Pathology Flashcards by Christine Le

OSTEOMALACIA

Softening of bone as a result of calcification failure due to vitamin D or calcium deficiency.
Can occur with renal tubular acidosis, paraneoplastic syndromes, renal failure
Chronic fatigue, bone pains and arthralgias, proximal muscle weakness, waddling gait, excessive lordosis, hypocalciuria, hypocalemia, hypophosphatemia, elevated alkaline phosphatase
Complications include nonreversible bone deformities and bone fractures

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RICKETS

Defective mineralization of the osteoid matrix resulting in weakened bone
Occurs in children
Caused by deficient vitamin D and/or calcium and excess calcium loss
Often asymptomatic, bowing of long bones (genu valgum), contracted pelvic outlet, generalized tenderness, craniotabes, delay in fontanelle closure, costochondral junction thickening (Rachitic rosary), depression along the diaphragmatic insertion along the ribcage (Harrison’s groove), Pigeon breast, short stature, hypocalcemia, hypophosphatemia, elevated alkaline phosophatase,
Complications include nonreversible bone deformities and bone fractures

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SCURVY

Connective tissue breakdown as a result of vitamin C deficiency
Impaired synthesis of hydroxyproline and hydroxylysine
Gum breakdown, impaired wound healing, fragile capillaries, abnormal bleeding, skin lesions, muscle, joint, and bone pain, subperiosteal hemorrhage, perifollicular petechial hemorrhages, lassitude, immunodeficiency, and death

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ANKYLOSING SPONDYLITIS (AS)

Chronic autoimmune inflammation of the sacroiliac and spinal joints
90% HLA-B27+
Morning stiffness, low back and hip pain particularly at night, myalgias, anorexia, chest pain, fatigue
Complications include progressive rigidity and fixation of the lumbar spine and SI joint, iritis, aortic valve insufficiency, ascending aortitis, osteoporosis, cauda equina syndrome

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FIBROMYALGIA

Non-articular rheumatic disorder with diffuse MSK pain, tender points, and non-restorative sleep
Point tenderness, aching and stiffness of the lower back, hips, trunk, and shoulders, hypermobility and joint laxity is common, myalgia, chronic fatigue, debilitating pain, insomnia due to pain, chronic illness, brain fog
Often associated with depression

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GOUT

Deposition of urate crystal in tissues, particularly joints, due to high levels of uric acid in the blood.
Crystal precipitate more readily at lower temperatures
Metatarsophalangeal joint of the large toe is a common site
Acute
Precipitated by a large meal or alcohol intake
Due to IgG coating the crystals, phagocytosis by neutrophils, and the release of inflammatory mediators which cause swelling and pain.
Chronic
Long-term deposition causes the formation of nodular tophi around joints, the outer ridges of the auricle, Achilles tendon, etc.
Composed of urate crystals surrounded by fibrous connective tissue
Painful and acute inflammatory monoarthritis (commonly the big toe or knee) and gouty tophi in the chronic state.

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Polymyositis

Symmetric pain and weakness of proximal limb and neck flexor muscles, distal musculature and muscles of deglutination are less commonly involved.
Symptoms develop over several weeks to months and have a waxing-waning course.

→ CD8+ cells invade muscle, >20 yoa, MC in females

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Dermatomyositis

Heliotrope purple rash around eyes and extremities, periorbital swelling, Gottron’s papules or raised erythematous rash over bony prominences, V-shaped thoracic rash, cracked skin on hands, symmetrical proximal muscle weakness
Elevated serum muscle enzyme levels (CK), often +ve ANA, muscle biopsy is confirmatory

→ CD4+ cells invade muscle, as early as 5 yoa

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POLYMYALGIA RHEUMATICA (PMR)

Chronic autoimmune disease in the elderly
Associated with temporal arteritis
Autoimmune synovitis present in the shoulders and hips
Proximal limb (shoulder and hip) weakness and pain, difficulty walking, morning stiffness, stiffness after inactivity, pain for > 2 months, weight loss, fever, depression, malaise, elevated ESR or CRP
Eye symptoms or headache highly suggestive of temporal arteritis
Complications include temporal arteritis which can cause blindness

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REACTIVE ARTHRITIS

Autoimmune syndrome associated with HLA-B27 and systemic immune reaction to distal GI or GU infections.
Infection by Chlamydia trachnomatis, S. flexneri, Salmonella enteritidis, Shigella dysenteriae, Yersinia enterocolitica, Y. pseudotuberculosis, or Campylobacter jejuni
Triad = arthritis, urethritis, conjunctivitis/iritis/uveitis
Malaise, sacroilitis, fever, incubation period = 1-3 weeks after urethritis or diarrhea

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MYASTHENIA GRAVIS

Autoimmune disorder caused by autoantibodies to acetylcholine receptors in neuromuscular junctions.
Muscle weakness which improves with rest
Women:men = 3:1

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ACROMEGALY

Excessive GH secretion after the closure of the epiphyseal plates.
Usually from a somatotrophic pituitary adenoma
Enlargement of hands, feet, nose, lips, jaw, and ears, voice deeping due to vocal cord growth, weakening of the heart and kidneys, deadly

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OSTEOPETROSIS

Rare genetic disorders with osteoclast dysfunction resulting in decreased bone resorption
Possibly due to carbonic anhydrase deficiency in the osteoclasts
Bone production by osteoblasts continues causing bone to become denser and more brittle.
Stunted growth, fractures, deformity, anemia, recurrent infections, hepatosplenomegaly, nerve compression resulting in blindness, deafness, and facial paralysis
Calcium and phosphate levels unaffected
Alkaline phosphatase is elevated.

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CONGENITAL MYOPATHIES

Hypotonia at birth (floppy infant syndrome)

Forms
Central core disease
Loss of mitochondria and other organelles which are part of the central part of type I muscle fibers
Nemaline myopathy
Mild, non-progressive disease to severe weakness and death due to respiratory failure
Mitochondrial myopathies
Transmitted maternally as mitochondrial DNA abnormalities

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MARFAN’S SYNDROME

Autosomal dominant syndrome characterized by connective tissue dysfunction
FBN1 gene encodes fibrillin-1 which is defective and results in excessive growth factor beta levels.
Long limbs and fingers, defective heart valves and aorta, dura, skeleton, lungs, hard palate, and lens of the eye (dislocation) can be affected, proximal aortic dissection

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MUSCULAR DYSTROPHY

Group of genetic, progressive disorders characterized by degeneration of skeletal muscle and profound muscle wasting and weakness.

Duchenne muscular dystrophy (most common and severe)
X-linked recessive; caused by mutations in the dystrophin gene which encodes dystrophin
Initially presents in the proximal muscles of the extremities and causes compensatory hypertrophy of distal sites.
Pseudohypertophy of the calves (fat infiltrate, no contraction)

Becker’s muscular dystrophy (less severe)
X-linked recessive; caused by mutations in the dystrophin gene which encodes dystrophin
Slowly progressive muscle weakness of the legs and pelvis

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OSTEOGENESIS IMPERFECTA

Autosomal dominant syndrome resulting in defective connective tissue formation
Brittle bones → fractures, scoliosis, loose joints, poor muscle tone, hearing loss risk, deformity, short stature possible

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OSTEOARTHRITIS

Chronic, non-inflammatory joint disease involving the degeneration of articular cartilage and new bone (spur) formation at the margins of the joint.
Elderly women affected 10x more than men
Asymmetrical weight bearing joint and distal interphalangeal (DIP) joints
Cartilage erosion resulting in polished bone, subcondral cystic changes, osteophyte formation, and nodes (hard and painless)
Heberden’s nodes = DIP joints
Bouchard’s nodes = PIP joints

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OSTEOPOROSIS

Decrease in bone mass resulting in increased fracture risk

Type I
Associated with estrogen deficiency of menopause
Common fracture locations include the wrist and spine

Type II
Associated with aging and reduced calcium absorption
Associated with hip fractures
Results from calcium deficiency, physical inactivity, hypercorticism, hyperthyroidism

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OSTEITIS DEFORMANS

Bone breakdown initially followed by replacement with denser bone which leads to bone deformity
Lytic mixed with sclerotic areas
Affects the skull primarily
Can result in bowing of the femur/tibia, osteoarthritis, and fractures

AKA Paget’s disease

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AVASCULAR NECROSIS

Avascular necrosis is the death of bone tissue due to a lack of blood supply.
The blood flow to a section of bone can be interrupted if the bone is fractured or the joint becomes dislocated.
Associated with long-term use of high-dose steroid medications and excessive alcohol intake.
Pain can be mild or severe and usually develops gradually.

Also called osteonecrosis
Can lead to tiny breaks in the bone and the bone’s eventual collapse.

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CHONDROSARCOMA

Malignant cartilaginous tumor
Common in men between 30-60 years of age
Affects the spine, scapula, pelvis, proximal humerus, proximal or distal femur, or proximal tibia

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EWING’S SARCOMA

Neoplastic, small-cell malignant tumor
Found in long bones, ribs, pelvis, scapula
Sunburst pattern seen on X-ray
Peak incidence occurs in boys under 15 years of age
Metastasizes early

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OSTEOID OSTEOMA

Osteoma
benign
Sessile tumor composed of dense, well-formed bone
Insignificant unless location affects organ function

Osteoid osteoma
Small benign neoplasm

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OSTEOSARCOMA

Most common primary malignant tumor of the bone Distal femur or proximal tibia Occurs in male aged 10-30 years of age Destructive, mixed lytic and blastic, lifts the periosteum resulting in pain Risk factors include bone infarcts, Paget’s disease, ionizing radiation

RHABDOMYOSARCOMA

Cancer affects skeletal muscle precursors and occurs in areas without skeletal muscle Occurs most frequently in children

GANGRENE

Necrosis of tissues due to ischemia caused by soft tissue infection Clostridis perfringes (wet) Cold, painful, or numb, dry and scaly skin with poor nail and hair growth are signs of severe ischemia prior to the onset of gangrene Ulceration occurs along with atrophy of the limb Risk factors include trauma + infection, arterial insufficiency, atherosclerosis, diabetes, immunosuppression Complications include sepsis, invasion to other tissues, death

NECROTIZING FASCIITIS

Causes include group A Streptococcus (group A strep), Klebsiella, Clostridium, Escherichia coli, Staphylococcus aureus, and Aeromonas hydrophila Presentation includes skin that is red, swollen, and hot to the touch, fever, chills, nausea, vomiting, diarrhea. The infection may spread rapidly. It quickly can become life-threatening. Commonly referred to as “flesh-eating infection” Causes include group A Streptococcus (group A strep), Klebsiella, Clostridium, Escherichia coli, Staphylococcus aureus, and Aeromonas hydrophila Group A strep is considered the most common cause of necrotizing fasciitis.

OSTEOMYELITIS

Pyogenic osteomyelitis Most commonly S. aureus Due to sepsis in children and as a result of a compound fracture or surgery in adults Primarily affects the distal end of femur and proximal ends of the tibia and humerus A sleeve of new bone (involucrum) can surround the necrotic area. Tubercular osteomyelitis Secondary to TB infection elsewhere Vertebrae (Pott’s disease), long bones (tibia and femur), hip, and hand and foot bones

SEPTIC ARTHRITIS

Infection of a joint with severe inflammation Gonorrhea is the most common bacterial cause Also caused by staph, strep, Haemophilus influenzae Viral causes include rubella, mumps, hepatitis B, Lyme disease Acute onset monoarticular arthritis (shoulder, wrist, knee, hip, fingers, or elbow), joint stiffness, warm tender swollen joints, leukocytosis, fever

Ehlers-Danlos syndrome

o excessive elastic tissue in skin and joint capsule | o hypermobile joints leading to severe joint degeneration

Osteogenesis imperfecta:

o defective collagen synthesis o frequent broken bones o blue sclera

Adult Polycystic Disease of the kidney:

o multiple cysts in both kidneys o hypertension o berry aneurysms

Glycogen storage disorders:

o Von Gierke-Glucose-6 Phosphatase deficiency-accumulates in the liver o McArdle-muscle phosphorylase deficiency-accumulates in the muscle o Pompe-maltase deficiency affects the heart pum

Lysosomal storage disorders

o Tay-Sachs-gangliosides accumulation in the brain; rapidly fatal  cherry red macula  severe mental retardation

Phenylketonuria

Amino acid disorders:  accumulation of phenylalanine due to lack of PA hydroxylase; mental retardation  restrict dietary phenylalanine if the Guthrie test for PKA is positive

Cystic fibrosis

 Autosomal recessive condition causing defective chloride transport  impaired mucociliary action and thick vicid secretions  recurrent infections in lung and sinuses  salty sweat

Sickle Cell Disease

 recessive gene  valine replaces glutamine at position 6 of the beta chain in hemoglobin  common in African-Americans [2% has the disease]  causes microvascular occlusion triggered by hypoxia, acidosis, fever  painful bones with anemia, jaundice and fatigue  hepatosplenomegaly in children  priapism [prolonged erections]  increased risk of salmonella osteomyelitis and pneumococcal pneumonia  protects from Plasmodium falciparum type of malaria

Thalassemia

 More common in Americans of Mediterranean descent [β Thalassemia]  defect in either the α or β globin chains of hemoglobin A  α Thalassemia is more common in South East Asia and West Africa  β Thalassemia is more common in Americans of Greek or Italian descent  results in sub-optimal hemoglobin synthesis  presents with varying degrees of anemia and fatigue  Thalassemia persons are also resistant to the malaria parasite

starry-sky appearance | it is caused by the Epstein Barr virus and is more common in children

Burkitt’s lymphoma

it is characterized by Reed-Sternberg cells

Hodgkin’s lymphoma is common in adults

o characterized by malignant plasma cells in the bone marrow o M spike [due to elevated IgG] o Bence Jones protein in urine o nocturnal bone pain o recurrent infections due to improperly formed immunoglobulins

Multiple myeloma is the most common primary bone cancer in adults

it commonly affects the bones around the knee joint-lower femur and upper tibia

Osteosarcoma is the most common primary bone cancer in children

most common benign smooth muscle tumor in the uterus in females

Uterine leiomyoma

4 main types of leukemia

o Acute Lymphoblastic Leukemia [ALL]-commonest leukemia in children under 5 years o Acute Myelogenous Leukemia [AML]-80% of acute leukemias in adults, Auer rods+ o Chronic Myelogenous Leukemia [CML]-30 to 60 years; Philadelphia chromosome, anemia, bleeding and infection o Chronic Lymphocytic Leukemia [CLL]- >60 year-old men; lymphadenopathy is common

Endocarditis

Endocarditis is the inflammation of endocardium [affecting the valves] and may be caused by Streptococcus pyogenes, Streptococcus viridans or Staphylococcus aureus

Syphilitic aortitis often affect the arch of the aorta

Treponema pallidum infection leading to aortic aneurysm, aortic stenosis and angina pectoris

Congestive Heart Failure

coronary artery disease, hypertension, valvular heart | disease, congenital heart disease or cardiomyopathy

Cardiomyopathy

Causes  alcohol  pregnancy  viral infections

Deep Vein Thrombosis is related to Virchow’s triad:

o Viscosity-increased clotting which may be related to the contraceptive pill o Stasis in the veins from prolonged immobilization o Damage to vessel wall due to trauma o may present with a painful swollen leg

Raynaud’s disease

o Decreased blood flow triggered by cold and emotion and is characterized by:  vasospasm [white]  cyanosis [blue]  vasodilation [red]  often in young females with no known cause

Raynaud’s phenomenon

o secondary to:  SLE  Atherosclerosis  Scleroderma ``` o may be part of the CREST syndrome:  Calcinosis cutis  Raynaud’s phenomenon  Esophageal dysfunction  Scleroderma  Telangiectasia ```

o Inflammation due to a Type III hypersensitivity reaction o affects medium size arteries, 30% are seropositive for Hepatitis B o may present with fever, joint, abdominal pains and palpable purpura

Polyarteritis nodosa

o associated with a raised ESR o in the elderly mainly o may affect other small arteries like branches of the ICA and vertebral arteries o may cause blindness if not treated promptly

Temporal arteritis is the localized giant cell inflammation in small arteries

o chronic underfunctioning of the adrenal cortex o may be an autoimmune disorder or associated with tuberculosis infection o low glucocorticoids and aldosterone o hyperpigmented skin creases and bronze skin o low Na, low BP, high K and high ACTH

Addison’s disease

o overfunctioning of the zona glomerulosa layer of the adrenal cortex o due to an adrenal adenoma which produces excess mineralocorticoids o low potassium, low renin, metabolic alkalosis and high BP

Conn’s disease

o may be due to exogenous steroids or a tumor of the adrenal cortex o truncal obesity, moon face and buffalo hump, hypertension, hyperglycemia o poor wound healing purple abdominal striae but no hyperpigmentation

Cushing’s syndrome

failure of Lower Esophageal Sphincter to relax; dysphagia for fluids not solids

Achalasia

o H. pylori infection, ulcer along lesser curvature of stomach [70%] or duodenum [95%] o Epigastric pain is greater with meals in gastric ulcers and decreases with duodenal ones

Peptic Ulcer Disease

non-caseous granulomas, cobblestone terminal ileum, skip lesions and fistula

Crohn’s disease [regional ileitis]

o inflammation of appendix following blockage of its lumen by a fecalith o periumbilical pain radiating to the RLQ pain with tenderness at McBurney’s point

Appendicitis

o arrested neural crest cell migration, congenital aganglionosis of the colon o presents with chronic constipation in a child

Hirschsprung’s disease

o chronic ulcerative inflammation mainly confined to the rectum o presents with bloody diarrhea, toxic megacolon and an increased risk of colon cancer

Ulcerative colitis

Irritable Bowel Syndrome [IBS] o spastic colon of unknown cause o presents with pain relieved by defecation, bloating, diarrhea and/or constipation

Irritable Bowel Syndrome [IBS]

o fair, fat, fertile, flatulent females over forty with right upper quadrant pain o 95% is caused by gallstones [cholelithiasis]:  cholesterol, pigment or mixed stones  70 to 80% of people with gallstones are asymptomatic

Cholecystitis: inflammation of gallbladder

o chronic liver condition with damage, fibrosis and regeneration nodules:  presents with portal hypertension o portal hypertension:  obstruction to portal blood flow to the liver due to liver fibrosis  causes ascites which is the accumulation of excess fluid in the abdomen  may also be due to decrease protein and increased aldosterone levels o caput medusae:  dilated varicose veins radiating from umbilicus due to portal hypertension

Cirrhosis [Laennec’s]

Hepatitis Hep A, B, C

o Hepatitis A: fecal/oral transmission; water borne infection o Hepatitis B: intravenous drug use and sexually transmitted; chronic carrier state o Hepatitis C: used to be the most common cause of post-transfusion hepatitis

o caused by alcohol, gallstones, trauma, steroids, mumps and hypercalcemia o swollen pancreas with leakage of pancreatic enzymes into the abdominal cavity o severe abdominal pain, bluish discoloration [Cullen’s sign] around umbilicus or in the flanks [Grey Turner’s sign]  severe epigastric pain radiating through to the back  nausea and vomiting

Pancreatitis: inflammation of the pancreas

Juvenile Rheumatoid Arthritis  affects small and medium-size joint pains mainly wrist and knee  lymphadenopathy and splenomegaly in children and teenagers

JRA (Still's disease)

``` o unknown cause o autoimmune disorder: AntiNuclear Antibodies, anti ds-DNA antibodies o more common in younger females o more severe in young black females o affects multiple organ systems ```  joints: polyarthritis-small and large joint  skin: butterfly [malar] rash and photosensitivity  kidney: nephrotic syndrome  heart: Libman-Sack’s endocarditis

Systemic Lupus Erythematosus

o dry eyes [xerophthalmia], dry mouth [xerostomia] and arthritis o may be seen in both RA and scleroderma o more common in women between 40 and 60 years o antibodies to ribonucleoproteins [SS-A and SS-B]

Sjðgren’s syndrome

o caused by Borrelia burgdorferi o transmitted by deer tick: Ixodes scapularis o polyarthritis with bulls-eye lesion [erythema chronicum migrans]

Lyme disease

o auto-antibodies to the pre-synaptic voltage-gated calcium channels in the neuromuscular junction o prevents acetylcholine from being released by the vesicles o seen in small [oat] cell lung cancers o older male population-60+ years o weakness improves with repetitive use o Tensilon test is usually negative

Lambert-Eaton syndrome

o Unknown cause o Autoimmune disorder o More common in females o Causes a heliotrope rash [reddish purple eyelids and papules on the knuckles of the hands [Gottron’s papules] o Produces antinuclear antibodies and anti-Jo-1 antibodies o 10% associated with underlying malignancies of the lung, breast, gut or ovary

Dermatomyositis

o progressive hereditary nerve damage o peroneal muscular wasting o inability to evert the foot

Charcot-Marie-Tooth disease

o unknown cause o older females > 50 years o pain and stiffness in the shoulder and hips o malaise and fever o associated with temporal arteritis o may lead to blindness o highly elevated ESR with normal creatine kinase

PMR

o infectious ascending demyelinating polyneuropathy o due to possible viral infection or immunizations o presenting with progressive motor loss starting in the legs o may affect the diaphragm causing respiratory problems

Guillain-Barré syndrome

``` o caused by Mycobacterium leprae o bacterium loves cool areas: skin and peripheral nerves o causes peripheral neuropathy o claw hand o loss of outer third of eyebrow o anesthetic hypopigmented skin lesions ```

Leprosy

o Ptosis o Anhydrosis o Miosis o “PAM is Horny” o caused by destruction of the cervical sympathetic trunk o as may be seen with Pancoast tumor [apical lung cancer]

Horner’s syndrome is characterized by unilateral

o caused by a severe local dysfunction of sympathetic nerves following minor injury o characterized by pain and swelling in the affected limb o more common in the foot and in females

 Reflex sympathetic dystrophy o aka Sudeck’s atrophy o aka Complex Regional Pain Syndrome

seen in alcoholics, dietary deficiency, anorexia, bulimia and hyperemesis gravidarum

Beriberi

o aka hepatolenticular disease o autosomal recessive disease o lack of ceruloplasmin-major copper-carrying protein in the blood o results in excessive copper deposition in brain and liver o may present with damage to the liver, brain and eyes:  Asterixis [coarse flapping tremor of the wrist when it Is extended]  Basal ganglia degeneration [Parkinson-like tremors]  Cirrhosis, corneal deposits [Kayser-Fleisher rings] due to copper accumulation  Dementia

Wilson’s disease

o most commonly associated with post-streptococcal infections o antigen-antibody complex damage to the glomeruli o activation of the complement system causes inflammation o causes leakage of RBCs [hematuria] and protein in the urine [proteinuria] o red blood cells casts are present in the urine o inflammation of the glomerulus results in renal ischemia o the ensuing renal ischemia results in hypertension by the activation of the renin- angiotensin system o the resulting renal damage causes edema  edema is the accumulation of fluid in the interstitial tissue  due to raised hydrostatic pressure

Glomerulonephritis

o idiopathic in many cases o may be caused by diabetes, SLE or drugs o minimal change damage to the basement membrane o large holes appear in the basement membrane allowing for loss of protein in the urine o causes massive proteinuria more than 3.5 grams/24 hour period o results in hypoproteinemia and hypoalbuminemia in the blood o as a result of the low protein content in the blood, there is edema  due to a decrease in the oncotic pressure  there may be ascites or pleural effusions if severe o there is also hyperlipidemia  related to the hypoproteinemia and increased lipoprotein synthesis

Nephrotic syndrome

o ascending E. coli infection from cystitis usually o inflamed collecting tubules and renal pelvis o causes white blood cell casts to be present in the urine o presents with chills, fever, nausea, vomiting and costovertebral angle tenderness o chronic pyelonephritis will result in a shrunken kidney and hypertension

Pyelonephritis

o ascending infection with enteric organisms o most commonly due to E. coli o causes dysuria, increased urinary frequency and nocturia o WBCs, bacteria and nitrites are found in the urine o many bacteria possess a reductase which reduces urinary nitrates to nitrites

Urinary Tract Infection

o caused by leakage of urine beneath the bladder epithelium o unknown etiology resulting in damage to the mucus lining the bladder mucosa o causes superficial cracks and Hunner’s ulcers of the bladder mucosa o seen more commonly in females o presents increased frequency and nocturia o urinalysis shows white blood cells but no bacteria or nitrites

Interstitial cystitis

o reversible bronchospasm due to hypersensitivity of the bronchi o extrinsic: allergens, eczema and hay fever; intrinsic: exercise o bronchial mucosa inflammation and constriction of bronchial smooth muscle o Curschmann spirals and Charcot-Leyden crystals may also be found in the sputum o presents with paroxysms of shortness of breath and wheezing worse at nights

Asthma

o Type IV hypersensitivity reaction o non-caseous granulomas with epithelioid macrophages o bilateral hilar lymphadenopathy and pulmonary fibrosis-dyspnea and dry cough o may affect the spleen, eye, nerves or skin also:  splenomegaly  uveitis  Bell’s palsy  erythema nodusum [red painful bumps over the shins] o elevated serum calcium due to increased conversion of Vitamin D in the epithelioid macrophages o associated with raised levels of Angiotensin Converting Enzyme in 40-80% of patients o ACE is also produced by the epithelioid cells in the granulomas

Sarcoidosis

o Ghon focus: caseous granulomas in the lung  epithelioid cells and Langhan’s giant cells  epithelioid cells are activated macrophages  lower part of the upper lobe or the upper part of the lower lobe o Ghon complex:  peripheral Ghon focus with involvement of regional lymph node  seen in primary tuberculosis o Langhan’s giant cells:  fused epithelioid cells with the nuclei arranged in a horse-shoe pattern o Apical cavitations are common in secondary tuberculosis

Tuberculosis

o bronchogenic carcinoma in one of the lung apices o may invade roots of the brachial plexus, first rib, sympathetic trunk, subclavian vein or artery o may cause Horner’s syndrome due to damage to the sympathetic trunk in the neck:

Pancoast tumor

o malignant tumor of the pleura | o associated with prolonged exposure to asbestos

Mesothelioma