REVISION PART2

PATHOLOGY OF THE HEMOPOEI TI C &LYMPHOI D

SYSTEM, BLOOD VESSELS, HEART, LUNG, KI DNEY,
GI T, LI VER, GALL BLADDER, PANCREAS
Hematopoietic system
Diagnostic approach to
ANEMIA
First of all- Think of the
following
What are the symptoms of the patient ?
What is the level of Hemoglobin?
What does the MCV reveal ?
What does the peripheral blood smear reveal ?
What is the type of anemia ?
What is the cause of this anemia?
What is the pathogenesis ?
What are the investigations for this type of anemia ?
To make it as simple as possible ?
Is this an IRON DEFICIENCY anemia?
Is this ANEMIA OF CHRONIC DISEASE?
Is this HEMOLYTIC ANEMIA ?
Is this MEGALOBLASTIC ANEMIA ?
A simple formula
Anemia + Microcytic hypochromic red cells = try to think of iron
deficiency anemia first.
Anemia + Normocytic red cells + chronic disease = try to think of
anemia of chronic disease.
Anemia + evidence of red cell destruction = try to think of haemolytic
anemia
Anemia + macrocytes = try to think of Megaloblastic anemia
Note : The MCV value will give you an idea about the size of the RBC (
normocytic/ microcytic/ macrocytic )
Aplastic anemia
Caused by bone marrow failure.
Pancytopenia
Bone marrow- hypocellular
Polycythemia
Increase in red cells/unit volume of peripheral blood
Types : absolute, relative
Type of absolute polycythemia : Primary, secondary
Investigation: Serum erthropoietin
Neoplastic proliferation of
white cells
LYMPHOID NEOPLASMS : ALL, LYMPHOCYTIC leukemias , NHL,
Hodgkin lymphoma, myeloma
MYELOID NEOPLASMS : AML, Myeloproliferative neoplasms (CML,
polycythemia vera etc.), myelodysplastic syndrome.
HISTIOCYTIC NEOPLASMS: rare
How do we make a diagnosis of
leukemia ?
The WBC count is markedly raised. Acute leukemias show many blasts.
Then we have to find out :
Is this AML
Is this ALL
Is this CML
Is this CLL

Bone marrow examination is absolutely essential for the diagnosis of

leukemia.
Blast count > 20% = acute leukemias
Depending on the type of blast we classify it as myeloblastic/ lymphoblastic
ALL- more common in children
AML- more common in adults
Bone marrow
aspiration/biopsy
Absolutely essential for the
diagnosis of leukemia / aplastic
anemia/ other neoplastic
disorders of marrow etc.
Lymphoma
HODGKIN LYMPHOMA :
Malignant REED STERNBERG CELL.
surrounded by reactive
lymphocytes, macrophages etc.
Orderly spread by contiguity
Morphological types : Five
subtypes
WHO classification: morphology+
immunophenotype
Clinical staging : ANN ARBOR
Classification
NON HODGKIN LYMPHOMA
Several types
Extranodal involvement common
Clinical staging : ANN ARBOR
WHO classification : morphology +
immunophenotype
Investigation for lymphoma
Histopathological study of the affected lymph node
Immunophenotype
Karyotype etc.
BLEEDING DISORDERS
Due to PLATELET abnormalities
THROMBOCYTOPENIA ( Example: ITP)
Due to CLOTTING FACTOR abnormalities
Hemophilia
Von Willebrand disease
Due to vessel wall abnormalities : example: Scurvy
Tests for bleeding disorders (
basic)
Platelet count
Prothrombin time(PT)
APTT
DIC
Discussed in the previous revision session.
Recap- Thrombohemorrhagic disorder caused by the systemic
activation of coagulation resulting in systemic microthrombi &
activation of fibrinolysis.
Pathogenesis
triggered by either releases of tissue factor/ thromboplastic substance or by
widespread endothelial damage
Results in platelet aggregation & formation of widespread microvascular
thrombosis
This results in ischemic tissue damage
The depletion of platelets & clotting factors along with the activation of
plasmin results in an associated bleeding diathesis.
Heart
CONGENITAL HEART DISEASE
ISCHEMIC HEART DISEASE
HYPERTENSIVE HEART DISEASE
VALVULAR HEART DISEASE
HEART FAILURE
Cardiomyopathy
pericarditis
Congenital heart disease
Left to right shunt
ASD
VSD
PDA etc
RIGHT TO LEFT SHUNT
early cyanosis is a feature
Tetralogy of Fallot
Transposition of the great
arteries etc.
Ischemic heart disease
Angina pectoris
Acute myocardial infarction
Chronic IHD
Sudden cardiac death
MORPHOLOGIC CHANGES IN
MI
COAGULATION NECROSIS- begins at >4 hrs
12-24 HOURS- NEUTROPHILIC INFILTRATE APPEARS
7 10 days granulation tissue
> 2 months- collagenous scar
Investigations for MI
ELECTROCARDIOGRAPH
TROPONIN/CK-MB
Consequences/ complications
of MI
VENTRICULAR RUPTURE
VENTRICULAR ANEURYSM
ARRHYTHMIA etc
ACUTE RHEUMATIC FEVER
Rheumatic fever is an acute immunologically mediated multisystem
inflammatory disease that occurs after group A beta haemolytic
streptococcal infection
Symptoms: Carditis, arthritis , fever etc
Jones criteria: Carditis, migratory polyarthritis, subcutaneous nodules ,
erythema marginatum along with raised ASLO.
Morphology : ASCHOFF BODIES , pancarditis
Pericarditis
Myocarditis
Valve involvement verrucae
hypertensive heart disease
Systemic ( left sided )
hypertensive heart disease.
Left ventricular hypertrophy
Complications- heart failure, IHD
etc
Pulmonary hypertensive heart
disease
Right ventricular hypertrophy &
dilation
Etiology : pulmonary
hypertension due to disorders of
lung parenchyma or pulmonary
vasculature
Types : acute , chronic cor
pulmonale
Complication : right heart failure
LUNG
Pneumonia, lung abscess
Obstructive lung diseases
Restrictive lung diseases
Pulmonary embolism
Lung tumors
Pleural effusions
Acute lung injury
Atelectasis
Obstructive lung diseases
Bronchial asthma
Chronic bronchitis
Emphysema
Bronchiectasis
Bronchial asthma
A clinical syndrome characterized by episodic reversible airway
obstruction, bronchial hyperreactivity & airway inflammation.
Types of asthma : atopic , non atopic, drug induced, occupational
Pathogenesis : Type 1 hypersensitivity, acute & chronic airway
inflammation, bronchial hyperesponsiveness.
Triggering of asthma ( sensitization) followed by immediate phase &
the late phase
Morphology: Eosinophils ,Mucous plugs, Charcot Leyden crystals,
Curschmann spirals
Clinical features : dyspnea + wheezing
Chronic bronchitis
Persistent production of cough for at least 3 consecutive months in
two consecutive years.
Risk factor_ cigarette smoking
Morphology- marked thickening of mucous gland layer
Emphysema
Chronic obstructive airway disease
Permanent enlargement of airspaces distal to terminal bronchiole
Types : Centriacinar smoking,
Panacinar- alpha 1 antitrypsin deficiency
Bronchiectasis
permanent dilation of bronchi & bronchioles caused by destruction of
the muscle & elastic tissue , resulting from or associated chronic
necrotizing infection.
Pathogenesis : persistent infection + obstruction
Restrictive lung diseases (
some examples)
Pneumoconiosis
Sarcoidosis
Hypersensitivity pneumonitis
Pneumonia
Infection of lung
Types :
Community acquired pneumonia : Types - Acute , atypical
Hospital acquired pneumonia
Morphology: congestion, red hepatisation, grey hepatisation,
resolution
Complications: lung abscess, empyema, meningitis, arthritis, infective
endocarditis
Pulmonary tuberculosis
Chronic granulomatous diseases caused by Mycobacterium
tuberculosis.
Pathogenesis :
Unexposed immunocompetent host : Primary pulmonary TB ( Ghon
complex)
Secondary tuberculosis : arises in a previously sensitized host- upper
parts of lung, caseation, cavitation
Atelectasis
Lung collapse
Types :
Resorption atelectasis
Compression atelectasis
Contraction atelectasis
Lung tumors
Risk factor for carcinomas- smoking
Types of lung tumors : adenocarcinoma, squamous cell carcinoma,
large cell carcinoma, small cell carcinoma, carcinoids.
Small cell carcinomas- best treated by chemotherapy.
Carcinoid- malignant tumors
Oral cavity
Oral inflammatory lesions
Proliferative & neoplastic lesions
Esophagus
Obstructive diseases
Reflux esophagitis
Esophageal tumors
Stomach
Inflammatory diseases : Gastritis
Neoplastic diseases :
polyps
Adenocarcinoma:
INTESTINAL TYPE OF GASTRIC ADENOCARCINOMA ( PRESENTS AS AN EXOPHYTIC MASS)
DIFFUSE TYPE OF GASTRIC ADENOCARCINOMA ( LINITIS PLASTICA)
Small & large intestines
Intestinal obstruction
diarrheal disease
Inflammatory bowel disease
Colonic polyps
Adenocarcinoma
Liver, gall bladder, biliary tract
Jaundice
Hepatic failure
Cirrhosis
Porta hypertension
Fatty liver
Tumors
Cholelithiasis
Cholecystitis
Tumors
Patterns of hepatic injury
Hepatic degeneration
Intracellular accumulation
Hepatic necrosis & apoptosis
Inflammation
Regeneration
Fibrosis
Pancreas
Congenital anomalies
Acute & chronic pancreatitis
Pancreatic neoplasma
Etiologic factors in acute
pancreatitis
Metabolic example: alcoholism
Genetic
Mechanical- gallstones, trauma
Vascular- shock
Infection- mumps
Pathogenesis of acute
pancreatitis
Inappropriate activation of trypsin is the key triggering event
Net result: proteolysis, lipolysis, hemorrhage
Chronic pancreatitis
Inflammation with irreversible parenchymal destruction & fibrosis.
Etiology: long term alcohol abuse
Pathogenesis : recurring bouts of acute pancreatitis. Events include
ductal obstruction, toxic effects, oxidative stress
Morphology: replacement of pancreatic acinar tissue by dense fibrous
connective tissue,
Kidney
Glomerular diseases
Nephrotic syndrome
Nephritic syndrome
RPGN
Tubulointerstitial diseases
Tubulointerstitial nephritis
Acute tubular necrosis
Cystic diseases of kidney : Simple cysts, autosomal dominant & recessive
polycystic kidney disease
Obstructive diseases : renal stones, hydronephrosis
Tumors : renal cell carcinoma
Pathology of BLOOD VESSELS
ARTERIOSCLEROSIS
ATHEROSCLEROSIS : EPIDEMIOLOGY, RISK FACTORS, PATHOGENESIS ,
MORPHOLOGY, CONSEQUENCES
HYPERTENSIVE VASCULAR DISEASE
ANEURYSMS AND DISSECTIONS
VASCULITIS
TUMORS
Types & causes of
hypertension
Essential hypertension
Secondary hypertension
Renal example acute glomerulonephritis
Endocrine- example Cushing syndrome
Cardiovascular- example- coarctation of aorta
Neurologic
Vascular pathology in
hypertension
Hyaline arteriosclerosis
Hyperplastic arteriosclerosis
Atherosclerosis
Risk factors: Modifiable, non modifiable
Slowly progressive disease
affects large to medium sized muscular & elastic arteries
Pathogenesis : endothelial injury ,Smooth muscle proliferation
Morphology: atheromatous plaque
Atheromatous plaque = necrotic core, superficial fibrous cap
composed of smooth muscle cells, inflammatory cells
Consequences of atherosclerosis
Stenosis
Thrombosis
Aneurysm
Abnormal vascular dilation
Types of aneurysms: Abdominal aortic aneurysm, thoracic aortic aneurysm
Thoracic aortic aneurysm
Most common etiology- hypertension. Others Marfan syndrome, syphilis
Abdominal aortic aneurysm
Etiology: Most common cause of abdominal aortic aneurysm is atherosclerosis .
Other causes include vasculitis, trauma ,mycotic aneurysms, inflammatory
Complication: rupture, compression of adjacent structures etc