Infections, Heart Disorders, Immunology Flashcards
1
Q
most common VIRAL cause of pericarditis
A
coxsackie B virus and echovirus
2
Q
Primary pericarditis (pericardial sac contains 50mL of pericardial fluid, lubricates the heart, barrier to spread of infection, prevents deformation and dislocation of heart) is almost of viral/bacterial origin
A
VIRAL
3
Q
name the infectious viruses that can cause pericarditis
A
HIV, herpes, echovirus, coxsackievirus, mumps
4
Q
name the pyogenic bacteria that can cause pericarditis
A
staph, strep, pneumococcus, meningococcus, haemophilus, influenza, mycoplasmosis, borreliosis, chlamydia, tuberculosis
5
Q
fungi that can cause pericarditis
A
histoplasmosis, coccidiodomycosis
6
Q
cardiac tamponade
A
type of pericardial effusion in which fluid accumulates in the pericardium.
7
Q
the most serious complication of pericarditis is
A
cardiac tamponade
8
Q
Beck’s triad (decreased BP, muffled heart sounds, bulging or distension of the veins in the neck) are signs of
A
cardiac tamponade
9
Q
___ pericarditis = serious, pericardium becomes thickened and so scarred it loses elasticity, compresses the heart so it cant pulp well, reduces amount of blood pumped to body.
A
Constrictive
10
Q
symptoms of ___ = chest pain, difficulty breathing, swelling of feet and ankles, fatigue and weakness
A
constrictive pericarditis
11
Q
aortic dissection aka dissecting aneurysm = results in aortic rupture, most often into __ causing ___
A
pericardial sac = fatal cardiac tamponade
12
Q
most common cause of right sided heart failure
A
left sided heart failure
13
Q
in heart failure, which side and part usually fails first?
A
left ventricle
14
Q
earliest and most common signs of heart failure
A
exertional dyspnea
and paroxysmal nocturnal dyspnea (patient wakes up gasping for air)
15
Q
other signs of CHF:
A
peripheral edema (swollen ankles), cyanosis, orthopnea (sitting or standing in order to breathe), high venous pressure
16
Q
Patients with heart failure should be in ___ position during dental treatment to decrease collection of fluid in the lungs.
A
upright
When fully reclined they may experience difficulty breathing
17
Q
unstable/stable angina - prolonged or recurrent chest pain at rest
A
unstable
18
Q
___ occurs when the heart’s need for oxygen increases beyond what is delivered
A
angina
19
Q
angina is the classic symptom of __ disease
A
coronary heart disease
20
Q
___ angina - repeating pattern of chest pain which has not changed in character frequency intensity or duration for several weeks. level of activity or stress that provoke angina is predicatable and the pattern changes slowly.
A
stable
21
Q
which kind of angina is the most common form
A
stable
22
Q
stable angina is precipitated by exertion but can be relieved by
A
rest, vasodilators (ex. nitroglycerin)
23
Q
_angina is variable, increasing in freq or intensity and with irregular timing or duration. it is PROLONGED OR RECURRENT PAIN AT REST.
A
unstable
24
Q
unstable angina is often indicative of
A
myocardial infarction
25
Prinzmetal's angina - aka variant angina is caused by ___
vasospasm - spasms that narrow the coronary artery and lessen the blood flow to the heart. it is intermittent chest pain at rest
26
1. intermittent chest pain at rest
2. prolonged/recurrent chest pain at rest
3. chest pain from exertion
1. prinzmetal's angina (variant angina)
2. unstable
3. stable
27
coronary artery disease is aka
ischemic heart disease
28
___ = atheromas (atherosclerotic plaque) accumulate in coronary artery and obstruct blood flow
coronary artery disease (ischemic heart disease)
29
major complications of coronary artery disease (ischemic heart disease)
heart attack and angina
30
the primary effect of CAD coronary artery disease is
loss of oxygen and nutrients to myocardial tissues bc diminished coronary blood flow
31
what is the first cardiac marker to increase after a myocardial infarction
myoglobin
32
1. ___ = rises in 1-2 hours after MI, peaks in 4-6 hours, duration 1-2 days.
2. ___= rises 3-6 hours, peaks 20 hours, duration 14 days
1. myogolobin
| 2, troponin (longest in system along with LDH)
33
1. Subunits of troponin: Troponin T and Troponin I- (troponin ___ > 1.0 suggests acute mi)
I
34
1. Creatine phosphokinase (CPK) rises 4-6 hours peaks 12-24 hours duration 4-5 days
2. Glutamic oxaloacetic transaminase (AST, SGOT) peaks 24-36 hours, duration 5 days
3. Lactic dehydrogenase: peaks 24-48 hours, duration 14 days
give order of markers= which appear first etc
myoglobin > troponin > creatine phosphokinase (CPK) > glutamic oxaloacetic transaminase and lactic dehdrogenase
35
MI are most commonly caused by
coronary atherosclerosis
36
CK-MB is only present if CPK increases.
| if CK-MB is >5% it means ___
myocardial injury
37
signs of __ are crushing pain in chest over the heart, sweating, and GI upset
MI
38
the prognosis of MI is good if they reach the hospital. most deaths from MI occur outside the hospital due to
arrhythmias causing ventricular fibrillaiton
39
1. Underlying structural valve disease is usually present in patients before developing ___ endocarditis
2. It is usually caused by a form of ___
1. subacute
2. streptococci viridans bacteria that normally live in the mouth and throat (Streptococcus mutans, mitis, sanguis or milleri). Other strains of streptococci (bovis and equines) can also cause subacute endocarditis, usually in patients who have a form of gastrointestinal cancer
40
__endocarditis is a fulminant (process that occurs suddenly and quickly, and is intense and severe to the point of lethality = explosive) illness over days to weeks, and is more likely due to Staphylococcus aureus which has much greater virulence, or disease-producing capacity and frequently causes metastatic infection
Acute bacterial endocarditis (ABE)
41
Infectious endocarditis is an inflammation of the
heart valves
42
1. infection of heart muscle
2. infection of heart lining
3. infection of heart valve
1. myocarditis
2. pericarditis
3. endocarditids
43
many bacteria can cause endocarditis in patients with underlying valve problems:
1. most common are (50%)
2. other common organisms
3. less common organisms
1. step viridans
2. staph aureus, enterococcus
3. candida, pseudomonas, serratia
44
___ can infect NORMAL heart valves and is the most common cause of infectious endocarditis in ___
Staph Aureus
| IV drug users
45
infectious endocarditis:
| large, soft, friable, easily detached ___ consisting of fibrin intermeshed with inflammatory cells and bacteria.
vegetations
46
complications with infectious endocarditis:
ulceration and perforation of the valve cusps or rupture of one of the chordae tendineae
47
__- endocarditis caused by staph aureus (50% of time). this type is usually secondary to infection occurring somewhere else in the body.
acute
| think Acute Aureus
48
subacute (bacterial) endocarditis caused by a less virulent organism such as Strep. Viridans
tends to occur in patients with ___ .
congenital heart disease or pre-existing valvular heart disease
49
What is the hallmark of acute and subacute endocardities
fever
50
which valve is most frequently involved in endocarditis
mitral
51
the mitral valve along with __ valve involved in 40% of endocarditis cases
aortic
52
the __ valve is involved in more than 50% of cases of endocarditis of IV drug users
tricuspid
53
____ result from changes in blood flow across valves when vegetations collect on valves
murmurs
54
Most common neck space infection: __
ludwig’s angina
55
Ludwig's angina is usually an extension of infection form the ___ since their roots lie below the attachment of which muscle
mandibular MOLAR TEETH into the floor of the mouth since their roots lie below the attachment of the mylohyoid muscle
56
Ludwig's angina
1. Brawny induraton = does it pit under pressure?
2. Does it have fluctuance?
3. how many facial spaces are involved?
4. is it unilateral or bilateral
5. patient has a __ appearance
6. onset is slow/fast
1. No it does not pit under pressure: brawny means strong and muscular
2. NO. Fluctuance is an indication of the presence of pus in a bacterial infection
3. three facial spaces
4. bilateral
5. open mouthed.
6. rapid onset
dysphagia (difficulty swallowing), dyspnea (difficulty swallowing), and fever present
57
when can Ludwig's angina become an emergency situation
if the swelling blocks the airway.
| intubation (breathing tube placed) or tracheostomy (direct opening to lungs thru surgical tube placed in neck).
58
Ludwig's Angina:
1. goal is to get rid of infection by giving
2. Most cases it is a ___ infection, however ___are almost always present
1. Antibiotics (penicillin or penicillin like drugs given to treat infection) via IV
2. mixed infection, streptococci
59
____chronic infection Slow growing deep, lumpy abscesses that extrude a thin, purulent exudate through multiple sinuses. Develops chiefly in jaw and neck, less freq in the lungs and alimentary tract . treated with long term penicillin therapy.
actinomycosis aka lumpy jaw
| infection with Actinomyces usually A. israelii.
60
1. Actinomyces naeslundii
| 2. vs Actinomycosis A. israeli
1. gram + branching, filamentous bacteria normal inhabitant of gingival crevice and tonsillar crypts
2. causes actinomycosis = lump jaw
61
actinomycotic lesions have characteristic __ granules
sulfur
62
Tetanospasmin is a neurotoxin that inactivates proteins that regulate the release of which neurotransmitters
glycine and GABA
63
tetanus is aka _jaw
lock
64
1. tetanus is caused by an acute EXOTOXIN mediated infection caused by anaerobic spore forming gram __
2. occurs thru a
positive bacillus Clostridium tetani
| 2. puncture wound that is contaminated by soil or dust
65
tetanus toxin (tetanospasmin) = neurotoxin that inactivates proteins that regulate the release of inhibitory neurotransmitters ___
glycine and GABA = leads to unregulated excitatory synaptic activity of motor neurons = spastic paralysis
66
is tetanus toxin binding reversible
no. recovery depends on whether new axonal terminals form
67
which kind of tetanus is the most common form?
generalized tetanus
68
in generalized tetanus what muscle is involved
masseter
69
Risus sardonicus seen in?
tetanus and poisoning with strychnine
70
opisthotonos seen in?
persistent back pains associated with tetanus. a state of severe hyperextension and spasticity in which an individual's head, neck and spinal column enter into a complete "bridging" or "arching" position. caused by spasm of the axial muscles along the spinal column. It is seen in some cases of severe cerebral palsy and traumatic brain injury or as a result of the severe muscular spasms associated with tetanus
71
1. diphtheria toxin inhibits
protein synthesis
72
____ toxin is made up of 3 proteins: one is a PROTECTIVE ANTIGEN and two are called EDEMA FACTOR and LETHAL FACTOR
anthrax toxin
73
clostridium is always anaerobic and gram +. causes what two things
tetanus and botulism
| clostridium tetani and botulinum
74
botulism can occur form
ingesting contaminated food, colonization of the infant GI tract, or wound infection
75
the most potent toxin known to man is
clostridium botulinum
76
also known as trismus
tetanus
77
The ___ toxin initially binds to peripheral nerve terminals. It is transported within the axon and across synaptic junctions until it reaches the central nervous system. There it becomes rapidly fixed to gangliosides at the presynaptic inhibitory motor nerve endings, and is taken up into the axon by endocytosis. The effect of the toxin is to block the release of inhibitory neurotransmitters glycine and gamma-Aminobutyric acid (GABA) across the synaptic cleft, which is required to check the nervous impulse. If nervous impulses cannot be checked by normal inhibitory mechanisms, the generalized muscular spasms characteristic of tetanus are produced
tetanus
78
1. Clostridium botulism prevents the release of ____
acetylcholine = blocks neurotransmission at peripheral cholinergic synapses leading to flaccid paralysis
79
1. flaccid paralysis caused by
| 2. spastic paralysis caused by
1. clostridium botulinum (inhibits AcH release)
| 2. clostridium tetanii (inhibits release of inhibitory NT's glycine and GABA)
80
the inability to transmit impulses thru motor neurons can cause ___ failure
respiratory (botulism)
81
as with tetanus, recovery of function after botulism requires
regeneration of the nerve endings
82
What are highly resistant to heat: the spores or the toxins
spores
83
this toxin is produced WITHIN canned food and ingested PREFORMED
c. botulinum
84
proper canning and heating of food prevents
botulism
85
nausea, vomiting, abdominal cramps precede neurological symptoms: dry mouth, diplopia (double vision) loss of pupillary reflexes, followed by descending paralysis and respiratory failure =
botulism
86
Eosinophilia is often associated with:
a. acute infections
b. viral infections
c. tuberculosis
d. parasitic infections
d. parasitic infections
87
___ = WBC greater than 11,000 per mm3. normal range is 5000-10,000 per mm(cubed)
Leukocytosis
88
an elevated WBC count =
bone marrow's normal response to infectious or inflammatory process
89
Leukocytosis Nuetrophils/eosinophils/lymphocytes/monocytes high in:
Allergy, asthma, parasitic infections
Eosinophils
90
```
Nuetrophils/eosinophils/lymphocytes/monocytes high in:
acute infections (bacterial) and stress
```
neutrophils
91
Nuetrophils/eosinophils/lymphocytes/monocytes high in: TB and Viral infections
lymphocytes
92
Nuetrophils/eosinophils/lymphocytes/monocytes high in:
| TB malaria rickettsia
monocytes
93
in an allergy Nuetrophils/eosinophils/lymphocytes/monocytes high in:
eosinophil
94
in rickettsia
| Nuetrophils/eosinophils/lymphocytes/monocytes high in:
monocytes
95
in malaria
| Nuetrophils/eosinophils/lymphocytes/monocytes high in:
monocytes
96
in tb
| Nuetrophils/eosinophils/lymphocytes/monocytes high in:
monocytes and lymphocytes
97
in stress
| Nuetrophils/eosinophils/lymphocytes/monocytes high in:
nuetrophils
98
in asthma
| Nuetrophils/eosinophils/lymphocytes/monocytes high in:
eosinophils
99
Not all bacterial infections show leukocytosis in neutrophils. name the 2 that result in depression of neutrophils
typhoid fever and brucellosis
100
many ___ infections result in a lowered number of leukocytes (leukopenia), particularly neutrophils.
viral infections
101
a general indication of whether a disease is of bacterial or viral origin can be obtained by performing a
leukocyte count (esp neutrophils)
102
on occasion the circulating blood level of leukocytes can reach very high level up to 100,000 per cu mm of blood. such an even is called
leukemoid rxn and hard to differentiate from leukemia
103
marigination of leukocytes refers to
lining up of Wbc along wall of a vessel
104
while the cause and cure are unknown, there is a link bw Reye's Syndrome and use of
aspirin
105
1. Reye's Syndrome - rare and fatal syndrome of __dysfunction.
2. occurs predominantly in
3. accumulation of __
1. mitochondrial
2. children
3. fat droplets within hepatocytes (microvesicular steatosis)
106
aspirin should be avoided in kids with ___illness
febrile (fever). basic rule is don't give aspirin to a child unless specifically recommended by the child's dr. when taking aspirin must minimize the risk of acquiring a viral illness (such as influenza and varicella vaccinations)
107
___ has been associated with aspirin consumption by children with viral illness
reye's syndrome
108
___ - viral infection that causes a fever, runny nose, cough, headache, malaise, and muscle ache.
influenza (flu)
109
what distinguishes influenza (flu) from the common cold?
the fever and symptoms distinguish it.
| influenza (flu) causes a fever
110
Influenza A, B, and C are the only member of what virus family
orthomyxovirus
111
which Influenza A, B, and C is the most common
A
112
influenza virus has what 2 envelope glycoprotein spikes
hemagglutinin and neuraminidase = exhibit the majority of antigen changes and increases ability for it to bind to human cells and establish infection
113
Amantadine (Symmetrel) inhibits the replication of
influenza A virus by interfering with viral attachment and uncoatin
114
Rimantadine
Zanamivir
Oseltamivir are medications
antiviral for Influenza A
115
main mode of prevention of influenza
```
vaccine = killed influenza A and B viruses
remember mnemonic: RIP Always:
killed viruses:
Rabies
Influenza
Polio (Stalk given orally)
HAV (hepatitis A)
```
116
___ symptoms = bad cough that last 3 weeks or longer, pain in the chest, coughing up blood or sputum, weakness or fatigue, weight loss, no appetite, chills, fever, and sweating at night
TB
hallmark: fever and night sweats but may not be present in elderly who may exhibit change in activity or weight
117
_____ is the INITIAL INFECTION characterized by development of GOHN FOCUS (parenchymal lung lesion) which then becomes the GHON COMPLEX (parenchymal lung lesion and nodal involvement). often asymptomatic and does not progress to clinically evident disease
primary tuberculosis
118
___ usually results from ACTIVATION OF GOHN COMPLEX which spreads to new pulmonary or extrapulmonary sites. Localized lesions favor the UPPER LOBES of the lung and involve HILAR LYMPH NODES.
secondary tuberculosis
119
tubercle formation: caseous granulomas frequently rupture and the contents are expelled and result in cavitary lesions. CAVITATIONS are characteristic of __ TB
secondary
120
secondary TB may be complicated by complicated lymphatic spread resulting in
miliary TB or disseminated TB
form of tuberculosis that is characterized by a wide dissemination into the human body and by the tiny size of the lesions (1–5 mm). Its name comes from a distinctive pattern seen on a chest radiograph of many tiny spots distributed throughout the lung fields with the appearance similar to millet seeds—thus the term "miliary" tuberculosis. Miliary TB may infect any number of organs, including the lungs, liver, and spleen
121
granulomatous inflammation is characteristic of __ TB
both primary and secondary
122
the granuloma of TB is called a
tubercle
123
rebound tenderness in lower RIGHT quadrant of the abdomen is characteristic of
acute appendicitis
124
what is rebound tenderness
It refers to pain upon removal of pressure rather than application of pressure to the abdomen. (The latter is referred to simply as abdominal tenderness.)
125
the most common emergency surgical procedure performed are
appendectomies
126
rebound tenderness suggests that the inflammation has
spread to peritoneum = the serous membrane that forms the lining of the abdominal cavity
127
if appendix ruptures, the pain may disappear for short time until peritonitis sets in and pain returns. t/f
true
128
does the appendix have a physiological function
no. it is a vestigial structure representing a degeneration of part of the cecum.
129
Non necrotizing granulomatous chronic inflammation of intestinal wall, with ulcers, structures, and fistulas
Crohn's disease
130
__= most common neoplasm of appendix
Carcinoid tumor
131
___ chronic disease in which LARGE INTESTINE becomes inflamed and ulcerated leading to episodes of bloody diarrhea abdominal cramps and fever
ulcerative colitis
132
the most common sexually transmitted infection
chlamydial cervicitis
133
chlamydial cervicitis caused by what bacteria
c. trachomatis
134
this bacteria can grow in warm moist areas of reproductive tract, including cervix, uterus, fallopian tubes in women, and in urethra in women and men. also can grow in the mouth throat eyes and anus
Neisseria gonorhoeae
135
second most common sexually transmitted infection
Neisseria gonorhoeae
136
Neisseria gonorhoeae treated with
single injection of ceftriaxone plus doxycycline
137
in women gonorrhea is a common cause of
pelvic inflammatory disease
138
in men ____causes epididymitis = painful condition of ducts attached to testicles – can lead to infertility
and acute purulent urethritis and burning when urinating
Neisseria gonorhoeae
139
symptoms in women who have ____ = bleeding with intercourse, painful/burning urination, vaginal discharge is yellow or bloody
Neisseria gonorhoeae
140
Gonorrhea often occurs together with what other 2 diseases
chlamydia and syphilis
141
Chlamydial cervicitis is the most common sexually transmitted disease caused by C. trachomatis and is most often symptomatic/asymptomatic
asymptomatic
142
young women who contract ____ may also acquire SALPINGITIS
CHLAMYDIAL CERVICITIS = SALPINGITIS = INFLAMMATION OF FALLOPIAN TBES
143
1. PID is the infection, salpingitis is the __-
inflammation of the fallopian tubes
144
the characteristic lesion of secondary syphilis is known as
condyloma lata
145
Spirochetes: Treponema pallidum causes
syphilis
146
Syphilis is contagious, systemic, venereal (sexually transmitted) or congenital disease. where does it begin and where does it travel to
begins in mucous membranes and quickly spreads to nearby lymph nodes and bloodstream.
147
transmission of syphilis occurs primarily thru ___ during what stage of the infection
sexual contact, secondary stage
148
There are 3 stages in syphilis: primary/secondary/tertiary
1. Primary stage: firm, painless ulcer called ____ appears 3-6 weeks later AT THE SITE OF LOCAL CONTACT.
2. the most common site for these in oral syphilis are?
1. chancre
| 2. lips
149
There are 3 stages in syphilis: primary/secondary/tertiary
| which stage is the most (highly) infectious stage
2nd
150
There are 3 stages in syphilis: primary/secondary/tertiary
1. Secondary stage = highly infectious, occurs 6 weeks after non treatment of primary syphilis. A ___ and ___ appear on the skin and mucosal surfaces
maculopapular rash and condyloma lata (gray, flattened wart-like lesion)
151
There are 3 stages in syphilis: primary/secondary/tertiary
1. the tertiary stage occurs in 30% of infected pp MANY YEARS AFTER NON TREATMENT OF SECONDARY SYPHILIS. the ___ typifies this stage.
2. most commonly occurs on the ___
3. is it contagious?
4. are there neurological signs
1. GUMMA
2. palate and the tongue
3. not contagious
4. yes
152
1. condyloma lata
2. chancre
3. maculopapular rash
4. gumma
1. secondary stage of syphilis (gray flat wart like lesion)
2. primary stage = painless ulcer often on lip
3. secondary stage
4. tertiary stage = nodular mass
153
prognosis of syphilis is good if treated early. tertiary syphilis causes irreversible
heart failure, dementia (long term loss of the ability to think and reason clearly), and disability
154
condyloma acuminatum is
benign squamous cell papilloma caused by human papilloma virus (HPV) sexually transmitted disease common in anogenital region. treated by surgical excision
155
encephalitis: is most often caused by Viral/bacterial infection
viral
156
viral encephalitis of the brain is almost always associated with ___
meningeal inflammation (meningoencephalitis) and sometime involves spinal cord (encephalomyelitis)
157
Latency is important in several __ infections of the CNS
viral
158
In urban areas encephalitis is most frequently caused by
enteroviruses: coxsackievirus, polio virus, and echovirus.
159
Arboviruses are an important cause of epidemic encephalitis especially in
tropical regions around the world
160
in meningitis, the _ and _ become inflamed
brain and spinal cord (CNS)
161
the most common organisms causing meningitis in adults is
Neisseria meningitidis and Strep pneumonia
162
the most common organisms causing meningitis in children under the age of 2
Hemophilus influenzae
163
the organisms that cause meningitis are thought to enter body thru
nose and throat
164
Waterhouse-Friderichsen syndrome caused by
Neisseria meningitidis = rapidly progressing infection produces severe diarrhea vomiting seizures internal bleeding (bilateral adrenal hemorrhage), low blood pressure, shock and often death.
165
1. ____= it has worldwide distribution
2. ____– occurs more frequently than normal in a population
3. ____ = occurs at minimal levels within a population
4. ___ = highly communicable
1. pandemic
2. epidemic
3. endemic (think it is about to end)
4. contagiuos
166
acute/chronic = short term active infection with symptoms
acute
167
acute/chronic = long term active infection with symptoms
chronic
168
many infections are unapparent or ____ and can only be detected by demonstrating a rise in antibody titer or isolating the organism
subclinical
169
____ - organism continues to grow with or without producing symptoms in the host
chronic carrier
170
___ is the phase in certain viruses' life cycles in which, after initial infection, proliferation of virus particles ceases. However, the viral genome is not fully eradicated. The result of this is that the virus can reactivate and begin producing large amounts of viral progeny without the host being infected by new outside virus
Latency
171
is latency part of the lysogenic or lytic part of the viral life cycle
lysogenic
172
which leukemia is most responsive to treatment
acute leukemia
173
the leading cause of cancer death in children under the age of 15
leukemia
174
acute leukemias symptoms are from suppression of normal bone marrow function. they are
anemia, fatigue, fever (usually bc of infection), bleeding, thrombocytopenia.
175
chronic leukemias can occur with non specific symptoms like
fatigue weight loss anemia
176
acute leukemias are fatal within
weeks if untreated
177
persons with __ leukemia live longer
chronic
178
acute vs chronic leukemia distinguished histologically by ?
acute leukemia have IMMATURE BLAST CELLS
| chronic leukemia have MATURE AND WELL DIFFERENTIATED CELLS
179
some chronic leukemias can transform into an acute phase called
blast crisis
180
leukemias can be classified into what 4 types
acute lymphoblastic leukemia (ALL)
chronic lymphoid leukemia (CLL)
acute myeloblastic leukemia (AML)
chronic myeloid leukemia (CML)
181
lymphoblastic leukemia means precursors are
b and t lymphocytes
182
myelogenous leukemia means precursors
are RBC, monocytes, megakaryoctyes
183
which form of luekemia is most responsive to therapy
acute lymphoblastic leukemia (ALL)
184
1. which form of leukemia is the most malignant type
| 2. which form of leukemia is the LEAST malignant type
1. acute myeloblastic leukemia (AML)
2. chronic lymphoid leukemia (CLL)
= rarely affects pp under 40 and has very slow progression
185
which leukemia is associated with Philadelphia chromosome
chronic myeloid leukemia (CML)
186
mnemonic to remember leukemias
```
AM = most malignant M = most
CL = least malignant think L = least
CM = Ph
AL = most responsive
```
187
the principal organ involve in acute leukemia is
bone marrow
188
in ___ leukemia the abnormal myeloblast cells grow rapidly and do not mature
acute myeloblastic leukemia (AML) = most malignant form
189
in acute lymphoblastic leukemias, the growth of the lymphoblasts are not as rapid as that of the myelpoblastic cells. the cells tend to
accumulate.
190
common to both types of leukemia is the
inability of carry out the functions of healthy white blood cells.
191
blast cells are
immature precursor of either lymphocytes (lymphoblasts) or granulocytes (myeloblasts)
192
blast cells are predominant in acute/chronic leukemia
acute
193
petechiae and ecchymosis
| feature of?
small (1 - 2 mm) red or purple spot on the skin, caused by a minor hemorrhage
acute leukemia
194
1. Laboratory findings in ____ leukemias: leukocytosis: 30,000 - 100,000 per cu.mm
2. leukocytosis above 100,000 per cu.mm with ___ forms predominating
```
1. acute = with immature forms of myeloblasts and lymphoblasts predominating
2 chronic,
mature forms (granulocytes and lymphocytes)
```
195
in 75% of the cases of acute lyphocytic leukemia, the lymphocytes are neither T or B cells and are called
null cells
196
Acute leukemia occur most often in children/adults and exhibit a second peak incidence after __ years of age
children
| 60
197
Luekemia can or cannot modify the inflammatory reaction
can modify
198
Philadelphia chromosome and low levels of leukocyte alkaline phosphatase are common characteristics of which type of leukemia
chronic myeloid leukemia
```
remember mneumonic
AM = most malignant M = most
CL = least malignant think L = least
CM = Ph
AL = most responsive = highest survival
```
199
Ph Chromosome describes a ___
TRANSLOCATION b/w chromosome 9 and 22. the resulting abnormal gene codes for enzyme tryrosine kinase that drives the growth of CML cells. (chronic myeloid leukemia)
200
although no definitive cause of leukemia, possible risk factors:
1. genetic predisposition: __ has higher incidence of acute leukemias
2. environmental exposure to chemicals like____
3. radiation usually involves ___ type leukemias
4. viruses like ___
1. down syndrome
2. benzene and some anti cancer drugs
3. myelogenous
4. HTLV-1 = ADULT T CELL LEUKEMIA AKA Human T-lymphotropic virus 1. leukemic patients may have antibody titer to EBV
201
Human T-cell lymphotropic virus or human T-lymphotropic virus type 1 (HTLV-I), also called the adult T-cell lymphoma virus type 1, is a ___ that has been implicated in several kinds of diseases including very aggressive adult T-cell lymphoma
retrovirus
202
immunoglobulins are glycoproteins found in blood serum synthesized by plasma cells in the
spleen and lymph nodes
203
Arthus reaction is a type of __reaction
local type III hypersensitivity
204
___ have two roles:
| they can act as antigen receptors bound to the plasma membrane of B cells or as antibodies free in fluid
immunoglobulins
205
immunoglobulins are composed of 4 polypeptide chains: 2 light chains made of ___ and two heavy chains =
```
light = kappa/lamda (think L = lamda and k right before it)
heavy = alpha, delta, episolon, or mu
```
206
the type of heavy/light chain determines the immunoglobulin isotype?
heavy chain
207
heavy chains = alpha, delta, episolon, or mu make?
```
Alpha = IgA
delta = IgD
epsilon = IgE
mu = IgM
```
208
the only immunoglobulin in mucosal secretions
IgA
209
the only immunoglobulin that can cross the placenta
IgG
210
this immunoglobulin principal biological effect is anaphylaxis
IgE
211
this immunoglobulin principal biological effect is B cell activation
IgD
212
this immunoglobulin principal biological effect is resistance, precipitin, and is the primary responder (1st responder on the scene)
IgM
213
precipitin is
is an antibody which can precipitate out of a solution upon antigen binding. (IgM)
214
which immunoglobulin principal biological effect is opsonin, secondary response, resistance
IgG
215
which Ig principal site of action is the serum
IgM
216
which Ig principal site of action is the serum and tissue
IgG
217
which Ig principal site of action is the mast cells
IgE
218
which Ig principal site of action is the secretions
IgA
219
which Ig principal site of action is as the receptor for B cells
IgD
220
which Ig principal biological effect is B cell activation
IgD
221
most abundant to least abundant Ig
IgG >>> IgA > IgM > IgD > IgE
| 85% 15% 10% < 1%
222
which Ig is a dimer
IgA
223
which Ig has the largest molecular mass
IgM > IgE > IgD > IgA > idG
224
which Ig has the longest serum half life
IgG (23 days) > IgA (6days) > IgM (5 days) > IgE/IgD (2-3 days)
225
Ig __ is the most abundant and second responder
IgG
226
Ig __ is the first responder
IgM (think momma comes first then comes Grandma)
227
a patient with a true allergy to a medication is unknowingly injected with a medication. this will lead to:
1. systemic anaphylaxis
2. localized anaphylaxix
3. hyperglobulinemia
1. systemic anaphylaxis
228
death by anaphylaxis usually caused by
constriction of airways and swelling of epiglottis
229
Immediate treatment of anaphylactic shock:
1. injection of epinephrine IM or subcutaneously into a ___patient
2. Injection of epinephrine IV
3. must always maintain ___
1. conscious patient
2. unconscious
3. airway
230
1. CPR is administered when someone’s ___(or both) stops.
| 2. It is a procedure that is as simple as ABC: which stands for?
1. breathing or pulse
| 2. Airway, Breathing and Circulation
231
epinephrine stimulates reformation of
tight junctions bw endothelial cells. this reduces their permeability and prevents fluid loss from the blood. it also relaxes bronchial smooth muscle and stimulates the heart
232
what may be given to further reduce symptoms of anaphyhlaxis (after life saving measures and epinephrine administered)
antihistamines such as diphenhydramine (Benadryl) and corticosteroids such as prednisone.
233
the most common cause of systemic anaphylaxis is an allergy to ___
penicillin and related antibiotics
234
cellular immunity is immunity mediated by
t lymphocytes
235
cellular immunity common in type _ hypersensitivity
3 delayed
236
cellular immunity is immunity produced by activation of
B lymphocytes
237
1. during complement activation, _ and _ are cleaved into two fragments
1. C3 and C5
238
C3b and C5b continue in the complement pathway while C3a and C5a which are also active will
increase inflammation at the site of complement activation via binding to receptors on several cell types
239
in some cases C3a and C5a induce _ and are therefore called ___
anaphylaxic shock = acute inflammatory response that occurs simultaneously in tissues throughout body
C3A AND C5A = CALLED ANAPHYLATOXINS
240
Of the anaphylatoxins, which one is more stable and more potent?
C5a is more stable and more potent than C3a
241
Phagocytes, endothelial cells, and mast cells have receptors for
the anaphylatoxins (C3a and C5a)
242
anaphylatoxins induce
1. __ of smooth muscle
2. ___ of mast cells and basophils
1 contract smooth muscle
2. degranulation of mast cells and basophils = increase capillary permeability, increase blood flow and vascular permeability.
243
C5a also acts directly on neutrophils and monocytes to
increase their adherence to blood vessel wall and acts as a chemoattractant to direct their migration toward the site.
244
which one is more common: anaphylaxis caused by complement components or anaphylaxis caused by Type 1 (IgE mediated) hypersensitivity
anaphylaxis caused by Type 1 (IgE mediated) hypersensitivity
245
complement fixationis the binding of complement as a result of its interaction with immune complexes = ___ or particular surfaces = ____-
immune complexes = classical pathway
| particular surfaces = alternative pathway
246
Wassermann test is for?
Syphilis = an antibody test for syphilis
247
only which antibodies can fix complement?
IgM and IgG
248
atopy =
exaggerated IgE response to allergen due to hereditary allergy
249
exaggerated IgE response to allergen, a condition known as atopy, manifests itself into
dermatitis, rhinitis, asthma
| TYPE 1 Hypersensitivity rxns, IgE
250
a child w/ one parent who has suffered allergies runs 30% risk of also being allergic. if both parents =
60% risk
| however allergies can JUMP a generation (skip)
251
allergic rhinitis is aka
hay fever = occurs when allergen interacts with sensitized cells of upper respiratory tract. coughing sneezing congestion teary eyes respiratory difficulties.
primary mediator is histamine
252
allergic asthma = rxn of __ respiratory tract. common in?
lower. common in children
253
Atopic dermatitis aka eczema = chronic skin disorder = scaly itchy rashes. it is most common in?
infants
254
most frequently used diagnostic lab technique for detection of antigens in tissue secretions or cell suspensions?
immunofluorescence = fluorescent dye such as fluorescein and rhodamine covalently attached to antibody = visible in uv light. this is a labeled antibody used to identify antigens on the surface of bacteria
255
___ method used for QUANTIFICATION of antigens or haptens (a small molecule that can elicit an immune response only when attached to a large carrier such as a protein) that can be radioactively labeled
radioimmunoassay (RIA)
256
Enzyme linked immunosorbent assay (ELISA)
quantification of antigen or antibodies in patient specimens
257
precipitation (Precipitin)
antigen is the solution, antibody is cross linked = aggregates and precipitates out
258
in this test the antigen is a particulate (bacteria/rbc). antibody (agglutinins).
agglutination
259
__ is the basis for blood typing and distinguishes presence of type A or type B antigen on RBC
hemagglutination
260
which MAJOR complement activation pathway is triggered by infection but does not involve antibody
alternative pathway
261
Complement activation is a feature of type __ hypersensitivity rxn
3 (delayed)
262
3 major pathways of complement activation are?
classical, alternative, and lectin
263
the __ pathway is activated by antibody bound to antigen ad involves C1, C4, and C2 in the generation of C3 and C5 convertase
classical
264
the __ pathway is activated by binding of mannose-binding lectin present in blood plasma to mannose-containing peptidoglycans on bacterial surfaces
lectin
265
the alternative and lectin pathways are activated in an antibody __ fashion
independent
266
all pathways of complement lead to
C3 activation, deposition of C3b on the pathogens surface
267
C3 is unique and potent because of its
high energy thioester bond with glycoprotein
268
cytolysis
lysis of bacteria or cells such as tumor or RBC's by insertion of MAC (membrane attack complex) derived from complement activation
269
C1 is part of ___ pathway and composed of what 3 proteins? what is required for its activation?
classical
C1q, C1r, C1s = 3 proteins
Calcium required for activation of C1
270
Acquired immunity occurs both naturally and artificially and can be active or passive. in naturally acquired immunity, if the person is exposed to the antigen and produces his own antibodies, it is called
natural acquired active immunity
271
Acquired immunity occurs both naturally and artificially and can be active or passive. in naturally acquired immunity, if mom passes IgG to fetus during pregnancy and IgA passed from mom to newborn during breast feeding, this is called
natural acquired passive immunity
272
does passive naturally acquired immunity last as long as active?
no! if mom passes IgG to fetus during pregnancy and IgA passed from mom to newborn during breast feeding, these antibodies will disappear between 6-12 months of age! so active lasts longer
273
Artificially acquired immunity, just like naturally acquired immunity can be active and passive. a vaccination with killed, inactivated or attenuated bacteria or toxoid is which one?
artificially acquired active immunity
274
Artificially acquired immunity, just like naturally acquired immunity can be active and passive. Injection of immune serum or gamma globulin is which one
artificially passive active immunity
275
1. person is exposed to the antigen and produces his own antibodies,
2. a vaccination with killed, inactivated or attenuated bacteria or toxoid
3. Injection of immune serum or gamma globulin
4. mom passes IgG to fetus during pregnancy and IgA passed from mom to newborn during breast feeding,
1. naturally acquired active immunity
2. artificially acquired active immunity
3. artificially acquired passive immunity
4. naturally acquired passive immunity
276
in __ immunity the host actively produces immune response.
active
277
1. the main advantage of active immunity is
| 2. the main disadvantage is
the resistance is long term (years)
| 2. slow onset
278
in __ immunity, antibodies are PREFORMED in another host. it is not as permanent and does not last as long as active immunity
passive
279
tetanus and snake venom are examples of __ immunity
passive
280
the main advantage of passive immunity is
| the main disadvantage is
```
immediate availability of antibodies
short duration (months)
```
281
a small molecule that is not antigenic by itself that can react with antibodies is called
a. epitope
b. hapten
c. plasmid
d. immunogen
hapten (incomplete immunogens) have antigenic determinants but are TOO SMALL to elicit the formation of antibodies by themselves they become immunogenic (provoke immune response) by attaching to a CARRIER MOLECULE such as a protein.
282
haptens are NOT immunogenic because they cannot
activate helper T cells
283
antibody production involves activation of __ lymphocytes by hapten and helper T lymphocytes by the __
1. B = hapten
| 2. T = carrier
284
___ is any substance that can specifically bind antibodies or the T cell antigen receptor
an antigen
285
antigens that can stimulate an immune response are called
immunogens
286
T/F all immunogens are antigens
true
287
T/F all antigens are immunogens
false
288
a large variety of molecules can bind antibodies like
proteins carbs lipids nucleic acids
289
only __ are recognized by T cells
peptides
290
in order to immunogenic, antigens must be foreign with a high/low MW
high
291
Plasmids are extrachromosomal genetic structures that can replicate independently in bacterial cell. they determine traits that are/are not essential for the viability of the organism
are not essential.
they change the ability to adapt
292
R (resistance) factor (Rf) is an example of a
plasmid
293
most antibiotic resistance in bacteria is caused by genes that are carried on DNA/plasmids
plasmids
294
___ is the specific portion of an antigen to which the antibody binds
epitope
295
type of immunity that is conferred by transferring lymphoid cells from an actively immunized donor to a naïve or immunocompromised host
adoptive immunity
296
__immunity occurs naturally as a result of a person's genetic constitution or physiology and DOES NOT ARISE from a previous infection or vaccination
natural/innate immunity
297
in contrast to acquired immunity, natural immunity is
1. specific/nonspecific
2. does/does not improve after exposure to organism
3. memory?
1. non specific (acquired is specific)
2. does not (acquired does)
3. no memory (acquired has LONG TERM MEMORY)
298
__ immunity is conferred by antiserum or antibodies. it grants immediate protection but is only temporary
passive
299
_ immunity is acquired by introducing an antigen which in turn provokes an adaptive immune response
active
300
__ immunity is conferred by transferring LYMPHOID CELLS from an actively immunized donor to a NAIVE OR IMMUNOCOMPROMISED HOST
ADOPTIVE IMMUNITY
301
T/F the complement system is a group of plasma proteins that attack pathogens
true
302
complement proteins are made in the
liver.
| some are made in macrophages
303
C1 in complement is made in
GI epithelium
304
Complement system is a system of 30 SOLUBLE and cell-surface proteins that act in innate and adaptive immunity. soluble means
not contained in cells. ie antibodies, cytokine. soluble substances act as messengers to attract and activate other cells.
305
the classical pathway is initiated in the INNATE immune response by the binding of __ to bacterial surfaces and
in the adaptive immune response by the binding of __ to pathogen surfaces
C-reactive protein
| antibodies
306
the alternate pathway is triggered by changes in the local environment that are caused by bacterial surfaces. this pathway acts at the ___ times during infection
earlies
307
the lectin pathway is initiated by the
mannose binding lectin (MBL) in plasma which bind to carbs found on bacterial cells and other pathogens. this pathways is induced by infection and contributes to innate immunity
308
Complement protein C5 is similar to C3 in structure but lacks the
thioester bond and has a different function
309
__ initiates the formation of the MAC
C5
310
After MAC makes holes in the membrane of bacterial pathogens and euk cells, C6 and C7 bin to ___
C5b = expose a hydrophilic site in C7 which inserts into the lipid bilayer
311
When C8 binds to C5b, a hydrophobic site in C8 is exposed and on insertion into the membrane, this part of C8 initiates
polymerization of C9 = the component that forms the transmembrane pores
312
Slow-reacting substance of anaphylaxis or SRS-A
which is stronger histamine or SRS-A?
a mixture of the leukotrienes LTC4, LTD4 and LTE4. Mast cells secrete it during the anaphylactic reaction, inducing inflammation. It can be found in basophils.
It induces prolonged, slow contraction of smooth muscle and has a major bronchoconstrictor role in asthma. Compared to histamine, it is approximately 5000 times more potent and has a slower onset but longer duration of action.
313
1. mast cell is a resident granulocyte of several types of tissues that contains many granules rich in ___ and __
2. are mast cells the same as basophils
1. histamine and heparin.
2. no. The mast cell is very similar in both appearance and function to the basophil, a type of white blood cell. However, they are not the same, as they arise from different cell lines. Both are granulated cells that contain histamine and heparin, an anticoagulant. Both cells also release histamine upon binding to immunoglobulin E. Basophils leave the bone marrow already mature, whereas the mast cell circulates in an immature form, only maturing once in a tissue site.
314
1. ___ is responsible for the principal symptoms of anaphylaxis
2. ___ are the principal mediators of asthma
1. histamine
| 2. SRS-As (slow reacting substance of anaphylaxis-A)
315
the __ reaction involves the degranulation of mast cells and the release of histamine, heparin, platelet activating factors, SRS-As, and serotonin into the bloodstream
anaphylaxis
316
1. serotonin is derived from what amino acid?
| 2. epinephrine and norepinephrine are derived from what amino acid?
1. serotonin = tryptophan
| 2. epi and norE = tyrosine and phenylalanine
317
3 places you find serotonin
GI tract, platelets, and CNS
318
1. Approximately 90% of the human body's total serotonin is located in the ____, where it is used to regulate intestinal movements
2. The remainder is synthesized in serotonergic neurons of the CNS, where it has various functions. These include the regulation of ___
1. enterochromaffin cells in the alimentary canal (gut
| 2. mood, appetite, and sleep
319
1. Serotonin secreted from the enterochromaffin cells eventually finds its way out of tissues into the blood. There, it is actively taken up by ____, which store it. 2. When the platelets bind to a clot, they release serotonin, where it serves as a vaso____ and helps to regulate hemostasis and blood clotting. Serotonin also is a growth factor for some types of cells, which may give it a role in wound healing.
blood platelets
| vasoconstrictor
320
1. Leukotrienes are ___ synthesized from
2. Prostoglandins are ___ synthesized from
3. leukotrienes and prostaglandins are known as
4. ___ cells synthesize and secrete these inflammatory mediators upon activation
1. lipids, fatty acids
2. lipids, fatty acids
3. eicosinoids
4. mast cells
321
Leukotrienes are a family of eicosanoid inflammatory mediators produced in _____ by the oxidation of arachidonic acid by the enzyme arachidonate 5-lipoxygenase
leukocytes
| leuko-triene = comes from the words leukocyte and triene (indicating the compound's three conjugated double bonds).
322
One of their roles (specifically, leukotriene D4) is to trigger ___ in the smooth muscles lining the bronchioles; their overproduction is a major cause of inflammation in asthma and allergic rhinitis.[
contractions
323
arachidonic acid is generated by inflammatory and injured tissues: it is metabolized thru 2 pathways:
1. cyclooxygenation = produces __ and ___
2. lipooxygenation producese __ and _ and _
1. prostaglandins and thromboxanes
| 2. leukotrienes and HETEs and diHETEs
324
leukotrienes activities are similar to those of histamine, which are more potent leukotrienes or histamine
lueukotrienes are 100x more potent
325
histamine provides a more __ response while leukotrienes are still being made. in the later stages of allergic reactins, leukotrienes are principally responsible for inflammation, smooth muscle contraction, constriction of airways and the secretion of mucus from mucosal epithelium
rapid
326
Luekotrienes C4, D4, and E4 are collectively known as __ and are responsible for much of the clinical symptoms of allergic rxns
slow reacting substances of anaphylaxis (SRS-As)
327
what are the main antibodies present in blood, lymph, and the intracellular fluid in CT
IgG, monomeric IgA, IgM
328
which antibody is dimeric
secretory IgA
329
__ antibody lines mucosal epithelium in GI, eyes, nose, throat, respiratory, urinary, genital, and mammary glands
dimeric secretory IgA
330
IgA has two subclasses (IgA1 and IgA2) and can exist in a dimeric form called secretory IgA (sIgA).The secretory component of sIgA protects the immunoglobulin from being degraded by proteolytic enzymes, thus sIgA can survive in the harsh gastrointestinal tract environment and provide protection against microbes that multiply in body secretions. Its heavy chains are of the type
α
331
1. IgA exists in two isotypes, IgA1 and IgA2. While ___predominates in serum (~80%),
2. ___ percentages are higher in secretions than in serum (35%)
1. IgA1
| 2. IgA2
332
1. ___ is the predominant IgA subclass found in serum. Most lymphoid tissues have a predominance of IgA-producing cells
IgA1
333
In secretory IgA, the form found in secretions, polymers of IgA monomers are linked by two additional chains; as such, the molecular weight of slgA is 385,000D. One of these is the ___, which is a polypeptide of molecular mass 15kD, rich with cysteine and structurally completely different from other immunoglobulin chains. This chain is formed in the IgA-secreting cells.
J chain (joining chain)
334
1. ____IgA circulates in the blood and is produced in the bone marrow by plasma cells derived from B cells activated in lymph nodes or the spleen.
2. __ IgA is secreted in mucosal tissues by plasma cells that derive from B cells activated in the mucosal immune system.
1. monomeric
| 2. secretory
335
which IgA has little capacity or opportunity to activate complement or act as an opsin and cannot induce infalammation
secretory IgA
336
IgA is one of the most prevalent humoral antibodies produced by the body. it is only second to
IgG
337
___ is always the first antibody to be secreted in the immune response
IgM (remember momma always comes first, then Grandma)
338
during the secondary humoral immune response (a second exposure to the same antigen, for example when a person receives a third immunization with tetanus toxoid, a more rapid and greater response ensues which is predominantly composed of __ antibody
IgG (not IgM)
339
as the severity of the infection increases (ex. periodontal disease), there is an increase in plasma cells that produce __ antibody
IgG
340
the most important function of __ antibodies is to facilitate the engulfment and destruction of extracellular microorganisms and toxins by phagocytes
IgG
341
no function is known for __ antibodies other than as a membrane receptor
IgD
342
_ is the immunoglobulin responsible for allergic or anaphylactic reactions
IgE
343
universal donor blood type
O. bc O has no antigens
344
AB has what antigens (agglutinogens) and what antibodies (agglutinins)
AB has A and B agglutinogens
| and no agglutinins (antibodies) = universal recipients
345
if blood was incorrectly cross matched and transfused, it would cause agglutination of the donor/recipients erythrocytes
donor
346
contact dermatitis is what type of hypersensitivity rxn
type IV
347
IgE is involved in what type of hypersensitivity rxn
Type 1
348
IgG is involved in what type of hypersensitivity rxn
Type II and Type III
349
1. humoral and cell mediated immunity are part of innate/adaptive immunity
2. __ immunity provides immunity against EXTRACELLULAR pathogens
3. __ immunity is mediated by antibodies produced by B cells
4. __ immunity antibodies neutralize and eliminate pathogens and toxins from the blood, mucosal surfaces and lumen of organs
1. adaptive
2. humoral = extracellular
3. humoral
4. humoral
350
___ immunity is designed to provide immunity against INTRACELLULAR pathogens
2. it is mediated by T cells which activate macrophages to kill phagocytosed microbes (T-Helper cells) and kill infected cells = eliminating infection (Cytotoxic T cells)
1. cell mediated immunity
351
MHC molecules are membrane glycoproteins that are/are not secreted by cells
are not secreted by any cells
352
MHC genes are highly polymorphic group of genes. The MHC genes are located on short arm of chromosome 6. they are divided into 3 subgroups: MHC1, MHC1, and MHC class3. Classes __ code for glycoproteins and class_ codes for proteins of the complement system (C2, C4 and factor B_
```
class 1 and 2 = glycoproteins
class 3 = complement proteins
```
353
MHC class __ are expressed on all nucleated cells
MHC Class 1
354
1. MHC Class 1 is recognized by CD__ T cells
| 2. MHC Class 2 is recognized by CD__T cells
1. Class 1 = CD8+ Tcells
| 2. Class 2 = CD4+ Tcells
355
in humans the MHC molecules are referred to as __
Human Leukocyte Antigens (HLA). HLA tissue typing is used to match donated tissue/organs/one marrow with transplant recipients. A mismatch results in acute rejection of the transplanted tissue
