic or Primary (85%) Secondary (15%)
No underlying disease Associated diseases such as infections, malignancies, metabolic,
SLE; drug effects, etc.

ETIOLOGY AND PATHOGENESIS
This is a form of chronic immune complex disease.
In secondary MGN, the Ag may be: 1. Endogenous, e.g., SLE
2. Exogenous, e.g., infections
13

In IDIOPATHIC MGN autoantibodies are formed against renal autoantigens. These are thought to be
neutral endopeptidase and PLA2R ( phospholipase A2 receptor) located at the base of the visceral
epithelial cells. This autoimmune disease (Idiopathic MGN) is similar to Heymann nephritis where
antibodies are formed against Megalin Ag. Genetic predisposition and HLA association play a role in the
pathogenesis.

The immune complexes ACTIVATE complements C5
b
-C
9
(MAC)
(
activates epithelial/mesangial cells
(
liberates proteases and oxidants
(
cap. wall damage and protein leak

Also, epithelial mediators reduce nephrin synthesis and distribution.

MORPHOLOGY
* L.M. Diffuse thickening of cap. wall, no hypercellularity
I.F. Ig and complements deposition in a granular pattern
E.M. Electron dense deposits (EDD) in subepithelial location
Loss of foot processes of epithelial cells
New BM material is deposited between the electron-dense deposits in the form of
spikes (seen on silver stains) SPIKE AND DOME PATTERN.
The spikes form domes, grow over and bury EDD to form a thick, irregular BM
The EDD are catabolized and the spaces filled by new BM material.

* With time, diffuse membrane thickening causes cap. lumen reduction and sclerosis of
mesangium. Total hyalinization of the glomeruli may occur.
Proximal tubular cells contain hyaline droplets (protein reabsorption).
Interstitial inflammation is noted.

CLINICAL COURSE
Nephrotic
Insidious onset with proteinuria
Non-nephrotic (15%)
Hematuria
1535% cases
Mild HTN

The disease follows an INDOLENT COURSE.
Relapses and remissions seen in 40%
Slow progression to renal insufficiency 40% (overall 10% develop renal failure in 10 years)
SPONTANEOUS REMISSION
occurs in 1030% cases especially in: 1. Women
2. Non nephrotic proteinuria
3. Kidneys with mild changes on EM

Rx: Variable response to steroids and other drugs. Transplantation is helpful in ESKD (end stage
kidney disease)

14

II. MINIMAL CHANGE DISEASE (LIPOID NEPHROSIS) (NILS DISEASE)
Most common cause of nephrotic syndrome in children 26 years of age. It follows a respiratory infection
or routine prophylactic immunization. It is also associated with atopy, leukemias, lymphomas, Hodgkins
disease, HIV and NSAID (drug) Rx.

ETIOLOGY AND PATHOGENESIS

Current hypothesis: 1. T-cell Disorder
T-cells produce circulating factors or cytokines (Interleukin 8, TNF, etc.) that damage visceral epithelial
cells with loss of foot processes and glomerular polyanions leading to proteinuria.
2. Gene Mutation
Abnormal protein (nephrin) formation causes congenital N.S. with minimal change morphology.
Nephrin is an Ig like cell adhesion receptor participating in cell-cell or cell-cell matrix interactions.
Abnormal nephrin formation and distribution can cause epithelial adhesion defects and diffuse effacement
of foot processes. T-cells may elaborate factors that affect nephrin synthesis.
Mutations of other genes involved in the synthesis of podocin, CD2AP, alpha actinin etc. can also cause
this disease ( as well as FSGS).

MORPHOLOGY
* L.M. GLOMERULI ARE NORMAL
I.F. NOTHING ABNORMAL SEEN

* Proximal tubule cells contain lipid due to reabsorption of lipoproteins. Hence, the term LIPOID
NEPHROSIS.

E.M. Uniform and diffuse effacement of foot processes (loss of foot processes of visceral
epithelial cells); flattening and retraction also seen
Vacuolization, swelling, and microvilli hyperplasia of visceral epithelial cells
NORMAL B.M.; NO EVIDENCE OF ELECTRON DENSE DEPOSITS

CLINICAL COURSE
Insidious development in healthy kids
Selective proteinuria present protein less through spaces between damaged foot processes
Renal function is usually good

IN CHILDREN
Spontaneous remissions occur in 30-40% of cases
EXCELLENT RESPONSE TO STEROIDS. More than 90% of cases recover. However, 2/3 of the
responders develop recurrent proteinuria. Some cases become steroid dependent or resistant and yet
have a good prognosis.

IN ADULTS
Spontaneous remission is less common
Excellent response to steroids (response is slower and relapses more common).
Other drugs such as cytoxan, cyclosporine, etc., may be helpful.

15

L.M.
I.F.
E.M.
@@@" L?9!F =DI3DC5!F IF?3DJHF?=9FDJ?=@=
Most common cause of NS in adults, this disease is characterized by sclerosis of some, but not all
glomeruli (focal) and only a portion of the capillary tufts (segmental).

FSG may be:

IDIOPATHIC SECONDARY
10% N.S. cases in children Associated with the following
35% of N.S. cases in adults diseases
Common in Blacks and Hispanics
1. HIV/heroin use/Sickle cell anemia/obesity
2. IgA nephropathy
3. Ablation nephropathy an
adaptation response as seen in
CPN/Reflux nephropathy/unilateral
renal agenesis; hypertension
4. Congenital nephrotic syndrome
gene mutations involving nephrin,
podocin and actinin-4 are present.
TRPC6 (Transient receptor potential
calcium channel 6) defect

MORPHOLOGY

Focal, segmental, sclerosis
Deposition of hyaline masses (HYALINOSIS) with lipoid droplets and foam cells
Increased mesangial matrix, mesangial cell proliferation, collapsed BM.

IgM and C
3
in the sclerotic areas due to non-specific insudation and entrapment

Diffuse loss of foot processes of visceral epithelial cells
Focal DETACHMENT of epithelial cells
DENUDATION of the underlying BM.

* With time, there is total sclerosis of glomeruli, hyaline thickening of arterioles, tubular atrophy, and
interstitial inflammation and fibrosis.

Collapsing FSG
Collapse and sclerosis of ENTIRE glomerulus
May be idiopathic or associated with HIV (poor prognosis)

PATHOGENESIS

A distinct entity
Is it:
OR

Subtype of Minimal change disease that becomes aggressive leading to damage,
disruption, and degeneration of visceral epithelial cells. B.M. permeability increases,
E.C.M. deposition !, plasma proteins are entrapped to cause hyalinosis/sclerosis
*
As compared to NILSs disease, FSG patients
have:

1. Higher incidence of HTN, hematuria
and ( GFR
2. Non-selective proteinuria
3. Poor response to steroids
4. 50% of cases " ESKD in 10 years
5. IgM and C3 deposition in
mesangium
16

L.M.
I.F.
E.M.
I.F.
E.M.
CLINICAL COURSE
No tendency for spontaneous remission
Variable response to steroids
20% of cases " a rapid course (malignant FSG) leading to renal failure within two years.
Overall 50% develop renal failure in ten years

Rx: Transplantation (recurrences are seen in 25-50% of cases receiving allografts; possible non-Ig
circulating factor causing disease)

IV. MEMBRANOPROLIFERATIVE GN (MESANGIO PROLIFERATIVE GN)
This disease may be idiopathic or secondary (associated with other diseases such as HBV, HCV, HIV,
SLE, SBE, leukemias, lymphomas, deficiency of !-antitrypsin and complement regulatory proteins).

MORPHOLOGY
Large, hypercellular glomeruli (increase in pmns, mesangial cells and endothelial cells)
LOBULAR appearance of tufts due to increased mesangial matrix and cells.
Epithelial crescents seen in many cases
DOUBLE OR TRAM TRACK appearance of capillary wall as seen on PAS or silver stain due to
DUPLICATION of BM and due to mesangial and monocyte interposition (cell processes extend
into capillary loops and get included in the lamina rara interna of BM (causing splitting of BM)

MPGN is of 2 types
A. Type I MPGN 80% of cases of N.S.
C
3
Deposited in a granular pattern
IgG, C1q and C
4

Electron dense deposits in SUBENDOTHELIAL location (occasionally also mesangial and
subepithelial)

B. Type II MPGN
Properdin, C
3
in BM on either sides of dense deposits seen as a granular-linear pattern
Also present in mesangium (mesangial rings)
IgG, C1q, and C
4
are ABSENT

Lamina densa of BM is converted into an irregular ribbon like electron dense structure due to
intramembrane deposition of electron dense material (DENSE DEPOSIT DISEASE)

PATHOGENESIS
Type I MPGN Immune complex disease with activation of both classic and alternative
complement pathways.
Ag is unknown
Type II MPGN Possible autoimmune disease
ACTIVATION OF ALTERNATIVE COMPLEMENT PATHWAY
C3bBb (alternative pathway C
3
convertase) is stabilized by Properdin and
an autoantibody C3NeF (nephritic factor). This causes increased
C
3
degradation.

Serum C
3
is ( (increased degradation + ( synthesis in liver)
Serum C1q, C
4
, IgG normal levels

C
3
Ne Fs role in glomerular injury is UNKNOWN. It is present in 70% of cases of Type II MPGN
(which may be an autoimmune disease with genetic predisposition) and also in partial lipodystrophy.
17

L.M.
I.F.
E.M.
CLINICAL COURSE
Fifty percent of cases present as nephrotic syndrome. Sometimes a mixed nephritic-nephrotic
syndrome occurs. There is no spontaneous remission. The disease has a slow progressive, unremitting
course.

Occasional cases " RPGN with crescents
30% cases " persistent NS without renal failure
30% cases " renal insufficiency
40% cases " develop CRF in ten years

Overall, the prognosis is uniformly poor (Type II worse than type I)

Rx: Steroids, antiplatelet drugs and immunosuppressive therapy not effective.
Transplantation " high incidence of recurrence in recipient (90% of cases in Type II)

V. IgA NEPHROPATHY (BERGER DISEASE)
Most common type of glomerulonephritis in the world

There are two types:

PRIMARY SECONDARY

1. Henoch-Schonlein purpura
2. Liver diseases
3. Intestinal diseases (celiac disease)
4. Respiratory diseases
5. Skin diseases
6. Urinary tract infections

NOTE: Some consider Berger disease and H.S. purpura as variants of the same disease.

MORPHOLOGY
1. Mesangial matrix increase and proliferation MPGN like
2. Segmental proliferation in some glomeruli FSG like
3. Rarely crescent formation CrGN like

IgA DEPOSITION IN MESANGIUM (IMPORTANT)
Properdin, C
3
, IgG or IgM present
C1q and C
4
are ABSENT

Electron dense deposits in MESANGIUM

PATHOGENESIS
IgA is the main Ig in mucosal secretions (subtypes IgA
1
and IgA
2
)

Monomeric form (mainly)
IgA in serum
Polymeric form (catabolized in liver)

In Bergers Disease
There is a genetic or acquired abnormality of immune regulation leading to increased IgA synthesis
(polymeric form). Abnormal glycosylation of IgA1 leads to diminished clearance. There is thus ! serum
IgA (IgA
1
type) leading to immune complex formation and deposition in the mesangium.
18

ALTERNATIVE COMPLEMENT PATHWAY IS ACTIVATED AND GLOMERULI ARE
INJURED.
The nature of Ag is unknown (infectious agents, food products, etc.). IgA deposited is polyclonal so there
may be different antigens involved.

Also noted are: 1. IgA antibodies that react with mesangial auto Ags.
2. Qualitative changes in IgA molecules make it more likely to bind to mesangial
Ags.

CLINICAL FEATURES
Occurs in children and young adults (15-30 years of age)

Following respiratory, GI or urinary tract infections patients develop
Gross hematuria 50% HEMATURIA SUBSIDES,
Micro. hematuria 3040% BUT MAY RECUR AFTER MONTHS
Nephrotic syndrome, renal failure 10%
Acute nephritic syndrome 510%
Proteinuria

COURSE
A variable course with normal renal function for decades
Slow progression to CRF (15 - 40% cases over 20 years)

TREATMENT
Transplantation
Recurrence rate is 2060% following transplantation.

NEPHRITIC VERSUS NEPHROTIC SYNDROME

Nephritic Syndrome Nephrotic Syndrome

Urine

Blood ++
Protein +
Blood 0 to +
Protein ++++
Plasma

Urea !
Creatinine !
Albumin normal
Cholesterol normal
Urea normal or !
Creatinine normal or !
Albumin (
Cholesterol !
Total Body Sodium ! !
Blood Volume ! Normal or (
Blood Pressure ! Normal or !
Edema + ++++

NOTE: The nephrotic syndrome is characterized by heavy proteinuria (over 3.5 gm per day)

19

1-2
30-50
50
50-80
30-50
1-2
Idiopathic
(cause unknown)
? asymptomatic
GN leading to
chronic GN
CHRONIC GLOMERULONEPHRITIS

This is defined as an end-stage renal or kidney disease (ESRD or ESKD) following glomerulonephritis.
%

Poststreptococcal

90
RPGN

Membranous GN

MPGN

FSG

IgA nephropathy

MORPHOLOGY

GROSS SHORT, SYMMETRICALLY, CONTRACTED KIDNEYS with a granular surface
Cortex is thin; peripelvic fat is increased

MICRO Hyalinized glomeruli they are seen as acellular, eosinophilic masses
Hyaline material is due to entrapped plasma proteins.
! mesangial matrix, B.M. like material, collagen
Marked arteriosclerosis due to HTN
Tubular atrophy, interstitial fibrosis, lymphocytic infiltration.

CLINICAL COURSE
Non-specific features such as weakness, fatigue, anorexia, vomiting, edema
Anemia, azotemia, etc.
HTN with associated cerebro or cardiovascular events

UREMIA Chronic renal failure associated with:

1. Pericarditis
2. Pneumonitis (diffuse alveolar damage)
3. Gastroenteritis
4. HTN induced left ventricular hypertrophy
5. 2 hyperparathyroidism, nephrocalcinosis and renal osteodystrophy.

TREATMENT

Dialysis or transplantation

Chronic
GN
20

L.M.
I. F.
E.M.
HEREDITARY NEPHRITIS

DEFINITION
A group of hereditary familial renal diseases associated primarily with glomerular injury

There are two such diseases.

@" ALPORTS SYNDROME
Nephritis
Nerve deafness
Ocular diseases (corneal dystrophy, cataracts and lens dislocation)

MORPHOLOGY
Segmental cell proliferation or sclerosis or both
! mesangial matrix
FOAM CELLS (glomerular or tubular epithelial cells accumulate neutral fats and
mucopolysaccharides)
Vascular narrowing, tubular atrophy, interstitial fibrosis

Antibodies to !
3
, !
4
, and !
5
collagen FAIL TO STAIN both GBM and Tubular BM.
!
5
staining in skin biopsy is ABSENT

GBM and Tubular BM show
Irregular foci of thickening and thinning
Splitting
Lamination of lamina densa contribute to a basket weave appearance

PATHOGENESIS
In all cases there is DEFECTIVE BM SYNTHESIS

A. In X-Linked Disease ( 85% cases)
Males suffer the full disease; females are carriers (hematuria only).
Mutations in the gene encoding !
5
chain of Type IV collagen.
Decreased synthesis of !
3
, !
4
, chains
%
6
chain mutation is associated with diffuse leiomyomatosis

B. In Autosomal Recessive Cases
Disease occurs equally in men and women
Mutations in !
3
, !
4
, chain genes located on chromosome 2

C. Autosomal dominant forms also exist.

CLINICAL FEATURES
More common and worse disease in males than in females
Age 520 years
Hematuria, rbc casts in urine, proteinuria
Rarely nephrotic syndrome
Renal failure usually after 1530 years

TREATMENT: 1. Dialysis
2. Renal transplantation. What is a likely complication
following transplantation?
21

II. THIN MEMBRANE DISEASE (BENIGN FAMILIAL HEMATURIA)
This disease is characterized by:
Diffuse THINNING OF GBM (150225 nm wide; normal GBM is 300400 nm).
Familial asymptomatic hematuria, usually diagnosed on routine urinalysis.

PATHOGENESIS
Genes encoding !
3
and !
4
chains are ABNORMAL.

A. In Heterozygous State
Patients are usually asymptomatic
Hematuria, mild proteinuria present
Renal function is normal with excellent prognosis

B. In Homozygous State
Disease resembles Alports syndrome (autosomal recessive type)
Hematuria, proteinuria and RENAL FAILURE may occur

ALPORTS SYNDROME THIN MEMBRANE DISEASE
(Autosomal recessive)

1. Deafness present
2. Eye disorders present
3. Antibody staining for !
5
in GMB/tubular
B.M. and skin is negative
4. E.M. B.M. thick and thin areas with
basket weave appearance.
(Homozygous state)

Absent
Absent
!
5
staining is positive

Uniform thinning of B.M.

NOTE: This disease may be familial or sporadic (where the exact cause is unknown).

22

CYSTIC DISEASES OF THE KIDNEY

I. CYSTIC RENAL DYSPLASIA
Occurs due to an abnormality in metanephric differentiation.

GROSS FEATURES
Unilateral or bilateral
Enlarged, irregular, multicystic kidneys

MICROSCOPIC
Cysts lined by flattened epithelium
ABNORMAL LOBAR ORGANIZATION WITH UNDIFFERENTIATED MESENCHYME,
CARTILAGE AND IMMATURE COLLECTING DUCTS

ASSOCIATED CONDITIONS
Ureteropelvic or urethral obstruction
Ureteral agenesis/atresia
Anomalies of the lower urinary tract
Cardiac malformations

CLINICAL FEATURES
Flank pain Occurs in
Abdominal mass children and
Renal dysfunction/failure newborns

TREATMENT If unilateral " nephrectomy (good prognosis)

II. ADULT POLYCYSTIC KIDNEY DISEASE
One in 500-1000 live births
AUTOSOMAL DOMINANT disease; PKD1 gene mutation occurs in 85 90% of cases

GENETICS

PKD1 gene PKD2 gene
1. Chromosome

16p13.3 4 q 21
2. Encodes (protein)

Polycystin-1 Polycystin-2
3. Protein localization

Tubular epithelial cells of
distal nephron
All renal tubules: also extra
renal sites (occurs in
endoplasmic reticulum)
4. Function

Suppressor of epithelial
cell proliferation; involved
in cell-cell and cell-matrix
interactions
Acts as Ca ion channel;
regulates calcium release;
complexes with polycystin-1

PATHOGENESIS Polycystins are localized to the primary cilia of tubular cells. The cilia project
into the lumen and serve as mechanosensors of fluid flow. Mutations cause CILIOPATHY with
defects in calcium influx leading to dysregulation of cell polarity, proliferation, cell-cell and cell-
matrix adhesion ! formation of cysts.

23

MORPHOLOGY

GROSS
Markedly enlarged, heavy multicystic kidneys; 3-4 cm. sized cysts with no intervening renal
parenchyma; contain clear, turbid or hemorrhagic fluid.

MICRO
Tubular cysts with flat lining, cell hyperplasia, papillations or polyp formation
Glomeruli caught up in cyst formation
Cysts compress calyces/pelvis

CLINICAL FEATURES
M=F; age 40-50 years
Asymptomatic
Abdominal flank pain/renal colic due to hemorrhage
Abdominal mass
Hematuria, proteinuria, polyuria
HTN occurs in 75% of cases. UTI/renal stones are noted.
Progressive renal insufficiency/failure (CRF)

ASSOCIATED CONGENITAL ANOMALIES
1. Cysts of liver, spleen, pancreas, lungs
2. Berry aneurysms in circle of Willis (10 30% of cases)
3. Mitral valve prolapse

COURSE
Slow progressive renal insufficiency " uremia ! death
PKD1 gene mutations (85- 90% of cases) are more severe than PKD2 gene mutations (10 -15% cases).

CAUSE OF DEATH
1. Coronary or hypertensive heart disease 40% of cases
2. Infection 25% of cases
3. Cerebral/subarachnoid hemorrhage/ruptured aneurysm 15% of cases

III. CHILDHOOD POLYCTIC KIDNEY DISEASE

Autosomal RECESSIVE disease; 1 in 20,000 live births

GENETICS PKHD1 gene (polycystic kidney hepatic disease 1) mutation noted

1. Chromosome 6p 21-23
2. Encodes protein fibrocystin expressed in kidney, liver, and pancreas
3. Function present in cilia of tubular epithelial cells; possible cell surface receptor,
role in collecting duct and biliary epithelial differentiation.
MORPHOLOGY
Bilateral, enlarged kidneys with cysts in cortex and medulla ( sponge like appearance)
DILATED ELONGATED CHANNELS PRESENT AT RIGHT ANGLES TO THE
CORTICAL SURFACE REPLACING MEDULLA AND CORTEX

MICROSCOPIC: Cysts of collecting tubules lined by cuboidal cells

24

CLINICAL FEATURES

DISEASE MAY BE:
1. Perinatal
2. Neonatal Most common
3. Infantile
4. Juvenile

Renal insufficiency/failure develop
Hepatic cysts, portal fibrosis, bile duct proliferation seen.
Congenital hepatic fibrosis (periportal fibrosis, bile ductular proliferation) noted
Portal HTN/ Splenomegaly and liver failure may occur in infantile and juvenile forms.

IV. MEDULLARY SPONGE KIDNEY
M=F; Age 30-40 years
CAUSE UNKNOWN
Multiple cystic dilations of the collecting ducts in medulla
Cysts lined by cuboidal or transitional epithelium
Interstitial inflammation/fibrosis may occur
Occurs in adults; discovered as an incidental finding on imaging studies or due to complications
(hematuria, infection, or stones).

V. NEPHRONOPHTHISIS MEDULLARY CYSTIC KIDNEY DISEASE COMPLEX

Progressive chronic renal disease in children

Genetics Genes Gene Protein Function
Autosomal 1. NPH 1 Nephrocystin proteins are components of epithelial cilia
Recessive 2. NPH 2
1-19 years 3. NPH 3 Note: NPH 4 NPH 9 have been identified.
of age

Autosomal 4. MCKD1
Dominant 5. MCKD2
32-62 years
of age

MORPHOLOGY
Small contracted kidneys
Small cysts in the cortex, corticomedullary junction, medulla

MICRO
Cysts lined by flattened or cuboidal epithelium
CHRONIC TUBULOINTERSTITIAL DAMAGE (tubular atrophy, interstitial inflammation,
fibrosis)
Thickening of tubular basement membrane

25

CLINICAL FEATURES

Occurs in children and adults. Four forms are noted

1. Sporadic, non-familial (20%)
2. Familial juvenile (40-50%, autosomal recessive)
3. Renal-retinal dysplasia (15%, autosomal recessive, ocular lesions seen); retinitis pigmentosa and
early-onset blindness occur.
4. Adult-onset medullary cystic disease (15%; autosomal dominant)

There may be polyuria, polydipsia, sodium wasting and tubular acidosis. Renal failure develops in
5-10 years.

NPH-MCKD complex must be considered as a diagnosis in cases of chronic renal failure and chronic
tubulo-interstitial disease occurring in children and young adults with a positive family history.

VI. DIALYSIS ASSOCIATED RENAL CYSTS

ESkD patients, on chronic dialysis, show renal cysts containing calcium oxalate crystals. Renal
cell adenomas and papillary carcinomas may develop in such cysts (7% of cases over 10 years).

VII. SIMPLE CYSTS

Single or multiple cortical cysts, 1-5 cm. in size, lined by gray smooth membrane, contain clear
fluid.
Microscopic: lined by a single layer of flat to cuboidal epithelium

Cysts are asymptomatic or found incidentally on imaging studies.

Updated 4.24.13

VASCULAR DISEASES OF THE KIDNEY

Nasser Gayed, M.D.
Pathology M-2 Vascular Diseases of the Kidney

1


2


3


4


5


6

TUBULOINTERSTITIAL NEPHRITIS


Pathology M-2 Tubulointerstitial Nephritis

1

TUBULOINTERSTITIAL NEPHRITIS

Renal diseases characterized by histologic and functional alterations involving predominantly the tubules
and interstitium.

The glomeruli and vessels are usually spared. The interstitial injury is the PRIMARY EVENT. Secondary
tubulointerstitial nephritis may occur in other renal, vascular, cystic (polycystic kidneys), and metabolic
(diabetes) disorders.

T.I.N. may be:
Acute Chronic
Edema of interstitium Fibrosis/scarring
Neutrophils noted Lymphocytes/plasma cells/mononuclear cells
Focal tubular necrosis Tubular atrophy

T.I.N. leads to defective tubular functions such as
Impaired ability to concentrate urine (polyuria, nocturia).
Salt wasting.
Diminished ability to excrete acids (metabolic acidosis).
Isolated defects in tubular reabsorption or excretion.

Causes of T.I.N.:
M Metabolic
Mechanical
Miscellaneous

T Toxins (drugs)
Tumor

V Vascular diseases

I Infections
Immunologic

Infections and toxins (drugs) are the major causes.

Urinary tract infection involves:
Urethra " Urethritis
Urinary bladder " Cystitis
Ureter " Ureteritis
Kidney " Pyelonephritis (involves the tubules interstitium and renal pelvis)

ETIOLOGY/PATHOGENESIS
Urine is normally sterile
Urine is a good culture medium
Infecting organisms are
Enteric (E. coli, Proteus, Klebsiella, Pseudomonas, Strep. faecalis, Enterobacter) 85% of cases
Non enteric (staphylococcus) fungi, viruses
Most infections are endogenous and are derived from ones own fecal flora

2

ROUTES OF INFECTION
Ascending infection from the lower urinary tract MOST COMMON
Hematogenous infection less common. Bacteria (staph), fungi, etc. can seed the kidneys in septicemia,
infective endocarditis, etc.

The risk factors are
ureteral obstruction.
debilitated patients.
immunosuppressive states.

WHY DOES URETHRA REMAIN STERILE?
Urethra as an anatomic barrier
IgA in mucosal secretions
Bactericidal substances from periurethral glands and prostate

IMPORTANT NOTE: URETHRAL INSTRUMENTATION/CATHETERIZATION ARE MAJOR
CAUSES OF U.T.I. ASCENDING INFECTION

UTI is more common in women than men due to
short urethra.
urethral trauma during sexual intercourse (honeymoon cystitis!).
hormonal changes affecting adherence of bacteria to mucosa.
absence of antibacterial substances as present in prostatic fluid.

For ascending infections, colonization of distal urethra and introitus (in women) must occur. Bacterial
adherence is due to adhesive molecules on the fimbriae (pili) of bacteria attaching to urothelial receptors.

QUESTION: What is the role of cranberry juice in preventing UTI ?

ANSWER:

BLADDER DEFENSES
Bacteria are usually eliminated by:
Dilution and voiding mechanism
Mucosal antibacterial factors
Outflow obstruction or bladder dysfunction can cause incomplete emptying " stasis of urine " bacterial
multiplication " U.T.I., e.g., prostate enlargement, tumor, calculi, neurogenic bladder

VESICO URETERAL REFLUX (V.U.R.)
Backflow of urine into the ureters (from the bladder) is V.U. reflux. It is due to INCOMPETENCE of the V.U.
valve.

The reasons are
congenital absence or shortening of the intravesical portion of ureter (ureter is not compressed during
micturition so it is patent and allows backflow).
bladder infection.
paraureteral diverticulum.
neurogenic bladder, e.g., spinal cord injury.

V.U.R. leads to backflow, residual urine and hence infection. Thirty to fifty percent of infants/children
with U.T.I. have V.U.R.

3

INTRARENAL REFLUX (I.R.R.)
V.U.R. allows urine to backflow into ureter and renal pelvis. Intrarenal reflux allows urine to reach the tips of
renal papillae and into renal parenchyma. I.R.R. is common in the upper and lower poles of the kidney. Reflux
(VUR/IRR) can be demonstrated by voiding cystourethrogram.

FACTORS INFLUENCING BACTERIAL GROWTH IN KIDNEYS
Antibacterial activity of renal cortex
Role of obstruction to outflow
Virulence of organisms
Susceptibility of renal medulla

Renal medullae are predisposed to infection because of
Low blood supply.
Hypertonicity inhibits phagocytosis.
Ammonia inactivates complement.

ACUTE PYELONEPHRITIS

Acute suppurative inflammation of the kidney caused by microbial infection.
NOTE: Polyoma viruses can cause pyelonephritis in renal allografts and lead to graft failure in 1-5% of
transplants.

GROSS:
Focal or patchy suppurative inflammation (abscess) usually involving the upper and lower poles.

MICRO:
Acute inflammation of interstitium with abscess formation and tubular necrosis
Healing occurs with chronic inflammatory cells such as monocytes, plasma cells and lymphocytes
replacing neutrophils.
Fibrosis
Scars (seen as depressions on the renal cortical surface especially polar areas). Why?
Glomeruli are usually SPARED!

IMPORTANT NOTE: SCARS LEAD TO DEFORMATION OF THE UNDERLYING CALYX AND
PELVIS!

RISK FACTORS
Age/Sex: U.T.I. is more common in male infants owing to congenital anomalies such as urethral valves.
After one year it is more common in women up to age 40. Older age group men suffer more U.T.I. due to
prostatic problems (enlargement).
Pregnancy: Up to 6% of pregnant woman develop bacteriuria. Twenty to 40 percent of these women
develop U.T.I. if NOT TREATED
Instrumentation
Obstruction
V.U.R.
Diabetes Mellitus
HTN/Other Renal Diseases
Immunodeficiency/Immunosuppression

SIGNS AND SYMPTOMS
Dysuria, nocturia, polyuria, frequency, and urgency
Fever and back pain

4

PYURIA
Pus cells in urine " cystitis, urethritis, pyelonephritis etc.
Pus casts (white cell casts) " pyelonephritis IMPORTANT BECAUSE CASTS ARE
FORMED ONLY IN NEPHRONS!

Urine culture (10
5
organisms or more) and antibiotic sensitivity tests (for identification of organisms
and R
x
)

COMPLICATIONS
Papillary necrosis (papilla undergoes coagulative necrosis)
Usually seen in diabetes mellitus, obstructive uropathy, analgesic nephropathy, sickle-cell anemia.
Often associated with acute renal failure.
Pyonephrosis
Perinephric abscess
Stone formation

CLINICAL COURSE
Healing and recovery with Rx.
Recurrence (30%) due to same or new organisms
Persistent bacteriuria
Chronic PN

QUESTION: How will you manage a case of asymptomatic bacteriuria?

ANSWER:

CHRONIC PYELONEPHRITIS

Chronic inflammation of tubules, interstitium and pelvicaliceal system with resultant scarring and pelvicalyceal
deformity.

One of the common causes of chronic renal failure (name two other causes).

Obstructive type (usually associated with infections)
Chronic PN
Non-obstructive reflux associated type MORE COMMON
(May or may not be associated with infection)
GROSS
Asymmetric, short contracted kidneys with irregular scarring, dilated, blunted, deformed, calyx and pelvis.

MICRO
Tubular inflammation, dilatation and atrophy with colloid casts in lumen (thyroidization)
Calyceal inflammation and deformity
Interstitial inflammation and fibrosis
Periglomerular fibrosis
In advanced cases where there is proteinuria
Focal, segmental glomerulosclerosis, (due to renal ablation nephropathy)
Obliterative endoarteritis and hyaline arteriosclerosis (due to HTN)


5

QUESTION: What is xanthogranulomatous PN?

ANSWER:

CLINICAL COURSE

Presents as:
Acute or recurrent pyelonephritis
Gradual onset of renal failure/HTN
Detection of bacteriuria or pyuria (on routine urinalysis)

Diagnosis by pyelography " blunting and deformity of calyces (CALIECTASIS)

PROTEINURIA usually suggests a POOR PROGNOSIS.

TREATMENT:

Dialysis
Surgery/renal transplantation

ANALGESIC NEPHRITIS

Analgesic abuse nephropathy is caused by excessive intake of analgesic mixtures (about 2-3 kg) over
prolonged periods (about 5-7 years), and usually combined with water depletion.
Occurs in southeast USA, Europe, Australia
1% of dialysis patients
More common in women than men (5:1)
Associated with analgesic mixtures containing aspirin, caffeine, acetaminophen (a metabolite of
phenacetin) and codeine (drugs taken ALONE usually do NOT cause renal damage)

PATHOGENESIS

Drug mixtures cause damage due to
CYTOTOXICITY by covalent binding and oxidative damage (due to acetaminophen)
ISCHEMIA
Aspirin inhibits prostaglandins causing vasoconstriction and ischemic damage

MORPHOLOGIC CHANGES

This disease causes chronic tubulointerstitial damage
PAPILLARY NECROSIS occurs first followed by tubulointerstitial disease
Necrotic papillae undergo calcification, fragmentation and sloughing
Columns of Bertin are spared
Microangiopathy (small vessels with thick basement membrane) is noted
Obstructive uropathy leads to interstitial fibrosis, atrophy, and chronic inflammation

6

CLINICAL FEATURES
Early cases are associated with inability to concentrate urine and distal tubular acidosis
UTI/Pyelonephritis (25-50% of cases)
Renal failure/HTN
Anemia (due to RBC damage by acetaminophen and renal damage)
Renal calculi with renal colic
PAPILLARY UROTHELIAL CARCINOMA of the renal pelvis is a known complication. 25% of
patients with this tumor have a history of chronic analgesic abuse.

PROMPT DIAGNOSIS, DRUG WITHDRAWAL AND R
x
ARE IMPORTANT.

NOTE: Papillary necrosis occurs in obstructive uropathy.
Pyelonephritis.
D. mellitus.
sickle cell anemia.
analgesic nephropathy.
T.B. of kidney.

IN ALAGESIC NEPHROPATHY ALMOST ALL PAPILLAE ARE AFFECTED WITH DIFFERENT
STAGES OF NECROSIS. IN DIABETES MELLITUS SEVERAL PAPILLAE ARE AFFECTED WITH
ALL AT THE SAME STAGE OF NECROSIS.

HYPERSENSITIVITY NEPHRITIS (acute drug induced), e.g., penicillin, rifampin, Lasix, diuretics,
NSAID etc. About 15 days after drug exposure,

Patients develop
Fever, rash, and eosinophilia.
Dysuria, pyuria, and hematuria.
Acute renal failure in 50% of cases.

Damage may be due to
Type I IgE mediated hypersensitivity.
Type IV delayed hypersensitivity.
Immune complex type disease.
Antibasement membrane Ab type disease.

NOTE: NSAID (Non-steroidal antiinflammatory drugs) are COX-inhibitors.

They cause
Acute renal failure due to inhibition of vasodilatory prostaglandins.
Acute interstitial nephritis.
Minimal change disease (nephrotic syndrome) possibly due to cytokine mediated damage to podocytes.
Membranous GN cause unknown.

Drug withdrawal results in recovery. Therefore, watch for rising BUN (blood urea nitrogen) and creatinine
levels clinically.

MYELOMA NEPHRITIS (nephritis associated with myeloma)
Plasma cells produce proteins (heavy chains and light chains)
Damage occurs due to Bence-Jones (light chain) proteins. About 50% of patients develop renal
insufficiency both acute and/or chronic renal failure may occur- due to
1. cytotoxicity tubular damage or glomerular damage.
2. cast formation " obstructive or cast nephropathy.

7

Other causes of damage are
Hypercalcemia.
Hyperuricemia.
Associated pyelonephritis.
Associated vascular diseases.
Amyloidosis.

Renal dysfunction because of renal infiltration by myeloma cells is very rare.

RADIATION NEPHRITIS damage due to radiation over 2,300 rads.

BALKAN NEPHROPATHY cause ? mycotoxins. Seen in the Balkan area in Europe.

METABOLIC NEPHROPATHY

I. URIC ACID NEPHROPATHY
A. Acute Urate Nephropathy
Uric acid precipitation, in acid pH, causes collecting tubular damage, obstruction and renal
failure. Chemo R
x
in patients with leukemia and lymphoma causes acute urate nephropathy.
Why?

B. Chronic Urate Nephropathy
e.g., Gout. Uric acid crystals deposit in tubules and interstitium causing renal damage

C. Nephrolithiasis (Uric Acid Stones)

II. HYPERCALCEMIA
Calcium deposition damages the tissues

III. HYPOKALEMIA
Cause is not known

Revised: 03/20/06
Reformatted: 11/22/11

8

ACUTE TUBULAR NECROSIS ( ACUTE KIDNEY INJURY)

ATN is the most common cause of renal failure.
This condition is characterized by
destruction of tubular epithelial cells.
acute suppression of renal function (oliguria/anuria).

There are 2 types of ATN

ISCHEMIC ATN
There is inadequate blood flow to the tubules, e.g., major trauma, shock, sepsis, pancreatitis, blood loss
etc.

CDK$J?5?B@9 !5C
Damage to tubules due to drugs, toxins, chemicals, poisons, x-ray contrast agents, Hemoglobinuria,
Myoglobinuria,etc. (50% of such ATN cases may not have OLIGURIA nonoliguric (ATN))

PATHOGENESIS

Tubular injury

Ischemia/toxins can cause structural, biochemical and functional alterations. Some of these are reversible (with
a good prognosis) whereas others are irreversible.

Figure 21-33. Possible
pathogenetic mechanisms in
ischemic acute renal failure
(see text)

9

Disturbances in blood flow
Endothelial damage/dysfunction can cause vasoconstriction through RAA system, decreased NO and
PGI2 and increased endothelin.

Direct effect on glomeruli
Ischemia and toxins cause contraction of mesangial cells leading to decrease in GFR.

MORPHOLOGIC CHANGES IN ATN

Ischemic ATN Nephrotoxic ATN
Patchy short areas of Extensive areas of necrosis
necrosis involving PCT, over larger segments of
PST, and distal ascending PCT, PST, and ascending limb
limb (skip areas present)

Basement membrane rupture Tubulorrhexis usually not
(tubulorrhexis) seen.

Proteinaceous casts present Casts present

Interstitial edema and Edema and non-specific
non-specific inflammation inflammation seen

NOTE: Some toxins may cause specific changes in
damaged cells

RECOVERY
Epithelial regeneration occurs over 23 months. Growth factors/cytokines produced by tubular
cells (autocrine effect) and by inflammatory cells (paracrine effect) help in repair.

CLINICAL COURSE

There are 3 phases

INITIATING PHASE MAINTENANCE PHASE
(Oliguric phase)
RECOVERY PHASE
(Diuretic phase)
Depends on cause (medical,
surgical, etc.)
oliguria
BUN !
ischemia of cells

Oliguria
BUN, Creatinine !
K !
Metabolic acidosis
Salt water overload
Uremia +

Concentrating mechanism of tubules is
lost - so loss of fluids 3 liters/day
H
2
0, K, Na LOST IN
URINE
infections ++

With regeneration, recovery begins.
BUN, creatinine become normal

With proper management/treatment the recovery rate is 5095% depending on the cause.

Revised: 2/ 4/11

HEMATOPOIESIS LECTURE

Steve Nandkumar, MD

READING ASSIGNMENT:
Big Robbins, 8
th
edition, read related topics on Hematopoiesis.

RECOMMENDED READING:

A Color Atlas and Instruction Manual of Peripheral Blood Cells Morphology, by Barbara O. Connor

Images on Web/ ppp

Pathology M-2 Hematopoiesis Lecture

1


2


3


4


5

Stem Cells

Look like small lymphocytes or
mononuclear cells
1% of bone marrow mononuclear
cells
0.01 to 0.1% of mononuclear cells in
peripheral blood
CD34 positive (CD34 ve cells also occur)

Umbilical cord
blood stem
cells

Readily
available

Less restrictive
HLA
compatibility
requirements

Less stem
cells than
in bone
marrow

6


7

BONE MARROW : DIFFERENTIAL CELL COUNT (%)

Total Normoblasts 21.5%
Pronormoblasts 0.6 Lymphocytes 15.8
Basophilic 2.0 Plasma cells 1.8
Polychromatophilic 12.4 Monocytes 1.8
Orthochromatic 6.5 Megakaryocytes <0.1
Reticulum cells 0.3

Total Granulocytes 60%
Myoloblasts 1.0
Promyelocytes 3.4
Myelocytes 11.9
Metamyelocytes 18.0
Bands 11.0
Segmented pmns 10.7
Eosinophils 3.2
Basophils <3.2

Aspirate smears Clot biopsy Special studies
Core biopsy 1. Flow cytometry
2. Genetic studies
3. Others
ASSESS THE FOLLOWING

Hypercellular
1. Cellularity Normocellular Look for fat:cell ratio (normal is 1:1)
Hypocellular

2. M:E ratio (Myeloid:erythroid ratio)
Normal about 3:1 (may vary from 2:1 to 4:1)

present
3. Mega karyocytes
absent

present
4. Malignant cells
absent

5. Erythroid cells

6. Granulocytic cells Look for normal maturation; any abnormalities?

7. Thrombocytic cells


8

8. Abnormal/unusual cells, e.g., granuloma
present (30-40% normoblasts contain ferritin called sideroblasts)
9. Iron stain
absent

Mitochondria
NOTE: 1. Iron + Protoporphyrin Heme
Heme synthetase

Heme + Globin Hemoglobin

2. ALWAYS CORRELATE CLINICALLY


9

Pathology M-2 - Myeloproliferative Diseases

MYELOPROLIFERATIVE DISEASES

Steve Nandkumar, MD

1

CHRONIC MYELOID LEUKEMIA (CML)

Abnormal clonal proliferation of pluripotent stem cell that gives rise to myeloid (and sometimes
lymphoid) cells with terminal differentiation.

Cause
Unknown
May be associated with radiation, chemotherapy, benzene, etc.

Cytogenetics
The critical pathogenic event is the acquisition of BCR-ABL FUSION GENE. (MAIN
DIAGNOSTIC FEATURE)
There is a reciprocal translocation involving BCR gene on chromosome 22 and ABL gene on
chromosome 9 resulting in a fusion gene which produces a protein p 210 with tyrosine kinase
activity. This enables continued, unregulated cell division and also inhibition of apoptosis leading
to myeloproliferation. This translocation t(9;22) (q 34;11) is DIAGNOSTIC for CML. The
PHILADELPHIA CHROMOSOME (Ph) is 22 q (see image). It is present in 90% of CML
cases and is detected by karyotyping. In five to ten percent of cases the rearrangement is cryptic
and can be diagnosed by FISH (fluorescent in situ hybridization) or RT-PCR (reverse transcriptase-
polymerase chain reaction).
, and/or T lymphoid cells can also exhibit the Ph chromosome. The fusion protein p190 is present
in Ph positive ALL arising from CML.

NOTE: IKAROS ( a
transcription factor for
progenitor cells)
MUTATION occurs
in CML and ALL.


2

MORPHOLOGY

A. Bone Marrow
Hypercellular with 100% cellularity (normal is about 50%)
Increased granulocytic precursors
Increased megakaryocytes with dysplastic forms
Erythroid cells are normal or decreased
SEA-BLUE HISTIOCYTES SEEN. These are storage histiocytes with wrinkled blue-green
cytoplasm.
Reticulin fibres are increased.

B. Peripheral Blood
Marked leucocytosis (50,000-100,000 cells/L)
Neutrophils, metamyelocytes, myelocytes all increased
< 10% myeloblasts
Eosinophilia, BASOPHILIA seen
Thrombocytosis (50% of cases)

C. Extramedullary Hematopoiesis
Splenomegaly, hepatomegaly, lymphadenopathy occur

Clinical Features
Occurs 25-60 years of age; also in children and adolescents
) > -
_ Insidious onset
Weakness, fatigue, weight loss, anorexia, anemia
Abdominal pain (due to splenomegaly " infarction); abdominal fullness

COURSE CHRONIC PHASE ACCELERATED PHASE BLAST PHASE
Changes seen are as
described under
Morphology

About 3 years duration;
50% go to accelerated phase
50 % cases ! Blast crisis
10-20% blasts
leukocytosis (not
responsive to Rx)
> 20% Basophils
Platelets increased (or
decreased)
Splenomegaly
Other chromosomal
abnormalities occur

Within 6-12 months
converts to Blast phase
(crisis)
Blasts > 20%
myeloblasts 70%
lymphoblasts 30%

Blasts in BM, LN,
Spleen, Skin, Bone,
Brain

Prognosis
Median survival 3-4 years
Rx with gleevac (a BCR-ABL inhibitor) " 90% remission
BMT in younger patients in stable phase can yield a cure in 75% of cases

NOTE: BCR = breakpoint cluster region; ABL = Abelson
NOTE: LAP (leucocyte alkaline
phosphatase) enzyme is present in
granules of normal granulocytes. It is
absent in granulocytes of CML.
LAP absent " CML
LAP present/high " leukemoid reaction

3

POLYCYTHEMIA VERA
A neoplastic, clonal proliferation of multipotent stem cell resulting in increased production of
erythroid, granulocytic and megakaryocytic elements.
Erythrocytosis (polycythemia) is mainly responsible for all clinical features.

Pathogenesis
The exact cause for such a neoplastic proliferation of stem cells is unknown. There is panmyelosis
(all cell lines are increased). The erythroid progenitor cells are sensitive to erythropoietin (EPO),
but are autonomous and can grow in EPOs absence. Overall, EPO levels are suppressed.
Extramedullary hematopoiesis (Myeloid metaplasia) occurs.

Cytogenetics
Mutations in JAK-2 (Januskinase 2 a tyrosine kinase protein) occurs in 97% of cases.
JAK-2 activates signal transducers and activators of transcription (STAT) proteins playing an
important role in cytokine signaling and leading to increased cell proliferation and survival. It is
also present in myelofibrosis and essential thrombocytosis.2 copies of JAK-2 occur in 25-30%
cases.
PRV-1 (polycythemia rubra vera) gene is overexpressed in granulocytes. PRV gene is part of CD
177 gene and is a member of urokinase type plasminogen activator receptor family. The exact
function is unknown.
BCR-ABL FUSION GENES ARE ABSENT.

Classification

MORPHOLOGY
A. Bone Marrow
Hypercellular marrow with panmyelosis
Myeloid and erythroid maturation is normal
Marrow Fe is decreased in 90% of cases. WHY ?
Reticulin fibre increase in 10% of cases
Marrow fibrosis is seen in 10% of cases

B. Peripheral Blood
Erythrocytosis Rbc count 6-10 millions/l
Increased Hb/Hct; H/H = 20/60

4

WBC count is increased 12 -50 K; Basophilia present
Platelet count is increased > 500 K; abnormal giant forms seen; dysfunction of
platelets

C. Extra Medullary Hematopoiesis
Myeloid metaplasia causes: Hepatosplenomegaly
Lymphadenopathy
Clinical Features
8-10 cases/million
Mean age = 60 years

1. Effects of increased Red Cell Mass/Blood Volume
Stagnation and sluggish flow in veins " Plethora, cyanosis
Deoxygenation of blood Headache, dizziness, HTN, vision problems
2. Effect of Histamine Release " Pruritus
from Increased Basophils Peptic ulcer
3. Effects of High Cell Turnover " Uric acid levels !
Hyperuricemia/gout occurs in 5-10% of cases
4. Effects of Abnormal Blood flow " Bleeding/Hemorrhages in 5 10% cases
and Abnormal Platelet Function (epistaxis, bleeding gums)
(25% of cases) Thrombosis " MI
" Stroke
" DVT
" Bowel, brain, spleen, kidney
infarction
" Hepatic veins (Budd Chiari
syndrome)
Course
Slow insidious onset
Maintaining normal levels of red cell mass by phlebotomy (blood letting) results in a median
survival of 10 years.
Extended survival with treatment can result in a
SPENT PHASE 15 - 20% cases " Myelofibrosis develops after 10 years
OR
TERMINAL AML PHASE 2% of treated cases (drugs, P32); JAK mutations absent !
THE CAUSE OF DEATH: THROMBOSIS
HEMORRHAGE
AML
NOTE: All other causes of polycythemia (relative and secondary) must be ruled out before making
a diagnosis of polycythemia vera.

HOMEWORK

Polycythemia Vera Secondary Polycythemia- O2 lack
Obvious cause of hypoxia (e.g., lung
diseases)
Splenomegaly
Hepatomegaly
Arterial 0
2
saturation
Leucocytosis
Thrombocytosis
ERYTHROPOIETIN (serum)
Vit. B12 (serum)
B.M. cytogenetic abnormalities


5

PRIMARY MYELOFIBROSIS (Myeloid Metaplasia)
A chronic myeloproliferative disorder characterized by obliterative
MARROW FIBROSIS.

Pathogenesis
Neoplastic clonal proliferation of megakaryocytes occurs. These malignant megakaryocytes
produce PDGF (platelet-derived growth factor) and TGF-& (transformed growth factor Beta) which
are potent fibroblast mitogens. Benign marrow fibroblasts proliferate and lead to narrow fibrosis.
Normal hematopoiesis is suppressed leading to cytopenias. Stem cells migrate to spleen, liver, and
lymph nodes with resultant extra-medullary hematopoiesis and disordered/ineffective
hematopoiesis.

Genetics
JAK-2 mutation is present in 50 60 % of cases; MPL ( Myeloproliferative Leukemia Virus) gene
mutation in 1 5% cases.
Ph chromosome is absent

Pathology

I. BONE MARROW

There are two stages in the bone marrow.

Cellular Stage
Hypercellular marrow with increase in all cell lines
Clusters of atypical, lobated megakaryocytes
Marrow fibrosis is minimal

Fibrotic Stage
Hypocellular marrow with diffuse fibrosis
Atypical megakaryocytes seen
Fibrous marrow can become osseous (osteosclerosis)

NOTE: BONE MARROW BX IS DIAGNOSTIC ( B.M. ASPIRATION ! DRY TAP ).

II. PERIPHERAL BLOOD

Leucocytosis or leucopenia or PANCYTOPENIA; Basophilia noted
Abnormally large platelets seen
Anemia

Leukoerythroblastosis

Inappropriate release of nucleated erythroid cells and immature/early granulocytes occurs in
peripheral blood.

Tear Drop RBCs (Dacryocytes)

Fibrotic marrow damages and distorts rbc membrane yielding teardrop shaped RBCs.


6

III. EXTRA MEDULLARY HEMATOPOIESIS

Splenomegaly and hepatomegaly occur. Lymph node enlargement is uncommon.

Clinical Features
1 per 100,000 of the population
Age about 70 years
Fatigue, fever, night sweat, weight loss
Abdominal pain (splenomegaly with infarcts)
Anemia
Thrombocytopenia with dysfunction (bleeding, thrombosis)
Hyperuricemia/gout

Course
Median survival 3-5 years; BM transplantation, Kinase inhibitors help.
Infections, bleeding, thrombosis are problematic
AML can occur in 5- 20 % of cases

ESSENTIAL THROBOCYTHEMIA (ET)

Also known as essential thrombocytosis, it is a chronic myeloproliferative disease characterized by
neoplastic clonal proliferation of stem cells differentiating mainly along
MEGAKARYOCYTIC PATHWAY.

Since thrombocytosis is a feature of other chronic myeloproliferative disorders, the diagnosis of ET
is one of exclusion, i.e., features of other diseases must be ABSENT.

Pathogenesis
Cause unknown
Megakaryocytic precursor cells have diminished need for growth factors. The platelets formed are
dysfunctional.

Genetics
JAK-2 mutations seen in 50 % of cases; MPL mutations in 5 -10 % cases.
Associated Tyrosine Kinnase activation causes cell proliferation independent of thrombopoietin.
Prv-1 gene is overexpressed in granulocytes.

MORPHOLOGY

A. Bone Marrow
Hypercellular with sheets and clusters of megakaryocytes displaying abnormal forms
Reticulin fibres ! in 33% of cases
FIBROSIS IS RARE
Fe stores normal or decreased.

B. Peripheral Blood
Leucocytosis
THROMBOCYTOSIS platelet count > 600 k with abnormal, large platelets
Mild anemia

7

C. Extra Medullary Hematopoiesis
Hepatosplenomegaly occurs ( 50% cases).

Clinical Features
Occurs > 60 years of age. 1- 3 per 100,000 population
Indolent disease; may be asymptomatic
Platelet abnormalities cause thrombosis and hemorrhage similar to Polycythemia Vera.
Erythromelalgia occlusion of small arterioles by platelet aggregates causes throbbing and
burning of hands and feet
Prognosis
Median survival 10-15 years ( usually has an indolent course).
Marrow fibrosis (spent phase) or terminal AML ( 5% of cases) can occur.

NOTE: ET must be distinguished from secondary or reactive thrombocytosis (conditions such as
blood loss, infection, Fe deficiency anemia, asplenia, cancer, etc.)


8

MYELODYSPLASTIC SYNDROME (MDS)
A clonal stem cell disorder wherein mutant multipotent stem cells differentiate along the three cell
lines (RBCs, WBCs, and platelets) but show

1. INEFFECTIVE HEMATOPOIESIS
2. DYSPLASTIC MORPHOLOGY OF CELLS
3. INCREASED APOPTOSIS OF CELLS
4. PERIPHERAL BLOOD CYTOPENIA

Cytogenetics
Chromosomal abnormalities are helpful in confirming the diagnosis of MDS.

Changes seen are:
1. Monosomy of 5 and 7
2. Deletion of 5q 7q and 20q
3. Trisomy 8

TYPES OF MDS

I. IDIOPATHIC OR PRIMARY
Over age 50
Develops insidiously

II. THERAPY RELATED
Associated with radiation, genotoxic drugs ( occurs after 2 8 years).
Benzene, virus, cigarette smoking, and Fanconis anemia are also associated with MDS

MORPHOLOGY

A. Bone Marrow
Usually hypercellular, maybe normo or even hypocellular
Myeloblasts are < 20% of cells

B. Dysplastic Changes in Cells
1. Erythrocytes: Erythroid precursors are megaloblastic, show multinucleation, nuclear
budding, bridging between nuclei and karyorrhexis
RINGED SIDEROBLASTS Erythroblasts with iron laden mitochondria are seen as
prominent peri-nuclear granules with Prussian blue stain.
2. Granulocytes:
Decreased cytoplasmic granulation
Nuclear hypersequestration
PSEUDO-PELGER- HUET CELLS (neutrophils with ONLY two nuclear
lobes)
3. Megakaryocytes:
Cells with single nuclear lobes
PAWN-BALL MEGAKARYOCYTES cells with multiple separate nuclei.

C. Peripheral Blood
< 10% myeloblasts
Macrocytes, poikilocytes
Giant platelets
Pseudo Pelger Hut cells; monocytosis, PANCYTOPENIA

9

Clinical Features
Occurs > 60 years
Cytopenia causes weakness, infections, and hemorrhages
50% of cases are discovered incidentally on routine CBC studies.

Course
Ten to forty percent of cases progress to AML

Prognosis
Median survival is 9-29 months.
For therapy associated MDS, it is 4-8 months.
_ Bleeding and Infections are the main causes of death.

Treatment
Older people " supportive Rx ( blood transfusion, antibiotics).
Younger patients " BMT
T-cell immunosuppression therapy may help.
_ DNA methylase inhibitors, Thalidomide like drugs are helpful

NOTE: Based on bone marrow, peripheral blood and cytogenetic findings, MDS can be classified as
follows:
1. Refractory anemia
2. Refractory anemia with ringed sideroblasts
3. Refractory cytopenia with multilineage dysplasia
4. Refractory anemia with excess blasts
5. 5q syndrome
All these vary in their prognosis.

ACUTE MYELOID LEUKEMIA (AML)

Abnormal neoplastic clonal proliferation of transformed hematopoietic progenitor cells resulting in
accumulation of

myelod blasts.

THERE IS BLOCKAGE OF TERMINAL DIFFERENTIATION AND MATURATION.

PATHOGENESIS Exact cause is unknown
Associated with radiation, cytotoxic drugs, benzene
Cigarette smoking doubles the risk for AML

Genetics
Abnormal chromosomal translocations (90% of cases) tend to disrupt genes encoding transcription factors
needed for normal myeloid differentiation, eventually leading to AML.

1. CBF (CLAAT binding factor) 1 ! and CBF1& are two subunits of a transcription factor needed for
terminal differentiation. Chromosomal rearrangements t(8; 21) and inv.16 result in an abnormal
fusion protein CBF1!/CBF1& leading to blockage in terminal differentiation.
2. c- KIT mutations occur in 25% cases of AML ( inv. 16 or t 8;21 abnormalities).
3. Chromosomal translocation t(15; 17) results in abnormal RAR! (Retinoic acid
receptor-!) affecting terminal differentiation of cells (see Promyelocytic leukemia).
4. Point mutations in FLT3 (fms-like tyrosine kinase) a tyrosine kinase, result in constitutive activation
leading to increased cell proliferation and survival (in PML).
5. Deletions or monosomies of chromosomes 5 and 7.
6. Translocation of MLL gene on chromosome 11 (Rx associated AML).

10

6. Deletions or monosomies of chromosomes 5 and 7.

Classification

NOTE: Please see Table 13-10 in
8
th
edition Big Robbins (page 622).
This is a combination of FAB and
WHO classification.

11

MORPHOLOGY

A. Bone Marrow
20% OR MORE MYELOBLASTS IN THE BONE MARROW.
(Less than 20% of blasts is called refractory anemia with excess blasts RAEB).

Myeloblasts
Nuclei with delicate chromatin, 2-4 nucleoli
Large cells with moderate cytoplasm
Fine peroxidase positive azurophilic granules
AUER RODS red staining rod-shaped peroxidase positive azurophilic granules
(IMPORTANT)

Monoblasts
Folded or lobated nuclei
NO AUER RODS
Peroxidase negative, nonspecific esterase positive granules in cytoplasm

Erythroblasts and Megakaryoblasts may be seen

NOTE: These abnormal cells crowd out other normal marrow cells.

B. Peripheral Smear
Myeloblasts seen in peripheral blood (blast count = 10,000 to 100,000/l)
Sometimes blasts are absent on peripheral smear (called Aleukemic leukemia).

C. Immunophenotype
Peripheral blood and/or bone marrow examination by FLOW CYTOMETRY is
quite helpful.
POSITIVE FOR MYELOID ANTIGENS CD 13 CD14 CD 15 CD117 (c-kit)
CD 33 CD34 CD64

Megakaryocytic differentiation " CD41 CD61 positive

Clinical Features
70% of all leukemias
Age 15-39; also in elderly people

1. Fatigue, fever (non-specific)
2. Anemia
3. Neutropenia infections ( oral cavity, colon, skin, lung, kidneys, UB)
Skin
4. Thrombocytopenia Bleeding problems Mucosa
Serosa (body cavities) and organs
NOTE: * DIC occurs in PML

5. Tissue Infiltration
Lymph nodes and organs may be involved.
Monocytic leukemia " Skin (leukemia cutis)
Gingiva


12

CHLOROMA (GRANULOCYTIC SARCOMA)
Localized soft tissue masses of myeloblasts occurring in the absence of narrow or peripheral
blood involvement, e.g., breast masses.
Progression to AML is inevitable in a few years.

Prognosis (Please see table 12-11B on page 10)
Complete remission with chemotherapy occurs in 60% cases.
Only 15 30% remain free of disease for 5 years.
Bone marrow transplantation (BMT) is helpful.

ACUTE PROMYELOCYTIC LEUKEMIA (PML)

Five to ten percent of all AML cases

Genetics
There is translocation of PML gene on chromosome 15 and RAR! gene on chromosome 17
yielding t(15;17) and resulting in an abnormal fusion protein (PML- RAR!). This protein acts as a
repressor (unlike normal RAR-!) and prevents complete myeloid differentiation. Abnormal pro
myelocytes proliferate. Degranulation of senescent cells causes DIC due to activation of
coagulation cascade.

Rx`
ATRA (all- trans retinoic acid) binds to abnormal fusion protein and inhibits it. So neoplastic
promyelocytes now differentiate into neutrophils. These are short lived and die making way for
normal marrow cells.

What is the drawback of this drug?

Arsenic trioxide promotes degradation of the abnormal PML-RAR! fusion protein and can help.

NOTE: (For AML)

MLL = Mixed Lineage Leukemia
MLL = Mixed lineage leulemia
FLT 3 = fms-like Tyrosine kinase
Fms = Macrophage stimulating factor
CLAAT = Clearance of Alpha-1 anti trypsin
ETO = Eight twenty one (ETO gene is on chromosome 8)
MYH = Myosin Heavy chain
NPM = Nucleophosmin
NPM and FLT 3 mutations are seen in some cases of AML.

Revised: 06.16.10

LYMPHOPROLIFERATIVE DISEASES

Steve Nandkumar, MD
Pathology M-2 Lymphoproliferative Diseases)
1

ACUTE LYMPHOBLASTIC LEUKEMIA (ALL)

Abnormal neoplastic clonal proliferation of precursor B(pre-B) or T (pre-T) lymphocytes called

LYMPHOBLASTS. These immature cells subsequently appear in blood and other tissues.

THERE IS A BLOCK IN TERMINAL DIFFERENTIATION OF SUCH CELLS.

I. B-CELL ALL
85% of such cases present as childhood leukemias ( there is maximum pre-B cells at age 3)

Morphology
Lymphoblasts comprise at least 20% of all cells in the marrow.
Small to medium size cells, scanty agranular cytoplasm with PAS positivity
Nuclei with delicate, finely stippled chromatin, inconspicuous nucleoli.
Nuclear membrane gives a convoluted appearance
Immunophenotype
Cells are positive for CD10 CD19 PAX5 ( paired box 5) and TdT
Cytoplasmic chains present
Surface Ig is absent.
NOTE: TdT is Terminal Deoxynucleotidyl Transferase ( seen in pre B and pre T cells).
Cytogenetics
Abnormal changes occur in 90% of cases of ALL.

Hyperploidy (> 50 chromosomes per cell) and hypodiploidy are seen in B- ALL.
t(12;21) translocation involving TEL 1 and AML 1 genes
t (4;11) involving MLL gene on chromosome 11
t (9;22) BCR-ABL fusion protein p190 in childhood ALL ( 3% cases)
CML fusion protein p 190 in adult ALL ( 25 30%cases)
t(1;19) involving PBX/E2A seen in 25% of cases of childhood ALL.

NOTE: TEL Translocation ets leukemia All are associated with
E2A Early region 2A (of adenovirus) loss of function and
PBX Pre B-cell homeobox maturation arrest.
MLL Mixed lineage leukemia

Lab Findings
Blasts in bone marrow and blood
WBC < 10,000 to > 100,000 cells/L.
Neutropenia, anemia, thrombocytopenia (< 100,000)
Aleukemic leukemia (no blasts in peripheral blood) can occur.

Clinical Features Usually under 6 years; W:Non W = 3:1, Boys > girls; more in Hispanics
a. Abrupt stormy onset
b. Fatigue (anemia) fever (infection), bleeding occur due to diminished cell lines
c. Bone pain/tenderness
d. Organomegaly due to tumor infiltration in liver, spleen, lymph nodes, testis
e. CNS involvement headache, vomiting, nerve palsies due to meningeal spread.

Prognosis

With aggressive chemotherapy, there is complete remission in 95% of cases ( 75 85%
are considered cured; in adults 35 45% cure). BMT helps.
2

Bad Prognostic Factors
1. Age < 2
2. Adolescents and young adults
3. Blast count > 100 K
4. t(9;22) Ph chromosome positive cases; MLL gene association is bad

II. T-CELL ALL

15% of childhood leukemias
40% of childhood lymphomas

MOST COMMON BETWEEN 15-20 YEARS PRESENTING AS A LYMPHOBLASTIC
LYMPHOMA

MORPHOLOGY Similar to B-cell ALL
IMMUNOPHENOTYPING CD1a CD2 CD3 CD5 CD7 CD4 CD8 are positive;
TdT positive

Cytogenetics
T cell receptor genes (! & * . chains) abnormalities noted. Translocation of such genes with
transcription factor genes (MYC, TAL-1) can lead to blast cell proliferation.
( NOTE: TAL-1 is T-cell Acute Lymphoblastic Leukemia protein 1 )

ACTIVATING MUTATIONS IN NOTCH 1 are present in 70% of T cell ALL. This is a
transmembrane receptor essential for T-cell development especially outside the thymus.
(Notches seen on edges of wings in Drosophila; genes associated with notches help in cell-
cell interaction). There is a gain of function mutation.

Clinical Features
PRESENTATION AS A MEDIASTINAL (THYMIC) MASS IN YOUNG ADULTS
(50-80% of cases). Pressure effects on mediastinal structures noted.
Blood, bone marrow, brain, liver, lymph nodes, spleen, gonads are involved.

Diagnosis and Prognosis
Similar to that of B cell ALL.

CHRONIC LYMPHOCYTIC LEUKEMIA (CLL)

Please see notes on small lymphocytic lymphoma/CLL.

3

HAIRY CELL LEUKEMIA

There is a clonal proliferation of POST GERMINAL CENTRE PERIPHERAL B CELL
(memory cell) causing 2% of all leukemias.

MORPHOLOGY

A. Bone Marrow
Diffuse interstitial infiltrate of cells with abundant pale blue cytoplasm.
Oblong or reniform nuclei with condensed chromatin
- FRIED EGG APPEARANCE OF TUMOUR CELLS.
- Bone marrow aspiration is a dry tap. Biopsy is needed.

B. Peripheral Blood

Hairy leukemic cells reveal thread-like or bleb-like cytoplasmic extensions.

C. Liver (Portal Triads), Spleen (Red and White Pulp) are involved

Immunophenotype
B. cell markers CD19 and CD20 positive Ig gene somatic hypermutation seen
CD11c, CD25, CD103 positive
CD5, CD10, CD23 are NEGATIVE
Surface Ig positive
Kappa or Lambda restriction noted

Genotype: Activating mutations in serine/threonine kinase BRAF noted (this is non-specific)

Clinical Features
Occurs in middle aged Caucasians ( median age 55)
M:F = 5:1
a. Pancytopenia due to marrow failure and splenic sequestration (50% cases)
b. Monocytopenia " atypical mycobacterial infections are more common (33% cases)
c. HAIRY CELLS ON BLOOD SMEAR
Cells are Tartrate resistant acid phosphatase (TRAP) positive
d. SPLENOMEGALY/HEPATOMEGALY occurs.

Course/Prognosis
Indolent course
Long-term remission with gentle chemotherapy noted.
Relapses ( after 5 years) respond to chemotherapy.
Excellent prognosis.

4

PLASMA CELL DISORDERS (DYSCRASIAS)

A neoplastic clonal proliferation of terminally differentiated B lymphocytes (plasma cells). These
cells produce complete or partial Ig molecule (M protein or paraprotein). There is somatic
hypermutation of Ig genes indicating a post-germinal center B-cell origin of tumor cells.

In NORMAL PLASMA CELLS Heavy and light chains
are balanced.

For PLASMA CELL NEOLASMS There is excess of heavy or light chains
along with complete Ig (unbalanced)

The monoclonal gammopathies are of the following types:
1. IgG, IgA, IgM and infrequently IgE and IgD types
2. Light chain disease ONLY kappa or Lambda chains are synthesized
3. Biclonal gammopathy 2 Ig clones (M components) present
4. Non-secretory type 1% of cases (no M component)

I. MULTIPLE MYELOMA

There is clonal proliferation of malignant plasma cells in the bone marrow associated with
multifocal LYTIC BONE LESIONS.

Pathogenesis
1. Genetic factors Blacks > Whites, first degree relatives !
2. Ionizing radiation 5 X increase
3. Chronic antigenic stimulation, e.g., chronic HIV, osteomyelitis, R.A.
(Polyclonal B cell proliferation clonal selection neoplasm)

Genetics
Translocations of Ig H locus on chromosome 14 can occur with
FGFR 3 (Fibroblast Growth Factor Receptor) gene on chromosome 4 ! t( 4;14)
Cyclin D1 gene on chromosome 11 t(11;14)
Cyclin D3 gene on chromosome 6 t(6;14)
PAX5 gene abnormality on chromosome 9
Deletions of 13q, 17 p etc.

Immunophenotype
Plasma cells are CD56 and CD79A positive; other B-cell antigens are usually ABSENT.
IgG (55% of cases), IgA (25% of cases) and only light chains (15% of cases) are seen.
Kappa and Lambda chain restriction establishes monoclonality

Pathology

A. Bone Marrow
Aggregates of plasma cells, > 30% of cells
Abnormal plasma cells with immature nuclei, prominent nucleoli and irregular
chromatin distribution seen.
Binucleate and/or bizarre multinucleated forms noted
5

Intracellular accumulation of intact or partially degraded Ig yield FLAME CELLS
with fiery red cytoplasm; MOTT CELLS (many grape-like cytoplasmic vacuoles)

CYTOPLASMIC INCLUSIONS Russell bodies seen as pink
NUCLEAR INCLUSIONS Dutcher bodies globules
CRYSTALLINE RODS in Cytoplasm
OTHER NORMAL HEMATOPOIETIC CELLS CROWDED OUT

B. Peripheral Smear
Normocytic, normochromic anemia
ROULEAUX FORMATION coinstack/linear array of rbcs due to increased Ig
Moderate leucopenia and thrombocytopenia
RARELY, plasma cells seen (PLASMA CELL LEUKEMIA)

C. Bone
Plasma cell proliferation erodes the cancellous bone and destroys the cortical bone all
leading to LYTIC (PUNCHED OUT) BONE LESIONS mainly involving the
vertebral column, ribs, skull, pelvis, femur, clavicle etc. PATHOLOGIC
FRACTURES can occur. Osteopenia is noted.
RANK produced by fibroblasts and macrophages acts as osteoclast activating factor
causing bone resorption. IL-6 helps support myeloma cell growth and RANKL
production.

D. Spleen, liver, lymph nodes, lung and skin may show plasma cell infiltration

E. Kidney
Myeloma nephrosis occurs in 50% of cases

1. Glomerulopathy Ig, light chain
2. Light-chain nephropathy causes damage
3. Amyloidosis
4. Nephrocalcinosis
5. Urate nephropathy
6. Pyelonephritis

Clinical Features
3/100,000 population
Common in middle age/elderly people
Mean age = 65
):- 1.5:1
B > W

a. Bone pain and fractures caused by tumor proliferation and destruction.
LYTIC LESIONS detected by imaging studies.
b. Hypercalcemia due to bone resorption can cause renal damage and cerebral
effects such as confusion, lethargy.
c. Hyperuricemia due to cell turnover.
d. Anemia normal cells replaced by myeloma cells
e. Infections. Recurrent infections due to suppression of normal Ig secretion.
e.g., S. aureus, S. pneumoniae, E. coli.

6

f. Hyperviscosity Syndrome. Increased M proteins cause increased viscosity of
blood leading to sluggish flow. e.g., IgA myeloma causes neurologic problems.
Cryoglobulins cause Raynaud phenomenon and acrocyanosis
g. Coagulation Problems. Igs (M proteins) bind to clotting factors; Ig can coat
platelets; cryoglobulins interact with clotting factors.
h. Renal Problems.
Due to:
1. BENCE JONES (light chain)
deposition and toxic damage of tubular epithelial cells
2. Hypercalcemia
3. Infections
i. Amyloidosis
Seen in 5-10% of cases

DIAGNOSIS
1. Serum/urine electrophoresis a monoclonal SPIKE is seen in urine/serum (99% of cases)
2. I.E.P. immunoelectrophoresis

NOTE: Bence Jones proteins and M proteins are seen in 60-70% of cases. Bence-Jones protein (in
urine) is seen in 20% of cases (isolated finding)
Serum Ig = > 3 gm/dL
Urine Bence Jones protein = > 6 gm/dL
In 1% of cases NO SECRETION (Absent M protein in serum/urine)
B.M. exam will help

3. Bone-marrow examination
4. Imaging studies Lytic bone lesions

COURSE
Incurable disease
Median survival 4 -6 years; untreated 6 12 months.

The disease is biphasic. A chronic stable phase may lead to an aggressive preterminal phase.
Treatment (chemotherapy) can cause: 1. AML (14-20%)
2. MDS

BMT may help. Proteosome inhibitors are useful. How?

CAUSE OF DEATH 1. Infections 2. Renal failure.

II. SMOLDERING MYELOMA
Patients are usually asymptomatic
Bone marrow contains 10 30% plasma cells
Serum M protein is greater than 3 gm/dl
75% of cases develop into multiple myeloma over 15 years.

III. MONOCLONAL GAMMOPATHY OF UNKNOWN SIGNIFICANCE (MGUS)

Most common cause of monoclonal gammopathy
Seen in 3 - 5% of ASYMPTOMATIC elderly people 50-70 years of age
Monoclonal spike of Ig detected (M protein)
7

M proteins < 3 gm/dL; usually no Bence Jones proteinuria
MGUS cells contain same genetic abnormalities as myeloma cells
HENCE THIS IS A PRECURSOR LESION to myeloma.
One to two percent of cases/year progress to Myeloma or B-cell neoplasms.

IV. SOLITARY PLASMACYTOMA

3-5% of plasma cell tumors.

1. Osseous Type
Bony lesions occur in the same locations as myeloma
Progress to multiple myeloma invariably in most cases over 10-20 years
Recurrence at a rate of 15%
Overall 10-year survival = 20%
Treatment Radiation therapy
2. Soft Tissue Type
Occurs in lung, lymph nodes, breast, nasal sinuses, oronasopharynx
Progression to myeloma in 20% of cases
Usually localized tumors, treated by surgery ( curative), radiation, etc.

V. LYMPHOPLASMACYTIC LYMPHOMA (WALDENSTRMS MACROGLOBULINEMIA)

A neoplastic clonal proliferation of small lymphocytes with terminal differentiation to plasma
cells. It behaves like an indolent B-cell lymphoma.
Plasma cells produce BALANCED amounts of heavy and light chains. Monoclonal IgM is
produced.

Genetics
6q deletion is most frequent
t(9;14) involves rearrangement of PAX 5 gene on chromosome 9 (this gene produces BSAP
B cell specific activator protein) and IgH gene on chromosome 14.

Immunophenotype
CD 20 positive
CD10 CD5 CD23 Negative
Surface Ig present on lymphoid cells
Monoclonal IgM produced by plasma cells. IgA and IgG may also occur.

Morphology
a. Bone marrow Increased cellularity with lymphocytes, plasma cells, and plasmacytoid
lymphocytes; reactive proliferation of MAST CELLS.
b. Blood smear Abnormal cells are similar to those of chronic lymphocytic leukemia/small
cell lymphoma
c. Liver, spleen, lymph nodes, brain, meninges, nerve roots are affected.
d. Bone NO LESIONS

Clinical Features
Occurrence 60-70 years of age
Weakness, fatigue, weight loss
Normochromic normocytic anemia common. Cold agglutinins (IgM antibodies bind to rbc)
and cause autoimmune hemolysis in 10% of cases.
8

Organomegaly Liver, spleen, lymph nodes, commonly involved ( 50% cases).
IMPORTANT Hyperviscosity Syndrome serum viscosity is high due to ! IgM which
is intravascular and causes
a. Visual problems, retinal hemorrhages and exudates ( veins distended and tortuous)
b. Neurologic problems headaches, dizziness, deafness, tinnitus, stupor
c. Bleeding ( macroglobulins interfere with platelet functions and also form
complexes with clotting factors).
d. Cryoglobulinemia due to IgM precipitation at cold temperatures (Raynauds
phenomenon, cold urticaria, etc.)

Treatment
Plasmapheresis, low dose chemotherapy, anti CD 20 antibodies.

Course
Indolent but incurable; median survival = 4 years
Transformation to large-cell lymphoma can occur

HOMEWORK

Multiple Myeloma Waldenstrms Macroglobulinemia

Tumor cells

Genetics

Immunophenotype

Ig Type

Free light chains

Bone

Kidney

Organomegaly

Hyperviscosity syndrome

Revised: 01/14/09

LYMPHOID DISORDERS

Steve Nandkumar, MD

Pathology M-2 Lymphoid Disorders
1

Figure 20-2. Scheme of lymphatic system.
2

LYMPHOID TISSUE AND NODES

White blood cells, especially lymphocytes and monocytes, circulate in the blood and lymph. They are
also present in the lymphoreticular system organs, such as lymph nodes, spleen, thymus, tonsils,
adenoids, and Peyer patches (bowel). Occasionally, lymphoid tissue is present in the bone marrow, lungs,
GI tract, etc. A diagnosis of lymphoreticular disorders can be made by examining lymph nodes and bone
marrow.

Please review the normal anatomy and physiology of lymph nodes.

ANY ENLARGEMENT OF LYMPH NODES IS CALLED LYMPHADENOPATHY.

A simple approach to diagnosing diseases is as follows:

LYMPHADENOPATHY

NON NEOPLASTIC NEOPLASTIC

INFECTIOUS NON
INFECTIOUS
BENIGN MALIGNANT

Acute Chronic or
Granulomatous
Primary Secondary
1. Leukemia Metastatic
2. Lymphoma
NOTE: Lymph nodes are the most common organs involved by metastatic cancers.
FIGURE 15-1. Normal lymph node architecture. A, Schematic diagram of a lymph node illustrating the
blood and lymphatic supply and the distribution of B- and T-cell zones. B, Low-power view of a lymph
node. (Modified from Abbas AK, et al. [eds]: Cellular and Molecular Immunology, 3
rd
ed. Philadelphia,
WB Saunders, 1997, p. 30)
3

LYMPH NODE PROCESSING
Lymph node obtained from surgeon (O.R. or outpatient suite)
sent fresh and sterile to pathologist
Pathologist sends part of tissue for culture studies (bacteria, TB, fungi, and virus)
Fresh tissue saved in special medium (Hanks solution or RPMI medium) for flow cytometry
Fresh tissue frozen for immunohistochemistry sometimes
Tissue placed in FORMALIN fixative
Thin sections are taken, processed by machine, H and E glass slides made (usually next day)
Immunochemical studies are done on formalin-fixed tissues (also molecular studies for gene
rearrangement).
FROZEN SECTIONS.
Quick freezing a small tissue sample, cut thin sections in cryotome, stain, and interpret time
taken about 10 minutes. This is NOT RECOMMENDED FOR DIAGNOSIS EXCEPT IN
CASES OF WANTING TO DETECT METASTASES.

ACUTE LYMPHADENITIS
Inflammation of the lymph node may be ACUTE and NONSPECIFIC. The causative agents may be
bacterial, viral, or any foreign matter causing secondary reactive changes in the lymph node.

MORPHOLOGY
The nodes are swollen, grayred, and rubbery
Lymphoid follicular hyperplasia with active germinal centers; neutrophilic infiltration and edema
are present
Necrotic abscessed areas may be seen
Marginal sinus lining cells may enlarge and become hyperplastic (sinus hyperplasia)

CLINICAL FEATURES
Nodes are enlarged and tender
Abscesses are fluctuant; sinuses may form
Overlying skin is red
Healing occurs with or without scarring

CHRONIC LYMPHADENITIS (non specific)

Chronic inflammation may cause the following patterns:

I. FOLLICULAR HYPERPLASIA

Enlarged; prominent lymphoid follicles with active germinal centers pushing against a mantle
B cell zone
GCs (germinal centers) contain a light zone of centrocytes (small, cleaved nuclei) and a dark
zone of centroblasts (active blast-like B cells); scattered macrophages containing nuclear
debris (tingible body macrophages) are seen
Eosinophils, neutrophils, plasma cells, etc. are seen
Marginal zone B cells accumulate around the mantle zone
Follicular hyperplasias are seen in toxoplasmosis, RA, and HIV

II. PARACORTICAL HYPERPLASIA

Reactive changes seen within the T cell regions of the lymph node; may encroach on and/or
efface the B cell follicles
Activated T cells (immunoblasts) are seen in the interfollicular areas; sometimes eosinophils and
macrophages
4

Hypertrophy of vascular and sinusoidal lining cells
Examples: infectious mononucleosis, drug (Dilantin) reactions, and post-vaccination states
III. RETICULAR HYPERPLASIA (SINUS HISTIOCYTOSIS)

Prominent lymphatic sinusoids with hypertrophy of lining endothelial cells
Marked distension of sinuses by histocyte engorgement
Seen in nodes draining cancers (e.g., cancer of breasts); part of immune response

NEOPLASTIC PROLIFERATIONS OF WHITE CELLS

Malignant proliferative diseases of the blood cells include:

I. LYMPHOID NEOPLASMS

Tumors of lymphocytes closely resembling a particular stage of normal lymphocyte differentiation
(phenotypically)

II. MYELOID NEOPLASMS

Tumors of myeloid cells (red blood cells, granulocytes, and thrombocytes) are of the following
types:
Acute myelogenous leukemia
Myelodysplastic syndromes
Chronic myeloproliferative disorders
III. HISTIOCYTOSES

Proliferative lesions of histocytes; e.g., histocytic lymphoma (very rare) and Langerhans cells
(special histocytes); e.g., Langerhans cell histiocytoses or histiocytosis X.

LEUKEMIA A malignant lymphoid or myeloid neoplasm affecting the bone marrow and
peripheral blood.

LYMPHOMA A malignant lymphoid neoplasm affecting lymphoid tissues such as lymph
nodes, spleen, Waldeyers ring, and other sites. The bone marrow/blood may be affected later.
Since white blood cells are present in the bone marrow/blood and tissues, there may be occasions
when leukemias and lymphomas overlap!
FIGURE 15-4. Follicular hyperplasia. A, Low-power view showing a reactive follicle and surrounding mantle
zone. The dark-staining mantle zone is polarized, being much more prominent adjacent to the germinal center light
zone in the left half of the follicle. The right half of the follicle consists of the dark zone. B, A high-power view of
the dark zone shows several mitotic figures and numerous tingible body macrophages, indicative of ongoing
apoptosis.
5

MALIGNANT LYMPHOMAS

There are two groups:
1. HODGKINS LYMPHOMA
2. NON-HODGKINS LYMPHOMA (NHL)
The clinical presentation of lymphomas is determined by the anatomic distribution of
disease.
Lymphadenopathy (lymph node enlargement), organomegaly (organ enlargement; e.g.,
liver and spleen), etc. occur.
Two-thirds of NHLs and all cases of HD present as non-tender nodal enlargement,
localized or generalized.
One-third of NHLs occur in extranodal sites (e.g., skin, GI, and brain).

GENERAL FACTS ABOUT LYMPHOMAS

HISTOPATHOLOGIC examination of tissue supplemented by special studies such as flow
cytometry, immunocytochemistry, and genetic testing are useful in diagnosing lymphomas. In any
given tissue, look for:

1. Partial or total effacement of parenchymal architecture by a more or less monotonous cell
population; loss of germinal centres may help
2. Tumor cells invade and go beyond capsule into surrounding tissue
3. Look for eosinophils; if so, think HL and look for RS (Reed-Sternberg) cells
4. If no eosinophils, think of NHL
5. Some cases may be very difficult (even experts may disagree)
6. Two growth patterns of cells are seen:
Nodular (follicular) and diffuse

NOTE: Nodular lymphoma has a better prognosis than diffuse

All clonal lymphoid proliferations are potentially biologically malignant. Behavior varies
from indolent tumor to rapidly growing, aggressive, fatal neoplasms.

B cells 85% of NHL Genotype and phenotypes of cells
T cells 10%15% help classify tumor
NK cells rare See Figure 15-5 (page 653)
Histocytes rare Table 15-3 (page 654)

Lymphomas disrupt normal regulatory mechanisms, causing immune abnormalities.
Infections (due to loss of vigilance and function) and autoimmune features (due to
breakdown of tolerance) are noted. Immune deficiency states may predispose to lymphoid
neoplasms.

All lymphomas are derived from a SINGLE TRANSFORMED CELL and are hence
MONOCLONAL. Heavy and light chain gene rearrangements for B cells and antigen
receptor gene rearrangements for T cells are unique to the neoplastic clones and thus helpful
in diagnosis (monoclonal vs. polyclonal).

Neoplastic B and T cells tend to HOME TO and grow in areas where their normal
counterparts reside. Thus, the patterns of tissue involvement, T cells " paracortical areas
and B cells " follicular areas, help in diagnosis.

6

Tumor cells circulate and can hence spread systemically. HL, however, has a slow,
contiguous spread and hence can be cured by local resection.
HL spread is predictable. Staging is thus of importance in determining therapy (and hence
prognosis). NHL spreads easily and is hence considered to be a systemic disease (and
hence needs systemic therapy).

ETIOLOGY OF LYMPHOID NEOPLASMS
a. chromosomal translocation and
oncogenes
b. inherited genetic factors
c. viruses and environmental agents
d. iatrogenic factors; e.g., chemotherapy and
radiation therapy

FIGURE 15-12. Schematic representation of normal
transformation of follicular center B cells in comparison
with transformation of T cells. (From Lukes, R. J., and
Collins, R. D.: New approaches to the classification of
the lymphomata. Br. J. Cancer 31(Suppl. 2):7, 1975.)
FIGURE 15-5. Schematic illustration of the
phenotypic and genotypic changes associated with the
differentiation of B cells and T cells. Not shown are
some CD4+/CD8+ cells (common thymocytes) that
also express CD3. Stages between resting B cells and
plasma cells are not depicted. CD, cluster designation;
TdT, terminal deoxynucleotidyl transferase; Ig,
immunoglobulin; TCR, T-cell receptor.
TABLE 15-3. CD, cluster designation; NK,
natural killer; CALLA, common acute
lymphoblastic leukemia antigen; EBV, Epstein-
Barr virus
7

NOTE:
BCL B cell leukemia/lymphoma
PRAD Parathyroid adenomatosis
IAP Inhibitor of apoptosis
MYC Myelocytoma (virus)

PERIPHERAL B CELL NEOPLASMS

I. SMALL LYMPHOCYTIC LYMPHOMA/CHRONIC LYMPHOCYTIC LEUKEMIA
SLL and CLL are essentially the same entities, differing only in the degree of peripheral blood
lymphocytosis.

CLL diagnostic requirement is absolute lymphocyte count > 4,000/cmm in peripheral blood
SLL " a tissue phase (can involve blood and bone marrow)
CLL " involves blood/bone marrow (and then tissues such as lymph nodes, etc.)

8

MORPHOLOGY TUMOR CELLS RESEMBLE NAVE B CELL OR POST GERMINAL
CENTRE MEMORY B CELLS (OR T CELLS)
Predominantly, small lymphocytes 612 round to irregular nuclei, condensed chromatin,
and scant cytoplasm and usually monomorphic
Variable number of larger cells called PROLYMPHOCYTES (large cells with central
nucleoli)
Loose aggregates of prolymphocytes called PROLIFERATION CENTERS (they contain
increased numbers of mitotic figures) ARE PATHOGNOMONIC FOR SLL/CLL
OVERALL, TUMORS HAVE A DIFFUSE PATTERN:
BLOOD " lymphocytosis with smudge cells
BONE MARROW " non para trabecular or interstitial infiltrates of small lymphocytes
in almost ALL CASES
SPLEEN " white and red pulp is involved
LIVER " portal tract area is affected

IMMUNOPHENOTYPE
The neoplastic cells are B cells (90%), T cells (10%)
Express pan B cell markers CD 19, CD 20, and CD 23, and also CD 5 (IMPORTANT)
- 8CL 2 overexpresslon occurs due Lo loss of regulaLory mlcro-8nA.
- Surface lgM or lgM and lgu seen, elLher kappa or lambda chalns presenL

- "#$%& Cu 3, a 1 cell marker, ls presenL ln a small subseL of ' ()**+. ln SLL/CLL, Cu 3 ls
),-.)++)/ on Lhe Lumor cells.

GENOTYPE Karyotype abnormalities seen: ( 50% cases)

Trisomy 12 Each of these is seen in
Deletion of 13 q 1214 20% to 30% of cases.
Deletion of 11 q
Deletion of 17 p

NOTE: Some cells reveal Ig gene somatic hypermutation. Notch-1 mutation seen in subset.

CLINICAL FEATURES
SLL constitutes 4% of NHL; CLL about 15,000 cases / year
CLL is the most common leukemia in adults
M:F = 2:1
Occurs in older patients (50 to 60 years of age); usually asymptomatic
Non specific symptoms of fatigue, anorexia, and weight loss
Lymphadenopathy and hepatosplenomegaly seen in 50% to 60% of cases
(Blood) lymphocytosis and monoclonal 1g spike in serum
Hypogammaglobulinemia " increased bacterial infections
10% to 15% cases have autoantibodies to RBCs " autoimmune hemolytic anemia
Auto Abs platelets " thrombocytopenia
NOTE: Auto Abs are polyclonal IgGs produced by NORMAL self-reactive B cells.

COURSE AND PROGNOSIS
Median survival is 4 to 6 years
Trisomy 12 and deletions of 11q and 17 p, lack of somatic hypermutation, and ZAP- 70
protein expression correlate with higher stage disease with worse prognosis
15% to 30% of cases transform to PROLYMPHOCYTIC LYMPHOID NEOPLASMS
(large numbers of prolymphocytes in blood)
9

10% of cases transform to DIFFUSE LARGE B CELL LYMPHOMA, (called RICHTER
SYNDROME)
Such transformations are due to mutations and ominous, with less than one year survival
Note: ZAP 70 protein ( zinc-finger associated protein) augments signals produced by Ig receptor
10

II. FOLLICULAR LYMPHOMA
The tumor cells closely resemble NORMAL GERMINAL CENTER B CELLS.

MORPHOLOGY
A predominantly nodular (follicular) or nodular and diffuse growth pattern is seen. Two principal
cell types are noted.

1. SMALL CLEAVED (CENTROCYTES)
Small cells with irregular or cleaved nuclear contours with prominent indentations, linear
foldings, indistinct nucleoli and scant cytoplasm.

2. CENTROBLASTS
larger cells with open nuclear chromatin, several nucleoli, and moderate cytoplasm
MITOSES/APOPTOSIS INFREQUENT!

BLOOD " lymphocytosis (< 20,000/cmm) in 10% of cases
BONE MARROW " PARA TRABECULAR LYMPHOID AGGREGATES seen in
85% of cases; ALMOST ALWAYS INVOLVED BY TUMOR
SPLEEN " WHITE PULP
LIVER " PORTAL TRIAD AREAS

IMMUNOPHENOTYPE

Tumor cells express CD 19, CD 20, and CD 10:
CD 5 IS NOT EXPRESSED (IMPORTANT)
Surface Ig present
BCL 2 protein expressed by 90% of tumor cells (normal follicular center B cells are BCL
NEGATIVE)
Tumor cells also express BCL-6 protein

GENOTYPE
HALLMARK OF MOST FOLLICULAR LYMPHOMAS IS A (14;18)
TRANSLOCATION .
IgH gene on chromosome 14 and BCL 2 gene on chromosome 18 come together.

BCL 2 gene is ANTI APOPTOTIC. BCL 2 protein overexpression PROMOTES prolonged
survival of follicular lymphoma cells
BCL 6 gene rearrangement on 3q27 chromosome also occurs

CLINICAL FEATURES

45% of adult lymphomas ( 15k 20k/year)
Occurs in the middle age and older group
M:F = 1:1
Presents as painless, generalized lymphadenopathy
Extra nodal sites (GI, CNS, and GONADS) are usually uninvolved

11

Follicular lymphoma is INCURABLE
A waxing and waning indolent course with an overall median survival of seven to nine years
Palliative treatment (low dose chemotherapy or radiation therapy) and NOT AGGRESSIVE
THERAPY is indicated
TRANSFORMATION to diffuse large B cell lymphoma occurs in 30% to 50% of cases
(associated with TP 53 gene mutations)
RARELY transformation to an aggressive tumor resembling lymphoblastic lymphoma
Burkitts lymphoma or leukemia (involves chromosomal translocation of c-myc locus)
Overall survival in such transformed cases is less than one year

III. DIFFUSE LARGE B CELL LYMPHOMA
The tumor cells are relatively large (four to five times the size of a small lymphocyte) and
reveal a diffuse growth pattern.

MORPHOLOGY Two forms are seen:

1. CENTROBLAST LIKE: large cells with moderate amounts of basophilic
cytoplasm; irregular cleaved, round to vesicular nuclei,
and prominent single, central nucleoli
2. IMMUNOBLAST LIKE: large cells with round, multilobated, vesicular nucleus with
central prominent nucleoli or multinucleated cells with
inclusion-like nucleoli resembling Reed-Sternberg like
cells

IMMUNOPHENOTYPE

Tumor cells express CD 19, CD 20, and CD 10. Also BCL 2 and BCL 6.
Surface Ig present (IgM, IgG, also ( or ) chains)
TdT negative

GENOTYPE
1. 30% of tumors contain t(14;18) with rearrangement of BCL 2 gene, suggesting a follicular
center cell origin
2. 33 percent of cases have rearrangements involving BCL 6 gene on chromosome 3

NOTE: BCL 6 gene encodes a transcription factor normally expressed in germinal centers, helping in
control of B cell differentiation. BCL 6 gene rearrangement or point mutation causes dysregulation
of BCL 6 and hence tumor formation. It acts against p53.
Tumors with BCL 6 rearrangement occur at extra nodal sites and LACK BCL 2
REARRANGEMENT! Hence indicates a non FCC (follicular center cell) origin
3. C-MYC GENE MUTATION also occurs in 5% of cases.
4. 33% cases show loss-of- function mutation in genes encoding histone acetyl transferases.

CLINICAL SUBTYPES OF LARGE B CELL LYMPHOMA

1. IMMUNODEFICIENCY ASSOCIATED TYPE (EBV TYPE)
The tumor B cells are often latently infected with EBV (Epstein-Barr virus) leading to cell
proliferation. There is often a severe T cell deficiency (e.g., end stage HIV disease, SCID,
following BMT and other organ transplantation), which, if rectified, may lead to regression of
the EBV tumor cells.
12

2. BODY CAVITY TUMOR (HHV8 TYPE)
These arise as malignant pleural effusions or ascites. The tumor cells are all infected with HHV8
(human herpes virus 8) and fail to reveal surface B or T cell markers but do have clonal IgH gene
rearrangements. Most cases are associated with HIV infection though HIV negative cases are
occasionally seen in elderly adults.

3. MEDIASTINAL TYPE
Occurs in young women. Usually spreads to abdominal viscera and the CNS.

CLINICAL FEATURES
Constitute 50% of all adult NHL ( 25000 cases/year) ; Median age of 60 years
_ can occur in children ( 15% cases) and young adults
Male greater than F
Rapidly enlarging, symptomatic mass at a single nodal or extra nodal sites (GI, skin, bone, and
brain)
Waldeyers ring (oropharyngeal site) is involved
Liver and spleen are involved; bone marrow involvement is not common at the time of
diagnosis, but can occur late

Aggressive tumors that are fatal if untreated
Complete remission can be achieved in 60% to 80% of cases with chemotherapy; anti -CD 20
therapy and stem- cell therapy help
Fifty percent remain disease-free for several years (cured ?)
Tumors with BCL 6 rearrangement have a better prognosis; P 53 mutations indicate a poor
outcome

IV. MANTLE CELL LYMPHOMA

TUMOR CELLS CLOSELY RESEMBLE THE NORMAL MANTLE ZONE CELLS THAT
SURROUND FOLLICULAR CENTERS OF LYMPHOID TISSUE.
There is no somatic hypermutation so possible nave B cell origin.

MORPHOLOGY Two patterns are noted:
1. Mantle zone pattern:
The tumor cells surround or efface B cell follicles, resulting in a vaguely nodular appearance.
2. Diffuse pattern:
There is a homogenous population of slightly larger than normal lymphocytes with round to
deeply clefted (cleaved) nuclei. Centroblasts and proliferation centers ARE ABSENT!
(Hence, not SLL/CLL or FCC lymphomas.) The chromatin is condensed, nucleoli are not
readily seen, and the cytoplasm is scanty. Rarely blast like cells may be seen.

BLOOD Lymphocytosis (< 20,000/cmm) in 20% to 40% of cases
BONE MARROW Para trabecular and non-para trabecular aggregates of
lymphoid cells are seen commonly
SPLEEN Expansion of white pulp
LIVER Periportal areas are involved
GI Multifocal submucosal nodules in GI tract resembling polyps
(LYMPHOMATOID POLYPOSIS)

13

IMMUNOPHENOTYPE

Tumor B cells express CD 19, CD 20, and CD 5*; Also CYCLIN D1.
CD 10 and CD 23 ARE NEGATIVE
Surface IgM and IgD
Either ( or ) light chains

* NOTE: Normal mantle zone cells are CD 5 negative!

GENOTYPE
Occurrence of t(11;14). This involves FUSION of IgH locus on chromosome 14 and BCL 1 or
PRAD1 locus on chromosome 11 (detected by cytogenetics or FISH fluorescent in situ
hybridization). CYCLIN D1 PROTEIN LEVELS ARE HIGH. BCL 1 locus encodes cyclin D1,
a protein cell cycle regulator that promotes G1 to S phase progression during cell cycle.
Overexpression and dysregulation of cyclin D1 protein causes cell proliferation ! tumor.

CLINICAL FEATURES
Constitute about 4% of NHL
Males greater than females
Common in the forty and fifty age group
Generalized lymphadenopathy with bone marrow, GI, and liver involvement
Splenomegaly 50% of cases

Poor prognosis; tumor is NOT CURABLE with chemotherapy
BMT and Proteosome inhibitors may help.
Median survival is 3 to 5 years
Death due to organ dysfunction

V. BURKITT LYMPHOMA

Tumors resemble relatively mature B cells (small non-cleaved) or germinal centre B cell.

MORPHOLOGY
Diffuse infiltration with intermediate sized lymphocytes, 1025 (microns) in diameter
Nuclei round to oval, coarse chromatin, several nucleoli, and moderate amount of
basophilic/amphophilic cytoplasm
HIGH MITOTIC INDEX PRESENT
APOPTOTIC TUMOR CELL DEATH NOTED
STARRY SKY PATTERN benign macrophages with ingested nuclear debris surrounded
by a clear space (like stars in the sky!) are seen scattered amidst tumor cells
tumor cells in bone marrow reveal royal blue cytoplasm with many clear lipid vacuoles

MMUNOPHENOTYPE
Tumor B cells express CD 19, CD 20, CD 10, and BCL6. No BCL 2 noted.
Surface IgM; monotypic ( or ) light chains

GENOTYPE
All forms of Burkitt lymphoma are associated with translocation of c-myc gene on chromosome 8
with fusion of IgH gene on chromosome 14,a t(8;14), causing overexpression and dysregulation of
MYC protein, leading to tumor formation.
14

Occasionally, translocations involve ( or ) light chains on chromosomes 2 and 22, respectively.
Thus t(2;8) for ( and t(8;22) for ) are seen.
P 53 inactivating mutations noted.

CLINICAL FEATURES
Occurs in children and young adults
30% of childhood NHL in the U.S.

There are three sub-types
1. Endemic (African) Type:
All tumors are infected with EBV
Tumors present as a maxillary or mandibular mass
Involvement of kidney, adrenal
2. Non-Endemic (Sporadic or American) Type:
A few cases (1520%) infected with EBV
Tumors present as abdominal masses involving bowel, ileocecal region, ovaries,and
retroperitoneum
3. HIV Associated Type:
25% of cases have EBV infection

LYMPH NODES ARE GENERALLY NOT INVOLVED IN SUBTYPES 1 AND 2

Burkitt lymphoma is an aggressive neoplasm
It responds well to chemotherapy
Fifty percent long-term survival (cure?) in children and young adults (not good in older
patients).

VI. MARGINAL ZONE LYMPHOMA (MALTOMA)*

THE TUMOR CELLS RESEMBLE NORMAL MARGINAL ZONE B CELLS
(MEMORY B CELLS)
Are composed of various stages of B cells, including plasma cells
Tumors involve lymph nodes, spleen, or extranodal tissues

*NOTE: Maltomas are mucosa-associated, low-grade B cell lymphoid tumors (e.g., bowel, salivary
glands,lungs,stomach, orbit, breast )

EXTRANODAL SITE LYMPHOMAS
Are associated with chronic autoimmune inflammation (e.g., lymphoma arising in
Hashimotos disease or salivary gland lymphoma in Sjgrens disease) or infections
(e.g., stomach in Helicobacter gastritis)
A reactive polyclonal immune reaction leads to an emergence of a monoclonal B cell
neoplasm (due to acquired genetic changes) that is dependent on T helper cell cytokines for
growth and survival. Further clonal evolution may lead to spread and transformation to
diffuse large B cell lymphoma
Usually remain localized until late in the disease
may regress if inciting agent is removed (e.g., Rx H. pylori infection gastric lymphoma
may regress)

IMMUNOPHENOTYPE

CD5 and CD10 are negative
Surface Ig present
15

GENOTYPE
t(1;14) involving BCL 10 and IgH genes such changes may cause
t(11;18) involving MALT 1 (BCL 1) and IAP 2 (BCL 2) resistance to treatment
- L (14, 18) lnvolvlng lgP and 8CL 2 genes (wlLh anLlbloLlcs eLc.)
PROGNOSIS
Often cured by local excision and radiation therapy.

VII. PRECURSOR B CELL AND T CELL NEOPLASMS

PRECURSOR B CELL and T CELL NEOPLASMS, such as acute lymphoblastic
leukemia/lymphoma (ALL) may be derived from immature precursor B or T lymphocytes
called lymphoblasts
85% ALL " pre B cell tumors occurring in children as acute leukemias (lymphomas
uncommon)
15% ALL " pre T cell tumors occurring in young (15- to 20-year-old) males as lymphomas,
often with thymic involvement (leukemia uncommon). Lymphadenopathy and splenomegaly
occur.

NOTE: Leukemias will be considered in a different lecture.

LYMPHOBLASTIC LYMPHOMA (Pre T Cell Type)

THE TUMOR IS COMPOSED OF LYMPHOBLASTS

MORPHOLOGY
Nuclei larger than that of small lymphocyte
Delicate, stippled chromatin with absent/inconspicuous nucleoli
Cytoplasm is scanty
Nuclear membrane shows a convoluted (lobulated) appearance
HIGH MITOTIC INDEX
STARRY SKY PATTERN
IMMUNOPHENOTYPE
Pre T cells express CD 1 and CD 7
Other markers are CD 2, CD 3, CD 4, CD 5, and CD 8
TdT (terminal deoxynucleotidyl transferase) is expressed in 95% of cases

GENOTYPE
Chromosomal translocation involves many T cell receptor loci

CLINICAL FEATURES
40% NHLs in adults; usually less than 20 years
40% of childhood lymphomas
Male greater than female; whites > non-whites
Presents as a mediastinal mass (50% to 70% of cases), suggesting a thymic origin; pressure
effects on vessels and airways may occur
Spread to bone marrow, blood, and meninges occurs due to rapid progressive dissemination
(leukemic phase)

Aggressive, acute leukemia-like therapy (as in ALL) results in a five-year survival rate of 40%.
CNS prophylactic treatment is CRITICAL as CNS is a sanctuary site (for recurrence).
16

VIII. ADULT T-CELL LEUKEMIA/LYMPHOMA

A T cell lymphoma caused by a retrovirus HTLV-1 (human T-cell leukemia virus type I)
It produces a protein tax, an activator of NF Kappa B leading to cell proliferation,
growth and survival.
Endemic in South Japan, W. Africa and Caribbean; sporadic in southeast U.S
HTLV-1 causes lymphomas and progressive demyelinating diseases of the CNS and spinal
cord ( transverse myelitis)
Skin lesions, generalized lymphadenopathy, hepatosplenomegaly, hypercalcemia, and
leucocytosis with multilobed CD 4 + lymphocytes (called flower or clover leaf cells;
may look like RS cells).
Tumor cells express high levels of IL-2 (Interleukin-2) alpha receptors and CD 25.
Very aggressive disease; median survival about eight months
15% to 20% follow a chronic indolent course and is indistinguishable from cutaneous
T-cell lymphoma

IX. MYCOSIS FUNGOIDES AND SZARY SYNDROME

MYCOSIS FUNGOIDES
Tumors composed of peripheral CD 4 + T cells; involve skin and hence belong to
cutaneous T cell lymphomas.
Tumor cells produce CLA ( cutaneous lymphocyte antigen ), an adhesion molecule, and
chemokine receptors CCR4 and CCR10 so they home to skin
Clinically presents as an inflammatory premycotic phase " plaque phase " tumor phase
Starts in skin with neoplastic T cells disseminating via blood to nodes, bone marrow, and
viscera

SZARY SYNDROME
There is a generalized exfoliative erythroderma associated with Szary cells circulating
in blood; here is no tumefaction

MORPHOLOGY
The tumor cells in BOTH DISEASES are CD 4 + T cells with a CEREBRIFORM
NUCLEUS characterized by marked infolding of the nuclear membrane.


Both diseases are incurable and indolent, with a median survival time of eight or nine years.
- 1umor -phase dlsease, vlsceral dlsease, Sezary syndrome survlve on average for 1 - 3
years.
- Cccaslonal cases Lransform Lo large cell 1 cell lymphoma.

17

HODGKINS, LYMPHOMA

Hodgkins lymphoma
1. Arises in a single node or chain of nodes
2. Spreads to the anatomically contiguous
nodes (i.e., predictable spread)
3. Is characterized by the presence of
neoplastic Reed-Sternberg (RS) cells
admixed with a variable infiltrate of
reactive non malignant inflammatory cells
such as eosinophils, lymphocytes,
neutrophils, plasma cells, and histiocytes

NOTE: Microscopic diagnosis of HL
depends on #3.

The disease accounts for 0.7% of all cancers in the U.S. (about 8000 new cases/year) and occurs in young
adults (average age is 32).

MORPHOLOGY OF REED-STERNBERG CELLS

CLASSIC TYPE
A distinctive, large tumor cell 1545 in size; binucleate or bilobed with the two halves
appearing as mirror images of each other
Occasionally a multilobate or multinucleated cell with abundant amphophilic cytoplasm and
large, red, inclusion-like nucleoli 57 in size surrounded by a clear halo (owl-eyed nucleoli)

VARIANTS OF RS CELLS
Mononuclear variants of RS cells with a single round nucleus and large nucleoli exist
Lacunar cells: seen in nodular sclerosis subtype, the cell has a multilobate nucleus with
abundant pale cytoplasm which retracts (cutting artifact), leaving the nucleus sitting in an
empty hole (lacune)
Lymphocytic and histiocytic variants (L and H cells) polypoid nuclei resembling popcorn
kernels (popcorn cells) with inconspicuous nucleoli and moderate amounts of cytoplasm
_ RS cells in classical HL undergo shrinkage and pyknotic change ! mummified cells

_ RS cells are ANEUPLOID
FIGURE 15-24. Reed-Sternberg cells and variants.
A, Diagnostic Reed-Sternberg cell, with two nuclear lobes,
large inclusion-like nucleoli, and abundant cytoplasm,
surrounded by lymphocytes, macrophages, and an
eosinophil. C, Reed-Sternberg cell, lacunar variant. This
variant is usually seen in the nodular sclerosis subtype and
has a folded nucleus or multilobate nucleus lying within a
clear space created by retraction of its cytoplasm during
processing of the tissue.
18

REED-STERNBERG LIKE CELLS MAY ALSO OCCUR IN:
Infectious mononucleosis
Non-Hodgkins lymphoma
Solid tissue cancers

WHO CLASSIFICATION OF HL

The subtypes are:
1. Lymphocyte predominance
2. Mixed cellularity
3. Lymphocyte depletion
4. Nodular sclerosis
5. Lymphocyte rich

NOTE: # 2-5 are considered as classical forms of HL. They are positive for PAX-5, CD15 and
CD30.

I. LYMPHOCYTE PREDOMINANCE

6% of HL
Tumor reveals popcorn cells (RS variant)
Classic RS cells are very difficult to find
Eosinophils, neutrophils, and plasma cells are scanty
Necrosis/fibrosis not seen

IMMUNOPHENOTYPE
The L and H cells (popcorn cells) are CD 20 and CD 45 positive (B cell markers)
CD 15 and CD 30 are NEGATIVE
BC L 6 positive
EBV negative

GENOTYPE
Tumor cells reveal IgH gene rearrangement and VH segment somatic hypermutation suggestive of
follicular B cells.

NOTE: 35% of such tumors transform to diffuse, large B cell lymphomas

CLINICAL FEATURES
Most patients are males less than 35 years of age
Present with cervical or axillary adenopathy
Bone marrow/mediastinal involvement rare
Excellent prognosis

II. MIXED CELLULARITY

25% of HL cases
Tumor composed of many classic RS cells and other mononuclear variants
Small lymphocytes, eosinophils, plasma cells, and macrophages seen

IMMUNOPHENOTYPE
Tumor cells are positive for CD 15 and CD 30
Negative for CD 45, B cell and T cell markers
Associated with EBV genome (70% of cases)
19

GENOTYPE
Clonal Ig rearrangements may be seen (suggestive of B cells)
Associated with EBV genome (70% of cases)

CLINICAL FEATURES
Occurs in older patients more than 55 years of age; may also occur in young adults
Male greater than female
Advanced tumor stage usually noted
Overall prognosis is very good

III. LYMPHOCYTE DEPLETION

Least common form of HL (< 5% of cases)
RS cells or their pleomorphic variants are abundant; lymphocytes are sparse
CD 15 and CD 30 positive; EBV positive in 90% of cases
Two forms are seen: diffuse fibrosis and reticular variants
In diffuse fibrosis, the node is hypocellular, replaced by fibrillar connective tissue with
scattered RS cells and lymphocytes
In reticular variant, there is more cellularity, with highly anaplastic, large, pleomorphic
cells resembling RS cells; only a few typical RS cells seen
Most patients are HIV positive, have disseminated disease, and systemic manifestations

NOTE: It is likely that this lymphocyte depletion type of HL is really an aggressive, large cell
lymphoma!

IV. NODULAR SCLEROSIS

Most common form of HL (65% to 70% of cases)
Tumor has:
a. Collagen bands dividing lymphoid tissue into circumscribed nodules
b. RS variant cells (lacunar cells)
Classic RS cells are infrequent; T lymphocytes, eosinophils, plasma cells, and macrophages
are noted

IMMUNOPHENOTYPE
Tumor cells are positive for CD 15 and CD 30
Negative for CD 45, B and T cell markers
Not associated with EBV

GENOTYPE
Clonal Ig rearrangements present (B cell origin)

CLINICAL FEATURES
Occurs in adolescents and young adults
Female greater than male (or F=M)
Involves lower cervical, supraclavicular, and mediastinal nodes
Excellent prognosis

20

V. LYMPHOCYTE RICH

Uncommon
Many lymphocytes noted
Classic RS cells and mononuclear variants seen
CD15 and CD30 are POSITIVE
CD20 and CD 45 are NEGATIVE
EBV genome positive in 40% of cases
Excellent prognosis

STAGING OF HL

Spread of HL is quite predictable
Nodes, spleen, liver, bone marrow, and (uncommonly) extranodal sites are involved (in that
order); nodular masses cause organomegaly
Limited disease can be cured by local radiation therapy
Staging hence predicts prognosis and guides choice of therapy
Disease management/staging include:
Chest x-ray, bone marrow biopsy, and CT of abdomen and pelvis
Staging: laparotomy with visualization of abdominal lymph nodes, liver biopsy and
splenectomy may be performed

ETIOLOGY AND PATHOGENESIS OF HL
HL is a clonal, neoplastic disorder wherein the RS and variant cells represent transformed
neoplastic cells
RS cells may express B cell, T cell, or monocyte/macrophage markers
RS cells/variants reveal Ig gene rearrangement supporting a B cell origin (e.g., nodular sclerosis,
mixed cellularity, and lymphocyte predominance sub type)
THUS, IN MOST CASES, HL APPEARS TO BE A NEOPLASM OF TRANSFORMED
GERMINAL CENTER OR POST GC B CELLS.
TABLE 15-6. CLINICAL STAGING OF HODGKIN AND NON HODGKIN LYMPHOMAS (ANN ARBOR
CLASSIFICATION)

21

CAUSE OF NEOPLASTIC TRANSFORMATION
The exact cause is unknown. Viruses such as Epstein-Barr virus may be involved in the
pathogenesis of HL. Latent membrane proteins encoded by the EBV genome increase
transformation of cells

EBV genome is present in 70% of RS cells (mixed cellularity)

clonal pattern

increased NF-kB (nuclear factor kappa B, a transcription factor for B cell proliferation
- it is also anti-apoptotic). c- REL ( Reticuloendotheliosis) gene mutation on
chromosome 2p can cause this.

B cell proliferation lymphoma

In EBV negative tumors, high levels of NF-kB may be due to somatic gene mutations
inhibiting a NF-kB inhibitor.
Cytokines aand chemokines produced by RS cells lead to accumulation of reactive cells

Example: IL-13, IL-4, IL-5, GM-CSF, TNF-!, and TGF-"

stimulates eosinophil fibrogenic
RS cells accumulation
(autocrine effect)

Reactive cells (non-neoplastic, inflammatory infiltrate) produce CD 30 ligand that aids the
growth and survival of RS cells.

CLINICAL COURSE
HL usually presents as a painless enlargement of lymph nodes. Biopsy of tissue is needed for
diagnosis
Younger patients with more favorable types tend to present in clinical stage I or II
Patients in stages III and IV present with systemic complaints, fever, night sweats,
weight loss, pruritus, and anemia
Cutaneous anergy may be due to defective cell-mediated immunity
CLINICAL STAGING IS THE MOST IMPORTANT PROGNOSTIC FACTOR
Five-year survival rate is about 100% for stage IA or IIA (cure rate is 90%) and about
6070% for stage IVA or IVB
Long-term survivors, following combination of chemo and radiation therapy, may develop
acute leukemia, MDS, cancers of lung, breast, and stomach, sarcoma, melanoma, and NHL
( mainly due to radiation therapy; chemotherapy causes MDS and AML). These diseases are
less common nowadays.

22

HISTIOCYTOSES

Proliferation of histiocytes (or macrophages) may be benign (i.e., reactive) or malignant (e.g., malignant
lymphoma). A special type of histiocyte called the Langerhans cell (antigen-presenting dendritic cell)
occurring in the skin and other organs may undergo clonal proliferation " Langerhans cell histiocytosis
(formerly called histiocytosis X). A mutation in serine/threonine kinase BRAF (a valine to glutamate
substitution in residue 600) causes increased cell proliferation and survival ! tumor.

TUMOR CELLS
Large cells with abundant, vacuolated cytoplasm and vesicular oval or indented nuclei with linear
grooves
HLA-DR, ( MHC Class II), S-100 and CD 1a positive (dendritic, antigen-presenting cells)
On EM (electron microscopy), cells reveal BIRBECK GRANULES OR HX bodies in the
cytoplasm. These are penta laminar, rod-shaped, tubular structures with characteristic periodicity
and a dilated terminal end (tennis racket appearance) and contain protein LANGERIN (a
transmembrane protein).

TYPES OF LANGERHANS CELL HISTIOCYTOSIS

I. LETTERER-SIWE DISEASE ( MULTISYSTEM)

An acute, disseminated form
Occurs before two years of age ; may also affect adults
Cutaneous eruptions on the trunk and scalp due to tumor cell infiltration
Lymphadenopathy and hepatosplenomegaly
Lung lesions and osteolytic bone lesions
Anemia and thrombocytopenia due to BM involvement
Recurrent infections, such as otitis media, mastoiditis
Untreated disease is FATAL
Intensive chemotherapy yields a 50% five-year survival

II. EOSINOPHILIC GRANULOMA (UNISYSTEM)

Unifocal lesions affecting the bones (ribs, femur, and calvarium)
Other sites such as skin, stomach, lungs, etc. may be affected ( multifocal).
May be asymptomatic or may cause pain, tenderness, and pathologic fractures
Tumor cells accumulate in the medullary cavities of bones and are admixed with
EOSINOPHILS, neutrophils, lymphocytes, and plasma cells
Usually indolent disease; may heal spontaneously or be cured by local excision or irradiation

III. HAND-SCHULLER-CHRISTIAN DISEASE (MULTIFOCAL)

Multifocal lesions characterized by a TRIAD of calvarial defects, diabetes insipidus (due
to posterior pituitary/hypothalamus lesions), and exophthalmos seen in 50% cases
Other features are similar to those of Letterer-Siwe disease
Lesions spontaneously regress or may be treated with chemotherapy
NOTE
PulmonaryLangerhan cell histiocytosis is a benign, reactive cell proliferation
associated with SMOKING. It can regress with cessation of smoking.
Langerhan cells express CCR6 ( chemokine receptor ). They attach to CCL 20 and hence
go to skin and bones; CCR7 attachment to CCL19 and CCL21 ! to lymphoid tissues.
23

INFECTIOUS MONONUCLEOSIS

Infectious Mononucleosis is usually a benign, self-limited disease caused by Epstein Barr Virus (EBV).

EPIDEMIOLOGY
EBV infections occur worldwide affecting young children and adults. Over 90% of individuals are
infected with the virus and develop antibodies. More than 90% of individuals shed the virus in secretions.

PATHOGENESIS
EBV occurs in saliva, oropharyngeal and nasopharyngeal secretions and memory B lymphocytes. Close
physical contact (e.g., kissing)
viral transmission

Virus gains entry and attaches to epithelial surface receptors with help of integrins

Virus passes through cells (transcytosis) and infects lymphoid tissue

Virus attaches to CD21 positive B lymphocytes

Productive infection Latent infection
(virus replicates, multiplies,
Cells lyse, virions are released
and infect other cells)

EBV genes synthesize several viral antigens
VCA viral capsid Ag
MA membrane Ag
EA Early Ag Diffuse type EA-D
Restricted type EA-R
EBNA Epstein Barr Nuclear Ag
LYDMA Lymphocyte Detected Membrane Ag
LMP-1 Latent Membrane Protein-1
Infected B cells become transformed, proliferate, circulate, and spread to various organs.

IMMUNE RESPONSE

A. Humoral Response
Polyclonal B cell activation leads to
the production of antibodies
to viral Ag and host-cells.

These antibodies are useful in
serologic diagnosis of IM

24

B. Cellular Response
EBV infection causes activation and proliferation of CD 8 suppressor T cells and CD 16 positive
NK cells. These cells destroy EBV infected B cells through ADCC (ab dependent cellular
cytotoxicity). However EBV persists throughout life, in a small clone of resting B cells containing
latent EBV genes. Gene re-expression causes cell proliferation. Defective cellular immunity
(e.g., AIDS) can cause uncontrolled clonal proliferation of B cells leading to malignant lymphoma.

PATHOLOGIC CHANGES

A. Blood
Elevated WBC count
Absolute lymphocytosis
ATYPICAL LYMPHOCYTES (VIROCYTE/DOWNEY CELL) > 10% of
differential cell count.

These are T cells and Nk cells, about 12-16 microns in size, with abundant vacuolated
cytoplasm and scattered azurophilic granules; indented, oval, folded nucleus. Surrounding
rbcs cause indentation of cell margins.

B. Lymph Nodes
Lymphadenopathy (95%) in neck, axilla, groin, and elsewhere.
Paracortical T cell area expansion noted
Occasionally follicular B cell hyperplasia seen
Some B cells may resemble RS cells!
Cellular changes may mimic a malignant lymphoma.

C. Spleen
Splenomegaly (48%)
White pulp follicles and red pulp sinusoids expand due to T cell activation and
proliferation
Spleen becomes soft; increase in size may cause rupture of capsule " splenic rupture

D. Liver
Hepatomegaly (22%)
Atypical lymphocytes in portal areas; foci of parenchymal necrosis seen (may simulate
viral hepatitis)

E. CNS
Congestion, edema, perivascular mononuclear infiltration in the meninges

F. Peripheral Nerves
Myelin degeneration
Axon destruction

G. Serology (Lab Tests)
Paul-Bunnell Test: Patients with IM develop heterophile IgM antibodies (cause
unknown not coded by EBV). These antibodies agglutinate sheep/horse red blood
cells. Thus,
serum from I.M. patient + sheep rbcs agglutination

Positive Test
Above principle is used in a rapid latex agglutination test called MONO SPOT TEST.
25

MONO PLUS TEST (NEWER TEST)
Direct solid phase immunoassay
(I.M. heterophile IgM antibodies in) patients blood/serum/plasma is added to
bovine rbc extract (on a test membrane) AbAg complex formed
Antihuman IgM Ab + dye conjugate is added
This will bind to the Ab Ag complex leading to the formation of a colored
band. Test is positive.

HETEROPHILE Ab DIFFERENTIAL TEST (SELDOM USED NOWADAYS)
(Davidsohns modification of Paul-Bunnell test)
Davidsohn found that

Associated with I.M.
1. Heterophile Abs

Not associated with I.M.

2. H.A. associated with I.M. were completely absorbed by BEEF RBCs.
3. H.A. not associated with I.M. were completely absorbed by guinea pig kidney
(Forsman Antigen)
The above principle is used in H.A. differential absorption test.

Thus

Heterophile Ab
Source of Serum Unabsorbed
Effect of Absorption
Guinea Pig
Kidney Beef RBCs

Infectious Mononucleosis ++++ +++ 0
Serum Sickness +++ 0 0
Normal Serum (Forsman Abs) + 0 +

ANTIBODIES TO EBV

1. IgM antibodies to viral capsid Ag Early infection

2. IgG antibodies to viral capsid Ag Recent/past infection

OTHER ANTIBODIES (NOT EBV)
ANA, RF, cold agglutinins, antibodies to rbcs, wbcs, platelets

CLINICAL FEATURES
Can occur at any age
In childhood usually asymptomatic
In Adolescents/young adults Common
Fever (87%)
Sore throat (60%) TRIAD OF COMMON FEATURES
Lymphadenopathy (95%)
Rash, fatigue, weakness, malaise,
headache, etc.
26

COMPLICATIONS
1. Liver Dysfunction Jaundice
Abnormal liver function tests (LFTs)
2. Thrombocytopenia (50%)
3. Hemolytic Anemia (1-3%) due to anti-i antibodies
4. Splenic rupture fatal, uncommon
5. B Cell Clonal Proliferation occurs in immunodeficiency, immunosuppression, following bone
marrow transplantation and in X-linked lymphoproliferation syndrome (XLP)

DIFFERENTIAL DIAGNOSIS
1. Other viral infections, e.g., CMV, Hepatitis
2. Drugs, e.g., Dilantin
3. Radiation
4. Stress

COURSE
IM is a benign self-limiting disorder
Resolves in 3-4 weeks
Symptomatic R
x

27

THYMUS

Embryology Originates from the third and occasionally from the fourth
pharyngeal pouches

Anatomy A pyramidal, well encapsulated, bi-lobed organ
Wt = 20-50 gm (puberty)
5-15 gm (elderly involutes in adults)
Location is anterosuperior mediastinum

Histology Lobules are composed of:

Cortex Medulla

1. epithelial cells epithelial cells (spindle shaped)
2. T-lymphocytes T-lymphocytes

Besides epithelial cells and T-lymphocytes (thymocytes), there are B-lymphocytes, macrophages,
dendritic cells, neutrophils, eosinophils and MYOID (muscle) CELLS

NOTE: Epithelial and myoid cells contain Nicotinic Acetylcholine Receptor Protein. Auto antibodies
to this protein occur in Myasthenia Gravis.

PATHOLOGIC DISORDERS OF THYMUS

I. THYMIC HYPERPLASIA

Thymic follicular hyperplasia contains lymphoid follicles with reactive germinal centers (B
lymphocytes)

Occurs in myasthenia gravis (65-75% cases) and other autoimmune diseases such as SLE,
RA, scleroderma, Graves disease, Addisons disease, etc.

II. THYMOMAS

Tumors of thymic epithelial cells (with a background of thymocytes or T-lymphocytes) are
called thymomas.

A. Benign Thymoma (50% of cases)

Tumor is well encapsulated, lobular with areas of cystic necrosis and calcification.
Tumor cells are cytologically benign and composed of epithelial cells and thymocytes.
Hassalls corpuscles are rarely present.

Prognosis

Excellent following surgery

28

B. Malignant Thymoma Type 1 (20-25% of cases)

Tumor composed of epithelial cells and thymocytes with an organoid pattern, palisading of
cells around blood vessels, rosettes and whorls suggestive of abortive Hassall corpuscles are
seen.

IMPORTANT: CYTOLOGICAL ATYPIA
CAPSULAR PENETRATION AND INVASION
OF PERITHYMIC TISSUE NOTED

Prognosis

Minimal invasion } 5 year survival rate is >90%
Extensive invasion with metastasis to liver, lung, nodes, bone} 5 year survival rate is < 50%

C. Malignant Thymoma Type II (5% of cases)

Also called Thymic Carcinoma

They are:
1. Squamous cell Ca (well to poorly differentiated)
2. Lymphoepithelioma-like Ca (50% of cases associated with EbV)
3. Sarcomatoid type
4. Others

CLINICAL FEATURES

Occurs > 40 years
M = F
Located in anterosuperior mediastinum, neck, thyroid, pulmonary hilum
Discovered incidentally or due to pressure effects on neighboring structures
Associated with Myasthenia Gravis (30-45%), hypogammaglobulinemia, pure red cell aplasia,
Graves disease, Cushings Syndrome, PA, dermatomyositis-polymyositis, RA, SLE, Sjgrens
Syndrome, etc.

BLEEDING AND COAGULATION DISORDERS

Brent Beenders, PhD

(Notes based on previous handout)

Pathology M-2 Bleeding and Coagulation Disorders.

1

BLEEDING DISORDERS
Excessive bleeding due to:
" Increased fragility of vessels
" Platelet deficiency or dysfunction
" Defect in coagulation
" Combination

I. TESTS USED TO EVALUATE DIFFERENT ASPECTS OF HEMOSTASIS

Bleeding time: measures platelet response (ability to form a platelet plug) by measuring time for
standardized skin puncture to stop bleeding; prolongation indicates low platelet numbers and/or
defective platelets

Platelet count: 150,000 to 300,000/microliter is normal
Abnormally high numbers probably indicate a myeloproliferative disorder (e.g. polycythemia
vera, essential thrombocytopenia)
Abnormally low numbers are associated with:
Platelet consumption e.g. DIC (look for fibrin split products/D-dimers)
Immune or non-immune mediated thrombocytopenia
Spurious thrombocytopenia lab error due to clumped platelets, confirm with visual
inspection of blood smear

Prothrombin time (PT):
measures extrinsic and
common coagulation
pathways
- Measured in seconds,
normal range depends on
lab
- Prolonged PT is
associated with deficient
or defective factor VII,
V, X, prothrombin (II) or
fibrinogen (I)
- PT is the best measure
for liver synthetic
function

Partial thromboplastin time
(PTT): measures intrinsic and
common coagulation
pathways
- Measured in seconds,
normal range depends on
lab


2

- Prolonged PTT is associated with deficient or defective factors XII, XI, IX, VIII, V, X,
prothrombin (II) or fibrinogen (I)

CLINICAL NOTE: Both PT and PTT are prolonged for patients on heparin therapy but PTT is
the better test to follow for clinical management

II. BLEEDING DISORDERS CAUSED BY VESSEL WALL ABNORMALITIES (non-
thrombocytopenic purpuras)

Signs and Symptoms:
Petechial and purpuric hemorrhages of skin and mucous membranes; serious cases may include
joints, muscles, bone; frequent nose bleeds (epistaxis), excessive menstrual bleeding
(menorrhagia), GI bleeding, or hematuria may occur
Platelet count, bleeding time, PT, and PTT are normal

Causes:
Infections, e.g., meningococcemia, septicemia, endocarditis, rickettsiosis microbes cause
damage to microvasculature
Drug Reactions type III hypersensitivity with drug-induced immune complex deposition in
vessel walls
Scurvy, Ehlers-Danlos syndrome impaired collagen formation weakens vessel walls (same
mechanism as spontaneous purpura in elderly)
Cushing syndrome excess corticosteroids cause protein wasting which causes a loss of
perivascular supporting structures
Henoch-Schonlein purpura systemic hypersensitivity of unknown cause characterized by
purpuric rash, colicky abdominal pain (due to focal hemorrhages in GI tract), polyarthralgia and
acute glomerulonephritis mechanism is type III hypersensitivity with the deposition of immune
complexes in vessel walls
Hereditary hemorrhagic telangiectasia autosomal dominant (AD); tortuous, dilated fragile blood
vessels that bleed easily, most commonly located in mucous membranes and GI tract
Amyloid infiltration of blood vessel walls causing mucocutaneous petechiae

III. BLEEDING RELATED TO REDUCED PLATELET NUMBER
THROMBOCYTOPENIA

Thrombocytopenia = platelet count < 100,000/microL
Spontaneous bleeding may occur as platelet counts fall below 20,000/microL- involves small
vessels usually in skin and mucous membranes of GI and GU tract, intracranial bleeding is the
most serious complication
20,000 50,000/microL is problematic with post-traumatic bleeding
Recall sign of prolonged bleeding time but normal PT and PTT

Causes of Thrombocytopenia: (see Robbins Table 14-9)

1. Decreased production of platelets e.g., aplastic anemias and leukemias; vitamin B12 or folic acid
deficiency cause ineffective megakaryopoiesis (megaloblastic anemia), alchohol, drugs, measles
virus, HIV
ROBBINS FIG. 4-8

3

2. Decreased platelet survival
A. Immunologic destruction caused by circulating antiplatelet antibodies (Abs) or immune
complexes that deposit on platelets. Abs often directed at gp IIb-IIIa or Ib-IX.
Autoimmune thrombocytopenias include primary/idiopathic immune thrombocytopenic
purpura (ITP) or secondary ITP due to systemic lupus erythematosis (SLE), chronic
lymphocytic leukemia (CLL), etc.
Drug-induced thrombocytopenia: quinidine, heparin, sulfa drugs
Infectious: HIV associated thrombocytopenia, mononucleosis, cytomegalovirus (CMV)
IgG alloantibodies against transfused or fetal platelets causing thrombocytopenia
B. Non-immunologic mechanical injury associated with mechanical valves and diffuse narrowing
of microvasculature as in malignant hypertension (HTN)
3. Sequestration occurs in pts w/ splenomegaly which may sequester >80% of platelets; usually
causes only moderate thrombocytopenia, but may be ameliorated by splenectomy
4. Dilution (following massive transfusions) blood stored longer than 24 hrs contains almost no viable
platelets

Chronic Immune Thrombocytopenic Purpura (primary or idiopathic ITP)
Caused by autoantibodies to platelet membrane glycoproteins gp IIb-IIIa or Ib-IX => opsonized
platelets are phagocytosed primarily in spleen
Spleen is normal size with congestion of splenic sinuses and hyperactive enlarged splenic follicles
Splenectomy improves bleeding in 75-80% pts
Increase in number and size of megakaryocytes in bone marrow; also likely to see abnormally large
platelets in a blood smear due to accelerated thrombopoiesis
If the number of megakaryocytes is decreased it is not ITP
Primary ITP is usually a diagnosis of exclusion
Clinical Features of CITP:
- Most common in adult women younger than 40 (3:1 female to male ratio)
- Pinpoint hemorrhages (petechiae) in mucosal surfaces and skin in dependent areas, may see
ecchymoses
- Often present with a history of easy bruising, nosebleeds, bleeding of the gums; may see melena,
hematuria, excessive menstrual flow
- Subarachnoid hemorrhage and intracerebral hemorrhage are rare but serious complications
- Treatment: glucocorticoids (inhibits phagocytes), splenectomy (increases risk for sepsis)

Acute ITP (also primary/idiopathic)
Self-limited disease of childhood, usually preceded by viral illness approximately 2 weeks earlier
Spontaneously resolves within 6 months in most cases
Most common cause of thrombocytopenia in children, occurs with equal frequency in boys and girls
20% of cases persist and lead to chronic ITP

Drug-Induced Thrombocytopenia
Associated with quinine, quinidine, vancomycin, sulfonamide antibiotics and heparin (5% of patients
receiving heparin)
Drugs bind glycoproteins on platelets creating antigenic determinants

Type I Heparin Induced Thrombocytopenia (HIT):
- Rapid onset, modest severity, clinically insignificant, usually resolves even with continuation of
heparin therapy
- Caused by platelet aggregating effects of heparin

4

Type II Heparin Induced Thrombocytopenia (HIT):
- Less common
- Caused by Ab immune reaction against heparin-platelet factor IV complex => immune complex
activates platelets and promotes thrombosis even with thrombocytopenia
- May cause life threatening venous and arterial thrombosis
- Can cause vascular insufficiency and potential limb loss or deep venous emboli leading to
pulmonary embolism
- Typically occurs 5-14 days after commencement of therapy (sooner if previously sensitized)
- Use of low molecular weight heparin decreases the risk of HIT II

HIV-Associated Thrombocytopenia
Due to impaired platelet production and increased platelet destruction
CD4 and CXCR4 receptors are also present on megakaryocytes => infection & apoptosis
HIV causes hyperplasia and dysregulation of B cells predisposing to development of autoantibodies
and immune-mediated thrombocytopenia

Thrombotic Microangiopathies: Thrombotic Thrombocytopenic Purpura (TTP) &
Hemolytic Uremic Syndrome (HUS)
TTP: 5 classical features fever, thrombocytopenia, microangiopathic hemolytic anemia, transient
neurologic deficits and renal failure
HUS: distinguished from TTP by absence of neurologic symptoms, the prominence of acute renal
failure, and more common occurrence in children
The technical distinction is often blurred in reality and the condition is simply called TTP/HUS with
TTP more commonly affecting the brain and HUS more commonly affecting the kidney
Common feature is widespread formation of platelet thrombi in microcirculation
Consumption of platelets causes thrombocytopenia
Intravascular thrombi cause microangiopathic hemolytic anemia and widespread organ dysfunction

Mechanism of TTP:
- Many patients have deficient levels of the plasma enzyme ADAMTS 13, which is a vWF
metalloprotease that normally degrades high molecular weight multimers of vWF
=> accumulation of vWF multimers in plasma which in turn causes platelet microaggregates
throughout microcirculation
- Deficiency may be inherited or acquired (autoantibodies inhibit ADAMTS 13)
- TTP is triggered by vascular injury or prothrombotic state
- TTP treatment: plasma exchange supplies missing ADAMTS 13 enzyme and removes
autoantibodies

Mechanism of HUS: normal levels of vWF metalloprotease (ADAMTS 13)
- Commonly caused by E. coli 0157:H7 shiga-like toxin, especially in children and elderly
- Patients often present with a recent history of bloody diarrhea
- Toxin binds to endothelial cells in glomerulus and other locations initiating damage and platelet
activation and aggregation
- May cause permanent renal damage and death in severe cases
- May also occur in setting of other chronic, life-threatening conditions such as cancer due to
radiation or chemotherapy-induced damage of endothelial cells
- HUS Treatment: treat underlying cause and provide supportive therapy


5

- Both TTP and HUS can be distinguished from DIC by a normal PT and PTT because coagulation
cascade is usually not important in the mechanism

IV. BLEEDING DISORDERS RELATED TO DEFECTIVE PLATELET FUNCTIONS

Key feature: Platelet counts usually normal, but bleeding times are prolonged

Congenital defects:
Bernard-Soulier Syndrome: autosomal
recessive (AR) disorder characterized by
defective platelet adhesion to
subendothelial matrix due to deficient
platelet membrane gp Ib-IX which is a
receptor for vWF
Glanzmanns Thrombasthenia: AR
disorder characterized by defective
platelet aggregation due to lack of or
dysfunctional gp IIb-IIIa which
participates in the formation of bridges
between platelets by binding fibrinogen
Disorders of platelet secretion
(thromboxanes, ADP) or storage pool
disorders

Acquired defects:
Aspirin irreversible inhibitor of COX necessary for synthesis of thromboxane A2 and
prostaglandins
Uremia- complex pathogenesis involving defects in adhesion, granule secretion and aggregation

V. HEMORRHAGIC DIATHESES RELATED TO ABNORMALITIES IN CLOTTING
FACTORS (Review Clotting Cascade in Chapter 4, pp. 118-121)

Characterized by large post-traumatic ecchymoses or hematomas, or prolonged bleeding after a
laceration or any type of surgery (e.g. tooth extraction)
Bleeding into GI and urinary tracts, and weight bearing joints (hemarthroses) is common
Differ from platelet disorders in that spontaneous petechiae or purpura are uncommon

Acquired clotting disorders:
Vitamin K deficiency results in impaired synthesis of factors X, IX, VII, II and protein C
Severe liver disease (e.g. alcoholic cirrhosis) because most clotting factors are made in the liver

Hereditary disorders:
Hemophilia A (factor VIII)
Hemophilia B or Christmas disease (factor IX) - less common than Hemophilia A
Von Willebrand Disease (vWF)

ROBBINS FIG. 4-7

6

Link between vWF and factor VIII: factor VIII is stabilized in the plasma by circulating vWF. A
deficiency of vWF will also manifest as a deficiency of factor VIII (see figure 14-26, next page)

FIG. 14-26 ROBBINS

Von Willebrand Disease
Most common inherited bleeding disorder (1% of adults in U.S.)
Primarily AD, but many variants with variable penetrance and expressivity lead to a wide range of
relatively mild to relatively severe cases
Normal platelet count, defective platelet function
Clinical Features: spontaneous bleeding from mucous membranes (epistaxis), excessive bleeding
from wounds, menorrhagia
Prolonged bleeding despite normal platelet count; may also see prolonged PTT due to reduced levels
of factor VIII
Plasma levels of active vWF measured by ristocetin agglutination test (mix pts plasma with
formalin fixed platelets and ristocetin, ristocetin activates vWF)
Differentiated from hemophilias in that hemarthroses are uncommon
Treatment: Desmopressin stimulates vWF release, plasma transfusions containing vWF and factor
VIII before dental work or surgery

Hemophilia A (Factor VIII Deficiency)
Most common hereditary disorder associated with serious bleeding
X-linked recessive (but 30% of cases have no family history)
Wide range of clinical severity depending on amount of factor VIII activity
Factor VIII serves as a cofactor for factor IX to activate factor X
Clinical Features: easy bruising and massive hemorrhage after trauma or surgery, spontaneous
hemorrhages are common in joints (hemarthroses)
Recurrent hemarthroses can lead to progressive crippling of joints
Petechiae are absent
Only the PTT is prolonged; bleeding time, platelet count and PT are normal
Treatment: infusion of recombinant factor VIII, this revolutionized therapy by preventing accidental
infection with HIV following donor plasma transfer

Hemophilia B (Christmas Disease, Factor IX Deficiency)
Clinically indistinguishable from factor VIII deficiency
X-linked recessive with variable severity
Only PTT is prolonged; bleeding time, platelet count, and PT are normal

7

VI. DISSEMINATED INTRAVASCULAR COAGULATION (DIC)

Always secondary to other diseases
Characterized by activation of coagulation cascade and widespread deposition of fibrin
microthrombi throughout microcirculation, often in a non-uniform distribution
This causes consumption of platelets, fibrin, and coagulation factors and activation of fibrinolytic
system
Often called a consumption coagulopathy
Characterized by increased D-dimers and other fibrin split products

Signs and symptoms:
Tissue hypoxia and infarction, excessive bleeding, and microangiopathic hemolytic anemia with
fragmented red blood cells; other common signs and symptoms include dyspnea, cyanosis, and
respiratory failure; convulsions and coma; oliguria and acute renal failure; circulatory failure and
shock

Mechanism:
Release of tissue factor or thromboplastic substances due to immunologic activation or
widespread endothelial injury which causes the release of tissue factor.

TNF and IL-1 increase the expression of tissue factor and decrease the expression of
thrombomodulin creating a procoagulation environment. TNF also upregulates the expression of
adhesion molecules on endothelial cells and leukocytes.

Examples include obstetric complications leading to the entry of placenta or fetal tissue into
maternal circulation; granules of leukemic cells which activate factor X; and bacterial endotoxins
which cause the release of IL-1 and TNF from macrophages.

DIC is most likely to be caused by obstetric complications, malignant neoplasia, sepsis, or major
trauma.

HEMATOPOIESIS AND ANEMIAS

Naveen Manchanda, MD
(Notes from Lawrence Konick, MD)

PLEASE REVIEW THE ATTACHED OBJECTIVES AND HANDOUTS PRIOR TO THIS
LECTURE

OPTIONAL READING: Robbins Basic Pathology: With STUDENT CONSULT Online Access
(Basic Pathology (Kumar)) by Vinay Kumar, Abul K. Abbas, Nelson Fausto, and Richard Mitchell
(May,2007).

If you have questions, I can be reached at manchand@uiuc.edu

Pathology M-2 Hematopoiesis and Anemias

1


2


3


4


5


6


7

ANEMIAS

Anemia is often diagnosed all over the world; there are many etiological factors and pathological
processes that contribute to this disorder. Frequently the laboratory evaluation of the patient with anemia
has already begun by the time a clinical problem is recognized. The etiology of the anemia should always
be investigated as the causative factors are mostly reversible.

Anemia is one of the most common problems that is encountered in a primary care practice as well in
hospital admissions. Approximately 20% of hospital admissions among the elderly are due to anemia,
and 75% of hospital anemias are due to iron deficiency or anemia of chronic disease. Alpha- and beta-
thalassemia (genetically inherited hemoglobin deficiency) are also quite common the world over; the
heterozygote is often asymptomatic whereas the homozygotic form presents with severe childhood
anemia.

FIGURE 1. From B. Djulbegovic: Reasoning and Decision Making in Hematology,
Churchill Livingstone, Inc., 1992, p. 14.

It is important to understand how anemias are classified. Multiple classifications of anemia have been
developed. Anemia based on the physiologic mechanism is given below:

PHYSIOLOGIC CLASSIFICATION OF ANEMIAS

I. DECREASED OR INEFFECTIVE RED CELL PRODUCTION (decreased, normal, or
increased reticulocyte count)

A. Decreased Erythropoietin Levels
1. Chronic renal disease
2. Inflammation
3. Hypothyroidism
4. Reduced oxygen need of tissues or increased oxygen pressure available

8

B. Marrow Damage or Displacement of Erythropoietic Elements
1. Aplasia after exposure to toxic chemicals or radiation
2. Stem cell disorders leading to hypoplasia, aplasia, or dyserythropoiesis
3. Myelofibrosis
4. Displacement by neoplasms of other cell lines

C. Nuclear Maturation Disorders
1. Vitamin B12 deficiency
2. Folic acid deficiency
3. Vitamin B-6 deficiency
3. Induced vitamin deficiency by folate antagonists

D. Iron Deficiency
1. Nutritional deficiency
2. Chronic hemorrhage
3. Pregnancy
4. Inflammation

E. Deficiency in Globin Production: Thalassemia

F. Deficiency in Heme Synthesis
1. Congenital porphyrias
2. Acquired porphyrias and heavy metal poisoning
3. Sideroblastic anemias

II. INCREASED RED CELL DESTRUCTION OR LOSS (increased reticulocyte count)

A. Hemorrhage
1. Acute, due to trauma
2. Chronic, due to gastrointestinal or menstrual mucosal abnormality

B. Intravascular Hemolysis
1. Thermal, chemical, osmotic or mechanical damage
2. Paroxysmal nocturnal hemoglobinuria
3. Autoimmune and alloimmune antibodies
4. Exposure to bacterial toxins or specific venoms
5. Malarial parasites
6. Prosthetic heart valve
7. Glucose-6-phosphate dehydrogenase deficiency

C. Extravascular Hemolysis
1. Membrane deficiencies
2. Thalassemias
3. Hemoglobinopathies, e.g., sickle cell and HbC disease
4. Autoimmune hemolytic anemias
5. Liver disease

However, sometimes a morphologic approach is easier to use to identify an anemia of unknown etiology.
This is typically based on the cell size, or more accurately, the cell volume. With the widespread use of
automated hematology instrumentation, the mean cell volume (MCV) of red blood cells is helpful in
classifying anemias.

9

MORPHOLOGIC CLASSIFICATION OF ANEMIAS

I. MICROCYTIC ANEMIAS (MCV < 80 fL)

A. Iron deficiency
B. Anemia of chronic disease
C. Thalassemia
D. Sideroblastic anemias

II. MACROCYTIC ANEMIAS (MCV > 100 fL)

A. Norm megaloblastic (MCV usually < 115 fL)
1. Hemolytic anemia or acute blood loss with secondary reticulocytosis
2. Chronic liver disease
3. Postsplenectomy
4. Hypothyroidism (in 50% of hypothyroid patients)
5. Myelophthisic anemia
6. Alcoholism
7. Hematopoietic disorders (myelodysplastic syndrome, leukemia, myeloproliferative
disease, multiple myeloma, aplastic anemia)
8. Artefactual macrocytosis due to cold agglutinins, very high white blood cell count, and
hyperglycemia and hypernatremia

B. Megaloblastic (suspect if MCV > 115 fL; Vitamin B12 and/or folate deficiency)
1. Decreased intake
2. Impaired absorption
3. Increased requirements

III. NORMOCYTIC ANEMIAS (80 < MCV < 100 fL)

A. Acute blood loss
B. Hemolytic anemias
C. Anemia of chronic disease
D. Hematologic malignancies
E. Myelophthisic anemia
F. Aplastic anemia
G. Endocrinopathies

10

FIGURE 2. Overlap in the Morphologic Classification of Anemias.

Understanding both classifications is helpful in categorizing anemias. Within this extensive list,
overlapping occurs which complicates the diagnosis. Diagnosis may also be complicated by the presence
of two or more types of anemia. Only the more common anemias, and a few others, will be described.

Before further discussion of anemias, some basic laboratory tests will be reviewed (the given
reference ranges are for adults). The first test ordered in the evaluation of any anemia is a
complete blood count (CBC). This includes white blood cell (WBC) count, red blood cell (RBC) count,
hemoglobin (Hb), hematocrit (Hct), platelet count, and the RBC indices.

Red Blood Cell Indices

Hct x 10
RBC

This is the mean RBC volume. When the MCV is decreased microcytes are
present, and when increased macrocytes are present.
MCV =

(reference range 80100 fL)

Hb x 10
RBC

The mean cell hemoglobin (MCH) is the mean amount of hemoglobin (Hb)
in each cell. When decreased, hypochromia may be present.
MCH =

(reference range 3134 pg)

Hb x 100
Hct
The mean cell hemoglobin concentration is the mean concentration of Hb in
each cell. This correlates with the RBC pallor seen on peripheral blood
smear, i.e., when MCHC is decreased, hypochromia is present.
MCHC =

(reference range 3226 g/dl)

Red Cell Distribution Width (RDW) and Anisocytosis are measures of the variation in red cell volume.
The RDW may be reported in at least a couple ways; however, in this handout only the RDW-CV will be

11

discussed and will be referred to as RDW. This is calculated by automated hematology analyzers as
follows:

RDW =
std deviation of the RBC curve x 100
MCV

The reference range is 1215%. This is helpful in detecting red cell abnormalities in which the red cell
distribution curve is abnormally narrowed, e.g., thalassemias and heterozygous hemoglobinopathies, and
abnormally widened, e.g., iron deficiency. Anisocytosis refers to variation in red cell size as seen on the
peripheral blood smear. The RDW in most cases correlates with the RBC anisocytosis. The larger the
RDW, the greater the degree of anisocytosis.

Poikilocytosis refers to variation in red blood cell shape as seen on the peripheral blood smear. Normal
red cells are biconcave. Abnormally shaped cells have descriptive names, and include spherocytes,
elliptocytes, target cells, sickle cells, schistocytes, tear drop cells, ovalocytes, and burr cells.

Reticulocyte Count Reticulocytes, also known as shift cells, are the young RBCs that are released
from the marrow. They are larger than mature RBCs and contain portions of ribosomal RNA material.
The number of reticulocytes are sometimes expressed as a percentage of RBCs (reference range is
0.5 to 1.5%). This may be reported in other ways as follows:

Corrected reticulocyte count = % reticulocytes x
(reference range is 0.5 to 1.5%)

pt Hct
45

Absolute reticulocyte count = % reticulocytes x RBC (reference range is 24 to 84 x 10
3
/ul)

Until recently reticulocyte counts have been manual tests that are subjective, and the precision and
accuracy are poor. Some of the newer hematology instruments provide reticulocyte counts. An absolute
reticulocyte count greater than 100,000/ul is a marker of hemolytic anemia.

Other useful laboratory tests in the evaluation of anemias will be discussed later. Many algorithms are
available for the diagnosis of anemia. Clinicians must be aware of the sensitivity and specificity of
clinical and laboratory findings; otherwise, the etiology of the anemia may be missed. (See FIGURES 3
and 4.)


12



13

Operating Characteristics of Common Tests Used in Diagnosis of Anemia

Test

Sensitivity (%)

Specificity (%)

Disease

Physical Exam
Pallor
(face, conjunctivae, nailbeds,
palms)
Palmar creases
Splenomegaly

4867

12
97100

5871

98
3050 (?)

Anemia (hematocrit = 30%)

Anemia (hematocrit = 30%)
Hereditary spherocytosis

Lab Blood Smear Reading
Microcytosis
Macrocytosis
Hypersegmented neutrophils
(5 cells with 5 lobes or 1 cell
with 6 lobes)

1663
484
9195

5395
6994
77

Iron deficiency anemia
Vitamin B12 deficiency/FAD

RBC Indices
RDW > 15
MCV < 100
MCV < 84
MCV < 80
MCV > 105
MCHC > 36

87100
100
48
100
11
100 (?)

66
1530
75
3050 (?)
95
95100

Thalassemia
Hereditary spherocytosis

Common Lab Tests
Ferritin < 12 ng/ml
Transferrin saturation < 16%
Reticulocyte count (%)
Coombs test

Hemosiderin (urine)
Low vitamin B12 (< 200)
Anti-intrinsic factor antibody
Achlorhydria

6597
95100
6290
9698

100
9095
6070
100

99
7095
99
a

9295

?
95 (?)
> 99
3050 (?)

Hemolysis
Autoimmune hemolytic anemia
(all reagents)
PNH
Vitamin B12 deficiency
Pernicious anemia
Pernicious anemia

Abbreviations: FAD, folic acid deficiency; PNH, paroxysmal nocturnal hemoglobinuria; MCV, mean cell
volume; MCHC, mean cell hemoglobin concentration; RDW, red (cell) distribution width.
a
If > 10%.

Churchill Livingstone, Inc., 1992., p. 15.

I. MICROCYTIC ANEMIAS

A. Iron Deficiency Anemia
The concentration of iron in the human body is normally about 40 to 50 mg Fe/kg body
weight. Most of this iron (6080%) is present in hemoglobin. Storage iron represents
approximately 1520% of total body iron. Iron deficiency anemia affects 30% of the worlds
population. In the U.S. it affects between 0.22% of adult males and 210% of adult
females. The higher incidence in women is due to pregnancy and gynecologic problems.
Figure 5 illustrates the distribution of iron in men and women. Iron is lost predominantly by
shedding of skin and epithelial cells. Iron balance is largely regulated by absorption of
dietary iron. The vast majority of iron is stored in macrophages of the bone marrow, spleen,

14

and liver. Iron combines with protoporphyrin to form heme, and heme combines with globin
chains to form hemoglobin.

FIGURE 5. Iron Stores in Men and Women.

Patients with iron deficiency may present with: (1) no signs or symptoms, coming to
medical attention only because of abnormalities in laboratory tests, (2) features of the
underlying disorder responsible for the development of iron deficiency, or (3) manifestations
common to all anemias. Signs and symptoms sometimes associated with iron deficiency
include pagophagia (ingestion of extraordinary amounts of ice), koilonychia (thin and
concave fingernails), and blue sclera.

Causes of iron deficiency include:

Increased iron requirements
Blood loss
Gastrointestinal tract
Genitourinary tract
Respiratory tract
Blood donation
Growth
Pregnancy and lactation
Inadequate iron supply
Diets with insufficient amounts of bioavailable iron
Impaired absorption of iron
Intestinal malabsorption
Gastric surgery

Approximately 25% of iron in meat is readily available for absorption; however, this is not
the case for nonheme iron in which only 12% is absorbed. Gastric acid is important for the
release of heme from its apoprotein. Iron is absorbed predominantly in the duodenum. In

15

normal men the daily basal iron loss is slightly less than 1.0 mg/day, and in normal
menstruating women it is about 1.5 mg/day. The median total loss with pregnancy is about
500 mg or almost 2 mg/day over the 280 days of gestation.


16

Special laboratory tests are helpful in the evaluation of microcytic anemias:

Iron, serum Adult reference ranges 65175 ug/dL (male)
50170 ug/dL (female)

TIBC (total iron binding capacity i.e. capacity of transferrin to bind iron)

Adult reference range 250450 ug/dL
The TIBC is directly proportional to serum transferrin, but the relationship is not
linear over a wide range of transferrin values. Transferrin carries iron in the plasma
and extracellular fluid to supply tissue needs. Inflammation, infection, malignancy,
liver disease, nephrotic syndrome, and malnutrition all depress TIBC. Pregnancy
and oral contraceptives produce TIBC elevations.

Iron Saturation (% transferrin saturation)

% saturation =
serum Iron x 100
TIBC

Adult reference ranges 2050% (male)
1550% (female)

Ferritin, serum

Adult reference ranges 20250 ug/dL (male)
10120 ug/dL (female)
Ferritin is the major iron storage protein and provides an indirect measure of
body iron stores in many cases. Ferritin is an acute phase reactant, i.e., increased
serum ferritin is a nonspecific response that is part of the general pattern of the
systemic effects of inflammation. Thus fever, acute infections, rheumatoid
arthritis, and other chronic inflammatory disorders elevate serum ferritin levels
and may hide an iron deficiency.

Free Erythrocyte Protoporphyrin (FEP)

Adult reference range less than 35 ug/dL RBC
In the last step of heme synthesis, iron is incorporated into protoporphyrin.
FEP accumulates when the iron supply cannot keep up with protoporphyrin
synthesis, or when the enzyme catalyzing incorporation of iron into
protoporphyrin, ferrochelatase, is impaired.

Bone Marrow Biopsy/Aspirate for Iron Stores

This is the gold standard for the diagnosis of iron deficiency, although this is
usually not necessary. Absent marrow iron is diagnostic for iron deficiency.


17

Development of Iron Deficiency Anemia

The development of iron deficiency is a gradual process (see FIGURE 6). It is not until the
final phase that the characteristic laboratory findings are present. Clinical suspicion early in
the course will lead to appropriate testing, and early diagnosis and treatment.

Normal

Reduced
Iron
Stores

Iron
Depletion

Iron
Deficient
Erythropoiesis

Iron Deficiency
Anemia

Marrow Iron Stores

23+

1+

0trace

0

0

Ferritin (ug/L)

10250

< 20

< 20

< 10

< 10

TIBC

nl

nl

nl-sl incr

incr

incr

Iron (ug/dL)

50175

< 115

< 115

< 60

< 40

% Saturation

1550

30

< 30

< 15

< 10

FEP (g/dl RBCs)

< 35

< 35

< 35

> 35

> 35

Hemoglobin

nl

nl

nl

nl

decr

MCV (fL)

nl

nl

nl

nl

< 80

RDW (%)

nl

nl

nl

nl

> 15

MCHC (g/dL)

nl

nl

nl

nl

< 32

RBC Morphology

nl

nl

nl

nl

anisocytosis
poikilocytosis
microcytosis
hypochromia

nl = normal
incr = increased
decr = decreased

FIGURE 6. Phases in Development of Iron Deficiency Anemia.

The classic morphologic features of iron deficiency anemia, i.e., anisocytosis, microcytosis,
poikilocytosis and hypochromia, are present only late in the disease process. Frequently
thrombocytosis occurs and is thought of as a adaptive response to iron deficiency as the
commonest cause of this used to be hookworm infestation until the late 20
th
century. The
reticulocyte count will remain low until iron supplementation is given. .

B. Anemia of Chronic Diseases (ACD)
Anemia of chronic diseases is a heterogenous group of anemias which shows decreased
erythropoiesis. These are associated with a variety of diseases and syndromes, including
chronic infections (tuberculosis, osteomyelitis, subacute bacterial endocarditis, syphilis,
typhoid) and noninfectious diseases (rheumatoid arthritis, ulcerative colitis, collagen vascular
disorders, malignancies, chronic renal disease, endocrine disorders).

18

A number of factors mediate the anemia of chronic inflammation. The most recently
described factor is Hepacidin, a protein made by the liver to negatively regulate iron
absorption. In inflammatory situations, higher amounts of Hepacidin are produced leading to
impaired absorption and resultant iron deficiency. The most prominent is abnormal iron
metabolism characterized by shunting of iron to the reticuloendothelial system and
withholding of iron in mononuclear phagocytes so that it is unavailable for erythropoiesis.
Other important factors include inhibition of erythropoietin production and inhibition of
erythroid progenitors in their response to erythropoietin.

Anemia is usually mild to moderate (Hb 711g/dl). The reticulocyte count is low, and the
RBCs are microcytic to normocytic. Slight poikilocytosis may be present. The serum iron is
decreased, TIBC is normal or decreased, and the serum ferritin and bone marrow iron stores
are normal to high.

C. Thalassemia Syndromes
The most common hemoglobin in adults, HbA, is composed of heme plus two alpha-globin
and two beta-globin polypeptide chains (Hetero-dimers). Thalassemias result from varying
degrees of impairment of synthesis of these polypeptide chains. Common to all thalassemic
syndromes are:

Impaired overall hemoglobin synthesis, which in most cases results in microcytic
RBCs plus sometimes added morphologic evidence of disordered RBC production in
the form of target cells, ovalocytes, and basophilic stippling.

Unbalanced production of globin chains leads to excess o0f one kind of globin chain,
the excess of globin forms homodimers and tetramers that are unstable and precipitate
intracellulary. This leads to red cell destruction in the bone marrow or spleen. There
may be elevated levels of either HbA
2
, or HbF, or both in the beta-thalassemia
syndromes. The %-chain precipitates are more toxic than the non %-chain precipitates.
Therefore, hemolytic anemia and ineffective erythropoiesis are less severe in
%-thalassemia.

Thalassemias are hereditary disorders, primarily affecting southern European, African, and
Asian peoples. It is believed that, like sickle hemoglobin and G-6-PD deficiency, thalassemia
may protect the heterozygote against malaria, although the mechanism is unknown. About
10% of certain Sicilian and Greek populations are heterozygous for beta-thalassemia. In
some areas of Greece and Sardinia, the incidence may be as high as 20%. The diagnosis
depends on clinical history, laboratory findings, and sometimes sophisticated DNA and
globin chain testing.

1. Alpha-thalassemias (!-thalassemias)
Alpha-thalassemia results from alpha-gene deletions. Normal diploid cells contain four
alpha genes, and are found on chromosome 16.

a. Deletion of a single gene (silent carrier) produces no clinical manifestations,
anemia, hemoglobin electrophoresis, microcytosis, or RBC morphology
abnormalities. About 30% of black Americans are silent carriers for alpha-
thalassemia. Globin chain synthesis and globin chain analysis are necessary to
make this diagnosis.
b. The other end of the alpha-thalassemia spectrum is the deletion of all four genes,
which results in stillbirth (hydrops fetalis syndrome). In hydrops fetalis the

19

hemoglobin that is present is gamma chain tetramers (*
4
), known as Hb Barts,
and beta chain tetramers (&
4
), known as HbH. Both HbH and Hb Barts have
very high oxygen affinity and are unable to function as oxygen carriers in vivo.
Both may precipitate within red cells, and shortens cell survival.

c. Alpha-thalassemia trait (alpha-thalassemia minor) results from deletion of two
alpha genes. These patients are asymptomatic. This is present in about 3% of
black Americans. This is largely a diagnosis of exclusion, although a
combination of certain laboratory findings suggest this diagnosis:
i. A minimally reduced hemoglobin and a normal to slightly
elevated RBC count
ii. Microcytosis out of proportion to the RBC count, with an MCV of
60-75l fL, and a low or normal RDW
iii. No other abnormality measurable by common laboratory tests; i.e., no
elevation of HbA
2
or HbF. A few cells with HbH (&
4
) inclusions
(precipitated Hb) may be seen following brilliant cresyl blue incubation.
(This is referred to as a supravital stain.)
iv. A definitive diagnosis can be made with globin chain synthesis and globin
gene analysis.

d. Hemoglobin H (alpha-thalassemia major) disease is the result of the deletion of
three genes. These patients have a lifelong moderate hemolytic anemia
(Hb 810 g/dL). Other laboratory findings include:

i. Microcytosis and an MCV of 6070 fL
ii. Increased reticulocyte count due to mild/chronic hemolysis
iii. Striking hypochromia, target cells, ovalocytes, and basophilic stippling of
the RBCs
iv. Slight bilirubinemia, due to extravascular hemolysis
v. Hb electrophoresis reveals increased HbH (&
4
)
vi. 10 to 100% of RBCs contain inclusions (precipitated Hb) following
incubation with brilliant cresyl blue
vii. As with most chronic hemolytic states infection, pregnancy, or exposure to
oxidative drugs or chemicals may cause an acute hemolytic crisis.


20

Phenotype

Genotype

HbA (%)*

HbH (%)*
(!
4
)

Hb Barts (%)*
(
4
)

Normal

!!/!!

> 95

0

0

Silent carrier

!!/!

98100

02

0
(02% at birth)

! Thalassemia trait

!!/
or
!/!

9095

510

0
(210% at birth)

HbH disease

!/

6095

540

trace
(1040% at birth)

Hydrops fetalis

/

0

1020

> 80%

*Results apply to children and adults, except hydrops fetalis (stillbirth) and where noted above

FIGURE 7. Types of Alpha-Thalassemia.

2. Beta-thalassemias (&-thalassemias)
These thalassemias result from either beta-gene deletions or point mutations. This may
lead to either complete suppression (&) or partial impairment (&
+
) of beta-chain
synthesis. Normal diploid cells contain two beta-globin genes; one located on each
chromosome 11. Three types of &-thalassemia occur based on the degree of anemia.

a. Beta-thalassemia minor occurs in heterozygous patients and most are
asymptomatic. Laboratory findings include:
i. Mild anemia with a Hb of 9.513.5 g/dL
ii. MCV of 6070 fL, and low or normal RDW
iii. On the blood smear there is microcytosis, hypochromia, target cells,
elliptocytes, and basophilic stippling of the RBCs
iv. Slightly increased HbA
2
of 46% (normal < 3.5%). HbF may be normal
or slightly increased.

b. Beta-thalassemia major (Cooley anemia) occurs in homozygous patients.
They are identified early in childhood and are characterized by
hepatosplenomegaly (due to extramedullary hematopoiesis), and bone changes
(due to an expanded marrow cavity secondary to massive erythroid hyperplasia).
The bony deformities produce frontal bossing and maxillary hypertrophy (with a
resultant overbite). This hyperplasia produces a hair on end appearance in a
radiograph of the skull. Cholelithiasis and jaundice may develop due to
intramedullary hemolysis. Laboratory findings include:


21

i. Severe anemia with a Hb of 2.56.0 g/dL
ii. MCV of 5060 fL
iii. On the blood smear there is microcytosis, hypochromia, and marked
anisocytosis and poikilocytosis
iv. Moderately elevated reticulocyte count of 515%
v. Precipitated * chains are present in RBCs following incubation with
supravital stains.

Frequent transfusions are necessary to maintain life, and this may lead to
transfusion hemosiderosis. Patients often die in their teens or early adult life
from cardiac failure secondary to heavy deposits of iron in the myocardium.

c. Beta-thalassemia intermedia is applied to individuals with symptoms of
intermediate severity. These individuals have a Hb of 6.0 to 9.5 g/dL and only
moderate degrees of splenomegaly. Blood smear features are similar to
beta-thalassemia major. These patients usually do not require transfusion, and
therefore do not develop the problems of hemosiderosis.

Phenotype

*Genotype

HbA(%)

HbA
2
(%)

HbF(%)

Normal

&/ &

> 95

14

< 2

& thalassemia
minor

&/ &

93

46

16%

& thalassemia
intermedia

&/ &
,
+
/ &
+

535

210

28

13

2080

> 85

& thalassemia
major

&/ &

0

16

> 94

*Other genotypes may produce these disorders.

FIGURE 8. Types of Beta-Thalassemia.


22

D. Sideroblastic Anemias
In this diverse group of anemias there is defective heme synthesis in erythrocytes producing
accumulation of iron in mitochondria. Multiple metabolic defects have been reported. The
most frequent has been the finding of diminished activity of the first and rate-limiting
enzyme in heme synthesis, mitochondrial delta-aminolevulinic acid synthetase. The
sideroblastic anemias include the following disorders:

1. Hereditary sideroblastic anemia This is a rare disorder that is transmitted on the
X chromosome and occurs in males.
2. Acquired sideroblastic anemias
a. Primary or idiopathic sideroblastic anemia This is part of the myelodysplastic
syndrome, and has a predilection for leukemic transformation.

b. Secondary sideroblastic anemias These usually result from exposure to drugs
or toxins, e.g., alcohol, antituberculous drugs (isoniazid, cycloserine,
pyrazinamide), chloramphenicol, and lead toxicity.

In the bone marrow of sideroblastic anemia patients, an iron stain will reveal nucleated
erythrocytes containing several large cytoplasmic aggregates of iron located around the
periphery of the nucleus known as ring sideroblasts. The peripheral red cell morphology may
be dimorphic, consisting of macrocytic cells and microcytic hypochromic cells, or simply
microcytic hypochromic. Bone marrow iron stores also are increased.

Iron Deficiency
Anemia

Anemia of
Chronic Diseases

Thalassemia
Syndromes

Sideroblastic
Anemia

MCV

low

low-nl

very low

low-nl-high

RDW

high

nl

nl

high

RBC count

low

low

high

low

BM iron

absent

nl-high

nl-high

high*

Serum iron

low

low

nl-high

high

TIBC

high

low-nl

low-nl

low-nl

% saturation

low

low

nl-high

high

Serum ferritin

low

nl-high

nl-high

high

FEP

high

high

nl

nl

HbA
2

nl

nl

nl-high**

nl
*Ring sideroblasts present
**Increased HbA
2
with beta-thalassemia minor
nl = normal

FIGURE 9. Comparison of Microcytic Anemias.


23

II. MACROCYTIC ANEMIAS (MCV > 100 fl)
A. Macrocytosis is found in 15 to 20% of hospitalized patients and 3+4% of adult hematologic
profiles. A significant proportion of patients (30+50%) may not have associated anemia.
Clinical history, physical examination and hematologic and special laboratory studies are
required to reach a correct diagnosis. The most common causes of macrocytic anemia are in
the non-megaloblastic category (see chart on page 6). If these etiologies are ruled out, then
vitamin B12 and folic acid related causes must be investigated.

B. Ninety-five percent of cases of megaloblastic anemia are caused by vitamin B12 and folic
acid deficiencies. Vitamin B12, also known as cyanocobalamin (Cbl), is synthesized by
certain microorganisms that reside in some animals (e.g., herbivores), or acquired by eating
animal products (e.g., meat, fish, eggs, and milk). Folic acid is present in vegetables and
meat products. The human body has a reserve of about 3+6 months of folic acid and
3+5 years of vitamin B12. Abnormalities at the level of the gastrointestinal tract are almost
always the underlying pathogenic mechanisms responsible for vitamin B12 and folic acid
deficiency. Malnutrition is the most common cause of folic acid deficiency. Malabsorption
is the most common mechanism responsible for vitamin B12 deficiency, of which pernicious
anemia (PA) is the most common cause. As many as 7% of the elderly population can be
expected to have a vitamin B12 deficiency. PA usually presents around the age of 60,
commonly affecting persons of Scandinavian origin. A more extensive list is given below.

Pathophysiologic Approach to Etiology of Megaloblastic Anemia
Decrease Intake
Folic Acid
Alcoholism, poor nutrition, old age
Hemodialysis, hyperalimentation
Goats milk anemia, premature infants
Vitamin B12
Vegetarianism

Impaired Absorption
Folic Acid
Nontropical sprue
Tropical sprue
Small intestinal diseases
Drugs including phenytoin, alcohol, barbiturates, and isoniazid

Vitamin B12
Pernicious anemia
Gastrectomy
Zollinger-Ellison syndrome
Ileal resection or Crohns disease
Fish tapeworm
Blind loop syndrome
Pancreatic insufficiency

Increased Requirements
Folic Acid
Pregnancy
Hemolytic anemia
Exfoliative dermatitis
Drugs including methotrexate, trimethoprim, and triamterene


24

C. Importance of Vitamin B12 and Folic Acid in Intermediary Metabolism
Vitamin B12 is an essential cofactor in the methylation of homocysteine to methionine. Folic
acid is a required cofactor in a number of reactions, all involving transfer of 1-carbon
fragments. Both vitamin B12 and folic acid are required for synthesis of thymidylate, and
therefore of DNA.

The morphologic findings characteristic of megaloblastic anemia are the result of defective
DNA synthesis. When normal dividing bone marrow cells reproduce, they rapidly double
their DNA, divide, and then return to a resting state. In contrast, few megaloblastic cells are
in a resting state. Most of the bone marrow cells in megaloblastic anemia are attempting to
complete the doubling of their DNA and are frequently arrested in the S (synthesis) phase.

This explains why the amount of DNA observed per megaloblastic cell and the size of the
nucleus are greater than those in a normal cell, in spite of defective DNA synthesis.
RNA synthesis is relatively normal in megaloblastic cells, resulting in abundant mature
cytoplasm. The nuclear cytoplasmic asynchrony resulting from the disparity in maturation of
DNA and RNA is apparent from the morphologic evaluation of the bone marrow cells,
i.e., immature chromatin and mature cytoplasm.

D. Absorption of Vitamin B12 and Folic Acid
Following ingestion, peptic digestion at low pH is a prerequisite for release of vitamin B12
from food. This is of clinical significance in the 70- to 80-year-old population among whom
achlorhydria is frequently present (in 25 to 50 percent) leading to inadequate release of
protein-bound vitamin B12. Following this, two binding proteins are of importance:

1. Intrinsic factor (IF) is a glycoprotein secreted by the gastric parietal cells. IF is
essential for the absorption of vitamin B12.
2. R proteins (so-called because they migrate more rapidly than does IF on
electrophoresis) are present in gastric juice and saliva, and have a much higher affinity
than IF for vitamin B12 at both acidic and neutral pH (50-fold higher at pH2 and 3-fold
higher at pH8).

Once in the duodenum, pancreatic proteases are important in releasing vitamin B12 from
R proteins. The released vitamin B12 is then bound to IF. The IF-Vitamin B12 complex
then binds to IF receptors in the ileum. Most of the Vitamin B12 (greater than 90%) is
present in the portal blood within 3 to 5 hours after it is transferred to the transcobalamin II
(TCII) transport protein. (See FIGURE 10)

The absorption of folic acid is much simpler than for vitamin B12. Folates in food are
polyglutamates that must be broken down to monoglutamates before absorption. Most
dietary folates are bioavailable; however, those in cabbage, lettuce, and oranges are less
efficiently absorbed. No cofactor is needed for absorption of folate, which occurs
preferentially in the upper small intestine (duodenum and jejunum).

E. Clinical Manifestations
The block to normal DNA synthesis by vitamin B12 and folic acid deficiency most affects
tissues that make new cells rapidly, i.e., the bone marrow and the mucosal lining of the
gastrointestinal (GI) tract. In the GI tract, this leads to atrophic glossitis and atrophic
gastritis. By a different mechanism, vitamin B12 deficiency impairs the formation of myelin
which leads to subacute combined degeneration of the nervous system. Neurologic
abnormalities do not occur with folic acid deficiency.

25

FIGURE 10. From A. C. Antony, Megaloblastic Anemia, in Hematology, ed. Hoffman
et al., Churchill Livingstone, Inc., 1991, p. 394.

F. Laboratory Findings
1. CBC and reticulocyte test results
a. Moderate to severe anemia
b. If the MCV is greater than 115 fL, megaloblastic anemia should be suspected. It is
important to note that a normal MCV does not exclude a diagnosis of
megaloblastic anemia. Megaloblastic anemia, combined with iron deficiency
anemia, anemia of chronic disease, or thalassemia may have an MCV in the
normal range.
c. RDW is greater than 15%
d. Corrected reticulocyte count is low
2. Peripheral blood findings include
a. RBCs macro-ovalocytes, dacryocytes (teardrop cells) and schistocytes
(fragmented cells), and anisocytosis (correlates with increased RDW).
Macrocytosis may precede the development of anemia by months to years.
b. Neutropenia, hypersegmented neutrophils. Hypersegmented neutrophils may
precede the appearance of macrocytosis and anemia; however,
hypersegmentation is neither invariably present nor specific for megaloblastic
anemia. It may be seen with renal disease, chronic myeloproliferative
syndromes, sepsis, and iron deficiency.
c. Thrombocytopenia

26

3. Serum levels of vitamin B12 and serum and RBC levels of folic acid should be
interpreted with caution. The lower limit of normal is not well defined.

Plasma unconjugated bilirubin may be mildly increased secondary to hemolysis.
Serum LDH is elevated and may be pronounced due to hemolysis. Many other serum
tests are useful in confirming the diagnosis. (See FIGURES 11 and 12.)

An increased urine methylmalonic acid level is the gold standard for vitamin B12
deficiency.
4. Bone marrow examination is only necessary if other tests are not diagnostic for
megaloblastic anemia.

a. The bone marrow is strikingly hypercellular with a megaloblastic erythroid
hyperplasia.
b. Giant bands and metamyelocytes.

G. Treatment
Following replacement of the deficient vitamin B12 and/or folic acid, the bone marrow
begins to convert from megaloblastic to normoblastic erythropoiesis within eight to twelve
hours, and completely transformed in two to four days. A marked reticulocytosis is seen in
the peripheral blood. Serum LDH is normal within two weeks.

Operating Test Characteristics Used in Diagnosis of Megaloblastic Anemia

Diagnostic Test

Sensitivity
(%)

Specificity
(%)

Disease

B12 level:
(< 300 pg/ml)
(< 200 pg/ml)

99
9095

7080 (?)
> 95 (?)

B12 deficiency
B12 deficiency
Folate level

7090 (?)

> 90 (?)

Folate acid deficiency
RBC folate

> 90 (?)

5060

Folate acid deficiency
MCV > 130

510 (?)

100

B12 deficiency/folate acid deficiency
MCV > 105

11

95

MCV > 95

62

82

RDW > 15

54

51

Hypersegmented neutrophils (5 cells
with 5 lobes or 1 cell with 6 lobes)

9195

77


Anti-intrinsic factor antibody

5060

> 99

Pernicious anemia
Antiparietal antibody

90

50

Pernicious anemia
Achlorhydria

100

3050 (?)

Pernicious anemia
Methylmalonic acid (M)
a

96

96

B12 deficiency
Total homocysteine (H)

98

96

B12 deficiency
M + H

77

92

Response to B12 treatment
Megaloblastic marrow

98100

95100

Schilling test (stage I and II)

2585

86

Pernicious anemia

a
Considered a gold standard test.

FIGURE 11. From B. Djulbegovic: Reasoning and Decision Making in Hematology, Churchill
Livingstone, Inc., 1992, p. 28.

27



28

H. Pernicious anemia is the most common cause of vitamin B12 deficiency.
These patients develop severe atrophic gastritis with consequent failure to secrete
intrinsic factor (IF). Many patients develop antibodies against parietal cells and against
intrinsic factor. The diagnosis of pernicious anemia depends on documenting lack of
intrinsic factor. This can be done by assay of gastric juice for the protein, or indirectly by the
Schilling test, or other isotopic tests of vitamin B12 absorption.

The Schilling test provides indirect evidence for the cause of megaloblastic anemia by testing
the ability of a patient to absorb oral vitamin B12 first without, and then with an exogenous
source of intrinsic factor. The Schilling test and interpretation of the results are as follows:

1. Patient given oral radioactive vitamin B12 dose.

2. Patient given large parenteral dose of nonradioactive vitamin B12. This saturates the
plasma vitamin B12 binding proteins and flushes vitamin B12 into the urine.

3. The urine is collected for 24 hours.

4. If the radioactive oral dose is absorbed normally, more than 7% of the dose will be
excreted in a 24-hour urine collection.

5. If absorption is impaired, less than 3% will be excreted in a 24-hour urine collection.

6. When the test is abnormal, the test is repeated, giving oral radioactive vitamin B12 and
intrinsic factor. The addition of intrinsic factor will correct abnormal absorption due to
lack of endogenous intrinsic factor (as in pernicious anemia), but not abnormal
absorption due to intestinal disease. (See FIGURE 13.)

Other causes of malabsorption may be identified with modifications of the Schilling
test.

*VitB12
(Stage I)

*VitB12 plus
IF
(Stage II)

*VitB12 plus
7+10 days
antibiotic
(Stage III)

*VitB12 plus
pancreatic
extract

Normal

NL

Lack of IF (PA)

Low

NL

Bacterial
overgrowth
utilizing VitB12

Low

Low

NL

Pancreatic
insufficiency

Low

Low

Low

NL

NL = normal absorption. Low = abnormal absorption. PA = Perncious anemia.
*VitB12 = radiolabeled vitamin B12.

FIGURE 13. Results of Schilling Tests.


29

III. NORMOCYTIC ANEMIA

A. Anemia Due to Acute Blood Loss
Acute hemorrhagic blood loss is the second most common cause of anemia in
the United States (2.2 to 25% of cases). Sudden blood loss leads to two problems:
shock produced by hypovolemia, and hypoxia due to decreased oxygen transport by
hemoglobin. An otherwise healthy individual can tolerate a 1020% blood volume loss
with minimal difficulties (dizziness when standing suddenly). A 2040% blood loss
leads to shock. A drop in Hct does not occur immediately.

In healthy individuals an erythropoietic response occurs at hemoglobin concentrations of
10 to 12 g/dL. If adequate iron stores are present, the reticulocyte count increases up to three
to four times the nonstimulated level at four to seven days. The reticulocytosis produces a
slight increase in the MCV and polychromasia on the peripheral blood smear. In patients with
inadequate iron stores, microcytic hypochromic cells may be produced.

Diagnostic Test Sensitivity (%) Specificity (%) Disease

History

75100

?

HS, HE

Reticulocyte count
b

6290

99 (if > 10%)

Hemolysis

Coombs test (anti-IgG only)

32

100

AIHA
b

Coombs test (all reagents)

9698

92

AIHA

MCHC

50

95100

HS

Spherocytes

95100

90 (?)

HS

Splenomegaly

80100

?

HS

Hb electrophoresis

95

> 95 (?)

,-thalassemia

Haptoglobin (< 25 mg/dl)

83

96

Hemolysis

LDH (total) (high)

83

61

Hemolysis

LDH (isoenzymes)

58

93

Hemolysis

H + LDH (series testing)

50

100

Hemolysis

H + LDH (parallel testing)

92

89

Hemolysis

Hemosiderin (urine)

100

?

Intravascular
Hemolysis (PNH)

MCV < 80 + RBC count increased

75

97

Thalassemia syndromes

Abbreviations: HS, hereditary spherocytosis; HE, hereditary elliptocytosis; MCHC, mean cell hemoglobin
concentration; AIHA, autoimmune hemolytic anemia; PNH, paroxysmal nocturnal hemoglobinuria;
MCV, mean cell volume; RBC, red blood cell; LDH, lactate dehydrogenase.
a
Red blood cell (RBC) survival study with Cr
51
is considered a gold standard test.
b
For value of approximately 2.5%, predictive value for hemolytic disease is 38% only.

FIGURE 14. Operating Test Characteristics Used in Diagnosis of Hemolytic Anemia
a
.
From B. Djulbegovic: Reasoning and Decision Making in Hematology, Churchill
Livingstone, Inc., 1992., p. 35.


30

Immediate intervention requires plasma expanders and packed red blood cells. One unit of
packed red blood cells will raise the hemoglobin concentration by about 1 g/dl, and the
hematocrit by 3%. Oral iron replacement may be necessary after the initial event.

B. Hemolytic Anemia
1. Classification of hemolytic anemias
Hemolytic anemia includes a diverse group of disorders that can be classified into two
groups:
a. Nonimmunologic (Non-immune) Hemolytic Anemias
Membrane defects (hereditary spherocytosis, hereditary elliptocytosis,
paroxysmal nocturnal hemoglobinuria (PNH))
Red cell enzyme deficiencies (G6PD deficiency, pyruvate kinase deficiency)
Abnormal hemoglobins (hemoglobin S, unstable hemoglobins)
Anemias caused by infectious agents (malaria, bacterial agents, and toxins)
Mechanical damage (prosthetic heart valve, disseminated intravascular
coagulation)
Chemical damage (lead, arsenic, copper, animal venom)
Osmotic damage from intravenous administration of distilled water
Thermal (heat) damage caused by severe burns
b. Immune-Mediated Hemolytic Anemias
Autoimmune hemolytic anemia (associated with other diseases, drugs,
postinfection, paroxysmal cold hemoglobinuria, cold agglutinin disease)
Alloimmune hemolytic anemias (hemolytic disease of newborn,
hemolytic transfusion reaction)

Another useful way of looking at hemolytic anemias is by the site of hemolysis,
i.e., extravascular vs. intravascular. The normal lifespan of red blood cells is 120 days.
After this time the cells are removed by the macrophages of the reticuloendothelial system
(RES). When the lifespan is shortened due to hemolysis and the red blood cells are
removed by the RES, this is referred to as extravascular hemolysis. In some types of acute
or chronic hemolysis, red cell destruction occurs intravascularly, e.g., paroxysmal nocturnal
hemoglobinuria, paroxysmal cold hemoglobinuria, major transfusion reaction, prosthetic
heart valve, falciparum malaria, cold hemagglutinins, and burns.

Many laboratory tests are helpful in separating this large group of anemias
(see FIGURE 14). In all hemolytic anemias, laboratory findings include the following:
reticulocytosis, bone marrow erythroid hyperplasia, decreased hemoglobin/hematocrit,
and increased LDH. In anemias with intravascular hemolysis, patients also have
hemoglobinemia, hemoglobinuria, hemosiderinuria, serum methemalbumin, and
decreased haptoglobin (see FIGURE 15).

All chronic hemolytic anemias may be complicated by events such as aplastic, or
megaloblastic crises. The aplastic crises may be associated with a viral infection. The
megaloblastic crisis is related to folic acid deficiency.


31

FIGURE 15. Comparison of Extravascular and Intravascular Hemolysis.

2. Membrane defects
a. Hereditary spherocytosis has an autosomal dominant transmission or rarely
autosomal recessive, and affects 1 in 5,000 persons in the United States. Most
commonly the spectrin protein within the red blood cell membrane is reduced in
amount. The red cells lose membrane and become spherocytic. These cells have
decreased deformability, so when the cells pass through the spleen, the cells are
damaged and prematurely removed from the circulation. Clinically, hereditary
spherocytosis is most often mild and clinically insignificant. Patients may be
mildly jaundiced, have pigmented gallstones, and a slightly enlarged spleen.
Laboratory findings include spherocytes on the peripheral blood smear, an
increased reticulocyte count, mildly increased indirect serum bilirubin, increased
osmotic fragility of the red blood cells, and an MCHC > 36. The osmotic
fragility test involves incubation of red blood cells in various concentrations of
sodium chloride (Figure 16). In this test spherocytes are more susceptible to
hemolysis than normal red cells, both before and after incubation. Treatment is
splenectomy. The anemia is corrected by splenectomy, but the membrane defect
persists.

32

FIGURE 16. Red Cell Osmotic Fragility Curves of a Normal Patient Control and a Patient
with Heredity Spherocytosis Before and After Incubation. From S. I Rapaport: Introduction
to Hematology, 2nd Ed., J. B. Lippincott Co., 1987, p. 135.

b. Hereditary elliptocytosis is a heterogeneous group of disorders which clinically
ranges from a heterozygous asymptomatic form to a moderately severe form in
homozygotes. Approximately 2 to 5 persons per 10,000 have some form of
hereditary elliptocytosis. The elliptical shape reflects failure of the red blood
cells, formed by shear stress in the microcirculation, to return to a normal
biconcave shape in the larger vessels. Numerous elliptocytes are present on the
peripheral blood smear. The osmotic fragility is generally normal in
asymptomatic patients.
c. Paroxysmal nocturnal hemoglobinuria (PNH) is a rare disorder characterized
by an ACQUIRED intrinsic abnormality of red blood cell membranes that
increases their sensitivity to lysis by complement. Arising in a clone of
hematopoietic stem cells, this defect involves a deficit in the glycophospholipid
anchor for several protein receptors that bind components of compliment,
acetylcholinesterase and other proteins. This hematopoietic stem cell clone then
differentiates for form not only red blood cells, but also granulocytes and
platelets. All three cell lines are abnormal in this disorder. Clinically, PNH
begins insidiously in a previously healthy person, and occasionally in a patient
with idiopathic or drug induced marrow aplasia. Hemolysis is often increased at
night because CO
2
retention during sleep leads to a slight fall in plasma pH that
facilitates activation of complement. Nocturnal hemoglobinuria may result and
causes the patients urine to be very dark. Laboratory findings include anemia
with reticulocytosis and occasional nucleated red blood cells on the blood smear,
moderate leukopenia and a variably decreased platelet count. Plasma and urine
hemoglobin and urine hemosiderin are present when the hemolysis is severe.


33

The Ham test (acid hemolysis test) is typically positive in PNH. This test
measures the susceptibility of red blood cells to hemolysis in the presence of
acidified serum. In acidified serum, complement is activated by the alternate
pathway.
3. Red cell enzyme deficiencies
a. Glucose 6-phosphate dehydrogenase (G6PD) deficiency is the most common
type of red cell enzyme deficiency. The enzyme is expressed as a sex-linked
trait in more than 150 molecular forms. The gene is present on the X
chromosome. This enzyme is part of the hexosemonophosphate (HMP) shunt
and is important in the conversion of NADP to NADPH, generating the
formation of reduced glutathione. Approximately 10% of American black males
have a different isoenzyme which possesses only about 10% of the normal
activity. This decreased activity is sufficient for cellular metabolism under
normal conditions, but exposure to certain infections, toxins, or drugs can
overwhelm the enzyme and produce an acute hemolytic episode of variable
severity. Mediterranean and Canton forms are more severe and have less than
1% of the normal enzyme activity. Many drugs have been implicated in
hemolytic episodes associated with G6PD deficiency: antimalarials,
sulfonamides, chloramphenicol, nalidixic acid, nitrofurazone, aspirin,
acetaminophen, and vitamins K and C. Infections as well as eating fava beans
may be a source of oxidation. Laboratory examination during a hemolytic
episode will reveal reticulocytosis, increased indirect serum bilirubin, and Heinz
bodies. Heinz bodies are clumps of denatured hemoglobin that becomes
attached to the red blood cell membrane. These are not seen with Wright or
Giemsa stains, but may be seen with supravital stains such as methylene blue.
Screening tests and quantitative procedures for measuring G6PD enzyme levels
are available for diagnosis. Family studies are also important.
b. Pyruvate kinase deficiency is the most common enzyme deficiency of the
glycolytic pathway. It is an autosomal recessive disorder. Heterozygotes are
frequently asymptomatic, but homozygotes have a mild to severe anemia.
Splenomegaly is present and pigment gallstones develop. Laboratory studies
reveal mildly increased indirect serum bilirubin level, echinocytes on the
peripheral blood smear, and increased reticulocyte count. A screening test for
pyruvate kinase is available.
4. Abnormal hemoglobins
a. Normal human hemoglobin is composed of a tetramer of globin chains, and
heme molecules. During fetal life, epsilon, zeta, and alpha-globin chains are
present. Later delta, gamma, and beta chains develop, and after the first year of
life only alpha, beta, delta, and gamma chains are produced. In adults
hemoglobin is composed of 97% hemoglobin A (!
2
&
2
), 23% hemoglobin
A
2
(!
2
.
2
), and less than 1% hemoglobin F !
2
*
2
)

More than 400 hemoglobin variants have been characterized. They are inherited
as autosomal dominant disorders and 95% represent single amino acid
substitutions in a globin chain, reflecting a single base change in the
corresponding triplet codon of globin gene DNA. Adverse effects include: 1) an
unstable form of hemoglobin that precipitates during oxidative stress, 2) altered
binding sites for oxygen resulting in an increased affinity and tissue hypoxia, and
3) altered binding sites resulting in decreased oxygen affinity and decreased
transport to tissues. Over half of the alterations do not result in clinically

34

significant disorders. About twice as many detectable variants involve the beta
chain compared to the alpha chain.

b. Sickle cell trait (HbAS) and sickle cell anemia (HbSS)
Sickle cell disease is inherited in an autosomal dominant manner in which a
defect occurs in the beta chain of hemoglobin. A hydrophobic amino acid,
valine, is substituted for a hydrophilic amino acid, glutamic acid, in position 6 in
the &-chain of the globin molecule. Low O
2
tension situations occurring in the
kidney medulla and spleen result in polymerization of hemoglobin S, formation
of intracellular crystals, distortion of the cells, and predisposing to the
destruction of the sickle cells by the macrophages of the reticuloendothelial
system. About 8% of American blacks have sickle cell trait (hemoglobin AS,
i.e., heterozygous), and 0.14% have sickle cell anemia (hemoglobin SS,
i.e., homozygous). Also double heterozygotes with hemoglobin S are not
uncommon, including hemoglobin SC, hemoglobin-S/beta-thalassemia, and
hemoglobin S/hereditary persistence of fetal hemoglobin.

The individual with sickle cell trait (HbAS) has essentially no resultant clinical
disease. Although extensive deoxygenation will cause red blood cells to sickle
in vitro, the degree of deoxygenation resulting from passage of blood through the
microcirculation does not lead to significant sickling in vivo. The one exception
is the renal medulla. Rare individuals with sickle cell trait have developed gross
hematuria due to ischemic ulceration of the renal papillary mucosa. Sickle cells
are not seen on a routine blood smear in these patients. Hemoglobin
electrophoresis reveals about 6070% hemoglobin A and 3040% hemoglobin S.
The increased propensity of hemoglobin A is thought to be reflective of the
greater affinity of alpha chains for normal beta chains than for beta chains with
the valine substitution.

The red blood cells of patients with sickle cell anemia (HbSS) undergo
continuous sickling in vivo producing a severe hemolytic anemia. The red cells
at birth are essentially normal, containing large amounts of hemoglobin F. As
fetal hemoglobin synthesis slows down to negligible levels, normal &-chain
synthesis is attempted but HbSS forms. During the first year of life, when
beta-chain synthesis normally results in production of hemoglobin A, only
hemoglobin S is produced. The natural history of this disease is characterized by
chronic hemolytic anemia, vulnerability to infection, anemic crisis, and
vaso-occlusive episodes (painful crisis). (See FIGURE 17.)

35



36

The chronic hemolytic anemia of sickle cell anemia leads to hemoglobin
concentrations of 69 gm/dl, and punctuated by episodes of aplastic anemia.
Peripheral blood smear reveals sickle cells, target cells, polychromatophilic cells,
and Howell-Jolly bodies (due to splenic dysfunction). Hemoglobin
electrophoresis reveals 7595% hemoglobin S and the remaining 5 to 25% is
largely hemoglobin F. Hemoglobin F is unevenly distributed in the
red blood cells. The cells with the highest hemoglobin F concentration survive
the longest.

Solubility tests for hemoglobin S are used widely to screen for sickle cell trait,
for genetic counseling, and as a means of differentiating it from other
hemoglobins with similar electrophoretic mobility. This test is based on the
relative insolubility of hemoglobin S compared to other hemoglobins. Both
sickle cell trait and other sickle cell disorders have positive solubility tests.

In sickle cell anemia, vaso-occlusive crises lead to progressive organ damage,
beginning with the spleen. This leads to functional asplenia as the child matures
and is recognized in the peripheral blood as an increase in the number of red cells
containing Howell-Jolly bodies (nuclear fragments). The lungs, kidneys, liver,
ocular and cerebral circulation, bones, and joints are especially prone to
circulatory interruption. The hand and foot syndrome occurs in young children
and is characterized by painful swelling of the hands and feet. Acute, episodic,
spreading musculoskeletal pain is the most prominent symptomatic manifestation
of sickle cell anemia and accounts for most hospital admissions. Childrens
attacks are most commonly associated with infection, but in adults most painful
crises are unexplained. Bone infarction may occur, commonly effecting the head
of the femur and humerus. Five to ten percent of children or young adults
experience major cerebral vascular accidents: stroke or hemorrhage resulting
from stenosis or aneurysm formation of the major cerebral arteries. As sickle cell
anemia patients progress through adult life, they may develop heart failure
secondary to pulmonary hypertension, high output state and kidney failure.

Anemic crises may be due to aplasia or sequestration. These are a sudden, but
temporary, cessation of erythropoiesis. With aplastic crisis, there is frequently a
related viral infection.

Immune function is also compromised leading to severe bacterial infections.
Pneumonia and meningitis are common. Sickle cell patients also have frequent
urinary tract infections, osteomyelitis, and skin ulceration. Gall-stones are common,
often necessitating a cholecystectomy.

c. Hemoglobin C, hemoglobin SC, and hemoglobin S/beta-thalassemia disease
Hemoglobin C is produced by the replacement of a glutamic acid on the
beta-chain position 6 by lysine. Heterozygosity for hemoglobin C
(hemoglobin AC) is present in 3% of American blacks and produces no
symptoms. Laboratory studies reveal target cells on the peripheral blood smear,
3040% hemoglobin C on hemoglobin electrophoresis and no increase in
hemoglobin F.

Homozygotes for hemoglobin C (hemoglobin CC) have a mild chronic
hemolytic anemia with arthralgia and splenomegaly. Peripheral blood smears

37

have many target and folded cells, and may contain hemoglobin C crystals when
smears are dried slowly. Hemoglobin electrophoresis reveals 8590%
hemoglobin C and a slight increase in hemoglobin F (up to 8%).

The world distribution of hemoglobin C and hemoglobin S overlap, thus the
double heterozygous hemoglobin SC is not uncommon. These patients are
anemic (hemoglobin 1012 gm/dl) and have a greater amount of hemoglobin S
than patients with sickle cell trait. This leads to a greater propensity to sickling
and episodes of vaso-occlusive crises. Laboratory findings include frequent
target cells, and approximately equal amounts of hemoglobin S and
hemoglobin C (4550%) and 58% hemoglobin F.

Hemoglobin S/beta-thalassemia is the most common cause of sickle cell
syndrome in patients of Mediterranean descent. The clinical severity of this
disease depends on the type of beta-thalassemia present. If impairment, rather
than total suppression of beta-chain production is inherited, the disease
manifestations are milder than sickle cell anemia. If the beta-thalassemia gene is
totally suppressed, then the red blood cells contain no hemoglobin A and the
severity of disease is similar to sickle cell anemia. Splenomegaly is present in
75% of patients. The peripheral blood smear will show a microcytic
hypochromic anemia with tear drop, target, and polychromatophilic cells.
Hemoglobin electrophoresis reveals 6090% hemoglobin S and 1025%
hemoglobin A or hemoglobin F depending on the nature of the thalassemic
defect. Hemoglobin A2 is usually slightly increased as well. (See FIGURE 18.)

The Principal Sickle Cell States

Diagnosis

Genotype

Hemoglobin Pattern

Manifestations

Hb level
(g/dL)

Sickle Cell
Crises

Spleno-
megaly

Sickle cell trait

AA
S

HbA > HbS

> 12

None

No

Sickle cell anemia

A
S
A
S

HbS, no HbA

69

4+

No

Sickle-HbC disease

A
S
A
C

HbS = HbC

1012

2+ to 4+

Yes
Sickle-S-
thalassemia

A
S
A
o

HbS, no HbA

710

4+

Yes

A
S
A
+

HbS > HbA

911

2 to 3+

Yes

FIGURE 18. Comparison of Sickle Cell Disorders.

38

d. Other unstable hemoglobins
Over 60 different structural abnormalities of globin have been described that
enhance the propensity of hemoglobin to denature and to form precipitates in the
red blood cell (Heinz bodies). This decreases the deformability of the cells,
enhances removal from the circulation, and leads to a hemolytic anemia.
Macrophages of the reticuloendothelial system remove the inclusions resulting in
pitting of the red cells, which appear in the peripheral blood smear as bite cells.

5. Autoimmune hemolytic anemia
Autoimmune hemolytic anemias (AIHA) are disorders in which red cell survival is
reduced because of the deposition of antibodies and/or complement on the red cell
membrane. In the laboratory this is recognized by the presence of a positive direct
antiglobulin test (DAT), also known as a direct Coombs test. Autoantibodies may
associate best with RBC antigens at body temperature (warm type) or best with
RBC antigens at 4 C (cold type). These two types produce different clinical
syndromes. (See FIGURE 19).

a. Warm reactive autoantibodies are IgG in about 90% of patients. They may be
idiopathic or secondary. The idiopathic disorder usually occurs in patients over
40 years of age who have persistent hemolysis, and lack evidence of an
underlying disorder. The secondary type may develop along with many diseases
(SLE, lymphomas, CLL, multiple myeloma, a variety of malignant neoplasms,
ulcerative colitis, demyelinating diseases of the central nervous system), or after
use of drugs (alpha methyldopa, penicillin, tetracycline, cephalothin,
acetaminophen, chlorpromazine, phenacetin, isoniazid, quinidine, insulin). The
antibody coated RBCs are removed by the spleen, liver, and bone marrow.
Laboratory findings frequently reveal a severe anemia, polychromatophilic
RBCs, and nucleated RBCs. The patients have markedly elevated reticulocyte
counts. Serum indirect bilirubin is also increased. Treatment in emergent
situations may require glucocorticosteroids. Treating the primary disease may be
effective. Other treatment modalities include immunosuppressive agents and
splenectomy.
b. Cold reactive autoantibodies are of the IgM class (except for paroxysmal cold
globulinuria which is IgG), and do not cause hemolysis at 37 C, but may react at
temperatures reached in the capillaries of the skin and subcutaneous tissue. This
may be seen as an acute hemolytic episode complicating infections (Mycoplasma
infection, infectious mononucleosis, CMV infection), or as a chronic process in
cold agglutinin disease (CAD). Postinfectious cold reacting AIHA has
specificity for the Ii antigen system.

Mycoplasma pneumoniae infection is associated with development of an anti-I
antibody and infectious mononucleosis is associated with anti-i antibody. CAD is
an idiopathic disorder of older patients characterized by chronic hemolysis. The
cold agglutinin is monoclonal in origin and may be associated with lymphoma or
macroglobulinemia of Waldenstrm. Both types of cold reactive AIHA show
RBC agglutination on the peripheral blood smear, and a high titer of cold
agglutinins. Treatment of postinfectious cases infrequently requires transfusion.
Patients with chronic cold agglutinin disease should be protected from
cold exposure.


39

Paroxysmal cold hemoglobinuria (PCH) is a rare disorder which may follow a viral
infection or associated with tertiary or congenital syphilis. The patient may
develop profound intravascular hemolysis after exposure to cold. The patient has a
complement-binding IgG anti-P antibody. The Donath-Landsteiner test is
diagnostic. This test involves cooling the patients serum, normal red cells and
serum to 4 C. This step fixes the first two components of complement. The
specimen is heated to 37 C, which activates the remaining complement factors
leading to hemolysis.

Clinical or Laboratory Finding

Warm Type

Cold Type

Onset

Jaundice

Origin of autoantibody
Idiopathic (Primary)
Drug-induced
Lymphoproliferative disorder
Viral or mycoplasma
Other (Inflammatory, other
malignancies)

Usual Ig type

DAT

Complement fixation

Antibody specificity for a
blood group

Peripheral blood findings

Abrupt

Usually present

5060%
2530%
1015%
0%
510%

IgG

24 +

Little or none

No

Spherocytes, nucleated
red blood cells

Insidious

Often absent

3040%
15%
1520%
2535%
510%

IgM (except PCH)

24 +

Yes for PCH

Sometimes

Red blood cell
agglutination
in vitro

FIGURE 19. Clinical and Laboratory Findings in AIHA. Adapted from
C. Kjeldsberg et al., Practiced Diagnosis of Hematologic Disorders, ASCP Press,
81995, pp. 208+209.


40

6. Alloimmune hemolytic anemia

Alloimmune hemolytic anemias are due to antibodies that will react with red blood
cells from another person, but not with red cells from the individual producing the
antibody.

a. Hemolytic transfusion reactions (HTR) occur when donor RBCs are
incompatible with a recipients blood. ABO incompatibility is the
most dangerous of HTR because the antibodies are already present in high titer
and the red cells contain a large number of antigen sites. Blood group A, group
B, and group O individuals contain naturally-occurring predominantly IgM
antibodies against the B antigen, A antigen, and A and B antigens respectively.
When ABO incompatible blood is transfused, an immediate HTR occurs. The
hemolysis is due to immune complex formation and complement activation.
When this occurs, the transfusion should be stopped immediately.
Manifestations include chills, fever, and lower back pain. Renal failure and
hypotension may occur without immediate intervention. As with all transfusion
reactions, an investigation of the cause always occurs. With immediate HTR, the
patient will have a positive DAT. Also present will be features of intravascular
hemolysis including decreased serum haptoglobin, increased
plasma hemoglobin, hemoglobinuria, and hemosiderinuria.

Many other red blood cell antigens on transfused cells may induce sensitization
when received by antigen-negative patients. The most common antibodies are
produced against antigens of the D (Rh), Kell, Duffy, and Kidd blood group
systems. With the initial sensitization, the immune response is small and
transient, usually IgM and of low titer. With the subsequent transfusion of red
cells containing this same antigen, the immune system responds anamnestically
to this second exposure producing large amounts of IgG, and producing a
delayed HTR. Delayed HTR are usually mild and seldom cause complications.
This is because intravascular hemolysis is uncommon. These patients develop a
positive DAT, and a gradual fall in the hematocrit. This is characteristic of
extravascular hemolysis. There may be problems in finding compatible blood if
multiple alloantibodies are present, or if the alloantibody developed is against an
antigen present in the vast majority of donors.

b. Hemolytic disease of the newborn: The most common and severe form of
hemolytic disease of the newborn (HDN) is due to the D(Rh) antigen. This
occurs when the fetus is D positive, and the mother is D negative and has been
previously sensitized to the D antigen. This sensitization may be from a
fetomaternal bleed in a previous pregnancy or exposure to blood products. The
antibody to D antigen is usually detected at time of prenatal antibody screen.
The IgG antibody against the D antigen (anti-D), crosses the placenta and reacts
with the fetal RBCs with resultant hemolysis. (See Figure 20.) If the fetus is not
able to maintain RBC production comparable to RBC destruction, the fetus may
die of heart failure with massive edema (hydrops fetalis).

The sensitized mother will have the anti-D titer monitored during the pregnancy.
The amniotic fluid bilirubin concentrations will also need to be followed, which
reflects the severity of intrauterine hemolysis. If necessary, transuterine
transfusions may be given. In utero, the fetal bilirubin crosses the placenta and is

41

excreted by the mother. If an infant affected by HDN is delivered prematurely,
and liver enzymes to conjugate bilirubin are not fully functioning, it is imperative
to monitor and treat the newborn to prevent cerebral damage due to rising levels
of bilirubin (kernicterus).

Laboratory findings in HDN include increased reticulocyte count, nucleated red
blood cells in the peripheral blood, increased indirect bilirubin, positive DAT,
and leukocytosis due to a stress-related increase in neutrophils. The amount of
transplacental bleeding can be estimated with a Betke-Kleihauer test, which
looks for fetal hemoglobin containing blood cells in the mothers circulation.

Fortunately HDN is a rare problem nowadays since women are screened early in
pregnancy for Rh status. If there is a possibility of exposure to the D antigen
during the pregnancy or at delivery, these women are given anti-D antibodies
(Rh immunoglobulin, RhoGam) which will bind to the foreign antigens prior to
the formation of an immune response.

FIGURE 20. Events leading to hemolytic disease of the newborn due to maternal
sensitization by the D antigen. From L. W. Powers, Diagnostic Hematology: Clinical
and Technical Principles, C. V. Mosby Co., 1989, p. 284.


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49


50


51


52


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55


56


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58


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60


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73

SICKLE CELL ANEMIA

Naveen Manchanda, M.D.

Objectives:

1. Learn about the inherited nature of sickle cell disease and its pathophysiology.
2. Know the clinical manifestations of this illness.
3. Appreciate current improvements in management.

Introduction:

Sickle cell disease is an autosomally inherited multisystem disorder caused by a point mutation in the
-chain of hemoglobin. A nucleotide substitution in the sixth codon of the -globin gene leads to a
Valine at position 6 of the molecule instead of glutamic acid. This leads to hydrophobic interactions
between the exposed valine on one strand with other residues on adjacent strands (Fig. 1). These
interactions result in abnormal solubility of the HbS, especially in presence of low oxygen tension. This
leads to precipitation and polymerization of the hemoglobin tetramers, impaired deformability of the
sickled erythrocytes, and results in microvascular occlusion.
1

FIGURE 1. Part of a polymerized sickle hemoglobin strand. Because of its exposed location, the -6-
valine of sickle hemoglobin is able to interact strongly with the oil-like 85-phenylalanine and 88-
leucine residues on the surface of the adjacent hemoglobin tetramer.
2


74

Epidemiology:

The prevalence of sickle cell trait (HbAS) is 810% in the U.S. African American population and can be
as frequent as 30% in western Africa. The sickle cell gene distribution closely mirrors the worldwide
malaria distribution, this fact has long been recognized as being indicative of a protective effect of the
sickle cell trait in parts of the world where falciparum malaria is endemic. The frequency of homozygotes
(HbSS) in the U.S. African American population is 1 in 1875, considerably less than predicted, and
probably due to the high mortality of this disease. Age expectancy of females and males afflicted by SS
anemia is 48 and 42 years respectively.
2

Pathophysiology:

While oxygenated HbS and HbA are equally soluble, deoxygenated HbS suffers a marked decrease in
solubility. In the deoxygenated state, surface interactions between Valine and neighboring residues
induces polymers of Hb to form, which can precipitate and form fibers called tactoids. These insoluble
fibers lead to a marked change in cellular deformability with resultant sickle forms. These changes tend
to occur in areas of low flow and reduced oxygen tension. These occlusive phenomena are the basis for
several of the patho-physiological aspects of this disease.

People with the sickle cell trait do not suffer from the severe manifestations that the homozygotes suffer
from. However, in areas of great osmotic stress, these cells too can sickle, e.g., in the hypertonic
interstitium of the renal medulla.

Vaso-occlusive phenomena are initiated by the sickle cells adhering to the vascular endothelium.
Mediated by several receptors and ligands, this adherence leads to a cascade of events leading to
endothelial activation and accumulation of sickle forms at a particular site, predisposing to vascular
occlusion (Fig. 2). Neutrophils are also activated and they contribute to the considerable morbidity of this
disease.
FIGURE 2. How sickle cells block the microcirculation.
2


75

Figure 2 b, c, d

FIGURE 2b, c, d. How sickle cells block the microcirculation.
2


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As a result of the poorly deformable erythrocytes, a hemolytic anemia results with predominant
extravascular hemolysis, as the sickle forms cannot traverse the splenic vascular beds in the low oxygen
tension present there (Fig 2 a-c). A number of cell surface molecules are expressed on the deformed red
cells and on the endothelium making the endovascular environment sticky, this process is thought to be
contributory to the bony infarctions and ischemic sequelae in various tissues. Repeated splenic infarctions
occur and the spleen atrophies at a young age, making patients prone to infections with encapsulated and
other organisms.

Clinical Manifestations:

The current mean survival for patients with HbSS is 42 years for men and 48 years for women These are
markedly improved numbers, mostly secondary to better supportive care. Carriers for the trait are, for the
most part, asymptomatic.

Chronic Anemia: As opposed to a normal life span of 120 days, sickle cells have a mean life span of
17 days. A moderate to severe hemolytic anemia is characteristic. Three types of acute exacerbations of
anemia occur; aplastic crises, hemolytic crises and acute splenic sequestration.

1. Aplastic Crises: Chronic hemolytic state puts a great strain on the marrow reserve. Aplastic crises can
be precipitated by folate deficiency as well as by Parvo virus infections. Thus, patients should be given
prophylactic folate (1 mg/day). A Parvo virus infection can be treated with intra-venous immune globulin.

2. Hemolytic Crises can occur spontaneously or can be associated with systemic illness. Acute splenic
sequestration is a more serious disorder occurring more commonly in infants and young children where
there is sudden pooling of blood in the engorged spleen with a rapid fall in hemoglobin. These crises can
be fatal.

3. Sickle Cell Crises: Most characteristic of this disease and most disabling, these consist of episodes of
severe pain for one to two weeks accompanied by low grade fever and leukocytosis. Precipitating factors
include infections, dehydration, and acidosis. Severe pain occurs in any part of the body, including the
chest, extremities and abdomen; sometimes mimicking a surgical emergency.
FIGURE 3. Clinical manifestations of sickle cell anemia.
2


77

Other Organ Systems: Many other organ systems are involved in both an acute and chronic fashion
(Fig. 3). The cardiopulmonary reserve is chronically tested. A prolonged high output state can lead to
cardiac hypertrophy and ultimately failure. Pulmonary infarcts from microvascular sludging as well as
venous thromboembolism are not uncommon. Gallstones form secondary to a chronic hemolytic state.
The spleen tends to atrophy, probably secondary to chronic microvascular occlusion. Splenic
sequestration occurs in children and constitutes an emergency. Splenic dysfunction leads to
predisposition to infection by encapsulated organisms. Kidneys lose their ability to concentrate urine
(hyposthenuria) while there is a higher incidence of pyelonephritis and hematuria. Aseptic necrosis of the
hip and ankle ulcers can occur; occasionally in the very young, a hand-foot syndrome results with
swelling of the fingers and toes (dactylitis). Osteomyelitis with Salmonella and Staphylococcus
organisms can occur. In young children, strokes can lead to profound and disabling sequelae. Priapism is
a particularly serious affliction of young males that can render them sterile.

Thus, sickle cell disease is a multi-system illness on account of the pathophysiology of this uniquely
abnormal hemoglobin and often leads to a lifetime of suffering and increased mortality.

Modifiers of the Disease Process:

The clinical syndrome in patients with sickle cell disease is very variable. All the factors accounting for
this variability are not known. Some of the factors include the haplotype of the affected individual and
high HbF levels which appears to be protective. The latter is most commonly found in the Arab
population. Hemoglobin C is a common trait found in 3% of African Americans. Hemoglobin SC
disease is usually less severe as is HbS/-Thallasemia.

Diagnosis:

The peripheral smear of patients with sickle-cell anemia shows many irreversibly sickled, target, and
nucleated red cells. Howell-Jolly bodies and red cell fragments are also present, especially after
functional asplenia. The diagnosis is suggested by the sickle cell solubility test, where, in presence of a
reducing agent like sodium metabisulfite, cells with the characteristic Hb tend to form crescent shaped
forms the traditional sickle cells. This test is by no means sensitive and Hemoglobin electrophoresis
should always be used (Fig. 4) if the disease is suspected. This will confirm the diagnosis of SS versus AS
(disease versus trait). Prenatal screening is possible with screening for the mutant DNA.

FIGURE 4. Hemoglobin electrophoresis in the sickle cell
diseases.
2


78

Treatment: Several aspects of the disease need attention and the process is begun in infancy and carried
through adulthood. Several specialized sickle cell anemia centers have now been developed, these
institutions have devised protocols to ensure an orderly and caring approach to treatment.
3,4

1. Supportive: A team approach is often utilized to fulfill the needs of this community of patients.
Physicians, nurses, social workers as well as community organizers often form the core of such a
team. Supportive measures include prophylactic as well as avoidance of known precipitating factors.
Folic acid (1 mg/d) should be given lifelong. Children benefit from prophylactic Penicillin VK
250 mg. bid. Vaccinations to prevent pneumococcal infections are prudent, other vaccines against
encapsulated bacteria can also be employed. Patients should avoid low oxygen environments such as
high altitudes and deep sea diving. Trans-cranial Doppler Ultrasound is performed in all homozygotes
and early decreases in blood flow with the resultant increase in risk for strokes can be detected and
the sequelae of strokes prevented.

2. Specific measures:

Hydroxyurea: An antimetabolite and an anti-cancer drug, hydroxyurea has been shown to be beneficial
in sickle cell disease.
5
It appears to work by increasing the quantity of intra-cellular HbF, thus decreasing
the relative concentration of sickle cell hemoglobin. This has been clinically proven to decrease painful
crises and hospital admissions, and improve quality of life. Its effects are titrated to produce a modest
neutropenia, thus also underscoring the importance of neutrophils in the pathophysiology of this illness.

Acute Painful Crisis: The treatment of an acute painful crisis includes hydration, aggressive treatment of
pain, and antibiotics to treat any apparent infection. Priapism is treated by giving fluids and Nifedipine,
but may require surgery. A high index of suspicion should be maintained for diagnosing and treating
infections. A respiratory spirometer is very helpful as it helps prevent atelectasis. These crises form the
basis for numerous admissions for pain control. They appear to affect certain members of the SS anemia
community more than others. Outpatient approaches to prompt and early treatment of these crises has lead
to impressive decreases in hospitalization rates and prevention of complications.

Acute Chest Syndrome: This is a sickle cell crisis with specific manifestations in the lung. Often
precipitated by pulmonary infections, it is associated with a high white count, severe sickling and a high
mortality.

Exchange Transfusions: Occasionally, the acute syndromes are so severe that exchange transfusions
may be necessary to temporarily remove the sickle cells from the circulation.

Hypertransfusion Therapy: Cerebro-vascular complications in children carry an immense burden with
them. Transfusion therapy with removal of iron has been proven to help children with sickle cell disease
avoid these complications. To be successful, this therapy requires patient compliance and strict adherence
to protocols.

Bone Marrow Transplant: Bone marrow transplants have been done for this condition as they offer the
chance of a cure. Patient and donor selection is of paramount importance as prior organ damage predicts
a poor prognosis.


79

References:

1. Stuart MJ, Nagel RL. Sickle-cell disease. Lancet 2004;364(9442):1343-60.
2. Quinn CT, Lee NJ, Shull EP, Ahmad N, Rogers ZR, Buchanan GR. Prediction of adverse
outcomes in children with sickle cell anemia: a study of the Dallas Newborn Cohort. Blood
2008;111(2):544-8.
3. Redding-Lallinger R, Knoll C. Sickle cell disease--pathophysiology and treatment. Curr Probl
Pediatr Adolesc Health Care 2006;36(10):346-76.
4. Steinberg MH, Brugnara C. Pathophysiological-based approaches to treatment of sickle cell
disease. Annu Rev Med 2003;54:89-112.
5. Platt OS. Hydroxyurea for the treatment of sickle cell anemia. N Engl J Med 2008;358(13):
1362-9.


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THALASSEMIAS


Thalassemias comprise quantitative disorders in hemoglobin production whereby there is inadequate
production of globin leading to less that normal amount of hemoglobin. The maturing red blood cell is
left with less than adequate hemoglobin, often giving rise to life-long symptoms of anemia.
1

Remembering that the adult hemoglobin tetramer is made up of two ! and two " chains, a large number
of possibilities exist for disabling this configuration.

!-thalassemias refer to lack of !-hemoglobin and "-thalassemias refer to lack of beta hemoglobin.

Pathophysiology:

Four ! and two " genes code for !2"2 (Adult hemoglobin). Thus, !-thalassemias are less common than
"-thalassemias as lack of one or more alpha chains can be made up by the other gene products. A large
number of mutations underlie thalassemias, at least 180 of these have been identified encoding for many
different ways of failing to make an adequate gene product in "-thalassemias alone.


99

With increasing imbalance between the chains, free ! or " chains are unstable and can be particularly
disabling as they tend to precipitate and denature in the developing red cell while in the bone marrow.
Most thalassemias result in smaller red blood cells (microcytosis) representing less than fully
hemoglobinized (hypochromic) RBCs. These hypochromic, microcytic red cells are recognized as
abnormal, leading to an element of hemolysis in the bone-marrow as well as in the splenic tissue (extra-
vascular hemolysis). Severe forms of thallasemia lead to disabling life-long anemia with many life-
threatening manifestations.

Prevalence of this genotype also mirrors the zones of endemicity for falciparum malaria. The thalassemic
red cell, due to its shortened life span, is a less than hospitable carrier of the malarial parasite.

Clinical features:

Clinical features depend on the severity of the disease. "-thalassemia is more common in the
Mediterranian population while !-thalassemia is more common in south-east Asia and among the
African-American population.

"-thalassemia minor
0
Patients with this genotype have one gene encoding for "-hemoglobin. These
patients have life-long mild anemia with microcytosis and often a mild splenomegaly. They tend to have
mild hemolysis with elevated serum LDH and bilirubin, as well as marked marrow hypercellularity. One
of the main clinical problems associated with this disease is the differentiation from iron-deficiency.
Thalassemics have elevated hemoglobin A2 (!2-2) while patients with iron deficiency do not. This
differentiation is more than academic since patients with thalassemia have a tendency to absorb more iron
and iron supplementation with a mistaken diagnosis of iron deficiency may lead to iron overload.

100

"-thalassemia major "
0
"
0
- When both "-gene products are not expressed, a severe anemia occurs. It
appears gradually during infancy (as the fetal hemoglobin is replaced by adult hemoglobin) and afflicts
the child with a severe anemia with features of extra-vascular hemolysis as well as extra-medullary
hematopoeisis. The affected child can have frontal bossing, malar prominence, hepato-splenomegaly,
jaundice, gallstones, growth retardation and other sequelae of severe anemia with hemolysis. An element
of iron overload confounds the situation as there is increased iron absorption from the gut as well as
retention of the iron released from the hemolysed RBCs. Combination of these features with an abnormal
hemoglobin electrophoresis is usually diagnostic.

"-Thalassemia Intermedia "
0
"
+
: This form is intermediate in severity and has variable amount of
Hemoglobin.

Treatment with blood transfusions ameliorates the anemia but complicates iron overload. Over the last
two decades, regular transfusions along with iron-chelation therapy have revolutionized treatment of
thalassemia. Splenectomy is reserved for patients with enlarged spleens that can aggravate hemolysis and
increase transfusion requirements. Cures have been attempted with bone-marrow transplants, however, of
late, oral iron chelators have made transfusions an acceptable and less risky alternative.
2,3

The !-thalassemias:

These disorders of hemoglobin production tend to affect African and Asian populations and give rise to a
varying clinical phenotype depending on the severity of the disorder (with varying lack of ! chain
production).

Mild !-thalassemia:
Malfunction of one or two genes gives rise to this problem. These individuals have mostly silent
disease/carrier state and the major clue is the presence of a more seriously affected family member.
!!/!!
0
- !
0
-Thalassemia trait, !
0
!
0/
!! or !
0
!/!
0
! - !+ Thalassemia trait

101

Severe !-thalassemia: These comprise Hemoglobin H disease and Hemoglobin Barts.

Hemoglobin H disease: !
0
!
0
/!
0
! Dysfunction of three !-globin chains leads to hemoglobin-H
disease. Very little !-globin is made and the resultant majority of hemoglobin is "-4, tetramers of which
are unstable. The disease manifests itself in early infancy with severe anemia and hemolysis. There are
features of anemia as in "-thalassemia major with demonstration of Hemoglobin H in the hemoglobin
electrophoresis.

Hemoglobin Barts: The fetus is grossly enlarged and there is fulminant intra-uterine congestive failure.
There are tetramers of fetal hemoglobin (Hemoglobin Barts -.4) which are very oxygen avid. Hence there
is severe hypoxic injury to the fetus. Prenatal diagnosis and exchange transfusions are indicated and are
the only hope for survival.

References:

1. Birgens H, Ljung R. The thalassaemia syndromes. Scand J Clin Lab Invest 2007;67(1):11-25.
2. Panigrahi I, Agarwal S. Thromboembolic complications in beta-thalassemia: Beyond the horizon.
Thromb Res 2007;120(6):783-9.
3. Quek L, Thein SL. Molecular therapies in beta-thalassaemia. Br J Haematol 2007;136(3):353-65.

Texts:

3. Hematology: A pathophysiological approach. B Babior and T. Stossel. 1995
4. Hematology in Clinical Practice. R. Hillman and K. Ault. 1998


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114

HEMOLYTIC ANEMIAS


Hemolysis or a premature breakdown of blood cells can occur via several processes. Physiological
hemolysis occurs to ensure an orderly breakdown of aging red cells. Hemolytic anemias are a large
category of anemias where the primary pathophysiological process is an uncompensated hemolysis
leading to symptoms of anemia. Given the right mixture of nutrients, the human bone-marrow can
compensate five-fold for an anemia i.e. can increase its synthesis of RBCs five fold from its base-line.

The average life-span of an RBC is 120 days, in several hemolytic anemias, it is halved or is as few as ten
days. Thus, symptoms of anemia develop rapidly in instances of a severe hemolytic episode e.g. in G-
6PD deficiency upon intake of a hemolytic agent.

Categories of Hemolytic Anemias

A simple classification divides them into disorders that can be extrinsic or intrinsic in relation to the red
blood cell.

Extrinsic Hemolytic Anemias:

1. TTP/HUS Thrombotic thrombocytopenic purpura and Hemolytic uremic syndrome.
2. Traumatic hemolysis e.g. from mechanical heart valve, march hemoglobinuria, burns
3. Severe vasculitis e.g. Scleroderma

Membrane Disorders:

1. Hereditary spherocytosis
2. PNH Paroxysmal
3. Auto-immune hemolytic anemia
4. Clostridial sepsis with bacterially secreted phospholipase-C
5. Spur cell anemia (Liver disease) and abetalipoproteinemia
6. Copper (Wilsons disease)

Intrinsic Disorders:

1. Unstable hemoglobins e.g. hemoglobin C
2. Sickle cell anemia and thalassemia
3. Parasitic infestation e.g. malaria, babesiosis, ehrlichiosis, bartonellosis
4. G6-PD deficiency

Mechanisms of Hemolysis

The pathophysiologic basis of hemolysis may involve the splenic/lymphatic tissue (extra-vascular
hemolysis) or could be independent of it (intravascular hemolysis).

Auto-immune hemolytic anemia occurs due to destruction of immunoglobulin coated red-cells in the
splenic tissue and is an example of extra-vascular hemolysis whereas hemolysis due to mechanical trauma

115

from thrombotic tissue on a mechanical heart valve is an example of intra-vascular hemolysis. Following
hemolysis, the tissue macrophage picks up the released hemoglobin from which the heme is metabolized.

Principal Manifestations of Extra-Vascular Hemolysis:

Mechanism Clinical Manifestation Laboratory Finding
Splenic hypertrophy Splenomegaly, abdominal pain Increased Bilirubin, LDH
Increased Red cell breakdown Icterus, tiredness, fatigue,
aggravation of underlying
cardiac, vascular, lung diseases
Anemia
Increased Hemoglobin
breakdown
Jaundice, gallstones Increased indirect bilirubin,
LDH, decreased or normal
Haptoglobin
Increased Red cell production Bone pain, frontal bossing
(chronic cases e.g.
Thalassemia)
Reticulocytosis

Principal Manifestations of Intra-Vascular Hemolysis:

Mechanism Clinical finding Laboratory finding
1. Red cell destruction Tiredness, fatigue, worsening
of symptoms of other diseases
Anemia, Coombs positive,
Reticulocytosis, Increased
bilirubin, LDH
2. Destruction of Hemoglobin Dark Urine, jaundice,
gallstones
Elevated bilirubin, plasma free
hemoglobin, reduced
Haptoglobin, Urine
Hemosiderin, Hemoglobinuria
3. Increased red cell
production
Bone pain, frontal bossing,
extra-medullary hematopoeisis
(chronic cases)
Reticulocytosis, increased
shift cells


116

Degradation of Heme: The tetrapyrrole ring of Hemoglobin is released after globin is broken up into
amino-acids and recycled. Heme is attached to Hemopexin in plasma and transported to the liver where it
is taken up and further metabolized. The first product of Heme metabolism by Heme oxygenase is
Biliverdin, this is converted to Bilirubin by Biliverdin reductase. Bilirubin is insoluble and is conjugated
in the liver to glucoronide to form a soluble Bilirubin diglucoronide (direct reacting bilirubin). This form
of Bilirubin is transported in the bile and is excreted in the stool. There is converted to Stercobilinogen
which is reabsorbed back into the plasma and is excreted in the urine as Urobilonogen. In severe intra-
vascular hemolysis, Hemoglobin when released directly into the blood stream binds to Haptoglobin and
transported to the liver. Haptoglobin levels can be depleted rapidly and the free Hemoglobin seen in
plasma in brisk hemolysis is broken up into its individual strands and released in the urine to give rise to
Hemoglobinuria. This can be a source of iron loss and deficiency.

Clinical Presentations of Hemolytic anemias:

Hereditary Spherocytosis:

These are a spectrum of inherited disorders where there is a deficiency in the RBC membrane.
1
Usually
occurring due to relative lack of membrane proteins such as spectrin and ankyrin, these disorders are
typically inherited in an autosomal dominant fashion. Lack of membrane protein leads to a deficiency in

117

the membrane structure and loss of membrane relative to a normal RBC. The spherocyte thus has a round
shape on account of inadequate membrane, and is also less deformable leading to it being trapped in the
splenic sinusoids where extra-vascular hemolysis occurs. Symptoms are often minimal or atypical, e.g.
mild anemia along with elevated LDH and bilirubin. Occasionally, gall -stones can form. Diagnosis can
be made by an Osmotic Fragility test where the HS spherocyte hemolyses faster in hypotonic saline as
compared to a normal erythrocyte with adequate membrane. Splenomegaly can be present and if the
anemia is severe, splenectomy can be helpful in controlling the disorder.

Immune Hemolytic Anemias:

The red cell membrane is decorated with a large component of proteins, many of which are involved in
transfusion reactions. They may also be involved in auto-immune reactions as well as associated with
drugs, infections, and malignancies especially lymphomas and CLL. These hemolytic anemias usually
involve IgG antibodies and give rise to the positive Coombs test. Hemolysis in these cases is usually
mediated by the spleen and is extra-vascular.
Rarely, IgM may be involved and in these cases complement can be fixed leading to intra-vascular
hemolysis. Treatment includes removal of offending agent, immunosuppression with prednisone, and
occasionally, splenectomy.

Common drug associated immune-hemolytic anemias include those in association with high-dose
penicillin therapy and with Quinidine therapy. Infection associated hemolytic anemias include those
associated with infectious mononucleosis or EBV; these are usually cold-reactive IgM antibodies.

Mechanism of drug mediated immune hemolytic anemia:

Drug Specific antibodies Penicillins, Cephalosporins
Antigen (drug Hapten) Antibody combination Quinidine
Autoantibody to Rh antigens Alpha Methyl Dopa
Complement fixing antibody - Streptomycin

Treatment consists of removing offending agents (drugs), immunosuppression for auto-immune
phenomena (Prednisone) and may also involve splenectomy to remove the site of red-cell destruction.

Paroxysmal Nocturnal Hemoglobinuria:

PNH is a rare stem cell disorder where there is a clonal expansion of stem cells that have a mutation for
the gene encoding for the glyco-phosphoinositide (GPI) membrane anchor protein. This protein provides
a membrane attachment factor for several proteins involved in membrane homeostasis. These include
receptors for complement proteins that help in turnover of these proteins. When this GPI anchor is absent,
there is deficient turnover of certain complement proteins. During night-time hours, when serum pH
drops, these patients have complement mediated lysis mediated by these complement components which
have not been degraded. Testing involves the sucrose hemolysis test as well as more modern testing
including flow-cytometry. The former is seldom used nowadays.
PNH is a classical intra-vascular hemolytic disorder where there is iron loss in the urine; hence the
nosology indicating brown urine on awakening. Treatment often involves chronic transfusions and
Prednisone. Recently, a monoclonal antibody to terminal complement components (Ecluzimab) has been
shown to ameliorate effects of this illness.


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G6-PD DEFICIENCY:

The red cell is well equipped to carry out its main function of oxygen transport. It also has an elaborate
machinery to neutralize any oxygen species that pose an oxidant stress. Oxidant stress can damage
membrane constituents as well as denature hemoglobin leading to hemolysis.

There is a glutathione related system for supplying reducing equivalents to neutralize oxidant stress. This
is kept in the reduced state by the NADPH generated from the HMP-shunt pathway in red cells. This
pathway is at considerable risk in people with deficiency of the starting enzyme in the HMP-shunt
pathway: Glucose-6 phosphate dehydrogenase.

G-6PD deficiency is inherited in a X-linked fashion, hence women are carriers and males are usually
affected. It is more common in the African-American population and also follows the geographical
pattern of malarial prevalence. The disease may be silent until an oxidant stress is placed.

Drugs associated with Hemolysis:

Oxidant drugs G6PD deficiency

Antibiotics Nalidixic acid, Nitrofurantion, Sulfa drugs, Dapsone
Antimalarials Primaquine
Pyridium
Doxorubicin

Clinical Features: I n G6-PD deficiency, there is brisk onset of hemolysis following oxidant stress. This
occurs after ingestion of drugs, infections and certain dietary factors, e.g. fava beans. The affected
individual can have intra-vascular as well as extra-vascular hemolysis with resultant anemia. Treatment
(and prevention) consists of avoiding the offending agent. Typically, patients anticipating malarial
therapy are routinely tested for G6-PD deficiency.

References:

1. Perrotta S, Gallagher PG, Mohandas N. Hereditary spherocytosis. Lancet 2008;372(9647):1411-26.
2. Hematology in Clinical Practice. R. Hillman and K. Ault 2005.
3. Hematology: A pathophysiological approach. B. Babior and T. Stossel 1998

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