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Processes Properties
Hyperplasia • Usually, hyperplasia and hypertrophy occur together
and • Permanent cell undergro hypertrophy only – cardiac myocytes, skeletal
Hypertrophy cells, and nerves.
• Pathologic hyperplasia (not physiologic ex- pregnancy) can progress to
dysplasia and cancer.
• Exception is benign prostatic hyperplasia (is pathologic but does not
increase risk of cancer).
Atrophy • can occur by decrease in cell number (apoptosis) or decrease in cell size.
• Decrease in cell size occurs by – ubiquitin-proteosome degradation of
cytoskeleton and autophagy of cellular components
Metaplasia • change in cell type.
• Mostly affects surface epithelium. Ex – barret’s esophagus (change from
squamous to columnar)
• MOA: occurs by reporgramming of stem cells
• Reversible
• Can progress to dysplasia and cancer. Ex – Barret’s. Exception –
Apocrine metaplasia doesn’t increase risk of breast cancer. Apocrine
metaplasia seen when fibrocystic changes in breast occur.
• Vitamin A deficiency can result in metaplasia. Ex – keratomalacia and
myositis ossificans.
• Mesenchymal tissue can undergo metaplasia (ex – bone, blood vessel,
fat etc). ex – myositis ossificans – inflammation of skeletal muscle reads
to metaplasia to bony tissue.
• Fig – keratomalacia.
9. What is methemoglobinemia?
- Normally, Fe in hemoglobin is in 2+ state and can bind to O2. If it gets oxidized to 3+, it can't bind
to O2 and this is methemoglobinemia.
3. Explain necrosis
• Necrosis occurs as a result of acute inflammation to a large group of cells and is always pathologic
• Types
1. Coagulative necrosis
2. Liquefactive necrosis
3. Gangrenous necrosis - dry and wet
4. Caseous necrosis
5. Fat necrosis
6. Fibrinoid necrosis
- Area of infracted tissue is often wedge shaped and pale. Wedge points to the blocked blood
vessel.
11. What are mechanism by which calcium can deposit in human tissue?
- Dystropic calcification
- Metastatic calcification
Apoptosis
14. Explain apoptosis. (apoptosis means falling of leaves)
- It is purposeful, energy dependent killing of small group of cells
- Examples - Endometrial shredding during menstruation, removal of cells in embryogenesis, CD8
cell mediated killing of virally infected cells
• Pathologic -
▪ ionizing radiation (creates hydroxide radical .OH),
▪ inflammation (in neutrophils, O2 is converted to superoxide by NADPH oxidase)
▪ Metals - iron and copper. Hemochromatosis and Wilson disease are disease of Fe and
Cu accumulation in body - creation of free radicals are main way that the disease
affect us. (Fenten reaction - reaction by which Fe generates hydroxide free radical
(HY))
▪ Drugs and chemicals - acetaminophen, carbon tetrachloride. High dose of
acetaminophen causes liver necrosis by free radical generation
▪ Thyroid hormones increase free radical formation
1. What is amyloid?
• Misfolded proteins that accumulates in extracellular space and damages tissue. Amyloid can't be
removed and damaged organs must be transplanted
12. Describe how medullary thyroid cancer can cause local amyloidosis in thyroid.
• In MTC, overproduction of calcitonin leads to formation of calcitonin amyloid plaques in thyroid.
(In FNA of thyroid, seeing tumor cells in amyloid background makes MTC more probable)
1. What is inflammation?
• Process by which inflammatory cells, plasma proteins and fluid exit blood vessel to enter
interstitial space
5. What are the products of cyclooxygenase pathway and what are their functions.
- Cyclooxygenase pathway produces prostaglandins (PG) - PGI2, PGD2 and PGE2. They increase
vascular permeability and vasodilation. PGE2 also mediates feeeever and pain. Note that
vasodilation happens at arteriole level and vascular permeability at post capillary venule level.
6. What are the products of lipooxygenase pathway and what are their functions
- 5-Lipooxygenase pathway produces leukotrienes (LT). LTB4 attracts and activates neutrophils.
LTC4, LTD4 and LTE4 mediate smooth muscle contraction (vasoconstriction, bronchospasm, and
increased vascular permeability (contraction of pericytes opens up space between endothelial
cells)).
Mast cells
7. What are 3 ways that activate mast cells?
- Mast cells are found throughout connective tissue of body and are activated by -
Complement
10. What are three pathways of complement activation?
- Classic pathway - C1 protein binds to IgG or IgM which is bound to antigen (pneumonic - GM
makes classic cars)
- Alternative pathway - microbial products directly activate complement
- Mannose binding lectin (MBL) pathway - MBL binds to mannose on microorganisms and activate
complement
13. What is hageman factor (aka factor 12 in coagulation cascade)? What systems does it activate?
- It's inactive proinflammatory protein produced in liver that's activated by exposure to
subendothelial or tissue collagen, and during severe gram negative sepsis
- Plays imp role in DIC (disseminated intravascular coagulation - pathologic activation of coagulation
cascade) and severe gram negative sepsis (sepsis activates hageman factor which in turn results in
DIC) (HY).
- It activates complement system, coagulation and fibrinolytic system (this results in DIC), and kinin
system
2. What are steps of neutorphil exit? What proteins are key in each step?
- Margination - Usually, heavy particles in blood are in center of vessel lumen. When blood
vessel dilates, heavy particles come to edge of vessel and this is margination. It's first step of
neutrophil arrival.
- Rolling - endothelial cells express proteins called selectins which act as speed bump so that
neutrophils roll and slow down.
- Adhesion - cellular adhesion molecules (CAM) on endothelium binds to integrins on
neutrophil resulting in adhesion. (HY)
- Transmigration and chemotaxis - transmigration happens across vessel wall of postcapillary
venules, and chemotaxis is movement to infection site after transmigration. Neutrophils are
attracted by bacterial products, IL8, C5a and LTB4
- Phagocytosis - enhanced by opsonins (IgG and C3b)
4. What are 5 catalase positive organism that cause symptomatic CGD? (HY)
○ S Aureus
○ P cepacia (often tested)
○ S marcescens
○ Nocardia
○ Aspergillus
7. What is clinical significance and NBT test result for people with myloperoxide (MPO) deficiency?
• Most MPO patients are asymptomatic but have increased risk for candida infection.
• They have normal NBT test.
12. What happens after fluid, neutrophil and macrophage phase of acute inflammation? (HY)
• Macrophage are managers which come in to check after 2-3 days of acute inflammation if
neutrophils did a good job at clearing the damage.
• If good job is done, macrophage secrete IL-10 and TGF-B. They are anti-inflammatory and induce
healing.
• If job is done poorly, macrophage secrete IL-8. It calls additional neutrophils to the site.
• If macrophage sense that the offending organism needs to walled off, they create abscess.
Abscess is walled off area of inflammation.
• If macrophage sense that neutrophils can't do the job well (ex- neutrophils don't work well in viral
injury), they initiate chronic inflammation by presenting antigen in MHC-2.
Fig - chronic inflammation. Note the absence of multilobed neutrophil. Cell on left is lymphocyte.
Middle cell is plasma cell (nucleus pushed to side, slight perinuclear halo). Cell on right is
macrophage (clock face nucleus).
T cells
3. Explain development and maturation of T-cells.
• They are made in bone marrow and go to thymus.
• In thymus, they become specific to an antigen and develop into either to CD4 helper or CD8
cytotoxic cell.
4. How are CD4 and CD8 T-cells activated? What is their second message for activation?
• T cells are activated when they recognize antigens presented on MHC molecules only while a
second signal is present.
• Helper CD4 T cells read antigen from MHC II. MHC II present extracellular antigen and are present
on antigen present cell.
• Cytotoxic CD8 T cells read antigen form MHC I. MHC I present intracellular or viral antigen and are
present on all cells in body
• For CD4 cells, B7 on antigen presenting cell is the second signal that binds to CD28 on CD4 cells.
CD40 on B cells also act as second signal that bind to CD40L on CD4 cells.
• For CD8 cells, IL2 from CD4 cells is second signal for activation.
6. Explain purpose and function of cytokines secreted by activated CD4 TH1 cells.
• TH1 secrete IFN gamma that enhances phagocytic ability of macrophage
• TH1 also secrete IL2 which is T cell growth factor and CD8 cells activator
7. Explain purpose and function of cytokines secreted by activated CD4 TH2 cells.
• TH2 cause eosinophil rich inflammation and/or reduce inflammation by secreting IL4, IL5 and IL10.
B cells
9. How are B cells produced?
• Immature B cells are produced in bone marrow. Naïve B cells express IgM and IgD.
10. How are 2 ways by which B cells activated? How does isotype switching occur?
• Binding of antigen to IgM or IgD activates B cells. Then they become IgM or IgD secreting plasma
cells.
• B cells can phagocytose and present antigen to CD4 cells via MHC II. CD40 on B cell can bind to
CD40L on helper T cell providing 2nd signal for activation.
• TH2 Helper T cell will secrete IL4 and IL5. IL4 and IL5 help in isotype switching of B cells, somatic
hypermutation (aka affinity maturation), and maturation to plasma cells.
Granulomatous inflammation
11. What is granulomatous inflammation?
• It’s a type of chronic inflammation. It's defined by presence of epitheloid histiocytes (macrophage
with abundant pink cytoplasm and elongated nuclei) (HY). You may also see multinucleated
macrophages. In healthy tissue, macrophage have clear (aka foamy) cytoplasm.
• Granulomas are surrounded by rim of lymphocytes and giant cells.
• Only a certain conditions give granuloma so they help to identify diseases.
4. Etiology of SCID?
• Cytokine receptor defects (main cause)
• Adenosine deaminase deficiency (second main cause)(HY) - enzyme necessary for deamination of adenosine and
deoxyadenosine. In lack of enzyme, adenosine and deoxyadenosine accumulates in immune cells causing toxicity.
• MHC class II deficiency - CD4 won't be able to be activated. It leads to defective function of CD8 and B cells.
5. Presentations of SCID?
• Lack of T cells result in fungal and viral infections
• Lack of B cells result in bacterial and protozoal infections
• Increased opportunistic infection and be wary to give live vaccines.
6. Treatment of SCID?
• Sterile isolation (bubble babies)
• Stem cell transplant
11. Presentation?
• Pt has increased risk of bacterial, enterovirus, giardia infection, often in late childhood.
• They have increased risk of autoimmune disease and lymphoma. (HY)
15. What is Wiskott-Aldrich syndrome (WAS)? What causes it? (just memorize)
• Pt have thrombocytopenia, eczema, and recurrent infections. Pt have defective humoral and cellular immunity.
• Happens due to mutation in WASP (Wiskott-Aldrich syndrome protein) gene and is x-linked.
16. What are the consequence of the following complement deficiencies? (just memorize)
• Deficiency from C5-C9 - increased risk of Neisseria infection (HY)
• C1 inhibitor deficiency - hereditary angioedema characterized by edema of skin (especially periorbital) and mucosal
Systemic Lupus
4. What happens in Lupus?
- Lupus is a systemic autoimmune disease in which autoantibodies can cause type II (cytotoxic -
antibody bind and kill cells) or type III hypersensitivity reaction (antigen-antibody complex form
and deposit in tissue causing damage).
9. What is antiphospholipid syndrome associated with SLE? What lab tests does it affect?
- Antibodies are made against proteins bound to phospholipid.
- Anticardioliptin antibody give false positive syphilis test.
- Lupus anticoagulant antibodies give falsely elevated PTT lab study but makes pt hypercoagulable.
Sjogren syndrome
11. What is sjogren syndrome?
- Type IV (lymphocyte mediated) autoimmune destruction of lacrimal and salivary glands with
resulting fibrosis.
17. What is diffuse type scleroderma? What are clinical presentation? How do you diagnose?
- Patient has diffuse skin and early visceral organ involvement.
- Esophagus most commonly affected - see solid and liquid dysphagia
- Diagnosis made by ANA and anti-DNA topoisomerase I antibody (aka SCL-70 antibody). SCL stands
for scleroderma.
17. What is localized type scleroderma? What are clinical presentation? How do you diagnose?
- Patient has local skin and late visceral organ involvement.
- Presentation (CREST)-
○ Calcinosis (calcification of skin), anti-centromere Ab
○ Raynaud phenomena
○ Esophageal dysmotility- see solid and liquid dysphagia
○ Sclerodactyly
○ Telangiectasis of skin
- Diagnosis made by anti-centromere antibody
1. What is regeneration?
- It's replacement of damaged tissue with native tissue.
2. What is repair?
- Repair is replacement of damaged tissue with fibrous scar. It occurs when tissue lacks
regenerative capacity or regenerative stem cells are lost.
4. What is granulation tissue (different from granuloma which occurs in chronic inflammation)?
What are 3 important cell types in it?
- It's present in early phase of repair. It contains -
○ Fibroblasts (deposit type 3 collagen)
○ Capillaries
○ Myofibroblast (contract wound)
Fig - granulation tissue showing blood vessels, collagen and fibroblast. Contrast it with granuloma
in chronic inflammation file.
5. What happens when granulation tissue is replaced by scar? What cofactor is needed?
- Collagenase removes type 3 collagen and replaces with type I collagen. It needs zinc as cofactor
(HY).
7. How do regeneration and repair happen? What are some key molecules?
- They occur by paracrine signaling via growth factors. Some of them are
○ Fibroblast growth factor (FGF) - powerfully induces angiogenesis and skeletal development
○ VEGF - angiogenesis
○ PDGF - induces growth of endothelium, smooth muscle and fibroblast
○ TGF alpha - epithelial and fibroblast growth factor
○ TGF beta - inhibits inflammation, important fibroblast growth factor
10. What are some common causes of delayed wound healing? (HY)
- Infection is most common cause
- Vitamin C deficiency - causes poor hydroxylation of lycine and proline.
- Copper deficiency - lysyl oxidase can't cross link procollagen well
- Zinc deficiency - type III collagen can't be converted to type I by collagenase
- Foreign body, ischemia, diabetes, malnutrition etc
9. What are leading cancers by incidence and death toll in male and females?
Cancer by incidence Male 1. Prostrate 2. Lung 3. Colorectal
Female 1. Breast 2. Lung 3. Colorectal
Cancer by death tolls Male 1. Lung 2. Prostrate 3. Colorectal
Female 1. Lung 2. Breast 3. Colorectal
- Table excludes squamous cell and basal cell carcinoma of skin - very common and
malignant but rarely metastasize. Detected early and easily treatable.
- Lung cancer doesn't have easy screening test like others. It's usually detected late.
Protooncogenes
2. What are protooncogenes and how can they cause cancer?
- Proto-oncogenes are essential for regular cell growth and differentiation
- Mutation produces oncogenes that leads to unregulated cell growth
4. What cancer are the following protooncogenes associated with and what's their
function and mechanism of causing cancer?
Cancer Function of MOA of cancer
protooncogene
Growth factor
PDGFB - Astrocytoma - Platelet derived Overexpression,
growth factor autocine loop
Growth factor
receptors
ERBB2 - Subset of breast Epidermal growth Amplification
(HER2/neu) cancer factor receptor
RET - MEN2A, MEN2B Neural growth factor Point mutation
- Sporadic MTC receptor
KIT - Gastrointestinal Stem cell growth Point mutation
stromal tumor factor receptor
Signal
Transducers
RAS gene family - Carcinoma GTP-binding protein Point mutation
- Melanoma
- Lymphoma
- (Found in ~70% of
all cancers)
ABL - CML Tyrosine kinase Translocation - t(9,22)
- Some ALL with BCR
Nuclear
regulators
C-MYC - Burkitt lymphoma Transcription factor T (8,14) involving IgH
Fig: Follicular thyroid adenoma (left) - note organized cell growth with colloid in between cells,
uniform nuclei with lots of cytoplasm, minimum mitotic activity. Anaplastic thryoid carcinoma
(right) - disorganized growth (cells look nothing like thyroid), large nuclei:cytoplasm ratio, nuclear
pleomorphism, mitotic figure (very dark nuclei cell).
3. What's the absolute distinguishing feature between benign and malignant tumors?
7. What does tumor grading of well differentiated and poorly differentiated mean?
- Well differentiated - tumor resembles parent tissue - good prognosis
- Poorly differentiated - tumor doesn't resemble parent tissue - poor prognosis
- Look at cellular architecture and nuclear morphology to classify differentiation
Quantitative disorders
8. What is idiopathic thrombocytopenic purpura (ITP)?
- Most common cause of thrombocytopenia in kids and adults. Autoimmune production of IgG
against platelet antigens (ex- GP IIB/IIIA)
- Antibodies are made in spleen, and tagged platelets are phagocytosed by spleen macrophages.
Low platelets cause purpura (bleeding spots in skin)
Fig - schistocyte - the two pointy things at the end is classic appearance of cut RBC
4. How do extrinsic and intrinsic pathway of coagulation cascade start? What lab tests measures intrinsic
and extrinsic pathways? What lab test is better is coumadin vs heparin?
• Intrinsic pathway - Starts with factor 12 which is activated by subendothelial collagen (SEC).
Measured by PTT lab test. Heparin results is better measured by PTT (PTT measures Hep - 3 letters
each)
• Extrinsic pathway - starts with factor 7 which is activated by tissue thromboplastin. Measured by
PT lab test. PT measures coumadin results.
Hemophilia A
9. What causes hemophilia A (think hemophilia 8)? What is it's clinical presentation?
• Caused by genetic factor 8 deficiency
• x- linked recessive.
• Can arise from new mutation without any family history
• Deep tissue, joint and post-surgical bleeding.
Hemophilia B
12. What causes hemophilia B (aka christmas disease)? What are its clinical features? What are the lab
values?
• Caused by genetic deficiency in factor 9.
• Clinically resembles hemophilia A.
• Lab values - same as hemophilia A except low factor 9 instead of factor 8.
14. How do you distinguish hemophilia A from coagulation factor inhibitor disease in lab? (HY)
• You mix patient's plasma with normal plasma (i.e, pt gets some normal factor 8).
• If you measure PTT time after that, hemophilia A pt will have lower PTT time whereas coagulation
factor inhibitor disease patient will have same PTT time (as the antibodies will destroy new factor
8).
18. Why is PTT elevated in vWF disease even though it's a platelet disease? (HY)
• PTT is elevated because vWF is required to stabilize factor 8. Bad factor8 leads to elevated PTT.
20. What is treatment for vWF disease? What's the mechanism? (HY)
• Desmopressin - they increase vWF release from Weibel Palade bodies of endothelial cells (primary
site of VWF storage, another substance in Weibel palade bodies = P selectin).
21. What is the function of vit K in coagulation cascade? How does coumadin work?(HY)
• They are necessary for gamma carboxylation of factor 2,7,9,10, factor c, factor s
• Vit K is activated by epoxide reductase in liver (coumadin blocks epoxide reductase and prevents
activation of vit K)
24. How to you observe liver failure patients for their coagulation function?
• By measuring their PT time (why?)
25. What does large volume transfusion lead to secondary coagulation problems?
• Because it dilutes the coagulation factors.
5. What are lab findings in disseminated intravascular coagulation disorder? What is the best lab
test?
- Low platelet count
- Increase PT and increase PTT
- Decrease fibrinogen
- Microangiopathic hemolytic anemia
- Elevated D-dimer (HY) - Best lab test - D dimer is product of breaking cross linked fibrin. If lots of
clots are forming, some are dissolving as well, increasing D-dimer in blood.
Hyperactive plasmin
8. What happens if plasmin is hyperactive? What are some conditions that give rise to hyperactive
plasmin?
- It prevents clot formation due to destruction of coagulation factors and fibrinogen
- Radical prostatectomy - releases urokinase that activates plasmin
- Cirrhosis of liver - it causes reduction if production of alpha 2 antiplasmin
10. What are lab findings in hyperactive plasmin? Contrast it with DIC lab findings.
- Increased PT and PTT
- Increased bleeding time with normal platelet count (DIC has low platelet count)
- Increased fibrinogen split products without D-dimers (low D-dimer as there's no fibrin to cleave)
Fig - lines of Zahn (the alternate layer of RBC and fibrosis - marked by R & f) is characteristic
of thrombosis
3. What are 3 main risk factor of thrombosis (virchow's triad)? Give examples of each.
- Disruption of blood flow - stasis or turbulence of flow. Ex - immobilization, cardiac wall
dysfunction, MI, aneurism (there's turbulence in an aneurism)
- Endothelial damage. Ex - artherosclerosis, vasculitis, high level of homocysteine (vit B12 or folate
deficiency or homocystinurea)
- Hypercoagulable state (excess procoagulant or defective anticoagulant)
5. Why does vit B12 or folate deficiency causes high level of homocysteine?
- Because vit B12 and folate are needed to convert homocysteine to methionine.
- MOA - Folate becomes tetrahydroflorate in body. It gets activated by giving its methyl group to vit
B12. It then participates in DNA synthesis. Vit B12 gives the methyl group to homocysteine and
homocysteine becomes methionine.
- High level of homocysteine is damaging to the endothelium
Homocystinurea
6. What is homocystinurea (aka cystathione beta synthase (CBS) deficiency)?
- Disease with high level of homocystine caused due to deficiency in Cystathione beta synthase
enzyme. CBS converts homocystine to cystathionine.
13. What is antithrombin 3 deficiency? What happens if you give them heparin? How are these
patients managed for their hypercoagulable state?
- It's a hypercoagulable state.
- Their PTT won't rise if you give normal dose heparin because heaparin works by increasing
antithrombin 3. PTT will rise a little with high doses.
- Start pt in high dose of heparin and then give warfarin.
1. What is embolism?
- It's a intravascular mass that travels and occludes downstream vessels.
- Thromboembolism is most common type (>95%) - embolus will have line of Zahn?.
Fig - presence of cholesterol crystal (three white columns) indicates that this embolus is
artherosclerotic and not thrombotic.
7. Why do patient with amniotic fluid embolus at high risk for DIC?
- Because amniotic fluid is filled with tissue thromboplastin which activates factor 7 that leads
to activation of extrinsic coagulation cascade.
Fig - amniotic fluid embolus in a blood vessel near alveoli. Note presence of keratin debris
(squiggly lines) inside the blood vessel.
9. What is most common cause of pulmonary embolism (PE). What is its most common clinical
presentation?
- Most common due to thromembolus from DVT.
- Most PE are clinically silent as lung has dual supply from pulmonary artery and bronchial
artery. Also, the embolus are usually small and self-resolve.
9. What increases chance of pulmonary infraction from PE? What is the gross feature of
infraction?
- Obstruction of large or medium sized artery
- Pre-existing cardiopulmonary compromise
- Hemorrhagic wedge shaped infraction (hemorrhagic because tissue in lung is loosely
organized and reperfusion occurs from the dual arterial supply).
13. What is the most common source of systemic embolus? Where do they most commonly
dislodge?
- Most commonly arise from left heart. Most commonly dislodge in lower extremities.
Fig: microcytic anemia. Normal RBC size is equal to size of nucleus of lymphocyte. Notice that multiple
RBC are smaller than that. Also notice variability in size of RBC and increased pallor in center of RBC
10. What are clinical features of lead poisoning leading to sideroblastic anemia?
- Pt at old house with chipped paint at high risk
- Mnemonic LEAD:
o L - Lead lines on gingivae and metaphyses of long bones (aka Burton lines)
o E - Erythrocyte basophilic stippling and encephalopathy (lead inhibits rRNA degradation causing
RBCs to retain aggregates of rRNA seen as basophilic stippling)
o A - sideroblastic Anemia, Abdominal colic
o D - Dimercaprol and EDTA for treatment; Wrist and foot Drop
o Succimer used for chelation in kids - sucks to be kid that eats lead
Fig: From right to left - basophilic stippling; Burton lines on gum; metaphysis
11. What are lab findings in sideroblastic anemia? What's its treatment?
- Lab findings based on Fe overload as they can’t attach to portoprophyrin
- As Fe increase in erythroblast, cells die due to free radical produced by Fenten reaction. Fe leaks out and
is taken by macrophage.
- ↑ferritin, ↓TIBC
- ↑serum Fe, ↑% saturation
- Very similar lab findings as hemochromatosis
- Treatment:
o Pyrodoxine (B6 - cofactor for ALAS)
Thalassemia
1. What are normal globin molecule in hemoglobin?
Hemoglo a- b- Developmental
bin subunit subunit stage
4. What causes alpha thalassemia? What chromosome is alpha gene located in?
- Alpha thalassemia is caused due to gene deletion of alpha chain of hemoglobin.
- Normally, 4 alpha alleles are present on chromosome 16 (2 allele per chromosome)
- 'a in alpha looks like d (deletion); if you rotate b in beta, you get m (mutation).
- Cis deletion classically seen in Asians - When HbA and HbA2 are - Gamma chain
(higher rate of spontaneous abortion in formed, B chain tetramers(aka
6. What causes beta thalassemia? What chromosome is beta gene located in?
- Beta thalassemia is caused due to mutation of beta chain of hemoglobin. Mutations result in absent (aka
B0) or diminished (aka B+) production of B-globin chain.
- Normally, 2 beta alleles are present on chromosome 11 (1 allele per chromosome)
- MOA- due to reduced hemoglobin in edge of RBC, the membrane in center gets floppy and some
hemoglobin comes to stay there.
Fig: chipmunk face (left) and crewcut appearance (right) seen in massive erythroid hyperplasia
Megaloblastic anemia
Vit B12 and Folate deficiency
2. Describe relationship between folate and Vit B12.
- Folate comes to body as methylated tetrahydrofolate (M-THF).
- THF is the active form. M-THF donates it's methyl group to Vit B12. Vit B12 then gives methyl
group to homocysteine. Homocysteine now becomes methionine.
Fig: hypersegmented neutrophils with large RBC (aka macroovalocyte) on the left- classic
finding in megaloblastic anemia
4. What is difference between megaloblastic anemia and macrocytic anemia that's not
megaloblastic?
- In macrocytic anemia that's not megaloblastic, hypersegmented neutrophils and megaloblastic
changes (ex - large intestinal epithelial cells) won't be seen. Large RBC will be seen.
6. Compare clinical and lab findings of folate and Vit B12 deficiency.
7. What are two important reactions that Vit B12 participate in?
- DNA precursor synthesis (with folate)
- Conversion of methylmalonic acid to succinyl Co. A
Orotic aciduria
Defn - Inability to convert orotic acid to uridine monophosphate (UMP) that leads to
accumulation of orotic acid (defect in de-novo purine synthesis pathway)
- AR inheritence
Presentati - Megaloblastic anemia in children refractive to folate and vit B12
on - Failure to thrive, developmental delay
- Orotic acid in urine but no hyperammonemia
Treatment - UMP to pass the mutated enzyme
3. How can reticulocyte be falsely elevated in anemia? How is reticulocyte count corrected?
Reticulocytes are measured as percent of total RBC. In anemia, total RBC goes down. It will
elevating the percent of reticulocytes.
It’s corrected by multiplying reticulocyte percent x hematocrit/45.
Total RBC Total % of HCT Corrected
Reticulocyte reticulocyte reticulocyte
Normal pt 100 2 (given) 2%
(given)
Anemic 50 (given) 2(given) 4% 23 (given) 4 x 23/50 = 2%
pt
In this example, if we only look at % of reticulocyte, it looks as if bone marrow is normal. But from
corrected reticulocyte, we know that anemic pt’s bone marrow is not producing adequate
reticulocytes.
Hereditary spherocytosis
1. What is hereditary spherocytosis? What are the mutations?
- In the disease, tethering proteins that attach RBC cytoskeleton to RBC membrane are mutated.
RBC membrane blebs and are lost over time. RBC becomes more spherical.
- Most common mutations are in proteins - ankyrin, spectrin, or band 3.
Fig: spherocytes with high RDW (note variability in RBC sizes and loss of central pallor)
Fig: chipmunk face (left) and crewcut appearance (right) seen in massive erythroid
hyperplasia
• Extensive sickling leads to vaso-occlusion
5.What are some physical findings in sickle cell disease due to vaso-occlusion?
•All findings based on infraction
•Dactylitis – due to vasoocclusive infaracts in bones – common in infants
•Autosplenectomy – shrunken, fibrotic and calcified spleen
○ Increased risk of encapsulated organism infection (staph aureus, strep pneumo,
haemophilus influenza)
○ Salmonella paratyphi osteomyelitis (encapsulated) - most common cause of osteomyelitis
is staph aureus; in sickle cell, it's salmonella.
○ Howel-Jolly bodies on blood smear - nucleated RBC
• Acute chest syndrome (vaso-occlusion of pulmonary microcirculation)
○ Often precipitated by pneumonia
○ Presents with chest pain, SOB, lung infiltrates
• Pain crisis
• Renal papillary necrosis – presents as gross hematuria and proteinuria
Fig: vaso-occlusive complications of sickle cell disease - from left to right - autosplenectomy - small
calcified spleen; renal papillary necrosis; dactilytis; Howel-Jolly bodies
Hemoglobin C
1. What is hemoglobin C?
- Hemoglobin C is formed due to mutation in Beta chain of hemoglobin (autosomal recessive).
- Glutamic acid is changed to lysine (lyCne for hemoglobin C) - think Gingiva - Glutamic acid to
lyCine as gingiva is C shaped)
- Less common than sickle cell disease
- DAF (decay accelerating factor) and MIRL (membrane inhibitor of reactive lysis) are present in
RBC, WBC and platelets. They block complement fixation in RBC. DAF decays C3 convertase.
- Protein called GPI (glycosylphophatidylinositol) anchors MIRL and DAF to cells.
Fig - schistocytes (helmet cells) - has mostly two acute angle and loss of about 50% of RBC;
contrast bite cells that have usually >2 acute angles and almost entire volume of RBC is present.
Malaria
1. How does malaria cause anemia?
- Plasmodium infects and replicates in RBC. RBC ruptures as merozoites (a stage in their lifecycle)
Erythroblastosis fetalis
Defn - Maternal IgG crossing placenta and attacking fetal RBC (ex - Rh -ve mother carrying
two consecutive Rh +ve babies)
Present - See extramedullary hematopoiesis (ex - in liver) because RBC are damaged
Aplastic anemia
1. What is aplastic anemia?
- Aplastic anemia is damage to hematopoietic stem cell resulting in pancytopenia (anemia,
leukopenia, thrombocytopenia)
Fig: Aplastic anemia (left) vs normal bone marrow on right. Note the depletion of marrow and
replacement by fat globules on left.
Myelophthisic process
1. What are melophthisic process?
- Pathologic processes that replace bone marrow (ex - cancer)
- Hematopoiesis is impaired resulting in pancytopenia
1. Spleen
- PALS (periarteriolar lymphatic sheath) - has T cells (drink tea with pals) - in white pulp
- Germinal center - has B cells - in white pulp
Leukopenia
1. List the differences between neutropenia and lymphopenia.
Neutropenia Lymphopenia
Decreased circulating neutrophils Decreased circulating lymphocytes
Causes: Causes:
- Drug toxicity- Chemotherapy - Damage - Immunodeficiency - HIV, DiGeorge syndrome
stem cell and decreased production of - High cortisol - Induces apoptosis of lymphocytes
WBC, specially neutrophil - Autoimmune destruction - Lupus
- Severe infection- Neutrophils move to - Whole body radiation - Lymphocytes are highly
tissue sensitive to radiation; lyphopenia is earliest change to
- Lupus emerge after whole body radiation
Infectious mononucleosis
1. What causes mono?
- EBV (most common), CMV (less common)
4. What are two cases where person has mono but monospot test is negative?
- Mono is caused by CMV (only EBV mono will have positive monospot test)
- Test is done within 1 week of infection
- Types:
○ Acute lymphoblastic leukemia (ALL) - presence of >20% lymphoblast stem cell
○ Acute myeloid leukemia (LML) - presence of >20% myeloid stem cell
Fig: blast cells with punched out nucleolus (as if punched via punching machine) - notice lots of
them (gives high WBC count)
Myelodysplastic syndrome
7. What is myelodysplastic syndrome?
- Dysplasia of myeloid stem cells. It increases risk of AML.
- Presents as
○ >3% but <20% blasts (if it's >20%, it's acute leukemia)
abnormal maturation of cells and increased blasts because cells can't fully differentiate-
CaLL - CLL
Epid - Most common leukemia in adults (old people in pic)
Presentati - Often asymptomatic - both elderly are happy and dancing
on - Smudge cell - cell smudged on glass of grandpa
Associatio - Autoimmune hemolytic anemia - both IgM and IgG - cold
n and warm sea anemone
Picmonic:
Adult T cell Mature CD4+ cells - Associated with HTLV-1; common in Japan and caribbean
leukemia/lymphoma - Skin rash, generalized lymphadenopathy, hepatosplenomegaly,
- lytic (punched out) bone lesion with hypercalcemia
1. What is lymphoma?
- Neoplastic proliferaion of lymphoid cells that makes a mass; may arise in lymph node or extranodal tissue.
3. What are different subtypes of Hodgkin lymhoma and what are their characters?
Subtype Characters
Nodular sclerosis - Most common type of HL
- Classic pt is young adult female
- Presents as enlarged cervical or mediastinal lymph nodes
- Biopsy:
• Lymph node is divided by band of fibrosis
• Reed sternberg cells are present in lake like spaces (lacunar cells)
Fig: band of fibrosis (left), lacunar cells (a variant of Reed sternberg cells - right)
Mixed cellularity - Associated with abundant eosinophils (reed sternberg cells produce IL-5)
Lymphocyte rich - Best prognosis of all types
Lymphocyte depleted - Most aggressive of all types
- Usually seen in HIV pt or old pt
Non-Hodgkin lymphoma
1. What are types of non-hodgkin lymphoma?
- Non-hodgkin lymphoma is classified based on cell size, cell type (B or T), pattern of cell growth, cell surface markers,
translocations.
- Types:
○ Small B cells
Follicular lymphoma - enlarged and too many follicles
Mantle cell lymphoma - cancer of mantle (area around follicle)
Marginal zone lymphoma - cancer of marginal zone (area around mantle)
Small lymphocytic lymphoma (CLL that involve tissue)
○ Intermediate B cell lymphoma
Burkitt lymphoma
○ Large B cells
Diffuse large B-cell lymphoma
Mantle cell t(11;14) - Cyclin D1 on ch 11 goes to Ig heavy chain locus on ch14 - Often present in late
lymphoma adulthood with painless
lymphadenopathy
Marginal zone - Chronic inflammatory state - Hashimoto thyroiditis, Sjogren - Marginal zone made of post-
lymphoma syndrome, H pylori gastritis (causes MALToma - a type of germinal B cells
marginal zone lymphoma)
Small - Chronic lymphocytic leukemia (naïve B cells; smudge cell)
lymphocytic affecting tissue
lymphoma
Burkitt - t(8;14) - c-myc on ch 8 goes to Ig heavy chain locus on ch14 (myc - Often present in child or young
lymphoma is a protein in RAS-MAPK pathway - cellular proliferation and adult as extranodal mass:
increased cyclin D production) • African form - in jaws
- Associated with BV infection • Sporadic form - in
- Biopsy finding abdomen
Diffuse large - Arise sporadically or transformation of low grade lymphoma (ex- - Most common NHL
B-cell follicular lymphoma, chronic lymphocytic leukemia) - High grade (aggressive)
lymphoma - Present in late adulthood as
extranodal mass or enlarging
lymph nodes
Multiple myeloma
1. What is multiple myeloma? What is molecular mechanism?
- MM is malignant proliferation of plasma cells in bone marrow. It's most common primary
malignancy of bone.
- Serum IL-6 (aka RANK-L) may be increased that induces plasma cell growth and Ig production.
Elevated serum protein (M - Classically due too much IgG (55% of cases) or IgA (25%)
spike present in serum production
protein electrophoresis -
SPEP)
Increased risk of infection - Even though too much Ig produced, lack of Ig specificity
Rouleaux formation on - Increased serum protein decreases charge between RBC and RBC
blood smear makes stacks
(rouleau = cylindrical
packet of coins)
Anemia • Plasma cells crowd out bone marrow so little RBC synthesis
Waldenstrom Macroglobulinemia
1. What is Waldenstrom macroglobulinemia? What are clinical features? What is treatment?
- B cell lymphoma with monoclonal IgM production (M for Macroblobulinemia)
- Clinical features:
○ M spike present - due to hyper IgM
○ Presentation based on hyperviscosicity of blood due to IgM pentamer (no CRAB findings
present)
▪ Retinal hemorrhage and stroke
▪ Bleeding - high blood viscosity leads to defective platelet aggregation
▪ Raynaud phenomena
- Classic features:
○ If you see person's name, it's malignant and you see rash
○ if disease has 2 person's name, pt is <2 year old
○ If disease has 3 person's name, pt is >3 years
Fig - temporal arteritis biopsy. M is the media, I is the intima, F is the area of fibrosis between media and
intima that has narrowed the lumen, circle above M shows giant multinucleated cells, circle left of F
shows inflammation.
8. Contrast symptoms of temporal arteritis with Takayasu arteritis (aka pulseless disease) - a type of large
vessel arteritis?
• Takayasu arteritis is same as temporal arteritis with a couple of exceptions-
○ Affects mainly adults <50. Classic pt is young asian female
○ Affects aortic arch at branch point instead of branches of carotid artery
▪ Visual and neurologic symptoms
▪ Weak or absent pulse in upper extremity (therefore disease called pulseless disease)
▪ ESR is elevated, vasculitis is granulomatous
▪ Treat with corticosteroids
10. What is clinical presentation of polyarteritis nodosa? What chemical is it associated with?
• Classic pt is young adults
• Symptoms depend on vessel involved-
○ Renal artery involvement cause hypertension
○ Mesenteric arteries - abdominal pain with melena
○ CNS arteries - neurologic disturbances
○ ESkin lesions
• Associated with serum HBsAG (hepatitis B surface antigen)
Fig - the red marking showing fibrinoid necrosis seen in polyarteritis nodosa.
13. What are clinical presentation of Kawasaki disease- a type of medium vessel vasculitis?
• Classic pt is asian child under 4
• Presentation (very nonspecific - pt has like viral infection)
○ Fever>5 days
○ Shrieking irritability - extremely irritable kid
○ Conjuctivitis sparring area right next to iris
○ Erythematous rash of palms and soles and any mucocutaenous membrane (ex - strawberry tongue)
○ Enlarged cervical lymph nodes
14. Why don't you give asprin to kids with viral disease?
• Because they can get Rye syndrome - encephalopathy and massive liver necrosis.
15. What is Buerger disease (medium vessel vasculitis)? How do you treat it?
• It's necrotizing vasculitis involving digits. Presents with ulceration, gangrene, and autoamputation of
fingers and toes.
• Disease associated with Raynaud phenomenon - pale to blue to red color change in digits due to
exposure to cold. Pale and blue color are due to vasospasm; red is due to return of circulation.
• Disease is associated with smoking - treatment is smoking cessation (HY)
Small vessel vasculitis (wegner granulomatosis, microscopic polyangitis, chug-strauss, and Henoch Schonlein)
• The first 3 of these disease can lead to RPGN.
• Henoch Schonlein has IgA deposition and can lead to IgA nephropathy
18. How do you diagnose Wegner Granulomatosis? How do you treat it?
• Pt are C-ANCA (cytoplasmic - anti neutrophil cytoplasmic antibodies) positive.
• Biopsy shows large necrotizing granuloma with adjacent necrotizing vasculitis.
• Treatment is Cyclophosphamide and corticosteroids. Relapse is common.
Fig - large necrotizing granuloma seen in Wegner granulomatosis. Granulomas are absent in microscopic
polyangiitis.
19. What is microscopic polyangiitis (type of small vessel vasculitis)? Contrast this disease with Wegner
granulomatosis (WG).
• Necrotizing vasculitis involving multiple organs (hence the name polyangiitis), especially lung and kidney
(similar to WG).
• It's very similar to WG but nasopharyngeal involvement and granulomas are absent.
• Serum P-ANCA (perinuclear - anti neutrophil cytoplasmic antibodis) correlate with disease activity instead
of C-ANCA.
• Treatment is same as WG - corticosteroids and cyclophosphamide. Relapses are common.
Artherosclerosis
2. Describe histology of artherosclerosis.
- Artherosclerosis is an intimal plaque that obstructs blood flow. It contains necrotic lipid core with
a fibromuscular wall. The lipid core can undergo dystropic calcification.
Fig - artherosclerosis. M is the media, I is the intima, the circle represents the necrotic lipid core
with cholesterol crystals. The necrotic core is surrounded by a fibromuscular wall.
Arteriolosclerosis
7. What is arteriolosclerosis?
- Narrowing of small arterioles.
- Causes - deposition of hyaline or hyperplastic media.
Fig- Enclosure shows monckeberg medial sclerosis. Note how it's limited to media and doesn't
have much effect on lumen diameter.
5. What are some connective tissue disorders that can lead to dissection?
- Marfan syndrome - mutation in fibrillin-1 protein. Fibrillin is the base on which elastic fibers are
laid down. Media has lots of elastic fibers
- Ehlers-Danlos syndrome - mutation in collagen or proteins that interact with collagen.
Aneurysms
7. What are two classic location of aneurysm?
- Thoracic aneurysm
- Abdominal aneurysm
10. What is the most common site of abdominal aortic aneurysm (AAA)? Why is this the most
common site?
- Below the renal arteries and above aortic bifurcation
- Vasa vasorum stops at the level of renal artery bifurcation. Therefore, artherosclerosis of aorta
below this level leads to high level of media atrophy due to poor diffusion of nutrient and gases.
The weak aortic wall leads to aneurysm. (note - most common location of artherosclerosis in
human is abdominal aorta).
Fig: normal abdominal aorta (left); AAA (right) - note calcification of vessel wall and thrombosis
11. What is presentation of AAA?
- >60 year old smoker male with HTN
- Pulsatile abdominal mass that grows with time
2. How long does a ischemia last before irreversible injury to cardiac myocytes occur?
- 20 minutes
Angina (reversible injury to cardiac myocytes)
3. Describe Stable angina. What type of damage is suffered by the cells?
- Chest pain develops with physical or emotional stress
- Caused due to >70% stenosis of coronary arteries
- Myocytes undergo reversible injury during stable angina (HY)
Fig - the box shows necrotic myocytes (no nuclei) and the circles show contraction band necrosis
1-3 days Inflammatio Yellow pallor - Fibrinous pericarditis (chest pain with friction
• Arrhythmia doesn't happen post 24 hrs because the conduction system is already damaged and necrosis
occurs < 1 day.
• Fibrinous pericarditis only occur with transmural infaract
• Papillary muscles are fed by right coronary artery
• Dressler syndrome - inflammation of pericardium and exposure of pericardial antigen can cause
autoimmune attack to pericardium
Fig - fibrinous pericarditis (fibrin exudate during neutrophil rich stage (day 1-3 post MI) rubs when hear
contracts producing and characteristic friction rub). Only see during transmural infraction
2. If there's a left-right shunt in heart, which direction does it initially present? Why does it reverse?
- Early shunt is left to right due to reduced resistance in pulmonary circulation.
- Shunt later becomes right to left - pulmonary circulation increases resulting in pulmonary HTN and
hypertrophy of pulmonary vessels
VSD
1. What's most common congenital heart defect? What is it associated with (HY)?
- Ventricular septal defect
- It's associated with fetal alcohol syndrome
3. How is it treated?
- Small defects close spontaneously. Surgery for large defects.
ASD
1. What are types of atrial septal defects?
- Ostium secundum (most common) - hole between atria. Ostium is primitive membrane that
divides heart to left and right sides.
- Ostium primum (aka endocardial cushion defect) -
○ ASD + valve defect + defect in intraventricular wall.
○ Endocardial cushion - junction of atrial septum, ventricular septum, tricuspid and mitral
valves.
○ Most associated heart defect with Down's syndrome
- Sinus venosus
PDA
1. What is patent ductous arteriosus? What's it associated with?
- Failure of ductous arteriorus to close after birth.
- Associated with congenital rubella
- Presents with left to right shunt between aorta and pulmonary artery. Later on, the shunt
becomes right to left due to pulmonary HTN and hypertrophy of pulmonary vessels
Tetralogy of fallot
1. What is tetralogy of fallot?
- Stenosis of right ventricular outflow tract
- Right ventricular hypertrophy
- VSD
- Aorta that overrides the VSD
- Right to left shunt. Almost all others are left to right in the beginning.
Truncus arteriosus
1. What is truncus arteriosus?
- It's when a single large vessel arises from both ventricles. (truncus fails to divide to aorta and
pulmonary artery)
- Presentation:
○ Early cyanosis
Coarctation of aorta
1. What's coarctation of aorta? What are two types?
- Coarctation of aorta is narrowing of aorta
Infantile type Adult type
Anatomy Narrowing is after aortic arc but before PDA Narrowing is after aortic arch (not
associated with PDA; if PDA
present, it's infantile type)
Associati Associated with PDA and Turner syndrome (one Associated with bicuspid aortic
on X, no Y) (HY) valve (HY)
Presenta Presents as lower extremity cyanosis in infants, - Presents as HTN in upper
tion often at birth - due to coarctation, lower extremitties and hypotension with
extremity isn't supplied by LV but by RV. Upper weak pulse in lower extremities;
extremities are fine because LV supplies there often discovered in adulthood
- Collateral circulation across
intercostal arteries causes
engorged artieries and notching on
ribs on X-ray (HY)
Aortic stenosis
1. What are some causes of aortic stenosis?
- Normal wear and tear of valve
- Bicuspid aortic valve (speeds up wear and tear)
- Chronic rheumatic fever
3. How do you distinguish stenosis from chronic rheumatic fever vs normal wear and tear?
- In chronic rheumatic fever, there is fusion of commissures of aortic valves. Also, we see mitral
stenosis.
Aortic regurgitation
1. What are causes of aortic regurgitation?
- Isolated aortic root dilation (most common cause)
- Aortic dissection, Syphillis (causes aortic root dilation)
- Valve damage, ex - infective endocarditis
Mitral regurgitation
1. What are some causes of mitral regurgitation?
- Complication of mitral prolapse
- LV dilation
- Infective endocarditis
- Acute rheumatic fever - vegetation on valve edge prevent smooth closing
- Papillary muscle rupture after MI
Mitral stenosis
1. What are some causes of mitral stenosis?
- Chronic rheumatic valve disease most common cause
1. What is endocarditis?
- Inflammation of endocardium (mostly valves) usually due to bacterial infection.
Pathogen
1 S. viridans Most common cause of Subacute endocarditis (small
endocarditis; dental vegetations)
procedure
2 S. aureus Most common cause of Acute endocarditis (large
endocarditis in IV drug vegetations)
users
3 S. epidermidis Key organism to cause
endocarditis of prosthetic
valves
4 Strep bovis Cause endocarditis in pt
with colorectal carcinoma
(HY)
5 HAECK organism Hemophilus, Cause endocarditis with negative
Actinobacillus, blood culture (because
Cardiobacterium, pathogens difficult to grow)
Eikenella, Kingella
6 Nonbacterial Occurs if pt is
thrombotic hypercoagulable or has
endocarditis adenocarcinoma
7 Libman-Sacks Sterile vegetations on Associated with lupus
endocarditis both side of mitral valve
8 Coxiella burnetti Most common cause of
culture -ve endocarditis
1. Describe endocarditis due to S. viridans.
- Most common cause of endocarditis.
- Low virulence pthogen; therefore mainly infects previously damaged valves
- Results in small vegetations that don't destroy valves (therefore called subacute endocarditis)
Fig - roth nodules (retinal hemorrhage); osler and roth nodules are immunologic.
Fig - myocarditis; notice the presence of lymphocytes. Most common cause is coxcakie virus;
acutely, it can cause death; in chronic cases, it can cause dialated cardiomyopathy
Hypertrophic cardiomyopathy
4. Describe hypertrophic cardiomyopathy.
- Massive hypertrophy of left ventricle
- Most common cause (HY): due to autosomal dominant mutations in sarcomere proteins
Restrictive cardiomyopathy
6. What is restrictive cardiomyopathy and it's causes?
- Diastolic dysfunction
- Causes
○ Amyloidosis
○ Sarcoidosis
○ Hemochromatosis
○ Endocardial fibroelastosis (in kids) - there's fibrosis and elastosis in endocardium
○ Loeffler syndrome - eosinophilic inflammation of endocardium and myocardium
Rhabomyoma
1. What is most common primary cardiac tumor in children?
- Rhabdomyoma
Fig: rhabdomyoma
Metastasis
1. What is most common type of cardiac tumor?
- Metastasis (more common than primary tumors)
Nasopharynx
1. Differentiate angiofibroma and nasopharyngeal carcinoma.
Angiofibroma Nasopharyngeal carcinoma
Defn Benign tumor of nasal mucosa Malignant tumor of nasopharyngeal epithelium
made up of large blood vessels
and fibrous tissue
Demograp Classically seen in adolescent - Classically seen in Chinese young adults and
hics males - very rare in females african kids
Larynx
1. Differentiate laryngeal papilloma and laryngeal carcinoma
Laryngeal papilloma Laryngeal carcinoma
Defn Benign papillary tumor of vocal cord SCC of epithelial lining of vocal cord
Cause HPV 6 and 11; EtOH and smoking (papilloma rarely
progress to carcinoma)
Presentatio - Hoarseness of voice - Hoarseness of voice
n - Usually single in adults and multiple - Cough and stridor
in children (HY)
Fig: vocal cord nodule (usually bilateral and seen on true vocal cord)
Fig - lobar pneumonia (right), bronchopneumonia (middle), interstitial pneumonia (left). Note lack of alveolar
exudate in interstitial pneumonia
6. What is aspiration pneumonia? What are it's causes? What's it's presentation?
• Seen in patients at risk for aspiration (ex - comatose, alcoholics)
• Causes: anaerobic bacteria of oropharynx:
○ Bacteroides
○ Fusobacterium
○ Peptococcus
○ Kliebsiella (is it anaerobic?)
• Classic presentation:
○ Right lower lobe abscess
Tuberculosis
1. Describe presentation of primary TB.
• Caused by inhalation of bacteria.
• Presentation:
○ Focal caseating necrosis classically in lower lobe and hilar lymph nodes
○ The foci undergo fibrosis and calcification resulting in Ghon complex
○ Mostly asymptomatic
○ Leads to positive PPD
Fig: Ghon complex (calcified and fibrosed lung): classic location is subpleural region near hylar nodes
Chronic bronchitis
3. What is chronic bronchitis? What is the mechanism?
- chronic productive cough lasting at least 3 months over a minimum of 2 years
- hypertrophy of bronchial mucinous glands--patients cough up cups of mucous
Fig: Cross section of chronic bronchitis. Top right portion has respiratory epithelium, bottom left
has cartilage. It's clearly visible that mucus glands make >50% thickness of airway.
Emphysema
8. What is emphysema?
• Destruction of alveolar air sac and multiple sacs combine to become one.
• Due to loss of elasticity of air sacs, lung becomes like a shopping bag, not effectively expelling air
out.
• Also, elasticity of air sacs attached to bronchioles keep the bronchiole open during expiration.
When the sacs are gone, then bronchioles collapse during expiration.
10. Differentiate two classic causes of emphysema (destruction of alveolar air sacs).
Smoking (no. 1 cause of emphysema) A1AT deficiency (alpha 1 antitrypsin) -
Pollutants cause inflammation that induce A1AT is an important antiprotease that
protease mediated damage to alveoli inhibits protease damage to alveoli
Centriacinar emphysema seen mainly in upper Panacinar emphysema seen mainly in lower
lobes (upper lobes have more air) lobes
Can cause liver cirrhosis too
Complications: hypoxemia and cor pulmonale Complications: hypoxemia and cor pulmonale
(pulm HTN) (pulm HTN)
Bronchiectasis
1. What is bronchieatasis?
- Necrotizing damage to airway walls lead to permanent dilation of bronchioles
- Imagine if you blow air into a big tube, the air will just move randomly inside the tube and might
not come out
Fig: hyaline membrane seen on alveoli represents ARDS (right); diffuse whiteout seen in Xray in
ARDS (left)
Fig-
intracellular
Fig: keratin pearl bridge
Large cell - Poorly differentiated and highly - Smoking Central or - Poor prognosis
carcinoma anaplastic cells (no keratin peripheral - Poor response to
pearls, intercellular bridges, chemotherapy; remove
glands or mucin) surgically
- Paraneoplastic - may secrete
B-HCG
(Bronchial - Well differentiated - Not related to Central or - MOST COMMON PRIMARY
) neuroendocrine cells; smoking peripheral LUNG CANCER IN CHILDREN
Carcinoid chromogranin positive (when central, - Low grade malignancy; rarely,
tumor makes polyp can cause carcinoid
like mass in syndrome - caused due to
bronchus) release of vasoactive
substance (mainly serotonin) -
flushing, diarrhea, restrictive
cardiomyopathy due to
Bronchiol - Columnar cells that grow along - Not related to Peripheral - Excellent prognosis
oalveolar preexisting bronchioles and smoking - Pneumonia like consolidation
carcinoma alveoli; arise from clara cells on imaging
(adenocar
cinoma in
situ)
- Small cell carcinoma is poorly differentiated neuroendocrine tumor; carcinoid tumor is well differentiated
neuroendocrine tumor.
- Neuroendocrine cells have neurosecretory granules; chromogranin stains positive for neurosecretory granule.
Fig: erythroplakia (right), leukoplakia (middle), hairy leukoplakia (left - not precancerous)
GI Page 1.1
10.2 Salivary Gland
GI Page 2.1
10.3 Esophagus
GI Page 3.1
Mallory - Longitudinal laceration of mucosa at gastroesophageal - Painful
Weiss junction hematemesis
syndrome - Cause - vomiting - usually alcoholism of bulimia
- Risk for Boerhaave syndrome
Esophageal varices
Definition - Dilated submucosal veins in lower esophagus due to portal hypertension
Anatomy - Esogpageal vein is connected to portal vein via left gastric vein
Epidemiology - Most common cause of death in cirrosis pt
Presentation - Asymptomatic or present as painless hematemesis
Achalasia
Definition - Disordered esophageal motility with inability to relax lower esophageal sphincter
(LES) due to damage of ganglion cells in myenteric plexus
Etiologies - Chagas disease (HY)
- Idiopathic
Clinical - Dysphagia of solid and liquid food
features - Putrid breath (rotting)
- High LES pressure on esophageal manometry
- Bird beak sign on X-ray
GI Page 3.2
Complicatio - Increased risk for squamous cell carcinoma
n
Barret's esohagus
Definition - Metaplasia in lower esophageal mucosa from stratified squamous epithelium to
columnar epithelium with goblet cells
Complicatio - May progress to adenocarcinoma
n
Histology
Fig: squamous epithelia on left, columnar epithelia with goblet cells (right) - barret's
esophagus
Esophageal carcinoma
Adenocarcinoma Squamous cell carcinoma
Epidemiolo - Most common esophageal cancer in western - Most common esophageal cancer
gy world (classically seen in lower 1/3rd of worldwide
esophagus)
Risk factor - Barret esophagus - EtOH and tobacco (most common
cause)
- Achalasia
- Esophageal web (ex- Plummer-
Vinson synd)
GI Page 3.3
Vinson synd)
- Esophageal injury (ex - lye
ingestion)
- Very hot tea
Prognosis - Poor (both type presents late)
Presentation - Progressive dysphagia of solid and liquid food
- Weight loss, pain
- Hematemesis
- SCC may have hoarse voice (recurrent laryngeal nerve involvement) and
cough (tracheal involvement) (HY)
Lymph node If cancer in upper 1/3rd of Cervical nodes
involvement esophagus
Middle 1/3rd Mediastinal or tracheobronchial
nodes
Lower 1/3rd Celiac and gastric nodes
GI Page 3.4
10.4 Stomach
Sections of stomach
Pyloric stenosis
Definition - Congenital hypertrophy of pyloric smooth muscle
Epidemology - M>F
- Presents after 2 weeks of birth
Presentation - Visible peristalsis and projectile non-bilious (non-green) vomiting after eating
- Olive like mass on abdomen
GI Page 4.1
Acute and chronic gastritis
Acute gastritis Chronic gastritis
Definition - Acidic damage to stomach mucosa - Chronic inflammation of stomach mucosa that leads to intestinal
metaplasia
Defense - Mucin produced by foveolar cells
against - Bicarb secretion
acid - Normal blood supply (provides nutrition
and picks up acid
GI Page 4.2
type) MALToma
GI Page 4.3
- Bilateral ovary (Kukenberg tumor) Diffuse type
GI Page 4.4
Mets - Periumbilical region (sister - Bilateral ovary (Kukenberg tumor)
mary joseph nodule)
GI Page 4.5
10.5 Small Bowel, 10.6 Appendix
Duodenal atresia
Defn - Failure of duodenum to canalize
Association - Down syndrome
Clinical features - Bilious vomiting
- Polyhydramnios
- Distension of stomach and blind loop of duodenum (double bubble sign)
GI Page 5.1
ischemia
Cause - Associated with leading edge (focus of traction)
• In kids, most common cause is rotavirus related
lymphoid hyperplasia - mostly occurs in terminal ileum
leading to intussuception into cecum
• In adults most common cause is tumor
Pres - Most common location are - See currant jelly stool
sigmoid colon (elderly),
cecum (young adult)
Lactose intolerance
Defn - Hypofunction of lactase enzyme found in brush-border of enterocytes. Enzyme breaks
lactose into glucose and galactose
Presentation - Lactose osmotically active (abdominal distension and diarrhea after eating milk products)
Cause - Congenital - autosomal recessive
- Acquired - develops in late childhood
- Temporary - after infection (lactase is highly susceptible to injury)
Celiac disease
Defn - Immune mediated damage to small bowel villi due to gluten exposure
- Damage most prominent in duodenum (Fe deficiency)
Genetics - Related to HLA DQ2 and HLA DQ8
Pathophys - Gliadin pathogenic component in gluten. After absorption, its deamidated by tissue
transglutaminase (tTG). Deamidated gliadin is presented by APC. CD4 T cells mediate tissue
damage.
Presentati - Chlidren present with failure to thrive, abdominal distention diarrhea
on - Adults present with chronic diarrhea and bloating
- Dermatitis herpetiformis - small, herpes like vesicles on skin due to IgA deposition on
dermal papillae
GI Page 5.2
dermal papillae
- IgA deficiency may be seen
- All symptoms resolve with gluten free diet
Lab - IgA against endomysium, tTG, or gliadin
findings - IgG against those antigens if pt have IgA deficiency
Biopsy - Flattening of villi, hyperplasia of crypts, increased intraepithelial lymphocytes
Fig - Flattened villi with crypt hyperplasia in Celiac (left) and normal villi (right)
Complicati - Small bowel carcinoma and T cell lymphoma despite good dietary control
on
Tropical sprue
Defn - Damage to small bowel villi due to unknown organism (disease responds to
antibiotics) resulting in malabsorption
- Biopsy finding similar to Celiac?
Difference from - Damage most prominent in jejunum and ileum (Vit B12 and folate deficiency - I fuck
celiac bitches in France) - In Celiac, damage is mostly in duodenum
- Arises after infectious diarrhea and responds to antibiotics
- Occurs in tropical regions - ex-Caribbean
Whipple disease
Defn - Systemic tissue damage due to macrophages loaded with Tropheryma whippelii
Presentati - Classic damage is done in small intestine lamina propria
on • Macrophages compress lacteal and interfere with chylomicron transport from
enterocytes - fat malabsorption and steatorrhea
- Other sites include joints (arthritis), cardiac valves, lymph nodes and CNS
Biopsy - Foamy macrophages in lamina propria of small intestine
- Tropheryma whipplii stain PAS +ve inside the lysosome of macrophage (mucin also PAS
+ve)
GI Page 5.3
Fig - PAS stain in whipple disease (mucin in goblet cells and bacteria inside macrophages
are staining pink)
Abetalipoproteinemia
Defn - Genetic lack of apolipoprotein B-48 and B-100 (autosomal recessive)
Presenta - Absent plasma VLDL and LDL (require B-100)
- Fat malabsorption due to defective chylomicron formation (requires B-100)
Carcinoid tumor
Defn - Malignant proliferation of neuroendocrine cells; low grade malignancy
Clinical - Can arise anywhere in gut; small bowel most common site
features - Grows as submucosal polyp-like nodule
- Often secretes serotonin (carcinoid syndrome) - asymptomatic as MAO in liver
metabolizes it to 5-HIAA (see 5-HIAA in urine)
Carcinoid - Seen after tumor metastasizes to liver (bypass hepatic circulation) and
syndrome (HY) secretes serotonin there
Trigger - EtOH or emotional stress that triggers serotonin release
Presentati - Bronchospasm
on - Facial flushing
- Diarrhea
- Carcinoid heart disease - right sided endocardial fibrosis, especially in
tricuspid valve and pulmonary valve (not seen in left heart due to
presence of MAO in lungs)
GI Page 5.4
presence of MAO in lungs)
APPENDIX
Acute appendicitis (MOST COMMON CAUSE OF ACUTE ABDOMEN)
Defn - Acute inflammation of appendix
Cause - Obstruction of appendix by lymphoid hyperplasia (common in kids) and fecolith (common
in adults)
Presen - Periumbilical pain, fever, nausea - pain eventually localizes to right lower quadrant
(McBurney point)
- Rupture results in peritonitis that presents with guarding and rebound tenderness
Complicatio - Periappendicular abscess common complication
n
GI Page 5.5
10.7 Inflammatory Bowel Disease (IBD)
GI Page 6.1
Complic - Toxic megacolon - Malabsorption (terminal ileum mostly affected)
ation - Carcinoma (depends on extend - Calcium oxalate nephrolithiasis
and duration of disease - no - Fistula formation
problem until >10 years) - Carcinoma if colonic disease present
Smokin - Protects against UC - Increases chance of chron
g
Associa - 10 sclerosing cholangitis (P- - Ankylosing spondylitis, sacroilitis
tion ANCA +ve) - Migratory polyarthritis
- Erythema nodosum
GI Page 6.2
10.8 Colon
Hirschprung disease
Definition Failure of Myenteric (auerbach) plexus and submucosal (Meissner) plexus migration
to distal sigmoid colon and rectum
Association Down's syndrome
Presentati - Presentation based on defective peristalsis/obstruction
on • Failure to pass meconium
• Empty rectal vault on digital rectal exam (DRE)
• Megacolon with risk for rupture
Colonic diverticula
Definition Outpouching of colonic mucosa and submucosa through muscularis propria (false
diverticulum)
GI Page 7.1
Angiodysplasia and Hereditary hemorrhagic telangiectasia
1. Differentiate the above two.
Angiodysplasia Hereditary hemorrhagic telangiectasia
Acquired malformation of mucosal and Autosomal dominant disorder resulting thin walled
submucosal capillary beds blood vessels, especially in mouth and GI tract
Mostly seen in cecum and right colon
due to high wall tension
Rupture of capillary beds present as Rupture of blood vessels present as bleeding
hematochezia in old adults
GI Page 7.2
10.9 Colorectal Carcinoma
Colonic polyps
1. Differentiate hyperplastic and adenomatous polyps.
Hyperplastic polyp Adenomatous polyp
Most common colon polyp; usually in rectosigmoid Second most common colon polyp
section
Occur due to hyperplasia of glands (polyclonal) - Occur due to neoplastic proliferation of
serrated appearance on microscopy - both are glands (monoclonal)
identical
Benign with no malignant potential Benign but may progress to
adenocarcinoma via adenoma-
carcinoma sequence
GI Page 8.1
3. How are screening of polyps done?
- Colonoscopy - both hyperplastic and adenomatous polyp look the same; distinguished by
microscopy
- Fecal occult blood - some polyps bleed
Turcot FAP + CNS tumor (medulloblastoma and glial tumor) - you put turban on head
syndrome
GI Page 8.2
(aka heriditary intestinal
polyposis)
Sporadic, in children <5 years Sporadic or AD (mutation in Inherited - autosomal
SMAD - don’t need to know) dominant
Usually presents as solitary Multiple juvenile polyp in - Multiple hamartomatous
rectal hamartomatous polyp stomach and colon (juvenile polyp in GI tract
that prolapses and bleeds refers to type of polyp, not age - Hyperpigmentation (freckle
of pt) like spots) on lips, oral
mucosa and genial skin
Colorectal cancer
1. What is colorectal cancer and what's its epidemiology?
- 3rd most common cause of cancer related death
- Peak incidence in 60-70 year olds (both men and women)
3. Describe microsatellite instability's role in CRC. What disorder is associated with microsatellite
instability?
- Microsatellites are repeating sequences of noncoding DNA; their number is maintained during
cell division (i.e. they're stable)
- Instability indicates defect in DNA mismatch repair enzymes
- Disorder associated:
○ Heriditary non-polyposis colorectal carcinoma (HNPCC) - aka Lynch syndrome
CRC is de novo (not from adenomatous polyps) at early age and usually right sided.
Adenoma-carcinoma sequence HNPCC
80% of sporadic colon cancer
1st mutation - APC - increases chance of polyp Mutation is in DNA mismatch repair
formation enzyme
2nd mutation - K-ras - polyps formed
3rd mutation - COX overexpression and p53
mutation - polyps turn to carcinoma
Cancer progresses from adenomatous polyps Cancer is de-novo (no need to see
adenomatous polyps)
Common age 60-70 Seen early
GI Page 8.3
Common age 60-70 Seen early
Cancer is usually right sided
GI Page 8.4
Glycogen storage disease
Von Gierke's (Van jerky) Pompe (pump) Cori (coral) Mcardle (muscle glider)
- Type 1 glycogen storage - Type 2 - Type 3 - Type 5
disease
- Glucose-6-phosphatase - Lysosomal alpha 1, 4, - Alpha 1, 6, glucosidase - Muscle glycogen
deficiency (last enzyme in glucosidase aka acid maltase deficiency (glycogen phosphorylase deficiency
glycogenolysis) deficiency debranching enzyme)
- Presentation: - Presentation: - Presentation: - Presentation:
• High glycogen in liver • Cardiomegaly • Stunted growth • Severe muscle cramp
• Enlarged kidney during exercise
• Myoglobinuria
• Increased glycogen in
muscle
• Hepatomegaly - Hepatomegaly • Hepatomegaly
- Severe hypoglycemia - Normal blood glucose - Hypoglycemia
- Lactic acidosis - Hypotonia - Normal lactic acid - Normal lactic acid
GI Page 9.1
- Lactic acidosis (lake acid with up arrow)
GI Page 9.2
- Type 3 glycogen storage disorder - 3 tree
MOA - Deficiency in glycogen debranching enzyme alpha 1, 6 glucosidase (saw cutting branch, and afro, wand, saxaphone,
glue with daisy)
Presentatio - Normal blood lactic acid level (body can go gluconeogenesis and some glucose can be taken off glycogn) - lake acid
- n with no up arrow
- Hepatomegaly - glycogen accumulates in liver due to lack of debranching enzyme
- Stunted growth - because body can't mobilize energy source - C clamp
- Hypoglycemia - due to lack of debranching enzyme (hippo-glue bottle)
4. Mcardles disease
GI Page 9.3
Lysosomal storage disorder
a. Hunters syndrome
GI Page 10.1
b. Hurlers syndrome
- Mucopolysaccharidoses disease - a set of disease where body can't break down long
sugar and they accumulate in various tissue and cause disease
MOA - Alpha -L- Iduronidase defeciency - (alpha 1 afro on Iditarod)
- As a result, Dermatan sulfate and heparan sulfate accumulates on lysosome (deer
tan man and hippie run)
Presentati - Gargoylism - flat face, depressed nasal bridge, bulging forehead - gargoyl
on - Airway obstruction - due to craniofacial abnormalities and glycosaminoglycan
deposition in neck tissue
- Corneal clouding
- Developmental delay
- Hepatosplenomegaly
GI Page 10.2
Genetics - Mutation in hexosaminidase A (hexagon tires with mini A) which breaks down GM2
ganglioside (GM2 car)
- Seen more in Ashkenazi jewish population - jew gangster
MOA - GM2 ganglioside accumulates (GM2 car with gangster on side)
Presentatio - Onion skin lysosomes (onion bulb)
n - Cherry red macula (due to accumulation of GM2 ganglioside in retina and
transparency of macula) - cherry on onion
- Progressive degeneration of CNS due to accumulation of GM2 ganglioside (neuron
hands of onion)
- Developmental delay due to GM2 ganglioside accumulation in CNS (developmental
delay bus)
e. Metachromatic leukodystrophy
GI Page 10.3
MOA - Deficiency of Arylsulfatase A (arrow sulfur match A). Cerebroside sulfate (cerebro
guy shooting arrow) builds and affect growth of myelin
Presentati - Presentation based on myelin damage
on - Ataxia (taxi)
- Dementia (d man)
GI Page 10.4
Epidemiolo - Most common lysosomal storage disease
gy
MOA - Deficiency of beta glucocerebrosidase (beta fish, glue, cerebrow guy) leads to
accumulation of glucocerebroside in cell and organs
Presentatio - Gaucher cells - macrophage with glucocerebroside that look like crumpled tissue
n paper - crumpled paper
- Hepatosplenomegaly due to glucocerebroside accumulation.
• Anemia due to RBC destruction in spleen
• Leukopenia and thrombocytopenia
- Bone crisis (crying bone) - severe pain in joints and bone due to glucocerebroside
accumulation
- Erlenmeyer flask deformity - aseptic necrosis of femur that makes it look like
Erlenmeyer flask (necrosis crow with femur)
Fig: Gaucher cell (left), Erlenmeyer flask deformity (middle), normal femur (right)
GI Page 10.5
g. Krabbes disease (Crab)
MOA - Deficiency of galactocerebrosidase (galaxy sign, guy with cerebro) that causes
accumulation of galactocerebroside which damages myelin
Presentati - Globoid cells on histology - enlarged macrophage with multiple nuclei - globe
on - Developmental delay - due to myelin damage- DD bus
- Peripheral neuropathy - damaged nerves
- Optic atrophy - damage to optic nerve fibers - optic atrophy glasses
GI Page 10.6
h. Fabry's disease (febreeze bottle, fairy carrot, fairy wedding)
Inheritance X linked
MOA - Deficiency of alpha galactosidase A (afro galaxy with side A) leads to accumulation
GI Page 10.7
MOA - Deficiency of alpha galactosidase A (afro galaxy with side A) leads to accumulation
of ceramide trihexaside
Presentatio - Globoid cells on histology - enlarged macrophage with multiple nuclei - globe
n - Developmental delay - due to myelin damage- DD bus
- Peripheral neuropathy - damaged nerves
- Optic atrophy - damage to optic nerve fibers - optic atrophy glasses
GI Page 10.8
Chapter 11: Exocrine Pancreas,
Gallbladder, and Liver Pathology
11.1 Exocrine Pancreas
Acute pancreatitis
1. Describe acute pancreatitis, it's etiology, pathophysiology and presentation.
- Acute pancreatitis is reversible enzymatic digestion of pancreas with hemorrhagic damage
(pancreas has lots of blood supply).
- Etiology
○ EtOH and gallstones cause >75% of cases
○ EtOh causes contraction of sphincter of oddi which slows drainage of pancreatic
enzymes --> risking premature activation of enzymes in pancreas
○ Other
Trauma (ex - automobile accident)
Hypercalcemia (Ca is activator of enzymes)
Hyperlipidemia (
Cystic fibrosis (In CF, low bicarb and water drainage to pancreatic ducts; slow flow
and thick enzyme --> enzyme activation)
Drugs, scorpion venom
Mumps
Rupture of duodenal ulcer
- Pathophysiology
○ Activation of trypsinogen is the first step that cause activation of other enzymes
- Presentation
○ Epigastric pain radiating to back (pancreas is secondary retroperitoneal organ)
○ Nausa, vomiting
○ Periumbilical and flank hemorrhage
Fig - liquifactive necrosis of pancreas with fat necrosis of surrounding fat in pancreatitis
Chronic pancreatitis
4. What causes chronic pancreatitis?
- Chronic pancreatitis is fibrosis of pancreatic parenchyma which occurs after multiple bouts of
acute pancreatitis
- Etiology
○ EtOH (most common in adults)
○ Cystic fibrosis (most common in kids)
○ Idiopathic
- These etiologies cause repeated attack to pancreas. Other etiology of acute pancreatitis (ex -
hypercalcemia, scorpion bite etc happen only once or so.
6. Why are serum lipase and amylase not good marker for chronic pancreatitis?
- Because in chronic pancreatitis, pancreas don't produce much enzyme so enzymes aren't
elevated in blood.
Pancreatic adenocarcinoma
7. Describe pancreatic adenocarcinoma, it's risk factor and patient population.
- It's adenocarcinoma arising from pancreatic ducts
- Most commonly seen in elderly
- Major risk factor (HY) -
○ Smoking and chronic pancreatitis
If you see thin old pt with sudden onset diabetis, suspect pancreatic adenocarcinoma. Because DM is
usually disease of fat people with onset during middle age, and pancreatic adenocarcinoma is disease of
old people.
Cholelithiasis
2. Describe causes of gall bladder stones.
Cholesterol - Very high cholesterol or
stones - low bile acids and phospholipids (bile acid and
phospholipids dissolve cholesterol) (some drugs lower bile
acids)
- Stasis
Pigment stones Pigment stones form due to breakdown of conjugated
- Black bilirubin or too much bilirubin.
stones - Black stones - non-bacterial, non-enzymatic
- Brown breakdown of conjugated bilirubin. One cause -
stones hemolysis
- Brown stones - bacterial enzymatic breakdown of
bilirubin (stasis can cause bacterial growth in
gallbladder)
5. What's presentation and risk factor for pigment stones (aka bilirubin stones)?
- Presentation
○ Radioopaque
- Risk factors
6. What are some complications of gallstones? (each are described with questions
below)
- Biliary colic
○ Pt has waxing and waning RUQ pain (pain starts when gall bladder
contracts against stone; pain goes away when bladder stops contraction)
- Acute pancreatitis and obstructive jaundice
○ Due to blockage of biliary tree
- Acute and chronic cholecystitis
- Ascending cholangitis
- Gallstone ileus - stone obstructing the intestine lumen
- Gallbladder cancer
Complications of gallstones
7. Describe acute cholecystisis and its presentation?
- Acute cholecystis occurs due to pressure build up in gall bladder due to biliary
tree blockage by stone. Pressure causes squeezing of vessels in gall bladder
wall --> ischemia and bacterial growth
- Presentation
○ RUQ pain that radiates to scapula (HY)
○ Fever with elevated WBC count
○ Increased serum alkaline phosphatase (cell lining biliary tree and gall
bladder contain alk phosphatase)
○ Risk of rupture if untreated
13. Describe gallbladder carcinoma, it's risk factor, presentation and prognosis.
- It's adenocarcinoma of glandular epithelium of gallbladder wall
- Gallstones are major risk factors, esp with procelain gallbladder
- Presentation
○ Cholecystitis in old woman (cholecystitis is a disease of 40-50 year olds)
- Poor prognosis.
Choledocolithiasis
14. Describe clinical features of choledocolithiasis.
- Stones within the biliary tree
- 90-95% of pt with choledocolithiasis have cholelithiasis. But only 15% of pt with
cholelithiasis have choledocolithiasis.
- Lab finding -
○ Contrast to cholelithiasis, we see sign of biliary tree blockage
Increased alk phosphatase
Increased bilirubin
Note: conjugated bilirubin and direct bilirubin are same thing; non -conjugated and indirect are same.
UGT is Uridine glucuronyl transferase
Dubin-Johnson High CB Low bilirubin canalicular transport - Dark liver (HY) (otherwise clinically silent)
syndrome protein (autosomal recessive)
Rotor syndrome High CB Low bilirubin canalicular transport - Lacks liver discoloration; otherwise same as
protein (autosomal recessive) Dubin-Johnson
Biliary tract obstruction High CB Seen with gallstones, pancreatic - Dark urine and pale stool
(obstructive jaundice) High alk carcinoma, cholangiocarcinoma, - Pruritus due to increased plasma bile acids
phosphatas parasites, liver fluke - Hypercholesterolemia with Xanthoma (bile
e is major way of cholesterol excretion)
Low urine - Steatorrhea with malabsorption of fat
urobilin soluble vitamin
Viral hepatitis High CB and Inflammation disrupts inflammation - Dark urine (due to CB)
UCB and small bile ductules - Normal or low urine urobilinogen (CB is
leaking out to blood and not going to
duodenum)
Notes
- Unconjugated bilirubin can't be excreted by urine as it's fat soluble. It floats in blood until it finds exit.
- Conjugated bilirubin is water soluble, can leak out to blood and will go to urine and make it dark
Fig - L is liver parenchyma, P is portal tract. Note inflammation is mainly in portal tract only.
1. Describe cirrhosis.
- It's end stage liver damage characterized by bridging fibrosis (fibrosis between portal tracts) and
regenerative nodules of hepatocytes
Fig - note the regenerative nodules with fibrosis in between - characterstic of cirrhosis.
(normal liver surface is smooth)
- Alcoholic hepatitis
○ Direct chemical injury to hepatocytes mediated by acetaldehyde (HY)
○ Generally seen with binge drinking
○ Histology
Balooning of hepatocytes
Mallory bodies (characterstic) - damaged intermediate filaments in hepatocytes (HY)
Inflammation
9. Describe hemochromatosis.
- Excess iron deposition (hemosiderosis) leads to tissue damage (hemochromatosis)
- Damage due to generation of free radical by Fenten reaction (HY).
Wilson disease
15. What is wilson disease?
- Autosomal recessive defect (ATP7B gene) that damages hepatocyte Cu transport and decreased
ability to bind Cu to ceruloplasmin (bile main way to excrete Cu; ceruloplasmin Cu carrier in blood)
leads to increased Cu in body.
- Free radical production leads to damage.
Reye syndrome
17. What is reye syndrome?
- Fulminant (severe and sudden onset) liver failure with encephalopathy in children with viral
syndrome that take asprin
- Related to mitochondrial damage of hepatocytes
- Kawasaki disease (vasculitis) affects mainly coronary artery and presents like viral illness in kids.
But asprin is good to use in that case (HY)
Hepatic cancer
19. Describe hepatic adenoma.
- Benign tumor of hepatocytes
- Associated with oral contraceptive use; tumor goes down with cessation of drug (HY)
- Risk of rupture because tumor is right below liver capsule - lead to hemorrhage, especially during
pregnancy
Fig - multinodular liver is classic presentation of liver metastasis and can be felt on physical exam
Dysplastic kidney
1. What is presentation of dysplastic kidney? Is it inherited?
- Mostly unilateral and non-inherited malformation of renal parenchyma with cysts and abnormal
tissue (ex-cartilage).
- Congenital but non-inherited
- If bilateral, must be distinguished from polycystic kidney disease
Fig: dysplastic kidney. Circle on left is cyst; circle on right shows growing cartilage
a) Classify the types of acute renal failure (azotemia) and its presentation.
- Pre-renal azotemia
- Intra-renal azotemia
○ Acute tubular necrosis (most common cause of ARF)
○ Acute interstitial nephritis
- Post-renal azotemia
- Presentation
○ Azotemia - hallmark (increase BUN in blood; uremia is symptoms due to increased BUN)
○ Oliguria (if we make <500ml urine/day, we can't excrete solid waste)
c) What is normal Bun/Cr ratio and how does it change during azotemia?
- Normally, Cr is excreted a little in PCT, and Bun is reabsorbed in PCT. Therefore, BUN is higher in
blood than Cr which makes normal BUN:Cr = 15
- In pre-renal azotemia, RAAS is activated due to decreased renal perfusion. More water is
reabsorbed, and more BUN is reabsorved with it. Therefore, BUN/Cr>15.
- In intra renal and post renal azotemia, Cr isn't excreted well. Build up of creatinine makes
Bun:Cr<15. (is this reasoning right)
Post-renal azotemia
e) Describe post-renal azotemia.
- Due to obstruction of urinary tract downstream, GFR decreases and results in azotemia, oliguria.
- Presentation
○ Early stage - FENa<1%, and BUN:Cr>15 (because increased backflow pushes BUN back to
blood.
○ Late stage - FENa>2%, BUN:Cr<15, and urine Osm<500 due to tubular damage and kidney
not working well.
Fig- ATN - T are tubules that are clogged up by dead cells. G is glomerulus.
k) Describe acute interstitial nephritis. What are some drugs that can cause it?
- An intra-renal cause of ARF.
- Hallmark is presence of inflammatory cells in kidney interstitium.
Nephrotic syndrome
1. What are presentation of nephrotic syndrome?
Hallmark is >3.5g protein/day in urine
Hypoalbuminurea
Hypogammaglobulinemia
Hypercoagulable state - loss of antithrombin 3
Hyperlipidemia and hypercholesteremia - liver dumps fat to blood to make it thick (compensate
for loss of disease)
Fig - effacement of foot process. Bottom part is capillary; black blobs are RBC.
○ Small and frequent deposits seen in EM. Immune deposition is subepithelial (below
epithelium - podocytes also called epithelium)
7.5.What are two types of membranoproliferative glomerulonephritis and what are they associated
with?
• Divided to two types based on immune deposit type-
○ Subendothelial (type 1) - associated with hepatitis B, hepatitis C. Type 1 has more tram
tracks association.
○ Within basement membrane (type 2) - pt have C3 nephritic factor (autoantibody) (HY). This
antibody binds and stabilizes c3 convertase.
• Compliment system is hyperactive which causes the disease.
• Membranoproliferative disease can cause nephritic, nephrotic or both
10. Describe how amyloidosis leads to nephrotic disease (most common organ affected in systemic
amyloidosis is kidney).
• amyloid deposits in mesangium leading to nephrotic syndrome
• characterized by apple-green birefringence in polarized light
• mesangial nodules in diabetes and amyloidosis are immunofuorescence negative. Diabetic
nodules are PAS positive, but amyloid nodules are PAS negative, why?
Fig - cellular crescent seen in RPGN. Note crescent made of fibrin and macrophage (inflammatory
stuff - not collagen)
2. What is cystisis?
• Inflammation of bladder
• Presentation-
○ Dysuria (pain with urination)
○ Urinary frequency and urgency
○ Suprapubic pain
○ Lack of systemic signs
10. pelvic inflammatory disease (PID) - infection of the upper part of the female reproductive system
namely the uterus, fallopian tubes, or the ovaries.(pyelonephritis version of cystitis)
□ Untreated PID can lead to fibrosis that can lead to infertility and ectopic pregnancy
Aka struvite
stone
Uric acid Third most Most common in pt with Hydration and alkalization
common (5%) gout, hyperuricemia (lukemia of urine (KHCO3);
Radiolucent or myeloproliferative allopurinol for gout-
(others are disorders) decreases uric acid
radiopaque) Risk factors - acidic PH, hot,
arid climite, low urine volume
Cysteine Rare; most Associated with cystinuria Hydration and May form
commonly (genetic disorder where alkalinization of urine staghorn
seen in there's low reabsorption of stone
children cysteine from tubules)
Notes:
• In Chron's, damage to small intestine causes increased absorption of oxalate. This results in high
chance of forming calcium oxalate in urine
•
4. What are some changes that happen when patients are put on dialysis?
- ESRD kidneys are small and shrunken (small kidney = chronic kidney disease); putting on dialysis
leads to cyst formation
- Big and cystic kidney = polycystic kidney disease. Small and cystic kidney = ESRD kidney on dialysis
- Pt have high risk for renal cell carcinoma in the shrunken kidney(HY)
- Patient get local amyloidosis in the joints.
Is acute kidney injury, acute renal failure and uremia the same thing?
Angiomyolipoma
1. What's angiomyolipoma? What's its associated with?
- Hamartoma made up of blood vessels, smooth muscle and adipose tissue (clear from name)
- It's associated with tuberous sclerosis (HY) (syndrome with benign tumor primarily in brain, eyes,
heart, kidney, skin and lungs. Common presentation: seizures, developmental delay, intellectual
disability and autism)
Wilm's tumor (nephroblastoma) (most common malignant renal tumor in children; average age 3
years)
1. What's histologic hallmark of Wilm's tumor?
- Blastema (primitive kidney mesenchyme cells that make glomerulus, tubules and stromal cells)
Fig: gross feature (left) and microscopic feature (right) of renal cell carcinoma
2. What are 3 common malignant tumor of lower urinary tract and what are their risk factors?
Cancer Risk factor Common
location
Urothelial (transitional cell) carcinoma - Cigarette smoking (major) - polycyclic Bladder.
(MOST COMMON CANCER OF LOWER URINARY aromatic hydrocarbon (major),
TRACT- urothelium lines entire lower urinary tract) napthylamine
- Azo dyes (cancer seen in hair dressers)
- Long term cyclophosphamide or
phenacetin use
Squamous cell carcinoma - Arises after squamous metaplasia (urinary Bladder
tract doesn't have squamous cells)
• Chronic cystitis (older woman)
• Schistosoma hematobium (HY)
infection (middle eastern male)
• Long standing nephrolithiasis
Adenocarcinoma - No glandular cells in bladder: Bladder
• Arises from urachal remnant (HY)
(tumor at dome of bladder - HY)
• Cystitis glandularis - columnar
metaplasia due to chronic bladder
inflammation
• Exstrophy (failure to form caudal
portion of anterior abdominal and
bladder wall) - bladder exposed to
outside world which increases risk
in future to have cancer
Fig: extrophy
- Urachal remnant - urachus is remnant of channel between bladder and umbilicus (urine drains this way in
fetus during 1st trimester of pregnancy). It's lined by glandular cells. From 12th week of gestation, it's called
median umbilical ligament.
Vulvar carcinoma
Epidemiology - Relatively rare (small portion of female genital cancer)
Fig: paget disease of nipple vs vulva (can occur in scrotum and other places
too)
Distinguish Paget cells - PAS+ve, keratin +ve and S100 -ve
from melanoma Melanoma - PAS-ve, keratin -ve and S100 -ve (PAS - shows mucus)
Vaginal carcinoma
Histology - Malignant proliferation of squamous epithelium lining vaginal canal
HPV
Prognosis - Mostly affects lower genital tract, especially cervix in transformation zone
- Infection usually eradicated by acute inflammation; persistent infection can lead to cervical
dysplasia and cervical intraepithelial neoplasia (CIN)
- Most common cause of SCC of genitourinal tract
Pathophys - Produces proteins:
• E6 - inactivates p53
• E7 - inactivates Rb
Vaccinatio - HPV 6, 11
n • Prevent against condolymata acuminata
- HPV 16, 18
• Prevent against CIN and cervical cancer
Cervical carcinoma
Types - Squamous cell carcinoma (80% of cases)
- Adenocarcinoma (15% of cases)
- Other - clear cell carcinoma, transitional cell carcinoma
Presentation - Mostly seen in middle aged woman (40-50 years)
- Presents as postcoital bleeding
Risk factor - HPV infection (main) - can cause both SCC and adenocarcinoma
- Immunosuppression (cervical carcinoma AIDS defining illness)
- Smoking
Complication - Hydronephrosis and post renal failure common cause of death
• Tumor invades through anterior uterine wall to bladder and blocks the ureters
Screening of cervical carcinoma - pap smear (THE MOST SUCCESSFUL SCREENING TEST DEVELOPED TO DATE)
- Cervical cancer went from being the most common to one of least common gynecologic cancers in US
Fig: right - normal squamous epithelial cells (small nuclei with abundant cytoplasm) present
in exocervix; left – normal squamous epithelial cells (red arrows), normal columnar
epithelial cells from endocervix – blue cytoplasm and cilia sometimes seen
Abnormal pap
Fig: black arrows indicate normal squamous epithelial cells with small round nuclei. Red
arrow - koliocytes - abnormally large and pleomorphic nuclei
Basics
Endometrium - Mucosal lining of uterus
Myometrium - Smooth muscle underlying the endometrium
Hormone cycle of Proliferative Estrogen driven Endometrium grows
endometrium phase
Secretory phase Progesterone driven Endometrium prepares for
implantation
Menstrual Due to loss of Endometrium falls
phase progesterone
Endometrial polyp
Definition - Polyps formed due to hyperplastic protrusion of endometrium
Endometriosis
Definition - Endometrial glands and stroma outside uterine endometrial lining (the glands
follow normal menstruation cycle)
Cause - Most likely due to retrograde menstruation with implantation at an ectopic site
Common - Ovary (most common) - makes hemorrhagic (aka chocolate) cyst
sites - Uterine ligament - cause pelvic pain
- Pouch of douglas - pain with defecation
- Bladder wall - pain with urination
- Bowel serosa - abdominal pain and adhesions
- Fallopian tube mucosa - scarring increases risk for ectopic tubal pregnancy
- Adenomyosis - if endometriosis occurs in myometrium of uterus
- Sites classically appear as yellow-brown 'gun powder' nodules
Endometrial hyperplasia
Definition - Hyperplasia of endometrial gland relative to stroma
Cause - Unopposed estrogen
• Obesity
• Polycystic ovary syndrome
• Estrogen replacement
Presentation - Classic is postmenopausal uterine bleeding
Classification - Based on architectural growth pattern (simple or complex)
- Or based on presence or absence or cellular atypia
Prognosis - If cellular atypia present, may progress to carcinoma (major complication
Leiomyosarcoma
Definition - Malignant neoplastic proliferation of muscle in myometrium
Epidemiology - Often seen in postmenopausal women
Cause - Arise de novo; do not arise from leiomyoma
4. Describe the following features of surface epithelial tumors of female reproductive tract.
Distant metastasis Peritoneum (via direct contact) - see omental caking
Serum marker CA-125 - monitor treatment response and screening for recurrence
Fig: Schiller-Duval
Fig: hair and teeth seen in bodies (glomerulus like
cystic teratoma structure) classically
Fig: fried egg appearance on
Fig: Tumor is small, seen on biopsy.
biopsy
hemorrhagic and spreads
hemotageneously early
- Good prognosis; responds to - Poor response to
radiotherapy chemotherapy
- Serum LDL maybe elevated - High Beta-HCG - Hyperthyroidism in case of
characterstic (made by Struma ovarii (teratoma
syncytiotrophoblasts) - mainly composed of
may lead to thecal cysts thyroid tissue)
in ovary
Metastasis
1. Describe the two common tumor metastasis to ovary.
Source Presentation
Krukenberg tumor Gastric carcinoma (diffuse - Mucinous tumor
type) - Mostly bilateral (if unilateral, think primary mucinous
carcinoma of ovary)
Pseudomyxoma peritonei (myxoma = Mucinous tumor of - Huge amount of mucus in peritoneum "jelly belly"
tumor of connective tissue with mucus appendix
and gelatinous material)
Ectopic pregnancy
Definition - Implantation of fertilized ovum at site other than uterine wall
- Most common site is fallopian tube
Risk - Key risk is scarring (secondary to pelvic inflammatory disease or endometriosis)
Presentation - Lower quadrant abdominal pain a few weeks after a missed period
Prognosis - Surgical emergency; bleeding and fallopian tube rupture can occur
Spontaneous abortion
Definition - Abortion <20 weeks of gestation (usually during first trimester)
Epidemiology - Common; occurs in up to 1/4th of pregnancies
Presentation - Vaginal bleeding with passage of fetal tissue
- Cramp like pain
Cause - Most often due to chromosomal abnormalities (especially trisomy 16)
- Hypercoagulable states (ex - antiphospholipid syndrome)
- Congenital infection
- Exposure to teratogens (especially during first 2 weeks of pregnancy)
Teratogens
1. What is common timewise effect of teratogen exposure?
0-2 weeks of gestation Spontaneous abortion
3-8 weeks Risk of organ malformation
3-9 months Risk of organ hypoplasia
Testicular torsion
Definition Twisting of spermatic cord which obstructs spermatic vein leading to
hemorrhagic testicular infraction in ~6 hrs
Cause Congenital failure of testes to attach to inner lining of scrotum (via processus
vaginalis)
Presentatio Sudden testicular pain and absent cremasteric reflex (nerves present in cord)
- B-HCG rarely - AFP or B-HCG - AFP or B-HCG - AFP increased - B-HCG increased
increased increased incresed (syncytiotrophoblasts
produce it)
- Alpha subunit of HCG
similar to FSH, LH and
TSH; may see
hyperthyroidism and
gynecomastia
Labs - Slightly increased prostate specific antigen (PSA) - made by prostatic glands and it
liquefies semen (still <10 ng/ml)
Treatment - Alpha1 antagonist (terazosin) to relax smooth muscle - also lowers BP
- Alpha1a antagonist (tamsulosin) - don't act on vascular smooth muscle; use for
normotensive pt
- 5alpha reductase inhibitor (reduce androgenerigc stimulation of prostate and
reduce its size)
• decrease conversion of testosterone to DHT
• Takes months to produce affect
• Helps with baldness
• Side effect - gynecomastia and sexual dysfunction
Prostate adenocarcinoma
Epidemiolog - Most common cancer in men
y - 2nd most common cause of cancer-related death in men
Risk factors - Age
- Race (AA>Caucasians>Asians)
- Diet high in saturated fats
Presentatio - Mostly clinically silent (tumor arises on posterior peripheral region of prostate;
n don't see urinary symptoms)
Screening - PSA and DRE from 50 years age
- PSA:
• Normal serum PSA increases with age due to BPH (~2.5 for 40-49; ~7.5 for
70-79)
• PSA > 10 ng/ml highly worrisome for any age
• Also see decreased free PSA as cancer makes PSA that’s bound.
Diagnosis Biopsy:
• See small invasive glands with prominent nucleoli
• Ducts maybe only one layer thick instead of having basal and laminal layer
Hypopituitary
8. When do we see hypopituitarism?
- When >75% of pituitary parenchyma is lost
Posterior pituitary
10. What are clinical presentation and causes of central diabetic insipidus? What is diagnosis and
treatment?
- Presentation (based on loss of free water)
○ Polyuria and polydipsia
○ Hypernatremia and high serum osmolality
○ Low urine osmolality and specific gravity
- Causes - damage (tumor, trauma, infection or inflammation) to hypothalamus or pituitary
11. What are clinical presentation and causes of nephrogenic diabetic insipidus?
- Presentation - same as central DI but no response to desmopressin
- Causes - mutation or drugs (demeclocycline - old antibiotic, not used often now; and lithium)
12. What are clinical presentation and causes of syndrome of inappropriate ADH (SIADH)?
- Presentation -
○ Hyponatremia and low serum osmolality
○ Mental status change and seizure. - due to nerve swelling
- Causes - ectopic production (ex - small cell carcinoma of lung)
○ CNS trauma
○ Pulmonary infection
○ Drugs (cyclophosphamide)
- Treatment - free water restriction, demeclocycline
1. Differentiate T3 and T4
T4 (thyroxine) T3 (triiodothyronine)
Both are made from tyrosine 10 times more potent than T4
Most of it made from T4
Thyroid secretes T4>>T3
T1/2 = 7 days T1/2 = 7 days
T4--> T3 conversion reduced in severe illness
3. How are T3 and T4 made in thyroid gland? What is the key enzyme?
- Key enzyme is thyroid peroxidase
- Thyroglobulin are long chain of tyrosine that's stored as colloid in thyroid gland. T3/T4 are made
from it.
- Steps
○ Iodine is oxidized to oxidized iodine by thyroid peroxidase (oxidation step)
○ Oxidized iodine reacts with tyrosine to make monoiodotyrosine
○ Oxidized iodine reacts with monoiodotyrosine to make diiodotyrosine
○ The last two steps are called organification
○ Monoiodotyrosine + diiodotyrosine = triiodothyronine
○ Diiodotyrosine + diiodotyrosine = thyroxine
○ The last two steps are called coupling
Hyperthyroidism (thyrotoxicosis)
7. What are presentation of hyperthyroidism?
a. Increased basal metabolic rate (due to increased synthesis of Na/K pump) (HY) -
i. wt loss despite increase hunger
ii. Tremor, anxiety, insomnia, and heightened emotions
iii. Heat intolerence and sweating
b. Increased SANS (due to increased expression and activity of B1 s)
i. Cardiac - tachycardia, arrhythmia (esp in elderley)
c. Hyperglycemia (increased gluconeogenesis and glycogenolysis) (HY)
d. Hypocholesteremia and low serum LDL (increased LDL receptors) (HY)
e. Diarrhea and malabsorption (increased GI motility)
f. Osteopenia and hyercalcemia (increased bone reabsorption)
g. Decreased muscle mass and weakness
h. Oligomenorrhea
10. What causes exopthalmos and pretibial myxedema (characterstic finding) in grave's?
○ Fibroblast behind eye and in tibia has TSH receptors. Excitation leads to glycosaminoglycan
(chondroitin sulfate and hyaluronic acid) buildup, inflammation, fibrosis, and edema.
○ Myxedema feels like dough. And myx refers that edema is not caused by water.
11. What is histology of Grave's?
- Histology shows irregular follicle and scalloped colloid and chronic inflammation
Hypothyroidism
15. What is cretinism? What are it's findings?
- It's developmental delay caused due to hypothyroidism.
- Classic findings
○ Mental retardation and dwarfism due to poor brain and skeletal development
○ Enlarged tongue (due to myxedema)
○ Umbilical hernia
17. What's classic findings in myxedema (hypothyroidism in old kids and adults)?
a. Myxedema - classically in tongue (large tongue) and larynx (gives deep voice) (HY) - due to
increased TSH
b. Decreased BMR and decreased SANS
i. Wt. gain despite normal activity
ii. Cold intolerane and decreased sweating
iii. Bradycardia
c. Hypoventilation and respiratory arrest - thyroid maintains respiratory drive
d. Slow mental activity
e. Muscle weakness
f. Hypoglycemia, hypercholesteremia
g. Oligomenorrhea (seen in both hyper and hypothyroidism)
h. Constipation
Thyroiditis
19. What is presentation of hashimoto's thyroiditis? What chemical is is associated with? What are lab
results?
- It's an autoimmune attack to thyroid peroxidase and thyroglobulins
- Associated with HLA-DR5 (HY)
- Initially see increase T3/T4 (and low TSH) due to gland destruction. Later on, we see decreased
T3/T4 (and high TSH) due to gland destruction.
- Suspect other autoimmune disease - type 1 DM, pernicious anaemia, rheumatic disease.
- Lab results - anti TPO, anti-thyroglobulin, anti-microsomal antibodies, high TSH, low T3/T4
21. What disease do pt. with Hashimoto's have increased risk of? How? What's presentation?
- B cell lymphoma.
- How - Germinal center makes post germinal center B cells. It makes marginal zone which results in
marginal zone lymphoma.
- Presentation is pt with long standing hypothyroidism that presents with enlarged thyroid.
22. What is SUBACUTE GRANULOMATOUS (DE QUERVAIN) THYROIDITIS? What's its presentation?
What's its prognosis?
- It's granulomatous thyroiditis that follows viral infection (subacute means it occurs after acute
process).
- Presentation - Hypothyroidism is transient, and pt has tender thyroid (if a young female has tender
thyroid, think subacute granulomatous thyroiditis).
- Prognosis - It's self-limited and don't progress to hypothyroidism.
Thyroid cancer
24. What are basics of thyroid cancer?
- Most nodules are distinct and solitary
- Most nodules are likely to be benign than malignant
26. Describe follicular adenoma (adenomas are benign; adenocarcinoma are cancerous).
- Follicle proliferate in a benign way and are surrounded by a fibrous capsule
- Called follicular because tumor also makes thyroid follicle.
- Tumor mostly non-functional (don't secrete hormone)
Fig - follicular adenoma. Red line is the capsule that divides adenoma (bottom half) from
normal thyroid (top half)
28. What is epidemiology, risk factor, prognosis and histologic feature of papillary carcinoma?
- Most common thyroid carcinoma (80% of thyroid carcinoma)
- Major risk - exposure to ionizing radiation in childhood
- Prognosis - excellent even though often spreads to cervical nodes
- Histology -
- Papillae of cells seen (so called papillary carcinoma
- Diagnosis is made by nuclear features -
Coffee bean nucleus (presence of nuclear groove)
Orphan eye annie nucleus (nucleus has white stuff resembling white of eye)
Psammomma bodies (concentric calcification of papillaes).
29. What is histologic feature of follicular carcinoma? Can you diagnose by FNA?
- Similar to follicular adenoma (has fibrous capsule) but cells invade through capsule (hallmark)
- FNA can't distinguish between follicular adenoma and follicular carcinoma because capsular
invasion can't be assessed by FNA.
- Even though most carcinomas spread via lymph nodes, follicular carcinoma spreads
hematogenously (by blood).
30. What are 4 carcinomas that spread by blood instead of lymph? (HY)
- Renal cell carcinoma
- Follicular carcinoma of thyroid
- Hepatocellular carcinoma
- Corneal carcinoma
Fig - MTC biopsy. All the pink stuff seen is calcitonin amyloid.
32. Describe familial cases of MTC (HY). What's significance of RET oncogene (HY)?
- Often associated with MEN 2A or 2B phenotype. (MEN = muliple endocrine neoplasia)
- MEN 2A - often see MTC, pheochromocytoma and parathyroid adenomas
Fig - highly malignant cells in anaplastic carcinoma that don't resemble anything seen in thyroid
usually
Primary hyperparathyroidism
7. Explain primary hyperparathyroidism.
- Excess PTH; most common cause is PT adenoma (80%)
- Other causes - PTH hyperplasia, PTH carcinoma
Secondary hyperparathyroidism
10. What are some causes for 20 hyperparathyroidism?
- Most common is chronic renal failure (HY)
○ Decreased phosphate excretion --> reduced free calcium in blood as most of it is bound
to phosphate ---> increased PTH production and increased bone reabsorption
Hypoparathyroidism
12. What are causes of hypoparythoroidism?
- Autoimmune
- DiGeorge syndrome (failure of develop 3rd and 4th pharyngeal pouch. Parathyroids develop
from 3rd and 4th pharyngeal pouch).
Pseudohypoparathyroidism
14. What causes pseudohypoparathyroidism?
- Caused due to end organ resistance of PTH
- Hypocalcemia with increased PTH level (also see this is secondary hyperparathyroidism; but 20
hyperparathyroidism has increased serum phosphate levels too)
- Autosomal dominant form (mutation of Gs) associated with short stature and short 4th and
5th digit
Insulin - major anabolic hormone. Upregulates GLUT4 receptors in muscle and fat. Increased
glucose leads to glycogen synthesis, fat synthesis, protein synthesis
Glucagon - major catabolic hormone. Causes gluconeogenesis from AA, lipolysis and
glycogenolysis.
Type 1 DM
2. Explain Type 1 DM
- Autoimmune destruction of B cells by T lymphocytes (type 4 hypersensitivity) - see inflammation
of islets
- Autoantibodies against insulin - can be seen years before disease
- Associated with HLA DR3 and DR4
Type 2 DM
7. Explain type 2 DM.
Fig - amyloid deposition in Islets in type 2 DM. Amyloid is made of amylin - a protein
produced with insulin.
12. What are two major complications of diabetes? Give examples of diseases.(HY)
- Non enzymatic glycosilation (NEG) of vascular basement membrane
○ NEG of large and medium vessels lead to artherosclerosis - ex - peripheral vascular disease
leading to amputation
○ NEG of small vessel leads to hyaline arteriolosclerosis - ex - diabetic nephropathy (nephrotic
syndrome)
○ NEG of hemoglobin leads to HbA1c - long term marker of glycemic control
- Osmotic damage
14. What are two proteins that are made together with insulin?
- Amylin - in type 2 DM, we see amyloid buildup due to amylin buildup
- C peptide - can be tested in blood to see if pt is overadminstering insulin
Crotex - hormones are made from cholesterol (cortex is yellow due to cholesterol)
Medulla- hormones made from tyrosine
4. What are functions of glucocorticoids (called glucocorticoid because it increases glucose in blood)?
Increased glucose output by liver and decrease glucose intake by muscle, adipose (to increase glucose
supply to brain and heart)
Decreased insulin sensitivity
Decreased immune activity via
o Decreased arachidonic acid production (due to inhibition of phospholipase A2)
o Low IL-2 production (IL2 important for proliferation of T cells)
o Low histamine production
Increased alpha one receptor production and sensitivity to catecholamines (lack of cortisol causes
extreme vasodialation, extreme hypotension and death)
Negative feedback to ACTH
8. How do you distinguish between cushing's due to ACTH made by pituitary vs pituitary made somewhere
esse (paraneoplastic)?
- Do a dexamethasone suppression test. ACTH produced by pituitary will go down but not the
paraneoplastic one.
Fig - pheochromocytoma. Yellow parts seen in left and right are adrenal cortex.
21. Why don't you give beta blocker in pheo to control HR?
- B2 is a vasodialator. B1 increases HR. If B blocker is given, we have uncontrolled alpha action (very
severe vasoconstriction).
1. Describe the following benign tumor and fibrocystic changes in the breast.
Epidemiology Presentation
Fibrocystic Most common change in premenopausal - Presents as vague irregularity
change women (hormone mediated) - seen in 30-60% (lumpy breast) in upper outer
of women quardant
- Cyst look blue-dome on gross
exam
Invasive lobular - Cells characteristically grows in single file (aka Indian file) and may show - Often bilateral and multiple lesions in
carcinoma signet ring morphology - cells don't make duct because they lack E- same location
cadherin - Better prognosis than invasive ductal
- Usually bilateral carcinoma
- Associated with lobular carcinoma in situ
in 90% of cases
- Has diffuse invasive pattern of spread so
difficult to detect by physical or radiologic
exam
Fig: Small runs of invasive lobular carcinoma (arrows) with two adjacent
foci of LCIS.
Detecti - Can be detected by elevated alpha-fetoprotein (AFP) in amniotic fluid and maternal blood.
on - AFP most abundant protein in young fetus blood (albumin of fetus) - made by fetal liver and yolk sac.
- AFP elevated in other cases too - hepatocellular carcinoma, liver metastasis, yolk sac tumor, germ cell tumor.
Anatom - Neural plate invaginates early in gestation to make neural tube
y - Walls of neural tube - makes CNS
- Hollow lumen of neural tube - makes ventricles and spinal cord canal
- Neural crest - makes peripheral nervous system
- CSF leaks from 4th ventricle to subarachnoid space via foramen of Magendie
(middle) and foramen of Luschka (lateral)
Seringomyelia
Defn - Cystic degeneration of spinal cord usually on C8-T1 that affects the spinothalamic
(anteriolateral) pathway and later on affects anterior horn (motor neurons) and
lateral horn (SANS)
- Typically spares dorsal column pathway (fine touch and position)
Presentati - Sensory loss of pain and temperature in upper extremities and 'cape like'
on distribution (anterior white commissure of spinothalamic tract)
- Muscle atrophy and weakness (anterior horn damage)
- Horner's (lateral horn - hypothalamospinal tract damage)
Poliomyelitis
Defn - Anterior horn neurons damage due to poliovirus infection
Presentation - Presentation based on lower motor neuron sign
• Flaccid paralysis with muscle atrophy
• Babinski -ve
• Impaired reflexes
Werding-Hoffman disease
Defn - AR inherited degeneration of anterior motor horn
- Presents as floppy baby and death within a few years after birth
Fredreich ataxia
Defn - Degenerative disorder of cerebellum and spinal cord due to unstable trinucleotide
repeat (GAA) in frataxin gene (autosomal recessive)
Pathophys - Frataxin gene imp for mitochondrial iron regulation; loss results in iron buildup with
free radical damage
Presentati - Loss of multiple spinal tracts:
on • Loss of vibration and proprioception
• Muscle weakness in lower extremities
• Loss of deep tendon reflex
- Presents in early childhood; pt are wheelchair bound in few years
Associatio - hypertrophic cardiomyopathy
n
Stroke
Epdm - No. 3 cause of death in USA
- Neurons are susceptible to ischemia and undergo necrosis within 3-5 mins
Types
HEMORRHAGIC STROKE
Intracerebral hemorrhage
Defn - Bleeding in brain parenchyma - classically due to rupture of Charcot-Bouchard micro-aneurysm of
lenticulostriate vessels in Basal ganglia (contrast to ischemic lacunar stroke of lenticulostriate vessels due
to arteriolosclerosis)
Subarachnoid hemorrhage
Defn - Bleeding to subarachnoid space (blood vessels are outside pia but inside the arachnoid layer)
Presentation - Worst headache of life (aka thundercloud headache) with nuchal rigidity
Cause - Rupture of berry aneurysm (85% of cases)
• Most commonly located in branch point of anterior communicating artery
• Aneurysm lacks media layer
- AV malformation
- Anticoagulated state
Berry aneurysm - Marfan syndrome
association - Dominant polycystic kidney disease
Leukodystrophy
Defn - Inherited mutation in enzymes necessary to produce or maintain
myelin
Metachromatic - MOST COMMON LEUKODYSTROPHY
leukodystrophy - Deficiency of arylsulfatase. Sulfatides can't be degraded and
accumulate in lysosome of oligodendrocytes
- Autosomal recessive
Krabbe disease - Deficiency in galactocerebrosidase. Galactocerebroside accumulates
in m
- Autosomal recessive
Adrenoleukody - Impaired addition of coenzyme A to long-chain fatty acids (X-linked
strophy defect)
- Accumulation of fatty acids damages adrenal glands and white
matter of brain
Multiple sclerosis
Defn - Autoimmune destruction of CNS myelin and oligodendrocytes
Epid - Most common chronic CNS disease of young adults (20-30 years)
- More common in women and who live far away from equator
Genetics - Associated with HLA-DR2
Diagnosis - MRI reveals white matter demyelination
- Lumbar puncture:
• Increased lymphocytes and immunoglobulin
• oligoclonal IgG bands on high resolution electrophoresis
• Myelin basic protein
Alzhimers
2. What is clinical presentation of Alzhimer's (no. 1 cause of dementia)?
• Begins with short term memory loss and then long term memory loss
• Loss of motor skills and language
• Change in behavior and personality
• Pt become mute and bed ridden; infection is common cause of death
• Focal neurologic defect in late stage
Fig: Neuritic plaques (left) and neurofibrillary tangles (tau tangle) on right
Vascular dementia
7. Describe vascular dementia?
• 2nd most common cause of dementia
• Occurs due to multifocal white matter infraction
• Associated with HTN, artherosclerosis and vasculitis (they decrease blood flow to brain resulting in
infraction)
Huntingtons disease
14. What is genetic features of Huntington's disease?
• Autosomal dominant disorder (chro 4) with expanded trinucleotide repeat (CAG - glutamate) in
huntington gene
• Damage to GABAergic neurons in caudate nucleus (GABA = inhibitory)
• See anticipation (expansion of repeat during spermatogenesis causes this) - early onset of disease
with each generation (anticipation)
Fig: C is caudate (makes head that ends at lateral ventricle floor), P is putame. C+P = striatum
(called striatum because there's stripe running in between C and P).
Spongiform encephalopathy
18. What is pathophysiology of spongiform encephalopathy?
• PrPc is normal CNS protein which is in alpha helical structure. It's converted to PrPsc which is in
beta pleated shape.
• PrPsc is congo red +ve (amyloid).
• PrPsc is resistant to damage by autoclave or sterilization or by proteases. Also, it can convert other
PrPc to PrPsc.
Adult tumors
1. Glioblastoma multiforme (GBM)
Defn - Malignant tumor of astrocytes
Epid. - Most common primary malignant brain tumor in adults
Presentatio - Often crosses corpus callosum (so called butterfly glioma)
n - Histoogy shows necrotic center with pseudopallisading tumor cells and (pallisade - wall).
Psuedopallisade = fuzzy wall (kiwi seed look like)
- Tumor cells are GFAP +ve (stains for glial cells)
Fig: butterfly glioma (left); pseudopallisading tumor cells (middle); GFAP stain on right
Prognosis - Poor prognosis; one of rare brain tumors to metastasize easily
2. Oligodendroglioma
Defn - Malignant tumor of oligodendrocytes
Presentation - Calcified tumor often involving frontal lobe
- May present as seizures
- Histology shows 'fired egg' appearance of tumor cells
4. Schwannoma
Defn - Benign tumor of schwann cells that involves cranial or spinal nerves
Cause - If bilateral, associated with neurofibromatosis type 2
Features - If present within the cranium, most frequently involves CN 8 (presents as loss of hearing and tinnitus)
- Tumor cells S-100 +ve
Kids tumor
1. Pilocytic astrocytoma
Defn - Benign tumor of astrocytes
Epid. - Most common 10 brain tumor in kids
Presentati - Imaging: cystic lesion with mural nodule in cerebellum
on - Histology: Rosenthal fibers (thick eosinophilic corkscrew process of astrocytes) and eosinophilic
granular bodies; GFAP +ve tumor cells
2. Ependymoma
Defn - Malignant tumor of ependymal cells usually seen in 4th ventricle
Presentati - Biopsy:
on • perivascular pseudorosette is characteristic (pseudorosette because the central structure isn’t
part of the tumor. Originally, pseudorosette meant any rosette that didn’t have a truly empty
lumen)
• True ependymal rosette - rosette with central lumen as tumor's attempt to make CSF
- Tumor can result in hydorcephalous
3. Medullobastoma
Defn - Malignant tumor of neuroectoderm cells of cerebellum (granular cells)
Presentation - Histology:
• Homer-Wright rosettes may be present (type of true rosette)
• Small, round, blue cells on biopsy
Prognosis - Poor; tumor rapidly grows and spreads via CSF giving 'drop metastasis in cauda equina
4. Craniopharyngioma
Defn - Benign tumor that arises from epidermal remnant of Rathke's pouch (makes parts of pituitary
gland)
Presentation - Supratentorial mass in child or young adult (only supratentorial kid tumor we study)
- Can cause bitemporal hemianopsia due to compression of optic chiasm
- Calcifications can be seen - derived from 'teeth like' tissue
age old male with PMH of ..... presents with .... most concerning with...
Osteopetrosis (bone-that-is-like-stone)
Defn - Poor osteoclast function leading to abnormally thick and heavy bone that fractures
Osteoporosis
Defn - Reduction of bone density due to loss of trabecular (spongy) bone that increases risk
of fracture
Risk - Risk based on peak bone mass (attained ~30 years) and rate of bone loss after that
- Peak bone mass depends on genetics (Vit D receptor variation), diet and exercise
- Rate of bone loss is <1% per year after that. Bone loss increases due to lack of
exercise (space travel), poor diet and lack of estrogen
Clinic. - Reduced bone density on DEXA scan
features - Normal serum Ca, PO4, PTH - distinguish from osteomalacia (presentation of both
may be similar otherwise)
- Fracture in weight bearing bones - vertebra (ht loss and kyphosis), hip and distal
radius
Treatmen - Bisphosphonates - induce apoptosis of osteoclast
t - Exercise, Vit D, and Ca
- Estrogen replacement therapy debated (increases risk of breast and endometrium
cancer)
- Glucocorticoid speeds up bone loss
Osteomyelitis
Defn - Infection of marrow and bone
Types - Transient bacteremia - seen in kids - affects metaphysis
- Open wound bacteremia - seen in adults - affects epiphysis
Causes Most common cause (90%) - Staph aurues
Sexually active young adult - Neisseria gonorrhoeae
Sickle cell disease - Salmonella
Diabetics and IV drug users - Pseudomonas
Dog or cat bite/scratch - Pasteurella
Vertebral osteomyelitis (Pott disease) - Mycobacterium TB
Benign tumors
Osteoma - benign tumor most commonly seen on face
- Associated with garderner's synrome (osteoma + FAP (familial adenomatous polyposis) +
retroperitoneal fibrosis)
Chondroma - Divided as enchondroma (seen on medulla, mainly on small bones of hand and feet) or juxtacortical
chondroma (seen on bone surface)
Giant cell - Biopsy shows multinucleated giant cells and sromal cells
tumor - Soap bubble lesions seen most commonly in epiphysis of long bones - mostly distal femur or proximal
tibia
- Locally aggressive and may recur
Malignant tumors
Osteosarco Defn - Malignant tumor of osteoblast that has two peak incidence - most common in teenagers,
ma then in elderly
Risk - Familial retinoblastoma
factors - Paget disease (during the osteolbastic hyperactivity phase)
- Radiation exposure
Presentati - Occurs mostly in metaphysis of long bones (distal femur or proximal tibia mainly)
on - Imaging shows destructive mass with 'sunbrust' appearance due to periosteal reaction
and lifting of periosteum by adjacent tumor(codman triangle)
Chondrosa - Malignant tumor of cartilage seen in medulla that can grow out through cortex to make sessile
rcoma paracortical mass
- Seen mostly in central skeleton or pelvis
Ewing Defn - Malignant tumor of poorly differentiated neuroectodermal cells seen most commonly in
sarcoma diaphysis of males <15 years
Imaging - Onion skin appearance on X-ray
- Tumor arises in medullary cavity and comes outside the cortex to make soft tan-white
mass
Biopsy - Small round blue cells that resemble lymphocytes (can be confused with lymphoma or
chronic osteomyelitis) (presence of homer wright rosettes indicate neural differentiation)
Cause - Often associated with 11;22 translocation (ewing sarcoma gene (EWS) on ch 22 merges
with transcripton factor gene; precise pathophys unknown)
-
Malignant - Most common malignant bone tumors
tumors - Classic site of origin (lead kettle - PB KTL) - Prostate>breast>kidney>thyroid>lung
- Usually causes osteolytic (punched out) lesion except prostate that cause oseoblastic (sclerotic) leison
DJD RA Spondyloarthropathy
+ve Rheumatic factor Negative rheumatic factor
Affects both DIP and PIP Affects mainly PIP symmetrically Affects mainly DIP (sausage
(heubordin-bouchard nodes) fingers)- for psoriatic only
Pain worsens during day Pain gets better during day
Associated with HLA-DR4 Associated with HLA-B27
Degenerative joint disease
Defn - progressive degeneration of articular cartilage
- aka non-inflammatory arthritis (no redness or swelling in joints). Synovial fluid accumulates but
lymphocyte infiltrate are not seen. Lymphocyte infiltrate are hallmark in inflammatory
arthritis - gout and RA.
Risk factors - Obesity
- Age
- Trauma
Clinical ○ Commonly affects hip, lower lumbar, DIP and PIP joints
features ○ Symptoms worsen during day (HY)
Pathologic ○ Eburnation (bone rub) of subchondral bone
features ○ Pieces of bone might fall off in joint space (aka joint mice)
○ Enlarged DIP and PIP joints (heubordin-bouchard nodes) due to osteophyte formation (bone
spurs) (HY)
Fig: from left to right - characterstic fibrillation of articular cartilage; 1=bone eburnation, 2
=subchondral cyst, 3 = normal articular cartilate; joint mice; osteophytes
Fig - osteophytes leading to heubordin-bouchard notes on the left x-ray. Right is normal hand x-
ray
Rheumatoid arthritis
Defn - chronic systemic autoimmune joint disease that causes symmetrical polyarthritis and mainly
Seronegative Spondyloarthropathy
7. What are clinical features of spondyloarthropathy? Explain its types.
- Negative rheumatoid factor (aka seronegative)
- Affects axial skeleton
- Associated with HLA-B27
- Types
○ Ankylosing spondyloarthritis
Seen in young adult males
Presents with sacroiliitis and ankylosis of spine (bamboospine)
Uveitis - eye inflammation
Aortitis (weak aorta can lead to aortic regurgitation)
○ Reiter syndrome (reactive arthritis)
Can't see (conjuctivitis)
Can't pee (urethritis - pains with urination)
Can't climb tree (arthritis)
Usually seen in young males a week after GI or C trachomatis infection.
○ Psoriatic arthritis
Affects 10% of psoriatic patients
Affects axial and peripheral joints
Affects DIP of hands and feet (leads to sausage finger and toes) (HY)
○ Infectious arthritis
Most commonly seen with Neisseria gonorrhea (young adults)
Staph aureus (old people or kids).
Pt usually have only one joint affected - only the knee
Dearmatomyositis vs polymysosits
Dermatomyositis Polymyositis
Defn - Inflammation of skin and skeletal muscle - Inflammation of skeletal muscle only
Cause - Unknown; some associated with carcinoma
Presentati - Bilateral proximal muscle weakness; distal - Other than skin involvement, mimics
on muscles can be affected late dermatomyositis (bilateral proximal muscle
- Rash on upper eyelids (heliotrope rash); malar weakness
rash
- Red papules on elbows, knuckles and knees
(Gottron papules)
Neuromuscular junction
Myasthenia gravis vs Lambert-Eaton syndrome
Myasthenia gravis Lambert-Eaton syndrome
Defn - Ab against postsynaptic Ach receptor at NM - Ab against presynaptic Ca channel at NM
junction junction
Pt popn - Commonly seen in women - Seen as paraneoplastic syndrome; commonly
- 15% of cases associated with thymic hyperplasia in small cell carcinoma of lung
or thymoma
Presentati - Muscle weakness that worsens with use and - Muscle weakness that improves with use and
on improves with rest worsens with rest
- Early eye involvement - ptosis and diplopia (MOST
MUSCULAR DISEASE SPARE EYES)
Treatment - Thymectomy improves symptoms - Resection of cancer resolves disease
- Use anti-cholinesterase agents to increase Ach in - Anti-cholinesterase don't help
synapse
Fig: Top left - arrow points to scalloped nucleus in liposacoma; bottom left -
scalloped definition; right - normal adipose tissue biopsy
Rhabdomyoma - Benign tumor of skeletal muscle
- Cardiac rhabdomyoma is associated with tuberous sclerosis
Rhabdomyosarc - Malignant tumor of skeletal muscle
oma - Most common soft tissue tumor in children
- Rhabdomyoblast is characterstic cell - desmin positive
- Most common site is eyes, head and neck; vagina is classic site in young girls
INFLAMMATORY DERMATOSES
Atopic dermatitis and contact dermatitis
1. Differentiate atopic dermatitis and contact dermatitis.
Acne vulgaris
Presentation - Comedones (whitehead and blackheads), pustules, and nodules
- Very common in adolescents
Cause - Chronic inflammation of hair follicle and associated sebaceous gland
Pathophysiol - Propionibacterium acnes - infection produces lipases that break sebum to
ogy proinflammatory fatty acids which results in pustules or nodule
- Hormone mediated - androgens increase sebum and excess keratin production.
They block follicles and produce comedones
Treatment - Benzoyl peroxide (antimicrobial)
- Vit A derivatives (reduce keratin production) - ex- isotretinoin
Psoriasis
Presentation - Well-circumscribed salmon-colored plaques with silvery scale, usually on
extensor surface and scales
- Pitting of nails
Pathophysiolo - Excess keratinocyte proliferation
gy
Etiology - Autoimmune: associated with HLA - C
- Environmental trigger may be present: ex - trauma
Histology - Acanthosis- epidermal hyperplasia
- Parakeratosis - retention of nuclei in stratum corneum
- Munro microabscess - neutrophil collection in stratum corneum
- Auspitz sign - thinning of epidermis above elongated dermal paiillae - results in
bleeding when scale is picked off
Treatment - Corticosteroids
- UV-A light with psoralen
- Immune modulating therapy
Lichen planus
Presentation - Pruritic, purple papules with reticular white lines on surface (wickham striae)
- Commonly seen on wrists, elbow, and oral mucosa
Histology - Inflammation of dermal-epidermal junction with a saw tooth appearance
Etiology - Unknown
- Associated with Hep C infection
Dermatitis herpetiformis
Cause - IgA deposition at tip of dermal papillae
Presentation - Grouped pruritic papule, vesicles and bullae
Seborrheic keratosis
Presentation - Benign squamous proliferation; common in elderly
- Keratin filled cysts (horn cysts) - on extremities or face, coin like stuck on
appearance
Acanthosis nigricans
Presentation - Epidermal hyperplasia with symmetric darkening of skin (velvet like skin)
- Often presents in axilla, neck, groin
Melanocytes basic
Melanocyte location Basal layer
Embryogenic development From neural crest cells
Melanin production - Make melanin from tyrosine in melanosomes
- Pass melanosomes to keratinocytes
Nevus
Definition - Benign neoplasm of melanocytes
Presentatio - Flat macule or raised papule
n - Symmetric with sharp borders, evenly distributed
Types - Junctional nevus - melanocyte at dermal-epidermal junction; most common in kids
- Compound (intradermal) nevus - melanocyte extension into dermis; most
common in adults
Prognosis - Most common acquired nevi appear in early childhood; evaluate lesions after 20
years age
- Nevi changes is normal. Ex - hormones, pregnancy
- Dysplasia is precursor to melanoma
Melanoma
Definition - Malignant neoplasm of melanocytes - often fatal
Epidemiology - Significant risk of metastasis (contrast to basal cell carcinoma and SCC of skin)
Growth types - Radial - horizontal growth across epidermis; low risk for metastasis
- Vertical - growth to deep dermis
• Depth of extension (Breslow thickness) most important prognostic factor
for metastasis
Genetics • Often associated with BRAF V600E kinase mutation (55% of cases) (HY)
Treatment • Vemurafenib (BRAF kinase inhibitor) for BRAF +ve tumors
• Surgical excision
Variant of
Molluscum contagiosum
Presentation - Firm, pink, umbilicated papules