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Year 5 Histopathology > 5s: Immune Disorders* > Flashcards

5s: Immune Disorders* Flashcards

1
Q

SOAP BRAIN MD for SLE (Systemic Lupus Erythematosus)

A
  • Serositis
  • Oral ulcers
  • Arthritis
  • Photosensitive rash
  • Blood (all counts low)
  • Renal (proteinuria)
  • ANA = used to screen for ANY nuclear antigens
  • Immunological (anti-dsDNA)
  • Neurological (psych, seizures)
  • Malar rash
  • Discoid rash
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2
Q

What are the three auto-antibodies in SLE

dsh

A

Anti-dsDNA (MOST SPECIFIC) = most specific (30%), not very sensitive

Anti-smith (Sm) = specific (20%), not very sensitivie

  • NB: all anti-ENAs (RNPs: anti-Ro, La, Sm, U1RNP) found in SLE

Anti-histone (drug-related e.g. hydralazine)

  • patients taking hydralazine for HTN may develop SLE
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3
Q

How do we measure anti-dsDNA?

A

Incubate patient’s serum with Crithidia Luciliae (a protozoa)

  • has big mitochondrion with dsDNA (kinetoplast)
  • if the patient has anti-dsDNA antibodies, it will bind to the DNA

Measured using ELISA

NB: old test looks for LE cells (neutrophils that have taken up denatured nuclei)

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4
Q

How do we measure anti-dsDNA?

A

Incubate patient’s serum with Crithidia Luciliae (a protozoa)

  • has big mitochondrion with dsDNA (kinetoplast)
  • if the patient has anti-dsDNA antibodies, it will bind to the DNA

Measured using ELISA

NB: old test looks for LE cells (neutrophils that have taken up denatured nuclei)

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5
Q

Skin histology of SLE (3)

A
  • lymphocytic infiltration of dermis
  • vacuolisation (cell dissolution) of basal epidermis
  • Extravasation of RBCs → rash
  • IF (antibody to IgG) will show immune complex deposition of the epidermis-dermis junction
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6
Q

Renal histology of SLE (1)

A

Thick glomerular capillaries (wire-loop)

IF to visualise immune complex deposition (dark areas on EM)

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7
Q

Renal histology of SLE (1)

A

Thick glomerular capillaries (wire-loop)

IF to visualise immune complex deposition (dark areas on EM)

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8
Q

What heart problem is associated with SLE?

A

Libman-Sacks Endocarditis

  • non-infective form of endocarditis
  • emboli, HF, murmurs
  • Vegetations = lymphocytes, neutrophils, fibrin stands etc.
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9
Q

Investigation of connective tissue disease

A
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10
Q

Investigation of connective tissue disease

A
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11
Q

Lupus can affect complement

A

Active lupus can cause secondary deficiency of classical pathway (C1,2,4) complement due to production of immune complexes depleting complement

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12
Q

What susceptibility allele is associated with SLE?

A

HLA-DR⅔

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13
Q

How do we treat SLE?

A

Mainly analgesia, steroids

Cyclophosphamide (chemo)

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14
Q

SLE summary

A
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15
Q

What is Scleoderma (systemic sclerosis)? and its types?

A

fibrosis and excess collagen (localised form is called morphoea in the skin)

Diffuse = involves the trunk (CREST + GIT + interstitial pulmonary disease and renal problems), F>M

Limited = NOT the trunk (CREST) → high risk of lung fibrosis and renal crisis

  • Calcinosis (i.e. calcium deposit on tip of thumb)
  • Raynaud’s phenomenon
  • Eosophageal dysmotility
  • Sclerodactlyly
  • Telangiectasia
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16
Q

What are the autoantibodies in systemic sclerosis (diffuse vs limited) which one has a specific pattern

A

Diffuse

  • Topoisomerase/Scl70
  • RNA Pol I/II/III
  • Fibrillarin (NUCLEOLAR PATTERN)

Limited

  • Anti-centromere antibody
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17
Q

Skin histology in SS

A

Increased depth and amount of collagen → reduced skin elasticity

  • difficulty swallowing and stomach dysmotility due to excess collagen within the lining
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18
Q

Vascular histology

A
  • Top picture is a normal artery with 3 layers
  • Bottom picture is a small artery in a patient presenting to A&E with a renal crisis (characterised by very high blood pressure)
    • There is intimal proliferation giving an onion skin appearance
    • Lumen effectively obliterated and some small thrombi form
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19
Q

Vascular histology

A
  • Top picture is a normal artery with 3 layers
  • Bottom picture is a small artery in a patient presenting to A&E with a renal crisis (characterised by very high blood pressure)
    • There is intimal proliferation giving an onion skin appearance
    • Lumen effectively obliterated and some small thrombi form
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20
Q

What is mixed connective tissue disease?

A

Overlap of several connective tissue diseases

  • SLE
  • Polymyositis
  • Scleroderma
  • Dermatomyositis
21
Q

What autoantibody for mixed connective tissue disease?

A

ANA → Anti-U1RNP antibody

  • shows a speckled pattern
22
Q

What areas does sarcoidosis affect?

A
  • Joints (arthritis, bone cysts)
  • Lungs (fibrosis, lymphocytosis → increased CD4_ cells in BAL)
  • Heart (any layer: pericardium, myocardium, endocardium)
  • Neuro (meningitis, CN lesions)
  • Parotids (bilateral enlargement)
  • Skin (lupus pernio, erythema nodosum)
  • Lymphadenopathy (painless, rubbery)
  • Eyes (uveitis, karatoconjunctivitis)
  • Liver (hepatitis, cirrhosis, cholestasis)
  • HYPERCALCAEMIA/HYPERCALCIURIA → renal calculi + nephrocalcinosis
  • Constitutional (malaise, fever, night sweats)
23
Q

Other than sarcoidosis, what other conditions can cause bilateral parotid enlargement

A

mumps

alcohol

Sjogren’;s syndrome

24
Q

What is sarcoidosis

epidemiology

investigations

histology findings

A

Multisystem disease of unknown origin, young adults, non-caseating granulomas

Afro-Caribbeans more severe, F>M

Lungs most commonly involved

Ix: DIAGNOSIS OF EXCLUSION

  • CXR = bilateral hilar lymphadenopathy (ddx TB lymphoma, bronchial caner)
  • increased Ca2+ (ectopic 1a-hydroxylase release by activated macrophages), increased ESR, increased ACE, transbronchial biopsy

Histology:

  • non-caveating granulomas
  • Schauman and asteroid bodies (inclusions of protein and calcium)
25
Q

Sarcoidosis histology

A

NON-CASEATING GRANULOMA (ball of activated macrophages) composed of:

  • histiocytes (epithelioid cells)
  • Multinucleated giant cells of Langerhans (peripheral nuclei) - fused macrophages → horsehoe appearance
  • lymphocytes → NO necrosis within granuloma (non-caveating)
26
Q

Ix for sarcoidosis (3)

A

Hypergammaglobulinaemia

Raised ACE

Hypercalcaemia (vit D hydroxylation (1a-hydroxylase) by activated macrophages)

27
Q

Summary of vasculitides

A
28
Q

Summary of vasculitides

A
29
Q

Features of vasculitides

A

Palpable purpuric rash

nail fold infarcts

primary (image)

secondary to another condition (e.g. infective endocarditis. SLE)

30
Q

Temporal arteritis (GCA, giant cell arteritis), features, ix, histology, and mx

A
  • elderly, scalp tenderness, temporal headache, jaw claudication, blurred vision, non-palpable temporal pulse
  • associated with poly myalgia rheumatica
  • ix: raised ESR, temporal artery biopsy → narrowing of lumen and lymphocytic infilitration of the tunica MEDIA, >50 y/o
  • histology: granulomatous transmural inflammation + giant cells + skip lesions
  • mx = oral prednisolone
31
Q

Takayasu arteritis

A

Pulseless disease = no pulse, low BP in arms, cold hands

JAPANESE WOMEN

vascular symptoms = absent pulse, bruits, claudication

32
Q

What is Polyarteritis Nodosa (PAN), its features and its associations?

A

inflammation of gut/renal vessels

  • fever, fatigue, weakness, arthralgia, skin/nerve/kideny involvement, pericarditis, MI
  • 30% have underlying HepB
  • necrotising arteritis → heals by fibrosis
  • polymorphs, lymphocytes, and eosinophils will infiltrate
  • arteritis is focal and sharply demarcated
  • Associations: rosary beads on angiograms (microaneurysms), HBV

Ix: clinical criteria and biopsy (raised ESR/WCC/CRP), rosary sign

Tx: prednisolone and cyclophosphamide

33
Q

What is Kawasaki’s disease

A
34
Q

What is Buerger’s disease (thomboangitis obliterans)? Ix

A
  • Inflammation of arteries of extremities (tibial/radial)
  • pain, ulceration of toes/feet/fingers
  • heavy smokers, men <35
  • ix = angiogram (corkscrew appearance from segmental occlusive lesions)
35
Q

What is the triad for Granulomatosis with Polyangitis (Wegener’s granulomatosis)? tx

A
  1. URT = sinusitis, epistaxis, saddle nose
  2. LRT = cavitation, pulmonary haemorrhage
  3. Kidneys = crescentic glomerulonephritis → haematuria + proteinuria

tx = prednisolone, cyclophosphamide, co-trimoxazole

36
Q

Granulomatosis with Polyangitis (Wegener’s granulomatosis) autoantibody?

A

cANCA (anti-PR3) +ve

(directed against proteinase 3)

37
Q

Triad for Churg Strauss Syndrome (Eosinophilic Granulomatosis with Polyangiitis) and tx

A
  1. asthma, allergic rhinitis (allergy → asthma → systemic disease)
  2. eosinophilia
  3. vasculitis

later systemic involvement

male dominance

tx = prednisolone, azathioprine, cyclophosphamide

38
Q

What is Churg-Strauss syndrome autoantibody

A

P-ANCA (directed against myeloperoxidase)

39
Q

What is Microscopic Polyangiitis? autoantibody, tx

A

Pulmonary Renal syndrome:

  • pulmonary haemorrhage
  • glomerulonephritis

pANCA (anti-MPO) +ve

tx: prednisolone, cyclophosphamide/azathioprine, plasmapheresis

40
Q

What is HSP?

A

IgA mediated small vessel vasculitis

  • <10 y/o
  • preceding URTI, purpuric rash (lower libs extensors + buttocks), colicky abdominal pain, GLOMERULONEPHRITIS, arthritis, orchitis

IgA nephropathy is commonest glomerulonephritis

41
Q

Summary of vasculitides

A
42
Q

What is Sjogren’s syndrome?

A

M:F=1:9 Onset in late 40s

Dry mouth (xerostomia), eyes (keratoconjunctivitis sicca), nose and skin

May affect kidneys, blood vessels, lungs, liver, pancreas and PNS

Anti-Ro and anti-La (speckled pattern) antibodies present

Use Schirmer test to measure production of tears-assessing for dry eye

May get parotid or salivary gland enlargement → may lead to parotid lymphoma (MALT)

43
Q

Which autoantibody can you see in congenital heart block in infants of mothers with SLE?

A

Anti-Ro antibody

44
Q

Describe dermatomyositis and what you can see O/E, autoantibody

A
  • They will have proximal muscle pain and weakness
  • High CK
  • Gottron’s papules (erythematous rash over the knuckles) + periorbital rash

T3 RESPONSE

Anti-Jo-1 (t-RNA Synthetase)

45
Q

Dermatomyositis and polymyositis

A
46
Q

What is this?

SLE

Scelorderma

Sarcoidosis

A

SLE

47
Q

What is this? SLE, scleroderma, sarcoidosis

A

scleroderma

48
Q

What is this?

SLE

Scleroderma

Sarcoidosis

A

Sarcoidosis

Year 5 Histopathology (10 decks)

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