Case Study 8 - Infarction & Necrosis Flashcards
A 19 year old man presents to A&E
with a history of 7 hours of right sided testicular pain. It came on
gradually but has been getting worse and is now described as 10/10. The doctor examines the testicle and notices that the skin appears erythematous, the scrotum is swollen and the testicle is lying in a horizontal position. It is acutely tender when touched. The doctor prescribes some diclofenac and goes
to speak to his senior colleague.
What could be the cause of this pain?
testicular torsion
acute orchitis (acute inflam of the testes due to mostly mumps)
infections from other viruses and other bacteria graduate onset over several days & scrotum will be swollen
acute epididymitis (onset of over several days but scrotum will not be swollen but painful) hematocoele (collection of blood in the tunica vaginilis, scrotum will be painful)
hydrosile (happens when the inguinal canal doesn’t close through which the testes descend - if it doesn’t close then it allows liquid to go out - causes swelling but no pain)
varicosile (dilation of the pampiniform venus plexus - causes swelling of spermatic cord, & painful if advanced)
A 19 year old man presents to A&E
with a history of 7 hours of right sided testicular pain. It came on
gradually but has been getting worse and is now described as 10/10. The doctor examines the testicle and notices that the skin appears erythematous, the scrotum is swollen and the testicle is lying in a horizontal position. It is acutely tender when touched. The doctor prescribes some diclofenac and goes
to speak to his senior colleague.
What is diclofenac and what it is mechanism of action?
it’s non-steroidal anti-inflammatory drug that is a non-selective inhibitor of cox1 and cox2 which prevents the conversion of arachidonic acid into pg2, pg2 is a precursor to prostaglandins which induce pain and inflammation
A 19 year old man presents to A&E
with a history of 7 hours of right sided testicular pain. It came on
gradually but has been getting worse and is now described as 10/10. The doctor examines the testicle and notices that the skin appears erythematous, the scrotum is swollen and the testicle is lying in a horizontal position. It is acutely tender when touched. The doctor prescribes some diclofenac and goes
to speak to his senior colleague.
What are the side effects of diclofenac?
GI bleeding, impaired renal function, nausea, swelling/oedema
A 19 year old man presents to A&E
with a history of 7 hours of right sided testicular pain. It came on
gradually but has been getting worse and is now described as 10/10. The doctor examines the testicle and notices that the skin appears erythematous, the scrotum is swollen and the testicle is lying in a horizontal position. It is acutely tender when touched. The doctor prescribes some diclofenac and goes
to speak to his senior colleague.
The consultant urologist comes to review the patient. He is very concerned and thinks the
patient may have testicular torsion. He explains to the patient that he needs to be
taken to theatre as soon as possible. However, he has to explain to the patient some of the risks associated with this condition first.
What is testicular torsion? (1)
testicles rotates and twist and cut off the venus drainage of the testes due to loose connective tissue
A 19 year old man presents to A&E
with a history of 7 hours of right sided testicular pain. It came on
gradually but has been getting worse and is now described as 10/10. The doctor examines the testicle and notices that the skin appears erythematous, the scrotum is swollen and the testicle is lying in a horizontal position. It is acutely tender when touched. The doctor prescribes some diclofenac and goes
to speak to his senior colleague.
The consultant urologist comes to review the patient. He is very concerned and thinks the
patient may have testicular torsion. He explains to the patient that he needs to be
taken to theatre as soon as possible. However, he has to explain to the patient some of the risks associated with this condition first.
What structures are found in the spermatic cord?
The spermatic cord is a structure that runs from the inguinal ring down to the testicle, and it contains various structures that are important for the function and support of the testicle. The layers and structures found in the spermatic cord include:
Three Layers:
External Spermatic Fascia: This is the outermost layer and serves as a protective covering. It is a continuation of the external abdominal oblique aponeurosis.
Cremasteric Fascia: The middle layer is the cremasteric fascia, which is a thin connective tissue. The cremaster muscle, which is part of the spermatic cord, is responsible for the contraction of the testicle towards the body in response to cold or other stimuli.
Internal Spermatic Fascia: This is the innermost layer, a band of connective tissue that surrounds the spermatic cord directly.
Nerves:
Genital Branch of the Genitofemoral Nerve: This nerve provides sensory innervation to the cremasteric muscle and the skin of the scrotum.
Ilioinguinal Nerve: A branch of the first lumbar nerve, it provides sensory innervation to the skin over the pubic symphysis, upper part of the scrotum, and the medial thigh.
Testicular Nerve: This nerve supplies sensory innervation to the testicle.
Vessels:
Testicular Artery: The main blood supply to the testicle, branching off from the abdominal aorta.
Artery of Vas Deferens: Also known as the deferential artery, it supplies blood to the vas deferens.
Premasteric Artery: This is a small artery that may be present, supplying blood to the cremaster muscle.
Veins:
Pampiniform Plexus: This is a network of veins that surrounds the testicular artery within the spermatic cord. The pampiniform plexus helps cool the arterial blood entering the testicle.
Lymphatic Vessels: Lymphatic vessels in the spermatic cord are involved in draining lymph fluid from the testicle.
A 19 year old man presents to A&E
with a history of 7 hours of right sided testicular pain. It came on
gradually but has been getting worse and is now described as 10/10. The doctor examines the testicle and notices that the skin appears erythematous, the scrotum is swollen and the testicle is lying in a horizontal position. It is acutely tender when touched. The doctor prescribes some diclofenac and goes
to speak to his senior colleague.
The consultant urologist comes to review the patient. He is very concerned and thinks the
patient may have testicular torsion. He explains to the patient that he needs to be
taken to theatre as soon as possible. However, he has to explain to the patient some of the risks associated with this condition first.
What is the risk associated with this condition?
testicular infarction (urologic emergency), infertility, tissue death
A 19 year old man presents to A&E
with a history of 7 hours of right sided testicular pain. It came on
gradually but has been getting worse and is now described as 10/10. The doctor examines the testicle and notices that the skin appears erythematous, the scrotum is swollen and the testicle is lying in a horizontal position. It is acutely tender when touched. The doctor prescribes some diclofenac and goes
to speak to his senior colleague.
The consultant urologist comes to review the patient. He is very concerned and thinks the
patient may have testicular torsion. He explains to the patient that he needs to be
taken to theatre as soon as possible. However, he has to explain to the patient some of the risks associated with this condition first.
What are the causes of infarction and what is the cause in this case?
compression, blockage, arterial thrombosis, arterial embolism, vasospasm, vascular rupture, torsion, oedema. The cause in this case is torsion
A 19 year old man presents to A&E
with a history of 7 hours of right sided testicular pain. It came on
gradually but has been getting worse and is now described as 10/10. The doctor examines the testicle and notices that the skin appears erythematous, the scrotum is swollen and the testicle is lying in a horizontal position. It is acutely tender when touched. The doctor prescribes some diclofenac and goes
to speak to his senior colleague.
The consultant urologist comes to review the patient. He is very concerned and thinks the
patient may have testicular torsion. He explains to the patient that he needs to be
taken to theatre as soon as possible. However, he has to explain to the patient some of the risks associated with this condition first.
The patient is taken to theatre. The surgeon opens the scrotal sac and looks at the testicle. He has to make a decision about what to do with the testicle. Should he remove it or leave it alone…
Look at the picture of the testicle below. What does it show? What would you
advice the surgeon to do? (2)
Image
A 19 year old man presents to A&E
with a history of 7 hours of right sided testicular pain. It came on
gradually but has been getting worse and is now described as 10/10. The doctor examines the testicle and notices that the skin appears erythematous, the scrotum is swollen and the testicle is lying in a horizontal position. It is acutely tender when touched. The doctor prescribes some diclofenac and goes
to speak to his senior colleague.
The consultant urologist comes to review the patient. He is very concerned and thinks the
patient may have testicular torsion. He explains to the patient that he needs to be
taken to theatre as soon as possible. However, he has to explain to the patient some of the risks associated with this condition first.
The patient is taken to theatre. The surgeon opens the scrotal sac and looks at the testicle. He has to make a decision about what to do with the testicle. Should he remove it or leave it alone…
The surgeon decides that the testicle is not viable and therefore performs an orchidectomy. He sends the specimen to the pathologist who reviews some sections under the microscope
The first picture shows the normal histology of the testis. The second picture shows the histology from our patient. Label the normal findings and describe the
abnormalities seen in the second picture. (3)
Image
A 19 year old man presents to A&E
with a history of 7 hours of right sided testicular pain. It came on
gradually but has been getting worse and is now described as 10/10. The doctor examines the testicle and notices that the skin appears erythematous, the scrotum is swollen and the testicle is lying in a horizontal position. It is acutely tender when touched. The doctor prescribes some diclofenac and goes
to speak to his senior colleague.
The consultant urologist comes to review the patient. He is very concerned and thinks the
patient may have testicular torsion. He explains to the patient that he needs to be
taken to theatre as soon as possible. However, he has to explain to the patient some of the risks associated with this condition first.
The patient is taken to theatre. The surgeon opens the scrotal sac and looks at the testicle. He has to make a decision about what to do with the testicle. Should he remove it or leave it alone…
The surgeon decides that the testicle is not viable and therefore performs an orchidectomy. He sends the specimen to the pathologist who reviews some sections under the microscope
What type of necrosis is this? (2)
coagulative
A 19 year old man presents to A&E
with a history of 7 hours of right sided testicular pain. It came on
gradually but has been getting worse and is now described as 10/10. The doctor examines the testicle and notices that the skin appears erythematous, the scrotum is swollen and the testicle is lying in a horizontal position. It is acutely tender when touched. The doctor prescribes some diclofenac and goes
to speak to his senior colleague.
The consultant urologist comes to review the patient. He is very concerned and thinks the
patient may have testicular torsion. He explains to the patient that he needs to be
taken to theatre as soon as possible. However, he has to explain to the patient some of the risks associated with this condition first.
The patient is taken to theatre. The surgeon opens the scrotal sac and looks at the testicle. He has to make a decision about what to do with the testicle. Should he remove it or leave it alone…
The surgeon decides that the testicle is not viable and therefore performs an orchidectomy. He sends the specimen to the pathologist who reviews some sections under the microscope
Describe the differences between coagulative and liquefactive necrosis and the organs where you will find them.
liquefact is due to bacterial and fungal infections, coagulative is due to lack of blood supply → infarction causing necrosis then ischaemia except the brain. We have liquefactive necrosis in the cns because of high concentration of lysosomes but ischaemia activates lysosomes to release lysozymes
A 69 year old man
suddenly clutches his
chest and collapses
whilst out shopping.
Passers by notice that he
has stopped breathing.
Paramedics arrive and
perform CPR and take
him to A&E. Attempts at
resuscitation fail and he
is pronounced dead. The
nurses find a bottle of GTN spray in his pocket and a packet of cigarettes in his coat. The coroner requests for a post-mortem to be performed.
Do you have any ideas what may be found at the post-mortem?
clot in coronary artery, myocardial ischaemia leads to cardiac tissue death, anyeurism, rupture
A 69 year old man
suddenly clutches his
chest and collapses
whilst out shopping.
Passers by notice that he
has stopped breathing.
Paramedics arrive and
perform CPR and take
him to A&E. Attempts at
resuscitation fail and he
is pronounced dead. The
nurses find a bottle of GTN spray in his pocket and a packet of cigarettes in his coat. The coroner requests for a post-mortem to be performed.
What is GTN spray? What is it prescribed for and how does it work?
GTN stands for glyceryl trinitrate, and it is a medication that belongs to the class of drugs known as nitrates. Glyceryl trinitrate is commonly used to treat angina pectoris, a condition characterized by chest pain or discomfort that occurs when the heart muscle does not receive enough oxygen-rich blood. GTN spray is a form of nitroglycerin that is administered through a spray, typically under the tongue.
How GTN Works:
Nitric Oxide (NO) Release: When GTN is administered, it is denitrated (broken down) in the body, releasing nitric oxide (NO). Nitric oxide is a signaling molecule that plays a crucial role in vasodilation.
Activation of cGMP: Nitric oxide activates an enzyme called guanylate cyclase, leading to the production of cyclic guanosine monophosphate (cGMP).
Muscle Relaxation: cGMP, in turn, activates protein kinase G, leading to the phosphorylation of proteins involved in smooth muscle relaxation. One of the key effects is the activation of myosin light chain phosphatase, which causes dephosphorylation of myosin and relaxation of smooth muscle.
Vasodilation: The ultimate effect of this molecular cascade is the relaxation of smooth muscle in blood vessel walls. This vasodilation results in an increase in the diameter of blood vessels, leading to improved blood flow. In the case of angina, this dilation helps to increase blood supply to the heart muscle, relieving the symptoms of chest pain.
A 69 year old man
suddenly clutches his
chest and collapses
whilst out shopping.
Passers by notice that he
has stopped breathing.
Paramedics arrive and
perform CPR and take
him to A&E. Attempts at
resuscitation fail and he
is pronounced dead. The
nurses find a bottle of GTN spray in his pocket and a packet of cigarettes in his coat. The coroner requests for a post-mortem to be performed.
The pathologist performs the post-mortem and presents the findings. The aorta shows evidence of mild atheroma. The gallbladder contains gallstones. The heart shows a pale fibrotic area of myocardium in the left ventricle. The left
anterior descending coronary artery shows a thrombosis with complete
occlusion of the vessel.
Can you construct a clinico-pathological correlation for what caused this patient’s
death?
Patient has ischaemic heart disease, coronary arteries will be atherosclerosed progressively leading to ischaemia & collagen deposition, hence the afibrotic area of the heart. He has had an acute thrombosis → myocardial infarction
A 69 year old man
suddenly clutches his
chest and collapses
whilst out shopping.
Passers by notice that he
has stopped breathing.
Paramedics arrive and
perform CPR and take
him to A&E. Attempts at
resuscitation fail and he
is pronounced dead. The
nurses find a bottle of GTN spray in his pocket and a packet of cigarettes in his coat. The coroner requests for a post-mortem to be performed.
The pathologist performs the post-mortem and presents the findings. The aorta shows evidence of mild atheroma. The gallbladder contains gallstones. The heart shows a pale fibrotic area of myocardium in the left ventricle. The left
anterior descending coronary artery shows a thrombosis with complete
occlusion of the vessel.
What are the risk factors for development of atherosclerosis?
Modifiable: smoking, diet
Non-modifiable: age, sex, genetic deposition
