Pathophysiology Pics Flashcards
joint space narrowing, marginal osteophytes, subchondral cysts, bony sclerosis, malalignment
osteoarthritis
herberden nodes: DIP, bouchard nodes: PIP, joint space narrowing
osteoarthritis
carpometacarpal joint
osteoarthritis
presents with deep groin pain that radiates to medial thigh
hip joint: osteophytes, subchondral sclerosis, loss of joint space
osteoarthritis
MTPs 2-5 involved in addition to the 1st bilaterally, destructive changes on xray is excessive
secondary osteoarthritis: dibetic neuropathy
(midfoot involvement also common)
normal cartilage
Hip
fibrillation of articular cartilage and colonies (clones) of regenerating cartilage cells
early osteoarthritis
Knee
highly polished (eburnated) appearance of exposed subchondral bone
advanced osteoarthritis
Knee
black arrow: eburnation
white arow: articular cartilage
advanced osteoarthritis
hip
fibrous lined cysts under exposed subchondral bone
advanced osteoarthritis
interphalangeal joint
osteophyte (spur)
osteoarthritis
normal cartilage
cartilage
osteoarthritis
osteoarthritis
ulnar deviation, subluxation, swan deformity (bottom), boutonniere deformity (top)
RA
RA
weakening of supporting structures in foot: pain, altered functional anatomy and mechanics of walking
RA
RA
rheumatoid nodules on skin
RA
rheumatoid nodules in olecranon bursa and along proximal ulna
RA
rheumatoid nodule with granulomatous transformation, prominent central fibrinoid necrosis with surrounding palisading histiocytes and outer layer of chronic fibrosing CT with inflammatory cells (lymphocytes and fibroblasts)
RA
small ulcer
RA
top left: episcleritis
bottom left: central keratolysis and corneal perforation
top right: scleromalacia
bottom right: marginal corneal melt (ulcer) with inflammation
RA
synovium
hyperemia of synovium with proliferation of synovial lining cells with infiltration by plasma cells and lymphocytes
early RA
hyperplastic synovial villi eroding and replacing cartilage at the joint margin
RA
multiple layers of proliferated (hyperplastic) synoviocytes with lymphocytic infiltration
top arrow: hyperplastic synovium
bottom arrow: lymphocytes
multinucleated giant cells underlying proliferated synovial lining cells
synovial membrane becomes focally and diffusely infiltrated with chronic inflammatory cells: lymphocytes, macrophages, plasama cells along with a scattering of PMN which are more numerous in acute stage
RA
low power: lymphoid nodules with pale germinal centers (hyperplastic synovial villi)
chronic RA
synovial membrane
fibrin deposition and foci of fibrinoid change and necrosis
RA
organization of inflammatory exudate by granulation tissue composed of newly formed capillaries, macrophages, and fibroblasts
chronic RA
synovial inflammatory and granulaiton tissue adjacent to the margin of the joint covers and adheres to the cartilage as a membrane or PANNUS
hyperplastic and chronically inflamed synovial villus extends over surface of articular cartilage as a fibrous inflammatory membrane (PANNUS) which erodes and replaces underlying cartilage
RA
metacarpal joint
articular cartilage under pannus undergoes degradation and disapperas beginning at joint MARGIN
RA
interphalangeal joint
fibrous ankylosis (fixation)
RA
cartilage was destroyed by MMPs and collagenase, can extend into subchondral bone resulting in cortical erosion; fibrous adhesions form (can also get osseous metaplasia leading to bony ankylosis)
skin
rheumatoid nodule: granulomatous
central zone of collagen necrosis, fibrinoid change (left arrow)
middle zone of epithelioid cell macrophages: histiocytes (right arrow)
outer zone of granulation tissue infiltrated by lymphocytes, plasma cells, macrophages
RA
salivary gland biopsy from lip
lymphocytes, interstitial fibrosis, acinar atrophy
Sjogren’s
salivary gland biopsy from lip
lymphocytes, interstitial fibrosis, acinar atrophy
Sjogren’s
labial salivary gland biopsy
bottom: anti-CD3 and CD21 stains of B cells
lymphocytes in a periductal distribution
Sjogren’s: not monoclonal
parotid gland
multiple lymphoid clusters around ducts and glands
MALT lymphoma (can see in Sjogren’s syndrome so must know if monoclonoal B cells)
anti-SSA and anti-SSB
subacute cutaneous lupus
Anti-SSA and Anti-SSB
neonatal lupus: complete heart block
presents with no erosion
can straighten joints: deformities not fixed
SLE arthritis
abscence of erosion on radiograph
Jaccoud’s like arthropathy: SLE
ulnar drift at MCP, swan neck, boutonniere, hyperextension at IP of thumb (looks like RA but no erosion)
SLE patient
serositis: pleural effusion and pneumothorax
SLE patient
Libman Sack’s endocarditis
vegetations on both sides of mitral valve
SLE patient
small vessel vasculitis with ulceration
Raynaud’s
skin biopsy
superficial and deep perivascular inflammation and mucin (bluish haze) in reticular dermis
SLE
top: dermis has variable edema and perivascular inflammation, vasculitis with fibrinoid necrosis
bottom: deposition of Ig and complement alond dermoepidermal junction (also seen in scleroderma, dermatomyositis)
SLE
two focal necrotizing lesions
SLE: FOCAL PROLIFERATIVE glomerulonephritis (class III)
marked increase in cellularity throughout glomerulus
SLE: DIFFUSE PROLIFERATIVE glomerulonephritis (class IV)
most common
normal glomerulus
left: lupus nephritis class IV: WIRE LOOP with extensive subendotelial deposits of immune complexes
right: EM or capillary/wire loop from patient with subendothelial dense deposit (arrow)
kidney glomeruli: IgG Ab
granular pattern
lupus nephritis
left: kidney
right: renal artery
35 yr old woman with microhematuria and non-nephrotic proteinuria
primary antiphospholipid syndrome
left: glomerulus with microthrombi occluding capillary lumina, endothelial swelling
right: organized thrombus with recanalization and arteriosclerosis
top: normal: will remain just Raynaud’s
bottom: abnormal widened capillary loops: develop secondary CT disease
Nailfold capillary pattern on bottom
active Raynaud’s phenomenon with well-demarcated pallor
Scleroderma patient
digital ulceration and gangrene
Raynaud’s or Scleroderma
vascular disease that has progressed to amputation
systemic sclerosis
A: sclerodactyly
B: truncal changes
C: inflammation in early active skin disease
D: finger contracture in chronic fibrotic phase of skin involvement in scleroderma
Diffuse cutaneous systemic sclerosis
top: vitilligo-like changes
bottom: telangiectasias
scleroderma
A: CT with severe esophageal dysmotility with dilation and retentionof gastric content (arrow)
B: upper endoscopy: gastric antral vascular ectasias: watermelon stomach
C and D: pseudo-obstruction, pneumatosis cytoides intestinalis
systemic sclerosis
linear scleroderma: en coup de sabre
skin
excessive collagen, deep fibrosis, perivascular lymphohistiocytic infiltrates
localized or systemic sclerosis
early: can’t diagnose with this, see inflammation
late: regression of inflammation, secondary structures (hair follicles, sebaceous and sweat glands) reduced, papilla have disappeared; very top hyperkaratosis loss of basket weave look
cutaneous systemic sclerosis or systemic scleroderma
calcareous lesion: tumoral calcinosis: large painful masses in periarucular soft tissue composed Ca hydroxyapatite
superficial fibrin deposition in synovial membrane, mild mononuclear infilitrate, mild synovial hyperplasia, proliferation of collagen fibers, focal obliteration of small vessels
Scleroderma
scleroderma renal crisis
A: interstitial fibrosis
B: occlusion of intrarenal arteries with neointima formation, necrosis of vessel wall and reduplication of internal elastic lamina
C: glomeruli shrunken and lack inflammatory cells or proliferative changes
D: intravascular thrombosis
pulmonary arteriole
systemic sclerosis vasculopathy
extensive medial hypertrophy and intimal thickening
digital artery
intamal thickening, lumen occluded with visible recanalization
limited cutaneous systemic sclerosis
top: enthesitis: inflammation where tendons and ligaments attach to bone
bottom: dactylitis
seronegative spondyloarthropathies
sacroiliitis (usually bilateral)
ankylosing spondylitis
squaring of vertebral bodies, syndesmophyte formation
ankylosing spondylitis
anterior uveitis
anklyosing spondylitis
conjuctivitis
reactive arthritis
mouth ulcer
reactive arthritis
onycholysis
reactive arthritis
Keratoderma blennorrhagica
reactive arthritis
uveitis
reactive arthritis
psoriasis
nail pitting, onycholysis, severe destructive change with nail loss and pustules
nails in psoriatic arthritis
psoriatic arthritis
arthritis mutilans
pencil in cup: DIP involvement, periostitis, bony ankylosis, erosive and proliferative
psoriatic arthritis
psoriatic arthritis
ileal biopsy of 21 yr old
dense chornic, inflammatory cell infiltrate, lymphoid follicles and a granuloma
ankylosing spondylitis associated with ileitis of spondylarthropathy
diffuse idiopathic skeletal hyperostosis
MELTED CANDLE WAX
dermatomyositis
A: Gottron’s papules
B: heliotrope rash
C: Gottron’s sign on knee
D: elbow
SLE or dermatomyositis?
A: dermatomyositis: changes on knuckles and dorsum of hand
B: SLE: rash absent on knuckles but present on phalanges
C: dermatomyositis: capillary nail fold changes
dermatomyositis
A: linear erythema
B: scalp rash
C: V like sign
D: shawl sign
mechanics hands
anti-synthetase syndrome
giant cell temporal arteritis
inclusion body myositis
left: trichrome: red rimmed inclusions, marked variation in muscle fiber size
right: variation in muscle fiber size
dermatomyositis
muscles show myositis with myofiber necrosis, fragmentation and phagocytosis
late: myofiber atrophy, fibrosis, fatty change
left: perifascular atrophy, PERIMYSIAL inflammation
right; perivascular monomuclear cells- vasculitis
polymyositis
lymphocytes INVADE a muscle fiber
X-linked muscular dystrophy: Duchenne or Beckeer
top: normal
bottom: replacement of skeletal muscle by adipose
temporal artery
granulomatous vasculitis, lymphocytes in internal elastic membrane, intimal fibrosis
temporal (giant cell) arteritis
tophi in gout
finger, ear, achilles tendon, olecranon
severe destructive changes in tophaceous gout
bony tophi: soft tissue distortion, erosion with sclerotic margins, overhanging edges, joint space narrowing is minimal
gout
calcium pyrophosphate dihydrate deposition arthropathy
cystic changes in multiple carpal cones, linear calcification at arrow indicating chondrocalcinosis, mild narrowing of radiocarpal joint (cartilage loss)
chondrocalcinosis in calcium pyrophosphate dihydrate deposition
A: linear calcifications in menisci and fibrocartilage
B: calcification of articular cartilage
C: calcification of intercarpal joints
D: calcifacation of pubis smphysis
hydroxyapatite deposition
A: right shoulder subacromial bursa: convex
B: calcification in rotator cuff
C: milk white, chalky subacromial fluid
D: subacromial fluid micro: aggregates of spherical CA Pi crystals
E: no biofringence
F: phagocyte with crystals
G: electron diffraction of HA crystal aggregates
gout
top: white chalky aggregates of uric acid crystals
bottom: needle shaped, neg. birefringence, yellow
intracellular urate crystals
gout: tophi
granuloma, central part formed by urate crystals, lymphocytes, plasma cells
gouty tophus
urate depostis (amorphus pink area) dissolved by formalin fixation
gouty bursitis
urate depostis (brown): silver stain
gout
tophaceous deposits around joints: erode cartilage and subchondral bone, urate deposis (alcohol fixation and silver stain)
gout
urate deposit in medulla of kidneys, alcohol fixed
pseudogout: calsium pyrophosphate crystals
positive birefringent, blue, rhomboid
pseudogout
A: calcium pyrophosphate dihydrate deposition in femoral condyle: chalky white
B: hypertrophic chondrocytes adjacent to crystal aggregates
C: polarized light: rod and rhomboid shapes, positive birefringent
cholesterol crystals in synovial fluid
may be seen in RA
Duchenne’s muscular dystrophy
necrotic and regenerating fibers
immunoperoxidase stain for dystrophin
left: normal
right: Duchenne’s
dystrophin stain
Becker’s dystrophy
lordosis and calf hypertrophy
some fibers still have dystrophin
myotonic dystrophy
muscle biopsy
McArdle’s
left: normal phosphorylase
middle: phosphorylase deficient
right: glycogen accumulation
