Pathology Flashcards
Fibroadenoma
Common in young women <30
“breast mice” - discrete, non-tender, firm lumps
Benign
Abscess
Common in lactating women.
Red, hot, tender swelling
More common in smokers
Pagets disease of the breast
Ca of the nipple-areolar complex presenting as an eczematous lesion of the nipple
Most associated with invasive BC
Usually unilateral
Fat necrosis
Obese W with large breasts
May follow trauma
Firm and round but may become irregular/hard
Fibrocystic breast
Breast pain - sx may fluctuate with menstrual cycles
Middle aged
Rubbery, well circumscribed, mobile mass
Intraductal papilloma
Bloody nipple discharge
Younger
Mammary duct ectasia
Dilatation of breast ducts
Common in meno W
Smokers
Thick + green discharge
Consequences of acute inflammation
Resolution
Scarring/fibrosis
Progression to chronic
Vascular changes in acute inflammation
Vasodilation (arterioles)
Increased permeability (capillary bed/venules)
Leukocyte margination
Leukocyte emigration
Margination - (stasis) movement to the periphery of the BV
Rolling - weak binding to endo by selectins
Adhesion - firm adhesion to endo by integrins
Transmigration
Clinical aspects of acute inflammation
Calor Rubor Tumour Dolor
Heat, redness, swelling, pain
Anti-inflammatory therapy
Broad spectrum e.g. NSAIDs - inhibit COX1/2 involved with arachidonic acid metabolism
Targeted treatments e.g. Anti-TNF antibodies, Anti-ICAM1
Stages of phagocytosis
Recognition + attachment of particle to leukocyte
Engulfment
Killing + degradation
Causes of chronic inflammation
Progression from acute e.g. repeated episodes of cholecystitis
Primary chronic e.g.micro-organisms associated with intracellular infections ( hep C, TB) or foreign body reactions (silica, atherosclerosis), or autoimmune diseases or unknown aetiology e.g. chronic IBD, sarcoidosis
Ratio of fat to haemopoietic cells in the BM?
30:70
Fat tissue is an important diagnostic criterion as it is increased in marrow aplastic states + decreased in myeloproliferative disorders
Erythrocyte in a BM sample
Looks purple + round
Granulocyte in BM sample
Looks pink with purple shaped thing inside
What does a megakaryocyte become?
A platelet
Megakaryocyte on a BM sample
Quite large - pink with purple in the middle (like granulocyte but a lot bigger)
Diagnosis of CLL on a BM film
Tumour cells express CD20 and CD23
Marrow shows nodular + diffuse infiltration by small lymphocytes with scanty cytoplasm, clumped chromatin and low mitotic activity
Diagnosis of CML on a BM film
BM is hyper cellular as attested by decrease in fat cells
and shows majority of mature (hyper segmented) neutrophil granulocytes
Diagnosis of AML on BM film
Hyper cellular marrow with monotonous proliferation of undifferentiated cells
High rate of proliferation as attested by expression of Ki67 molecule within nuclei of tumour cells
Proliferating blasts express CD34
More than 90% of causes of transmural MI are due to..
Acute thrombosis of a ruptured atherosclerotic plaque
What precipitates angina in patients with underlying coronary artery atherosclerosis
An increase in HR - increases demand for energy + decreases duration of diastole relative to systole therefore decreases time of myocardial perfusion
Reduced BP - less pressure to overcome resistance of stenotic arteries + there is associated increased in HR which increases the myocardial energy requirements and decrease time for perfusion of heart
What does the RCA supply?
RV free wall, posterobasal wall of LV and posterior third of ventricular septum
What does the L circumflex supply?
Lateral wall of L ventricle
What does the LAD supply?
Anterior wall of LV, apex of heart + anterior 2/3 of interventricular septum
Occlusion of the LAD artery produces a …. infarct
Anterior
Occlusion of the L CFX artery produces a …. infarct
Lateral
Occlusion of the RCA produces a …. infarct
Posterior
Pulmonary HTN results in which sided HF?
Right
Which type of HF causes congestion of the liver with a nutmeg liver
Right
Which type of HF causes impairment of renal function due to hypoperfusion of the kidneys?
Left
Which type of HF causes impairment of renal function due to congestion of the kidneys?
Right
Is rheumatic heart disease related to RA?
Yes - occurs in 20-40% of severe prolonged RA. Most common finding is fibrinous pericarditis
Most common long term problem of rheumatic heart disease?
Mitral stenosis
Does rheumatic heart disease predispose to infective endocarditis?
Yes - deforming fibrotic valvular disease is a feature of chronic rheumatic heart disease. Valve abnormalities predispose to infective endocarditis
Most common cause of sudden explained death in young athletes
Hypertrophic cardiomyopathy
3 types of cardiomyopathy
Dilated cardiomyopathy
Hypertrophic cardiomyopathy
Restrictive cardiomyopathy
There are overlaps of features between the groups
Most common primary tumour of the heart
Atrial myxoma
What is bronchopneumonia?
Inflammation of the lung beginning as inflammation of bronchi and bronchioles with extension into adjacent alveolar spaces
What is lobar pneumonia?
Acute inflammation of the lung in which a large part of a lobe or an entire lobe is involved (acute bronchi pneumonia is different because it is patchy)
4 classic stages of lobar pneumonia
Congestion in the first 24h
Red hepatisation or consolidation
Grey hepatisation
Resolution
Complications of acute pneumonia
Death Lung abscess Empyema Spread of infection - meningitis, arthritis, IE Fibrosis of lung
Causes of lung abscesses
Acute pneumonia
Septic emboli
Puncture wounds of the chest
What are opportunistic infections that HIV pts may develop in the lung?
TB pneumocystis carinii Cytomegalovirus Herpes simplex virus Varicella-zoster Atypical mycobacteria Aspergillus
What conditions predispose to PE?
Immobility Pregnancy COCP CHF Thrombosing disorders
Consequences of PE?
Many have no effect as undergo fibrinolysis + disappear
Large emboli may cause sudden death
Repeated small emboli may lead to fibrous narrowing of small pulmonary arteries causing pulmonary HTN
An embolism may cause pulmonary infarction but only if there is HF with a rise in pressure in the pulmonary circulation
Changes seen in bronchial lining of smokers?
Squamous metaplasia
Increased no. of mucous glands
Epithelial atypia leading to carcinoma in situ
What may be local effects of a bronchial carcinoma?
- Bleeding into a bronchus
- Obstruction of a bronchus causing bronchopneumonia, lung abscess, bronchiectasis or collapse of lobe
- Pleural effusion
- Invasion of recurrent laryngeal nerve causing hoarseness
- Invasion of ribs, oesophagus, phrenic nerve, SVC or pericardium
- Invasion of symp chain causing Horner’s syndrome
Common patterns of metastatic neoplasia in the lung?
Multiple small masses
Few large masses = cannon ball
What is ARDS?
Defined clinically as acute respiratory failure with decreased arterial oxygen content, decreased lung compliance so lungs are stiff and diffuse lung infiltrates on XR.
Pathologically - diffuse alveolar damage with oedema, haemorrhage and hyaline membranes in alveolar ducts in early stages with fibrosis later
What is pneumoconiosis?
Non-neoplastic lung condition caused by inhalation or inorganic or organic particles
Most common cancer in the kidney?
Renal cell carcinoma - don’t confirm with biopsy because of risk of dissemination of cancer along needle track - yellowish mash with degenerate, cystic areas
Transitional neoplasia much less common
Kidney is unusual site for metastatic carcinoma
Spread of renal cell carcinoma
May be local invasion of kidney, fat around kidney + renal pelvis that leads to haematuria. Main route of spread is into renal vein + then dissemination to lungs, bones + sometimes unusual sites e.g. skin
Lymph node spread is not common
Investigations for MS
MRI - plaques of demyelination and exclude other diagnoses
Oligoclonal bands in the CSF
Visual evoked potentials (VEPs) on an EEG
Pathology of MS
Multiple, discrete areas in white matter where axons have lost myelin sheaths + early active stage - inflammatory changes
Lesions scattered through the CNS and can appear anywhere but certain sites: optic nerves, SC and periventricular sites such as corpus callosum
Huntington disease pathology
Atrophy of corpus striatum (caudate nucleus + putamen) with some compensatory dilatation of the lateral ventricles
Huntingtons
Repeat of CAG in gene for protein huntingtin. 38+ repeats in individuals with HD.
Anticipation occurs in children as number of repeats can increase at meiosis
How is HSV encephalitis in the immunocompetent managed?
If acyclovir is given in early stages - both mortality + morbidity are reduced
Which heart murmur presents with pulsatile hepatomegaly?
Tricuspid regurgitation - backflow of blood into liver during cardiac cycle
where does LDL build up in atherosclerosis?
Tunica intima
which arteries are more prone to atherosclerosis?
Abdo aorta Coronary ateries Popliteal arteries Thoracic aorta Internal carotids Circle of Willis
Most common cause of ischaemic heart disease?
90% is due to atherosclerosis
What is critical stenosis?
> 75% reduction in diameter of the artery
Leads to compensatory vasodilation but not enough to meet increased demands
Consequences of atherosclerosis
Narrowing - plaque size protrudes into lumen, overlying thrombus, haemorrhage into plaque
Dilation (aneurysm) - rupture, mural thrombi which can embolise
Thrombosis Plaque rupture Haemorrhage Wall weakening Calcification
Stable v unstable plaque
Stable = thick fibrous cap
Unstable = no thick cap, risk of rupture/fissure, emboli +/- thrombosis
What aggravates ischaemic heart disease?
Hypertrophy - more muscle so need more oxygen
Hypotension - less pressure to overcome resistance in arteries + compensatory rise in HR
Hypoxaemia
Increased HR
Difference between angina + MI ?
Cell death (necrosis)
Transmural MI
Full thickness of the wall
Usually associated with acute thrombosis/occlusion of vessel. Occasionally related to vasospasm or emboli
Subendocardial MI
inner 1/3 to 1/2 myocardium
Usually critical stenosis but no acute plaque change
At how many hours do you see MI?
Histologically - 4hrs
Macroscopically - 12h
Preconditioning
Repetitive short lived ischaemia may be protective
Complications of MI?
Cardiogenic shock Arrhythmias Myocardial rupture - tamponade, Pericarditis Ventricular aneurysm
Compensatory mechanisms of heart in HF
Dilatation - increased preload
Hypertrophy - increase in size of myocytes
Neurohumoral mechanisms
L sided HF
Pulmonary oedema
Organ ischemia - impaired renal function (high creatinine)
R sided HF
Peripheral oedema
Congestion of organs
Ascites/pleural effusion
What is pure R sided HF called?
Cor pulmonale (uncommon)
How does systemic HTN affect the L V?
LV hypertrophy
No dilation of LV
Increased heart weight
Thick wall
Impaired diastolic filling
Histological features of hypertrophy
Increased size of myocyte
Increased nuclear size
Interstitial fibrosis
Valvular heart disease - stenosis
failure of valve to open completely - impedes forward flow of blood
Valvular heart disease - incompetence
Regurgitation - failure of valve to close so allows reverse flow of blood
What is functional regurgitation?
valves become imcompetent due to dilation of ventricles (valve gets stretched so ends can’t touch)
Most common functional valvular lesions
Mitral stenosis
Mitral incompetence
Aortic stenosis
Aortic incompetence
Mitral stenosis
From rheumatic heart disease
Mitral incompetence
Floppy mitral valve
Aortic stenosis
Calcification of normal + congenitally bicuspid aortic valves
Aortic incompetence
Dilation of ascending aorta related to HTN + age + connective tissue disorders
Most common type of valvular heart disease?
Mitral regurgitation due to floppy mitral valve
What is rheumatic fever?
Occurs a few weeks after group A b-haemolytic streptococcal pharyngitis
Thought to by hypersensitivity reaction induced by group A strep
Signs and symptoms of rheumatic fever
Fever
Painful joints
Involuntary muscle movements
Non itchy rash - erhythema marginatum
Most important complication of rheumatic heart disease
Chronic rheumatic heart disease - characterised by:
- Deforming fibrotic valvular disease (especially mitral stenosis)
- Fish mouth/button hole stenosis
- Chordea tendinae become fibrotic + stick togther
How many cases of mitral stenosis are caused by rheumatic heart disease?
99%
What does infective endocarditis cause on the heart?
Thrombotic debris
Organisms
Types of infective endocarditis
Acute - previously normal valve, acute onsent, 50% mortality, necrotising + ulcerative destruction
Subacute - abnormal valve, insidious onset, most recover, less destructive
Which organisms cause acute endocarditis?
S aureus
Pneumococcus
S pyogenes
Which organisms cause subacute endocarditis?
Strep viridans
Enterococci
Which organism causes IE on prosthetic valves?
Staph epidermis
Which valves are most commonly affected in IE?
Aortic + mitral
Tricuspid in IVDU
Complications of IE?
Myocardial abscess Valve rupture/perforation Systemic emboli Septic emboli Immune complexes e.g. in kidney
What is nonbacterial thrombotic endocarditis?
Deposition of fibrin/plt thrombi on valve - quite small
on a normal valve
non-destructive
3 types of cardiomyopathy
Dilated (90%)
Hypertrophic
Restrictive (least common)
Overlap of features in each group + spectrum of severity
Causes of dilated cardiomyopathy
Most idiopathic Alcohol Genetics Haemachromatosis Drugs Sarcoidosis
EF in dilated cardiomyopathy
25%
Hypertrophic cardiomyopathy
Myocardial hypertrophy - wall thick + assymetric with IV septum thicker than LV wall
No ventricular dilation
Interstitial fibrosis
When does the septum become wider than the wall?
Hypertrophic cardiomyopathy
Restrictive cardiomyopathy
Normal sized ventricles + chambers
Both atrial dilated
Firm myocardium
Get decreased ventricular compliance so impaired filling
Most common cause of myocarditis
Viruses
What is myocarditis
Inflammatory process of the myocardium which results in injury to cardiac myocytes
Causes of pericarditis
Infections, immune mediated, MI, uraemia, trauma
Types of pericarditis
Serous - clear fluid Fibrinous - fibrin Purulent - pus Haemorrhagic - blood Caseous - TB
What does metastatic melanoma in heart look like?
Black dots through myocardium
Right to left shunt
Blood shunted from pulmonary to systemic circulation Cyanotic 5 't's: - Tetralogy of fallot - Transposition of great arteries - Perisistent Truncus arteriosus - Tricuspid atresia - Total anomalous pulmonary venous connection
L to R shunt
Get pulmonary HTN
ASD
VSD
Patent ductus arteriosus
AV septal defect
