PAPER 1

GENERAL PATHOLOGY

Chapter 1| Cell Adaptations, Cell Injury, Coll Doath

(1.01) Cellular adaptations 1

-
(1.02) Mechanisms of Cell lnjury
(1.03) Morphological changes Reversible versus irreversible cell injury
7
12
(1.04) Apoptosis and Efferocytosis 13
(1.05) Necrosis 17
(1.06) Necrotosis, Pyroptosis, Ferroptosis 21
(1.07) Gangrene 22
(1.08) Pathological calcification 24
(1.09) Pigments 26
(1.10) Cellular Ageing 30

Chapter 2 | Inflammation
(2.01) Vascular events of Acute inflammation 33
(2.02))Cellular events of Acute inflammation 38
(2.03) Chronic inflammation or Granulomatous inflammation 43
(2.04) Chemical mediators of Inflammation 47

Chapter3 | Wound Healing and Repair

(3.01) Wound healing (Regeneration and Repair) 55
(3.02) Healing of skin wounds (Primary and Secondary intention) 57
(3.03) Factors affecting wound healing and Complications of Wound Healing 58

Chapter 4 | Hemodynamic Disorders

(4.01) Edema and Effusion 61
(4.02) Hyperemia and Congestion (CVC lung, CVC Liver, CVC Spleen) 66
(4.03) Thrombosis 69
(4.04) Embolism 73
(4.05) Ischemia 76
(4.06) Infarction 79
(4.07) Shock 81

Chapter 5 | Genetic Disorders

(5.01) Genetic inheritance of Single gene disorders (AD, AR, XD, XR) 85
(5.02) Cytogenetic Abnormalities 87

Chapter 6 | Immunopathology
(6.01) Hypersensitivity reactions 93
(6.02) Transplant rejection 99
(6.03) Autoimmunity 101
(6.04) Systemic Lupus Erythematosus (SLE) 104
(6.05) HIVIAIDS 110
(6.06) Amyloidosis 121

Chapter 7 | Neoplasia
(7.01)Neoplasia (Definition, Nomenclature and Predisposing conditions) 127
(7.02) Teratoma, Hamartoma and Choristoma 130
(7.03) Benign versus Malignant tumours 131
(7.04) Spread of tumours (Metastasis) 136
(7.05) Proto-oncogenes - RAS, ABL- BCR 140
(7.06) Tumour suppressor genes RB, P53 144
(7.07) Carcinogenesis (PHYSICAL, CHEMICAL, Biological) 145
(7.08) CIinical Features (Tumour Lysis Syndrome and Paraneoplastic syndromes) 150
(7.09) Grading and staging of cancers 153
(7.10) Laboratory diagnosis of cancer (Tumour markers) 155
 PAPER1

Chapter 8| Environmental and Nutritlonal Disorders

159
(8.01) Obesity

Chapter 9 | Cancers of Infancy and Childhood

163
(9.01) Cancers of infancy and childhood

Hematology
Chapter 10 | RBC Disorders
171
(10.01) Bone marrow aspiration and biopsy 176
(10.02) Reticulocytes 178
(10.03) RBC indices and ESR 182
(10.04) Anemia Definition, classification, clf 185
(10.05) Hemolytic anemias Definition, classification, lab diagnosis
189
(10.06) Hereditary spherocytosis 192
(10.07)G6PD deficiency Anemia 194
(10.08) Paroxysmal Noctural Hematuria (PNH) 196
(10.09) Autoimmune Hemolytic Anemia (AIHA)
199
(10.10) Sickle cell Anemia
204
(10.11) Thalassemia 208
(10.12) Iron deficiency Anemia (|DA)
Sideroblastic Anemia 212
(10.13)
(10.14) Anemia of Chronic disease (A0CD) 214
216
(10.15) Megaloblastic Anemia 221
(10.16) Pernecious Anemia
(10.17) Aplastic Anemia and Pure Red cell Aplasia (PRCA) 222
224
(10.18) Pancytopenia

Chapter 11 | WBC Disorders

227
(11.01) Interpretation of DLC
(11.02) Leukemoid Reaction 231
(11.03) Leukemias and Lymphomas (Definition and Classification) 232
Chronic Myeloid Leukemia (CML) 236
(11.04)
239
(11.05) Acute Myeloid Leukemia (AML)
241
(11.06) Acute Lymphoblastic Leukemia (ALL)
(11.07) Chronic Lymphocytic Leukemia (CLL) 244
(11.08) Polycythemia Vera 246
(11.09) Myelodysplastic syndrome 249
(11.10) Hodgkin's Lymphoma (HL) 250
Non-Hodgkin's Lymphoma (NHL) 253
(11.11)
(11.12) Plasma cell disorders Multiple Myeloma 258
(11.13) Spleenomegaly 264

Chapter 12 | Platelet Disorders

Classiflcation) 267
(12.01) Bleeding disorders (Definition and
(12.02) Thrombocytopenia (|TP, TTP, HUS) 270
(12.03) Functional platelet disorders (Bernard Souller syndrome,
Glanzmann's 274
sndrome)
Von Willebrand's disease
(12.04) Coagulation Disorders- Hemophla and 275
Coagulation (DIC) 277
(12.04) Disseminated Intravascular
 CHAPTER

CELL INJURY, AND DEATH

CELL ADAPTATIONS,
1
| (1.01) CELLULAR ADAPTATIONS
University Exa ms
Long questions
1
Define Cellular adaptations. Write its types with mechanisms and examples
Short questions
1
Definition, types, mechanism and examples of hypertrophy.
Definition, types, mechanism and examples of Atrophy.
3 Definition, types, mechanism and examples of Metaplasia.
4 Definition, types, mechanism and examples of Dysplasia.
5 Definition, types, mechanism
hw
and examples of Hyperplasia
6. Differentiate Hypertrophy arand hyperplasia.
7. Differences between atrophy, hypertrophy and hyperplasia.
Differences between hypertrophy, hyperplasia and metaplasia.
9. Differentiate metaplasia and Dysplasia.
Very short questions
1. Define hypertrophy.
Define Atrophy.
3 Define Metaplasia.
Define Dysplasia.
5 Define Hyperplasia.
Write two examples of hypertrophy.
7 Write two examples of Atrophy.
Write two examples of Metaplasia.
9. Write two examples of Dvsplasia.
10. Write two examples of Hyperplasia.

Overview
Introduction (00:01:55)
Definition (00:04:57)
Types (00:07:45)
1 Hyperplasia (00:10:54)
2 Hypertrophy (00:27:45) Definition, Mechanism, Types
3 Atrophy (00:38:23)
4. (00:50:20)
5 Dsla
Dy (01:03:12)

Introduction
Stress
(Physiological or Pathological)

Cellular adaptation

Cell injury

Reversible Cell injury

"Polntof no return

Irreversible Cell injury

Definition
Adaptations >
Reversible
Structural responses to physiologic stress (e.g., pregnancy) and pathologic stress
During which new but altered steady states are achieved
Allowing cell to survive and continue to function
 DR. PRIYANKA SACHDEV

Esophagus
(oe etog ael
tpPincte es et e
Esophagus
Lower esophageal
RA (LES)
Pyloriç
sphincter sténosis

Aorts
Stomachy Stomach
fsephgs 6ites

Normal Achalasia Duodenum

Esophageal Achalasia Pyloric stenosis

(3) Atrophy STRESS

Definition Adaptation
Decrease in cell size and number of cells
Atrophied cells are smaller than normal but they are stillviable Atrophy

Mechanism
Shrinkage in cell size is due to reduction in cell organelles

Normal Atrophy

Types
(A) Physiologic atrophy
(B) Pathologic atrophy

(A) Physiologic atrophy

1. Atrophy of thymus in adult life.
2. Atrophy of ovary after menopause.
3. Atrophy of brain with ageing.
4. Atrophy of uterus after parturition

Young age- Normal Old age- Atrophy

Uterus

Hypertrophy
Atrophy
Hyperplasia

Normal Pregnancy Parturition

(B) Pathologic atrophy
1. Starvation atrophy > cachexia seen in cancer and severely ill
patients.
2. lschaemic atrophy > atrophic kidney in atherosclerosis of renal artery, Atrophy of brain in cereDtal
atherosclerosis.
3. Neuropathic atrophy e.g. Poliomyelitis
4. Disuse atrophy > e.g. Wasting of muscles of limb immobilized in cast, Atrophy of the pancred
obstruction of pancreatic duct.

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 m
PATHOLoGY PROF BUSTER

5. Endocrine atrophy eg. Hypopituitarism may lead to atrophy of thyroid, adrenal

and gonads
6. Pressure atrophy eg. Erosion of skull by meningioma, Erosion of the sternum by aneurysm of
arch of aorta
7. ldiopathic atrophy no cause present

1
Releasinghormones
TRH
CRH
Hypothalamus GnRH

2
hormones

Anterlor
pltuitary gland

ACTH TSH LH FSH

organ

Target Glucocortlcolds T3 /T4 Estrogen Testosterone

Androgens

Adrenal gland Thyrold Ovarles Testicles

(4) Metaplasia
Definition >
One mature/adult cell type is replaced by another mature/adult cell type

STRESS STRESS

Adaptation Adaptation

Squamous Columnar Columnar Squamous

Normal columnar epithelium

Squamous epithelium
Mechanism
Metaplasia does not result from a change
in phenotype of an already differentiated
cell type
Result of a reprogramming of stem cells
that are known to exiist in normal tissues.
Normal
Basement columnar eplthelium
membrane SQUAMOUS METAPLASIA

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DR. PRIYANKA SACHDEV

Types Bronchus
Gallbladder
(A) Squamous (Col Sq)
(B) Columnar (Sq Col) fcalcaltusy
(A) Squamous metaplasia Examples
1. In bronchus in chronic smokers.
2. In gallbladder in cholelithiasis.
3. In prostate in chronic prostatitis Uterus
4. In uterine endocervix in prolapse of uterus Prolapse

Inflammation

(B)
Columnar metaplasia Examples
Prostate Endocervix
1.Barrett's oesophagus due to GERD
2. Cervical erosion Ectocervix due to increased exposure of cervical epithelium to estrogen

GERD

HCr,

Normal Barrett's Oesophagus

Cervix
Squamous Metaplasla Columnar Metaplasla

Uterus
Prolapse
Endo (Col) Endo (Col)
Ecto (Sq) Ecto (Sq) Cervical erosion
(due to estrogen
exposure)

(5) Dysplasia

Definition
Disordered cellular development
Characterised by cellular cytologic
changes
Mechanism
Cytological changes
1. Increased number of layers
2. Disorderly arrangement of cells from NORMAL ENDOCERVICAL
DYSPLASIA
basal layer to surface layer EPITHELIUM
3 Loss of basal polarity i.e. nuclei lying No. of layers normal No. of layers t
away from basement membrane Ordered arrangement Disordered arrangement
4 Cellular and nuclear pleomorphism Basal Polarity Basal Polarity
5. Increased nucleocytoplasmic (N/C) PleomorphismO Pleomorphlsm
ratio Normal
6. Nuclear hyperchromatism - Hyper chromatism C
Hyper chromatism
7. Increased mitotic activity - Mitosis normal Mitosis t

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 PATHOLOGY PROF BUSTER

Full thickness dysplasia is known as carcinoma in situ (Precurssor of cancer)

NORMAL ENDOCERVICAL SQUAMOUS METAPLASIA DYSPLASIA CARCINOMA IN SITU

EPITHELIUM

Hyperplasia Hypertrophy Atrophy Metaplasia Dysplasia

Definition Number 1 Size JNumber Transformation one Disordered
J
Size cell Another development
Diagram

Mechanis In GR and In celI L In cell Reprogramming of -No. of layers 1

m GF organelles organelles Stem Cells Disordered
arrangement
-Basal
-
Polarity
Types Physio Physio Physio Epi Pleomorphism®
Sq
with e.g. C
Patho Patho Patho Mesen Col Hyper chromatism

Mitosis t

(1.02) MECHANISMS OF CELL INJURY

University Exams
Long questions
1. Describe biochemical mechanisms of cell injury
2. What are free radicals? Describe free radical-induced cell injury.
Short questions
1
2.
Role of free radicals in cell injury
Role of ATP depletion in cell injury
Very short questions
1. Types of free radicals
2 Scavangers of free radicals
3 Antioxidants

Overview
4 mechanisms
1 ATP depletion (00:01:11)
Mitochondrlal Damage (00:09:26)
3 Loss of calclum homeostasis (00:13:07)
4 Free radlcal injury (00:16:33)
Introduction
Generation
Types
Effects
Removal

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 DR. PRIYANKA SACHDEV

(1) ATP depletion

Ischemla

Ischemic

-
Mitochondria reduced oxidative phosphorylation

ATP depletion

Cell membrane - reduced sodium pump Anaerobic glycolysis occurs RER loses rib0somes

Sodium, water enter the cell and potassium exits Loss of glycogen Protein synthesis falls

Endoplasmic reticulum dilates Accumulation of lactic acid Structural proteins

Cell swells Blebs appear (membranes, cytoskeleton)
and enzymes depletes
Acid pH

Clumping of nuclear chromatin

Ischemia

Mitochondrion

Oxidative phosphorylation

ATP

Nat pump Anaerobic glycolysis

Detachment
of ribosomes
tInflux of Ca2+
H'O,and Nat Glycogen Lactic
+ Efflux of K*
acid PH Protein
synthesis
ER swelling
Cellular swelling
Loss of microvili Clumping of
Blebs nuclear
chromatin

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 PATHOL0GY PROF eUSTER m
(2) Mitochondrial Damage
Mitochondria supply life-sustainíng energy by producing ATP (Power house of cell)

Mitochondrial damago
Formation of a high-conductance channel in
mitochondrial mombrane mitochondrial permeability
transitíon pore

Loss of
mitochondrial membrane

Failure of NORMAL
oxidative phosphorylation

Depletion of
ATP

Mitochondrial damage

Abnormal
oxidative phosphorylatíon

Formation of
reactive oxygen species (ROS)
Deleterious effects

Mitochondrial damage
Increased permeability of
outer mitochondrial membrane

Leakage of cytochrome c into cytosol

(Mitochondria sequester cytochrome c between their outer and inner membranes)

Apoptosis

Mitochondría Injury

Oponing of the mltochondrlal permeabllty transltlon pore

Falluro of ATP generatlon

Formatlon of ROS

Releaso of Cytochrome C

Apoptosle

CELL ADAPTATIONS, CELL INJURY,CELL DEATHIPAGE9

 DR. PRIYANKA SACHDEV

O, supply Survival signals

Toxins DNA, protein
Radiatlon damage

Pro- apoptotic proteins

i Antl-apoptotic proteins

Mitochondrial damage
or dysfunctlon

ATP Leakage Of
4 Productlon
generation of ROS mitochondriat
protelns

Multiple cellular abnormalltles

NECROSIs APOPTOSIS

(3) Loss of calcium homeostasis

Intracellular free calcium is very low compared with extracellular levels
Most intracellular calcium is sequestered in mitochondria and ER.
Injury Caz Extracellular
Caz•
Injurious agent
Increased influx and Release of
Ca 2+ from intracellular stores
ie. mitochondria and ER
Mitochondrion Smooth ER
Increased cytosolic Ca 2+
Increased cytosolic Ca2•
Activates many enzyme
Activatlon of
cellular enzymes
Phospholipases (membrane
damage) Phospholipase Protease Endo ATPase + Mitochondrial
Proteases (breakdown proteins) nuclease permeability transition
Endonucleases (DNA Phospholiplds Disruptlon
fragmentation) of membrane and
cytoskeletal proteins
ATPases (hastening ATP
depletion) MEMBRANE
NUCLEAR DAMAGE|
DAMACE
(4) Free Radical Injury
Introduction>
Normally generation of ATP by oxidative process > oxygen (02) combines with hydrogen atom (H),
water (H20) is formed
This reaction of 02 to H20 involves 'four electron donation' in four steps involving transfer of
one electron at each step.
Fonton roactlon
Auto oxidation

Hydrogon Ho
Oxygon Superoxkde peroxde
SOD
Enzymatlc Radlolyss A
(xanthlne oxldase
cytochrome P s)
Catalaso
GSH

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 PATHOLOGY PROF BUSTER m
Generation
Free radicals are intermediate chemical species having a sinale
unpaired electron in its OUter oroll.
Unpaired electrons are highly reactive and "attack" inorganic or oraganic
lipids, carbohydrates, nucleic acids chemicals > proteins,
Generated within mitochondrial inner membrane

Pathologic effects
Radiation
Toxins Productlon of ROs:
Reperfusion ipid peroxidation Mermbrane damage

HO, OH
Superoxide Hydrogen Hydroy Protein
peroxide radical Breakdown
modifications misfolding

DNA damage
Mutations

Conversion Decomposition to
to HO, HO by glutathione
by SOD peroxidase, catalaso

Removal of free radicals

Types
3 types

1. Superoxide oxygen (02-): one electron

2. Hydrogen peroxide (H202): two electrons
3. Hydroxyl radical (OH-): three electrons
Fenton reaction iron is converted from ferrous to ferric form.

(H202 + Fe2+
Fe3t + OH* + OH-)
Haber- Weiss reaction generation of free radical (OH) during normal metabolíc process

(H202 + O2
20H- + O2)

Effects
1. Damage proteins, lipids, carbohydrates, nucleic acids
2. Lipid peroxidation in cell membranes
3. Oxidation of amino acids and proteins resulting in
fragmentation
4. Protein-protein cross linkages.

OH
wywd
Lipld
peroxldatlon tuhtAuaud, Protein
oxidation

OHT
OH

OH
OH

Cytoskeletal
damage DNA
damage

OH

CELL ADAPTATIONS,
CELL INJURY, CELL DEATH
|PAGE 11
m DR. PRIYANKA SACHDEV

Removal
Scavengers of free radicals
1. Superoxide dismutase Fenton
2. reaction
Glutathione peroxidase
3. Catalase
4. Vitamin E, vitamin C Superoxide H,o, OH+OHH,0
5 Transferrin, ferritin and dismutase 2SH
ceruloplasmin
(Iron and copper catalyze free Glutathlone Glutathione
radical formation) Catalaso
peroxldos0 roduct0se

H,0 H,0 OSSG

Superoxide dismutase (SOD)

Present in mitochondria (manganese-SOD) and in cytosol (copper-zinc- SOD)
Converts superoxide to hydrogen peroxide
20- + 2H 2 H202 + 02

Glutathione peroxidase
Present in mitochondria and cytosol
Converts hydrogen peroxide to hydroxyl ion
H202 > OH

Catalase
Present in peroxisomes
Converts hydrogen peroxide to water +
2H202 02 2H20

(1.03) MORPHOLOGICAL CHANGES

REVERSIBLE VERSUS IRREVERSIBLE CELL INJURY

University Exams
Long questions
injury
1. Compare and contrast structural changes in reversible and irreversible cell
Differences between reversible and irreversible cell injury
3. Morphological features of reversible and Irreversible cell injury
Short questions
Describe and Draw Morphological features of Reversible cell injury
2 Describe and Draw Morphological features of Irreversible cell injury

Overviow
Introduction (00:00:45)
Diagramatic presentation of Reversible injury and Irreversible Injury (00:02:21)
Irreversible Injury - Nuclear Changes (00:08:06)
Differences between Reversible injury and Irreversible Injury (00:09:50)

Introduction
Stress
(Physlological or Pathological)

Cellular adaptation

Cell injury

Reversible Cell injury

'Palnt ef ne return

Irreversible Cell injury

DEATH
ADAPTATIONS, CELL INJURY, CELL
PAGE 12| CELL
 PATHOLOGY PROF BUSTER M
Diagrammatic presentation of
Reversible injury and Irreversible Injury
RESretion ef
intramebrho
partleies
Blebs
Pptre ef speinfpures
tos
-ER Swetting
dtotis Lysts of ER
Generalzed
Swelling

Nucleus: Defects in cett

Dispersteon of A-yknoss membrane
Clumping of
uclear ribosees
chromatin
Mtochondrial
-Carge densieles
swetlng B-Karydtyts
Autophary by
tysosomes
- Smafl Mitochondat
densties
C-Karyorhests

REVERSIBLE INJURY IRREVERSIBLE INJURY

Irreversible Injury - Nuclear Changes

Pyknosis Nuclear shrinkage and increased basophilia
Karyorrhexis Fragmentation of pyknotic nucleus
Karyolysis Fading of basophilia of chromatin

Normal cell Pyknosis Karyorrhexis Karyotysis

Differences between
Reversible injury and Irreversible Injury
Reversible injury Irreversible Injury
Cell membrane
-
Swell EDTIDo
-
not swell
Intact Disrüpts
o-Blebs
ER -
-SwelI Lysis
- -
Dispersion ney
Ribosomes Dispersion
- -
Mitochondria Swell Swells
- - Large
Small densities densities
Lysosomes - Autophagy
Rupture
Nucleus -
Clumping -
Pyknosis, Karyolysis, Karyorrhexis

(1.04) APOPTOSISAND EFFEROCYTOSIS

Universlty Exams
Long questions
1. What is apoptosis? Mention the causes and discuss mechanisms of apoptosis.
Short questions
1
Write diagnosis of apoptosis
2. Describe Mechanisms (pathogenesis) of apoptosis wlth dlagramsitS
3 Describe íntrinsic pathway of apoptosis
4 Descritbe extrinsíc pathway of apoptosis

CELL ADAPTATIONS, CELL INJURY, CELL DEATH | PAGE 13

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DR. PRIYANKA
SACHDEV

5. Describe Morphological features of apoptosis.

Draw Morphol
rphology of
7 Define Efferocytosis.apoptotic
Write
cells.
8 Differentiate apoptosis and its mechanlsm
Necrosis
Very short questions
1. Morphology of apoptotic cells.
Define Apoptosis. Write its Types.

Overyiew
Introduction (00:03:00)
Apoptosis Definition (00:09:42)
Types (00:10:52)
Mechanisms (00:13:00)
Extrinsic pathway Initiation phase (00:14:50)
Intrinsic pathway Initiation phase (00:18:20)
Execution phase (00:24:06)
Efferocytosis (00:26:39)
Morphological changes in apoptosis (00:30:36)
Diagnosis of Apoptosis (00:33:16)
Differences between Apoptosls and necrosis (00:35:55)

Introduction
Cell Death
Apoptosis Suicide
Necrosis Murder

Apoptosis > Definition

Cell Suicide
It is a pathway of cell death that is induced by a tightly regulated intracellular program in which
cells destined to die activate enzymes (caspase) degrade cells own nuclear DNA and cytoplasmic
proteins.

Cell is phagocytosed
No leakage outside
No inflammation

Types
APOPTOSIS

Physlological
Pathological
1.Embryogenesis 1. Tumor cells exposed to
2.Elimination of potentially self chemotherapeutic agents.
reacting lymphocytes. 2. Depletion of CD44T cells in
AIDS.

Mechanism
Mechanism

Extrinsic pathway Intrinsic pathway

Initiation Execution Initiation Execution

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 PATHOLOGY PROF BOSIEK Ly

Extrinsic pathway > Initiation phase

FAS (CD- 95)
Initiated through specific receptors called death
receptors
1. FAS protein (CD95)
2. TNF receptors
FASreceptor (Death receptor)

FAS protein (CD95) binds with it

Multiple FAS receptors come together

FADD
Cytoplasmic death domain FADD formed
Activate pro- Caspase 8 and 10 to active caspase 8 Active
Caspase-8
and 10 Caspase-8
Pro

Intrinsic pathway Initiation phase

Stimuli DNA damage (beyond repair)

Stimuli (DNA damage)

Anti apoptotic molecules Bcl-2, Bcl

X, Mcl -1 are lost

Replaced by pro-apoptotic
molecules like Bak, Bax, Bim, Bad Bcl- 2 Cyt. c
8ax
Bcl-X Bak
Increased mitochondrial permeability Mcl- 1 Bim
Bad
(MPT)
Procaspase 9
Release to cytochrome C into apaf- 1
cytoplasm DNA Active
Damage Caspase9
Activates Apaf-1 along with
procaspase-9

Activated caspase-9

Execution phase
Convergence point for both extrinsic and intrinsic pathways.
Extrinsic pathway Intrinsic pathway

Caspase 8,10 Caspase 9

Activates
CASPASE
Activates caspase 3,6, 7

Sequentially activates all other caspase

Apoptotic bodies
Caspases cleave cytoskeletal and nuclear matrix proteins Phagocyte

Cell degenerate/ apoptotic bodies formed

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 DR. PRIYANKA
SACHDEV

Efferocytosis
Immunologically
(efferocytes) silent clearance of
apoptotic cells by professional and non-professional phagocytes

Healthy cells avoid

being
efferocytosed by displaying Apoptotic cells carry specific 'eat me' signals
me" signals > "don't eat e.g. phosphatidylserine (resulting from
eg. CD47 phospholipid flip-flop)

Phagocyte
CD47
A

PS e

Phosphatidylserine is a phospholipid
present on inner surface membrane normally
During apoptosisbeist ee
Flipped to outer surface

Externalization of phosphatidylserine
causes its tagging

Phagocytes ingulf it

Morphological changes in apoptosis

1. Cell shrinkag 3. Pyknosis

6. Phagocytosis 2. Eosinophilia

5. Apoptotic bodies 4. Blebs Karyorrhexis

Diagnosis of Apoptosis
1. Apoptosis markers Annexin-V is a recombinant protein with high affinity for phosphatidylserine.

FITC Recognitlon of apoptotic cells

Annexin V
Ca
PI PI FITC

AnnexinV

Cae+

Plasma
membrane
alteratlons

Phosphatidylserine
VIABLE CELL APOPTOTIC CELL
CELL DEATH
CELL ADAPTATIONS, CELL INJURY,
PAGE 16|
 PATHOLOGY PROF BUSTER m
M 1
23

2. Agarose gel electrophoresis Fragmented DNAshows Step Ladder Pattern

due to inter-nucleosomal cleavage of DNAby endonuclease

Differences between Apoptosis and necrosis

Apoptosis (Sulatde) Nocrosls (Murder)
Single cells or small clusters of cells Ofton contiguous colls
Cell shrinkage Cell swelling
Pyknosis and karyorrhexis Karyolysis, pyknosis and karyorthexis
Intact cell membrane Disrupted cell membrane
Cytoplasm retained in apoptotic bodies Cytoplasm leaked
Inflammation absent Inflammation present

(1.05) NECROSIS

University Exams
Long questions
1. Define necrosis. Mention the types, explain the causes and pathology of oach type of necrosis.
2. Define ne crosis. Enlist differnttypes of,necrosis with relevant examples
Short questlons
Enumerate types of necrosis with approprlate examples and mention their mechanisms.
2
Define Coagulative necrosis. Write Its causes and draw microscopic features
3. Define Colliquative necrosis. Write Its causes and draw microscoplc features
Define Caseous.necrosis: Write its causes and draw mictoscopic features
Define Fat necrosis. Write its causes and draw microscopic features
6. Define Fibrinoid necrosis. Wilte its causes and draw microscopic features
Very short questions
1 Coagulative necrosis.
2
Liquifactive necrosis
Caseous necrosis.
4 Fat necrosis."
5. Fibrinoid necrosis.

Overview
Definition (00:02:44)
Types (00:08:45)
1, Coagulative necrosis (00:09:30)
2 Liquefactive necrosis (00:19:31)
3 Caseous necrosis (00:24:53)
4 Fat necrosis (00:29:50)
5. Fibrinoid necrosis (00:32:14)

Definition
STEM CELLS
Death of cells and tissues in the living muscle cells
animal intestinal cells
Necrosis is defined as a localised area of
death of tissue followed later by
of tissue by hydrolytic
degradation
enzymes liberated from dead cells
Accompanied by inflammatory reaction. llver cells
blood cells
Architectural detall (outline)
ytoplasmic detail nerve cells
cardiac cells
Nuclear detal

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 m DR, PRIYANKA SACHDEV

Types
1. Coagulative necrosis
2. Liquefactive necrosis
3. Caseous necrosis
4. Fat necrosis
5. Fibrinoid necrosis

(1) Coagulative necrosis Alive Coagulation

Necrosis
Introduction
Most common type of necrosis
Architectural outlines persist but cellular and nuclear
details are lost Ghost or tombstone appearance
Type of tissue can be recognized
Ghost Tombstone
Causes
Ischemia due to thrombosis/ embolism in all organs
except brain
Mild burns (thermal injury)
Zenker's degeneration necrosis
Gross
Pale, firm, and slightly swollen

Inflammatory
Viable renal tissue cell infiltrate Necrotic tissue

Microscopy
Hallmark conversion of normal cells into "tomb
stones'
i.e., outlines of cells retained and cell type can
still be recognised but their cytoplasmic and
nuclear details are lost.

(2) Liquefactive necrosis

Introduction
Architectural, cytoplasmic and nuclear details are lost semi-fluid material (due to degradation by
Hydrolytic enzymes)
Also known as Colliquative necrosis

Alive Liquefaction
Necrosis

PAGE 18 CELL ADAPTATIONs, CELL INJURY, CELL DEATH

 PATHOLOGY PROF BUSTER

Causes
1. Pyogenic bacterial infections
2. Ischemic necrosis of brain

Gross
.
Liquefied center containing necrotic debris with a cyst
wall

Giosts Granlton tssue Uquetactive necross

Microscopy
Necrotic area > cavity containing a mass of necrotic
neutrophils, bacteria and tissue debris
Surrounded by a cyst wall formed by proliferating
capillaries and inflammatory cells

(3) Caseous necrosis

Introduction
Alive Caseous Necrosis
Architectural, cytoplasmic and nuclear details are lost
amorphous debris (resembling cottage cheese)
Looks Cheese like Caseous necrosis

Causes
Mycobacterium tuberculosis
Syphilis
Histoplasma
Coccidiomycosis

Gross
Soft, granular and yellowish > resemble dry
cheese
Viable lymphoid tissue Caseous nearosis
Granulomatous inflammation |
Microscopy
Centre structureless, eosinophilic material
having scattered granular debris of disintegrated
nuclei
Surrounding tissue granulomatous
inflammatory reaction

(4) Fat necrosis

Introduction
Special form of cell death occurring at fat-rich anatomic locations in body.
Death of adipose tissue in a living animal
Causes
Pancreatic (acute pancreatitis)
Breast (Traumatic)
Mesentery (Inflammation)

CELL ADAPTATIONS, CELL INJURY, CELL DEATH PAGE 19

 m
DR, PRIYANKA SACHDEV

Gross
Fat necrosis > yellowish-white and firm deposits.
Formation of calcium soaps chalky white appearance

Cloudy appearance Mixed inflammatory cells

Microscopy
Necrosed fat cells cloudy appearance
Surrounded by inflammatory reaction.

(5) Fibrinoid Necrosis

Introduction
Deposition of fibrin-like material
Causes
Immunologic injury of vessel wall
Microscopy
Brightly eosinophilic, hyaline-like dep0sition in
the vessel walI.
Surrounded by nuclear debris of neutrophils
(leucocytoclasis)

Coagulative Liquefactive Caseous Fat Fibrinoid

Introduction
Arch
Cyto
NucleusO
Arch
Cyto .
O
NucleusO|
Fgel
-
Arch
-Cyto
Nucleusol
Fdebris Fat rich Iocations
Blood
vessels

Ischemia of Ischemia Brain

TB Breast trauma
all organs Pyogenic Syphilis Pancreatitis
Vasculitis
Causes (Except Histoplasma Mesentery
infection Coccidiomycosis
Brain) inflammation

Liq. Centre Yellowish

Gross Pale Dry cheese like
with Cyst Wall white

Structureless
Tomb- stone material with Cloudy Fibrinoid
Microscopy Cavity Cont. debris
appearance granulomatous appearance (ribbon) like
inflammation

PAGE 20| CELL ADAPTATIONS, CELL INJURY, CELL DEATH

 PATHOLOGY PROF BUSTER m
(1.06) NECROTOSIS, PYROPTOSIS, FERROPTOSIS

Unlversity Exams
Short questions
1. Define Necroptosis. Write its mechanism.
2 Define Pyroplosis. Write its mechanism.
3 Define Ferroptosis. Write its mechanism.
4. Differentiate Necroptosis from apoplosis
5 Differentiate Pyroptosis from apoplosis

Overview
Necrotosis (00:00:55)
Pyroptosis (00:04:05)
Ferroptosis (00:08:18)

Necroptosis
Introduction >
Hybrid of necrosis and apoptosis but considered as a part of TNF
necrosis.
Programmed cell death without caspase activation. TNF-R

Differences from apoptosis

Necroptosis differs from apoptosis by following features RIPK-1 RIPK:3
a) Shows cell swelling MIKL-Phosphorylaton
b) Increased lysosomal permeability
c) Cell membrane damage MLKL- Oligomers

d) Presence of inflammation
• Plasma membrane Damage
Inflammatlon
So, they are considered as Necrosis > caspase independent programmed celldeath

Mechanism
Ligation of TNFRI

Recruits receptor-interacting protein kinase 1

and 3 (RIPKIand RIPK3)

RIPK3 phosphorylates a cytoplasmic protein called MLKL

MLKL monomers assemble into oligomers

Translocate from the cytosol to plasma membrane

Cause plasma membrane disruption with inflammation

Necroptosis

Pyroptosis
Introduction >
Caspase (caspase 1,4,5 and 11) dependent programmed cell death
Programmed cell death associated with antimicrobial responses during inflammation (innate
immunity response).

CELL ADAPTATIONS, CELL INJURY, CELL DEATH|PAGE 21

 DR. PRIYANKA SACHDEV

Differences from apoptosis

Pyroptosis differs from apoptosis by following features
a) Shows cell swelling
b) Cell membrane damage
Pro-C-11 011
c) Presence of inflammation 11
NLR
d) It involves enzyme Caspase-1,4,5, and

caspase dependent Inflammation

So. they are considered
programmed cell death Pro-C-1,4,s C145 Cell Memb. Damage
Pro-ll-1 l-1 Inflammation

Mechanism
NOD like receptors (NLRS)

Recognize Flagellin components of salmonella and shigella species

Activation of inflammasome

Activation of caspase-1, 4, 5)

Cleaves precursor form of IL-1 to generate biologically active IL-1

Cell Membrane Damage and Inflammation

Pyroptosis

Ferroptosis
ystine
Introduction > reduced
Programmed cell death dependent on iron
Characterized by the accumulation of lipid peroxides
Cysteine Glutathione
eductase
Fenton
Differences from apoptosis Reaction
GSSG
(o)
Dependent on iron ROS GPX4
Characterized by accumulation of lipid peroxides Lipid
Master regulator is: Glutathione Peroxidase 4 (Gpx4) peroxide
Inactivate

Mechanism
Inactivation of Glutathione Peroxidase 4 (GPx4)

Failure of glutathione-dependent antioxidant defenses

Iron release in the cytosol

Generate Reactive Oxygen Species (ROS) by Fenton Reaction

ROS leads to lipid peroxidation (No repair since GPx4 is inactivated)
Cell death

Ferroptosis

I(1.07) GANGRENE
Unfversity Ex ans
Long questions wet gangrene
1.
Define gangrene and mention the differences between dry and
Short questions
its types.
Gangrene andgangrene.
2 Describe Dry

INJURY, CELL DEATH

PAGE 22 |CELL ADAPTATIONS, CELL
 m

PATHOLOGY PROF BUSTER

Describe Wet gangreno.

A Describe Gas gangrene.
5. Differences betwoen dry and wet gangrones.

Oyervlew
Definition (00:00:47)
Types (00:02:41)
nifferences between dry and wet gangrenos (00:02:58)
Gas Gangrene (00:08:16)

Definition
Necrosis of tissue associated with superadded putrefaction
GANGRENE = Necrosis +
Putrefaction

Types
1. gangrene less bacterial superinfection > tissue appears dry
Dry
gangrene > abundant bacterial superinfectlon> tissue looks wet
Wet
and liquefactive
3. Gas gangrene A variant of wet gangrene

Differences between dry and wet gangrenes

Features Dry Gangrene Wet Gangrene
Site Commonly limbs Commonly in bowel
Mechanisms Arterial occlusion Blockage of both venous drainage
and arterial obstruction
Bacteria Bacteria fail to survive Numerous present
Putrefaction Limited due to very little Marked due to stuffing of organ
blood supply with blood
,
Macroscopy Organ dry, shrunken and black Part moist soft, swollen, rotten
and dark
Line demarcation Present
of
Absent
Prognosis Better due to little septicaemia Poor due to profound toxaemia
Type of necrosis Variant of Coagulative necrosis Liquifactive necrosis is superimposed
on coagulative necrosis

Dry Gangrene Wet Gangrene

wllen, deek
Dry, shrlvelled Thrmbe
to0s

CELL ADAPTATIONS, CELL INJURY, CELL DEATHIPAGE 23

m DR. PRIYANKA SACHDEV

Gas Gangrene
Special form of wet gangrene
Caused by gas-forming clostridia
(gram-positive anaerobic
bacteria)
Swollen, edematous, painful and
crepitant due to accumulation of
gas bubbles of C02 within
tissues formed by fermentation
of sugars by bacterial toxins

(1.08) PATHOLOGICAL CALCIFICATION

University Exams
Short questlons
1, Describe Pathological calcitication and its typos
Describe Dystrophic calcification. Write Its pathogenosIs and sitos
3 Describe Metastatic calcification. Write lts path ond sites
Difference between Dystrophic & metastatic calcification.

Overvicw
Definition (00:00:50)
Types (00:01:24)
Dystrophic calcification (00:04:23)
2. Metastatic calcification (00:06:48)
Difference between Dystrophic & metastatic calcification (00:09:55)
Special stain for caicification (00:10:39)

Definition
Deposition of calcium salts in tissues other than osteoid or enamel

Types
Calcium normal Hyper Calcemia

Dead
And Normal
Degenerated tlssue
tlssuo

Dystrophic Motastatlc

Dystrophic calcification
Pathogenesis
Membrane of dead and degenerated cell > damaged
Phospholipid is released

Phosphatases within phospholipid generate phosphate ions

Calcium binds to phosphate ions

Form calcium phosphate

PAGE 24| CELL ADAPTATIONS, CELL INJURY, CELL DEATH

 PATHOLOGY PROF BUSTER m
Sites
Dead tissues Degenerative Tissues
Caseation eg. Tuberculosis Atherosclerosis- Monkeberg sclerosis
Dead parasites like trichinosis,
Damaged heart valves
Onchocercosis. Infected lymph nodes
Fat necrosis Degenerating tumors
Infarcts
Thrombi
Mede (asfee) etio (riad
Hematoma

Metastatic calcification
Pathogenesis
Those organs that 'lose' acid
Have an underlying alkaline compartment

Alkaline internal component is susceptible to calcification

Sites
Basement membrane & tubular lamina of kidneyoa
Pulmonary veins
Alveolar wall of Iung (most common site)
Cornea & Conjunctiva
Interstitial tissue of gastric mucosa
Synovium of the joint
Systemic arteries
Tendons

Difference between Dystrophic & metastatic calcification

Dystrophic Calcification Metastatic Calcification
Tissue Calcium deposits in dead and Calcium deposits in normal tissues
dying tissues
Calcium Normal calcium metabolism Deranged calcium metabolism
metabolism
Calcium in Normal serum calcium levels Hypercalcemia
blood
Reversibility Irreversible Reversible upon correction of metabolic
disorder
Pathogenesis Occurs due to increased binding Increased precipitates of calciumphosphate
of phosphates with necrotic and due to hypercalcemia at certain sites (lungs,
degenerative stomach, blood vessels, cornea)
tissue binds to calcium forming
calcium
phosphate precipitates

CELL ADAPTATIONS, CELL INJURY, CELL DEATH |PAGE 25

 m DR. PRIYANKA SACHDEV

Special stain for calcification

1. Von Kossa black color
2. Alizarin redS red staining

I (1.09) PIGMENTS
Von Kossa Allzarln red 3

Üniversity Exans
Short questions
1
Exogenous and endogenous pigments.
2 Hemosiderosis.
3 Brown atrophy of heart.
Lipofuscin pigment.
Disorders of melanin plgmentation
6 Pathological pigmentation.
7 How is Hemosiderin plgment formed? Give its pathological significance.
8. What is hemosiderin and how it is demonstrated? Enumerate two causes of hemosiderosis.
9 Tattoos
10, Wear and toar pigment

Overview
Definition (00:00:52)
Types (00:01:04)
Endogenous Pigrnents (00:01:18)
4 Melanin 0:01:29)
2. Hemosiderin (00:05:38)
3 Líoifuschín (00:07:43)
Exogenous Pigments (00:11:19)
1. Carbon (00:11:20)
Tatto (00:12:10)

Definition
colored substances present in most living beings including humans.

Types
Plgments

Endogenous Exogenous

Melanin Carbon
Haemosiderin Tatto
Lipofushcin

Endogenous Pigments
1. Melanín
2. Hemosiderin
3. Lioifuschin

(1) Melanin

Introductlon
Brown-black
Non-hemoglobin derived pigment
Normally present in hair, skin, mucosa, choroid of eye,
meninges and adrenal medulla,
Synthesized in melanocytes (enzyme tyrosinase) present in

basal cells of epidermis

PAGE 26| CELL ADAPTATIONS, CELL. INJURY,CELL DEATH

 PATHOLOGY PROF BUSTER

Disorders
(A)Generalized hyperpigmentation:
a) Addison's disease > generalized
hyper pigmentation of the skin
b) Chloasma observed during
pregnancy hyperpigmentation on
skin of face, nipples, and genitalia Addison's Dlsease Chloasma Chronic
under influence of estrogen. Arsenical Polsoning
c) Chronic arsenical poisoning
raindrop pigmentation of skin.

(B)Focal hyperpigmentation:
a) Cäfe-au-lait spots in
neurofibromatosis
b) Peutz-Jeghers syndrome
focal peri-oral
pigmentation.
c) Melanosis coli
pigmentation of mucosa
of the colon. Cafo-aualt spots PoutzJeghers Syndrome Melanosis Cofl
Perloral Plg.
d) Melanotic tumors, both
benign such as
pigmented naevi and
malignant such as
melanoma
e) Dermatopathic
lymphadenitis > melanin
pigment in macrophages Dermatopathy lymphadenitis Plgmented naevd
of lymph nodes

(C) Generalized hypopigmentation

Albinism

(D) Localized hypopigmentation:

Vitiligo

(2) Haemosiderin
Introduction
Iron is stored in the tissues
in 2 forms:
1. Ferritin (iron complexed to apoferritin)
2..Haemosiderin (formed by aggregates
of ferritin)
Haemosiderin Light microscopy >
Golden-yellow to brown pigment
Granular
Golden brown granular plgment Prusslan blue eactlon

CELL ADAPTATIONS, CELL INJURY, CELL DEATH |PAGE 27

 DR. PRIYANKA SACHDEV

Prussian blue reaction

Iron can be identified by the Prussian blue histochemical reaction

Disorders

HAEMOSIDEROSIS

LOCALISED GENERALISED (SYSTEMIC)

Local Tissues Parenchymal Deposits

(Liver, Pancreas, Kidney, Heart, Skin)
(Macrophages, fibroblasts,
RE Cell (Liver, Spleen, Bone marrow)
endothelial and alveolar cells)
Examples: Examples:
Hemorrhage in tissues Acquired hemosiderosis (Chronic
Black eye haemolytic disorders, blood transfusion,
Brown induration lung parenteral administration of iron)
Infarction Hereditary (Idiopathic)
haemochromatosis (Increased
absorption, genetic defect)
Excessive dietary intake (African iron
overload)

(3) Lipofuscin
Introduction
= =
Also known as wear and tear pigment aging pigment Lipochrome Tell tale sign of
injury
Not injurious to the cell but is important as marker of past free-radical
a

free radical injury and lipid peroxidation.

Composed of polymers of lipids and phospholipids in complex with protein.
By light microscopy coarse, golden-brown granular
Perinuclear brown pigment.

Perinuclear lipofuscin granules

Disorders
Aging
Severe malnutrition
Cancer cachexia
In heart muscle change is associated with wasting of muscle brown atrophy of myocardium

DEATH
PAGE 28 CELL ADAPTATIONS, CELL INJURY, CELL
|
 PATHOLOGY PROF BUSTER

Melanin Hemosiderin Lipofuscin

Skin Iron excess Wear and tear pigment
Sign of cell ageing
Brown Brown Brown
Uniform distribution Uniform distribution Perinuclear

Stain- Masson Fontana Pearls Prussian blue

Exogenous Pigments
1. Carbon
2. Tatto

(1) Carbon. Distended respiratory bronchicles

Coal macule Dust-aden macrophages Dated atreoi
Inhaled
Phagocytosed by alveolar macrophages

Transported through lymphatic channels to regional

tracheobronchial lymph nodes.

Aggregates of pigment blacken lymph nodes

Anthracosis
Induce emphysema or a fibroblastic reaction
Coal workers' pneumoconiosis

(2) Tatto
Pigments like India ink, cinnabar and carbon

Injected into dermis EB

Taken up by macrophages
Plgment Inside
Lies permanently in connective tissue

CELL ADAPTATIONS, CELL INJURY,CELL

DEATHIPAGE 29
 PATHOLOGY PROF BUSTER m
Melanln Hemosldorin Lipofuscn
Skin Iron excOss Wear and tear pígment
Sign of coll ageing
Brown Brown Brown
Uniform distribution Uniform distrlbution Perinuclear

Stain- Masson Fontana Pearls Prussian blue

Exogenous Pigments
1. Carbon
2. Tatto

(1) Carbon Distended respirztory bronchioles

Coal macule Dust-laden macrophages Dlated ahreol
Inhaled
Phagocytosed by alveolar macrophages

Transported through lymphatic channels to regional

tracheobronchial lymph nodes.
Aggregates of pigment blacken lymph nodes
Anthracosis
Induce emphysema or a fibroblastic reaction
Coal workers' pneumoconiosis

(2) Tatto
Pigments like India ink, cinnabar and carbon

Injected into dermis

Taken up by macrophages
Plgment Inslde
Lies permanently in connective tissue

CELL ADAPTATIONS, CELL INJURY, CELL DEATH| PAGE 29

 DR. PRIYANKA SACHDEV

(1.10) CELLULAR AGEING

University exan
Short questlons
1 Role of Telomerase in cellulat ageing
Role of Sirtuin in cellular aging
Morphological changes during agelng

Overview
Introduction (00:01:05)
Pathogenesis of Ageing (00:02:45)
Telomere Theory (00:03:17)
Morphological changes during ageing (00:11:19)
Sirtuin (00:14:40)

Introduction Genetic
in cellular function and viability caused by
Cellular ageing is result of a progressive decline exposure to exogenous influences
abnormalities and accumulation of cellular damage because
of

Cell
Pathogenesis of Ageing
1. Telomere Theory
Chromosome
2. Genetic control in invertebrates
3 Diseases of accelerated ageing
4. Oxidative stress hypothesis (free radical-mediated
injury)
5. Hormonal decline Nucleus
6. Defective host defenses
7. Failure to renew Telomere
DNA

Telomere Theory a terminally nondividing state

After a fixed number of divisions all somatic cells become arrested
in

> senescence. present at linear ends of

Telomeres are short repeated sequences of DNA (TTAGGG)
chromosomes that are important for protecting DNA present at tips of
With every cell division, there is progressive shortening of telomere
chromosomes
an enzyme called telomerase
Telomere length is normally maintained by

With every cell division

progressive shortening of telomere present at tips of chromosomes

Shortened telomere is repaired by the presence of RNA

enzyme- telomerase

After repetitive mitosis (max 60 to 70 times) Telomerase activity is terminated

Lost telomere is not repaired

DNA cannot be protected

Activation of p53
No mitosis

Cellular senescence (Aging)

PAGE 30 | CELL ADAPTATIONS, CELL INJURY, CELL DEATH
 PATHOLOGY PROF BUSTER m
Telomere Shortening
Cel dvisios

ChromoSome

Talomere fength

Tefomere Reposts

TTAGGGTTAGGGTTAAGGGTTAQAaTTAGGGTTAGG 3"

AATCCCAATCCCAATCCC 8

Telomerase activity Germ cots

Highest germ cells
Lower levels stem cells Stem cells
Very low > somatic tissues
Somatic

length cells
Canear
Telomere

Gronth arst

Morphologicalchanges during ageing Cell dvislons

A)
Cellular changes Decrease in cell size and number
Decreased in size and number. of mitochondria
Detachment of rib0somes from ER
Increased number of phagolysosomal vacuoles
Defective DNA repair
Non-enzymatic glycosylation of protein
B) Connective tissue changes Loss of elasticity (wrinkling of skin)
BPdue to decreased elasticity of artery
Ground glass substance changes (cataract)
Cartilage and bone changes (osteoarthritis osteoporosis)
C) Decreased immunity Decreased Tcells, B cells, plasma cells, Ab

Sirtuin
Most effective way to prolong life span is calorie restriction.
Calorie restriction will induce sirtuin (family of NAO-dependent protein deacetylases).

Mechanism of action >

a) Inhibit metabolic activity.
b) Reduce apoptosis.
c) Stimulate protein folding.
d) Inhibits free radical damage.
e) Increase insulin sensitivity and glucose metabolism

CELL ADAPTATIONS,CELL INJURY, CELL DEATH |PAGE 31

 CHAPTER

(2.01) VASCULAR EVENTS OF

INFLAMMATION 2
ACUTE INFLAMMATION
Unlversity Exa ms
Long questions
Define inflammation. Mention the types. Explain
Define inflammation. Write types of inflammation.the sequential vascular changes in aculo inflammtion.
Describe the cardinal signs of acute inflarnmation,
3 Discuss the vascular phenomenon of inflammation.
4 Describe varioUs mechanisms of vascular leakage
(increasod vascular pormeability) in inflafnmation.
Short questions
1 Write and explain Cardinal signs of inflammation.
2 Vascular changes in acute inflammation.
3 Differences between acute and chronic inflammation.
Very Short questions
1. Definition of acute inflammation.
2 Types of inflammation

Overview
Inflammation >
Definition (00:01:47)
Classification (00:04:54)
Acute inflammation
Cardinal Signs (00:08:59)
Steps (00:11:42)
Vascular events
1. Transient vasoconstriction of arterioles (00:17:20)
2. Persistent progressive vasodilatation (00:18:28)
3 Elevate the local hydrostatic pressure (00:20:17)
Increased vascular permeability (00:25:32)
5 Slowing or stasis (00:41:17)
Triple Response (00:41:31)

Inflammation
Definition
Body defense reaction in order to eliminate or limit
the spread of injurious agent, followed by removal of
the necrosed cells and repair of damaged tissue
WBC or leukocytes body's major infection-fighting
cells.
Classification
Acute Chronic
Rapid onset Late onset
Short duration Longer duration
Odema Granuloma formation
Neutrophils Macrophage, lymphocyte

Acute inflammation
Cardinal Signs
Latin English
1. Rubor :redness Acute Inflammation
2. Calor ted local femperature Celsus
3. Tumor : swelling
4 Dolor :
pain
: loss
Vascular ovents Cellular reaction
5. Functio laesa of function Virchow
 DR. PRIYANKA
SACHDEV

Steps
Vascular Events
1
Transient vasoconstriction of Collular Events
2. Persistent progressive arterioles 1. Margination and pavementing
3. Elevate vasodilatation 2. Rolling
the
4 Increased local hydrostatic pressure 3. Adhesion
5. Slowing orvascular permeability 4. Transmigration (diapedeses)
stasis 5. Chomotaxis
6. Phagocytosis
SkIn

Mlcrobe
BM

WBC

Vascular events
(1)Transient vasoconstriction of arterioles
Responsible for blanching seen immediately after injury.
With mild injury 3-5 seconds
Severe injury> 5 minutes
Skin

Mlcrobe

BM

WBC

(2)Persistent progressive vasodilatation

Vasodilatation resuts in increased blood volume> redness(rubor) and warmth (calor)
Skin

Mlcrobe

BM

WBC
OOOOOOO
PAGE 34 |INFLAMMATION
 m

PATHOLOGY PROF BUSTER

HydrostattePressUre Oncotle Pressure

(3) Elevate the local hydros tatic pressure

Starling's hypothesis
Capllary

Mlcrobe

BM

WBC

Transudation of fluid into extracellular space (Oedema Transudate) Tumor

(4) Increased vascular permeability
Hallmark of acute inflammation
Leads to escape of protein rich fluid (Oedema Exudate) swelling (tumor)
Most affected vessels are venules
Mlcrobe

Oedema
(Exudate)

BM

WBC

Hydrostatic Colloid osmotic

pressure pressure

Normal Plasma proteins

Fluid leatage

Increased hydrostatíc pressure Decreased colloid osmotic pressure

• venous outflow obstruction, • decreased protein Synthesis (Eg tiver diseasel
[E.g congestive heart faílure] • Increased protein loss [Eg kidney disease]

Transudate
(Low protein content, few cells)

o Fluid & protein leakage

Ooo.o Oo
Exudate
(High protein contet & may contain some white Vasodilation uongwwU

&red cells) & stasis

Increased
interndothellal spaces

INFLAMMATIONI PAGE 35
 m DR. PRIYANKA SACHDEV

Triple Response
Demonstrated by Lewis experiment
Lewis induced changes in skin of inner aspect of
forearm by firm stroking with a blunt point.

2 Red llne Wheal

Red line Rare Wheal Flare

1. Red line due to local vasodilatation of capillaries

Flare Whoal
and venules. Red lino
2. Flare bright reddish surrounding red line and results
from vasodilatation of adjacent arterioles
EPIOERMTs
3. Wheal swelling due to transudation of fluid into
extravascular space

DERMIS

I(2.02) CELLULAR EVENTS OF ACUTE INFLAMMATION

University Exams
Long questlons
Define inflammation. Describe the cellular changes that take place in acute inflammation?
Define inflammation. Enumerate cellular events in inflammation and discuss in detail about phagocytosis.
Short questions
Ennumerate Cellular events in acute inflammation.
Explain Leukocyte transmigration.
Describe Chemotaxis.
Mechanism of Phagocytosis and killing
5. Describe chemotaxis and
piagllular events in acute inflammation.
6 Describe Rolling and adhesio during
Very Short questions
1. Chemoattractants in acute inflammation.
2. Name three steps in phagocytosis

Overview
Acute inflammation Steps (00:02:09)
Summary of vascular events (00:02:44)

Cellular Events
1 Margination and pavementing (00:13:21)
Rolling (00:14:16)
3 Adhesion (00:15:42)
4: Transmigration (diapedeses) (00:22:17)
5. Chemotaxis
6.
Phagocytosis Steps (00:24:42)

Acute inflammation > Steps

Vascular Events Cellular Events
1. Transient vasoconstriction of arterioles 1. Margination and pavementing
2. Persistent progressive vasodilatation 2. Rolling
3. Elevate the local hydrostatic pressure 3. Adhesion
4 Increased vascular permeability 4. Transmigration (diapedeses)
5. Slowing or stasis 5. Chemotaxis
6. Phagocytosis

PAGE 38 |
INFLAMMATION
 PATHOL0GY PROF BUSTER m
Summary of vascular events
Stin

Microbe Endothelal gap

WBC

Cellular Events
1. Margination and pavementing
2. Rolling
3. Adhesion
4. Transmigration (diapedes)
5. Chemotaxis
6. Phagocytosis

Skin

Phagocytosis Chemotaxis Transmigration

Adhesion
Margnation

ROLLUNa
NTEQRIN ACTIVATION
HEMOXINEC

slalyets Kmodiñed pycoproteln

Leukocyte HABLE
ADHESION

Intergin (low-afMinity state) MIARATION

THROuam
ENDOTHELIU
Intergrin (high-afrinlty state)

Helectn
E4electin

Preteeglycaa PECAM-1
(cDJ1)

Integin lgand
(0CAM1)

Ortokdnes
(TNF, IL1) Chemokines

INFLAMMATION | PAGE 39
 m
DR. PRIYANKA SACHDEV

(1)Margination
Normally central stream of WBCs and RBCs and peripheral cell-free layer of plasma close to
vessel wall Normal axial flow
Acute inflammation WBCs leave enter and comes at periphery of blood vessel Reversal of
axial blood flow
Skin

Marglnatlon

(2) Rolling
Transient Bond between WBCs and endothelial cells Rolling
Skin

Rolling

Marglnatlon

(3) Adhesion
Bond between WBCs and endothelial cells becoming firmer > Adhesion
Skin

Rollng
Adheslon
Marginatlon

Complementary adhesion molecules (CAM)

Endothelial Molecule Leukocyte Molecule Major Role
1. P-selectin Sialyl-Lewis X eRolling
2. E-selectin Sialyl-Lewis X Rolling and adhesion
3. GlyCam-1 (CD34) L-selectin Rolling
4. ICAM-1 B2 integrins Adhesion
5. VCAM-1 B1 integrins Adhesion
6. PECAM-1 (CD-31) PECAM-1 (CD-31) Diapedesis (trasmigration)

PAGE 40 |
INFLAMMATION
 PATHOLOGY PROF BUSTER m

Slalyl Slalyl
Leyis-X Levis-X L-Selectln b2 Integrin b1 Integrin PECAM

p- Selectin E-Selectin Glycam-1 ICAM VCAM

CO11/PtCAM-1
(4) Transmigration (diapedes)
WBCs Escape out into extravascular space
Passive phenomenon
PECAM

Skin

Transmigration

Rolung Adheslon
Margination

(5) Chemotaxis
Unidirectional oriented along a chemical gradient
Potent chemotactic substance
1. LT-B4
2. C3a
3. C5a most powerful
4. Interleukines (|L-8)
Skln

Transmlgratlon
Chemotaxls

Adheslon

Marginatlon

(6) Phagocytosis
Engulfment of microbes by the WBC's (cell-eating)
Appreciated by Metchnikoff (1880)

INFLAMMATION | PAGE 41
 m, DR. PRIYANKA SACHDEV

Skin

hagocytoe Chemotds Transmgtion

Adhesion
Marpintlon

Steps of Phagocytosis
1. Recognition and Atlachment
2. Engulfment
3. Killing and degradation > 3 steps
a) MPO-dependent
b) MP0-independent

L RECOGNITION AND ATTACHMENT

Microbes bind to
phagocyte receptors Lysosome
with entymes
Fuslon of
phagosome
Phagocyic. Mlcrobe lngested With
receptor In phagosome lysosome

Degradatlon of microbes
2. ENGULFMENT by lysosomal enzymes
Phagocyte membrane Phagolysosome in phagolysosome
zips up around Phagosome with
mlcrobe ingested microbe 3. KILLING AND DEGRADATION

Cytoplasnie

KADPH
Acthve oxidase

or OCI -Arginlne
Membrane
oddase
ROS
Membrane
Phagocyta
PHAGOCYTIC VACUOLE oxldase

Step 1

NADPH-oxidase present in cellmembrane of phagosome reduces oxygen to

superoxide ion (02-)

20, 20;
NADPH
oxidase (Superoxide
anlon)

NADPH NADP + H*

PAGE 42 | INFLAMMATION
 m

PATHOLOGY PROF BUSTER

Step 2
Superoxide is subsequently converted into H202:

202 + 2H*
H202
(Hydrogen peroxide)
3
Step
MPO-independent killing MPO-indepondont killing
Enzyme MPO acts on H202 in presence of Mature macrophages lack enzyme MPO
halides (chloride, iodide or bromide) Carry out bactericidal activity by
form hypohalous acid (HOCI, HOI, HOB) producing OH- ions from H202 >
Antibacterial action Antibacterial action
In presence of O2 (Haber-Weiss
MPO
reaction)
H202 --HOCL +H2O V In presence of Fe++ (Fenton reaction)
CI,
Br" (Hypochlorous acid)
OH
reation
Haber-Werss

H,05 +
renton Fe
rear
action
OH

CYTOPLASM

Cytoplasmic
oxidase Primary
MPO granule

MPO

NADPH
CL
Active oxidase
NADP*

H,0,
Fe*
Membrane
oxidase OH
Membrane

(2.03) CHRONIC INFLAMMATION OR GRANULOMATOUS INFLAMMATION

University Exams
Long questlons
1
Define and classify granuloma. Explain the evolutlon and morphology of tuberculous granuloma.
2. Define granuloma. Explain the pathogenesis of granulomatous diseases
3. ulomatOUs Inflammatlon.
Define granuloma., Explaln its morphology. List the diseases wlth granulor
Define Chronic inflammatlon. How does It differ Trom acure chronic
.
lnfectlve granuloma.
5. A 42-year-old male presented with of ver, cOugh and welgh loss since two months X-ray chest showed cavitary leslon In
right apical lobe.
6 What is your
alagnos and why?of thls disease.
7 Describe eis
8. Describe microscoplc findings In lung.

INFLAMMATION | PAGE 43
 m
DR. PRIYANKA SACHDEV

Short questlons
1 Granulomatous lymphadenitis.
2. Discuss granulomatous inflammation with examples.
3. Microscoplc appearance of granuloma.
Write short note on Granuloma.
Define granuloma. Writo its types with examples.
Write short note on Giant cells.
7. Chemicals of tuberculous bacilll responsible for producing granuloma.
8. Microscopy of tuberculous granuloma with a dlagram
Very Short Answer
aro associated.
What are various types of giant cells? Name them and conditlons with which they
Define Granuloma.
List types of granulomas with example.

Overview
Introduction (00:01:35)
Granuloma >
Pathogenesis (00:02:21)
Definition (00:10:08)
Structure or microscopy (00:11:17)
Types of Giant cells (00:11:52)
Types of Granulomas (00:14:52)
Examples of granulomatous inflammation (00:16:48)

Introduction
Chronic inflammation is a response of prolonged duration (weeks or months) in which inflammation,
tissue injury and attempts at repair (fibrosis) coexist.
Granuloma >
Pathogenesis
Formation of granuloma is a type IV hypersensitivity reaction

3 Steps
1. Engulfment by macrophages
2. Activation of CD4+ T cells
3. Release of Cytokines

CD4+
Thi cell
ANTIGEN- PRESENTING
CELL
Presents
antigen to
T cell

Blood vessel Cytoklnes

(E.g, TNF, Glant cell Epithellold cell
chemoklines)
IFN:Y Cytoklnes
(Eg, IL-12)

Lymphocyte Actlvated
recrultment, Monocyte
inflammation Macrophage

Flbróblast

Lymphocyte Actlvated
Macrophage

PAGE 44 |
INFLAMMATION
 m

PATHOLOGY PROF BUSTER

(1) Engulfment by macrophages

Macrophages engulf Ag
Try to destroy il

But Ag is poorly degradable

Macrophages fail to digest and degrade Ag

(2) Activation of CD4+ T cells

Macrophages failed deal with Ag
Present antigen to CD4+ T lymphocytes
CD4+ T Iymphocyte activated

Release lymphokines
a) Interferon-Y
b) IL-1, IL-2
c) TNF-a

(3) Release of Cytokines

Interferon-y activates macrophages and transformit into epitheloid cells
IL-1 and IL-2 T cells proliferation
TNF-a > Fibroblast proliferation

Definition
A focus of chronic inflammation consisting of a microscopic aggregation of
Macrophages that are transformed into epithelioid cells
Epithelioid cells fuse to form giant cells
Surrounded by a Collar of mononuclear leukocytes > lymphocytes and plasma cells.

Giant cell Epithellold cell

Structure or Microscopy
Macrophages modified as epithelioid cells in
center
Some epitheloid cells fuse to form multinucleate
giant cells.
Surrounded peripherally by T lymphocytes
Healing by fibroblasts or collagen
Caseous necrosis in some granulomatous
conditions

Flbróblast
Activated
Types of Giant celis Lymphocyte Macrophage
1. Foreign body giant cells
2. Langhans' giant cells
3. Trouton giant cells
4. Giant cells in tumors

INFLAMMATION | PAGE 45
 DR. PRIYANKA SACHDEV

INFLAMMATORYGIANT OELLS TUMOUR GIANT CELLS

Foreign Body Langhans Touton Type Anaplastic

Type Reed. Osteoclastlc
Type Tumour Glant Sternberg Tumour Giant
Cell Cells Cell

Foreign body giant cells

Nuclei are scattered throughout cytoplasm.
E.g. chronic infective granulomas, leprosy
and tuberculosis

Langhans' giant cells >

Nuclei are arranged either around periphery in
form of horseshoe ring or clustered at two
giant cell. poles of
E.g. tuberculosis and sarcoidosis.

Touton giant cells>

Vacuolated cytoplasm due to lipid content
E.g. Xanthoma

Types of Granulomas
Caseating Granuloma Non-caseating Granuloma
1. Tuberculosis 1. Tuberculosis
2. Histoplasmosis 2.
3. Syphilis
Sarcoidosis
3. Hodgkin's lymphoma
4. Coccidiomycoses

Naked Granulomas >

Not have surroundingrim
of mononuclear
Composed of epithelioid histiocytes cells
Example and multinucleated giant cells
Sarcoidosis

PAGE 46| INFLAMMATION

 BUSTER
PATHOLOGY PROF

Stellate granuloma
Star shaped Granuloma
Granuloma with central neutrophilic infiltrates.
Examples >
Cat scratch disease
LGV (lymphogranuloma venereum)

Examples of Granulomatous Inflammation

Bacterial
1)Tuberculosis Mycobacterium tuberculosis
Mycobacterium leprae
2) Leprosy
Treponema pallidum
3) Syphilis
C. donovani
4) Granuloma inguinale Donovanosis)
Brucella abortus
5) Brucellosis (Mediterranean fever)
6) Cat scratch disease Coccobacillus
Francisella tularensis
7) Tularaemia
Actinobacillus mallei
8) Glanders

Fungal
Actinomycetes israelii
1.Actinomycosis
Blastomyces demtitidis
2. Blastomycosis
Cryptococcus neoformans
3. Cryptococcosis
Coccidioidesimmitis
4. Coccidioidomycosis

Parasitic haematobiumjaponicum
(Bilharziasis) Schistosoma mansoni,
1. Schistosomiasis

Miscellaneous
Unknown
1.Sarcoidosis
Unknown
2.Crohn's disease
Silica dust
3. Silicosis
Metallic beryllium
4.Berylliosis
Talc, suture, oils, wood
splinter etc.
5.foreign body granulomas
INFLAMMATION
CHEMICAL MEDIATORS OF
(2.04)
University Exams
inflammation. mediator.
Long questions chemical medlators of derived chemical
inflammation. DisCUss In detail aboutClasslfy them. Descrlbe functions of plasma derlvatives.
1. Define inflammation. Arachldonlc acid
of functions of
2 Define chemical mediators of Inflammation. Describe the
Classify chemlcal mediators
3
Short questions inflammation.
1 Chemlcal mediators of Inflammation.
Cell-derived mediator of
2 of Inflammatlon.
Plasma-derived mediator metabolites Inflammatlon.
3 in acute
arachidonlc acid
4 Role of
m, DR., PRIYANKASACHDEV

Very short questlons

1 Name the cell-derlved mediator Inflammation.
Role of prostaglandins In aculo lnflammatlon.
3 Thromboxane A.
4 Platelet activation factor.
5 Histamine and Serotonln.

Overviaw
Classification (00:01:45) Plasma Inflammatory
Cellular Inflammatory
Cellular Inflammalory mediators (00:13:15)
medlators Kinin and clotting
system
mediators (00:08:42) a)
Preformed (00:02:51) Nowly Synthoslzod b) Complernents
Histamine a) Nitric Oxido
a)
b) Serotonin b) Platelet octivating factor
Lysosomal enzymes c) Cytokinos
d) Neuropeptides d) Arachldonlc acld derivative

Inflammatory mediatorS

Plasma
Classification Collular
a. Kinín and clotting system
2 types b. Complements
within cells)
a) Cellular (mediators present
b) Plasma (synthesized by liver and secreted Perormed Newlysyntheslsed
in plasma) a. Histamine (formed during Inflammatlon)
a. Nitric Oxide
b. Serotonln
C. Lysosomal
enzymes b. Arachidonic acid derivative
C. Platelet actívating factor
d. Neuropeptides
d. Cytokines

Cellular Inflammatory mediators

Performed
a) Histamine
b) Serotonin
c) Lysosomal enzymes
d) Neuropeptides

(a) Histamine
Synthesized from histidine amino acid.
Richest source are mast cells.
Functions
a) Vasodilation mainly (but induce vasoconstriction of large arteries)
b) Increased vascular permeability.
c) Increased smooth muscle contraction (bronchoconstriction).

(b) Serotonin
5-hydroxytryptamine, 5-HT
Richest source are platelets
Also present in enterochromaffin cells.
Function is same as of histamine.

(c) Lysosomal Enzymes

Present in Lysosomes of neutrophil and monocytes.
Lysosomal granules are of three types:
a) Primary (Azurophilic)
b) Secondary (Specific)
c) Tertiary granules

PAGE 48| INFLAMMATION

 BUSTER
PATHOLOGY PROF

Primary granules Secondary granules Tertlary gránules

.Azurophilic granules Specific granules C-particle
Mainly involved in
chemotaxis
Develop at Develop at
promyelocytic stage diapedesis and matrix
myelocytic stage
More destructive Less destructive degradation
It contains It contains It contains
MPO Lactoferrin Gelatinase
(myeloperoxidase) Lysozyme
Elastase Type IV collagenase
Defensin B1 microglobulin
Cathepsin G Gelatinase
Bacterial permeability Vitamin B12 binding
proteins proteins
Acid hydrolase Cytochrome B
Phospholipase- Az
Non-specific
collagenase

(d) Neuropeptides
Examples are substance p & neurokinin A.
Secreted by sensory nerves and leukocyte.
Nerve fibers containing substancep is rich in lung and gastrointestinal tract.
Actions are:
a) Mediator of vascular permeability.
b) Pain Signal transmission.
c) Blood pressure' regulation.
d) Stimulates immune and endocrine cell secretion.

Cellular inflammatory mediators

Newly Synthesized
Formed during process of inflammation.
a) Nitric Oxide
b) Platelet activating factor
c) Cytokines
d) Arachidonic acid derivative

(a) Nitric oxide (NO)

Synthesized from arginine amino acid by enzyme nitric oxide synthase (NOS).
Actions are
a) Vasodilation
b) Platelet anti-aggregators
c) Microbicidal action

(b) Platelet-activating factor (PAF)

Phospholipid derived mediator.
Most potent inflammatory mediators
Actions are:
a) Platelet aggregation
b) Vasoconstriction
c) Bronchoconstriction
d) Increased vascular permeability
e) Transmits signals" between cells.

INFLAMMATION| PAGE 49
 m
DR. PRIYANKA SACHDEV

(c) Cytokines
Soluble polypeptides.
Secreted by both hematopoietic and nonhematopoiolic cells.
Highly specific
Involved in inflammation, immunologicalroactions and wound healing.
Chemokines
Family of small (8 to 10 KO) proteins.
Stimulate leukocyte movement (chemotaxis)
Perform their action by binding to seven-transmembrane G protein-coupled receptors.

C-X-C (a-chemoklnos) C-C(b-chemokInos) c(g CXC

chemoklnes)
FUNCTION Neutrophil Recruit monocytes, Recruit
recruitment eosinophils, lymphocytes
basophils and
lymphocytes but
not neutrophil.

IL-8 (produced by Eotaxin (for Lymphotactin Fractalkine

macrophages and eosinophil) It
exists in two forms:
endothelial cells) Monocyte chemo Endothelial surface
activation by IL-1 attractant protein-1 bound protein
MEMBERS

and TNF-a RANTES Promotes,

(Regulated and mononuclear cell
Normal T-cells adhesion
Expressed and Soluble form
Secreted) Chemoattra ctant
MIP 1a for mononuclear
(macrophage
Inflammatory
protein 1a)

(d) Arachidonic acid (AA) metabolites

from essential fatty acid
Arachidonic acid is a 20-carbon polyunsaturated fatty acid derived
Linoleic acid. (AA) through enzymatic activity of
Activated cells release membrane-bound arachidonic acid
phospholipase A2. Lipid mediators (eicosanoids) through enzymatic
AA is then catabolized to generated short-range
activities. involve in almost every aspect of
Eicosanoids bind to membrane G-protein- coupled receptors and
inflammation.

Arachidonic acid Metabolite

Phospholipids

Phosphollpase A

Arachldonlc acld

Cytochromo p450 8o-6lcosanold pathway

Cycloxygenaso pathway Llpoxygenase pathway epoxygenaso pathway

1. Leukotrienes 1.EET (epoxyelcosatetraenolc acld)

1. Iso-prostanes
1. Prostaglandins B 2. HETE (hydroryelcosatetraenolc acd)
2. Prostacyclins 2. LipoxlnA and
3. Thromboxane A,(TXA;)

PAGE 50 |
INFLAMMATION
 PATHOLOGY PROF
BUSTER

Cyclo-oxygenase pathway

AA

Cyclo-oxygenaso pathway (cox

PGG2 and PGH2

PGI2 (prostacyclin) TXA,(thromboxano AJ PGD,

PGE,
Synthesised In ondothollum Formod by platolots PGF
- Inhibits platelet aggregatlon
Platelet aggregation Vasodilation
Vasodilatation Vasoconstrictlon E1 Vascular permeability
pain and fever
for
PGEis
PGD,, &PGF, for neutrophil
chemotaxís

LOX (Lipoxygenase) pathway

Arachidonic acid

Lpoxygenase pathway(LOx)

5-LOX 12-LOX

LTA, Lipoxin (Endogenous negative regulator of

leukotrienes)
Antiinflammatory
LTCA
LTB a. Inhibit neutrophil chemotaxis
Chemotaxis LTD b. Inhibits NK-cellcytotoxicity
for
Slow-reacting (SRS-A) substance of
LTE,
C.Activates monocytes and macrophage
anaphylaxis. phagocytosis of neutrophils

1. Vasoconstriction
2. Increase vascular perneability
3. Bronchoconstriction

Epoxygenase pathway
AA

Cytp450 epoxyVgenase pathway

1, EET (epoxyeicosatrienoic acid) 2. HETE (hydroryelcosatetraenoic acid)

Anti-inflammatory Actions -Renal vasoconstriction

-Anti-apoptotic (involved in pathogenesis of hypertension)
-Angiogenic
Anti-hypertensive

INFLAMMATION | PAGE 51
 Im DR, PRIYANKA SACHDEV

Iso-eicosanoid pathway

AA
-

s0-elcosanold pathway

Non enzymatic free-radical peroxidation

Isoprostanes
Functlons:
a. Vasoconstriction

b. Modulate WBC and platelet interaction

c. Angiogenesis

Plasma lInflammatory mediators

a) Kinin and clotting system
b) Complement

(a) Kinin and clotting system

Inflammation promotes clotting by increasing production of several.coagulation factors.
Thrombin promotes inflammation by binding to protease-activated receptors (PARS) on platelets,
endothelium, and smooth muscle cells.
This mobilizes P-selectin to induce cytokine and chemokine production and increases synthesis of
PAF, NO, and prostaglandins.

Kinin system

Factor Xll
(Fcontact factor)
Hageman factor

Xlla

Pre-Kallikrein Kallikrein

Kinin
Kininogen
(=bradykinin)

(b) Complement
3 major pathways
1. Classic pathway
2. Mannose Binding Lectin (MBL)pathway
3. Alternative pathway

PAGE 52 | INFLAMMATION
 m

PATHOLOGY PROF BUSTER

Complement Pathways

Ag-Ab Complex
Microbe with Mannose Endotoxin/ Cancer cells

Cab
C.

CAb
2a 3b o
2a3b C3b Bb 36

Cell Lysis

INFLAMMATION |PAGE 53
 (3.01) WOUND HEALING (REGENERATION
WOUND HEALING
AND REPAIR

AND REPAIR)
3
Univorsity Exams
Long questions
1 What do you understand by the terms-"healing", regeneration" and "repair"?
Describe steps of Repair.
2. Define repair, Describe Its steps in detall
Short questlons
1 Differentiate Regeneration and Repair
2. Granulation tissue.
3 Scar
4 Angiogenesis (neovascularizalion) in repair.
5. Steps of wound healing.

Overview
Healing
Definition (00:01:10)
Mechanisms (00:02:16)
Repair 3 Phases
1 Inflammatory phase (00:05:55)
2. Proliferative phase (00:12:46)
a) Epithelialization
b) Fibroplasia
c) Angiogenesis Steps
3 Maturation phase (00:23:50)

NORMAL

Healing
Definition >
Body's response to injury in an attempt to MIld, superflcdal Injury Severe Injury
restore normal structure and function
l
Mechanisms
Regeneration
Parenchyma replaced by parenchymal cells SCAR FOMATION
of the same type REGENERATION
Restoration of normal structure and function
Result - Same tissue
Repair
REGENERATION REPAIR
Parenchyma replaced by fibrous tissue
Restoration of normal shape and function is Within seconds of the lnjury
impaired Release of eplnephrine, nore pinephrine,
Result- scar prostaglandins, serotonin, and thromboxane
Vasoconstriction
Endothellal cells retract
Repair 3
Phases Expose the subendothellal collagen surfaces
1. Inflammatory phase Platelets adhesion
2. Proliferative phase Platelet Activation

a) Epithelialization Release Platelet Aggregation

b) Fibroplasia Granulation Neutrophlls and
macrophages Primary platelet plug formation
tissue Coagulation cascade
c) Angiogenesis Inflammation
Secondary plug(fibrinproduct)
3. Maturation phase: Scar
Hemostasis
 m DR. PRIYANKA SACHDEV

(1) Inflammatory Phase

Inflammatory phase

Wounding time 0 hour 1-6 hours 2

days
Hbrir Clot - Scab

Epíthelizatipn.
Neutrophils begins

Fibronectin
Platelets - Macrophages
free
ADP Radicals
TGF
TXA, (+)
Lymphocytes TGF
Disrupted PDGF
collagen Lymphokine
RBC - FGF
PAF

Disrupted KGF

blood
vessel

Clot formation Neutrophils Macrophages

3-5 days
Scab

(2) Proliferative Phase

(a) Epithelialization
Fibroblasts
Celltravel about 3 cm from point of origin in all Macrophages
directions
Fibrogenesis Collagen

(b) Fibroblasts lay bed of collagen

Fills defect
Endothellal
buds

(c) Angiogenesis
Steps of angiogenesis
1. Vasodilation > in response to Vasodllation
Qulescent vessel VEGF)
NO
2. Increased permeability Angiogenic
Leading (*tip") cell
(VEGF, NOtch signals)
induced by VEGF factors
3. Separation of pericytes Perlcyte Perlcyate detachment
from abluminal surface Basement (angiopoletin)
membrane
4. Breakdown of basement Endothellum Basement membrane
membrane to allow degradation (MMPs)
formation of a vessel sprout Perlcyte
recrultment
5. Migration of endothelial cells ECM

toward area of tissue injury

6. Proliferation of endothelial Elongatlon of vascular stalk
cells just behind leading
front tip of migrating cells
7. Recruitment of periendothelial Formatlon of new vessel

cells to form mature vessel

End product of Proliferation
Phase Granulation tissue

PAGE 56 | WOUND HEALING AND REPAIR

 PATHOLOGY PROF BUSTER m,

(3) Maturation Phase

New collagen forms

Collagen is remodelled into a more

organized matrix

Increases tensile strength to wounds Flbroblast

Fibroblasts leave wound Flxed tlasue

monocyte
Blood
Final product scar Macrophage -

Tensile strength never reaches the normal strength of unwounded

Maximum strength is 70-80% of normal tissue. (at ond of 3
tissue (i.e., 100%).
months)

Platelet
Eschar

Flbroblast Eplthelal cells

Macrophage Granutton Collagen star
Neutophl tssue
New blood vessels
Capllary B
C
Inflammation Granulation tissue Scar

(3.02) HEALING OF SKIN WOUNDS

(PRIMARY AND SECONDARY INTENTION)
University Exams
Long questions
1. Describe and compare with help of suitable diagrams a wound healing by primary and secondary Intentlon.
2. What is repair? Describe healing of wound by first intention.
Short questions
1
Describe healing. Write down the differences between primary and secondary healing.
Mechanism of wound healing by first intention (primary union).
3. Mechanism of wound healing by secondary intention (secondary unlon).

Overview
Healing of Skin Wounds > (00:01:01)
Intention (primary union)
ndary Intention (Secondary union)
Differences between primary union and Secondary union (00:06:44)

Healing of Skin Wounds

(1) Primary Intention (primary union):
No separation of wound edges
are closed.
All Layers
a
In minimum amount of time
Minimal scar formation.

WOUND HEALING AND REPAIR|PAGE 57

 DR. PRIYANKASACHDEV

(2) Secondary Intention (Secondary union):

Wound edges separated
are left to heal from the inside out.
Deep layers are closed but superficial layers
More time required
Abundant scar formation.

Heallng by Primary Intontlon (primary union)

Seab
Suture track Macrophage Collegen
Haemorrhage Plasma celle

Rogeneratlng upure
FIbroblaats

Neovaseularloation

Healing by Secondary Intention (Secondary union)

Haemorrhage PMNs
Macrophage Scab Plasma cells Collagen scar

Regeneration

NNeovascularisatlon
FIbroblasts

Differences between primary union and Secondary union

Features Primary Union Secondary Union
1. Cleanliness of wound Clean Unclean
2. Infection Uninfected May be infected
3. Margins Surgical, clean Irregular
4. Sutures Used Not used
5. Healing Scanty granulation tissueJExuberant granulation tissue
6 Outcome Neat linear scar Contracted irregular scar
7. Complications Infrequent Frequent

(3.03) FACTORS AFFECTING

WOUND HEALING AND COMPLICATIONS OF WOUND HEALING
University Exams
Short questlons
Enumerate factors affecting wound heallng.
DIfferentlate Hypertrophlc scar and Kelold
3. Describe complicatlons of wound healing.
Very Short questlons
1. Enumerate Local factors whlch delay wound.healing.
Enumerate Systemic factors Influencing wound healing.

Overview
Factors Affectíng Wound Healing (00:00:45)
Complications of Wound Heallng (00:04:23)
1 Hypertrophic scar (00:05:32) Introductlon
Keloid (00:07:30) Gross
- Microscopy
Differences between Hypertrophlc scar and Kelold (00:09:07)

PAGE 58 | WOUND HEALING AND REPAIR

 BUSTER
PATHOLOGY PROF

Factors Affecting Wound Healing

Local Systeml
1 Infections 1
Increased age
Decreased blood supply 2. Anemia (Hypoxia)
3. Denervation 3. Steroldal or cytotoxic drugs
4. Forelgn body 4. Diabetes
5. Poor surglcal technlque 5. Obesity
6. Hematoma 6. Malilgnancy
7. Mechanicalstress 7. Malnütrition
Vitamins A, Cand E deficiency
Deficloncy of polyunsaturated long fatty acids
Zinc deficlency
8. Uremla

Complications of Wound Healing

Insufficient fibrosis:
Wound dehiscence
Hernia
Ulceration

Excessive fibrosis:
Hypertrophic scars
Keloid

(1) Hypertrophic scar

Introduction >
Excessive collagen acoumulation forms a raised scar within wound
boundaries.
Onset less than 3 months.
Spontaneous regression > within 12 to 18 months.
Gross
Scar tissue do not grow beyond boundaries of original wound
and may regress spontaneously.
vortlealy orlented veSsels
Microscopy >
Scar tissue with thin collagen bundles that is oriented
parallel to skin surface. cotlagen ben, erlentad
Paraldto rtc

(2) Keloid

Introduction
Can progression beyond original area of injury without subsequent
regression.
Onset within 1 months to 1 year.
May be genetically associated.
Most common site affected sternum.
No spontaneous regression.
Gross
Scar Tissue extends beyond borders of original wound and it does not
usually regress, spontaneously.
Microscopy >
Well demarcated haphazardly arranged and thicker dense eosinophilic
collagen fibers involving dermis.

WOUND HEALING AND REPAIR| PAGE 59

 m DR. PRIYANKA SACHDEV

Differences between Hypertrophic scar and Keloid

Hypertrophic scar Kelold
Remains within boundaries of OutgrowS Wound area
Gross
Wound No spontaneously regression
Spontaneously regression Tend to reoccur if excised
Tend not to reoccur if excised Affect variety of sites- ear lobes.
Most often affect the skin shoulders, anterior chest wall,
overlying joints upper back
Microscopy Larger number of Fewer myofibroblasts
myofibroblasts Extracellular matrix composed of
Extracellular matrix composed type Icollagen arranged
of type Ill collagen in linear chaotically in thick bundles that
fibrils running parallel with the project under normal epidermis
skin Less vascular
Highly vascular
Epidemiology Non-inheritable Inheritable
Etiology Only occur following injury ocur without injury
May
Symptoms Mild pruritis, not painful Pruritic and painful

PAGE 601WOUND HEALING AND REPAIR

 CHAPTER

HEMODYNAMIC
DISORDERS 4
(4.01) EDEMA ANDEFFUSION
Unlversity Exa#1s
Long questions
1 piscuss causos and pathogonosls of doma,
2 Classify and list difforentpathophysiologlc calegories of edems and doseribe pathogenesls of cardiac odema.
3
Edema, Discuss in detall otlopathogenesis of edema, Dosorlbo different typos of adena wilh ox9mplss
4. Defino oedema. Discuss palhogenesis of 06dema ln congestlve Cardiac fallurG and tenal disoA64,
Short quostlons
1 Differences between transudates and exudateS,
Define oedema, Glve classification of oedema.
Define edema, Mention the types and write pathogénesis In brief.
Cardiac edema pathogenesis
5 Ronal edema pathogenesia
6. a
Draw figuro showing pathways leading to systemlc odema from primary hoart fallure,
Vory short questlons
Transudato.
2. Exudate
3 Dofino oedema and offuslon

Overvlaw
Oodema Definitlon (00:01:10)
Effusion Definition (00:02;58)
Normal luid oxchange (Starlings law) (00:04:12)
Pathogenosis of oodema (00:17:15)
Types of oodema (00:36:54)

Oedema> Definition
Abnormal and exXcessive accumulation of fluld in Intorstitlal tissue spaco

Intracellular
Fluld

Fluld

Intravascular
Fluld
 m
DR. PRIYANKASACHDEV

Effusion> Definition
Abnormal and excessive accumulation of fluid in body cavities

Perlcardlal Effuslon
Healty Heart Perlcardial Effusion
Trachea

Pleura
(lung lining)

Lung

Pleural effusion
(fluid beween
pleural space)
Cheveland Perlcardlum Excess luld

Normal fluid exchange

At arterial end
CAPILLARY NETWORK
Hydrostatic pressure (outward force) >
osmotic pressure (inward force) ARTERIOLE

Net Outward driving force = 38 25 VENULE

= 13 mmHg
Fluid comes out from capillary into
interstitialspace.
ARTERY
VEIN
At venous end >
Osmotic pressure (inward pressure) > hydrostatic pressure
Net Inward-driving force = 25 -12 = 13 mmHg (outward pressure)
Fluid comes back in capillary from
interstitial space.

13mm 13mm
E

ARTERIAL
END
CAPILLARY

Hydrostatic Pressurem38
Osmotlc Prossureu 25
H
Osmotlc Pressures 25
Hydrostatic Pressure =12 VENOUS
END
38-25= 13 mm
25-12= 13mm

INTERSTITIAL SPACE

[LYMPHATICS

PAGE 62| HEMODYNAMIC DISORDERS

 PATHOL0GY PROF BUSTER m

Pathogenesis of edema
4
Increased capillary hydrostatic pressure
2. Decreased plasma oncotic pressure
3. Lymphatic obstruction
4. Sodium and water retention
5. Increased capillary permeability
1) Increased capillary Hydrostatic prossure
Oedema of cardiac disease e.g. in congestive cardiac failuro
Postural oedema e.g. transient oedema of feet and ankles due to increased venous pressure
seen individuals Whose job involves standing for long hours such as traffic constables

RA A

RV

PA Aorta
Organs

Luns

2) Decreased plasma oncotic

pressure
Oncotic pressure pressure exerted
by total plasma proteins.
Albumin has four times higher plasma
oncotic pressure than globulin Synthesis
Hypoalbuminemia Oedema From liver
Absorption
Edema takes place when
Total plasma protein is below 5 From GIT
gm/dl (normal 6-8 gm/dl)
Albumin is below 2.5 gm/dl
(normal 3.5- 5gm/dl)
Excretion
Examples
Inadequate synthesis of albumin > end ol From kidney
stage cirrhosis
Protein malnutrition
Increased loss of albumin Nephrotic syndrome

3) Lymphatic Obstruction
Normally interstitial fluid in tissue spaces escapes lymphatics.
Obstruction to outflow of lymphatics
Lymphoedema
-Lymph nodes
Examples >
Removal of axlllary lymph nodes in Sentinel node
radical mastectomy for carcinoma of
Cancer
breast lymphoedema of affected arm.
Nipple

HEMODYNAMIC DISORDERS | PAGE 63

 m, DR. PRIYANKA SACHDEV

Inflammation of the lymphatics as seen in filarlasis

(elephantiasis) > lymphoedema of scrotum and legs
elephantiasis

Milroy's disease or hereditary lymphoedema due to abnormal

development of lymphatic channels

4) Sodium And Water Retention

Oedema of cardiac disease e.g. in congestive cardiac failure.
Oedema of renal disease e.g. in nephrotic and nephritic syndrome.
Increased capillary permeability

HEART FAILURE Malnutrition,

Hepatic Synthesis,
1

Nephrotic Syndrome
1Capillary
I Renal blood flow
hydrostatic
pressure I Plasma albumin
Activation of the
renin-angiotensin
system

Retention of RENAL FAILURE

Na* and H,0
J Plasma osmotic
Blood volume pressure

EDEMA

5) Increased capillary permeability

Inflammation

Capillary endothelium is injured

Gaps between endothelial cells

Leakage of plasma proteins into interstitial fluid

Reduced plasma oncotic pressure and elevated oncotic pressure of interstitial fluid
Oedema

Fluid & protein leakage

Exudate
(High protein content & may contaln some whlte Vasodilation Inflammation

& red cells) & stasis

Increased
interndothelial spaces

PAGE 64 | HEMODYNAMIC DISORDERS

 m
BUSTER
PATHOLOGY PROF

Examples
Generalized oedema in systemic infections, poisonings, certain drugs and chemao
anaphylactic reactions and anoxia,
Localised oedema > allergic reactions, insect-bite, irritant drugs and chemicals.

Generallzed oedema Locallsed oedema

Pathogenesis of edema
Lymphatic Sodium
Hydrostatlc Plasma osmotic obstruction retention Gapilary
pressure pressure (Lymphedema) permeability
Cardiac failure Liver cirrhosis After breast Cardiac Acute and chronic
surgery failure inflammation

Postural oedema Malnutrition Filariasis Renal

failure
Renal failure Milroy disease
(Nephrotic syn)

Types of oedema
Features Transudate Exudate
Definition Protein-poor, cell-poor fluid Protein-rich, cell-rich fluid
Low (less than 1
gm/dl) High (2.5-3.5 gm/dl)
Protein content
Few cells Many cells
Cells
LDH Low High
Low (less than 1.015) High (more than 1.018)
Specific gravity
pH >7.3 <7.3
Same as in plasma Low (less than 60 mg/di)
Glucose content
Character Non-inflammatory oedema Inflammatory oedema

Examples Oedema in congestive cardiac Purulent exudate such as

failure pus

HEMODYNAMIC DISORDERS |PAGE 65

 m
DR, PRIYANKA SACHDEV

Hydrostatic Collold osmotic

pressure pressure

Normal
Plasma proteins

Fluld leakage

Increased hydrostatic pressure

• venous outflow Decreased collold osmotic pressure
obstruction,
[Eg. congestlve heart fallure) • decreased
protein Synthesis (Eg liver
• Increased protein loss
[E.g kidney diseasel iseat
Transudate
(Low protein content, few cells)

o. Fluid & protein leakage

Exudate
(High protein content & may contain some
white
&
red cells) Vasodilatíon Inflammation

&
stasis

Increased
interndothelial spaces

(4.02) HYPEREMIA AND CONGESTION

(CVC LUNG, CVC LIVER, CVC
SPLEEN)
University Exams
Long questlons
1. Define hyperemia and Congestion.
passive venous congestion. Describe types of congestion.
Describe gross & microscopic features of lung & liver in chronic
Short questions
1 Differences between hyperemia
2. Chronic venous congestion (CVC) and Congestion
3 Chronic venous congestion (CVC) liver > Causes, gross and microscopic features.
Chronic venous congestion-spleen lungs Causes, gross and microscopic features.
5. Heart failure cells Causes, gross and microscopic
features.
6. Nutmeg liver.
7. Gamma-Gandy bodies.
Very short questions
1
Microscopy of CVC lung with a
2 Microscopy of CVC liver diagram.
with a
3. Microscopy of CVC spleen with diagram
a
4
Brown induration of lungs diagram

Overview
Hyperaemia And Congestion >
Definition (00:01:22)
Differences (00:03:52)
Congestion > (00:04:12)
In Left heart failure
In Right heart failure
CVC of lung (00:08:15)
CVC of liver (00:16:02) Gross
cVC of spleen (00:22:57) Microscopy

Hyperaemia And Congestion CAPILLARY NETWORK

Definition > ARTERIOLE

Localised increase in volume
dilated vessels of an organ orof blood within
VENULE

tissue.

ARTERY
VEIN
PAGE 66| HEMODYNAMIC
DISORDERS
 PATHOLOGY PROF
BUSTER m
Differences
Hyperemla Congestlon
Active process Passive process
of artery Impaired venous blood flow
2 Vasodilatation
3During exercise & in inflammation Venous obstruction & cardiac failure
4 Oxygenated blood (Red, Erythema) Deoxygenated blood (Blue, Cyanosis)

Congestion
In left heart failure
Pulmonary congestion (CVC Iungs)
In right heart failure >
Systemic venous congestion (CVC of systemic organs Liver, spleen)

NC/ SVC

Organs

Right-sided failure Left-sided failure

Pressure transmitted upstream of right heart Pressure transmitted upstream of left heart

SYSTEMICVENOUS CONGESTION PULMONARY,CONGESTION

CVCUVER CVC KIDNEYCONGESTED LEG VEINS CVCLUNGS

VCSPLEEN

CVC Lung
Gross
C/S dark and rusty brown > brown induration of lungs

Microscopy
Alveolar capillaries congested.
Initially excess fluid collects in interstitial lung spaces Interstitial oedema
Later > fluid fills alveolar spaces > Alveolar oedema
Hemosiderin-containing macrophages in lung alveoli Heart failure Cells
HEMODYNAMIC DISORDERS | PAGE 67
 m
DR. PRIYANKA SACHDEV

Congested vessels Oedema fluid Thickened alveolar septa Heart failure cells Intra- alveolar RRC.
RBCS

CVC Liver
Gross
C/S Nutmeg appearance due to red
(congested centre of lobules) and yellow (Fatty
peripheral zone) mottled appearance

SPEr
Microscopy
Red Centrilobular haemorrhagic necrosis
Yellow fatty change in peripheral zone of lobule
So nutmeg appearance

Fatty change Central haemorrhagic Portal triad

necrosis

CVC Spleen
Gross
Congested, tense and cyanotic
C/S gray tan

PAGE 68 |HEMODYNAMIC DISORDERS

 PATHOLOGY PROF
BUSTER m
Gamma-Gandy
Microscopy Thickened capsule Congested sinusoids body
Red pulp > enlarged due to marked
sinusoidal dilatation
Capillarization of sinusoids Sinusoids
may get converted into capillaries
Fibrous tissue get deposits of hemosiderin
oigment Gamna-Gandy bodies

Remember
CVC of lung > presence of heart failure
cells (hemosiderin laden macrophages)
CVC of liver > produces nut-meg liver
CVC of spleen presence of Gamna
Gandy bodies

CVG Lung CVC Liver CVC Spleen

Gross Brown induration Nütmeg liver Cyanotic, grey-tan

Interstitial oedema Centri lobular Hemorrhagic Red pulp

Microscopy

necrosis enlargement
Alveolar oedema Peripheral Fatty Change Gamna-gandy body
Heart Failure
Cells

(4.03) THROMBOSIS
University Exams
Long questions
1 Define and describe pathogenesis of thrombus. Add a note on fate of thrombus.
Define and classify thrombosis. Explain the etiopathogenesis and pathology of thrombosis. Add a note on fate of thrombus.
Discuss causes, pathogenesis and effects of venous thrombosis.
a
4 Discuss the pathogenesis, types, morphology & fates of thrombus.
Short guestions
Fate of a thrombus.
What is Virchow triad? Discuss its role in thrombus formation.
3. Define and classify thrombosis
4. ypes of thrombus.
5.
M

thrombus.
6. Difference between arterial and venous thrombus.
Very short questions
1: 3 primary conditions associated with increased risk for thrombosis.
Fate of thrombus.

Overview
Introduction (00:01:51)
Pathophysiology (00:07:20)
1. Endothelial injury
2. Altered blood flow
3. Hypercoagulable States
Types of thrombus (00:27:15)
Gross (00:30:13)
Differentiate Arterial vs Venous thrombus (00:31:10)
Fate of thrombus (00:32:24)

HEMODYNAMIC DISORDERS | PAGE 69

 m DR. PRIYANKA SACHDEV

Introduction
Veln clot Arterial clot
Haemostasis occurs after injury to
CVS and is useful as it stop escape of Platelates
blood and plasma Flbrin
Thrombosis occurs in unruptured
CVS (without injury) and has harmful
effects of ischemia
Thrombosis is formation of a blood clot
(solid mass) in unruptured CVS from
constituents of flowing blood
obstructin flow of blood

Stasls of blood flow

Pathophysiology
Virchow's triad
1. Endothelial injury
2. Altered blood flow (Stasis or turbulence)
3. Hypercoagulable States (Thrombophilia)
Hypercoagulablity Endothelial injury
1) Endothellal Injury
Intact endothelium has both antithrombotic property
and prothrombotic property > So no
thrombosis

Prothrombotic Antithrombotic
Thromboplastin or tissue factor Heparin-like
released from endothelial cells. substance
accelerates action of antithrombin IIl
Von Willebrand factor causes adherence of Thrombomodulin >
platelets to subendothelium. Converts thrombin into activator of protein C

Platelet activating factor > Tissue plasminogen activator >

activator and aggregator of platelets. accelerates fibrinolytic activity.
Inhibitor of plasminogen activator-> Inhibitors of platelet aggregation >
suppresses fibrinolysis. s ADPase, PGI2 (or prostacyclin).

Endothelial injury

Exposes vWF and tissue factor (prothrombotic)

Thrombosis

2)
Alterated Blood Flow
Normally Turbulence and stasis
Platelets separated.from endothelium by a Bring platelets into contact with the
slower. moving layer of plasma Endothelium
Prevent washout of activated clotting factors by
Axial or Laminar flow of blood fresh flowing blood
Prevents inflow of clotting factor inhibitors
Normal axial flow of blood is disturbed

Thrombosis

PAGE 70 | HEMODYNAMIC DISORDERS

 m

PATHOLOGY PROF BUSTER

Turbulence > Arterial and cardiac thrombi Peripheral stream

Central stream Plstalets (ces-free plasma zone)
Stasis Venous thrombi (leucocytes pnd red cefls)

3) Hypercoagulable States (Thrombophlla)

Hypercoagulability
(also called thrombophilia)
any disorder of blood that predisposes to
thrombosis.
A, NORMAL AXIAL FLOW

2 Types
1. Hereditary or primary
2. Acquired or secondary

(1) Hereditary (primary) factors

i. Deficiency of antithrombin I| B, MAROINATION AND PAVEMENTING

ii. Deficiency of proteinC

ii. Deficiency of protein S
iv. Mutation in factor V Leiden
V. Defects in fibrinolysis (dysfibrinogenaemia, plasminogen disorders)
vi. Increased levels of coagulations factors (ll and VIll)

(2) Acquired (secondary) factors

a) Risk factors: i) Advancing age, ii) prolonged bed-rest, ii) prolonged immobilisation (e.g. in plaster
cast, long distance travel), iv) cigarette smoking, v) obesity
b) Predisposing clinical conditions:
Heart diseases (e.g. myocardial infarction, CHF, rheumatic mitral stenosis, cardiomyopathy)
ii. Vascular diseases (e.g. atherosclerosis, aneurysms of the aorta and other vessels,
varicosities of leg veins)
i. Hypercoagulable conditions (e.g. polycythaemia, myeloproliferative disorders, dehydration,
nephrotic syndrome, disseminated cancers)
iv, Shock
V. Tissue damage e.g. trauma, fractures, burns, major surgery on bones, abdomen or brain.
vi. Late pregnancy and puerperium
vii. Certain drugs (e.g. anaesthetic agents, oral contraceptives, hormonal replacement therapy).
c) Antiphospholipid antibody (APLA) syndrome:
i. Lupus anticoagulant antibody
ii. Anti-cardiolipin antibody
Most common inherited cause of thrombosis mutation in factor V gene called Leiden
mutation formation of defective (mutated) factor V called factor V Leiden > causes unchecked
coagulation.

Veln clot Arterial clot

Types of Thrombi Platelates
3 types depending on site of origin> Flbrin
1. Cardiac thrombi (vegetations)
2. Arterial thrombi
3. Venous thrombi

Gross
Arterial thrombus white thrombi contains more platelets and relatively less fibrin
Venous thrombi > red thrombi contain more enmeshed red cells and relatively few platelets.

HEMODYNAMIC DISORDERS | PAGE 71

m DR. PRYANKA SACHDEV

Artery Veln

Retrograde
Organ Antegrade

Whlte (more platelet) -Red (more RBC)

-
Mural •Occlusive
- -
Lines of Zahn+ Linesof Zahn
-Ischemia -Oedema

Differentiate Arterial vs Venous thrombus

Features Arterial thrombus Venous thrombus
Pathogenesis Endothelial injury or turbulence Stasis
Blood flow Active Sluggish
Sites Coronary, cerebral, femoral arteries Superficial and deep leg veins
Propagation Retrograde manner Antegrade manner
Lines of Zahn Present Absent
Microscopic Pale platelet layer alternating with dark red RBC mixed with relatively less
cell layer so also called as white thrombi platelets, so also called as red
thrombi
Occlusion Incomplete Complete
Complications Ischemia and infarction Edema and ulceration

Residual iumen
Arterial wall
Lines of Zahn
Thrombus

Fate of Thrombus

THROMBOSIS

Resolution Organisation Propagation Thromboembolism

PAGE 72 | HEMODYNAMIC DISORDERS

 PATHOLoGY PROF BUSTER m
(4.04) EMBOLISM
University Ezatns
Long questions
pefne embolism. Discu$s different types
of
What is embolism? Mention different types ofembolisms.
1

2 embolism with examples, Add a note on air embolism ano

A 20-year-old mnale suffered tar ein
3 What is the diagnosis? Whatfracture femur in road trafic accidenl aod was treated 2 Weeks
aro the postmortem findings fatet he suddenly coMapse
What is embolism? Describe relevant to diagnosis?
local and distant effoct on oroan due to diffetent types of
Define embolism. Discuss different types of emboli.
embolus. Enumerate different types ofembolisms.
5 Writo in brief about thromboembolism.
6 embolism. Write in brief about pulmonaty embolism.
Short questions
1. Embolism-types.
2
Thromboembolism
3 Fat embolism.
4 Air embolism.
5 Amniotic fluid embolism.
6 Pulmonary thromboembolism.
Very short questions3
1 pefine and list different types of emboll.
2 Paradoxical embolism.
3 Decompression sickness
4 Arterial and venous effects of embolism

Overview
Definition (00:02:43)
Classification (00:04:50)
a) Depending upon matter in emboli
Depending upon whether infected or not
Depending upon source of emboli
Depending upon flow of blood
Effects of Arterial embolism (00:11:29)
Effects of Venous embolism (00:11:29)
Important embolism >
1 Thromboembolism (00:19:02)
Fat Embolism (00:19:54)
3. Amniotic Fluid Embolism (00:25:39)
4. Gas Embolism Decompression Sickness (00:28:33)

Definition
An embolus is a detached intravascular solid, liquid, or
gaseous mass that is carried by blood from its point of origin
to a distant site, where it often causes tissue dysfunction or
infarction.

Classification
a) Depending upon matter in emboli
1. Solid e.g. detached thrombi (thrombo-emboli), atheromatous material, tumor cell lumps,
parasites, bacterial clumps, foreign bodies.
2. Liquid e.g. fat globules, amniotic fluid
3. Gaseous e.g. air
b) Depending upon whether infected or not:
1. Bland when sterile
2. Septic when infected
c) Depending upon source of emboli
1. Arterial emboli : sh
2. Venous emboli A
d) Depending upon flow of blood
1. Paradoxical embolus An embolus which is carried from venous side of RA
circulation to arterial side or vice versa e.g. through patent foramen ovale
2. Retrograde embolus > An embolus which travels against flow of blood RV

HEMODYNAMIC DISORDERS | PAGE 73

 m DR, PRIYANKASACHDEV

Effects of arterial emboli

Depend upon their oizo, slte of lodgoment, and adequacy of collateral
circulation
1. Infarction of organ
2. Gangreno in lowor limbs
3. Myocardial inferction following coronary ombolism,
4. Sudden death rom middlg corobrol artory ombolism
Effect of venous embolísm

Embolus In voln

Flows through venous drainago into largor

voins (SVC and IVC)
Right sldo of hoart (RA RV)

Pulmonary artory

Pulmonary ombolism

Important embolism
1)Thromboembollsm
detached thrombus or part of thrombus
A

Most common typo of ombolism (90%)

2) Fat Embollsm
Fat globules

Etlology

Traumatic Non traumatic

Trauma to bones and soft tissuo Extenslve burns
Dlabetes mellitus
Fatty liver
Pancrcatítis
8lckle coll anasmla
Decompression slckness
Inflarmmatlon of bones and soft tissues
Exarlneic fat or cils Introduced Into the body
Hyporllpldaernla
Cardlopulmonary bypass surgery

8peclal stalns for fat

Pulmonary fat embolism

In patients fractures of bones

Sudden Death
On Autopsy

Presence of numerous fat emboll in

capillaries lung
Guden black Oilred O

PAGE 74 | HEIMODYNAIC DISORDERS

 PATHOLO0GY PROF BUSTER m
3) Amniotic Fluid Embolism
Most serious, unpredictable and
unpreventable cause of maternal mortality.
During labor and in immediate
postpartum period

Contents of amniotic fluid may

enter uterine veins

Reach right side of heart

Pulmonary arteriole packed
with foetal squamous cells
Pulmonary embolism

Composition
Amniotic fluid components:
Epithelial squames
vernix caseosa
Lanugo hair
Bile from meconium
Mucus

4) Gas Embolism
Air, nitrogen and other gases can
produce
bubbles within circulation > obstruct
blood vessels> damage to tissue.

2
forms
1. Air embolism Blood vessel
2. Decompression sickness
Air bubble

Decompression Sickness
Specialized form of gas embolism

Also known as
Caisson's disease
Divers' palsy
Aeroembolism

Pathogenesis

Divers or workers in
caissons (diving-bells)
Descend to
high atmospheric pressure

Increased amount of atmospheric gases (N2, O2, CO2)

dissolved in blood
When such an individual
ascends too rapidly ietent
Dissolved gases comes out as
minute bubbles

Decompression sickness

HEMODYNAMIC DISORDERS |PAGE 75

 DR. PRIYANKA SACHDEV

Decompresslon sickness Pathophysiology

Hypoperfusion Edema Stasis
Ischemia Hypoperfusion
Ischemla
Direct effect
Indirect effect

Obstruction of a
vein or an artery
1, Complement
1 Coagulatlon factors
t Platelets
tVascular permeablity

Decornpresslon Gas Gas pressure

pressüre decreoses
Isopression

Effects
Bends pain in joints, ligaments and tendons.
Chokes occur due to accumulation of bubbles in Lungs > acute
respiratory distress.
Cerebral effects > vertigo, coma, and sometimes death.

I(4.05) ISCHEMIA
University Exams
Long questions
Define lschemia. Write its etiology. Ennumerate Factors determining
2. Define lschemia. What are its adverse effects. severity of lschaemic injury.
Short questions
1 Define ischaemia.
Adverse effects of ischaemia.
Factors determining severity of lschaemic injury.
Types of hypoxia.

Overview
Definition (00:01:01)
Types (00:02:04)
Etiology (00:02:10)
Adverse effects of ischaemia Hypoxia (00:07:07)
Factors determining severity of lschaemic injury (00:15:01)

Definition >
Deficient blood supply to part of a tissue relative to its metabolic needs

Types >
1. Complete (complete ischaemia)
2. Partial (partial ischaemia)

PAGE 76| HEMODYNAMIC DISORDERS

 PATHOLOGY PROF BUSTER m

ARTERIAL
VENOUs

MaJor caUses
Major causes
• Thrombosis
Thrombosls
•Atherosclerotle secondary to
Intra-abdominal
dlsease
mallgnancles,
Non occluslve
•Dlssectlon Ínflammatory
Mesenterle lschaemla
• Extrinsle isorders,
thrombophille
compresslon etates,
•Embollsm
compraOy
In low myeloprolilferatlve
blood low states dlsorders

Etiology
1. Causes in heart
2. Causes in arteries
3. Causes in veins

1. Causes in heart
Inadequate cardiac output resulting from heart block, ventricular arrest and fibrillation
2. Causes in arteries
Luminal occlusion of artery (intraluminal):
a) Thrombosis
b) Embolism
Outside pressure on an artery (extramural):
a) Ligature
b) Tourniquet
c) Tight plaster, bandages
d) Torsion
Causes in arterial walls (intramural):
a) Vasospasm
b) Arteriosclerosis
c) Polyarteritis nodosa
d) Thromboangitis obliterans
e) Severed vessel wall
3. Causes in veins
Luminal occlusion of vein (intraluminal)::th stle
a) Thrombosis of mesenteric veins
b) Cavernous sinus thrombosis
Causes in the vessel wall of vein (intramural):b
a) Varicose veins of the legs
Outside pressure on vein (extramural):
a) Strangulated hernia
b) Intussusception
c) Volvulus

Adverse effects of ischaemia > Hypoxia

Hypoxic hypoxia: due to low oxygen in arterial blood.
Anaemic hypoxia: due to low level of haemoglobin in blood.
Stagnant hypoxia: due to inadequate blood supply
Histotoxic hypoxia: low oxygen uptake due to cellular toxicity.

HEMODYNAMIC DISORDERS )PAGE 77

 m DR. PRIYANKA SACHDEV

Atmosphere
PO, H0,x barometrlc pressure

P.02 Cardlac output

MUscle blood Now

PO,
Oxygen extractlon

Lungs

Hemoglobln Cellular
Heart metabollsm

Blood vessel
J Skeletal
muscle

1. Hypoxlc hypoxla 2. Anemle hypoxla 3. Circulatory hypoxla 4. Histoxic hypoxla

Factors Determining Severity of Ischaemic Injury

1. Anatomic patternof arterial blood supply
2. Type of tissue affected
3. Rapidity of development
4. Degree of vascular occlusion

1) Anatomic pattern of arterial blood supply>

4 different patterns
a) Single arterial supply without anastomosis-->
Results in ischaemic necrosis
Example:
a) Central artery of retina
b) Interlobular arteries of kidneys

b) Single arterial supply with rich anastomosis

Blockage of one vessel > re-establish blood supply bypassing blocked arterial branch
Infarction is less common
Example:
1. Superior mesenteric artery supplying blood to small intestine.
2. Inferior mesenteric artery supplying blood to distal colon.

c) Parallel arterial supply

Vitality of tissue is maintained by alte rnative blood supply in case of occlusion of one
Example:
a) Blood supply to the brain in region of circle of Willis.
b) Arterial supply to forearm by radial and ulnar arteries.

d) Double blood supply

Dual blood supply
Example:
a) Lungs are perfused by bronchial circulation as well as by pulmonary arterial branches.
b) Liver is supplied by both portal circulation and hepatic arterial flow.

PAGE 78| HEMODYNAMIC DISORDERS

 m
BUSTER
PATHOLOGY PROF

2) Type of tissue affected

Vulnerability of tissue to ischaemia is variable
More vulnerable tissues
Brain (cerebral cortical neurons).
Heart (myocardial cells).
Kidney (epithelial cells of PCT).

3) Rapidity of development
Sudden vascular obstruction more severe effects (there is less time for collaterals to develop)
Cradual vascular obstruction > less severe effects

4) Degree of vasculàr occlusion

Complete obstruction > more severe ischaemic injury
Partial occlusion less severe ischaemic injury

(4.06) INFARCTION
University Exams
Long questions
1. Define and classify Infarction. Types of Infarction.
2 Define and classify Infarction. Write its gross and mlcroscoplc features
Short questions
1. Infarct typeswith examples.
2 Differentiatebetween red and white lnfarcts.
Very short questions
Define infarction. What are the different types of infarcts with common sites of occurrence.
Organs involved in pale and red infarction.
3. Kidney infarct.

Overview
Definition (00:00:42)
Etiology (00:03:50)
Types of infarcts (00:03:59)
Gross (00:08:57)
Microscopy (00:10:50)

Definition
An infarct is an area of ischemic necrosis caused by occlusionof either
arterial supply or venous drainage.

Etiology
1. Interruption in arterial blood supply
2. Venous obstruction

Types of Infarcts
1. According to their age
2. According to presence or absence of infection
3. According to their colour
1) According to their age:
Recent or fresh
Old or healed

HEMODYNAMIC DISORDERS | PAGE79

 m
DR. PRIYANKA SACHDEV

2) According to presence or absence of Infection:

Bland when free of bacterial contamination
Septic when infected

3) According to thelr colour:

Pale or anaemic
Caused by arterial occlusion
Seen in compact organs e.g. in the
kidneys, heart, spleen.
Red or haemorrhagic
Caused either by pulmonary arterial
obstruction (e.g. in the lungs) or by
venouS Occlusion
Seen in soft loose tissues

Red Infarct In lung White infarct in spleen

Feature Red infarcts Whlte infarcts

Cause Arterial occlusion in loose tissues or Arterial occlusíon in solid organs

organs having dual blood supply with end arterial circulation
Venous occlusion (in ovarian torsion)
Affected Lung and small intestine Solid organs (heart, spleen, kidney)
organs
Properties margins and
Welldefined
ll define hemorrhagic margins which
change in color to brown progressively paler with time
Edema Usually present Usually absent

Gross
Wedge-shaped
Apex pointing towards occluded artery
Wide base on surface of organ

Microscopy Wedge shaped infarct

AIl infacts > coagulative necrosis
Exception > Cerebral infarcts liquefactive necrosis

Inflammatory
Viable renal tissue Cell Intiltrate Necrotlc tissue Gllosis Granulatlon Llquefactlve
tissue necrosis

All organ Infarct Cerebral infarct

PAGE 80 | HEMODYNAMIC DISORDERS

 (4.07) SHOCK
m
PATHOLOGY PROF BUSTER

Unlverslty Exams
Long questions
1 Define shock. Enumeratetypes of shock
Discuss pathogenesis of and discUSs
2 D
shock. septic shock. Describe pathogenesls
3 Whal are different morphological and morphological changes
Define shock and describe types of shock? changes in various organs in shock.
ne shock pathogenesis Describe pathogenosis in shock.
5 and describe palhogenesis of cardiogenic of septic shock.
shock.
Short questions and clinical features
of hypovolemic
1 Define shock. Discuss shock.
7
endotoxic (seplic)
Hypovolumic Hemorrhagic shock.
Discuss pathogenesis of shock.
3 cardiogenic
Morphological features of shock shock.
Very Short questlons
Definition and causes of shock.
Enumerate 3 major types
ofshock with suitable examples.

Overview.
Introduction (00:01:03)
Classification - (00:03:22)
1. Hypovolemic shock (00:03:50)
2. Cardiogenic shock (00:09:09) Introduction
3 Septic shock (00:13:42) Causes
Pathogenesls
Morphological features of Shock Symptoms
(00:21:40)

Introduction
Shock is clinical syndrome
that results from poor tissue perfusion

Poor tissue perfusion

Body do not receive enough oxygen
and nutrients to allow cells to functíon
Cellular death

Organ failure

Whole body failure

Death
Classification
1. Hypovolemic shock
2. Cardiogenic shock
3. Septic shock

1) Hypovolemic shock
Introduction >
Most common form of shock
Occurs due to decreased blood volume

Causes
1. Acute haemorrhage
2. Dehydration from vomiting's, diarrhoea
3. Burns
4. Excessive use of diuretics
5 Acute pancreatitis

HEMODYNAMIC DISORDERS | PAGE 81

 m DR. PRIYANKA SACHDEV

Pathogen osis
ETIOLOOY
PATHOGENESIS

HYPOVOLAEMIC SHOCK
I
Effectve circuiting blood volume

Haemorhage
! Venous return to heart
Treuma
Surgery
Burns 1 Cardiac output
Dehydratlon

! Blood flow
SEPTIC (TOXAEMIC) SHOCK

Gram-ve septicoemia 4 Supply of oxygen

Gramtve septicaemla

OCARDIOGENIC SHOCK Anoxda

Deficiency of emptying
Inflammatory mediators
Deliclency of filing
OUtlow obstruction

OTHER TYPES
Traumatic shock SHOCK
Neurogenle shock
Hypoadrenal shock

Symptonms
1. Increased heart rate (tachycardia)
2. Low blood pressure (hypotension)
3. Low urinary output (oliguria to anuria)
4. Alteration in mental state (agitated to confused to
lethargic)
3 stages>
Mild hypovolemia or stage I
< 20% volume loss Only mild tachycardia is there with
normal BP.
Moderate hypovolemia or stage Il 20-40% volume loss
supine position but hypotension iin erect posture. Tachycardia with normal BP in
Severe hypovolemia or stage
ll > 40% volume loss
tachycardia, hypotension, disorientation etc. Classical signs of shock appear e.g.

2) Cardiogenic shock
Introduction
Caused by inadequate pumping action of heart

Causes
1. Deficient emptying e.g. Rt. Lt.

a) Myocardial infarction
b) Cardiomyopathies
c) Rupture of the heart, ventricle or RA LA

papillary muscle
VC/SVC
d) cardiac arrhythmias
PV

2. Deficient filling e.g. 10 RV LV

a) Cardiac tamponade from PA

Aorta
haemopericardium Organs

3. Obstruction to the outflow e.g.

a) Pulmonary embolism
b) Ball valve thrombus
c) Tension pneumothorax
d) Dissecting aortic aneurysm

PAGE 82| HEMODYNAMIC DISORDERS

 PATHOLOGY PROF
BUSTER m
Pathogenesis
Acute Circulatory Failure
Cardiogenic shoCk occurS When > 40% of left ventricle is destroyed.

Symptoms
Decreased tissue perfusion (tissue hypoxia) Forward failure
Pulmonary oedema Backward fallure

3) Septic (Toxaemic) shock

Introduction
Severe bacterial infections or septicaemia

Causes
1. Gram-negative septicaemia (endotoxic shock)
e.g.
E.coli, Proteus, Klebsiella, Pseudomonas and Bacteroides
2. Gram-positive septicaemia (exotoxic shock) e.g.
streptococci, pneumococci

Pathogenesis

Gram negative bacteria Gram posltive bactera

Lipopolysaccharide (LPS) Lipothelcolc acid

LPS binds to CD14 Lipotheicolc acld binds to ILR-2

Macrophages stimulated

Secrete prolnflammatory cytokine (TNF-a and IL-1)

Vasodilatation and increased vascular permeability

Inadequate perfuslon of cells and tissues

Septic Shock

GP LTA
ILR-2 VD

Cytoklnes
CD14
(TNFa, IL-1)
GN LPS
Macrophage
tVP

Symptoms
2Stages
1. Early hyperdynamic stage vasodilatation Tachycardia and warm extremities,
2. Late hypodynamic stage Increased vascular permeability > decreased output, and oliguria
(renal failure).

HEMODYNAMIC DISORDERS | PAGE 83

m DR. PRIYANKA SACHDEV

Hypovolemlc Shock Cardlogonlc Soptlc

Shock Shock
• MI Gram Positive Septicaemla
Causes Hemorrhage Gram Negative Septicaemia
Vomiting Arrhythmlas
Dlarrhea Cardiomyopathles
Burns Tamponade
Diuretics
Pathogenesis Circulatory Blood Acute Circulatory Bacteria-Macrophage
Volume Failure activation

Cytokines
VD Permeability
Symptoms HR Tissue Hypoxia Hyperdynamic circulation (warm
J BP Pulmonary Oedema extremities)
LUrine Output Inflammatory Oedema
Altered Mental
Status

Morphological changes in shock

Brain Ischemic encephalopathy
Heart Coagulative necrosis
Liver Fatty change with hemorrhagic central necrosis
Kidneys Acute tubular necrosis oliguria and electrolyte
disturbances
Adrenal Cortical cell lipid depletion
GIT Hemorrhagic enteropathy
Lungs are uncommonly affected but may show
features of diffuse alveolar damage or shock
lung.

PAGE 84 | HEMODYNAMIC DISORDERS

 CHHAPTER

GENETIC DISORDERS
5
(5.01) GENETIC INHERITANCE
(AD, AR, XD, XR)
OF SINGLE GENE DISORDERS

Short questlons
nNCHbe pedlgee ond
Da6cHte pedigree and lmportant featuro of
Important features of Aut0somal ominant
X linked rooesslyo (AO)Inhoritanco ol6sases with exnmpiss
Very 8hort questlons disordors (XR) with ox
anples:
Name 4 aulosomal dominant disorders
Ennumorate au\osomal rOcosolve disordoro.
3
Name Aox-linked inherited diseasos,
Xllnked disorders glve 4 Oxamples.
Ennumerate X linked rocenslvo disordera:
Ennumerate X linkod dominant dltordora,

Normal human Koryotype (00:01:20)

Genetlo inheritanco of Single gene
dsordere -> (00:02144)
1,Autosomal Domlnant (AD) Dlsoasos
Autosomal Recosslyo (AR) Dlsoasos(00:04110) Foaturos
(00:11:32)
3. XLInked Domlnant (XD) Dlsordors (00:16:44)
X
Podigro0
Linkod Recossivo (XR) DlGordor (00:21:31) Exomplo5

Normal human Karyotype

Qut of a total number of 46 chromosomo-
1
2 3 S 6
a) 22 palrs > Autosomes
b) 23rd pair > sex chromosomes.
XX Femalos
XY Male 9 10 11 12 13 14 1S 16

17::18 1920 21 22 XX XY

DoNoo Male

Female
Genetic inheritance of Single gene disorders
Affected
1. Autosomal Dominant (AD) Dlseasos
2. Autosomal Recessive (AR) Diseases
3. X - Linked Dominant (XD) Disorders Carrier

4. X - Linked Recessive (XR) Disorder

Xtinked (carrier)

Pedigrce Symbols
 DR. PRIYANKA SACHDEV

(1)Autosomal Dominant (AD) Diseases

Pedigree
Features
Mutated genes can express themselves in heterozygous
state.
Onset Variable
Generation skip Not seen
Gender bias Do not show
pto
Examples
Vo Familial Hypercholesterolemia Autosomal DOMINANT Hal
Vo Von Willebrand Disease
Familial Familial Adenomatous Polyposis
Hypercholesterolemia Hypercholesterolemia (Familial).
Autosomal Adult polycystic kidney

Dystrophia myotonica
Osteogenesis imperfecta
Marfan syndrome
Intermittent porphyria
Neurofibromatosis-1
A
N
|Achondroplasia
Neurofibromatosis 2
T Tuberous sclerosis
Hai Huntington's disease; Hereditary pherocytosis

(2) Autosomal Recessive (AR) Diseases Pedigree

Features >
Mutant genes express themselves only in Hom0zygous state.
Onset Early uniform (usually in childhood).
Generation skip > seen
Gender bias Do not show

Examples
ABCDEFGH SPW
A Albinism, Alpha 1
Antitrypsin Deficiency
Beta Thalassemia
Cystic Fibrosis, CGD, CAH
Deafness (SNHL), Dubin Johnson
Enzyme Deficiencies (Glycogen Storage and Lysosomal Storage)
Friedrich's Ataxia, Fanconi Anemia
Galactosemia
Hemochromatosis, Hurler syndrome
Sickle Cell Disease
P Phenylketonuria
W Wilson's disease
Pedigree
(3) X - Linked Dominant (XD) Disorders
Features
Affected male transmit it to 100% of their daughters and
none of their sons.
Affected female transmit it to 50% of their sons and
daughters.

PAGE 86| GENETIC DISORDERS

 BUSTER
PATHOL.OGY PROF

Examples
FAIR
Facial (oro) syndrome
Alports
A Incontinenta pigmento
Resistant rickets
R

(4) X - Linked Recessive (XR) Disorder

Features
Mutant recessIve gene expresses itself in a male Pedigree
bildbecause is not suppressed by a normal allele
it

So males are Cases a

Mutant recessive gene do NOT expressos Itsolf in
Fomale child because in female > presence of a
normal allele on other X-chronmosome preventsas
expression of disease > So females only act
carriers.

Examples
GRAHAM BELL

G6 PD deficency
Retinitis pigmentosaaiis
G
R
Androgen insensitivity
Hemophilia A & B, Hydrocephalus
A

A Adrenoleukodystrophy
Menkes disease
B Beckers & Duchenne's muscular dystrophy, Blindness (color blindness)
E Emery- Dreifuss dystrophy
L Lesch nyhan syndrome
- Lowe disease

AD AR XD XR
Features

Pedigree

Examples

(5.02) CYTOGENETIC ABNORMALITIES

University Exams
Short questions
1.Barr body
2 Aneuploidy
3 Down's syndrome
4 Klinefelter syndrome
5. Turner's syndrome
6 Patau syndrome
7. Lyon hypothesis
8. Trisomy 18 and Trisomy 13
9. Cytogenetic disorders involving Sex chromosomes

GENETIC DISORDERS| PAGE 87

 DR PRIYANKA SACHDEV
(m

titrsduetion teoi04.04)
Cytogenetie disordera tnveving Autáomes
Dhown Syndrome (0012133) ntroduetion
rateu yetrone (00113:20) Karvotype
ftwarda yndrome (e0:19:38) Cinical Features
yon hyehesis (00.21:47)
Qytogenetlo Disorde tnvoving Sex Chranesomes
1Kinetelter Sradreme (00:26.02) tntreduetion
Tutner Syndrome (00:27:53) Raryotype
ClinicatFeatutes

Introduction
Gametes contain half the number of chromosonmes (haploid)
(23, X) or (23, Y),
and are ropresented as
An exact multiple of haploid chromosomes is
called Euploldy
When eXact multiple of haploid chromosomos is not present, it(2n, 3n, 4n etc.).
is called Anouploldy.
Genome mutations involve loss or gain of whole
chromosomes, giving rise to monosomy or
trisomy.

20 (2n
Nonal Ntoiosis Anaphase lag or Non disjunction

nt1
Normal gametes
Abnomal gamates
When these fuse with omal gametes When thesa fuso with nomal gametes

2n 2n 2n+1 211
Normal diploid cells Trisomy Monosony

Cytogenetic disorders involving

Autosomes
1. Down Syndrome
2. Patau syndrome
3. Edwards syndrome

(1) Down Syndrome

Introduction >
Trisomy 21
Most common chromosomal disorder
3 mechanisms
Meiotic nondisjunction (maternal non disjunction)
Robertsonian translocation
Mosaicism

Karyotype
PAGE 88| GENETIC DISORDERS
 PATHOLOGY PROF
BUSTER M

Clinical
features
profile
Flat facial ftrosd fet fsee
Mental
retardation Plat back of head slantng eys Lplanthle
Microgenia (abnormally small
chin) yfolds short
nose

fissures with Congenltal heart dlsease

Oblique palpebral Unllateral or bilataral Abnormal esrs
anicanthic skin folds (mongoloid slant) absence of one rdb
tone)
Muscle hypotonia (poor muscle Bmalt & awEhed pslate
Single palmar fold (Simian crease) 8iLwrlnkied Tongue
Dental anomales
Curvature of little finger towards other
Many "loops"
on inger tlps
(Clinodactyly)
four fingers PALm eresss
Protruding tongue or macroglossia Intestinal blockage specdal skin nde
as
White spots on the iris known Umbllcal hernia
Pstterns
Brushfield spots ntargod Colen
atlanto
Excessive joint laxity including
axial instability plmlnlshed muscle tone Growth fallure
Excessive space between large toe and
Mental retardstlon

second toe (Sandle

toe) Big toes wldely
fifth finger
single flexion furrow of the
A spaced

Complica tions
Congenital cardiac defects > Most common is ventricular septal defect
Increased risk of leukemia > More commonly ALL
Hypothyroidism
in females
Males are totally infertile and Reduced fertility
. Virtually all patients with Down syndrome develops Alzheimer disease after 4th decade.

(2) Patau syndrome

Introduction >
Trisomy 13

12 3 4 6

9 10 11 12 13 14 15 16

20 21 22 XX XY
17 18 19

Karyotype

Clinical features
• Cleft Lip
Flexed fingers with Polydactyly
•
Low-set malformed ears
•
Ocular hypotelorism
Microphthalmia
Cardiac malformations
Scalp defects
•
Hypoplastic or absent ribs

GENETIC DISORDERS | PAGE 89

 DR. PRIYANKA SACHDEV

(3) Edwards syndrome

Introduction
Trisomy 18

26
21 22

Karyotype

Clinical features Hypertelorism

Upturned nose
Closed fists with index finger overlapping the 3rd digit Small Jaw Low set ears
and the 5th digit overlapping the 4th
Narrow hips with limited abduction Clenched flst
with digits 2 &5
Short sternum overlappling 3 &4
Rocker-bottom feet
Microcephaly and prominent occiput
Micrognathia
Mental retardation
Rocker bottom feet

Lyon hypothesis (X chromosome BARR BODIES

inactivation)
Only one of the X chromosomes is genetically active
Other X undergoes heteropyknosis and is rendered Mitosls

inactive Random
Inactive X is seen in interphase nucleus as a darkly Zygote Invactlvatlon

staining small mass > Barr body

Used to test genetic femaleness.
Number of Barr bodies = (N-1) (where N number of X
chromosomes)

Examples
Genotype Number of Barr bodles
In normalimale (XY) (1-1=O Barr body)
In normal female (XX) (2 - 1 = 1
Barr body)
In turner syndrome (X0) (1-1=0 Barr body)
In Klinefelter syndrome (XXY) (2 -1 = 1 Barr body)
Superfemale (XXX) (3-1= 2 Barr bodies)

PAGE 90 |GENETIC DISORDERS

 BUSTER
PATHOLOGY PROF

Karyotype
Cytogenetic Disorders Involving Sex
ChromoSomes
Klinefelter Syndrome
2
Introduction
Hypogonadism in phenotypic males resulting from trisomy of
. chromosomes 19
sex XXY 12
14
Karyotype > 47,
common causes of hypogonadism In male.
Most

19 20 21

Frontat baldness absent

clinical
features Poor besd yowth
infertility Tendency to yow
Male fewer chest hasrs Marrow shoulders
Eunuchoid body
habitus
retardation
Minimal or no mental Breast developme
Coilure of male secondary sexual characteristics Wide hos
Gynecomastia Small tstalr
sze
Female-ype
Atrophic testes puble halr pattern

Elevated FSH and

estrogen.
testosterone levels. Long le
Low
Increased incidence of type 2
diabetes
Most common cardiac abnormality is
mitral valve
prolapse.

Karyotype

(2) Turner Syndrome

2 3 6
Introduction
. Hypogonadism in phenotypic females resulting from
monosomy of X chromosome.
14. 15 16
Karyotype (45, X) 10 11 12 13

17 19 20 21 2 YO

Characteristic facial features

Clinical features
Fold of skin
• Lymph edema of neck, hands, and feet Low halrline

Short fourth metacarpal Shield-shaped Constriction of aorta

thoru
Webbing of neck Poor breast development
Short stature Widety spaced nipples
Cubitus valgus Elbow deformity
• Broad chest and widely spaced nipples.
Small finger nalls Rudimentary ovaries
Primary amenorrhea Gonadal streak
•
Failure of the development of normal i (underdeveloped gonadal structures)
secondary sex characteristics Shortened metacarpal IV

•
Severely atrophic and fibrous ovaries
Congenital heart diseases: Bicuspid No menstruatlon
Brown spots (nev)
aortic valve (most common cardiac
defect); preductal coarctation of aorta

GENETIC DISORDERS| PAGE 91

 CHAPTER

IMMUNOPATHOLOGY 6
(6.01) HYPERSENSITIVITY REACTIONS
University Exams
Long questions
1. Define Hypersensitivity reactions. Write pathogenesis and examples of various types of Hypersensitivity reactions
Short questions
1 Type I hypersensitivity reaction (anaphylaxis) pathogenesis and examples
2 Type 1l hypersensitivity reaction (Cytotoxic) pathogenesis and examples
3. Type ll hypersensitivity reaction (Immune complex) > pathogenesis and examples
4 Type IV hypersensitivity reaction (delayed type) pathogenesis and examples
TYpe V hypersensitivity reactíon examples
Very Short questions
1. Types of hypersensitivity.
2. Atopy and Anaphylaxis.

Overview
Introduction (00:01:25)
Classification (00:04:32)
1. Type I (Allergy) (00:05:45)
2 Type Il (Cytotoxic) (00:17:22) Pathogenesis
3 Type V (Stimulatory Type) (00:24:51) Examples
4 Type Ill (lmmune complex Mediated) (00:27:50)
5 Type IV (T Cell-mediated) (00:31:06)

Introduction
Immune response is a protective process but it may sometimes be injurious to the host.
Hypersensitivity Exaggerated state of normal immune response which results in adverse effects
on body.

Classification
Coomb and Gel classification
1. Type I(Allergy)
2. Type Il (Cytotoxic) Immediate, Humoral immunity
3. Type V (Stimulatory Type)
4. Type I (Immune complex Mediated)
5. Type IV (T Cell- mediated) Delayed, Cell medlated immunity
 m DR. PRIYANKA SACHDEV

1) Type I (Allergy) Reaction

Pathogenesis Allergen (e.g., pollen)

Exposure
During first contact of host with to allergen
the Ag
Ag is captured by APC Dendrltic cell
Presented to T cell which
differentiates into TH2 cell Nettve
Tcell
TH2 cell releases IL-3, IL-4 and
IL-5
Actlvatlon of TH2 cells
IL-4 causes activation of B cell land IgE class
Activated B cells differentiate to switchlng In B colls B cell TH
CELL
form igE-secreting plasma cells

IgE antibodies formed

Bind to the Fc receptors present Production of lgE IgE-secreting

on mast cells plasma cell

Mast cells are now fully

sensitized for next event
Binding of lgE to FceRI
During second contact with Mast cell
FceRI on mast cells
same Ag (shocking dose)

antibodies on surface of
lgE
mast cells-basophils are
activated Repeat exposure
to allergen
Cause cell damage-membrane
lysis

Degranulation of mast cells Actlvatlon of mast coll;

basophils release of medlators

Histamine, Serotonin,
Vasoactive intestinal peptide Mediators :
(VIP),
Leukotrienes B4 and D4, Vasoactlve amines,
Prostaglandins, Platelet llpld medlators Cytoklnes
activating factor
Immedlate hypersensltlvity Late phase reactlon
reactlon (mlnutes after (2-24 hours after
repeat exposure to allergen) xposure to allera

Effects of granules:
1. Increased vascular permeability
2. Smooth muscle contraction
3. Early vasoconstriction followed by vasodilatation
4. Shock
5. Increased gastric secretion
6. Increased nasal and lacrimal secretions

PAGE 94 | IMMUNOPATHOLOGY
 BUSTER
PATHOLOGY PROF

formsute.
2 potentially tatal, systemic form > Anaphylaxis
Recurrent non-fatal localised form Atopy

Examples
All
Allergies
Eczema
Hay fever
Asthma (atopy)
Urticaria
Anaphylactic shock
Acute dermatitis

PCTS (proximal convulated tubuleS)

PK rxn
P Casoni test
Theoblad smith phenomena
T phenomenon
s- Schultz Dale

2) Type Il (Cytotoxic) Reaction

Pathogenesis

Antigen on the surface of target -Target cell

cells -Surface antigen
Antibody
Circulating B lymphocytes get
activated

Differentiate to form plasma cells

-Binding of antibody
Antibodies formed (IgG or lgM) to surface antigen
Antlbody dependent
Ag - Ab complex formed cell-medated
Cytotoxic action by NK cell
ytotodcfty
Complement medlated teacetlons
Activation of classical pathway of
serum complement
-C3b
Generates activated complement Membrane -Phagocyte
componentC3b attack complex

Activated C3b bound to the target

cell acts as an opsonin Osmotie lysis opsontzaton by cab
phOcytosls
Phagocytosis

Examples
My Myasthenia gravis
Blood Blood transfusion reactions
Group Goodpasture syndrome and Graves' disease
Is Insulin resistant diabetes, ITP
R Rheumatic fever
H Hyperacute graft rejection
|Positive Pernicious anemia and Pemphigus vülgaris

IMMUNOPATHOLOGY | PAGE 95
 DR. PRIYANKA SACHDEV

3) Type V (Stimulatory Type) Reaction

Pathogenesis
Modification of Type Il hypersensitivity
Ag on target cell surface
Ab interact with Ag

Ag - Ab
reaction enhances the activity of affected cell
Cell proliferation and differontiation (instoad of inhibition or kiling)

Examples >
a) Grave's disease
b) Myasthenia gravis

4) Type Il (Immune Complex Mediated) Reaction

Pathogenesis
Soluble Antigen
Circulating B lymphocytes get activated B cell
Antlgen
Differentiate to form plasma cells
Antibodies formed Produetlon ef antíbedles

Immune complexes are formed by interaction of

soluble antibody and antigen
-O-: Plasma cell
lmmune comples formatten

Immune complexes get deposited into tissues

Complement Neutrophil
Fc component ofantibody links with complement
and activates complement
Complement Neutrophl
Formation of C3a, C5a and membrane attack actlvatlon actlvation
complex
rlsue damage
Accumulatedneutrophils and macrophages in the
tissue release cytokines
Inflammation and Tissue destruction

2
forms
>due to relative antibody excess
Arthus reaction (localised)
Serum sickness (generalised) > due to relative antigen excess.

Examples
s Serum sickness, Schick test and SLE
H Henoch-Schonlein Purpura
A Arthus reaction
R Reactive arthritis, Raji assay
P Polyarteritis nodosa (PAN) and Post Streptococcal glomerulonephritis (P SsGN)

PAGE 96 | IMMUNOPATHOLOGY
 PATHOLOGY PROF BUSTER

IV (T Cell-mediated) Reaction
5) Type
Pathogenesis

Ag is recognised and
processed by APC
Presented to helper T cells (TH1
cels)
TH1 cells release cytokines
(TNF-d, IFN-y, IL-2 and IL-12)

Granuloma formation

CD4+
Thi cell
ANTIGEN- PRESENTING
CELL
Presents
antlgen to
Tcell
Blood vessel Cytokines
(E.g, TNE,
chemoklnes) Glant celu Epithellold cell
IFN-Y
ytokines
(Eg IL-12)

-
Lymphocyte
recrultment, Monocyte Actlvated
inflammation Macrophage

Fibrblast

Lymphocyte
Activated
Macrophage

Release of Cytokines
•
IL-1 and IL-2 Proliferation of more T cells.
Interferon-y > Activates macrophages and transform it into epitheloid cells
• TNF-a Fibroblast proliferation
Examples
John gave TU LIP and Pop Corn to Hashi

John mote reaction

Tuberculin reaction
LePromin reaction
Pernicious anaemia
Contact dermatitis
Hashimoto thyroiditis

Remember
Types I, Il and IIl Immediate Antibody-mediated Humoral immunity
ype IV Delayed Cell mediated

IMMUNOPATHOLOGY PAGE
| 97
 m
DR. PRIYANKA SACHDEV

D. TYPE IV
A TYPEI
B
TYPEI C. TYPE II

RBCS
D coll

Piret eontaet wlth Ag Blndin ef Ag en AtAb blndin

(eet en) target eell with PAB ef Ab

Oe,
29 igM Ab
At peeeetlet eetf
Ag-A eempleR AgAb eemplen
IgE-0eereting plaema eelie (Tleeue epeetfle Ar) (0elubie Abeeolublefineeleble A)

igE Abs oomplement aottvatlen MIgratlon of

A

preseetisg eeff
Released

Basophll-mast cell domplement actlvation. Deposltlon of Ag-Ab complex

on veeel wall

PMNS

Target oell destruotion pestruotion oft tlssue aetivated

Firmly-bound Fo receptor
eelle and maerephafee

(0psealn)

Mast ell degranuiatien Phagoeytesie

Mast cell degranulation Phagocytesis

Type I (Allergy) Type II Type lll Type IV

(antibody-mediated (immune-complex) (delayed, T
cytotoxic) cell-mediated)
Definition Rapidly developing Reaction of humoral Results from Cell-mediated,
immune response in antibodies that attack deposition of slow &
a previously cell surface antigens & antigen-antibody prolonged
sensitized person cause cell lysis complexes on response
tissues
Peak 15-30 minutes 15-30 minutes Within 6 hours After 24 hours
action
time
Mediated lgE antibodies IgG or lgM antibodies IgG, lgM antibodies Cell-mediated
by

PAGE 98 | IMMUNOPATHOLOGY
 PATHOLOGY PROF
BUSTER m
(6.02) TRANSPLANT REJECTION
I Exams
University
questlons
Long mechanisms of transplant rejection
reactíons.
1. pescrimechanisms of Hyperacute, AcUte and chtonic transplant rejectíon
2. quostions
short
Types of grafts
Discuss Graft Versus Host Disease (GVHD).
H
1

2. Homograft rejection.
reactions.
3 Tronsplant rejection
4 Direct and Indirect Transplant rèjection reactions.
5
Very Short quostlons
Autograt
1
Isograft
2 Allograft
3 Xenograft

Overview
Introduction (00:01:32)
Classificalion of Transplants (00:02:30)
1 Basedon genetlc relationshlp between donot and tecipient
2 Based on anatomical slte of gtaft
Histocompatibility (00:11:22)
Tvpes of Graft Rejection > Hyperacule, Acute, Chronic (00:15:14)
Mechanism of Graft Rejection Ditect
ndirect pathway (00:47-12%
Graft versus host (GVH) reactlon (00:26nY

DONOR CELL
Introduction (THE GRAFT)

Transplantation transfer of a graft or transplant (cells,

tissues, or organs) from one site to another.
Individual from whom transplant is taken Donor
Individual to whom it is transplanted Recipient TRANSPLANT

DONOR PATIENT (HOST)

Classification of Transplants
1. Based on genetic relationship between donor and recipient
2. Based on anatomical site of graft

1)Based on genetic relationship between donor and recipient

Autograft (autogenic graft): Graft from self
Isograft (syngraft): Graft from genetically identical' person, e.g. identical twin
Allograft (homograft): Graft from genetically unrelated member of same species
Xenograft (heterograft): Graft from different species

ldentical twins Another person A

differentSpecies
Autologous

Genetlcally
Human A HumanA HumanB modlfled plg

SYNGENEIC
ALLOGENEIC

XENOGENEIC

IMMUNOPATHOLOGY | PAGE 99
 DR. PRIYANKA SACHDEV

2) Based on anatomical site of graft

Orthotopic grafts When tissue or organ grafts are transplanted to their anatomically normal
in
sites recipient e.g. as in skin grafts
Heterotopic grafts Placed in anatomically abnormal sites e.g. thyroid tissue is transplanted in a
subcutaneous pocket.
Histocompatibility
Histocompatible
Ifa graft and recipient tissues are histocompatible to each other (i.e. antigenically similar)> graft
is accepted
Autografts and isografts are histocompatible

Histoincompatible
If a graft and recipient tissues are histoincompatible (i.e. antigenically dissimilar) > graft is
rejected
Allografts and xenografts are usually histoincompatible
Types of Graft rejection
Graft rejection Time taken for rejection Immune mechanisms involved

Hyperacute Minutes to hours Preformed antibodies

(Anti AB0 and/or anti-HLA)

Acute Weeks to months Cytotoxic T cell mediated

Antibody mediated

Chronic Months to years ChronicDTH mediated

Antibody mediated

Mechanism of Graft rejection

T cells in recipient may recognize donor alloantigens in the graft in 2 different ways depending on
what cells in graft are displaying these alloantigens to recipient T cells

Direct pathway Allogeneic MHC molecules on graft's APCs are directly presented to recipient's
helper T cells responsible for acute graft rejections
Indirect pathway Donor alloantigens are processed and presented by MHC molecules present
on recipient APCs to recipient's helper T cells> responsible for chronic rejection

Donor MHC carrylng

allogenelc antlgen

Donor's APC
Indirect presentatlon
Dlrect presentatlon

Reciplent's APC CD4

Reclplenr's MHC carrying

allogenelc peptide antiren
IL-2

TOTH Bcell

Activated
macrophare IFN-Y TNF-D

NK cell or
MHG ADCC
macrophase
lexpression me
CDB
CTL
Lyss
Lyde
Complement
enzymes
Membrane
madlated.
Class MHC
Grat alloantigen damate
Fc receptor

PAGE 100 | IMMUNOPATHOLOGY

 BUSTER
PATHOLOGY PROF

Graft
versus host (GVH) reaction
Craft mounts an immune response
araft Host tissue
against the host (1.e. recipient) and
rejects the host stem oells
to usual situation of graft develop lnto
Iln contrary which : new blood
rejections in recipient mounts
colle
an immune response against graft
antigens)
Runt disease in animals

Conditions for GVHD

Graft must contain immunocompetent
cells (e.g. stem cells or bone
T Uer
marrow or thymus transplants) Immune oelle
Recipient may be immunologically may attack Bowel
suppressed and therefore cannot host tlesuee

mount immune response against the

Skin
graft. Donor tiesue

(6.03) AUTOIMMUNITY
Uoiversity Exams
Long questions
pefine Autommunity. Describe mechanisms of Autoimmunity with examples
Short questions >
1. Immunological Tolerance
2 Mechanisii of Central tolerance and Peripheral tolerance
Ennumerate hanisms of Autoimmunity
3
Sequestration of self-antigen
5 Anergy

Overview
Introduction (00:03:11))
Immunological Tolerance (00:07:19)
a) Central tolerance (00:10:09)
b) Peripheral tolerance > (00:11:47)
1 Anergy (00:15:48)
Phenotypic Skewing (00:19:17)
3 Apoptosis By AICD(00:19:36)
4 Regulatory T Cells (Treg Cells) (00:24:35)
5. Sequestration of seif-antigen (00:26:30)
Mechanisms of Autoimmunity
1. Breakdown of T Cell Anergy (00:31:15)
2 Failure of AlCD (00:32:03)
3. Loss of Treg cells (00:32:35)
4 Providing T Cell help to Stimulate Self-reacting B Cells
5 Release of Sequestered Antigens (00:33:02)
6 Molecular Mimicry (00:34:03)
Examples of Autoimmune Diseases

Introduction
Group of disorders in which tissue injury is caused by humoral (by auto- antibodies) or cell
mediated immune response (by auto-reactive T cells) to self-antigens
Normally > a protective mechanism called tolerance immune system does not attack self
antigens
Autoimmune diseases Any breach in tolerance mechanisms immune system attack self-cells

IMMUNOPATHOLOGY | PAGE
101
 DR. PRIYANKA SACHDEV

Antigenic
determinant

Antbodies
Antigen

Immunological Tolerance
a) Central Tolerance
Deletion of self-reactive T and B lymphocytes during their maturation in central lymphoid organs
1. In thymus for T cells
2. In bone marrow > for B cells

b) Peripheral Tolerance
Back-up mechanisms that occur in peripheral tissues to counteract self-reactive T cells that
escape central tolerance.
1. Anergy
2. Phenotypic Skewing
3. Apoptosis By AlCD
4. Regulatory T Cells (Treg Cells)
5. Sequestration of self-antigen

1. Anergy Anerglc T Coll

Unresponsiveness to antigenic stimulus.

Self-reactive T cells interact

T Cell
with APCs presenting self-antigen
B7 molecules on APC bind to CTLA-4 molecules on CTLA

T cells instead of CD28 molecules

B7
Co-stimulatory signal is blocked
APC
No activation

Activated T Cell
2. Phenotypic Skewing +NenPathesenle
Oytekines
Self-reactive T cells interacting t
with APCs presented with self-antigens Coll

Activation of T cells Cp28

TCR
MHC
Secrete non-pathogenic cytokines and chemokine B7

APC

PAGE 102 | IMMUNOPATHOLOGY

 PATHOLO0GY PROF
BUSTER m
By AICD
3. Apoptosis
.
Activation-induced cell death
Apoptotle T CelI
self-reactive T cells interacting 4
with APCs presented with self-antigens

Activation of T cells Fas

Induces upregulation of Fas ligand
FasL
Interacts with death receptor Fas

Apoptosis APO

4. Regulatory T Cells (Treg Cells) Apoptosls By AlOD

Treg Cells

Secrete cytokines (e.g., IL-10 and TGF-P])

or killing by direct cell to coll
contact
Down regulate self-reactive T
cells
5. Sequestra tion of self-antigen
Certain self-antigens can evade immune recognition by sequestration in immunologiícally privileged
sites
ea. corneal and lens proteins, testicular antigens and
antigens from brain.

Mechanisms of Autoimmunity
Autoimmunity results due to breakdown of one or more of the mechanisms of immunological tolerance.
1. Breakdown of T Cell Anergy
2. Failure of AICD
3. Loss of Treg cells
4. Providing T Cell help to Stimulate Self-reacting B Cells
5. Release of Sequestered Antigens
6. Molecular Mimicry

1. Breakdown of T Cell Anergy

• In presence of tissue necrosis and local inflammation
Eg. Multiple Sclerosis, Rheumatoid Arthritis and Psoriasis

Self-reactive B cell -O Self-reactive B cell

2. Failure of AICD (lacks T cell help)
• Failure of auto reactive activated o00000)
Produce
T cells to undergo activation >No auto-Ab
auto against
induced cell death (AICD) RBC Ag
Ab
Eg. SLE (Systemic Lupus
Erythematosus) Helper
Protein,
factors

3. Loss of Treg Cells

• Loss of regulatory T cell TH cell
mediated suppression of self RBC TH cell
reactive lymphocytes. membrane Drug Induced altoratlons on
Normal RBCs RBC mombrano

IMMUNOPATHOLOGY PAGE 103

|
 m DR, PRIYANKA SACHODEV

4. Providing T Coll Holp to Stimulato Solf-Reacting B Colls

Antibody rosponse to self-antigons occurs only whon potontlally solf-roactivo B colls roceive holo
from T colls,
5. Rolease of Sequestorod Antigons
Soquesterod antigons -novor oxp0sod to
tolerance mochanisms during devolopmont of lmmuno systam
Injury to thoso organs

Reloase of such soquostorod antigons

Mount an Immune rosponso
E.g.
Post vasectomy orchitis> Spermatozoa roloase
Post-traumatic uveitis ocular antigons reloaso
6. Molecular Mimicry Autologous coll

Microorganisms which share antigenic determinants

with self-antigens entre human body >
(opitopos)
Molecular Mimicry VIus

Antibodies are produced for micro-organism Auto

Viral
antlgon
antigen
Antibodies cross-react with self-antigen
T cell
E.g.
a) Shigella flexneri and HLAB27
b) Mycobacterium tuberculosis and
joint
c) CoxXsackie B virus and myocardium membranes
d) Streptococcus bacteria and RHD

Examples of Autoimmune Diseases

1. Graves' disease
2. Hashimoto's disease
3. Diabetes mellitus type 1
4. Goodpasture's syndrome
5. Rheumatoid fever
6. Addison's disease Ankylosing
7. Antiphospholipid antibody spondylitis
8. Aplastic anemia
syndrome (APS)
9. Guillain-Barr syndrome
(GBS)
10. Idiopathic thrombocytopenic purpura
11. Multiple sclerosis
12. Sjögren's syndrome

(6.04) SYSTEMIC LUPUS ERYTHEMATOSUS

(SLE)
Uniyersity Exams
Long Questlons
13 Defino SLE, Describe
the etiopathogenosis,
2Defino SLE, Discuss Ronal manifestations types and cllnical foaturas of systomic lupus
in SLE erythematosus (SLE)
Short Questlons
Dofine SLE. Discuss autoimmunily In
Etiology and Ipathogonesis of relation to SLE.
Lupus erythematosus (LE) cell,systemic tupus erythemalosus
Clinical criterla of SLE
5 Anttbodies in SLE
7 Eorescenc Pattorns in SLE
assoclated conditlons.
Criteria for diagnosis of SLE
 Overview PATHOLOGY PROF BUSTER m,
Introduction
Types
Spectrum of autoantibodies
Immunofluores cence Patterns
Etio-Pathogenesis
LE celIPhenomenon
Clinical and pathologic
manifestations
Criteria for diagnosis of SLE

Introduction
SIE s an autoimmune disease involving multiple organs,
of autoantibodies,
(particularly ANAs) in characterized by vast array
immune complexes which
and binding of antibodies toinjury is caused by deposition of
various cells and tissues.
Systemic lupus erythematosus
(SLE) is a progressive
disease that results in inflammation chronic autoimmune
Characterized by flares, spontaneousand tissue damage
Highly heterogeneous remission, and relapses
Can affect any part of
the body
Often damages skin,
joints, heart, kidneys, lungs, nervous
system

Types
1) Systemic/ Disseminated form
2) Discoid form
Acute and chronic inflammatory
lesions Chronic lesion
Lesions are widely scattered in body
Localised skin lesion involving bridge
of nose and
adjacent cheeks without any sytemic manifestation
There is presence of various nuclear
cytoplasmic autoantibodies in plasma.and Autoantibodies may or may not present

Spectrum of Autoantibodies in SLE

Hallmark of SLE is production of
autoantibodies.
Specificity of
Autoantibody positive Association with specific disease features
ANA
95-98 Found against DNA and RNA antigen,
test used as screening
ds- DNA 40-60 Nephritis, specific for SLE
U1 RNP
30-40 more often in Sjogren's syndrome
SMITH (Sm) antigen 20-30 Sm antigen is a Core protein of small
ribonucleoprotein
particle, and is specific for SLE
Ro (SS-A)N(SS-B)
30-50 congenital heart block, neonatal lupus
nucleoprotein
Phospholipid protein 30-40 Antiphospholipid syndrome (a thrombotic complication)
complex (anti- PL) in
10% of SLE patient
Multiple nuclear antigen 95-100 not specific
(generic ANA)
Histone In drug induced lupus
|Anti ribosomal P antibody in CNS lupus

IMMUNOPATHOLOGY | PAGE
105
 nDR. PRIYANKA SACHDEV
Immunofluorescence Patterns
anti-DNA (not SLE
Peripheral
(rim) seen on HEp-2)

anti-DNA RA & SLE

Homogerneous anti-histone Misc. Disorders
(iffuse) ant-DNP (onti-ssDNA)
(nucleosomes)

anti-Sm & RNP

Speckled anti-Ro & La SLE & SS
antiJo-1 M-2
&

PM/DM
anti-Sc-70 PSS (Systemic)

Centromere anti-centromere PSS (CREST)

Nucdeolar anti-nucleolar SLE & PSS

Etio-Pathogenesis
1. Genetic factors
2. Immunological factors
3. Environmental factors SUSCEPTIBILITY EXTERNAL TRIGGERS
GENES
(0.g-, UV radlation)
UV radiations
leads to apoptosis of cells Apoptosis

Inadequate clearance of nuclear antigen Defective clearance

creates increased burden of nuclear Ag in all of apoptotic bodies
organs
B and T cells specific for Increased burden of
B
and T cells with defective tolerance, sell nuclear antigens nuclear antigens
stimulated by nuclear Ag.
start to form Ab against it, even though these Anti-nuclear antibody.
antigen-antibody
are self Ag complexes
Endocytosis of
antigen-antibod B cell
Ag-Ab complexes binds to Fc portion of complexes
TLR engagement
Dendritic
dendritic cell and B celI by nuclear antigens
cell

TLR stimulation of
Nucleic acid component engages TLR leading B cells and DCs
Bcell to produce more autoantibodies Stimulatlon of Type 1 interferons
Dendritic cell to produce more Ty IFN
1 B cells and T cells
by IFN

stimulating more apoptosis

continuing vicious cycle Perslstent hlghlevel antl-nucleat

lgG antibody productlon
Mechanisms of Injury
Type Ill hypersensitivity reaction: DNAcomplexes can be
Most of the systemic lupus is caused by immune complexes DNA- anti-
detected in the glomeruli and small blood vessels.
T cell infiltrates are also frequently seen in kidneys.
Type IIhypersensitivity reaction: promote
Autoantibodies specific for red cells, white cells and platelets opsonize these cells and
their phagocytosis and lysis

PAGE 106 | IMMUNOPATHOLOGY

 BUSTER
PATHOLOGY PROF

Antiphospholipid antibody syndrome (APLA):

Patients with antiphospholipid antibodies may develop venous and arterial thromboses.
When it is
Ssociated with SLE secondary antiphosholipid antibody syndrome
associated with SLE Primary antiphospholipid antibody syndrome
Alot

LE Cell Phenomenon
Antinucdear antibody
E
cell Phenomenon
Principle
AAAS Cannot penetrate the intact cells and thus cell nuclei should be
ANAS
exposed to bind them with the
Bindingof exposed nucleus with ANAs results in homogeneous mass of
puclear chromatin material > LE body or haematoxylin body. Nucleus pushed
Sor demonstration of LE cell phenomenon In vitro
hlood sample is traumatized to expose the nuclel of
blood leucocytes to ANAs. This results in binding of
denatured and damaged nucleus with ANAs. The ANA
coated denatured nucleus is chemo tactic for
phagocytic cells.
f this mass is engulfed by a neutrophil, displacing the LE Cel Tart ced
nucleus of neutrophil to the rim of the cell> LE cell
If the mass is phago-cytosed by a monocyte Tart cell.

Clinical and pathologic manifestations

Clinical Prevalence in
Manifestation patients (%)
Hematologic 100

Fatigue 80-100

Arthritis/ Arthralgia/ Myalgia 80-90

Skin 85

Fever 55-85

Weight loss 60

Renal 50-70

Pleuritis 45

|Neuropsychiatric 25-35
Pericarditis 25

Raynoud phenomenon 15-40

Gastrointestinal 20

Peripheral neuropathy 15

Ocular 10

IMMUNOPATHOLOGY | PAGE 107

 m
DR. PRIYANKA SACHDEV

Integumentary Neurologlc
Alopecla Stroke
Butterfly rash Seizures
• Discoid erythema •Peripheral neuropathy
•Palmar
erythema Psychosis
Mucosal ulcers Cognitive Impairment

Cardlopulmonary Hematologlc
•Endocarditis •Anemia
Myocarditis
•Leukopenia
•Pericarditis Lymphadenopathy
Pleural effuslon Splenomegaly
Pneumonitis •
Thrombocytopenia
Raynaud's phenomenon

Urlnary Gastrolntestlnal
Glomerulonephritis Abdominal pain
•Hematuria Diarrhea
• Proteinuria Dysphagia
Nausea and vomiting

Musculoskeletal
•Arthritis Reproductlve
•Myosltis Menstrual abnormalities
• Synovitis

(1) Skin
Most commonly in sun-exposed areas
Oral/nasopharyngeal ulcers
Alopecia
Butterfly rash
(2) CvS:
Myocarditis
Mitral / Aortic valve stenosis or regurgitation
-
Libman Sachs endocarditis
Coronary artherosclerosis
(3) Musculoskeletal
Polyarthralgia with morning stiffness
Arthritis
Swan neck fingers
Ulnar deviation
Subluxation with hyperlaxity of joints
Increased risk of bone loss and fracture
(4) Blood vessels: Acute nerotizing vasculitis of small arteries and arterioles and may progress into
fibrosis and lumen narrowing
(5) Spleen: Spleenomegaly, capsular thickening and follicular hyperplasia
(6) Lungs: Pleuritis, plueral effusion, interstital fibrosis and so pulmonary hypertenti
(7) CNS: Neuropschycotic syndromes ascribes to vasculitis or non-immune occlusion of smallvessels
(8) Renal > lupus nephritis

According to the WHO, six patterns of renal lesions are seen >
Class I: Minimal lesions
Class ll: Mesangial lupus nephritis
Class IIl: Focal segmental lupus nephritis
Class IV: Diffuse proliferative luptus nephritis
Class V: Membranous lupus nephritis
Class VI: Sclerosing lupus nephritis

PAGE 108| IMMUNOPATHOLOGY

Class I: Minimal lesions
Light microscopy > do not
PATHOLoGY PROF BUSTER m
show
Electron microscopy and immuno any abnormality.
deposits within mesangium which fluorescence
consist of mlcroscopy
lgG and C3.

Class Il: Mesanglal lupus nephritis

• Light microscopy increase
amount of mesangial matrix. in number of mesangial
Electron microscopy and cells and
immunofluorescence
deposits of lgG and C3 >
granular mesangial

Focal Involvement Uninvotved

of a lobule lobule

class ll: Focal segmental lupus

Iight microscopy
nephritis
focal
mesangial cells, together and segmental proliferation of
with infiltration by endothelial and
neutrophils. macrophages and sometimes
Electron microscopy>
often with lgM or lgA
Subendothelial and subepithelial
and C3, are seen. deposits of lgG,

Uninvolved Segmental mesangia

glomerulus hypercellularity

Hypercellular glomerulus
Endothelial cells
Proliferated mesanglal cells Acute nflammatory cols
Class IV:
Diffuse proliferative lupus nephritis
Most severe and the most common
form of lupus
nephritis
Light
microscopy Diffuse proliferation of
mesangial, and sometimes epithelial cells,endothelial,
involving all
glomeruli.
Electron microscopy> large electron-dense
deposits in
the mesangium and in the subendothelial region

Normal glomerular Diffusely thickened GBM

cellularitly (Duplicaion of GBM)

Class V: Membranous lupus nephritis

Light microscopy diffuse thickening of glomerular
capillary wall
Electron microscopy show subendothelial deposits of
immune complexes

IMMUNOPATHOLOGY |PAGE 109

 DR. PRIYANKA SACHDEV

Thickened blood vessel Chronic Inflammatory cets

Atrophied tubute
Aceflular,
Interstitiat fbrosis hysfinísed glomerutus

Class Vl: Sclerosing lupus nephritis

This is chronic kidney disease of SLE, similar to chronic
GN.
Most glomeruli are sclerosed and hyalinised

Criteria for diagnosis of SLE

CLINICAL CRITERIA IMMUNOLOGICAL CRITERIA

1. Acute Cutaneous Lupus 12. ANA

2. Chronic Cutaneous Lupus 13. Anti-dsDNA
3. Oral/Nasopharyngeal ulcers 14. Anti-Sm
4. Non-scarring alopecia 15. Anti Phospholipid Antibody
5. Synovitis involving > 2
joints 16. Low Complement
6. Serositis 17. Direct Coombs Test
7. Renal manifestations
8. Neurological manifestations
9. Hemolytic anemia
10. Leucopenia/ Lymphopenia
11. Thrombocytopenia

Classify a patient as having SLE if >

one clinical criterion and one
a) The patient satisfies four of the criteria, including at least
immunologic criterion OR
b) The patient has biopsy-proven nephritis compatible with SLE and with
(+) ANA or (+) anti-dsDNA
antibodies.

(6.05) HIV/AIDS
University Exam
Long Questions
of HIV
1. Describe Structure, Mode of Transmission, Replication, Opportunistic Infections and Lab diagnosis
Short Questions
1 Pathogenesis of human immune deficiency virus (HIV)infection
2. HIV disease and opportunistic infections
3. Oppurtunistic infections In AIDS
4
Laboratory diagnosis of AIDS.
5 High risk groups of AIDS.
6 Replication of HIV virus
7. WHO clinical staging of HIVIAIDS
8 Structural genes and non-structural genes of HIV
9
NACO Strategy for HIV Diagnosis
10. HIV Genes, Antigens and Serotyplng
11. Mode of Transmission of HIV
12. CD4 count in AIDS.
Very Short Questlons
1 Four common neoplasms found inpatients with HIV infection.
Mention 4 opportunistic Infections In AIDS.
Enlist 4 most common Infections found in AIDS patients
Name the fungal infections in AIDS,
5 Enlist 4 CNS lesions found In AIDS.

PAGE 110 | IMMUNOPATHOLOGY

 PATHOLOGY PROF BUSTER m
OvervInttoduction
History
Structure Antigens
HIV Genes ond
HIV Serotyping
Transmission
Mode of
Receptor Attechment
Replcation
Natural Courso
Opporlunistic tnfections
MMOcIiolcol staging of HIVIAIDS for adtte
groups
High risk
Kinetics of Immune Responso
Lab diagnosis
NACO Strategy for HIV Dlagnosis

Introduction
patroviruses are group oT RNA Viruses that possoss a unique enzyne
which directs synthesis of DNA from tho viral RNA aftor
callod reverse transcriptase
a
they infect
Globally 1st December is observed as World AIDS Day every
host cell.
yoar.

History
uIN in humans was believed to be acquired from
chimpanzee by the cross species infections or
counterpart of HIV (simian immunodeficiency
iian virus or SiVcpz) in rural Africa
Eirst case of AlDS was described from New York (USA) in 1981
Discovery of HIV-1 1s one at Pasteur Institute, Paris in 1983

Structure
Spherical
80-110 nm in size
Envelope: Present > Lipoprotein
.
Lipid part: host cell membrane derived
Protein part: 2 components: gp120
a) GP 120 > projected as knob like Envelope

spikes on the surface Core

b) GP 41 anchoring
transmembrane pedicles. gp41
RNA
Nucleocapsid: Lipid
Capsid is icosahedral in symmetry
Inner core encloses:
RNA: 2 identical copies of single Reverse
transcriptase
stranded positive sense linear RNA
Viral enzymes reverse
transcriptase, integrase and Matrix
proteases

HIV Genes and Antigens

3 structural genes
6 non-structural or regulatory genes
Structural Genes
1, Gag
2. Pol
3. env

IMMUNOPATHOL0GY | PAGE 111

m DR. PRIYANKA SACHDEV

1) gag gene
Codes for the core and shell of the virus.
Expressed as a precursor protein p55 which is cleaved into three proteins:
P18 constitutes the matrix or shell antigen
p24 constitute the core antigens
•
p15
2) pol gene
Codes for viral enzymes
Expressed as a precursor protein cleaved into>
p31 integrase
p51 reverse transcriptase
p66 protease
3) env gene
Codes for the envelope glycoprotein
Precursor GP (gp 160) which is cleaved into two components:
gp120: main receptor of HIV that binds to CD4 molecules on host cell to initiate the infection
gp41: fusion protein

Non-structural Genes
Essential regulatory genes:
tat (transcriptional transactivator)
nef (negative factor)
rev

Accessory regulatory genes:

vif (viral infectivity factor)
vpr
vpu

HIV Serotyping
Based on sequence differences in env gene HIV comprises of two serotypes
1. HIV - 1

HIV
2. -2

1) HIV-1
Divided into three distinct groups:
a) M dominant group worldwide, 11 subtypes or "clades" (A-K)
b) N
c) O
Geographical distribution
Subtype A is common in West Africa
Subtype B is predominant in Europe, America, Japan, and Australia
in Southern
Subtype C is the most common form worldwide (47%). It is alsothe dominant form
and Eastern Africa, India, and China

2) HIV-2
Itcomprises of eight subtypes (A-H)
Mainly confined to Africa and fewother places including India.
Group A is the most common form.
PAGE 112 | IMMUNOPATHOLOGY
 PATHOLOGY PROF
BUSTER m

HV
Types: HIV.1 HIV-2

Groups:N N
Sub FA CRFS
types: B D H J K
Circulating
recombinant forms

CRFO1-AE CRFÖ4-cpx

Mode of Transmission
1. Blood transfusion
2. Sexual intercourse
Vaginal
Anal
Oral
Percutaneous > Injection drug abuse, Needle stick exposure
4. Parent to child
%

Route of Risk of transmission of total transmlsslon

transmission (Worldwide, %) World India

Blood transfusion >90 5 1

Sexual intercourse 0.1-1 75 88.9

Vaginal0.05-0.1 60 87.4 (heterosexual)
Anal 0.065-0.5 15 1.5 (homosexual)
Oral 0.005-0.1 Rare Not reported
Percutaneous
Drug abuse 0.5-1.0 10 1.6%
Needle stick exposure0.3 0.1 1

Parent to child 13-40 10 5.4

Sexual mode
Most common mode of transmission (75%)
But risk of transmission is minimal (0.1-1% per coitus)

Blood transfusion
Least common mode of transmission (5%)
transmission is maximum (90-95%)
But risk of

Percutaneous transmission
Needle stick injury, injection drug abuse and sharing razors or tattooing
Less effective modes of transmission

Perinatal mode:
Risk of transmission from mother to fetus is about 20-40%
Transmission may occur at any time during pregnancy and breastfeeding but the
risk is maximum during delivery

IMMUNOPATHOLOGY |PAGE 113

 DR, PRIYANKA SACHDEV

Receptor Attachment
Main receptor:
Host-DNA,
HIVenters intothe target cells
Viral-DNA RNAs
by binding its gp120 to the HIV
CD4 receptor on host cell
surface. CD, Transcriptlon
CD4 molecules are mainly HccRSI
Assembiy
expressed on helper T cells CXCR4
Integration
and also on the surface of
various other cells like
monocytes, macrophages, mRNA
Langerhans cells, astrocytes, Reverse Translatlon
DNA Coples
keratinocytes and glial cells transcription

Co-receptor
Necessaryfor fusion of HIV to gain entry into the host cell.
Usually, the chemokine receptors act as co-receptors for HIV and act by binding to gp120.

Examples include:
CXCR4 molecules present on Tlymphocytes
CCR5 molecules present on cells of macrophage lineage

Replication
Fusion:
Following attachment of receptor and coreceptor to gp120, fusion of HIV to host cell takes place;
mediated by the fusion protein gp41

Penetration and uncoating:

After fusion, HIV nucleocapsid enters into the host cell cytoplasm, which is followed by uncoating and
release of two copies of ssRNA and viral enzymes

Reverse transcription:
Viral reverse transcriptase mediates transcription of its ssRNA into ssDNA so that DNA-RNA hybrid is
formed.

Integration:
The viral dsDNA gets integrated into the host cell chromosome; mediated by viral integrase. The
integrated virus is called as provirus
Gp 120 binds to Conformational gp120, CD4 binds to
CD4 receptor change chemokine receptor
Latency:
In the integrated state, HIV
establishes a latent Attack Gp 41 expose "Fusion
infection for variable new cell peptide (hydrophobic)
period. However, HIV is LIFE CYCLE OF HIV
different from other latent
viruses as it is able to |Budding of Membrane
replicate even in latent mature virion fusion
state and is infectious to
other neighboring cells.
Synthesis of Integration of provirus
Assembly HIV proteins with host genome

Natural Course
About 80-90% of HIV, infected individuals are "typical progressors, " with a median survival time of
approximately 10 years.

PAGE 114 | IMMUNOPATHOLOGY

5 stages PATHOLOGY PROF BUSTER m
Acute HIV Disease or Acute
1.
2. Asymptomatic Strage (Clinical Retroviral Syndrome
Persistent Generalized Latency)
3. Lymphadenopathy
Symptomatic HIV Infection
AIDS (AlDS-related (PGL)
5. Complex)

1. Acute HIV Discase or ACute Rotroviral

Initially, HIVdestroys the infected T Syndromo
(or acute mononucleosis-like cells and spills over
Significant drop syndrome) into bloodstream
the number of circulating initial flu-like illness
in
to cause primary viremia
CD4 T
cells
2. Asymptomatic Stage (Clinical
Latency)
Adequate immune response
develops within 1
Dath effective month in most of
cell-mediated immune response the patients
and humoral immune response
come into
viremia drops down play

CD4T cell count

becomes normal
Immune response
cannot clear the infection
completely
HIV-infected cells
persist in the lymph
nodes
High level of ongoing
viral replication
This period of clinical
latency is variable, may
10years but ranges from few last for
months to 30 years
Once the latency is broken
disease progresses rapidly
Death usually occurs within 2 years if
left untreated
3. Persistent
Generalized Lymphadenopathy (PGL)
25-30% of infected people who are
PGL s defined as enlarged lymph otherwise asymptomatic develop lymphadenopathy.
nodes more than 1 cm size in two or mnore
sites that persist for at least 3 months of non-contiguous
4. Symptomatic HIV Infection (AlDS-related Complex)
After variable period of clinical latency
CD4 T cell level starts falling.
Patients develop constitutional symptoms such as:
Unexplained diarrhea, lasting for more than 1 month
Weight loss (>10%), fatigue, malaise and night sweat
Mild opportunistic infections such as oral thrush.

5. AIDS

Gradually patient moves towards the advanced end stage of HIV infection
AIDS is called AIDS
characterized by:
Rapid fall in CD4 T cellcount (usually <200 cells/pL)
High viral load
Lymphoid tissue is totally destroyed and replaced by fibrous tissue
Opportunistic infections set in secondary to profound immune suppression. Depending on the CD4
T
cellcount, various infections occur
Development of neoplasia (e.g. CNS lymphoma)

IMMUNOPATHOLOGY | PAGE
115
 DR. PRIYANKASACHDEV

Opportunistic Infections
Tuberculosis is the most commonopportunistic infection that occurs in HIV-infected people
Fungal infections candidiasis (oral thrush) and Pneumocystis jirovecii
Viral infections herpes simplex mucosal lesions and CMV retinitis
Parasitic infections Cryptosporidium parvum diarrhea, Toxoplasma encephalitis and
Strongyloides stercoralis hyperinfection syndrome

Opportunistic infections associated with

HIV infection and correlation with CD4 T cell counts

800
Bacterlal skin infections
(eww
HSV, fungal infections
600 LNT
Platelet cKaposl's sarcoma
Jd) 500
Hairy leukoplakia
1unoo
Tuberculosis
400 400
-PCP
|j0 300 Cryptococcosis
Toxoplasmosis
a 200 200
-MAC, CMV
50 Lymphoma

Months Years Time

WHO clinical staging of HIVIAIDS for adults

World Health Organization, revised 2007
Based only on clinical conditions associated with the patient.
Itclassifies HIV infection into 4 stages
Clinical Stage
> Asymptomatic HIV infection
Persistent generalized lymphadenopathy
Clinical Stage 2

Unexplained moderate weight loss (<10%)

A Recurrent respiratory tract infections (sinusitis, tonsillitis,
otitis media, pharyngitis)
A Herpes zoster
A Angular cheilitis
A Recurrent oral ulcers
A Papular pruritic eruptions
A Seborrheic dermatitis
A Fungal nail infection

Clinical Stage 3

AAAA
Unexplained severe weight loss (>10%)
Unexplained chronic diarrhea: >1 month
1
Unexplained persistent fever: month
Oral candidiasis
AA Oral hairy leukoplakia
Pulmonary tuberculosis
AA Severe bacterial infections (pneumonia, empyema, etc.)
Unexplained anemia, neutropenia or chronic thrombocytopenia

PAGE 116 | IMMUNOPATHOLOGY

 m
PATHOLOGY PROF BUSTER
Clinical Stage 4
HIV wasting syndrome (Slim
(>10%), chronic diarrhea disease): Characterized
loss (>1 month), prolonged by profound weight
Bacterial opportunistic infections:
unexplained
fever (1 month)
Recurrent severe bacterial
Extrapulmonary tuberculosisinfections
Disseminated non-tubercular
Recurrent septicemia mycobacterial infection
(including non-typhoidal
salmonellosis)
Viral opportunistic infections:
Chronic HSV infection
b Progressive multifocal
CMV (retinitis, or leukoencephalopathy
infection of other organs)
Fungal opportunistic infections:
Pneumocystis jirovecii pneumonia
> Esophageal candidiasis
> Extrapulmonary
cryptococcosis (meningitis)
Disseminated mycoses
(histoplasmosis and coccidioidomycoses)
Parasitic opportunistic infections:
> Toxoplasma encephalitis
Chronic intestinal cystoisosporiasis
> Atypical disseminated (>1 month)
leishmaniasis
Neoplasia:
> Kaposi's sarcoma
> Invasive cervical cancer
Lymphoma (cerebral, B-cell and non-Hodgkin)

High-risk Groups
Extremely high-risk group:
Female sex workers
Men who have sex with men
Transgenders
IV drug
abuser group

Moderately high-risk group:

Health care workers (via needle pricks or splashes injury)
Hemophiliacs and other recipients of blood products
People with other STIs (sexually-transmitted infections).

Kinetics of Immune Response

Entry of the virus into the body

Transient high-level viremia and p24 antigenemia

Window period (3 to 12 weeks)
Humoral response formation of antibodies (lgM, IgA, IgG)against structural proteins
(gag: p15, p17, p24, p55; env: gp 41, gp 120, gp 160; and pol: p31, p51 and p66)
regulatory proteins (nef, rev, tat)
accessory proteins (vif, vpu and vpr)
only lgG response is consistent and long lasting
IMMUNOPATHOLOGY | PAGE 117
 DR. PRIYANKA SACHDEV

Laboratory Diagnosis
A number of moral, ethical, legal and psychosocial issues are associated with a positive HIV
status.
The disease is life long, outcome is fatal, no cure or vaccine is available and in majority
transmission is through sexual contact.
Hence, individuals known to be HIVinfected are stigmatized and develop a fear of being
discriminated and socially outcasted.

3Cs while performing the test for HIV

Consent in written format should be taken before the test is done. The patient should be
explained about the nature of the test being performed
Confidentiality of a positive test result is a must. Patient name or the word "HIV positive" should
not be written on the report form
Counseling should be provided to motivate the individual to tell the spouselfamily and induce
behavioral change

Specific Tests for HIV Infection:

Screening tests (antibody detection)
Supplemental tests (antibody detection)
Confirmatory tests

Non-specific Immunological Methods

Screening Assays
ELISA
Rapid/simple test

Antigens used >

a) HIV-1 specific (p24, gp 120, gp160, gp41)
b) HIV-2 specific gp36
Should be confirmed

Supplemental Tests
1. Western Blot
2. Lineimmune assay
Highly specific antibody detection methods
Used for validation of positive results of screening tests
Expensive
Need expertise to interpret

Confirmatory tests
1. Detection of p24 Core Antigen
2. Viral RNA Detection
3. DNA PCR
4. Isolation of the Virus from Blood or Tissues

Detection of p24 Core Antigen

p24 Ag is detected by 4th generation ELISA

p24 antigen becomes detectable

after 12-26 days of infection
Lasts for 3-4 weeks
Again, elevated during
late advanced stage of AIDS

PAGE 118 | IMMUNOPATHOLOGY

 of p24 antigen detection test:
Uses
For
coonfirmation of diagnosis
PATHOLoGY PROF BUSTER m
of HIVIAIDS
Diagnosis of HIV during
the window period
Todiagnose the late slage of HIVIAIDS
Monitoringthe progress of HIV infection (immune
H
collapse) or
CNS disease
Non-specific Tests
CD4 T cell count: By flow cytometry method.

Useful for:
Assessing the risk of opportunistic
Monitoring the infections
response to antiretroviral
therapy
NACO Strategy for HIV Diagnosis
In poor countries
it is impracticable
western blot as these to confirm
assays are the result of HIV
WeNlational AIDS Control expensive and avalable screoning tests by PCR or
Organization, India) only at limited
diagnosis. centers.
has formulated a strategic
plan for HIV
Guidelines
anending on the situation,
tor which the test is
euldbe either considered
as Such or confirmeddone> Positive result of the first screening
Rereening tests
should use different principles by another one or two screening tests test
or
different antigens.
used again The same kit should not
Eirst
screening test should be
be highly sensitive, whereas
have high specificity second and third screening tests
Supolemental or contirmatory should
tests should be used only
equivocallintermediate. when screening test
results are

Strategy |
Purpose: done for transfusion
and transplantation
safety: i.e. for the screening
of the blood donors in
blood banks
Only one test should be done.
.
Iffound reactive, then the unit of blood
is destroved.

Strategy/Algorithm
(For transfusion/transplantation
safety)
1 Test kit required
A.

A, + A

Consider Consider
positive
negative
(Destroy the unit of blood as per guidelines.
Refer to ICTC for confirmation of status after consent)

IMMUNOPATHOLOGY |PAGE 119

 m
DR, PRIYANKA SACHDEV

Strategy lla
Purpose: It is done for sentinel surveillance of
HIV infection to estimate the prevalence of StrategyIAlgorithm I|A
infection (For surveillance)
UAT: Unlinked anonymous testing (UAT) 2 Tost kits roquirod
screening of blood specimens taken for
purposes other than HIV testing. Then the
samples are permanently decoded of personal
identifiers. This process occurs without A
Report negative
informed consent
Two tests format: Positive results of the first
A,)
test should be confirmed by a second test. If
the second test is negative, then it is reported A,+A, A, A;
as negative Report positive Report negative

StrategylAlgorithm I B
(Diagnosis of an individual with AIDS
indicator disease with symptoms)
Strategy llb 2 or 3 Test kits reguired
A
Purpose: It is followed for the diagnosis
of HIVIAIDS in symptomatic patients
Positive result of the first test should be
confirmed by a second test. Report negative
If the second test is negative, then a
third test is done for confirmation.
A, +

Report positive
A2 +] A, +
A,gtt st
with post-test A3
counseling

[A, + A,- A3 +) (A, + A,-

A3-)ss
Indeterminate Report negative

Strategy Ill: StrategylAlgorithm ll

(To detect HIV infection in
3
Test kits required
Purpose: It A

is done for the asymptomatic individuals)

diagnosis of asymptomatic HIV
patients, antenatal screening and
screpning of patients awaiting
A,+) A,
Report negative
surgeries
Three tests format: Allpositive A, + A,+t ) A, + A,
results in the first test should be
confirmed by the second and
third test. Positive report is sent A3
only if all three test results are
(A,+ A,+ A+) (A, + A2 + A3-) [A,+ A,- A3 +) A, + A, A3-)
found reactive
Report positive Indeterminate Indeterminate
For indeterminate results of with post-test
strategy |B and IIl, (i.e. first test counseling High-risk Low-risk
positive but second or third test consider Consider
negative), a repeat test is done indeterminate negative
after 14-28 days and the sample
should be sent to the reference
center

PAGE 120| IMMUNOPATHOLOGY

 PATHOLOGY PROF
BUSTER m
AMYLOIDOSIS
(6.06))
/ Exams
unlverslly amyloid.
questlons Describe the physical and chemical nature of amyloid. Enumerato the special
stains for
Long classify amyloid.
amyloidosis. gross secondary amytoldosis.
Define and classify Explain the ond microscopic features of ofgans involved In
efine and
pathogenesis, morphology and stalning chatacteristics of amyloidosis.
Deline
Describe demonstration of amyloid.
3. Methods of
questlons
amylold. Give classification
of
Short amyloidosis.
Define chemical nature of amyloid
Physical and
for amylold and the result.
Special stains amyloidosis.
Pathogernesis of stains Used for lts demonstratlon.
Classification amyloldosis and
3.
morphology.
5 spleen inaroscopic appearance of Kidney in amyloldosis.
6. Gross and
7. questions
Very Short of amyloid.
Precursor proteins amyloidosis.
Types of localized amyloidosie
Types of systemic
merate Special stalns for amylold and result.
Role of Congo red
in Amyloidosis
5 Sago spleen
Lordoceous spleen

Overvie w
Definition (00:02:28)
Physical nature
(00:06:29)
Tvpes of Amyloidosis
(00:10:00)
lassification on(00:13:55)
1 Based
Based on extent of amyloid deposition
Introduction
AL
AA
(00:3) Pathogenesis

Diagnosis (00:28:48)
Staining Characteristics of Amyloid (00:29:16)
Organs affected (00:35:45)

Normal Azheier's
NeLtoibrilask
angles
Definition
A
condition in which amyloid proteins are abnormally
deposited extracellularly between cells in various organs
/

NeuroD Amyoid
tissues. paques
Amyloid protein that has an alteration in its secondary
structure> insoluble form

Amyloid progln chains

Physical nature Congo red molecules

Electron microscopy >

Nonbranching fibrils with diameter 7.5-10
nm and indefinite length

X Ray crystallography / Infrared

spectroscopy>
Cross B pleated sheet conformation

Fibrll composed of
paired filaments

B•pleated sheet

IMMUNOPATHOLOGY | PAGE 121

 UACHDEV

Types of Amyloidosis
AL Light chao (lambda
AA
and kappa)
SAA (serum Plasma celldyscrasias (multiple myeloma)
amyloid associated
Aßam protein) chronic inflammatory conditions
Bmicroglobulin
ATTR Transthyretin Hemodialysis
Familial amyloidotic polyneuropathies,
Aß Senile cardiomyopathy
AB protein precursor (ABPP)
APrp Alzheimer's disease
Prion protein
Spongiform encephalopathy
AGal Calcitonin
Medullary carcinoma of thyroid
A
IAPP Islet amyloid polypeptide Type I| diabetes, Insulinomas
AANF Atrial natriuretic factor Isolated atrial amyloid

Classification
1) Based on cause
Primary with unknown cause and deposition is in disease itself (AL)
Secondary >as a complication of some underlying known disease amyloidosis (AA)

2) Based on extent of amyloid deposition

Systemic (Generalised) involving multiple organs
Localised involving 1 organ

Systemic Amyloidosis
PRECURSOR SYNDROME ORINVOLVED
AMYLOID
PROTEIN TISSUE

AL Immunoglobulin light chain| Primary, Myeloma associated

AA Serum AA (SAA) Reactive, chronic inflammatory condition,
Familial mediterranean fever

ABzm B2 microglobulin Hemodialysis

ATTR Transthyretin Familial amyloidotic polyneuropathies

Localised Amyloidosis
SYNDROME OR INVOLVED
AMYLOID PRECURSOR
PROTEIN TISSUE
Aß AB protein precursor (AßPP)| Alzheimer's disease

APrP Prion protein Spongiform encephalopathy

AIAPP Calcitonin Medullary carcinoma of thyroid
A
Cal Islet amyloid polypeptide Type I| diabetes, Insulinomas

AANF Atrial natriuretic factor Isolated atrial amyloid

PAGE 122 | IMMUNOPATHOLOGY

 PATHOLOGY PROF
BUSTER m

Protein
AL
Introduction
immunoglobulin light chain (lambda and kappa (k)
Derived from
plasma cell dyscrasias (multiple myeloma)
Seen in systemic amyloidosis
Primary

Pathogenesis
multiple AMOUTI 0 POTEON
stimulus lymphoma, PRODUCTION O ABNOMAL
myeloma, B cell dyscrasias,
other plasma
cell Cronle Rammetlon
Nath foided Acqure mrtaions
proliferation of
Monoclonal (Monoclonal
Merphag vadon
plasma cells
gammopathy)
AmAoldogenk lntemedlate
6Lnsteldod pretein
of
Excessive production Iiaht
or kappa
either lambda
chain
occurs in
Monomers aembls o lom
Partial degradation Ahtcture
macrophages

Non-fibrillar components
like AA PROTEN
ALPROTEIN
causes FIBRIL
AP and GAGs proteins
aggregation of fibril
AL

AAProtein

Introduction >
Derived from larger precursor protein in
serum called SAA (serum amyloid associated protein)
an acute phase reactant protein synthesized
response to
in liver in inflammatory chronic
SAA is
conditions
Secondary amyloidosis

Pathogenesis
Stimulus chronic inflammation and some tumours

Activated macrophages
Cytokines (IL- 1
and 6)

Levels of SAA elevated from liver

Partial degradation in reticuloendothelial cells

Non-fibrillar components like AP and GAGs causes aggregation of fibril proteins

AA

Diagnosis
Definitive investigation for amyloidosis Biopsy.
Best sites for biopsy> rectum and abdominal fat pad
Other sites salivary glands, gingiva, skin, tongue, bone marroW and
stomach.

IMMUNOPATHOLOGY | PAGE 123

m DR. PRIYANKA SACHDEV

Staining Characteristics of Amyloid

Stain Appearance
1. H&E Pink, hyaline, homogeneous
2. Methyl violet/Crystal violet Metachromasia: rose-pink
3. Congo red Light microscopy: pink-red
Polarising light: Apple greon birofringence
4. Thioflavin-T/Thioflavin-s Ultraviolet light: fluorescence
5. Immunohistochemistry Immunoroactivity: Positive
(antibody against fibrilprotein)

Congo Red
Visible light Pink red colour
Polarised light Apple-green
birefringence (due to cross-B-pleated
sheet configuration)
Visible light Polarised light
Congo red

Organs affected
1. Kidney
2. Heart
3. Spleen
4. Liver
5. Adrenal
6. Tongue
7. Brain
Congo red, xa00 Polarsing microscopy. X400
1. Kidneys
Glomerular Deposit in Amyloid
Most common form of systemic amyloidosis. deposit Interstitial vessel cast
Most serious form of organ involvement.
Earliest pathological change thickening of GBM

2. Heart>
second most common presentation
Major organ involved in senile systemic amyloidosis

Normal myocardlum (heart musclo)

Transnsretin
proteins
misfold
NORMAL HEART SAmylold flbrlls
Msfold

Amylold deposits ln myocardium

AMYLOIDO5IS

PAGE 124 | IMMUNOPATHOLOGY

 m
BUSTER
PATHOLOGY PROF

3. Spleen - Lerdaceous
Two patterns of deposition is
seen Sago spleen
spleen
Sag0 spleen > Amyloid deposition in splenic follicles
(White pulp)
ardaceous spleen > Amyloid deposition in splenic sinuses
(Red pulp)
Atrophied
Amylold deposit hepatocytes
Portgl uiad
4. Liver
Central vein
Amyloid deposition in space of Disse

5. Adrenal >
Deposits in zona glomarulosa.
6. Tongue >
Macroglossia
7. Brain >
In senile plaques of Alzheimer disease
Liver
Capsule
Adrenal cortec Neurotibrilary
Sangles
Zona glomerulosa
Zong lasdalata

Zona retialars
Amyoid
Catecholamines plaqueS
Medula

Adosterone Androgens

Cortsol

Adrenal Tongue Braln

IMMUNOPATHOLOGY PAGE
| 125
 CHAPTER

NEOPLASIA 7
(7.01) NEOPLASIA
iDEFINITION, NOMENCLATURE AND PREDISPOSING CONDITIONS)

University Exams
Long questions of
Define-Neoplasia. Write the nomenclature of Neoplasla. Ennumerate Genetic and non-hereditary predisposing conditions
Neoplasia.
Short questions
Define-Neoplasia.
sarcoma.
Differences between carcinoma and
Precancerous conditions.
4 Definition and two examples of sarcoma.

Overview
Definition (00:00:41)
Nomenclature (00:04:42)
Precancerous lesions (00:09:16)
1. Genetic predisposition (00:09:35)
a) AD inherited cancer syndromes
b) Defective DNA-repair syndromes
c) Familial cancers
2 Nonhereditary Predisposing conditions > (00:13:35)
a) Proliferation
b) Chronic inflammations

Definition
Term 'neoplasia' means new growth
New growth produced neoplasm or tumour
Branch of science dealing with the study of neoplasms oncology

Normal Cell Neoplastic cell

Growth factor (Stimulus) Absence of Growth factor (Stimulus)

Growth receptor

Mitosis Mitosis

Neoplasm
 DR. PRIYANKA SACHDEV

Neoplasm
An abnormal mass of tissue
Growth of which exceeds and is uncoordinated with that of normal tissues
Persists in same excessive manner even after cossation of stimuli which evoked the changa
Neoplastic cells lose control and rogulation of roplicatlon and form an abnormal mass of tissua

Nomenclature
a) Benign tumors
Suffix oma

Papilloma - Benigntumor with

finger-like projections

Adenoma - Benign epithelial tumor

arising from glands or forming a
glandular pattern Gres
Papilloma Adenoma
Exceptions
Malignant neoplasms with suffix - Oma -
1. Melanomas
2. Seminoma
3. Mesothelioma
4. Lymphoma
Malignant tumors

Mesenchymál cell origin Epitheàl cell origin

Sarcoma carcinoma

Adenocarcinoma Squamous cell carcinoma

2) Malignant tumors

TISSUE OF ORIGIN BENIGN MALIGNANT

Epithelial Tumours
1. Squamous epithelium Squamous cell papilloma Squamous cell carcinoma
2. Transitional epithelium Transitional cell Transitional cell carcinoma
3. Glandular epithelium papilloma Adenocarcinoma
4. Hepatocytes Adenoma Hepatoma (Hepatocellular
5. Placenta (Chorionic epithelium) liver cell adenoma carcinoma)
6. Neuroectoderm Hydatidiform mole Choriocarcinoma
Naevus Melanoma (Melanocarcinoma)
Mesenchymal Tumours
1. Adipose tissue Lipoma Liposarcoma
2 Adult fibrous tissue Fibroma Fibrosarcoma
3 Embryonic fibrous tissue Myxoma Myxosarcoma
4 Cartilage Chondroma Chondrosarcoma
5 Bone Osteoma Osteosarcoma
6. Synovium Benign synovioma Synovial sarcoma
7 Smooth muscle Leiomyoma Leiomyosarcoma
Skeletal muscle Rhabdomyoma Rhabdomyosarcoma
Blood vessels Haemangioma Angiosarcoma
10. Lymph vessels Lymphangioma Lymphangiosarcoma
11. Meninges Meningioma Invasive meningioma
12. Lymphoid tissue Pseudo lymphoma Malignant lymphomas
13. Nerve sheath Neurofibroma Neurogenic sarcoma

PAGE 128 | NEOPLASIA

 PATHOLOGY PROF BUSTER

precancerous lesions

Cancer Predisposition
cOnditions

Genetic predisposition
Nonhereditary Predisposing
1. AD inherited cancer syndromes
1. Proliferation
2. Defective DNA-repair syndromes
2. Chronic inflammations
3. Familial cancers

1)
Genetic Predisposition
a) Autosomal dominant inherited cancer syndromes
Mnemonic
Wey Rich, Cute, Nice Men Hereditarily Like Familiar
Females
Very :Von Hippel Lindau (VHL) syndrome
causing renal cell cancer
Rich :Retinoblastoma
Cute Cowden syndrome (PTEN gene)
Nice :Neurofibromatosis 1,2
:
Men Melanoma, MEN 1 and2
Hereditarily :HNPCC
Like :Li-Fraumeni syndrome
Familiar : Familial adenomatous
polyposis
Females :Ovarian and breast tumor

b) Defective DNA-repair syndromes

Predisposes to DNA instability when
exposed to environmental carcinogens.
Autosomal recessive.

Defects ín DNA repalr

Nucleotide excision
Mismatch Recombination
repair repair repair

Xeroderma Hereditary Non

Bloom syndrome
pigmentosum Polyposis Colorectal FAlaxia telangiectasia
Carcinoma syndrome
Fanconi's anemia
Mnemonic
Big FAX
Hai
Blg
Bloom syndrome
A
Fanconi's syndrome
Ataxia telengectesia
Hat Xeroderma pigmentosa
-HNPPC

NEOPLASIA J PAGE
129
 m
DR, PRIYANKA SACHDEV

c) Famnilial cancers
Cancers occuring with high frequenclos In familes but without distinct pattern of hereditary
transmission.
Onset > early with multiple or bilate ral tumors.

2) Nonhereditary Predisposing Conditions

a) Proliferation
Increase risk of developing malignancy since proliferating cells accumulate genetic mutations
necessary for carcinogenesis.

Example of proliferations are:

1. Regeneration, e.g. liver cirrhosis to Hepatocellular carcinoma.
2. Metaplasia
3. Hyperplasia
4. Dysplasia

b) Chronic inflammations
Induces cancers by
1. Increasing genomic instability by producing free radicals.
2. Produces cytokines to drive cell survival and proliferation

I(7.02) TERATOMA, HAMARTOMA AND CHORISTOMA

University Exams
Short questions
1. Teratoma
2. Hamartoma
Choristoma

Overview
Teratoma (00:00:35)
Not actual tumors (neoplasms) (00:02:42)
Hamartoma (00:03:19)
Choristoma (00:04:37)

Teratoma
AllTumors are composed of cells representative of a single germ layer.

Teratoma
Arise from totipotent cells
Composed of multiple celltypes derived from 3 germ layers ectoderm,
mesoderm and endoderm
Contain immature or fully formed tissue including teeth, hair, bone and
muscle.
Usually benign but may be malignant

PAGE 130 | NEOPLASIA

 BUSTER
PATHOLOGY PROF

Not actual tumors (neoplasms)

Leslons with tumor like names but not actual tumors

Normally arranged tlssue at a Abnormally arranged tissue

different anatomlcal site present at normal site
(heterotoplc rest of cells)

Chorlstoma Hamartoma

Hamartoma
Focal developmental malformation
Mass of disorganized but mature
specialized cells indigenous /native
to particular site

Hamartoma of lung Hamartoma of Spleen

Choristoma
. Ectopic islands of normal tissue.
Heterotopia but is not a true tumor

Osteocartllagerous Choristoma of tongue Pancreatic choristoma of Stomach

TUMOURS
I(7.03) BENIGN VERSUS MALIGNANT
University Exams
Long questlons
neoplasms.
Define neoplasm. Explain differences between benign and malignant
2 Difference between benign & malignant tumors.
3. Characteristics of malignant tumours.
of benign tumors. tumors.
. Characteristics histogenesls of benign and malignant
4

Define Anaplasia, Classify neoplasia, Discuss

Short questlons
1. Features of anaplasia
Differences between benign and mallgnant neoplasms.
Describe morphology of anaplastic tumor cells.
Morphology of malignant cells

NEOPLASIA | PAGE 131

 m,
DR. PRIYANKA SACHDEV

Overview
Rate of growth (00:01:44)
Clinical features (00:03:26)
Gross features (00:04:35)
Microscopic features Features of anaplasla (00:00;30)
1, LosS of polarity
2 Pleomorphlsm
3 N:C ratio
4 Anisonucleosis
5 Hyperchromatism
Nucleolar changes
7 Mitotic figures
8. Tumor giont cells
9. Cytoplasm Increased mucln
10, DNA aneuploidy
Spread of tumours (00:28:30)

Rate of growth
Benign tumour cells Less mitotic rate (more doubling time)
Malignant tumour cells Increased mitotic rate (less doubling time) and slower death rate ie. cel
production exceeds cell loss.

Clinical Features
Benign tumours Malignant tumours
Slowgrowing Grow rapidly
Asymptomatic (e.g. subcutaneous lipoma) Ulcerate on surface
May produce serious symptoms (e.g. Invade locally into deeper tissues
meningioma in the CNS) Spread to distant sites (metastasis)
Systemic features such as weight loss,
anoreXia and anaemnia.

Gross Features
Benign tumours Malignant tumours
Spherical or ovoid in shape. Irregular in shape
Encapsulated or well-circumscribed Poorly-circumscribed
Freely movable Extend into adjacent tissues.
More firm and uniform Sarcomas > fishflesh like consistency
Surrounding tissue compressed Carcinomas firm
Surrounding tissue invaded

Benign Tumor Malignant Tumor

Fibroadenoma Invasvoductal carcinoma of breast

PAGE 132 | NEOPLASIA

 BUSTER
PATHOLoGY PROF

Microscopic Features
Lack of differentiation
OR
Presence of Anaplasia

pifferentiation
cells.
Extent of
orphological and functional resemblance of tumour cells to corresponding normal
Cancer cells

Anaplasia
differentiation
Lack of
Hallmark of malignant
transformation
Irreversible

Features of anaplasia cancer cells dlvldint normal ests

1. Loss of
polarity
2. Pleomorphism
3. N:C ratio
4,
Anisonucleosis
5.
Hyperchromatism
6. Nucleolar changes
Mitotic figures
7.

8. Tumor giant cells

9. Cytoplasm increased mucin
10. DNA aneuploidy

Basal polarity Loss of polarity

No pleomorphism Pleomorphism

N/C ratio
N/C ration law

No anisonucleosis Anlsonucleosis

Normal nuclear chromatin Nuclear hyperchromatism

Nucleoli normal Nucleoli promlnent

Abnormal mitotic figures

Normal mitotlc flgures

Tumor glant cells

No giant cells

Increased mucln
ytoplasm normal
Chromosomal diploldy DNA anuploldy

1) Loss of polarity
polarity.
Normally nuclei of epithelial cells
are oriented along basement membrane> basal
to lle away from basement membrane
Tumour cells lose their basal polarity > nuclel tend

2) Pleomorphism
Variation
>
in size and shape of tumour cells.
NEOPLASIA |PAGE 133
 DR. PRIYANKA SACHDEV

3) N:C ratio>
Nucleiaro enlargod disproportionate to coll sizo so that N:C ratio is increased.
Innormal cells 1:4
Anaplastic cells. 1:1

4) Anisonucleosis
Nucleishow variation in size and shape in malignant tumour cells

5) Hyperchromatism
Increased nuclear material or DNA s responsible for dark staining of the cells

6) Nucleolar changes
Malignant cells have a prominont nucloolus in nucleus

7) Mitotic figures
Tumour cells show large number of normal or abnormal mitosos

8) Tumor giant cells >

Important feature of malignant cells

9) Cytoplasm >
Increased mucin

10) DNA aneuploidy

Spread Of Tumours
1.Local invasion (direct spread)
2. Metastasis (distant spread)

Prlmary tumor formatlon Local Invasion Intravasation

Arrest at a
Extravasation distant organ slte Survival In the circulation

Mlcrometastasls Cünically detectable

formatlon macroscoplc metastases
Metastatlc colonlzation

PAGE 134 | NEOPLASIA

 BUSTER
PATHOLOGY PROF

Local invasion (direct spread)

BENIGN TUMOR MALIGNANT TUMOR

Cells are not cancerous

& wont spread
Cells are cancerous
& can spread to
other
tissues end organs

to distinguish malignant frombenign

tevasiveness and metastasis > 2most important features
tumours.
nor
Metastasis
Benign tumour > Neither show local invasion
as well as Metastasis
Malignant tumour > Show local invasion
most reliable feature of a malignant tumor
Metastasis >
Invasiveness > 2nd most reliable sign of malignancy (after metastasis)

MALIGNANT
FEATURE BENIGN

L Clinical And Gross

Features Poorly-circumscribed and
1. Boundaries
Encapsulated or well
circumscribed irregular
Invaded
2. Surrounding tissue Compressed Often larger
Usually small
3.Size Occur more often
4.Secondary changes Occur less often
IL. Microscopic Features Lost
Retained Present
1. Basal polarity
Absent Increased
2. Pleomorphism
Normal
3. N/ C ratio
Absent
Present
4. Anisonucleosis Present
5. Hyperchromatism
Absent Mitotic figures lIncreased and
May be present but are always are generally atypical and
6. Mitosis
typical mitoses abnormal
Present with nuclear atypia
May be present but without
7. Tumour giant cells
nuclear atypia Invariably present
Infrequent
8. Chromosomal
abnormalities
Rapid
Slow Infiltrates and invades the
II. Growth Rate Compresses the surrounding
or adjacent tissues
IV. Local Invasion
tissues without Invading
Infiltrating them
Frequently present
V.
Absent Death by local and metastatic
Metastasis Local complications complications
VI. Prognosis

NEOPLASIA |PAGE 135

 m DR. PRIYANKA SACHDEV

I(7.04) SPREAD OF TUMOURS (METASTASIS)

University Ex ms
Long questlons
13 Define heoplasm. DiscUss their modes of sproad.
Define neoplasm. List important features of transcoelomic sptead of neoplasm.
Define neoplasms. Describe various methods of sptead of tumors. What is metastases?
Write the various pathways of Describe the mechanisms of invasion and metasta sis of tumor.
5.
Spreau
Enumerate modes of spre ad of malignant
O

ee Deibe in brief mechanism of Metastasis.

Short questions
Spread of tumors.
Metastasis (routes of spread of malignant tumors with examples).
Lymphatic of tumor,
Hematoo8ndspread of cancor.
Transcoelomic spread of malignant tumor.
6 Metastatic cascado.
7 Virchow's node.

Overview
Introduction (00:01:15)
Routes of Metastasis (00:05:55)
1, Lymphatic spread (00:11:56)
2. Hematogenous spread (00:29:14)
3. Trans coelomic spread (00:34:01)
a) Direct seeding into body cavitles or surface
b Spread via CSF
c) Implantation
Mechanism of Metastasis 8 Steps (00:42:18)

Introduction Caner

Spread of tumour by invasion in such a way that

discontinuous secondary tumour mass/masses are
formed at site of lodgment away from primary site
Most reliable feature of a malignant tumor
Benign tumours do not metastasize
All Malignant tumours can
metastasize Except >
Lymph nodes
1. Gliomas of CNS
2. Basal cell carcinoma of the skin To otherTFars
of the body

Routes of Metastasis
1. Lymphatic spread
2. Hematogenous spread
3. Transcoelomic spread

Remember
Carcinomas metastasize by lymphatic route
Sarcomas metastasize by hematogenous route

Cancer lung
1) Lymphatic Spread
Follows natural routes of
Nodal
lymphatic drainage metastasls
producing regional nodal
metastasis

Cancer breast

PAGE 136 | NEOPLASIA

 BUSTER
PATHOLOGY PROF

in regional lymphatic that receives

a

First node VEIN

lymph flow from primary
tumor sentinel lymph Second-tier
ARTERY ymph node
node. useful in breast cancer,
Sentinel lymph node
is
SENTINEL
uulvar cancer and melanoma. was
LYMPH

Term 'sentinel lymph node' first used by

Gould
PRIMARY
UMOR
Third-tler
.omoh node tumor cells lodge in first in LYMPH
CHANNEL lymph node
subcapsular sinus

dtier Third-tler
Second-t tymph node
node
Virchow's lymph node
Subcapsular slnus
Afferent lymphatics
Mallgnant cells

Efferent lymphaticl

Tumor cells in subcapsular sinus

from cancers of
•
Virchow's lymph node is nodal metastasis to left supraclavicular lymph node
abdominal organs e.g. cancer stomach, colon, and gallbladder.
It
thoracic duct
is end node
abdomen, pelvis, and bilateral
Receives afferent lymphatic drainage from left head, neck, chest, venous
junction via thoracic duct
lower extremities, which eventually drains into jugulo-subclavian
Supraclavicular node

To blood stream

Thoracic duct

NEOPLASIA | PAGE 137

 m DR. PRIYANKA SACHDEV

2) Hematogenous Spread Artery

Common route for sarcomas
Veins are more commonly involved than arteries because veins have
thinner walls that can be penetrated readily (In contrast arteries have
thicker walls)

Withvenous invasion tumor cells in blood follow venous flow draining site of
neoplasm.
1. All portal area drainage flows to liver Most common site
2. All caval blood flows to lung 2nd most common site
Liver Hepatic artery
Hepatle
velns Sinusolds

Stomach

vein cellac
artery

caval
Spleen
Aorta

Inferior

Pancreas
Superlor
mesenterie

Small Artery
Intestines
mesenterlc

Inferlor

Artery
Colon

3) Transcoeiomic spread
a) Direct seeding into body cavities or STOMACH

surface
Occurs when a malignant neoplasm
penetrates into a natural open field
E.g. Carcinoma of stomach seeding to both
TRANS-cOELOMIC
ovaries (Krukenberg tumour) SPREAD

OVARY

PAGE 138 | NEOPLASIA

 PATHOLOGY PROF
BUSTER m
Spread via CSE
b)
Malignant tumour of ependyma and leptomeninges

Release of tumour cells into CSE

Tumors shed DNA
Pregmenti irto the Cs#
Metastases at other sites in CNS

Anatysis cftuor pNA

tretmerts from CS#

Implantation
c)
Surgeon's scalpel, needles, sutures
pirect prolonged contact of cancer of lower lip
causing its implantation t apposing upper lip

Mechanism of Metastasis
8 steps
Primary
1) Clonal proliferation and tumour
angiogenesis->
ECM
ECM ECM
Loosened
From Population of ECM tumour Basement
membrane
monoclonalTumor cells cells

A subpopulation or clone of
tumour become more
aggressive Thrombus

Involved in development of
metastasis Metastatic
tumour
Tumour heterogeneity
Aggressive clone with Tumour cell-ECM Entry of tumour cells Extravagatlon of
anglogenesis. Interaction. In lumen. tumour cells.
Loosening of tumour
Degradation of Thrombus formatlon Formation of metastasls
ECM
cells

2) Tumour cell loosening

Normal cells remain glued to each other due to presence of cell adhesion molecules (CAMs) i.e.
E (epithelial)-cadherin.
In cancers

loss or inactivation of E-cadherin and CAMs

Loosening of cancer cells

3) Tumour cell ECM interaction

Loosened cancer cells

Have receptors for ECM proteins

Attached to ECM proteins (laminin, fibronectin, vitronectin, and collagen)

NEOPLASIA |PAGE 139

m DR. PRIYANKA SACHDEV

4) Degradation of ECM
Tumour cells Overexpress matrix-degrading enzymes metalloproteinases (e.g. collagenases
and gelatinase)

5) Entry of tumour cells into capillary lumen

Autocrine motility factor (AME) > acytokine derived from tumour cells which stimulates
receptor-mediated motility of tumour cells.

6) Thrombus formation
Tumour cells

covered with constituents of circulating blood

Forms thrombus

provides nourishment to tumour cells and protects them

from immune attack by the circulating host cells

7) Extravasation of tumour cells

Tumour cells attach to vascular endothelium
Extravasate to extravascular space.

8) Survival and growth of metastatic deposit

Extravasated malignant cells on lodgment in the right environment
Grow further under influence of growth factors produced tumour

(7.05) PROTO-ONCOGENES - RAS, ABL- BCR

University Exams
Long questions
1. Describe molecular pathogenesis of cancer Oncogenes, tumor suppressor genes
2
Proto - oncogenes & Cancer.
3
Describe role of RAS gene mutation in pathogenesis of cancer.
4 ABL - BCR Translocation
Short questions
1
Enumerate steps molecular evolution of cancer from a normal cell.
2. Define Oncogenes. Write its classification
3 Philadelphia chromosome
4. t (9; 22) translocation
Very short questions
1. What is Proto- oncogene
2 Imatinib targeted therapy

Overview
Genetic regulators of cancer (00:01:29)
Proto-oncogenes (00:17:59)
Introduction
Classification
RAS gene (00:25:07)
ABL-BCR hybrid gene (00:37:02)

PAGE 140| NEOPLASIA

 BUSTER
PATHOLOGY PROF

Genetic regulators of cancer

Normal cell
growth 4 regulatory genes:
Normal Cell
Proto-oncogenes
arowth-promoting genes
4
GF No GF
Anti-oncogenes or tumour GR
X GR
2. suppressor genes
arowth-inhibiting or growth
suppressor genes.
3. Apoptosis regulatory Proto-oncogene Tumor
genes >control suppresSor
programmed cell death. gene

A DNA repair genes

regulate repair of DNA
damage that has occurred. Mitosis
during mitosis No mitosis

Remember Normal Cell

In cancer > GF
GF XNo
GR
1. Overstimulation of GR

proto-oncogenes
2. Inhibition of tumour
suppressor genes Overstimulation Inhibition
Proto-oncogene Tumor
suppressor
gene

Cancer
Proto-oncogenes
Introduction >
Discovered by Harold Varmus and Michael Bishop.
Normal genes required for cell proliferation
Act under proper physiological stimuli
no replication.
Without physiological stimuli > silent >

Proto-oncogenes
differentiation)
(Normal genes required for cell proliferation and
Mutation
Oncogenes
cancer cells)
(Genes promoting autonomous cell growth in

Oncoproteins
promoting cell growth)
(Proteins lackíng regulatory control and responslble for

NEOPLASIA | PAGE 141

 m DR. PRIYANKA SACHDEV

Classification

Nuclear Cell cycle

Growth Factors Cytoplasmic signal
Receptors for GES transduction regulatoryY
transduction
fattors. proteins
proteins

PDGF-B EGF-R Mutated RAS C-MYC + Cyclín D

TGF-a C-KIT-R ABL-BCR +N-MYC +Cyclin E

CDKA
FGF • RET-R L-MYC
C-MET FMS-like

RAS gene
RAS protein > signal transducing protein
Point mutation of RAS family genes > most common abnormality of Proto-oncogenes in human
tumor.

2 scenarios
Normal function
Mutation

Normal function GF
In Inactive state RAS proteins bind GDP GR

Growth factors RAS

GAP
RAS proteins become activated by GDP
exchanging GDP for GTP
Actíve Active
Activated RAS recruits RAF-1 and also RAS RAS
activates PI3K

Mitosis RAF PI3K 3GTP

GTPase Activating Proteins (GAP) MAPK

GTP breaks into GDP

Mitosís
RAS Back to inactive state
(Activated state is transient)

PAGE 142 | NEOPLASIA

 m
BUSTER
PATHOLoGY PROF

Mutation GF
GR
Mutation in the RAS gene RAS

(Mutated)
GTPase Activating Proteins (GAP) not
working
Active Actlve
ATPase activity Cannot be increased RAS RAS

No breakdown of GTP
RAF PI3K GTP
Permanent activation of RAS
MAPK
Uncontrolled mitosis
Uncontrolled mitosis
Cancer
!
Cancer

Examples
K. RAS Colon, lung and pancreatic tumors
N. RAS Melanoma, blood tumors (AML)
H. RAS Bladder and kidney tumors

ABL-BCR hybrid gene

.ABL gene > normal location on chromosome 9
BCR gene> normal location on chromosome 22

ABL gene > normal location on

chromosome 9

translocated to NORMAL CHRONIC (Philadelphia Chromosome)

chromosome 22 CHROMOSOMES MYELOID LEUKEMIA t(9;22)
22 9 22
Fuses with BCR gene (breakpoint
BCR BCR
cluster region) locus locus
Forms an ABL-BCR hybrid gene ABL-BCR
Hybrid gene
Philadelphia chromosome on
chromosome 22 ABL
oncogene
Abnormal signal transduction even
without growth factors
ABL
Uncontrolled mitosis oncogene

Cancer

Example CML
Treatment of CML Specific tyosine kinase inhibitor drug imatinib

NEOPLASIA |PAGE 143

m DR. PRIYANKA SACHDEV

I(7.06) TUMOUR SUPPRESSOR GENES - RB, P53

University Exams
Long questions
1. Enumerate steps of malignant transformatlon of a cell, Discuss role of p53 gene In neoplasta.
2. ERPlain Drietly the role of tumor suppresslon genes In oncogenesis. Discuss role of p53 gene in neoplasia,
Short questlons
1. Mutation in p53 oncogene.
2 Li-Fraumeni syndrome
3. List five tumor suppressor genes and cancers caused,by their mutatlons

Overvlew
Classification (00:06:00)
P53 gene >
Introduction (00:07:26)
Normal function (00:08:31)
Mutation (00:18:26)
Li-Fraumeni syndrome (00:22:40)

Classification
GENE ASSOCIATED HUMAN TUMOURS
1. RB Retinoblastoma, osteosarcoma
2. p53 (TP53) Most human cancers, common in Ca lung, head and neck,
colon, breast
3. TGF-b and its receptor Ca pancreas, colon, stomach
4. APC and b-catenin Ca colon
proteins

5. Others
Ca breast, ovary
BRCA 1 and 2 Renal cell carcinoma
ii. VHL Wilms' tumour
ii. WT and 2
1
Neurofibromatosis type 1and 2
v. NF 1
and 2

P53 gene
Introduction >
P53 is a tumour suppressor gene as well as DNA repair gene
Located on chromosome 17
Guardian of genome
Molecular policeman
Normal function >
UV radiation (DNA damage)

P53 accumulate in cell

P21

Cellcycle arrest DNA repair

successful Unsuccessful

MDM-3 BAX

Degradation of p53 Apoptosis

PAGE 144 | NEOPLASIA

 PATHOLOGY PROF BUSTER

Mutation lonlzing radstlon

Cells with
mutation or loss of
p53

DNA damage Normal cel

(p58 normai Cotl with

D53 dependent genes not Oncogenc Stress

activated Hypoxla DNA danage DNA damage
p53 aceumulates snd
blnds to DNA p53-dependnt terses
No cell cycle arrest Mo eet
Syet arrest no senescenc
No DNA repair ErUplon dependant Snd
on
targete
Mutam ells
ion and
Senescence P21
Mutant cells> Expansion and
(COK InNIbIter)(oNA
BAK PUMA 4 mutattons
prenpeptotic
additional mutations G1 arrest
uccesstul repair Repalr fals

Cancer
Normal cells Apoptosls Mallgnat tumor
Li-Fraumeni syndrome
Individual inherit one mnutant p53 allele and second acguired 'hit' inactivate normal p53 allele.
Associated with development of sarcoma, breast cancer, leukemia and brain tumors.

(7.07) CARCINOGENESIS
(PHYSICAL, CHEMICAL, BIOLOGICAL)
University Exams
Long questions
1 Describe Physicalcal carcinogenesis in detail.
2.
Define carcinogenesis. Discuss mechanism of Radiation induced cancers
3 Describe Chemical carcinogenesis in detail.
4
Enumerate major chemical carcinogens. Describe mechanisms of action of chemical carcinogens.
Define and classify oncogenicviruses. Explain the mechanism involved in tumor production by viruses.
6 Define carcinogenesis. Discuss role of RNA viruses in carcinogenesis.
7 Define carcinogenesis. Discuss role of DNA viruses in carcinogenesis.
8 Give examples of oncogenic viruses and discuss oncogenesis by HPV
9 Give examples of oncogenic viruses and discuSs oncogenesis by EBV

Short questions
1 Role of UV rays in Radiation induced cancers
Role of lR rays in Radiation induced cancers
Steps of Chemical carcinogenesis
Differences between Initiators and Promotors in Chemical carcinogenesis
5 Biological carcinogens.
6 Viral carcinogenesis or Oncogenic viruses.
7 Oncogenic deoxyribonucleic acid (DNA) viruses.
8. HPV-induced carcinogenesis.
9. Enumerate oncogenic viruses with example of cancer caused by each.
Very short questions
1
Mention four radiation-induced cancers.
Name any four chemical carcinogens.
3 erate DNA and RNA oncogenic viruses and name cancers caused by them
4. Ennumerate oncogenic parasites and name cancers caused by them
5. List diseases caused by Epstein-Barr virus

Overview
Introduction (00:01:05)
Types (00:04:04)
a) Physical carcinogens (00:04:43)
1 Ultraviolet Light
2. lonising Radiation
b) Chemical carcinogens (00:14:20)
1. Initiation
Promotion
3 Progression
Tests For Chemical Carcinogenicity
c) Biologic carcinogens (00:32:00)
Carcinogenic Viruses HPV, EBV
Carcinogenic Bacterlas
Carcinogenic Parasites

NEOPLASIA |PAGE 145

 DR. PRIYANKASACHDEV

Introduction
Carcinogenesis > Mechanism of induction of tumours
Carcinogens Agents which can induce tumours

Types
a) Physical carcinogens
b) Chemical carcinogens
c) Biologic carcinogens

a) Physical Carcinogenesis
Alsoknown as Radiation induced Carcinogenesis
1. Ultraviolet Light
2. lonising Radiation

1)
Ultraviolet Light
Source Sunlight

3 subtypes
1. UV-A 320-400 nm
2. UV-B 280- 320 nm
3. UV-C 200 - 280 nm
UV-C gets filtered by ozone layer
UV-B is the most carcinogenic UV ray to reach the earth

(UV-B is Bad for humans as it causes cancers)

Mechanism > Cancers

Exposure to UV rays 1. Basal cell carcinoma (most common)
2. Squamous Cell carcinoma
Pyrimidine dimers in DNA 3. Melanoma

Mutation in oncogenes and tumor

suppressor genes

Cancer

2) lonizing
Radiation
Source x-rays, y rays, a rays, B particles

Mechanism > Cancers >

Exposure to ionizíng radiation 1. All forms
of leukaemias (except chronic
Iymphocytic leukaemia CLL)
dislodge ions from water 2. Cancers of the thyroid (most commonly
papillary carcinoma)
Formation of highly reactive free radicals 3. Others skin, breast, ovary, uterus, lung,
myeloma, and salivary glands
DNA damage Maximum sensitivity is at G2 stage
Cancer

PAGE 146| NEOPLASIA

 M
BUSTER
PATHOLOGY PROF

Uitraviolet Light lonizing Radlatlon

Sunlight X-ray, a-ray, b-ray
Source (UV-B is Carcinogenic)
Skin Cancers All leukaemia's (except CLL)
Cancers - AML
BCC
- - ALL
SCC
- Melanoma - CML
Thyroid tumours
Mechanism Pyrimidine dimers in DNA Reactive free Radical Formation
Carcinogenesis
) Chemical
3
stages
1. Initiation
Promotion
2.
3.
Progression
Direct-acting carcinogens Indirect-acting carcinogens (Procarcinogens)

No Metabolic
activation Metabolic activat/on
TARGET CELL
TARGET CELL
Initlator

Reactive electrophiles

INITIATION
INITIATED (MUTATED) CELLS
Target molecules
(Chiefly DNA) Promoter Porslstont
oxposuro to Inltiator

Permanent DNA damage

(Initíated or mutated cell)

Clonal proliferation of PROMOTION CANCER CELLS

altered cells

Cancer phenotype

PROGRESSION
MALIGNANT TUMOUR

1) Initiation
a) Metabolic activation
b) Reactive electrophiles
c) Target molecules mutations
d) Initiated cell Group1 A No tumors
2) Promotion of Carcinogenesis Group 2 Tumors
Promoter carcinogens Group 3 TUmors
Do not damage DNA per se
(not mutagenic) Group 4 No tumors
Enhance effect of initiators Group 5 No tumors
Cause clonal proliferation
and expansion of initiated Time
(mutated) cells X *Applicatlon of initfator VÁpplícation of promoter
To produce
tumour> Initiator (polycyclic hydrocarbon) (Croton olt)
should be followed by promoter
Sequence of initlator and Promotor
NEOPLASIA |PAGE 147
 nDR PRYANKA SACHDEN

3) Progression of Carcinogenesis S.typhmeg

Ett stra)
Stage when mutated proferated Histidine-tree
celishoNs phenotypic features
of malignancy.

Bacterial colontes
Tests For Chemical Suspected chemical
Carcinogenicity cartinsen
Ames' Test
Evatuates ability of a chemical to induce mutation in mutant strain of Salmonella typhimurium that
cannot synthesize histidine.

Chemical carcinogens Assoclated cancor or neoplasm

Alkylating agents AML. bladder cancer
Androgens Prostate cancer
Aromatic amines (dyes) (aniline Bladder cancer
dyes) Cancer of the lung, skin
Arsenic Cancer of the lung. pleura, Peritoneum
Asbestos Mesothelioma
Cancer of the endometrium liver breast
Estrogen Cancer of the liver, esophagus, head and neck
Ethyl alcoho! Cancer of the upper aerodigestive tract, biadder
Tobacco (including smokeless) Liver cancer (angiosarcoma)
Vinyl chloride Lung cancer
Chromium and nickel. Leukemia, Hodgkin's lymphoma
Benzene Gastric cancer
Nitrates Liver cancer
Aflatoxin

c) Biologic Carcinogenesis
Carcinogenic Organisms
Infectious agent Tumos
Virus HPV Cervical,vulvar& penile cancers (squamous cell carcinoma)
EBV Nasopharyngeal carcinoma, Burkitt's lymphoma, Hodgkin's
lymphoma
HBV, HCV Hepatocellular carcinoma
HTLV-1 Adult T- cell leukemia
HHV-8 Kaposi sarcoma, primary effusion lymphomna
Bacteria H. Pylori Gastric Cancer

Parasite Schistosomiasis Bladder cancer (squamous cell)

Clonorchis sinensis Liver cancer (HCC), bile duct carcinoma
(cholangiocarcinoma), Pancreatic cancer
Opisthorchis viverrine Bile duct carcinoma (cholangiocarcinoma)
Fasciola hepatica Bile duct carcinoma (cholangiocarcinoma)

PAGE 148 | NEOPLASIA

 BUSTER
PATHOLOGY PROF

VirusSes
Carcinogenic
Carcinogenic Viruses

RNA viruses
DNA viruses
Human T cell leukemia Hepatitis B virus (HBV)
virus-1 (HTLV-1) Human herpes virus 8 (HHV8)
Hepatitis Cvirus (HCV) Human papilloma virus (HPV)
Epstein Barr virus (EBV)

Increased
telomerase
Papillomavirus (HPV)
TERT
expression
Wuman
HPV (16,11) cause benign
>

Low in Inhlbltlon of p53

squamous papilloma (warts) humans. HPVE6
P53
High-risk HPVs (16,18,31,33,445)> cause
squamous cell carcinomas of the cervix,
anogenital region Immortalization
Penis, Inhlbltlon of p21
HPV E7 Increased cell
proliferation
Fostein-Barr Virus (EBV) Genomic instability
Increased
cDKALCyclin D
. Burkitt lymphoma
, Nasopharyngeal carcinoma
T-cell lymphoma Inhibition
.Subset of Hodgkin lymphoma (lymphocyte RB-E2F
of RB-I
B-E2F
depleted)
.
Natural killer (NK) cell lymphoma

LATENT EBV receptor (C021)

INFECTION -EBV Vrus
WITH EBV
EBV
EBV-specmc
cyotoxdc
Enters epithelial cells of oropharynx andB- cells via POLYCLONAL T ceis
CD21 receptor BCELL
EXPANSION
Bcol kting
LMP-1 gene present in EBV integrate with human by CTLs
DNA
EBV antigens

Activation of NF-kB and JAKISTAT signaling B-cel

pathways Mutation growth
cor ed
(MYC transkocatlon)
Chromosomes
promoting B-cell survival and proliferation
ONA Deaks
INCREASED
Acquisition of t (8;14) translocation PAOTEIN

Burkitt Iymphoma
Addrtonal mutatons

OUTGROWTH
OF NEOPLASTIc
CLONE:BURKITT
LYMPHOMA

Carcinogenic Bacteria
H.
pylori first bacterium classified as a carcinogen.
•
Causes >
1. Gastric adenocarcinomas
2. Gastric lymphomas

NEOPLASIA | PAGE 149

 m DR. PRIYANKA SACHDEv

Carcinogenic Parasites
1. Schistosomiasis Bladder cancer (squamous cell)
2. Clonorchis sinensis Liver cancer (HCC), bile duct carcinoma
(cholangiocarcinoma), Pancreatic cancer
3. Opisthorchis viverrine Bile duct carcinoma (cholangiocarcinoma)
4. Fasciola hepatica Bile duct carcinoma (cholangiocarcinoma)

(7.08) CLINICAL FEATURES

(TUMOUR LYSIS SYNDROME AND PARANEOPLASTIC SYNDROMES)
Universily Exams
Long questlons
Local and Systemic manlfestations of cancer
Paraneoplastic syndromos with four examples.
Malignant cachexia,
4. Tumour lysis syndrome
Short questions
1. Systemic effects of cancer.
2, Enumerate paraneoplastic syndromes with appropriate
examples.
Very Short questions
1. Cachexia.
2 List five tumors which produce paraneoplastic
syndrome.

Overview
Clinical Features (00:01:19)
Local Effects (00:01:54)
1. Compression
2 Obstruction
Tissue destruction
Infarction, ulceration, haemorrhage
Systemic Effects (00:06:40)
1. Cacer cachexia
2 Fever
3. Tumour lysis syndrome
4. Paraneoplastic syndrome

Clinical Features

Clinical Features

Local Efects Systemlc Effects

1. Compression 1. Cancer cachexia
2. Obstruction
2. Fever
3. Tissue destruction 3. Tumour lysis syndrome
4. Infarction, ulceration, 4. Paraneoplasticsyndrome
haemorhage

Local Effects
1) Compression>
Some benign tumours due to their critical location
have more serious consequences e.g. pituitary
adenoma

PAGE 150 | NEOPLASIA

 Mechanical obstruction >
2)
tumours
PATHOLoGY PROF BUSTER m
Benign and
malignant
in gut may
-> produce intestinal
3)
Tissue destruction obstruction.
Malignant tumours infiltrate and destroy
int
vital structures
4)
Infarction, ulceration, hemorrhage

Systemic Effects
)Cancer
Cachexia
Due to anorexia and increased
Certain
nutritional demands
cytokines such as tumour of the tumour.
role in cachexia necrosis factor a
(TNF-a), IL-1
and INF-9 play a
contributory
Cancer

Prolnflammatory
(IL-1, IL-6, TNF-c)
cytoklnes
TGF-P naholle hormones
(myostatln) Tumor (insulin, IGF-1)
factors (PIF?)

- Proteolysis Anorexla Adipogeness

Lipolysls
Protein synthesis
Oxidative stress
|Cachexia Myogenesls

Welght
lossMuscle atrophy
Anemla Chemotherapy tolerance
2)
Fever
.
Tumour cells
themselves elaborate pyrogens.

NECROTIC
1SSUE Inflammatory cytokine
TUMOR CELL.
ILS
PGE2 IL-6
IL-10
TNE-a LIVER
HYPOTHALAMUS Interferon
etc

FEVER CRP

3)Tumour Lysis Syndrome

•
Caused by extensive destruction of a large
number of rapidly proliferating tumour cells
Tumor lysis syndrome
with > is associated
Hyperkalemla: K*
High Potasslum Levels In the Blood
1. Burkitt lymphoma
2. Acute lymphoblastic leukemia (ALL)
3. Chronic tumors (CLL) Hyperurlcemla:
Excess Uric Acld in the Blood
4. Uncommonly solid tumors
Hyperphosphatemla:
High Blood Phosphate Levels (PO+)

Hypocalcemla:
Low Calcium Levels In the Blood Ca2+)

NEOPLASIA | PAGE 151

 DR. PRIYANKA SACHDEV

Characterized by
1. Hyperuricemia due to increased
turnover of nucleic acids Hyper
uric Effux of K+ Release of nucleic acid phosphatemia
acid precipitation in the kidney >
acute renal failure.
2. Hyperkalemia due to release of
intracellular potassium Purine catabolism
Arrythmias
3. Hyperphosphatemia due to Hyperuricemia
release of intracellular phosphate
4. Hypocalcemia Hyperkalaemia Calciumphosphate
due to Precipitation of
complexing of calcium with imbalance
uric acid crystals
elevated phosphate Arrythmias
EKG abnormal
Acute renal failure
Fluid depletion
Fever, vomiting,
diarhea
poor intake
4) Paraneoplastic Syndronme
A group of conditions developing in
patients with advanced cancer which are neither explained
direct and distant spread of the tumour hy
10 to 15% of the patients with
advanced cancer develop
Sometimes PNS may be the earliest manifestation a paraneoplastic syndromes
of latent cancer.
CLINICAL SYNDROME
UNDERLYING CANCER MECHANISM
1. Endocrine Syndrome
i. Hypercalcaemia -Lung (sq. cell Ca), kidney, -Parathormone-like protein
breast,
Adult T-cell leukaemia
-Vitamin D
ii. Cushing's syndrome lymphoma
-Lung (smallcell carcinoma), -ACTH or ACTH-like
pancreas, neural tumours
ii. Inappropriate anti-diuresis -Lung (small cell Ca), prostate, substance
-ADH or atrial natriuretic
iv. Hypoglycaemia intracranial tumour factor
-Pancreas (islet cell tumour), -Insulin or insulin-like
V. Carcinoid syndrome mesothelioma, fibrosarcoma
-Bronchial carcinoid tumour, substance
carcinoma pancreas, stomach -Serotonin, bradykinin
vi. Polycythaemia
-Kidney, liver, cerebellar
haemangioma -Erythropoietin
2. Neuromuscular Syndromes
i. Myasthenia
gravis -Thymoma
ii.
-Immunologic
Neuromuscular disorders -Lung (smallcell Ca),
breast -Immunologic
3. Osseous, Joint,
i.
Soft Tissue
Hypertrophic
osteoarthro pathy Lung
ii. Clubbing of Not known
fingers Lung
4. Haematologic Syndromes Not known
i. Thrombophlebitis
(Trousseau's phenomenon) Pancreas, lung, GIT
ii. Non-bacterial thrombotic Hypercoagulability
endocarditis Advanced cancers
iii. Disseminated Hypercoagulability
intravascular AML,
coagulation (DIC) adenocarcinoma
iv. Anaemia Chronic thrombotic
Thymoma phenomena
Unknown
 Gastrointestinal Syndromes
Malabsorption PATHOLOGY PROF BUSTER m

Lymphoma
Renal Syndromes
of small
A bowel
Nephrotic syndrome Hypoalbuminemia
Advanced
Cutaneous Syndromes cancers
Acanthosis nigricans Renalvein thrombosis.
H
Seborrheic dermatitis Stomach, systemíc amyloidosis
Bowel large bowel
il Exfoliative dermatitis Inmunotogic
Lymphoma
Amyloidosis Immunologic
B.
Imnunotogic
i Primary Multiple
ii. Secondary
myeloma
Kidney, ymphoma,
tumours solid Inmunologic (AL protein)
AA protein

Most common tumor associated

with paraneoplastlc
Most common paraneoplastic
syndrome syndromo
peptide by squamous cellI carcinoma Hypercalcomia small coll carcinoma of
Most common endocrinopathy lung) (causodby parathytoid lung
Cushing's syndrome hormone rolated
cellcarcinoma lung)
(duo to production of
ectopic ACTH by small

|(7.09) GRADING AND STAGING OF

CANCERS
University Exams
Short questions
1. Grading and staging of cancer.
2. Grading of tumors.
TNM Staging
Differentiate Grading and staging
of cancer.

Overview
Introduction (00:00:52)
Grading (00:04:26)
Staging (00:08:05)
TNM Staging (00:08:45)

Introduction
Grading'
tumour
and 'staging' > 2 systems to predict tumour behavior and guide therapy after a
is detected. malignant
• Grading gross appearance and microscopic degree of differentiation
of tumour
Staging extent of spread of tumour within patient

Remember
•
Grading > done on patholologic basis
Staging doneon clinical grounds

Grading
Gross
appearance and microscopic degree of differentiation of the tumour

NEOPLASIA |PAGE 153

m DR. PRIYANKA SACHDEV

Broders' grading CANCER CELLS

Grade i: Woll-diflerentiated (less than 25% anaplastic
cells)
Grade Il: Moderately-differentiated (25-50% anaplastic
cells)
Grade 1Il: Moderately-differentiated (50-75%
anaplastic cells)
Grade IV: Poorly-differentiated or anaplastic (more
than 75% anaplastic cells)
MGRMAL CELLS
Staging
Extent of spread of tumour vwithin pationt.
Assessed by 3 ways-
a) By clinical examination
b) By investigations
c) By pathologic examination of the tissUe removed

2 important staging systems currently followed aro:

1. TNM staging
2. AJC staging

TNM staging
3 components T, N and M
TO to T4:
In situ lesion to largest and most extensive primary tumour.
NO to N3: No nodal involvement to widespread lymph node involvement.
MO to M2: No metastasis to disseminated haematogenous metastases.

Tumor size < 2 cm Tumor síze 2-5 cm Tumor size >5 cm Tumor extends to
skin orchest
wal
Tumor Size

T1 T2 T3
T4
NO N1 N2 N3
Lymph No lymph node Metastasis to Metastasis to Metastasis to
Nodes metastasis ipsilateral, ípsilateral fixed infraclavicularl
movable, axillary axillary, or IM supraclavicular
N LNs LNs LN, or to axillary
and IM LNS
MO M1
Metastasis LNs= Lymph Nodes; IM= Internal
No distant Distant
M Metastasis metastasis
Mammary

Stage I
Stage ll Stage Stage IV
lI

PAGE 154 | NEOPLASIA

 UICC TNM Category PATHOLOGY PROF BUSTER
stage
Ti, No, Mo Early cancer
(operable, 5-year
T1, Ni, Mo Early cancer curable) survival ()
T2, NO1, Mo
(operable, 84
curable)
Any T, N2-3, Mo Locally
Any N, Mo advanced
(Neoadjuvant 74
breast
treatment cancer
Any T, N, M1 Metastatic (Not to make operablo)
curable, Inoperable, 48
Palliative care)
18
(7.10) LLABORATORY DIAGNOSIS
(TUMOUR MARKERS) OF
CANCER

tiversity Exams
Long questions
Laboratory diagnosis of cancer.
1.at do you underStand by tumor
markers? Discuss them in dotai
Short Answer
tumor markers and
Discuss the role of
Histochemistry. their role In diagnosls.
FNAC (Fine needle aspiration cytology)

Very short questions

nnhistochemistry and its role
Cemerate six tumor markers in diagnosis of tumors-list
giving one example of tumor four tumors.
Exfoliative cytology associated with each.
Alpha feto protein.

Overview
Diagnosis Of Cancer
1. Histological method (00:01:37)
a) Paraffin embedded technique
b) Frozen section
2. Cytological method (00:20:22)
a) Exfoliative cytology
FNAC
3. Histochemistry and Cytochemistry (00:27:57)
4. Immunohistochemistry ((HC) (00:28:40)
Electron microscopy (00:31:30)
6. Tumour markers (00:33:30)

1) Histological Methods
a) Paraffin embedded
technique
Steps >
Fixation Processing
i.
Fixation Embedding

i. Processing
i..Embedding
iv. Cutting And Trimming
V. Staining
vi. Examination
Cutting And Trimming Staining Examination
b)Frozen section
Procedure is generally carried out when patient is
undergoing surgery
Unfixed tissue is used
Tissue is embedded in ice instead of paraffin wax
frozen section
Cryostat machine is used

NEOPLASIA | PAGE 155

 m DR. PRIYANKA SACHDEV

2) Cytological Methods
2 types
a) Exfoliative cytology
Microscopic examination of shed, desquamated cells from body surfaces or cells
by rubbing or brushing a lesional tissue surface. harvested

Exfoliative cytology is used for

1. Cervical Carcinoma
2. Endotnetrial Carcinoma
3. Bronchogenic Carcinoma
4. Bladder Carcinoma
5. Prostatic Carcinoma
6. Stomach Carcinoma Buccal mucosa • Floor of the
mouth
The lovwer labial and
•

Junction of the hard & soft palate

• Dorsum of the tongue region.
b) FNAC
Cell morphology and nuclear features is well
seen
Cell architecture is not seen

FNAconsist of four steps

1. Palpation
2. Aspiration
3. Smear preparation
4. Micros copy

Surgical Biopsy FNAC

Diagnosis Histopathological Cytopathological
Diagnostic difficulty NarroW Broad
Anaesthetic Yes No
Length of procedure More than 5 min Less than 5 min
Report available 2-4 days 2-4 hrs
False positive None Rare
Cost Relatively high Economical
Trauma Yes Little if any

3) Histochemistry and Cytochemistry

1. Basement membrane/collagen -
Periodic acid-Schiff (PAS)
-
Reticulin
-
Van Gieson
-
-
Masson's trichrome
2. Glycogen PAS with diastase loss
3. Glycoproteins, glycolipids, glycomucins- PAS withdiastase persistence
-
4. Acid mucin Alcian blue
5.Argyrophilic/argentaffin granules Silver stains
6. Nucleolar organiser regions (NORS) Colloidal silver stain

PAGE 156 | NEOPLASIA

4).Inmunohistochemistry (IHC) PATHOLOGY PROF BUSTER
FTUMOUR MMUNoSTAIN
tumours
4 Epithelial Pankeratin
(Carcinomas)
Epithelial (HMW-K, LMWN-K)
membrane
Carcinoembryonic antigen
Mesenchymal Neuron-specific antigen (EMA)
2.
Vimentin (CEA)
enolase (NSE)
tumours
(Sarcomas)
Desmin (general mesenchymal)
Myoglobinmyogenlc)
(for skeletal
a-1-anti-chymotrypsin myogenic)
CD34 (endothellal (for malignant
MB-45 marker) fibrous histiocytoma)
(most specific)
Melanoma Vimentin
3.
S-100
Leucocyte common
4. Lymphoma Pan-B (lmmunoglobullns,
antigen (LCA/CD45)
Pan-T (CD3) CD20)
RS cell marker
Neurofilaments for Hodgkin's (CD15,
NSE (NF) CD30)
5. Neural and
GFAP (for
neuroendocrine gllal
tumours
Chromogranin tumours)
(for neuroendocrine)

5) Electron Microscopy
Ultrastructural examination
of tumour cells

6) Tumour Markers
• Somne tumor produce markers that can be measured in serum or urine or
Tumor markers
biochemical indicators of presence the a other body fluids.
Many of these products are of tumor
Thus, biochemical estimation
produced by normal body cells too
of the product in blood reflects total
cells alone. substance and not by the tumour
So, lack sensitivity as as
well specificity
Use as an adjunct to pathologic
diagnosis and for prognostic and therapeutic purposes
Clinical applications
Screening in general population
Diagnosis in symptomatic
patients
Estimating tumor volume
Prognostic indicator of disease progression
Monitoring responses to
therapy
Detectingrecurrence of cancer

NEOPLASIA | PAGE 157

 m
DA, PRIYANKA SACHDEV

Tumor Markers Tumor Types

Hormonos
Human chorionic gonadotropin Trophoblastic tumors, nonseminomatous
testicular tumors
Calcitonìn Medullary carcinoma of thyroid
Catecholamine and metabolites Pheochromocytoma and related tumors
Oncofoetal Antigens
a-Fetoprotein Liver cell cancer, nonseminomatous germ
cal
tumors of testis
Carcinoembryonic antigen Carcinomas of the colon, pancreas, lung.
stomach, and heart
Isoenzymes
Prostatic acid phosphatase Prostate cancer
Neuron-specific enolase Small-cell cancer of lung, neuroblastoma
Specific Proteins
Immunoglobulins Multiple myeloma and other gammopathies
Prostate-specific antigen and Prostate cancer
prostate-specific membrane antigen
Mucins and Other Glycoproteins
CA-125 Ovarian cancer
CA-19-9 Colon cancer, pancreatic cancer
CA-15-3 Breast cancer

PAGE 158 |NEOPLASIA

 CHAPTER

ENVIRONMENTAL AND
NUTRITIONAL DISORDERS 8
OBESITY
(8.01)
I
Exams
tniversity
questions
hort and pathogenesis of Obesity
Sho
D8scribe etiology of obesity
for assessment
Parameters (BMI)
1.
ite
Body mass index

Overview (00:00:48)
assessment of obesity (00:01:43)
Introduction
erameters for
(00:13:29)
Etiology (00:15:23)
Pathogenesis (00:16:35)
Effects of Obesity

Introduction
risk
Excess of adipose tissue that imparts health
excess over ideal weight for age, sex and heiaht is considered a health risk.
.A body weight of 20%

Parameters for assessment of obesity

1. BMI (Quetlets index)
2. Broca's index
3. Lorentz's formula
4. Corpulence index (HT. independent)
5. Skin fold thickness
1. BMI (Quetlets index)
Internationally accepted method of assessment of obesity
Most widely used method to gauge obesity

BMI
Wt (Kg)
(Quetlets index) =
Ht² (m)
• A cut-off BMI value of 30 is used for obesity in both men and women.
 m, DR. PRIYANKA SACHDEV

Classificatlon BMI(GIobal)
Underweight <18.5
Grade I
17.00-18.49
Grade Il 16.00-16.99
Grade Im < 16

Normal range 18.50-24.99

Overweight >25.00
Preobese 25.00-29.99
Obesity- | 30.00-34.99
Obesity 35.00-39.99
Obesity- II (Morbid) >40.00
2. Broca's index = Ht - 100 =
ldeal wt

3. Lorentz's formula = Ht (cm)-150

Ht(cm) -100
2 (women) or 4 (men)
Actual Wt
4. Corpulence index (HT. independent) = < 1.2
Desirable Wt
5. Skin fold thickness
Noninvasive method for body assessment fat
4 sites - biceps / midtriceps / Subscapular & suprailiac region
Measured by - Herpenden skin calliper
Single best measurement - Midtriceps

-
Obesity Cut off
> 18mm (boys)
> 32mm (girls)

Etiology
Obesity results when caloric intake exceeds utilisation.

Imbalance occur in following situations >

1. Inadequate pushing of oneself away from dining table causing overeating.
2. Insufficient pushing of oneself out of chair leading to inactivity and sedentary life style.
3. Genetic predisposition to develop obesity.
4. Diets derived from carbohydrates and fats
5. Secondary obesity underlying diseases hypothyroidism, Cushing's disease, insulinoma and
hypothalamic disorders.

PAGE 160 | ENVIRONMENTAL AND NUTRITIONAL DISORDERS

 PATHOLoGY PROF
BUSTER m)

pathogenesis
Specific/Over nutrition
Proinflammatory
cytokines
leptin

Inflammation
Hyperleptinemia
Obesity

Central and Peripheral

Leptin resistances

Impaired Impaired gucose

nutrient Food intake
T
and lipid
absorption metabolism

Effects Of Obesity
Hyperìnsulinaemia
9 Type 2 diabetes mellitus -Stroke
Hypertension
3. Hyperlipoproteinaemia Hypoventilatlon syndrome
4,
5. Atherosclerosis Poronary atery ises
e
Nonalcoholic fatty liver disease (NAFLD)
Cholelithiasis Hypertesion
7.
HVDoventilation Fatty lver
syndrome (Pickwickian syndrome) Type 2 diabetes
9. Osteoarthritis
10. Cancer CholeGthiass

Atherosdeross,
Hypoventilation syndrome byperipidaemia
(Pickwickian syndrome)
Obese individuals
Osteoatitts
Carbon dioxide retention and hypoxia
Polycythaemia and Hypersomnolence
(Mr.Pickwick was a character, the fat boy, in Charles Dickens' Pickwick Papers Term Pickwickian
syndrome was first used by Sir William Osler for sleep apnea syndrome).

ENVIRONMENTAL AND NUTRITIONAL DISORDERS | PAGE 161

 CHAPTER

CANCERS INFANGY
OF
9
AND CHILDHOOD

OF INFANCY AND CHILDHOOD

(9.01) CANCERS
[
Extms
University
questions Gross and mlcroscopy of
Rotinoblastoma.
Gross, microscopy of any 3
Long Molecular pathogenesis, Cllnical features, pathogonosi Clinical foatures,
Describe etiology, tumors. Descrlbe Molecular
common pediatric malignant
Deree tumors.
pediatric malignant
questions tumors.
Short common pediatric malignant
List four
Retinoblastoma gene.
hypothesis.
Knudson's two hit
TVpes of
Retinoblastoma.
Molecular pathogenesis
of Retinoblastoma.
Retinoblastoma.
5 Trilateral
of Retinoblastoma.
6 Gross and microScopy Wilms tumour.
Gross and microscopy of Neuroblastoma.
7

8 Gross and microscopy

of retinoblastoma.
9. Differentiate Familial and sporadic
10. retinoblastoma. tumour.
11. Rosettes in Neuroblastoma and Wilms
12 Differentiate

Overview
Common Cancers of infancy and childhood Introduction
Retinoblastoma (00:03:00)
1. Arises from
2. Wilms tumour (00:23:55) Age
3
Neuroblastoma (00:28:26)
Gender
Molecular pathogenesis
Clinical features
Gross
Microscopy
Spread
Prognosis

Common Cancers of infancy and childhood 1014Years

0-4 Years 59.Years
Leukemia
Leukemia
Retinoblastoma
Neuroblastoma Renal cell carcinoma
Neuroblastoma
Wilms tumor Hepatocellular carcinoma
Hepatocellular carcinoma
Hepatoblastoma Soft tissue sarcoma
Soft tissue sarcoma
Soft tissue sarcoma
(especially rhabdomyosarcoma) Ewing sarcoma
Ewing sarcoma
Osteogenic sarcoma
Teratoma
Central nervous system tumors
Central nervous system tumors Lymphoma, including
Lymphoma Hodgkin lymphoma

(1) Retinoblastoma
Introduction >
MOSt common primary intraocular malignancy of childhood
 DR. PRIYANKASACHDEV

Arises from
Primitive retinal cells
Age
<3 years of age
Gender
M =F
Molecular pathogenosis
Mutation of RB gene
Located on long arm (g) of chromosome 13 (chromosomo 13q14)
Normally
Growth inhibitors Growth factors

Inactivates cyclins andCDKS Activates cyclins and CDKS

Hypophosphorylation of RB Hyperphosphorylation of RB

RB RB becomes inactive
becomes active
Form an inactive complex with Dislocation of RB from
transcription factor EF-2 transcription factor EF-2

Blocks cell division Celldivision (mitosis)

(no mitosis)

GROWTHINHIBITORS (TGF-b, p53, others) GROWTHFACTORS (EGF, PDGF)

Simulate
CDK Inhibitors p16(NK4a) Activate

Inactivate

Cyclins D/CDK4,6 Cyclins D/CDK4.6

Cyclin E/CDK2 Cyclin ElCDK2

Hypophosphorylated RB Hypophosphorylated RB

E2F

E2F
Histone Histone
methytransferase deacetylase

E2F siteS phase genes E2F site S phase genes

Transciptional Transcriptional
block activation

Mutationin RB
Mutation in RB

Permanent inactivation of RB
Permanent Dislocation of RB from transcription factor EF-2
Abnormal Cell division (mitosis)

Cancer
PAGE 164 | CANCERS OF INFANCY AND CHILDHOOD
 gene
Active RB
Active in hypophosphorylated
Prevents replication by formlngstate
PATHOLOGY PROF BUSTER
m
an
Blocks cell division inactive
Inhibiting the cell cycle at complex
G1 with
transcription
Inactive RB
gene S phase factor EF-2.
Phosphorylation of RB gene
Dissociation of RB from causes
EF-2. Inactlvatlon
Activation of EF-2 of RB gene
Cell replication
Mutation in RB
Permanent inactivation ofRR
Knudson's two hit hypothesis
Retinoblastoma develops
when both
the normal allolos of
tho RB
gonos aro inactivo
Types of Retinoblastoma
1. Familial / Hereditary retinoblastoma
2. Sporadic/non- hereditary
retinoblastoma

PATHOGENESIS
OF RETINOBLASTOMA

FORM
88
SPORADIC

88

Somatic cels Germ

of parents cells Zygote Somaticcells of child
Retinal colls
Retinoblstoma
FORM

FAMILIAL
-0
88
Normal
(ene
Mutat
RB ene 88
1. Familial retinoblastoma
comprises 40% of cases
bilateral
somaticcells inherit one mutant RB gene from a
The other mutation occurs carrier parent (i.e. germline mutation).
after birth.
Besides retinoblastoma, children inheriting
mutant RB gene have 200
development of other cancers eg osteosarcoma, times greater risk of
breast, colon and lungs.
2. Sporadic retinoblastoma
constitutes 60% of cases
unilateral
acquired both the somatic mutations in
the two alleles after birth.

CANCERS OF INFANCY AND CHILDHOOD

| PAGE 165
 m DR. PRIYANKA SACHDE

Heritable vs Nonheritable Retinoblastoma

Tnherlted Sporadic
Family history Positive, but affected child may No affected
represent a new mutation relatíves
Average age at prosentatlon 8 months 24 months
Tumor distribution Usually bilateral and multifocal Unilateral
Increased risk for other Osteosarcoma, other sarcomas, None
primary tumors melanoma, bladder cancer
Mutatlonal origin One germline and one somatic Both somatic
Comprises 40% of cases 60% of cases

Trilateral RB
Bilateral RB with ectopic intracranlal RB (pineal gland or
parasellar region

Clinical Features
1. White reflex in pupillary area (cat's eye)
2. Squint
3. Cataract/ Bulging eye/ large eye
Unllateral leukocoria
Gross
Patterns of Growth
TUMOR

ENDOPHYTIC EXOPHYTIC
Arises from inner Arises from outer
layers of retina. layers of retina.he
Flls vitreous cavlty • Fills subretinal
Anteriorly reaches Space,
aqueouS venous •
Posterlorly causes
channels serous RD.
May permeate Choroldal Invaslon
through lymphatic ENDOPHYTIC LESION EXOPHYTIC LESION
Proptosls & RD.
channels. White eye reflex. Proptosis.
Visual disturbance &
white eye reflex.

Undifferentiated tumour cells Retina

Neurofibrillary structure Rosette

Microscopy
Tumour shows wide areas of necrosis and
calcification
1. Flexner-Wintersteiner rosettes small
tumour cells arranged around a lumen with
their nuclei away from the lumen
2. Homer-Wright rosettes radial
arrangement of tumour cells around central
neurofibrillar structure

PAGE 166| CANCERS OF INFANCY AND CHILDHOOD

Spread PATHOLOGY PROF BUSTER
m

ROUTEB
OF SPREAD

Dlrect local
Tumor Inflltratlon Subarachnold
Space Ot Anterlor
spread
optlc nerve Conjuncttvs, to Hematogenous
Eyellds & dlsseminatlon
Extra ocular From orbltal, bone of
tlssue
lymphatlc Invaslon
Chorold invaslon
CSF disseminatlon
To braln &
spine Lymphauc
disseminalon
Scleral Invaslon
Orbltal soft
tissue, bone &
brain invaslon

Prognosis
95% survivalrate
Poor prognostic factors >
a) Size of the tumor
hi Optic nerve involvement
c) Extra-ocular
spread
d) Older age at diagnosis

(2) Wilms Tumour

Introduction
Kidney
Also known as Nephroblastoma
Most common
abdominal malignant tumour
of young children

Arises from
primitive renal epithelial and mesenchymal components
Tumór

Age
3-5 yearS of age

Gender
M=F

Molecular Pathogenesis
Mutation of Wilms' tumour associated gene, WT1 gene
(chromosome 11p13)

Clinical Features
a) Palpable abdominal mass in a child detected by mother
b) Abdominal swelling
c) Abdominal pain
Gross
Tumour is large, spheroidal, replacing most of the
kidney.
Solitary and unilateral (5-10% bilateral tumour)
On cut section variegated appearance

CANCERS OF INFANCY AND CHILDHOOD| PAGE 167

 DR. PRIYANKA SACHDEV

Microscopy
Abortive tubule Tumour cells Poorly-formed
Triphasic tumour 3 components
glomeruus
1. Blastemal > small, round, blue, anaplastic
tumour cells
2. Epithelial Abortive tubules and poorly
formed glomerular structures
3. Stromal Mesenchymal elements such as
smooth and skeletal muscle, cartilage and
bone, fat cells and fibrous tissue
Spread
Spreads via blood especially to lungs

Prognosis

The prognosis of tumour with combination therapy of nephrectomy,

post-operative irradiation and
chemotherapy is good
5-year survival now is 80-90%

(3) Neuroblastoma
Introduction>
Most common extracranial solid tumor of childhood
Most common malignant tumor of infancy
Arise from
Cells of neural crest that form the adrenal medulla and sympathetic ganglia

Sites
Adrenal gland
Sympathetic chain
Neck
Thorax
Retroperitoneum
Pelvis
Age >
1 to 2 years
of age
Gender
M=F
Molecular pathogenesis
Autosomal dominant pattern of inheritance
Amplification of the N-MYConcogene
Hereditary neuroblastoma predisposition gene chromosonme 16p
Deletion of the short arm of chromosome 1
Clinical features
a) Constitutional symptoms: Anorexia, weight loss, malaise, fever
b) Pain
a) Most common presenting symptom
b) Due to local spread &lor metastatic disease
c) Abdominal lump
d) Respiratory compromise: in young infants with massive hepatomegaly.
e) Mimic pheochromocytoma:
a) Paroxysmal hypertension, palpitations, flushing, and headache.

PAGE 168 | CANCERS OF INFANCY AND CHILDHOOD

Gross
Tumour is large, soft and lobulated PATHOLOGY PROF BUSTER
Extensive areas of necrosis mass
grey white and haemorrhages
Cut surface
>

Microscopy
Tumour cells
Small,round and oval, slightly
largerthan lymphocytes
Have scanty
Poorly-defined cytoplasm
Hyperchromatic nuclei
lamer-Nright's rosettes
(pseudorosettes)> have a
surrounded by radially central fibrillar eosinophilic
arranged tumour cells. material

Undiffereniated tumour
Neurofibrillary structure cells
PseudorOsette
Rosette

Spread
Spreads via blood especially to bones, bone marrow, liver

Prognosis
Favorable prognostic features are
a) Age of child below 2 years.
D)
Extra-abdominal location of tumour than abdominal masses.
c) Patients in clinicalstage Ior stage
l
F
ravourable genetic features hyperdiploidy, lack of amplification of N-myc oncogene

CANCERS OF INFANCY AND CHILDHOOD |PAGE 169

 DR. PRIYANKASACHDEV

Rotlnoblastoma WIlm's tumous Neúroblastoma

Foaturos
Introductlon MC primary Most common abdominal MC extracranial
intraocular mallgnant tumour of young solid tumor of
malignancy of childron childhood
childhood MC malignant
tumor of infancy
Primitive retinal cells Primitive retinal epithelial cells Neutral crest from
Arlse from
adrenal medulla or
sympathetic ganglion
<3 Yr. 3-5 Yr. 1-2 Yr.
Age
Gender M=F M=F M=F
Mutation in RB gene Mutation in WT-1 gene (Ch. 11) Amplification of N-Myc
Molecular
Pathogenesis (Ch. 13) gene
White reflex, Squint, Abdominal mass, Pain Abdominal mass, Pain
CIF
Catract, Glancoma
Gross Endophytic Solitary, UIL, C/s varigated Large lobulated,.
Exophytic calcification
Mixed
Microscopy FW rosettes Triphasic Blastemal HW Rosettes
HW rosettes Epithelial
Stromal
Spread Direct Blood Blood
Lymphatic
Blood
Prognosis > 95% 80-90% 82%
5 Yr. Survival

PAGE 17O |CANCERS OF INFANCY AND CHILDHOOD

 CHAPTER

RBC DISORDERS 10
BONE MARROW ASPIRATION AND BIOPSY
10.01) B
Exams
versity
questions of Bone marrow examination. what is the importance of study of Bone marrow in hematological disorders.
ng methods
Describe

ques tlons of bone marrow asplration.

ort and contraindications :
Indications between Bone marrow aspiration and Bone marrow Blopsy
Diflererces
questions
y Shortmarrow aspiration
Bone marrow Biopsy
Bone

w (00:01:20)
ervie
Introduction
Haematopoiesis (00:02:32)
(00:07:42)
Haematopoietic organs
Bone marrow
examination (00:10:03)
Preferred sites
Indications
Absolute Contraindications
Methods (00:15:50) Needles, Method, Information
Aspiration (00:16:33)
(00:18:32)
Trephine biopsy (00:20:04)
vs Biopsy
Bone marrow aspiration

troduction
eulating blood contains 3 main types of mature blood cells
RBCs (erythrocytes)
WBCs (leucocytes)
Platelets (thrombocytes)

aematopoiesis
Production of formed elements of blood
RBCs,WBCs, platelets > derived from Pluripotent Hematopoietic stem cells (HSC)
CD34 positive

CD34
 DR. PRIYANKA SACHDEV

Red blood
cells

Hematopoietlc
stem cells (HSCs)
Red bone
marow

Whlte blood
cells

Platelets

Haematopoietic Organs
Age Predominant site for erythropoiesls
2nd. 10th week of gestation (mosoblastic stage) Yolk sac

10th-24 week of gestation (hepatic stage) Liver

24 weeks -till birth (myeloid stage) Bone marrow throughout skeleton

Birth to puberty Bone marrow throughout skeleton
After puberty (after 16-18 years) Bone marrow of vertebrae, ribs, sternum, skull,
pelvis, and proximal ends of humerus & femur

HSC

Lymphoid stem cells Myeloid (trilineage) stem cells

Prolymphocyte Granulocyte monocyte Erythroid Megakaryocytes

precursor precursor

Neutrophils RBC Platelet

Eosinophils
T,B and NK cells Basophils
Monocytes

PAGE 172| RBC DISORDERS

 PLURIPOTENT
PATHOLoGY PROF BUSTER m
STEM CELL
MYELO1D STEM CELL
(TRILINEAGE),
LYMPHOID STEM CELL

Protymphocyte
Granulocyte-monocyte progenitor Megakaryocyte
Erythrold progenitot progentor
GM-CSF Bone
Erythropoletin Thymus Bone
martOw martow
Thrombopoletin

Neutrophil Basophil Eosinophil Monocyte Redcells

Platelets Lymphocytes
0:NK

one Marrow Examination

Provides an invaluable diagnostic help in Bone Marrow
Aspiration and Biopsy
hematological disorders
A
peripheral blood smear examination Bone marro needte
must always precede bone marrow
examination

eferred site Bone

Hip
marow
a) Posterior iliac crest In adults and Stin bone
children
b) Anteromedial area of tibial head
In infants
c) Anterior superior iliac crest >
obese patients
d) Sternum (aspiration only)

Cortlcal bone
Spongy bone

RBC DISORDERS | PAGE 173

m DR. PRIYANKA SACHDEV

Indlcatlons
(Mnemonic MM FF AA LL)

Definitlve diagnosls of>

Multiple myeloma
Myelodysplastic syndrome
Fever of unknown origin.
Atypical fungal and parasitic disorders such as histoplasmosis, leishmaniasis, cryptococCus,
and Q fever.
Anemia Unexplained
Aneuploidy in neonates
Leukemia
Lymphoma

Absoluto contralndicatlons
(Mnemonic BD)
Severe bleeding diatheses such as sovere homophilia
Severe disseminated intravascular coagülopathy

Methods
(1)Bone Marrow Aspiration (2) Trophino Blopsy
Aspirate of contents of bone marrow drawn Removal of a small core (1-2cm long) of BM
under pressure by puncturing marrow cavity. under local anesthetic.

(1)Asplratlon

Needle
Salah bone marrow aspiration needle

Method
Salah bone marrow aspiration needle is used
Suction of marrow via needle
Smears are prepared immediately
Smears are air-dryed
Smears fixed in 95% methanol
Romanowsky technique for staining
Pearl's stail to assess reticuloendothelial stores of iron

Information
Cellularity
Details of developing blood cells (i.e. normoblastic or
megaloblastic, myeloid, lymphoid, macrophages and
megakaryocytic)
Ratio between erythroid and myeloid cells
Storage diseases
Fungi (e.g. histoplasmosis) and parasites (e.g. malaria,
leishmaniasis, trypanosomiasis).

PAGE 174 | RBC DISORDERS

 m

PATHOLOGY PROF BUSTER

Blopsy
Trephine

needle
trephine
Jamshidi

Stylet

Blopsy needle

Wethod
Performed by a Jamshidi trephine needle
a) core of tissue from periosteum to bone
marrow
A
b) cavity is obtained
formalin
c) Fixed in
Decalcified
d) block is prepared
al Paraffin with microtome
n Cutting with haematoxylin and eosin
Stained

Haematopoietíc tissue (50%)

Information
a) Overall marrow architecture
b) Cellularity
c) Presence or absence of infiltrates
. But is
less valuable than aspiration for individual cell
morphology

Bone marrow aspiration vs Biopsy

Feature Aspiration Trephine Biopsy
1. Site Sternum, posterior iliac crest Posterior iliac crest
2. Instrument Salah BM aspiration needle Jamshidi trephine needle
3.Stains Romanowsky, Perl's' reaction for iron Haematoxylin and eosin

4.Time Within 1-2 hours Within 1-7 days

5. Morphology Better cellular morphology of Better marrow architectural pattern
aspiration smears but marrow but cell morphology is indistinct
architecture is indistinct

RBC DISORDERS | PAGE 175

 m
DR, PRIYANKA SACHDEV
Corree 44 For

(10.02) RETICUL0CYTES >

Correkd reht Co
University Exams alalmt-l-2)
Short questlons
1. What is reticulocyte? Mention its morphology and staining method.
2 Significanco of reliculocytosis and reticulocytopenia
Very Short questions
1
Reticulocyte-normal ond abnormal values.
2 Reticulocyte count- utility,
Four conditions where reticulocyte increases.
4 Stains for Reticulocyles.

Overview
Erythropolesis (00:01:05)
Introduction (00:11:22)
Stains of Reticulocytes (00:13:31)
Reticulocyte count (00:15:13)
Reticulocytosis versus Reticulocytopenia (00:15:53)

Erythropoiesis

Muttlpotent
hematopoletic
ENUCLEATION
stem cell Myelold
progenltor
Bone marrow
Proerythroblast
(Pronormoblast)
Basophilic
erythroblast
Polychromatic
erythroblast
orthochromatie
erythroblast
LN Polychromatlc
erythrocyte
(Hb first appears) Proerythroblast (Large number of erythropoletin (reticulo cyte) Erythrooyte
receptors)

Early Normoblast (Basophilic)

(Hb first detected

by Gelmsa Stain)
Intermediate
Normoblast
(Polychromatic) BPO
H
Late Normoblast (Orthochromatic)
(Nucleus extruded)

Reticulocyte Requires 1-2 days for maturation

Normal RBC

PAGE 176| RBC DISORDERS

 PATHOLOGY PROF
BUSTER m

ntroduction
devoid of nuclei
Juvenile red cells RBCs
Slightly larger than
Polychromatic. (having a blue color
RNA
Contain ribosomal

Stains of
Reticulocytes
Supravital stains
methylene blue Deep blue reticulofilamentous material
New blue
Brilliant cresyl

etuloytes

O :Retlc, X1000 Ol
N methylene blu xl000

Reticulocyte count
amnong red cells present in peripheral blood
Percentage of reticulocytes marrow
Indicator of erythropoeitic activity of bone
Vormal Values >
. Infants 2-6%
,Adults and children >0.5-2.5%|
25,000-75,000/MI
,Absolute reticulocyte count
>

Reticulocytosis versus Reticulocytopenia

Retlculocytopenia
Retculocytosls
Decreased RBC production
Increased RBC production
Reticulocyte Count < 0.5%
Reticulocyte Count > 1.5%
Conditions
Conditions
Aplastic anemia
Acute blood loss or hemorrhage Bone marrow infiltration
Postsplenectomy Bone marrow suppression
Microangiopathic Anemia (Sepsis/Chemotherapy radiotherapy)
Autoimmune Hemolytic Anemia Blood transfusion
Hemoglobinopathy (Sickle cell anemia Liver disease
and Thalassemia) Disordered RBC maturation (Iron, B12,
Post anemia Treatment like Folate Folate Deficiency, Hypothyroidism,
Supplementation, Iron Supplementation Sideroblastic Anemia or Anemia of Chronic
and vitamin B12 Supplementation. Disease)

RBC DISORDERS |PAGE 177

 meH 27-33 (P) /6L
cHc 33-3
m DR. PRIYANKASACHDEV

I (10.03) RBC INDICES AND ESR

University Exsms
Short questlons
1
Mean corpuscular volume (MCV)
2 Mean corpuscular haemoglobin (MCH)
3 Mean corpuscular haemogtotbin concentration (MCHC)
Red cell distribution width (RDW)
Hematocrit or Pa cked cell volume (PCV)
6 Factors determining value of ESR.
7. Principle and methods of determining ESR.
Very Short questions
1 Normal values of RBC indices.
2 Ennumerate diseases cousing Raised ESR
3 Ennumerate diseases CAUsing Low ESR

Overview
Red Cell Indices (00:01:51)
1, Mean corpusculat volume (MCV) (00:03:18)
Mean corpuscular haemoglobin (MCH) (00:06:27)
Mean corpuscular haemoglobin concentratlon (MCHC) (00:10:58)
4 Red cell distribution width (RDW) (00:11:39)
5. Hernatocrit or Packed cell volume (PCV) (00:13:26)
Erythrocyte Sedimentation Rate (ESR) (00:17:20)
Definition
Principle
Factors
Phases
Methods
Diseases with abnormal ESR

Red Cell lndices s9

1) Mean cell volume (MCV)
Average volume of red blood cell.
Normal value X82-96 fLfemtolitres)

=
PCV in L/L
MCV
RBC Count/L

Increased in > megaloblastic anemia

Decreased in >iron deficiency anemia

2) Mean cell hemoglobin (MCH)

Hemoglobin content per RBC.
Normal value 27-33 Pg tPioqr)
Hb/L
MCH=
RBC Count/L
Decreased in microcytic hypochromic anemia.
Increased in > megaloblastic anemia.

3) Mean cell hemoglobin concentration (MCHC)

Average hemoglobin concentration in a given volume of packed RBC.i
Normal value is 33-37 gm/DI

Hb/L
MCHC=
PCV in L/L

Decreased in >microcytic hypoch romic anemia.

Increased in > hereditary spherocytosis.
Remains normal in megaloblastic anemia.)

PAGE 178 | RBC DISORDERS

 PATHOLOGY PROF
BUSTER m

blood cell distribution width

(RDW) 5-194S)
d anisocytosis (size variation of
RBCs).
Degree of
Normal value is 11.5 to 14.5.
Increased in
> megaloblastic anemia, iron deficiency anemia and immune
hemolytic anemia,
Remains normal in thalassemia.
Increased RDW
Normal RDW Kidney disease
Inflammation

Nutritional Oxidative stress ANISOCYTOSIS

deficiencies

Ageing

(PCV)
5) Hematocrit or packed cell volume
by RBC
Blood volume proportion occupied Plasma
Polycythemla

Normal values >

Anemla
55%
Normal

45% for men

42%for women
or of RBC
Increased in Increase in the number orsize of RBC Buffy

Decreased in Decrease in the number size coat 1%

Formed
elements
45%

HEMATOCRIT

Red Cell Indices

=
PCV in L/L Normal value = 82-96 fL
a) MCV
RBC count/L

Hb/L Normal range 27-33 Pg.

b) MCH = RBC count/L

=
Hb/dl Normal value = 33-37 gm/dL
c) MCHC PCVin L/L

of Anisocytosis Normal value

= 11.5 to 14.5.
d) RDW= Degree by RBC
proportion occupied women
e) PCV=Blood volume
= men and 42%for
Normal value 45% for
RBC DISORDERS |PAGE 179
 m DR. PRIYANKA SACHDEV

Erythrocyte Sedimentation Rate (ESR)

Definition>
ESR is used as an index for presence of
an active disease which could be due to
many causes.

Principle
When well-mixed anticoagulated blood is The distan
ance,
the R8C fall in mm,
placed in a vertical tube in1 het
stheSed Rate

Erythrocytes tend to fall towards the

bottom of thetube/pipetto
a
Form packed column in the lower part
of the tube in a given time

Rate at which they fall is ESR

Factors
1. Rouleaux formation When a number of erythrocytes aggregate in
form of rouleauUx and settle down their area is much less than that of
sum of area of constituent corpuscles.
2. Concentration of fibrinogen causes increased viscosity of plasma..
Concentration of fibrinogen parallels ESR.
3. Concentration of globulins Erythrocytes
decreases negative charge of RBCs that
to
tends keep them apart > promoting rouleaux formation > retards
ESR. Conditions in which albumin is low, ESR is higher.
4. Length of the tube If length of tube is more > RBCs will have to
a Rouleaux
travel longer distance > ESR is lower than when length of tube is
short and vice versa.
5. Bore of the tube bore of tube is more > negative charge which keeps the RBCs apart will be
If
less ESR more and vice versa.
will be
6. Position of the tube If tube or pipette is not vertical
> RBCs will have to travel less distance
ESR Will more.
be

Phases
ESR by all methods is expressed as mm first hour
3 phases occur in sequence within 1 hour >

1. Phase of rouleaux formation > In initial 10 minutes> process of rouleaux formation occurs
2. Phase of settling > In next 40
minutes settling of RBCs
Occurs at a constant rate.
3. Phase of packing In last 10
minutes> sedimentation slows
and packing of RBCs to bottom
occurs and it continues slowly
later too.
Rouleaux
Settling Packing
formation

Methods
1 Westergren's method
2. Wintrobe's method
3. Micro ESR method
4. Automated methods
PAGE 180 |RBC DISORDERS
 PATHOLOGY PROF
BUSTER M

Method
Westergren's
1) ends
ulutqmtnlnunquntmbnimjunumtnm

Open at both cm lona

Straight pipette 30
of 2.5 mm
Internal bore diameter
Calibrated from 0-200 mm from top to bottom 20
40

Normal values 60
mm 1st hoUr
Males > 3-5 80
Eemales 4-7 mm 1st hour
100

Advantages 120
method
a) More sensitive 140
Easy to fill and clean Westergren's pipette
160

Disadvantages 180

al Requires
more amount of blood. 200
Dilution of blood in anticoagulant affects
ESR.
0 Eilling of blood by mouth pipetting should be strictly discouraged. Westereren's plpette

2) Wintrobe's Method
Glass tube closed at
one end.
110mm long mm.
Internal bore diameter of 2.5 on
cm on one side and 10 to 0 cm
Graduated on both sides: from 0 to 10
the other side

Normal values
mm 1st hour
Males0-7
Females > 0-15 mm 1st hour

Advantages
1. Requires small amount of
blood. 10
2. No dilution with anticoagulant, Wintrobe's tube &
3. PCV can also be done by
same tube. pasteur plpette

Disadvantages > it is not as sensitive as Westergren's

1. Because of short column and
choice of anticoagulant
method. can lower ESR.
2. Addition of more anticoagulant
mm cannot be measured.
3. ESR of more than 100

Diseases with abnormal ESR

Diseases Causing Raised ESR
Diseases Causing Low ESR
1. Polycythaemia
1. Tuberculosis Spherocytosis
2. SABE
2.
myocardial infarction 3. Sickle cell anaemia
3. Acute Congestive heart failure
4.
4. Rheumatoid arthritis New-born and infant
5.
5. Shock
6. Anaemias
7. Chronic liver diseases
8. Multiple myeloma
9. Pregnancy
10. Ankylosing spondylitis

RBC DISORDERS | PAGE 181

 m DR, PRIYANKA SACHDEV

(10.04) ANEMIA DEFINITION, CLASSIFICATION, C/F

Unlversity Exams
Long questlons
1. Define anemia. Write etiological and morphological classification of anemias
Define anemia and writo its Clinical fe aturos. Enumerate various causes of macrocytic anemia.
3 Define anemla. Classify onemia according to mechanisms of its production.
Short questions
1
Etiological classification of anemias
2 Morphological classification of anemias
3. Clinical features of anemla
Very Short questlons
1
Anisocytosis
Poikilocytosis
Enumerate various causes of microcytic anemla.
4 Enumetate various causes of macrocytic anemla.
5.
Enumerate various causes of normocytic anemla.

Overviow
Definition (00:01:33)
Morphology of RBC (00:05:26)
Variations in Size (00:07:21)
Variations in Colour (00:11:27)
Abnormal shapes of RBC (00:14:27)
Classification of Anaemias (00:16:07)
Clinical, Features (00:27:36)
Anenja is. dene redu tluoh ot
may belo noral Tissoe
4edves 4he bloD d hypoia

Definition
Anaemia is defined as reduced haemoglobin concentration in blood below the lower limit of the
normal range for the age and sex the individual.
of

The lower extreme of the normal haemoglobin is taken as >

13.6 g/dl for males
12.0 g/dl for females
15 g/dl for newborns

Morphology of RBC
Shape> biconcavé (due tospectrin)
Size > diameter of 7 to 8 um.
Biconcave shape is
Slde vlew
Colour Hb. is located peripherally, leaving an area of
central pallor equal to 30-35% of diameter of the cells
(Centrai1/3rd pallor)
Variations in Size ofte
RBC of normal size > Normocytic
When red cell diameter is greater than 9 they are
m

-75 um
referred as macrocytes
When red celldiameter is less than[6 umthey are referred
as microcytes
On smear size of RBC is compared with small
lymphocyte
Top vlew

Normocytes Microcytes Macrocytes

PAGE 182 | RBC DISORDERS

 BUSTER
PATHOLOGY PROF

Variations in Colour >

ehrome
RBC with normal hemoglobin content (color) (Central 1/3rd pallor) Normochromic
When area of central pollar is greater than/50%of
diameter, it is referred as hypochromic
Variation is/Szel of RBCs is know aslanisocytosis)
ariation in shape of RBCs is know as poikilocytosis

bo,

Normochromic Hypochromic

Anisocytosis Poikilocytosis

Abnormal shapes of R
Target cells Thalassemia,
Post splenectomy

Bite cells G6PD deficiency

Sickle cell Sickle cell anemia

Teardropcell Myelofibrosis

Spurr cell (Acanthocyte) Abetalipoproteinemia

Uremia
Burr cell (Echinocyte)

Rouleaux formation Multiple myeloma

RBC agglutination Cold autoimmune haemolytic anemia

Paroxysmal cold hemoglobinuria

RBC DISORDERS| PAGE 183

m DR.PRIYANKA
SAHDEV
in

Classification of Anaemias
1. Morhological Classification
2. Pathophysiological Classification

1) Morphologic Classification > on sine L khnpt

nic
1. Microcytic, hypochromic
2. Normocytic, normochromic
3. Macrocytic, normochromic
poooos
boo0080

Mlcrocytic/hypochromlc Normocytic/Normochromic Macrocytic/Normocthromic

2) Pathophysiologicall Etiological Classification

Anemia prebH4

Blood Loss Productlon t Destruction

Acute Chronic Cytoplasmlc Stem cell

Nuclear
defect defect proliferation defect

Heam deficltGlobin deficitlMegaloblastic) Aplastic anemia

Anemla

SCA
Iron deficlency anemia Thalassemia|ebun
Slderoblastic anemla
Anemla of chronic disease

HEMOLYTIC ANEMIAS

SGT 4 Heredltary Acquired

Spherocytosis AIHA
G6PD
SCA
MAHA noetu
PNH
Thalassemia fRi0*4"otabnns

Classificatlon of anemlas according to MCV

Microcytlc Normocytlc Macrocytlc

Sideroblastic L -Liver disease
Iron deficiency H - Hypothroidism
M -Megalobastic anemia
TThalassemia
A-Anemla of S.Sickle cell anemla C
Cytotoxic drugs like
H- Hereditary spherocytosis Methotrexate and
chronic disease -
|A Autoimmune hemolytic other drugs like
anemia phenytoin
|P-Paroxysmal noctumal
hemoglobinuria
|E - Enzyme deficiency
(most important is
G-6PD deficlency

PAGE 184 | RBC DISORDERS

 PATHOLOGY PROF BUSTER

Clinical Features
Symptoms FaltingLat0e
Rasptratory
1.
Tiredness
2.
Easy fatiguability
Angina & hesrt attack
Generalised muscular Shortness of
3 weakness breath
Lethargy and headache.
older patients symptoms of
5 Dgeston
failure, cardiac
angina pectoris, intermittent
laudication, contusion ENLARGEMENT
and visual
disturbances Change ln stool
color
splen

Signs Mus
skin
1.Pallor Pain
Most common
and characteristic
Seen in mucous
Yetlowing
sian
membranes, conjunctivae
and skin.

NO PALLOR
PALLOR INNANEMIA
NO PALLOR
MLLOR IN ANEMIA

PROMINENT CREASES
ON THE PALM PALE PALMAR CREASES
IN ANEMIA
2. Cardiovascular system
A hyperdynamic
circulation may be present
midsystolic flow murmur, with tachycardja, collapsing
3. Central nervous system
dyspnoea on exertion,congestive pulse, cardiomegaly,
heart failure.
Attacks of faintness,
giddiness, headache, tinnitus,
sensations of the hands and feet. drowsiness, numbness and
tingling
4. Ocular manifestations
Retinal haemorrhages may occur if
diathesis. there is associated vascular disease or
bleeding
5. Reproductive system
Menstrual disturbances such as
amenorrhoea and menorrhagia and
6. Gastrointestinal system loss of libido
Anorexia, flatulence, nausea, constipation
and weight loss may occur.
(10.05) HEMOLYTIC ANEMIAS
>
DEFINITION, CLASSIFICATION, LAB
DIAGNOSIS
University
Exans
Long questlons
1
Classify heamolytic anemias. DisCuss laboratory
2 Write investigatlons for dlagnosis of heamolytlc anemla.
3
Characteristic features of haemolytlc anaemla. Discuss approach to laboratory dlagnosls In a case of heamolytic
DISCUss broad mechanisms of hemolytic
anemla. anemlas.

RBC DISORDERS|PAGE 185

 m
DR. PRIYANKA SACHDEV

Short questions
1
Laboratory tests htmolytic
in anemias.
2 Peripheral Smear d
picture
3 How do you classify hemolytic of hemolytic anemia.
4. anemias?
Intravascular vs Extravascular hemolysis
5 Characteristic fe atures ofhaemnolytic anaemia
Very Short questlons
1
Ennumerate examples of IntravVascular and Extravascular
hemolysis

Overview
Introduction (00:01:04)
Characte ristic fe atures (00:05:54)
Types (00:08:46)
Intravascular haemolysis (00:11:43)
Extravas cular haemolysis (00:15:21)
Extravas cular versus Intravascular Haemolysis
Classification (00:18:09) (00:17:06)
Lab Diagnosis (00:20:0S)

RBC breakdown in RE system

Introduction
Haemolytic anaemias are defined as anaemias Haemoglobin liberated
resulting from an increase in the rate of red cell
destruction Globin Haem
Shorked ed ce e
Span belo12d Protoporphyfín
Amino acids Iron
uu
Aeeuolatuoyfhp'o
Protein synthesis Recirculation Bilirubin
Characteristic features,niursbin gauie
yperllylar Marrow erythroblasts Conjugated in lrver
Gone maroj
1. A shortened red cell life span nse Tehulouyte laua RBC destruction
premature destruction of
red cells.
2. Inceased erythropoiesis in the
marroW to compensate the loss of Destruction inside mononuciear
red cells Destruction inside blood
increased ceticulocyte Vessels or in the circulation phagocytic system
count.I
3. AcCumulation of products of
hemoglobin catabolism Increased |Intravascular hemolysis Extravascular hemolysis
bilirubin Jaundice

Types
2 Types
1 Intravascular haemolysis >Raxs
2. Extravascular haemolysis uoy <s20 an
Intravascular Hemolysis Extravascular Hemolysis

1. RBC in circulation 1. Antibody-coated or irregular RBC

2. Direct lysis:
Shear stress 2. Phagocytosis
Toxins
Complement 3. Degradation
in lysosome 4.Intracellular
hemoglobin
3. Intravascular
free hemoglobin
MACROPHAGE 5. Biliverdin

If haptoglobin 6. Bilirubln
capacity exceeded Billary clearance
4. Bound to haptoglobin 5. Renal tubular
excretion HEPATOCYTE
Hepatic clearance (hemoglobinuria)

PAGE 186| RBCDISORDERS

 PATHOLoGY PROF
BUSTER m
Feafore)
Intravascular haemolysis
1)
Common
Less
6RC'SUndergo Iysis in the circulatron
Release their contents into plasma
plasma haemoglobin rises > haemoglobinemia
urine > haemoglobinuria
Part of it excreted in the
to(hemosiderinwhich is excreted
hemoglobin is reabsorbed in kidney and is Converted
Some of the
hemosiderinuria
ree hemoglebin is oxidized to methemoglobin XMethemoglobinemia cleared by
hemoglobin in plasma bound to haptoglobin and this complex is rapidly
Free
mononuclear phagocytic system ->Decreasedheptoglobin serum LDH
During hemolysis LDH released in blod increased system
Mild\Jncrease
catabolized to bilirubin within mononuclear phagocytic
Excess heme
indirect bilirubin and/jaundiceland gall stones
Intravascular Hemolysis

RBC destruction in the blood vessels

Unconjugated bilirubin
Free Hb In serum

SJaundice
1Risk of
bilirubin
or pigment
gallstones
Complex with Oxidation of Hb
Hemoglobinemia
haptoglobin Into
which iscleared methemoglobin
in
the RES)
tHb excretion
in urine |Methemoglobinuría
|Methemoglobinemia

Hemoglobinuria I Haptoglobin neea

do
no

2) Extravascular haemolysis ncl

More common or marrow where they
RE system of spleen (major site), liver bone
RBCs are taken up by cells of
are destroyed and digested
Plasma haemoglobin level is not raised.

Hemoglobinemia
Hemoglobinuria All absent
Hemosiderinuria
Methemoglobinemia
escapes into plasma heptoglobin does not decrease
Because little hemoglobin
LDH mildly raised
into indirect bilirubin)
Jaundice (due conversion of heme
Increased urinary urobilinogen y
Increased fecal stercobilinogen
(Splenomegaly and Hepatomegaly
Extravascular Hemolysls|
system
RBC destruction in reticuloendothelial

Destruction No free Hb released In

t Destruction clrculatlon
Anemia in liver
in spleen No hemoglobinurla
Jaundice
• No hemoglobinemia
•No methemoglobinuria

Splenomegaly Hepatomegaly

RBC DISORDERS | PAGE 187

 m DR PRIYANKA SACHDEV

Extravascular versus ntravascular HaemoIy'sis

Featunes
Extayascular Haemolysls Intravascular Haemolysi
1.Frequency
More common Less common
2. Location RE system organs Inperipheral
(spleen, bone marrow, liver) blood
3(Iron stores
Increased Decreased
4. Serum ferritin
Normal to high Low
5. Plasma haemoglobin
Absent Present
6. Methaemoglobin
Absent Present
7. Haemoglobinuria
Absent Present
8. Haemosiderinuria
Absent Present
9. Unconjugated Markedily elevated Mildly elevated,
hyperbilirubinaemia
10. Serum LDH Mildly elevated Markediy elevated

Classification
HENOLYTIC ANENLAS

Acquired

Spherocytosis
AIHA
GEPD
ALAHA
SCA
Thalassemia PNH

Lab Diagnosis
1) Tests of Increased Red Gell Breakdown BUS LOH}7se4
1. Serum bilirubin >
raised
2. Urine urobilinoger raised
3. Faecal stercobilinogen raised
4. Serum haptoglobin > reduced
5. LDH raised
6. Evidences of intravascular haemolysis in the form of haemoglobinaemia,
methaemoglobinaemia, haemoglobinuria, and haemosiderinuria.
2) Tests of Increased Red Cell Production
1. Reticulocytosis most useful initial test of marrow erythroid hyperplasia.
2. Bone marrow showserythroid hyperplasia
3. X-ray of bones shows evidence ofj eXpansion of marrow spaceespecially intubular bones and
skull.

Reticulocytosis Erythrold Hyperplasia X-Ray

PAGE 188 | RBC DISORDERS

 PATHOLoGY PROF BUSTER m
Tests for Shortened Red Cell Lifespan
3)
1 Tested by 51Cr labelling method.

4) Morphology of RBC
Red cell morphology Homolytlc
Polychromasia

Reticulocyte (supra-vital stain)

Spherocyte Hereditary spherocytosis, Autoimmune

hemolytic Anemia

Elliptocyte Horeditary elliptocytosis speetitu

Stomatocyte Liver disease

Sickle cell Sickle cell anemia

Fragments Microangiopathy, HUS, TTP, Cardiac valve, DIC

Blister cell G6PD deficiency

Spur cell ) Severe liver disease

I (10.06) HEREDITARY
SPHEROCYTOSIS Autozryy donnonh
carav stula r haenolgss
heihe
Pathogen esla

University Exams
Long questions
1. Mention two conditions where you get spherocytes in the peripheral smear. Discuss the etiology and diagnosis of hereditary
spherocytosis.
2 Describe pathogenesis and laboratory diagnosis of hereditary spherocytosis.
Short auestions
1
Osmotic fragility test
2.
Discuss molecular pathology and morphology of hereditary spherocytosis.
Very Short questions
1
Draw peripheral smear diagram of hereditary spherocytosis.
2. Why MCHC is increased in hereditary spherocytosis,

Overview
Introduction (00:00:33)
Pathogenesis (00:01:33)
Lab diagnosis (00:11:05)

R8C DISORDERS |PAGE 189

 m DR. PRIYANKA SACHDEV

Introduction
Autosomal fominantinheritanco)
RBC membrane is abnormal
niientavfap Sphina
shap
Pahogenesis
1. (Spectrin)The
a polton
chief protein component responsible for blconcavo shape
2. Ankyrin and band 4.2 -Binds spectrin to band 3
3. Band 3 Atransmembrane ion transport protein.
4. Band 4.1 Binds spectrin to glycophorin A, a transmembrano protein.

(Bnnd 3 Glycophorin A)
oue ments t

Mombrano-RBC)

(4.2
Ankyrin) hctin

Spectrin

Spectrin 2 subunits/a,and 9)
This spectrin is attached to cell membrane at two Band 3
Go
sites> I9000000 O0000000000000099r
upid bilayer
t3E
1. Spectrin binds to ion transporter, band 3 of io000000o90009090000000
membrane with ankyrin and band 4.2 4.2 Ankyrin
2. Spectrin binds to glycophorin A
of the membrane
by protein 4.1 and actin Acun
Mutation most commonly involves the gene coding for > Spectrin
Ankyrin> Band-3 > Spectrin >Band 4.2 (also called
paladin)

Remember
Most common defect in hereditary Spherocytosis is inAnkyrin.)
Most common defect in hereditary elliptocytosis is in(spectrin)

Mutation
Loss of membrane cytoskeleton
proteins
(ankyrin, spectrin, Band 3, 4.2)

Reduced
membrane stability
Loss of membrane Primary membrane Loss of membrane due
to decreased stability
relative to cytoplasm cytoskeletal defect Decreased
Surface to
volume
Cells become microspherocytes ratio

(smallest possible diameter for a

given volume)

Trapped in to spleen
(Due to reduced deformability) Phagocytosis
SPHEROcYTES
Decreased deformibility
EXTRAVASCULAR HEMOLYSIS Erythrostasis due to
RBCare phagocytosed by RE cells splenlc rapplng

Extravascular hemolysis
PAGE 190 |RBC DISORDERS
 PATHOLOGY PROF BUSTER m
èn
Lab diagnosis RGe dstr tiern
4 Extravascular hemolysis >
2. Morphology of RBC 4estato,
Microspherocytes

Normal red cells Platelets LymphocyteSpherotytes

3. Increase in MCHC due to dehydration causedby loss of K+ and wator.

Hereditary spherocytosis is the only important anomia in which(MCHC s incteased!
4. Special test
1. Osmotic fragility test / Pink test
RBCs lyses more readily in solutions of low salt concentration i.e. osmotic fragilíty is
increased
2. Direct Coombs isfnegative)so as to distinguish it from acquired spherocytosis ofAJHAjn
tet
which it ispositive

0.45 0.40 0.35 0.30 0.20 0.10

Concentration 0.85 0.75 0.65 0.60 0.55 0.50
Sodium
Chloride (%)
(0.45 S0-90 90-99 97-100 100 100
Nonincubated 0-5
Hemolysis (%)
NORMAL

HERED|TARY S
PHEROCYTOSIS

0.60 0.55 0.50 0.45 0.40 0.35 0.30 0.20 010

Concentration 0.85 0.75 0.65
Sodium
Chloride (%)
20-80% 60-100% 100% 100% 100% 100% 100% 100%
Hemolysls (%) 0-5 5.10

R8C DISORDERS | PAGE 191

 m DR. PRIYANKA SACHDEV

(10.07) G6PD DEFICIENCY ANEMIAned

veewsi du
Unlversity Examn
Long questlons
1
Doscribe pathogenesis, types and labotatory diagnosis of G6PD deficiency Anemia
Short questlons
1 G6PD deflciency stnte.
2 Helnz bodies
Bite cells

Overview
Introduction (00:00:35)
Pathogenesis (00:01:44)
Types (00:06:10)
Lab diagnosis (00:06:32)

n
Introduction Afriean.America
X-linked recessive disorder
Characterized by hemolytic anemia on exposure to(oxidative stress

Oxidant stross
a) Viral and bacterial infections
b) Certain drugs (antimalarials Primaquine, sulfonamides, nitrofurantoin,
c) Metabolic acidosis aspirin, vitamin K)
phena Fbn
d) Ingestion of fava beans (favism)

Pathogenesis
Normally RBCs are protected from oxidant injury byreduced glutathione
Reduced glutathione is generated from oxidized glutathione and reducing equivalent for this
reaction is provided by/NADPH.
This NADPH is generated in HMP shunt by enzyme Glucose-6-phosphate
dehydrogenase

Glucose-6-phosphate 6-phosphogluconate

fGGPD

NADP NADPH

Glutathione
reductase

GSH GSSG

Glutathlone
peroxidase

H,o, [Ha0

PAGE 192 | RBC DISORDERS

 BUSTER
PATHOLOGY PROF

Normal person Person with G6PD deficiency

Oxidant stress Oxidant stress
G6PD present G6PD absent

NADPH is generated in HMP shunt a) NADPH is not generated in HMP shunt

to
Oxidized glutathione is converted to Reduced Oxidized glutathione is not converted
glutathione educed glutathione
Reduced glutathione protects RBCs from RBCs are not protected from
foxidant injury oxidant injury
No hemolysis Intravascular and extravascular hemolysis

Types - 30
1. Type-1 (mildest form) 2o '
>
2. Type-2 (moderately sever) 50
3. Type-3 (most severe form) - 9o

Lab diagnosis
a) Intravascular and extravascular hemolysis
Heinz bodies, Bite cells
b) Morphology of RBC

Heinz bodies
Precipitate of denatured Hb. in RBC due to oxidative
stress)
Revealed by supravital staining
Bite cells (eaten RBCs by splenic macrophages)

Denaurd H5

Spleenic Macrophage Bite cell )

Heinz bodies in RBC bites out Heinz bodeis

Heinz bodies on
supravital stain

Bite cell

RBC DISORDERS| PAGE 193

 DR. PRIYANKA SACHDEV

I(10.08) PAROXYSMAL NOCTURA HEMATURIA (PNH)

M
(ome atak
University Exams
Long questions
1. Describe pathogenesis, clinical features and laboratory diagnosis of Paroxysmal Noctural Haemoglobinuria
Short questions
1
2.
Screening test for Paroxysmal Noctural Haemoglobinuria
Confirmatory test for Paroxysmal Noctural Haemoglobinuria
Very Short questions
1 Ham test
2 Triad of Paroxysmal Noctural Haemoglobinuria

Overview
Introduction (00:00:56)
Pathogenesis (00:06:56)
Clinical features Triad (00:09:38)
Lab diagnosis (00:11:27)
Screening test
Confirmatory test

Introduction
Caused by an acquired intrinsic defect in the cell membrane.
Results from acquired mutation that inhibits the synthesis of GlycosylphospatidylinositoGP)
(OAF
Pathogenesis
2 anchoring proteins called complement
regulating proteins
a) Decay accelerating factorl(DAF, CD55)
A
b) membrane inhibitor of reactive Iysis
(MIRL, CD59) Plasma Membrane

CD55/DAF CD59/MIRL
Blocks binding of C9.
Prevents C3 convertase so no MAC
formation

RBC
Neutrophils
Platelets

CD55 and CD 59

Anchored to cell membrane of blood cells bý GPL

Prevent activation of complement (During sleep)
Prevent complement mediated lysis of blood cells
No hemolysis

PAGE 194 | RBC DISORDERS

 PATHOLOSY PROF USTEA

Complenent

MAC

Complement
Bctlvation

Hb
PNH RBC

Mutation of PIG-A (phosphatidyl inositol glycan) gene

Synthesis of glycosyl phosphatidyl inositol (GPI) does not occur

Absence of comploment regulating proteins (CD55, CD59) on blood cells

Bloodcells sensitive to complement mediated lysis (during sleop)

Intravascular hamolysis

Clinícal features > Triad-(PH7)

a) Hemolysis
Paroxysmal (intermíttent attacks)
Nocturnal (occurs in the night) Because during sleep the pH of blood gets slightly redvced
and acidic medium leads to activatíon of the cormnplerment.
b) Pancytopenia
Because causative somatic mutations occur in pluripotent stem cells all cells are sensitive
to complement mediated lysis pancytopenia Anemia, Leucopenía, Thrornbocytopenia
c) Thrombosis Due to absence of CD-59 on platelets externilízation of
phosphotidylserine thrombosis

Lab diagnosis
a) Screening test
b) Confirmatory test
Lysed REs Lactieg te
1) Screening test
1. Ham test Acidic pH vill activate
complement pathway for RBC lysis. PHH RPC
2. Sucrose lysis test Sucrose will reduce
pH and this will activate complement Incubated in
pathway for hernolysis.
Red celts supenslon (patlent) CD56 or
CDS9 Lyud A8sC
relsisshemottstig
Controlserum(or ame blood type)!

Sucrose
Room temperature 1H

No hemolysis Hemolysis

Exclude PNH PNH (lysls>5%)

MA, IHA or
some leukemla

REC DISORDERS IPAGE 195

m DR. PRIYANKA SACHDEV

2) Confirnmatory toat
Flowcytomotry >
Bimodal distribution of the rod colls

CO55

(10.09) AUTOIMMUNE HEMOLYTIC ANEMIA (AIHA)

Unlversity Exams
Long questlons
1 Describe Types, pathogenesis and Causes oft Autolmmuno Haomolytic Anaomia (AiHA)
Short questlons
1
Coomb's Test.
2 Pathogenesis of Warm Autolmmune Haemolytic Anaemia
3. Pathogenesis of Cold Autolmmuno Haemolytio Anaemia
Very Short questlons
1
Donath-Landsteiner antibody

Overvlew
Introduction (00:02:19)
Types (00:04:02)
1. Warm AIHA (00:06:00) Introduction, Pathogenesls, causes
2. Cold AlHA (00:10:45)
Lab diagnosis (00:19:07)

Introduction
Caused by autoantibodies directed against aed cell antigen)
Types
Warm Antibody AIHA|
Cold Antibody AlHA
9
1) Warm Antlbody AIHA
Introduction
Most common form of AlHA
Antibody react with RBC at 37°C.
Most causative antibodies are of the(lgGlclass
Extravascular hemolysis occur.
Pathogenesis
lgGlantibodles attach to rod blood cells at 37 degreo C

loaving thero Fc portion)sticking out

Antibody coated RBCs pass through spleon

The Fc portlon of antibody RBCcomplex is rocognized by(Fo)

recoptor on phagocytos

Phagocytosls of RBCs In tho spleen Membrane lost

Extravascular hemolysls Acquired spherocytosis

PAGE 196 | RBC DISORDERS

 PATHOLOGY PROF BUSTER m
Causes
Autoimmune disorders SLE, RA, Ulcerative colitis, Maerophage
1.
Scleroderma, Antiphospholipid antibodies.
2. Chronic lymphocytic leukemia (CLL)
(spherocyte)
3. Hodgkin disease
Non-Hodgkin lymphoma
4.
5. Multiple myeloma
Thymoma lg
6.
7. Drugs Methyldopa, penicillin, Cephalosporine,
quinidine.
8. PAN

Cold Antibody AlHA

Spleen
2)

2 conditions: lgM
a) Cold agglutinin disease (PCH)
b) Paroxysmal Cold haemoglobinuria

a) Cold agglutinin disease

Introduction >
Antibodies react with RBC at 0° to 4°C.
Caused by cold agglutininllgMjantibodies.
Extravascular hemolysis occur.
Pathogenesis
RBC
antibody directed against the antigen of
I

lgM

bind to l antigen of RBC at 4 degree C

Fix complement on RBC (transient reaction)

(C3bJacts as an opsonin
Extravascular lysis
system of
It enhances the phagocytosis of RBCs in phagocytic
liver and spleen

Extravascular hemolysis

b) Paroxysmal cold haemoglobinuria (PCH)

Introduction
Antibodies react with RBC at/0° to 4°cl as Donath-Landsteinerantibody
Autoantibodies are of lgG class> also known
Intravascular hemolysis occur.

Pathogenesis P
IgG (Donath-Landsteiner) antibody directed against the
antigen of RÉC

bind to P antigen of RBC at 4 degree C

Antigen antibody complex on the red blood cell activates

complement
(MAC)forms
Large amount of membrane attack complex

Destroys red cells directly in blood vessel

Intravascular hemolysis
RBC DISORDERS | PAGE 197
 DISORDERS RBC | 198 PAGE

erythrocyto
Reagent

lgM,

IgM
serum In Antlbodles

Test Antiglobulin Indirect

agglutinate to washed aro
rocytes
erythrocyt TgG-coated erythrocytes erythrocytes of coating
rei AHG after added
reagent AHG Antl-igG antibody vivo In

Antigen
Erythrocyte

IgM

IgM
Test Antiglobulin Dlrect

| test Coombs directjand/indirect Positive

test Special 3.
film. blood peripheral the in is spherocytos Prominent
Morphology 2.
s,
EXtravascUaae as well as haemolysis Intravascular 1.
diagnosis, Lab
sphesytosu
Intravascular Extravasular Extrayasular Hemolysis
(Donath-Landsteiner) IgG IgM IgG Ab.

40C 4°C 37°C Temperature

PCH CAD
AIHA Cold AlHA Cold AIHA Warm

syndrome Flu
Measles
Mumps
Mycoplasma
Syphilis
Causes
antibody D-L to
blunds URTI) (o.g. trigger to duo
(C3d) Complement produced antibodies D-L

Haemotysis
Intravascutar
circulation the in
tysis cel Red

<JTC
temperatures At
<37CAt

RDC on ?
P-antlgen to
bind antibodies, D-L

SACHDEV PRIYANKA DR. m

 PATHOLoGY PROF BUSTER m

I(10.10) SICKLE CELL ANEMIA

University Exams
Long questlons
Give the classification of anemlas. DiscUss palhogenesis and laboratory diagnosis of
1
Classify hemolytic anemias. Describe sickle cell anemia. sicile taft dissAs6
2
Short questions
1. Clinical features of Slckle cell anemla
2 Pathogenesis of sickle cell disease
3 Factors determining rate of sickling
4 Lab. investigation in sickle cell disease.
5 Why Sickle cell anemia gives Protection against falciparum malarla
6 Quálitative and Quantitative Haemoglobinopathies
Very Short questions
1. Diagnosis of sickle cell anemia.
HbS
Enumerate tests for sickling in sickle cell anemia.
Principle of Sickling/sickle cell test
5. Screening of sickle cell anemla
6. Hb. Electrophoresis in sickle cell anemia

Overviiew
Haemoglobin types (00:01:34)
Haemoglobinopathies (00:02:46)
Sickle Cell Anaemia>
Introduction (00:03:39)
Pathogenesis (00:06:56)
Consequences of Sickling (00:14:11)
Factors determining rate of sickling (00:21:55)
Clinical features (00:24:00)
Protection against falciparum malaria (00:26:55)
Screening (00:29:37)
Diagnosis (00:31:04)

Haemoglobin types

A A D

HbA HbF HbA,

95-98% ~1% <3.5%
Adult Hb) Fotal HD) Minog Hb

Haemoglobinopathies
2 types:
Qualitative disorders there is structural abnormality in synthesis of haemoglobin e.g. sickle
cell syndrome
Quantitative disorders there is quantitatively decreaed globin chain synthesis of

Thalua haemoglobin e.g. thalassaemias

Sickle Cell Anaemia

Introduction >
Autosomalrecessive disorder
Homozygous state of HbS in RBCs (SS)
RBC DISORDERS|PAGE 199
 11h
m DR. PRIYANKA SACHDEV

Sickle Cell Anaemia

Presence of sickle haemoglobin (HbS) in the RBCs (Qualitative disorders)

RBCs with HbS develop sickling when they are exposed to low oxygen tension
Normal -1bA) Mutant yHbs
Pathogenesis
Haemoglobin

B-globin chain gene mutation (chromosomo11) valn

p DNA
Single point mutation at sixth position of
globin chain (mis-sense mutation)hT Mutation
Substution of a valine residue for a
glutamic
acid residue
VAL Protein
Sickle hemoglobin HbS) instead of(HbA) GLU
Normal Mutant

Consequences of Sickling
1
Vaso occlusion of microcirculation
2. Haemolytic anaemia
3. Increased MCHC

Deoxygenationj of
HbS-containing RBC With repeated episodes of
deoxygenation and sickling
Polymerisation of deoxygenated Hbs
Membrane damages permanently
Elongated rod-like)polymers align
RBC become irreversiblsickled)
Distort(RBcjnto (sickle shapel(sickling)
Difficulty in passing through
Express higher levels of adhesion molecules splenic sinusoids Spleenic Sequestratíon
(abnormally sticky)
Rapid phagocytosis
Vaso occlusion of microcirculation
Covte ischcen Extravascular
Haemolysis Haemolytic anaemia

With membrane damage

Normal Hemoglobin Clumped Hemoglobin
Water comes out of the cell
Intracellular dehydration
Healthy red Slcklo red
blood cell
Increascd MCHC blood cell

Unrestrlcted blood flow, Blood flow blocked

by slckle cells

PAGE 200 | RBC DISORDERS

 PATHOLOGY PROF BUSTER m

Point
HbA Mutation
(HbS)

Irreverslbly Deoxygenatlon K*, H,o

Extenslve
slckled membrano
Hemolysis cell damago
Ca'
Additional
Oxygenation cycles of
Deoxygenation deoxygenation
prolonged
transit times
Microvascular
occluslon cell wíth dehydration &
membrane damage

sig Tota
Factors determining rate of sickling Acidou
ehydràlo
1. Amount of_
and interaction with other Hb
HbS
In homozygous individuals> all Hb. is HbS sickling.
In heterozygous> only 40% of Hb. is HbS Sickling does not occur because HbA
(remaining 60%) has an inhibitory effect on polymerization of HbS
Fetal hemoglobin HbF also has inhibitory effect on sickling of HbS > Newborns do not
manifest until 6 months of age
2 Hemoglobin concentration of RBC Greater MCHC> greater is sickling
3 Intracellular dehydration >increases the MCHC facilíatates sickling
4 Decrease in Ph > Acidosis-> Reduces the oxygen afinity of Hb. > Increasing the fraction of
deoxygenated HbS faciliatates sickling
5. Length of time RBCs exposed to low oxygen
tenion> Organs having slow or sluggish circulation
(bone and spleen) have an increased chance of sickling

Clinical Features
1. Anaemia
Irreversible sickle cells have difficulty in passing the splenic sinusoids> sequestration>
rapid phagocytosis.
Associated with Jaundice and reticulocytosis.
2. Vaso-0cclusive phenomena >
Reversible sickle cells express higher levels of adhesion molecules abnormally sticky
occlusion of microcirculation
Most common manifestations of sickle cell anemia)

A)(Bone
a) Dactylitis or inflammation of bones of hands and feet > Hand foot syndrome
b) Fish mouth appearance of vertebra due to vaso occlusive crisis of vertebral arteries.
c) Prominent cheek bones
d) Crew cut appearance of skull > due to marrow expansion causing bone resorption

RBC DISORDERS | PAGE 201

 DR, PRIYANKA SACHDEV

(Hand Foot Syndrome)

Prominent
cheek bones
azille

Crew cut
appearance

(Fish Mouth Vertebra)

B) Lungs
Acute chest syndrome characterized by cough, fever and chest pain

C) Brain >
Seizures or stroke

D) Skin
Leg ulcers

E) Penis >
Stagnation in corpora cavernosa leads to priapism

F) Aplastic crises
Occurs from the infection of red cellprogenitors by parvovirus B19> sudden worsening of the
anemia

G) Spleen
Initial stages splenomegaly due to congestion and trapping of RBCs in sinusolds
Prolonged hypoxia and infarction Autosplenectomy increases susceptibility to infectlon
with capsulated organisms like Hemophilus influenzae, Pneumococcus, etc.

Protectlon agalnst(talciparum malarlaeNJ

Patients with HbS are relatively protected against falciparum malaria
dey
Malarial parasites consume 02
Decrease intracellulår pH
Promote sickling
Distorted RBCs cleared rapidly by phagocytes in spleen
Keep parasite loads/down

PAGE 202| RBC DISORDERS

Rinuple RLCs Condatnug ghape vpon
ceposum
EOTA Bood
conaip
m

PATHOLOGY PROF BUSTER

Screening
(Sickling Test) Used os ichle Cel) nncia
Inheited
Venous (Arm)
Blood Sample Capillary (Fingertips, Ear lobes in adults/
Heel in Infants)
Mix with
Sodium(Metabisulphito
(Reducing agent)

Wait for 20 minutos

Microscopo

Normal RBC slckled RBC

Negativetest HbA) Posltlvo test HbS

Erythroblast Slckle cells Torget cell

Diagnosis
1) Peripheal smnear
a) Sickle cells
b) Target cells
c) Features of splenic atrophy such as
presence of Howell-Jolly bodies
(o
2) ESR 000
Leishnan, X1000 O

Increased in all anemia except in

sickle cell anemia where ESR is
decreased because there is no
rouleaux formation.

3) Haemoglobin electrophoresis
HbS moves Slowly towards Anode.
HbA moves faster towards Anode

Interpretation>
Formation of 1 band sickle cell anemia
Formation of 2 bands sickle cell carrier or trait.

Sample
loaded

<-Hb-A
Electrophoresis direction

fHb-s)
Callyele

Normal (Slckle-cell Sickle-cell

tralt anemla

RBC DISORDERS | PAGE 203

 Aisorder dee*a
drcheun glosen
-lhe yt
and red
Yola
lebin chan
m DR. PRIYANKA SACHDEV

(10.11) THALASSEMIA
Unlyetity Ek*en
Long questions
1. Classify heemolytic onemia, Give an account of thalassemia.
2 Classify thalassemia syndromes. Wrte a note on molecular pathogenesis of p Thalassaemia and de s cribe the bfood plcture in p

Thelas$oemia majot.
3 p -thalassemia -Pathogenesis. Types. Clinical features, Lab diagnosis
4 o Thalassaemla - Pathogenesis, Types, Clinlcal featutes, Lab diagnosis
Short questions
1
Discuss hematological findings in thales$emia majot,
2 B-thalassemia - Lob
-
diagnosis
a
3 ThalaSsaemia Types and Clinical features
Very Short questions
1.
Classification of Ihalassemia.
2 Peripheral blood picture In thalassemia.

Overview
Introduction (00:01:13)
Classification (00:03:27)
a Thalassaemla p Thalassaomla >
Definition (00:09:27) Definition (00:16:44)
Molecular pathogenesis (00:09:49) Molecular pathogenesis (00:17:05)
Types (00:10:11) Types (00:17:35)
Clinical features (00:16:13) Clinical features (00:20:57)
Lab diagnosis (00:22:23)

Introduction
Quantitative) abnormalities ofglobin chainsynthesis
Reduced synthesis of one or more of the globin polypeptide chains.

Classification
1 a Thalassaemia>
Absent or reduced synthesis of(a globin) chain (chromosome (16) with normal ß -chain synthesis.
2. Thalassaemia
Absent or reduced synthesis ofB globin chain (chromosome(11) with normal a -chain synthesis

0,
a

B
,
a
1) thalassemia
Definition
Absent or reduced production of(a globin chain)
Reduced formation of HbA in RBCs

Molecular pathogenesis
Deletion of one or more of a -chain genes located on short arm of chromosome 16.

PAGE 204 | RBC DISORDERS

 PATHOLOGY PROF
BUSTER m
Types
TYPE Hb Electrophoresls Gonotype Clinical Syndromne

1. Hydrops foetalls 3-10 Hb Barts Deletion of Fatal in utero or in

gm/di Loudu-genos early infancy.

2. HbH disease 2-12 HbF, HbH Deletion of hree)Haemolytic anaemia

gm/dl 0-genes
a-Thalassaemia 10-14 Almost normal Deletion of Microcytic
3.
gm/dl (woa-gonos hypochromic blood
trait
picture but no änaemia

a-Thalassaemia Normal Normal Doletion of Asynptomatic

4.
Carrier One-genes

a thalassemla

Normal Sllent a Thalassemla 3-0 4-a

tralt chaln deletion chaln defletíon
carrier
aa jaa

Arans
ty chain
100% a chain tp chain
70% a chain Tetramer of
Asymptomatic Y chain
Tetramer of
ß chain

Aslans Africans
CBarts hemoglobin
American Hydropsferaisauk
HbH Lethalin uteto

aechalns not produced

Formatlon of ß and y chalns is normal

3a chaln deletion 4-achalndeletion

B-chains formstetramers Y- chains forms tetramers
L(P,or HbH) (Yor Barts Hb)-n49
Ineffective erythropolesis Not able to transport
Oxygen properly
HbH Incluslon in red cells not able to release
oXygen to tissue
Fetus develops
Intrauterine hypoxia
Trapping of these cells in spleen

Extravascular hemolytic anemla Fetaldeath or Still blrth

RBC DISORDERS | PAGE 205

m, DR. PRIYANKASACHDEV

Clinical features
1. Clinlcally asymptomatic
a-thalassaemia carrier
Minimal or no anemia
2. a-thalassaemia frait > modoratoly sovero
3.
HbHHbH has extremely high affinity for oxygon > tissuo hypoxia
anemia occasional blood transfusion. form totramors Hb barte
4. Hydrops fetalis (Most dangorous) In fetus> oxcoss y-globln.chains.
fotal deaths
high affinity for oxygen Sovere tissue onoxla ntrautorino
ioind mutoats
nualioykot
2) B thalassomia > )-+ Cause, 1obin chain

Definltlon >
Absont or reduced productin of globin chain
B

Reduced formation of HbA in RBC6,

Molocular pathogenosis
Point Mutations)of B-globin gono rOsulting from singlo baso changos
3
types of mutations >
a) Splicíng mutations (most common)
b) Chain terminator mutations
c) Promoter rogion mutations

Types
TYPE HB Eloctrophorosls Gonotypo Cllnlcal Syndromo
1. B-Thalnajor)<5 HbA (0-50%), pthol/ gthal Sovero anaomia, requiros
gm/d| /HbF(50-98%) transfusions
2. ß-Thal 5-10 Variable Multiple Sevoro anaomia, but rogular
intermedia gm/dl mechanisms transfusions not required
3, p-Thala 10-12 HbA2(4-9%),n)pN pthal Usually, asymptomatic
minor gm/dl HbF (1-5%)

p
chains not produced

a chain accumulate

Combine with y chain, Destructlon of normoblasts in the bone marrow

to forma, ) <(|bf
Ineffective erythropolesis

|Anemia
THBF
Hypoxla in tissues

Repeated EPO secretion by renal cells

blood
transfusion Erythrold hyperplasla in bone marrow

T
Iron absorptlon Bone changes because of
medullary cavity expanslon
Death Iron overload

PAGE 206| RBC DISORDERS haenocHooalon)

 PATHOLOGY PROF BUSTER m
clinical features
1. Anaemia starts within
Hepatosplenomegaly first(4-6 monthslof
3. Expansion of bones dueto extramedullarylife
thalassaemic facies due to marked
and erythroidhaematopoiesis'
due to malocclusion of
CA. Iron overload
hyperplasia
endocrine organs repeated blood the jaw. leading to
mellitus)and (slow rate of transfusions
damage to the growth, delayed damage to
liver and heart. puberty, diabetes the
Lab Diagnosis
1) Peripheral smear

Ojeneral Rlood parqmekr s

ucleated RDC

pochromatic Cell

Target Cef
Couns
itte a
Lest
Platele lot rny
Mierocytic Anisocytosis
Poikilocytosis Target hypochromic RBC'
cells Nucleated RBls
Gasophilic Stippling )
e
Peni du, cel s oHh Target cetts
Poikllocytosis
Cabot
2)Osmotic fragility test Norel Thal
Decreased osmotic fragility > Increased resistance to saline haemolysis
Typical Graphs for RBC Osmotic Fragility
Hemolysis
100%
i80%ti
60% Normal Range
40% Slckle Cell Anemia
Thalassemla Major Herediatry
20% Spherocytosis
0%
0,1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9
% NaCl Solution

3) NESTROF Test
Naked Eye Single Tube Red cell Osmotic Fragilitý
(NESTROF) test
blood samples (1 of control and1 of patient) are
added to 2 tubes with 0.35% saline)
a
After 30 min white paper with black line is placed
a

behind both tubes.

RBCsin control sample undergo hemolysis > black
line is visible
line is not )
RBCs in thalassemia resistant> black
clearly visible.) Thalassemla "Control

R8C DISORDERS | PAGE 207

 DR. PRIYANKA SACHDEV

Hbn
4) Haemoglobin electrophoresis
Almost complete absence of HbA Hb
Since ß chains are not produced but y, chains are synthesized
normally increased amounts of(HbFEX90%).
Increased amount of HbA2)

5) Skull X-ray
Widening of the diploe gives rise to
Crew cut appearance on skull X-ray
Hair on
end appearance)
HeNochroatosy > Tron stove inerau
E
(10.12) IRON DEFICIENCY ANEMIA (IDA)
University Exams
Long questions
1. Define anemia. Gve etiologic classification of anemias. Describe peripheral blood smear and bone marrow picture and list
laboratory investiga tions in iron deficiency anemia.
2. Describe the etiology, clinical features and the laboratory dlagnosis of iron deficiency anemla.
Short questions
1 Laboratory diagnosis of iron deficiency anemia (peripheral blood smear and bone marrow findings),
TuSA TeelinA
2
3.
Blood picture in iron deficiency anemia.
Role of Hepcidine in Iron regulation
Absorflioi
pude TS
4 Clinical features of iron deficiency anemia.
Very Short questions DUodenu-Iron
Peripheral blood smear findings in iron deficiency anemia Folal-e
JTm
1
2 Ennumerate Factors of Iron absorption )
3. Earliest Response to therapy in iron deficiency anemia

Overview
Introduction (00:01:26)
Normal iron metabolism (00:01:43)
Regulation of iron absorption (00:08:45)
Factors of Iron absorption (00:11:58)
Etiology (00:14:13)
Clinical features (00:16:44)
Lab diagnosis (00:18:38)
Differential diagnosis (00:28:06)
Treatment (00:28:26)
Response to therapy (00:29:49)
ron e NOSt CoNNOnnutaionldyordey
Deiueny of
Introduction
oord and result tn
to
inndagva,
cliea Hb
qt that Nosy related
Most common cause of anemia worldwide and in India

Normal iron metabolism

Hepcldin

Spferopruleh HSC
Hepcidin

(Fes)
Fa2
PMIO Fe2 )
rrio.
(Tincfe

NOrra

PAGE 208 | RBC DISORDERS

 PATHOLoGY PROF
BUSTER M

Iron in diet is in Fe3+ (ferric) state

Reduced to Fe2+ (ferrous) iron gastric acid

in

transporter 1 (DMT1)
Transported across apical membrane by divalent metal

Transported from cytoplasm across basolateral membrane byFerropor1howTlasa tron,

Coupled to oxidation of Fe2+ iron to Fe3+ iron
celbo
epitkaial
Fe3+ iron binds to plasma protein transferrin hspili
marrow koo plasya
in syskaui
Transferrin delivers iron to red cell progenitors In
Hah playa ioflann
Extra iron is stored in liver in form of(ferritin
by
lot
meah chin, plaa
Heme Iron Hepcldin
Heme transpoton |Liver
Ferroportin 1
FOOD
IRON
FgJ
Duodenal
cyochrome B Blood
Nonheme
iron Fe+

Fe2+ Hephaestin Plasma

Mucosal
transferrin
DMT1 ferritin

Erythrold
Lost by shedding marrow
of epithellal cells
Enterocyke plasya
Remember with a glycoprotein transferrin.
• Iron is transported is blood in combination
Iron is stored as ferritin or haemosiderin rale of

Regulation of iron absorption

Increases in intrahepatic iron levels

Hepcidin is synthesized and

reieased from liver

Hepcidin binds to ferroportin

Degrade it
enterocyte to plasma
Inhibits iron transfer from
within duodenal cells
Iron becomes trapped
oipoi Iron is lost as these cells are(sloughed
(uegiidin
When body iron stores is low
with iron
When body is replete
Hepcidin synthesis falls
High hepcidin levels
Facilitates iron absorption into the blood
into blood
Inhibit iron absorption
R8C DISORDERS| PAGE 209
 DR. PRIYANKA SACHDEV

Factors of Iron absorption

Factors Increaslng absorptlon Factors docreasing absorption
Ferrous form(Fe2+)| Ferric form (Fe3+)
Acid (HCI) in the stomach (Achlorhydria)(absence of HCI secretion)
Ascorbic acid Akaline food (pancreatic secretions)
Amino acid and sugars in
the food Phytates, tannates and phosphates in
Physiological conditions (pregnancy and diet
hypoxia) Tetracyclinesand EDTA
Inflammatory disorders
mats
Etiology ( tavseu)
JTDietary lack Impalred Increased Chronic blood loss
absorptlon roqulromont
Infants Steatorrhea Growing infants GITXpeptic ulcer, gastric
Children Sprue and children cancer, hemorrhoids,
Low Chronic Pregnant females hookworm disease)
socioeconomic diarrhea Premenopausal Urinary tract (renal, pelvic or
status Gastrectomy Women bladder cancers)
Elderly
Genitaltract (uterine cancer
menorrhagia)

Clinical Features
1) Anaemia
Weakness
Fatigue
Dyspnoea on exertion: vU
Palpitations -
Pallor of the skin, mucous membranes and sclerae.
Older patients may develop angina and congestive cardiac failure. Koilonychia

2) Epithelial tissue changes toncrity

Spooning,
a) Nails or
(koilonychias spoon-shapednails)
b) Tongue (atrophic glossitis)
c) Mouth (angular stomatitis)

Normal tongue Atrophic glossitis Angular stomatitis

-keu Sync ior

3) Plummer-Vinson syndrome CPateson
Iron
Deficiency
Anemia

Dysphagia Esophageal
Webs

Plummer
Vinson
Syndrome

PAGE 210| RBC DISORDERS

 Sere fenitiy Lave
30-25
ma BUSTER
PATHOLOGY PROF
6
Lab Diagnosis
Lab diagiosis

ABIood Bone Marrow

Blochemistry|
a) Hb
RBC Cellularity a) Serum iron
4e b) Erythropolesls b) Serum Forritin + L
Retic c) Marrow Iron 4
d) Indices C) TIBC
e d) Transferrin
WBGA
Platelets saturation

1)Blood picture
a) Hb. concentration \Fal)
b) RBCs PoC
Hypochromic
Microcytic
Anisocytosis
Poikilocytosis
Normal Microcytic Hypochromic
Target cells Red Cell
Red Cell
Ring / pessary cellsl

04o
Anisocytosis and Poikilocytosis Target Cells
Microcytic hypochromic RBCs
epatiet Retoloyh Cound >seseponse
c) Reticulocyte count slightly low IE 4rea
d) Indices
Diminished MCV +
Diminished MCH
Diminished MCHCJ
e) Leucocytes TLC and DLC normal
>
f)
Platelets normall
ROwse. Normoblastic Micronormoblasts
2)Bone marrow findings
a) Marrow cellularity Marrow
Increased due to erythroid hyperplasia orythropolesis
Myeloid-erythroid ratio decreased
b) Erythropoiesis Deflclent Marrow iron stores
Normal
(micronormoblast)
Small normoblasts huclear maturation Prussian blue stain (Iron Stores)
Cytoplasmic maturation lags behind
reaction) Deficient)
c) Marrow iron (Prussian blue

3) Biochemical findings >

ug/dd)
ja) Serum iron level >Low(50(Indicating poor tissue iron stores) Norma Iron deflciency
b)
C)
Serum ferritin level> Low
(TIBC) High)
Total iron binding capacityLow (below 15%)
sensih
Ll'nictoreng
Anemia

d) Transferrin saturation >

RBC DISORDERS| PAGE 211

iuralici bindirs Cofmeil

TLGC CTot in
 DR. PRIYANKA SACHDEV

FE FE
Transferrin
FE FE
Iron

CAPACITY
SERUM IRON BOUND TO TRANSFERRIN UNSATURATED SERUM IRON BINDING

Differential Diagnosis
Test Iron Chronlc Thalassaemla Sldoroblastíc Anaemia
Deficlency Dlsorders Minor
1. MCV, MCH, MCHC Very low (except MCV
Reduced Low normal Very low
to-reducod raised in acquired type)
2. Serum iron Reduced Normal Raised
Reduced
3. Serum ferritin Reduced Raised Normal Raised (complete
saturation)
4. TIBC Raised Low-to Normal Normal
normal
5. Marrow-iron stores Absent Present High High
6. Iron in normoblasts Absent Absent Present Ring sideroblasts
7. Hb electrophoresis Normal Normal Abnormal Normal

Treatment
a) Correction of disorder causing the anemia TERROUS
b) Correction of iron deficiency BWATE
1 Oral therapy>
a) Ferrous sulfate
b)/ Ferrous fumarate
c)
Ferrous gluconatev
2. Parenteral therapy Indications
a) Intolerance tooral iron therapy
b) Malabsorption
c) Post-operative, cases IRON
d) Cases requiring a rapid replenishment of iron stores e.g. in
women with severe anaemia a few weeks before expected date INFUSION
of delivery.
Common preparation is iron dextran > single intramuscular injection
PREP
or intravenous infusion

Response to therapy
Earliest hematological evidence of improvement increase in reticulocvtes

(10.13) SIDEROBLASTIC ANEMIA

Unlversity Exams
Short questions
1. Define and classify anemla. Write Pathogenesis and Laboratory diagnosis of Sideroblastlc Anaemlas
Very Short questions
1 Ring Sideroblast
Types of Sideroblast

PAGE 212 |RBC DISORDERS

 PATHOLOGY PROF BUSTER

Ovtrvie
Introduction (D0:00:59)
Pathogenesis (00:10:11)
Types of Sideroblast (00:10:46)
Types of Sideroblastic Anaemias (00:13;45)
Lab diagnosis (00:14:09)
Differential diagnosis (00:22:50)
Treatment (00:23:35)

Introduction
Body has adequate amount of iron but is unable to corporate it into hernoglobin.

Pathogenesis
Mitochondrial Enzymes defect activity in erythroblasts
Iron enters into mitochondria

Cannot be utilized to synthesize heme de to 2 S ees

Iron accumulates mitochrondria of erythroblasts

(Ringed sideroblast)
Ypes 3
Types 1 Types 2
(25 siderotíc grarules in
Types of Sideroblast (<5 siderotic granules
in cytoplasm)
(25 siderotic granules
In cytoplasm but not In ytoplasm averiseneatleast
. perinuclear distribution) one-third of circumf
Type
Dsideroblasts:
granules in cytoplasm.
< 5 siderotic of nucleus)

Type 2)sideroblasts: 2 5 siderotic

granules, but not in perinuclear
distribution.
Type 3or ringed sideroblasts:25
siderotic granules in perinuclear
distribution.
Normal Excess iron Abnormal Iron
metabollsm
<5
Types of Sideroblastic Anaemias 25
a) Hereditary sideroblastic anaemia AX-linked disorder defective enzyme activity of
(aminolevülinic acid(ALA)$ynthetase required for haem synthesis.
b) Acquired sideroblastic anaemia
Previous chemotherapy
Irradiation
Myelodysplasia
Myelproliferative disorders
Drugs> Alcohol, isoanizid, choramphenicol, pyridoxine deficiency. lead poisoning
Lab Diagnosis
Lab diagnosis

Blood Bone Marrow Biochemistry

Fall
a) Cellularity Serum iron
) Hb
RBC
gic) b) Erythropoiesis b) Serum Ferritin
c) Retic lc) Marrow Iron c) TIBC
d) Indices d) Transferrin
e) WBC saturation
|) Platelets

R8C DISORDERS | PAGE 213

 m DR. PRYANKA SACHDEV

1) Blood picture
a) Haemoglobin Fall
b) RBC Hypochromic anaemia which may be microcytic or normocytic (dimorphic).
c) Reticulocyte count normal but may be slightly low
d) Indices (MCV, MCH and MCHC) Reduced in hereditary type but MCV is often raised in
acquired type.
e) Leucocytes TLC and DLC normal
f) Platelets normal

2) Bone marrow findings

a) Marrow cellularity
Increased due to erythroid hyperplasia
Myeloid-erythroid ratio decreased
b) Erythropoisis
Erythroid hyperplasia
c) Marrow iron
Raised
Ring sideroblasts TYpea3

3)Biochemical Findings
a) Serum iron level >(Raised)
DDpticb) Serum ferritin level >Raised)
c) Total iron binding capacity (TIBC) normal 33%
d) Transferrin saturation Increased

Differential Diagnosis
Iron deficiency Anemia
Thalassaemia
Anemia of Chronic disorders

Treatment
1. Removal of the offending agent.
2. No definite treatment is available for/hereditary types
3. Pyridoxine administered routinely to all cases of sideroblastic anaemia
4. Blood transfusions

(10.14) ANEMIA OF CHRONIC DISEASE (AOCD)

University Exams
Long questions
1 Define and classify anemia. Write Pathogenesis and Laboratory diagnosis of Anaemia of chronic disorders (AOCD)
Short questions
1 Pathogenesis of Anaemia of chronic disorders
2. Describe investigations in Anaemia of chronic disorders
3 Causes of Anaemia of chronic disorders

Overview
Introduction (00:01:01)
Etiology (00:03:08)
Pathogenesis (00:04:13)
Lab diagnosis (00:12:21)
Differential diagnosis (00:14:04)
Treatment (00:14:26)

PAGE 214 | RBC DISORDERS

 BUSTER
PATHOLOGY PROF

Introduction
In patients of chronic systemic
process but there is no diseases in which anaemia develops secondary to
actualinvasion of the bone marrowW.
Severity of anaemia is usually directly
Anaemia is corrected only if the primaryrelated to the primary disease proces
disease Is alleviated

Etiology
4
Anaemia in chronic infections/inflammation
a) Infections e.g. tuberculosis, lung abscess, pneumonia, osteomyelitis, subacute bacterial
endocarditis, pyelonephritis.
b) Non-infectious inflammations e.g. rheumatold arthritis, SLE, vasculitis, dermatomyositis,
scleroderma, sarcoidosis, Crohn's disease.
c) Disseminated malignancies e.g. Hodgkin's disease, disseminated carcinomas and sarcomas.
2 Anaemia of renal disease e.g.
uraemia, renal failure
3. Anaemia of hypometabolic state e.g. endocrinopathies, protein malnutrition, sCurvy, pregnany
liver disease.

Pathogenesis
Chronic Disorders

Proinflammatory cytokines (|L 6, IFN, IL-1, TNF)

Decreased synthesis of erythropoietin Increased synthesis of hepicidin

E. precursors do not proliferate Inhibits ferroportin

Defective erytheopoisis Reduces the transfer of iron from

storage pool_to E. precursors

Increased stores of iron

Kidney Erythrocyte
Retlculocyte
Hypoxia induced kidney
EPO expression

EPO Pro orthochromatophlllc

Pericytes produce erythroblast
EPO

EPO-R

Erythrold
Uneage Uneage
decislon
GATAI
KLF1
PU1 Polychromatophllle
BFU-E CFU-E Proerythrcblast Basophlllc
Hematopoletlc Megakaryocytic erythroblast erythroblast
steam cell erythrold
progentors
EPO dependent

RBC DISORDERS | PAGE 215

m DR. PRIYANKA SACHDEV

Lab Diagnosis
Lab dingnosis

Blood Bone Marrow Biochemistry Others

a) Hb a) Cellularlty a) Serum iron a) Acute Phase reactants

b) RBC b) Erythropoiesis b) Serum Ferritin b) £SR
c) Retic c) Marrow Iron c) TIBC
d) Indices d) Transferin saturation
e) WBC
) Platelets
1) Blood picture
a) Haemoglobin Fall
b) RBO Normocytic normochromic
c) Reticulocyte count normal but may be slightly low
d) Indices MCHC is slightly low.
e) Leucocytes TLCand DLC normal
f) Platelets normal
2) Bone marrow findings
a) Marrow cellularity
Increased due to erythroid hyperplasia
Myeloid-erythroid ratio decreased
b) Erythropoisis Normal erythroid maturation
c) Marrow iron Raised
3) Biochemical Findings
a) Serum iron level Reduced aM
b) Serum ferritin level Increased
c) Total iron binding capacity (TIBC) > Normal or
d) Transferrin saturation > Decrease
decreases
4) Others
a) Acute phase, reactants (gamma-globulin, C3, haptoglobin, a1-antitrypsin and fibrinogen)
Raised
b) ESR Raised)
saliva1 1lad
Differential Diagnosis Hepleorsy
a) Iron deficiency Anemia BP
b) Thalassaemia
c) Sideroblastic Anemia

Treatment
Treat underlying cause
P)
(10.15) MEGALOBLASTIC ANEMIA
orotie aud pathoy riegaloblah Heptetorin
University Exams
Long questions
Define and classify anemia. Write Pathogenesis and Laboratory diagnosis of theg
egalóblastic anemia.
2 Enumerate causes of megaloblastic anemia. Describe its peripheralblood and-bone marrow (inGngs.
Short questions
1 Laboratory diagnosis of megaloblastic anemia (peripheral þlood smear and bone marrow flndings),
2 Megaloblast.
3 Describe investigations in macrocytic anemia.
Describe PS and BM findings in Megaloblastic anemia.
a
Draw well labelled diagram of peripheral smear in megaloblalic anemia.
6 What is schilling test?
Very Short questions
1
Causes of megaloblastic anemia.
2. Effects of vitamin B12 deficiency on the nervous system.

PAGE 216 | RBC DISORDERS

Groteas ubu'n
cob alu
 PATHOLOGY PROF
BUSTER
Overview
Introduction (00:03:01)
Etiology (00:11:30)
Pathogenesis (00:14:55)
Clinical features (00:18:02)
Lab diagnosis (00:18:24)
Treatment (00:34:06)

Nvcteut (annd
t altn
Tupa et of c
cncu
Introduction a'stinctive DNA
inefleete hertatoporeus
Prteurs or
morpholag, ynthusu eads abnoryal eryyrord
Impaired DNA synthesis
Vit B12 and foliç acid are
required forDNA
megaloblastic anaemia is synthesis?
due to deficiency ofvit. B12
yoplateeaynchvouig
Cavse,
hnd(olic acid
torned
Etiologys not
Vitamin B12 deficiency
Decrease intake: Inadequate diet, alcoholism. Folate deficiency
infancy. 1. Decrease intake: Inadequate diet, alcoholism,
Impaired_absorption: Malabsorption state: infancy.
intestinal diseases. 2. Impaired absorption: Malabsorption state,
Increased requirement: Pregnancy, infancy, intestinal diseases.
disseminated cancer. 3. Increased requirement: Pregnancy, infancy,
viamuu disseminated cancer.
Pathogenesis
Inadequate DNA synthesis
Defective nuclear maturation
Maturation of nucleus lag behind to that of
cytoplasm
Nuclear/Cytoplasmic asynchrony
Formation of megaloblasts and macrocytes]

BASOPHILIC POLYCHROMATIC ORTHOCHROMATIC RETICULOCYTE MATURE RED CELL

PROERYTHROBLAST ERYTHROBLAST ERYTHROBLAST ERYTHRoBLAST

THYMIDYLATE SYNTHETASE REACTION

dUMP dTMP DNA

Methylene THF DHF PGA

DHF reductase
THE,
Methlonine

Methyl HOMOCYSTEINEMETHIONINE
Vtamln B12 REACTION

Homocystelne

Methyl THF XBlock due to folate deflclency

(Plasma folate) Block due to drug with normal tlssue folate level
A

R8C DISORDERS | PAGE 217

 Terminal ilevg - nt
salivary glid Cubylis
L mehyl alonyl co Sueinyl toh et
m DR. PRIYANKA SACHDEV

Vit. B12)s also involved in conversion ofmthylmalonyl CoA to succinyl CoAJwhich

for the formation of hormal neuronalLpids) isrequired
So, deficiency of vibmin B12 (but not offolic acid) results in (neurological featuros

Clinical Features
1. Anaemia In both vt, B12 and folate_def_
2. Neurologic manifestatjons > only init, B12 det) Not in folate def.
Subacute combined.degeneration of the spinal cord
Peripheral neuropathy
Numbness, paraesthesia, weakness, ataxia, poor finger coordination and diminiek
reflexes; Dorsuy of hnd (Knule)/
Sen hyperpigyenta
Lab Diagnosis 5)
Lab diagnosis

Blood Bone Marrow Biochemistry| |Special Tests

a) Hb
b) RBC
a) Cellularity
b) Erythropoiesis
a) Serum iron
b) Serum
aX Schiling test
b) FIGLU
1t-bn
c) Retic c) Marow Iron Ferritin
d) Indices
e) WBC
) Platelets
1) Blood picture
a) Haemoglobin concentration > FalI
b) RBCs
Macrocytosis
Macroovalocytes
Anisocytosis
LABORATORY
FINDINGsNORMLALs MEGALOBLASTIC ANAEMUA

Poikilocytosis
Normal Macrocytic
Tear drop cells) BLOOD

RED CELL red cell red cell

Basophilic stippling MORPHOLOGY
Cabott Ring
Howell-jolly bodies

Howell-jolly Basophillc carbot rlng

eutrephi body stippling Macrocyosss

Howel - Jolly bodies Cabot ring Basophilc stippling

PAGE 218 | RBC DISORDERS

 m, DR. PRIYANKASACHDEV

Hot
Bze
1mg

Absorption Kidney
G

Blood Vessel Excrotion in Urine

1. 1 mg of unlabelled vitamin B12 ('cold' B12)lis given by[intramuscular route)(to saturate binding
sites)
2. 1 mg of radioactively labelled vitamin B12 Chot B12) is given byoral dose)
3. The patient is kept fasting for a further period of'2-hours
4. Urinary excretion of B12 is estimated

Interpretation >
In normal individuals > 24-hour urinary exçretion is(>10%) of the oral dose of 'hot' B12
Patients with B12 deficiency 24-hour urinary excretion is(< 10%)of 'hot' B12

Stage l: With IF
If the 24-hour urinary excretion of hot' B12 is low
Test is repeated using the same procedure as in stage I but in addition high oral dose of IF

Interpretation >
Ifthe 24-hour urinary excretion of 'hot' B12 is now normal (>10% of the oral dose of 'hot' B12) >
IF deficiency (Pernicious anaemia)f

Stage ll: with antibiotics

-, RUnd Loop m

If the 24-hour urinary excretion of 'hot' B12 is still low>

Test is repeated after a course of treatment with antibiotics or anti-inflammatory drugs.

Interpretation
of 'hot' B12 is now normal (>10% of the oral dose
If the 24-hour urinary excretion ofhot' B12) >
Malabsorption or Bacterial overgrowth

Stage IIl: with Pancreatic enzymes,

Ifthe 24-hour urinary excretion of 'hot' B12 is still low
Test is repeated after a course of treatment with Pancreatic enzymes.

Interpretation>
If the 24-hour urinary excretion of 'hot' B12 is now normal (>10% of the oral dose of 'hot' B12 )

Chronic pancreatitis

Schilling Test
58Co-Cb1 WIintrinsic After 5 Days WIPancreatic Enzymes
Factor of Antibiotics
Pernicious Anemia ReducedNormal Reduced Reduced
Bacterial overgrowth Reduced Reduced Normal Reduced
Chronic pancreatitis Reduced Reduced Reduced Normal

PAGE 220 | RBC DISORDERS

 PATHOLOGY PROF
BUSTER
Special Tests for for folate deficiency
Urinary excretion
of FIGLU

Folic acid is required for conversion of formiminoglutamic.

catabolism of histidine.
On oral administration of
acid,(EIGLU) to glutamic acid in the
present histidine urinary excretion
of FIGLUlis increased if folate deficiency is
(Histldino)

Formiminoglutamio
acid (FIGLU)
Folic acid
Glutamic acidl
Treatment
Vitamin B12 deficiency Hydroxycobalamin) as
lte acid deficiency > Oral folic acid 5
intramuscular injectior 1000 pgjfor
mg tablets
3 weeks
daily for 4 months.
I(10.16) PERNECIOUS ANEMIA
University Exams
Short questions
AIhatis Pernecious anemia. Write its
1. Pathogenesis, morphological
Very Short questions features and Lab diagnosis
1. Pathogenesis of Pernecious anemia
2. Lab diagnosis of Pernecious anemia

Overview
Introduction (00:00:39)
Pathogenesis (00:04:54)
Morphological features (00:05:53)
Lab diagnosis (00:07:28)
Treatment (00:10:13)

Introduction Autounune disorde

Pernicious anemia is megaloblastic anemia due to vit.
B12 deficiency (due to F
deficiency)
Intrinsic factor is secreted from parietal
cells of stomach.

Pathogenesis
Autoantibodies against gastric
s
Vit B2
parietal cells Vit B,z
CAuto Ab.
Atrophy of
gastric mucosa:: No IF
IF absent
No absorption of Vitamin B 12
Absorbed
absorption
Vitamin B 12 deficiency X
Pernecious anemia Blood Vessel
Normal Pernecious Blood Vessel
anemia

RBC DISORDERS | PAGE

221
m DR. PRIYANKA SACHDEV

Morphologic features
Gastric atrophy
Intestinalization of stomach (replacement of gastric mucosa by muscus-SeCreting globlet cells)
All features of megaloblastic
anemia -> Neurologic abnormalities such as peripheral neuropathy
and spinal cord damage
Associated with increased risk of gastric cancer
Lab diagnosis
• Schiling test
Treatment
Parenteral vitamin B12 replacement therapy
Corticosteroids

I(10.17) APLASTIC ANEMIA AND PURE RED CELL APLASIA (PRCA)

University Exams
Short questions
1
What is Aplastic anemia. Write its Etlology, Pathogenosis, Clinical featuros and Lab diagnosis
Very Short questions
1
Four causes of aplastic anemia.
2 Peripheral blood picture In aplastic anomla.
3 Dry tap
4 Pure Red Cell Aplasia (PRCA)
Aplaskie anemi Liyelody
Overview
Aplastic anaemia
4rans?
Introduction (00:04:00)
Etiology (00:04:49)
Pathogenesis (00:06:22)
Clinical features (00:06:46)
Lab diagnosis (00:07:34)
Treatment (00:09:20)
Pure red cell aplasia (PRCA)
Introduction (00:10:55)
Causes (00:11:25)

Aplastic anaemia
Introduction
Aplastic anaemia result from aplasia of the Red biood

bone marrow
In aplastic anaemia, there ispancytopenia
i.e. simultaneous presence of
1. Anaemia Red bone
2. Leucopenia > maToo
3. Thrombocytopenia

Etiology
1. Primary aplastic anaemia APLASTICANEMIA
a) Fanconi's anaemia (congenital) Ratlts
b) lmmunologically-mediated (acquired)

2 Secondary aplastic anaemia

a) Drugs e.g. with antimetabolites<(methotrexate), mitotic inhibitors (daunorubicin), alkylating
agents (busulfan), nitroso urea, anthracyclines.
b) Toxic chemicals e.g. benzene derivatives, insecticides, arsenicals.
c) Infeçtions e.g. infectious hepatitis, EB virus infection, AIDs, other. viral illnesses.

PAGE 222| RB DISORDERS

 BUSTER
PATHOLOGY PROF

Pathogenesis
Aplasia of bone marrow
Sufficient reduction in number of
haematopoietic pluripotent stem cels
Lower counts of all 3 blood cells types
a) Red blood.cels (anemia, reticulocytopenia)
b) WBCs (leukopenial neutropenia)
c) Platelets (thrombocytopenia)

Pancytopenia with hypocollular bone marrow

clinical features
4
Anaemia > mild progressive weakness and fatigue.
2. Thrombocytopenia Haemorrhage from varlous sitos such as from skin, nose, gums, vagina,
bowel, CNS and retina,
3. Leucopenia Infections)
A. The lymph nodes, liver and spleen are generallynot enlarged>
Laboratory findings
1. Blood picture
2. Bone marrow picture
1) Blood picture
a) Haemoglobin >Fall
b) Red cells >Normocytic normochromic_anaemia
w
c) Reticulocyte >
reduced or zero
d) WBC Leucopenia The absolute granulocyte count is particularly low (below 1500/pl) with
relative lymphocytosis. Aeetlue
le) Platelet > Thrombocytopenia
2) Bone marrow picture
Les ell:
Cellularity >
A
bone marrow aspirate
> dry tap
A trephine Hypocellular or
biopsy
aplastic marrow due to replacement by fat.
Haematopoietic stem cells bearing CD34
marker are markedly reduced or absent.
Treatment Healthy bone marrow Aplastic anemia
(Dry tap) Bony trabeulae
1. General management
a) ldentification and elimination of cause
b) Supportive care > blood transfusions, platelet concentrates
2. Specific treatment.
a) (Marrow stimulating agentssuch as androgen
b) Immunosuppressive therapy.
3. Bone marrow transplantationBut reatye
Considered in severe casesunder the age of 40 yearswhere the HLA matched
available.
donor is

-
Pure red cell aplasia (PRCA) > Erjrid rtw
Introduction >
Selective failure in production oferythrold elements] in bone marrowbut with normal granulopoiesis
and megakaryocytopoiesis.
Patients have normocytic normochromic anaemia and reticulocytopenia with normal WBC and
platelet count.

RBC DISORDERS | PAGE

223
im DR. PRIYANKA SACHDEV

Causes
1. Congenital PRCA (Blackfan-Diamond syntrome)
Mutation in a ribosomal RNA processing gene RPs19)
2. Acquired PRCA
Thymoma (most common)c )6f)
3. Chroni B19 parvovirus infeclions)

|(10.18) PANCYTOPENIA
Univertity Exams
Short guestiôns
1
Pancytopénia define, causes
2 Pancytopenia with hypocellulat bone mattow:
Pancytopenia with hypercellulat bone matrow:

Overview ni
H

Introduction (00:00:28) R6C 45Ss

NGG: 4000- ||0 oo
m
Causes (00:09:31)

Introduction
Cytopenia > Reduction in either of cellular component of blood
Pancytopenia Reduction in all 3 cell lines of blood
Hemoglobin < 13.5 (M)/ 11.5 (F) g/dl y Aneria
Total leukocyte count < 4000 /cumm
Platelet < 150,000/cumm Throy bouytopeic.

Red blood
cells

Red bone
marrow

White blood
cells

APLASTIC ANEMIA
Platelets

PAGE 224 | RBC DISORDERS

 PATHOLOGY PROF BUSTER

Causes
Pancytopenia

Increased destructlon
Soquostratlon
Docreased production

Hypercellular Bone MarrowW

Hypocellular Bone Marrow

Pancytopenia with $Ao

hypocellular bone marrow: Pancytopenia with Sun ngeni pillig
Aplastic anemia
hypercellular marrow:
Fanconi anemia Myelodysplasia
Dyskeratosis congenital PNH
Myelofibrosis
hairy cell leukemia
megaloblastic.anemia
bone marrow lymphoma
SLE
Hypersplenism
Sarcoidosis
alcohol

spuen

RBC DISORDERS | PAGE

225
 DR. PRIYANKA SACHDEV

IDA
J eatnu ,Fatigue, Dysp nean
*** THISPAGE IS INTENTIONALLY KEPT BLANK *s*

PVS DIES
ROC Tarqe es, Ring |ressarg cell.
Mev, mcH, mcHc bidNskde
Indie
Palhogentsd
Iron deficieny
|Long qnenia
qöestton
Thalassemia B-thallueu
"hegaloblast Comnldt
nemia
tHo
Haemoa +ralloeasi PeS
Lab

sphro eqtoo

PAGE 226 | RBC DISORDERS

 CHAPTER

WBC DISORDERS 11
I(11.01) INTERPRETATION OF DLC

University Exams
Very Short questions
1 Leukocytosis (definition and causes).
2
Neutrophilia and Neutropenia
3 Causes for lymphocytosis and Lymphopenia
Name six causes for monocytosis.
Normal and abnormal absolute eosinophil count values.
Normal eosinophil count, two causes for eosinophilia.
5
6
7
Conditions associated with eosinophilia.
Conditions associated with Basophilia.

Overview
Introduction (00:01:38)
Types of WBCs (00:02:05)
Hematopoiesis (00:04:24)
Normal counts (00:06:59)
1. Neutrophils > Neutrophilia, Neutropenia (00:10:50)
Lymphocytes > Lymphocytosis, Lymphopenia (00:19:07)
2.
3 Monocytes Monocytosis (00:23:52)
4 Eosinophil > Eosinophilia (00:25:47)
Basophils > Basophilia (00:27:49)

Introduction
study of various cells and components of
white
Hematology > blead cel
blood >
1. RBCs (erythrocytes)
2. WBCs (leucocytes) Platelets Red
blood celt
3. Platelets (thrombocytes)

Type of WBC
Types of WBC

Agranulocytes
Granulocytes

Neutrophils Eosinophils BasophilsLymphocytes Monocyte

 m DR. PRIYANKA SACHDEV

Hematopoiesis
HSC

Lymphold stem cells Myelold (trilineage) stem cells

Prolymphocyte

Granulocyte-monocytep. Erythroid p Megakaryocytes

Lymphocytes Neutrophils RBC Platelet

Eosinophils
Basophils
Monocytes

PLURIPOTENT STEM CELL

MYELOID STEM CELL LYMPHOID STEM CELL

(TRILINEAGE

Prolymphocyte

Megakaryocyte
progenltor
Granulocyte-monocyte progenltor Erythrold progenltor
Bone Bone
Thymus
marrOW marrow
GM-CSF Erythropoletin Thrombopoletin

B NK
Neutrophil Basophil Eosinophil Monocyte Red cells Platelets Lymphocytes

Normal Counts
ABSOLUTE COUNT
TLC
Adults 4,000-11,000/1
DLC In Adults
Polymorphs (neutrophils) 40-75% 2,000-7,500/ml
Lymphocytes 20-50% 1,500-4,000/ml
Monocytes 2- 1 0% 200-800/ml
Eosinophils 1-6 % 40-400/ml
Basophils <1% 10-100/ml

PAGE 228 | WBC DISORDERS

 PATHOLOGY PROF
BUSTER M.
Neutrophils (Polymorphs)
Normal count 1500 to 7500
. Characteristic dense cells/mm3
nucleus > 2-5
Pale Cytoplasm numerous lobes
fine violet
pink granules

Myeloblast Promyelocyte Myelocyte Metamyelocyte

Band Cetl Mature
Granules > 2 types Neutrophil
Primary or azurophilic granules
Large and coarse
Appear early at promyelocyte
stage.
Contain > hydrolases,
elastase, myeloperoxidase, cathepsin-G.
increasing protein, and microbicidal cationic proteins, permeabmy
protein called defensins.
Secondary or specific granules>
Smaller and more numerous
Appear later at myelocyte stage
Contain > lactoferrin, NADPH
oxidase, histaminase, vitamin B12
chemoattractant and for laminin. binding proteíin, and receptorS To

Neutrophilia
Above 7,500 /mm3

Causes
1. Acute infections and inflammations
2. Intoxication >e.g. uremia, diabetic ketosis, eclampsia,
poisonings by chemicals and drugs.
3. Acute hemorrhage
4. Acute hemolysis
5. Disseminated malignancies
6. Myeloproliferative disorders
Neutropenia
Below 1,500 /mm3

Causes
1. Infections > e.g. typhoid, paratyphoid, brucellosis,
influenza, measles, viral hepatitis, malaria,
kala-azar etc.
2. Drugs induce aplasia of bone marrow > e.g. antimetabolites, nitrogen
mustards, benzene, ionising
radiation.
3. Hematological diseases e.g. pernicious anemia, aplastic anemia, cirrhosis of the liver with
splenomegaly, SLE, Gaucher's disease.

2) Lymphocytes
Normal count 1500 to 3500 cells/mm3.
Round or slightly indented nucleus with coarsely-clumped chromatin
Scanty basophilic cytoplasm.
Plasma cells are derived from B lymphocytes
Nucleus of plasma cell is eccentric and has cart-wheel pattern of clumped nuclear chromatin.

WBC DISORDERS | PAGE

229
 DR. PRIYANKA SACHDEV

Lymphocytosis
Above 3,500 /mm3
Differentlation
Causes
1. Acute infections e.g. pertussis,
infectious mononucleosis, viral hepatitis,
infectious lymphocytosis.
2. Chronic infections e.g. brucellosis, Memory B cell Plasma Cell
tuberculosis, secondary syphilis.
3. Haematopoietic disorders e.g. lymphocytic leukemias, lymphoma, heavy chain disease.

Lymphopenia
Below 1,500/pm

Causes
1
Severe bone marrow failure
2. Corticosteroid and immunosuppressive therapy
3. Widespread irradiation

3) Monocytes
Normal count 200 to 1000 cells/mm3.
Largest mature leucocyte
Large, central, oval, notched or indented or horseshoe-shaped nucleus

Monocytosis
Above 1000/mm3
Causes
1. Bacterial infections > e.g. TB, SABE, syphilis.
2. 2. Viral infections.
3. Protozoal and rickettsial infections > e.g. malaria, typhus, trypanosomiasis, kala-azar.
4 Haematopoietic disorders > e.g. monocytic leukemia, lymphomas, myeloproliferative disorders
5. Granulomatous diseases e.g. sarcoidosis, IBD
6. Collagen-vascular diseases

4) Eosinophils
Normal count 50 to 500 cells/mm3.
2 nuclear lobes.
Deep red staining granules in cytoplasm

Eosinophilia
Above 500/mm3

Causes
1. Allergic disorders e.g. Asthma, urticaria, angioneurotic oedema, hay fever, drug hypersensitivity.
2. Parasitic infestations e.g. intestinal parasitism.
3. Skin diseases e.g. pemphigus, dermatitis herpetiformis, erythema multiforme.
4. Loefler's syndrome.
5. Pulmonary infiltration with eosinophilia (PIE) syndrome.
6. Tropical eosinophilia.

PAGE 230 | WBC DISORDERS

 BUSTER
PATHOLOGY PROF

Basophils
5)
Aormal count 10to 100 cells/mm3.
Coarse intensely basophilic granules
Basophilia
Above 100/ul

Causes
Chronic myeloid leukemia
Polycythemia vera
1.

2
Myxedema
3
Ulcerative colitis
4
Hodgkin's disease
5
Urticaria pigmentosa
6 yeloid
(11.02) LEUKEMOID REACTION <ymphoi a.

Univers ity Exams

Short questions
Leukemoid Reaction CML
1.
Differentiate Leukemoid Reaction from
2.

Overview
Definition (00:05:04)
Types Causes, Lab Findings, Differential diagnosis
1. Myeloid (00:07:00)
2
Lymphoid (00:14:29)

Definition blood
a who
blood resembling that of leukemia in subject
Reactive excessive leukocytosis in peripheral
does not have leukemia.
Blood picture confusing with leukemia are
Clinical features of leukemiasuch
as splenomegaly, Iymphadenopathy and hemorrhages
absent

Types to phils ^se

1. Myeloid > Ne ui
2. Lymphojd Lmphouy te 4se
s
>
1) Myeloid Leukaemoid Reaction
Causes >
tuberculosis, meningitis, diphtheria,
1. Infections e.g. staphylococcal pneumonia, disseminated
abortions etc.
sepsis, endocarditis, plague, infected
mercury poisoning, severe burns.
2. Intoxication e.g. eclampsia, metastases.
Hodgkin's disease, bone
3. Malignant diseases e.g. multiple myeloma, myelofibrosis,
4. Severe hemorrhages and
severe hemolysis.

WBC DISORDERS | PAGE 231

 mo n
Less 4nt
m
DR. PRIYANKA SACHDEV

Lab
1. Leukocytosis not exceeding 100,000/pl
2. Proportion of immature cells metamyelocytes,
myelocytes, and blasts fewer tha 5% Dohle bodies
3.Infective cases show toxic granulation and Dohle bodies in
cytoplasm of neutrophils.
4. Neutrophil /Leucocyte alkaline phosphatase (NAP or LAP) SCore
in cytoplasm of mature neutrophils in leukemoidreaction is high
and is very useful to distinguish it from CML
5. Cytogenetic studies > negative, Philadelphia chromosome Toxic Granules i.e. t
(9; 22) or BCR-ABL fusion
Leukemoid reaction
Toxic qranules
OYDohle bodies- consist of ribosomes and endoplasmic reticulum

a
Differential diagnosis
CML

Feature Leukemold Reactlon CML

1TLC 25,000-100,000/ml > 100,000/ml
2 DLC Dominant cells PMN's All maturation stages
Basophils normal Basophilia present
3NAPscore Elevated Reduced
Philadelphia Absent Present
chromosome
Halwor 5/ ABL-BCR fusion) Absent Present
gene
6 Major etiology Infections, intoxication, disseminated Genetic factors, radiations,
malignancy, severe hemorrhage certain drugs and chemicals
7 Organ infiltration Absent May be present
Massive Absent Present
splenomegaly

2) Lymphoid Leukemoid Reaction

Causes
Infections e.g. infectious mononucleosis, cytomegalovirus infection, pertussis, chickenpox,
measles, infectious lymphocytosis, tuberculosis.

Lab Findings
1. Leukocytosis not exceeding 100,000/ul.)
2. DLC mature lymphocytes simulating blood picture of CLL.
olood cell
(11.03) LEUKEMIAS AND LYMPHOMAS ptàtele:
(DEFINITION AND CLASSIFICATION)
University Questions
Short questions
1.
Define Leukemia and Write its classification
2 Define Lymphoma and Write its classification Myelenaid
PAGE 232 | WBC DISORDERS
 BUSTER
PATHOLOGY PROF

Very Short questions

Classification of Leukemia
1
Classification of Lymphoma
2

Overview
Introduction (00:01:05)
TVpes of Leukemia (00:11:12)
Myeloblast Versus Lymphoblast (00:13:44)
Lymphoma (00:16:36)
WHO Classification of Lymphoma (00:17:18)

Arvi val
or fmmature Form
Introduction
LEUKEMIA LYMPHOMA
chroniz
<ymphaict

MB. LB
PL+ Po-ymphoote MB
PM
L lymphoeyte
lyeleyk-M
detam MM
(o BF
Aeute chron
neufrop
Blood Solid Organs
Blood Cancer

Types of Leukemia
Leukemias
preyrsor
vphorid precosor myeloid blood
Come in B (ome io
Lymphoid Myeloid

Acute Chronic Acute Chronic

CLL AML
8 CML
ALL

Acute leukemia
Malignant disease of bone marrow stem cells in which > to mature.
Bone marrow: Diffuse replacement with proliferating neoplastic blast cells that fail
Blast cells(more than 20 (WHO criteria) of nucleated cells in[marrow (Normally blast cells
are less thar 5% pf nucleated cells in the marrow)
Peripheral blood: Abnormal numbers and forms of immature WBCs.
Have a rapidly downhill course.

WBC DISORDERS | PAGE 233

m DR, PRIYANKA SACHDEV

Chronic leukemias
Chronic leukemias have easily recognizable(late precursor series]of leucocytes circulating in 1ares
number as predominant leukemic cell type
Have more/indolent behaviour)

Myeloblast Versus Lymphoblast

Myeloblast Lymphoblast

Size Larger Smaller

Color Cytoplasm Moderate Scanty
red May be present Absent
KAuer rod)
VNuclear chromatin Fine Coarse
q
nade vpof Nucleoli Prominent, 1-4 Indistinct
grands

Lymphoma
Proliferations that arise as [discrete tisue massesl(e.g. within lymph nodes, spleen, or extra nodal
tissues). +nt o
Solid Reed:citrnba1
Lymphomasbased on gis coll

Hodgkin's Non-Hodgkin's
Lymphoma Lymphoma
abso

WHO Classification of Lymphoma

WHO CIassification of Myeloid
neoplasm
WHO Classification of Lymphoid neoplasm

WHO GLASSIFICATION OF MYELOID NEOPLASMS

I. MYELOPROLIFERATIVE DISEASES
1. Chronicmyeloid leukaemia (CML), (Ph chromosome t(9;22) (q34;11), BCRIABL
positive)
2. Chronic neutrophilic leukaemia
3. Chronic eosinophilic leukaemia/ hypereosinophilic syndrome
4. Chronic idiopathic myelofibrosis
5. Polycythaemia vera (PV)
6. Essential thrombocythaemia (ET)
7. Chronic myeloproliferative disease, unclassifiable

PAGE 234 | WBC DISORDERS

 PATHOLoGY PROF
BUSTER m
II.
MYELO oDYSPLASTICIMYELOPROLIFERATIVE
DISEASES
1. Chronic myelomonocytic leukaemia (CMML)
M MYELODYSPLASTIC SYNDROME (MDS)
1. Refractory anaemia (RA)
2. Refractory anaemia
with ring sideroblasts (RARS)
3. Refractory cytopenia with multilineage
dysplasia (RCMD)
4. RCMD with ringed sideroblasts (RCMD-RS)
5, Refractory anaemia with excess
blasts (RAEB-1)
6. RAEB-2
7. Myelodysplastic syndrome unclassified (MDS-U)
8. MDSwith isolated del 5a

IV. ACUTE MYELOlD LEUKAEMIA (AML)

1. Acute myeloid leukaemias with recurrent genetic abnormalities
AML with t(8;21)(q22;q22): RUNX1-RUNX1T1
ii. AML with inv (1 6) (p 13.1; g22) or t (1 6:16) (o13.1: g22): CBF & P-MYH 11
ii. Acute promyelocytic leukaemla (M3) with t (15;17)
(q22; q!2); PML7RAR-CCand variants
iv. AML with t (9; I 1) (p22; q23); MLLT3-MLL
V.
AML with t (6, -9) (p23; q34); DEK-NUP214
vi. AML with Inv (3) (q21q26.2) or t (3;3) (g21; q26.2); RPN1-EVI1
vii. AML (megakaryoblastic) with t (1;22) (pl 3; ql3); RBM15-MKL1
vii. AML with mutated NPM1
ix. AML with mutated CEBPA
2. Acute myeloid leukaemia with myelodysplasia related changes
3. Therapy related acute myeloid leukaemia
Alkylating agent related
i.
Topoisomerase ll inhibitor related (some may be lymphoid)
ii.

4. Acute myeloid leukaemia, not otherwise categorised

i. AML minimally differentiated (MO)
i. AML without maturation (M 1)
iii. AML with maturation (M2)
iv. Acute myelomonocytic leukaemia (M4)
V. Acute monoblastic and monocytic leukaemia (M5a, M5b)
vi. Acute erythroid leukaemia (M6)
megakaryoblastic leukaemia (M7)
vii. Acute
viii. Acute
basophilic leukaemia
ix. Acute panmyelosis with myelofibrosis
5. Myeloid sarcoma
6. Myeloid proliferations related to Down's syndrome
i. Transient abnormal myelopoiesis
ii. Myeloid leukaemia associated with Down's syndrome

7. Blastic plasmacytoid dentritic cell neoplasm

V. ACUTE BIPHENOTYPIC LEUKAEMIA

WBC DISORDERS |PAGE 235

 im DR. PRIYANKA SACHDEV

WHO CLASSIFICATION OF LYMPHOID NEOPLASM

Precursor Precursor Peripheral Peripheral T-cell, Hodgkin's
B-cell T-cell B-cell and NK-cell lymphoma
neoplasm neoplasm neoplasm neoplasm
B-cell T-cell Chronic lymphocytic Mycosis Classical
acute acute leukemia/small fungoides/Sez Nodular
lymphobl lymphobla lymphocytic lymphoma ary syndrome Sclerosis
astic stic Mantle cell lymphoma Large granular Mixed
leukemial leukemia/ Follicular lymphoma lymphocytic cellularity
lymphom lymphoma Marginal zone B-cell lymphoma Lymphocyte
a (B-ALL) lymphoma Anaplastic rich
Burkitt's lymphoma large cell Lymphocyte
Hairy cell leukemia lymphoma depleted
Diffuse large B-cell Enteropathy Lymphocyte
T
lymphoma associated predominant
Splenic and nodal cell lymphoma
marginal zone B-cell Hepatosplenic
lymphoma dt- cell
Plasmacytoma/plasma lymphoma
cell myeloma NK-cell
Lymphoplasmacytic leukemia
lymphoma Angioimmuno
blastic T-cell
lymphoma
Extranodal
NK/T-cell
lymphoma

I(11.04) CHRONIC MYELOIDLEUKEMIA (CML)

University Exams
Long questions
1. Define and classify leukemias. Discus peripheral blood smear, bone marrow, biochemical findings and the characteristic
chromosomal abnormality associated with chronic myeloid leukemia.
2 Define and classify leukemias. Describe the clinical features and laboratory diagnosis of Chronic myeloid leukemia (CML).
Short questions
1
Differentiate between leukemoid reaction and CML.
2 Philadelphia chromosome.
3 Laboratory diagnosis of chronic myeloid leukemia
Blood picture in chronic myeloid leukemia
5 Chromosomal abnormality in chronic myelold leukemla
6. t (9;22)/ ABL-BCR Translocation
7 Phases of CML
8 Prognostic index in CML
Very Short questions
1 Special stains used to differentiate leukemoid reaction and CML.
2 Peripheral smear findings in chronic myeloid leukemia

Overview
Introduction (00:01:35)
Age (00:01:35)
Pathogenesis (00:03:15)
Phases of CML (00:12:36)
Clinical features (00:13:58)
Lab diagnosis (00:16:42)
Treatment (00:24:42)
Prognostic factors (00:25:37)

PAGE 236 | WBC DISORDERS

 PATHOLOGY PROF
BUSTER M

Introduction >
Characte rized by>
Leukocytosis with granulocyticimmaturities
2. Basophilia
3. Splenomegaly
Bistinct chromosomal abnormality - Philadelphia
(Ph') chromosome.

Age >
Old age (> 50 years) parm
Pathogenesis Chromosomol

Translocations t (9;22) / ABL-BCR q arm

Translocation > Philadelphia 22q
chrom0some
ABL gene > normal location on parm
chromosome 9
BCR gene > normal location on
Chromosom2)
berabt
chromosome 22 q arm [bcr bcr ber br fuson sens)
4ybid gene
NORMAL CML(922)
Philadelphla chromosome
chromosoMe ne- 22|
Abnormml4jrosine kindse Torm.

In Translocation
ABL gene
(normal location on chromosome 9)

Translocated to chromosome 22

Fuses with BCR gene

ABL-BOCR hybrid gene > Philadelphia chromosome
210 KD fusion protein
even without growth factors
Abnormal (tyrosine kinase)> signal transduction
Uncontrolled mitosis
CMLI

CAB
Phases of CML
CML (Triphasic leukemia)
I. Chronic phase II. Accelerated phase
lIl. Blast crisis
> 20%
Blast cells < 10% Blast cells 10-19% Blast cells

Clinical Features
Due To Bone Marrow Failure>
a) Anemia > pallor, lethargy, dyspnea.' qums
b) Bleeding manifestations > spontaneous bruises, petechiae, bleeding from
c) Infections
sweats,
Hypermetabolism > weight loss, lassitude, anorexia, night
Splenomegaly massive

WBC DISORDERS |PAGE 237

 DR. PRIYANKA SACHDEV
Universi
Lab diagnosis
Lab diognosisc)

Blood Bone Marrow Cytogenetics Cytochemistry Others

a) Hb1 a Cellularity ((9;22) NAP SCores S. urlc acld- dye to

b) Platelets+b) Myeloid cells HIpermenballim
c) WBC c) Erythropolesis Tromyelotyte casinophj
d) Megakaryopolesis

1) Blood Picture hardeo Tarty.. ley

apparaiu atfereot
a) Anemia> Normocytic normochromic
b) Thrombocytopenia
c) White blood cells 200,00] or4or
Marked leukocytosis (approx. 200,000/ul or more)
Immature Neutrophils (band forms, metamyelocytes,
myelacytes, promyelocytes)»(< )
Basophilia
Eosinophilia weulro ph
2) Bone Marrow Examination
a) Cellularity Hypercellularity (proliferating myeloid cells) Bang Fory
b) Myeloid cells predominate in marrow with increased myeloid-erythroid ratio
. bone
Seg blue histo ytS,
c) Erythropoiesis Reduced
d) Megakaryocytes Reduced Pseudo Gavcher
3) Cytogenetics
Show characteristic chromosomal abnormality
BCRI ABL fusion gene
Philadelphia (Ph) chromosome t (9;22)

4) Cytochemistry High LAP score LAP negative Low LAP score

Neutrophil alkaline phosphatase (NPJ distinguish CML
from Leukemoid reaction L N<40 o0)
CML NAP scores|Reduced|
Floro seent Leukemoid reaction > NAP scores elevated
sito
In hytrid5, FISH To Confirg te9: 22) Arans to caton
Insise'n Ireatment
1. Treatment of Anemia and Hemorrhage
a) Blod transfusions
b) Platelet transfusions
2. (Imatinib)oral therapy
Tyrosl kingse inhibitor
a) Inhitbits signal transduction BCRIABL fusion protein
b) Induces apoptosis in BCRIABL-positive cells and eliminates them
3. Allogenic bone marrow transplantation

Prognostic factors
Index to assess
prognosls of CML

Sokal Index Hasford system)

a) Age a) Age
b) Platelet count b) Platelet count
c) Spleen slze c) Spleen slze
d) Clrculating blasts d) Clrculating blasts
) Cytogeneic changos e) Basophlls and eosinophlls

PAGE 238 |WBC DISORDERS

 m
BUSTER
PATHOLOGY PROF

(11.05) ACUTE MYELOID LEUKEMIA(AML)

University Exams
Long questlons
Define and classify leukemias.
Dlscus chromosomal abnormality
associated with Acute myelold leukemia.peripheralblood smear, bone marrow, blochemical findings and
1

of Acute
classification of AML. Describe the clinical foatures and laboratoty diagnosís
2
Define and classify leukemias. Write FAB
myeloid leukemia (AML).
Short questions
1 Describe peripheral blO0d smear and bone marrow asplration
Laboratory diagnosis of Acute Myelold leukemia. indings in Acute Myolold leukomla,
3
Blood picture in Acute Myeloid leukemia.
FAB Classification of Acute Myeloid
4 leukemla
5 Prognostic factors of AML
Very Short questlons
1 Cytochemistry of acute Myeloid leukemias.
2 Peripheral smear tindings in acute myelold leukemla.
3 Enlist cytochemical for typing of leukemlas.
4 Chloroma or granulocytic sarcoma
5 Aeur rods
6 Faggot cells

Overview
Introduction (00:01:05)
Age (00:01:05)
Pathogenesis (00:03:41)
Classification (00:05:05)
Clinical features (00:07:34)
Lab diagnosis (00:12:23)
Treatment (00:20:58)
Prognostic factors (00:22:10)

Introduction
Infiltration of malignant myeloid cells into blood, bone marrow and other.tissues.

Age >
15 to`40 years

Pathogenesis
a) t (8;21)
b) t (15;17)
c) inv (16)

Classification MPO
negattve
-> French gmericqn british. (8) without maturq lion
FAB CIassification D
11 Myelo blast
po
>3 blass
FAB OLD 3, a Comno nest yPe
CLASS NAME tC8,21) ?s present
M0: Minimally differentiated AML mar incidence of chloro ma
M1: AML Without maturation 4 M3
t(15, 17) Seen
M2: AML with maturation Auer rod qre
promyelocyte leukemia DIC • most Comon. Seen
M3: Acute Ass oclate d DIC
M4: Acute myelomonocytic leukemia (Naegeli type) with
M5: Acute monocytic leukemia (Schilling type) 5 My Inversion (6 Present
M6: Acute erythroleukemia (DiGuglielmo's syndrome) present of bbth yeloblqst &
M7: Acute megakaryocyte leukemia Monoblast
ighest
WBC DISORDERS| PAGE 239
1, M
AborHal erythrojd Precursos qre Scens
8, lg Keqst Common
t
ype of AM
Co mmOnes
Cause Kye (o
Fibrosis
 m DR. PRIYANKA SACHDEV

Clinical Features
Due To Bone Marrow Failure
1.
a) Anemia pallor, lethargy, dyspnea
b) Bleeding manifestations spontaneous bruises, petechiae, bleeding from gums
c)
Infections > woc abundant ( ye loblas4) 4nt
2. Due to organ infiltration by leukemic cells

a) Bones Pain and tenderness e.g.

sternal tenderness
b) JLymphadenopathy)
c) TSplenomegaly
d) Hepatomegaly)
e) Kidney Leukemic infiltration
f) Gum hypertrophy Common in AML
M4 and AML M5
Gum hypertrophy Chloroma
(M4 and M5) (M2)

9) Chloroma or granulocytic sarcoma localized tumor forming mass occurring in skin of orbit
(Proptosis) common inAML M2
Lab diagnosis
Lab diagnosls

,ALL

Blood Bone Marrow Cytogenetics cytochemistry |Others

ve
a) Hb |) Cellularity a) t(8;21) a) MPO S. Uric acid
b) Plateletsb) Leukemic cells b) t(15;17) b) Sudan black +ue
c) Erythropoiesis c) inv(16) c) NSE - t
ve
d) Megakaryopoiesis d) PAS
myeloblas k
e) Acid phosphataseve
1) Blood Plcturo
a) Anaemia Normocytic normochromic
b) Thrombocytopenia (Acute promyelocytic leukemia (M3) associated with DIC).
c) White blood cells
Exceed 100,000/pl
Myeloblasts with Auer rods present (Faggot cells> Maximum in M3)

ACUTE MYELOBLASTIC LEUKEMIA School uniform

appearn
MYELOBLAST
Large cell with round to oval
nucleus, with fine chromatin,
and 2 to 4 nucleoll and scanty
cytoplasm with fine granules

AUER RODS
Crystaline cytoplasmlc Inclusions
as a result of abnormal fuslon of
azurophilic granules

PAGE 240 |WBC DISORDERS

 m
BUSTER
PATHOLOGY PROF

2) Bone Marrow Examination

a) Cellularity > Hypercellular
b) Leukemic cells
Myeloblasts more than 20% of cells in marrow
Auer rods present in myeloblasts
c) Erythropoiesis Reduced
d) Megakaryocytes Reduced

3) Cytogenetics
a) M2 t(8;21)
b) M3 >t(15;17)
c) M4 inv (16)

4) Cytochemistry
AML ALL
Myeloperoxidase (MPO) Positive (Negative in MO ) Negative
Sudan Black Positive Negative
Non-specific esterase (NSE) Positive in monocytic series (M3,M4 and M5) Negative
Periodic acid-Schiff (PAS) Negative (Positive in M6) Positive
Acid phosphatase Negative (Diffuse reaction in M4 and M5) Focal positivity

Treatment
1. Treatment of Anemia and Hemorrhage
a) Blood transfusions
b) Platelet transfusions
2. Cytotoxic Drug Therapy
a) Cytosine arabinoside
b) Anthracyclines (daunorubicin, adriamycin)
c) 6-thioguanine
Promyelocytic leukemia (M3) ->Tretinoin (retinoic acid)
3. Allogenic bone marrow transplantation

Prognostic factors
Good prognosis Bad prognosis
Age <40 years Age <2 years or >55 years
M2,. M3, M4 forms of AML MO, M6, M7 forms of AML
Blast cell with Auer rods Complex karyotypes
TLC < 25 X 10°/L TLC >100X109/L
t (15;17), t (8;21), inv 16 Deletions 5q, 7q
Leukemia without preceding MDS AML with preceding MDS or anticancer drug exposure

(11.06) ACUTE LYMPHOBLASTIC LEUKEMIA (ALL)

University Exams
Long questions
1, Define and classify leukemias. Discus peripheral blood smear, bone marrow, biochemical flndings and chromosomal abnormality
associated with Acute lymphoblastic leukemia.
2 Define andclassify leukemias. Describe the clinlcal features and laboratory dlagnosis of Acute lymphoblastic leukemia (ALL).

WBC DISORDERS | PAGE 241

im DR, PRIYANKA SACHDEV

Short guestions
1
Descritbe the bone marrow findings in ALL Inctuding special
stains
3
Describe poripheral blood smear and bone marrow aspiration findings in Acute lymphoblastic leukemia (ALL).
Lnboratory dlagnosis of Acute lymphoblastic leukemia.
4 Blood plcture in Acute lymphoblastic leukemia (ALL).
5 Prognostic factors of ALL
Very Short questlons
1
Cytochemistry of Acute lymphoblastic leukemia.
2. French-Amerlcan-Brifish (FAB) classification of ALL
3.
Peripheral smear findings in Acute tynphoblastic tukemia.

Overview
Introduction (00:01:15)
Age (00:01:15)
Pathogenesis (00:02:36)
Classifcation (DO:07:05)
Clinical features (00:07:47)
Lab diagnosis (bb:11:07)
Treatment (D0:16:03)
Prognostic factors (00:16:39)

Introduction >,e-1 cell

ALL composed of immature, precursor B (Pre-B) or T (Pro-T) lymphocytes lymphoblast.
Age >
1. Pre B-cell ALL 3-5 years|
2. Pre T-cell ALL >Adolescent male)

Pathogenesis
Pre B cellALL
Hyperdiploidy most common
Hypodiploidy
Loss-of function mutations > PAX5, E2A, or EBF genes.
g-2?) translocations (BCR and ABL)
Pre T cell ALL
Gain-of function mutations NOTCH 1 gene

Remember
t(9;22); (BCR-ABL protein):
stronger
B-ALD90RDa tyrosi tingu
ac iuity
BCR-ABL protein is 190 kDa Stronger tyrosine kinase activity.

Da NEqT ee
CMLr aetiv
BCR-ABL protein of 210 kDa Weaker tyrosine kinase activity.
Eiodalto
Classification
FAB Classification -P
L1ALL L2 ALL L3 ALL
JCommonest typel Next common type Rarest type
Best prognosis Worse prognosis. Worst prognosis.E3AE

PAGE 242 | WBC DISORDERS

 BUSTER
PATHOLOGY PROF

Clinical Features
4
Due To Bone Marrow Failure
a) Anemia > pallor, lethargy, dyspnea
b) Bleeding manifestations spontaneous bruises. petechiae, bleeding tro 9
c) Infections

Due to organ infiltration by leukemic cells >

a) Bone pain and tenderness
b) Lymphadenopathy
c) Splenomegaly
d) Hepatomegaly
e) Compression of mediastinal vessels or airway In Pre-T
f) Meningeal involvement ALLvvI
g) Testicular involvement
-
Lab Diagnosis
|Lab diagnosls

Blood Bone Marrow Cytogenetics Cytochemistry

a
Hb a) Cellularity a) Hyperdiploidy a MPO
|b) Platelets b) Leukemlc cells b) Hypodiploldy b
Sudan black
c) wBc c) Erythropolesls c) t (9;22) C
NSE
Lynpho blasd) Megakaryopolesls d) PAS
e
Acid phosphatase
AUersen
rod
1) Blood Picture
a) Anemia
b) Thrombocytopenia
c) White blood cells >
Leukocytosis
Large number of circulating lymphoblasts

2) Bone Marrow Examination

a) Cellularity > Hypercellular
b) Leukemic cels > 30 % blasts in bone marrow (FAB diagnostic criteria)
c) Erythropoiesis > Reduced
d) Megakaryocytes Reduced

ACUTE LYMPHOBLASTIC LEUKEMIA > School uniForm appeqrante

3) Cytogenetics
Hyperdiploidy
LYMPHOBLAST
Hypodiploidy Large cel with round to oval
Trisomy 4, 7,10 nucleus, with coarse, clumped
chromatin, and inconsplcuous
t (9;12) nucleoli and scanty cytoplasm
t(9;22)
t (4;11)

WBC DISORDERS | PAGE 243

 m
DR. PRIYANKA SACHDEV

4) Cytochemistry
AML ALL
Myeloperoxidase (MPO) Positive (Negative in MO) Negative
Sudan Black Positive Negative
Non-specific esterase Positive in monocytic series (M3 ,M4 and Negative
(NSE) M5)
Periodic acid-Schiff (PAS) Negative (Positive in M6) Positive
Acid phosphatase Negative (Diffuse reaction in M4 and M5) Focal positivity

Treatment
1. Treatment of Anemia and Hemorrhage
a) Blood transfusions
b) Platelet transfusions
2. Chemotherapy
a) Vincristine
b) Prednisolone
c) Anthracyclines (daunorubicin, adriamycin)
d) L-asparaginase
3. Allogenic bone marrow transplantation

Prognostic factors
Griteria Good Bad
1. Age 2-10 years <2 years; > 10 years
2. Gender /Femalel Male
3. Race White Black
4. CNS, mediastinum, Absent Present
testicular involvement
5. Peripheral blood blast <100000 >100000
COunt
6. Cytogenetics a. Hyperdiploidy (>50 a. Hypodiploidy (<50
chromosomes) chromosomes)
b. Trisomy 4, 7, 10 b. t (8:14)
C. t (9:12) and t (12:21) C. t (1:19)
d. t (9:22)
e. t (4:11)

(11.07) CHRONIC LYMPHOCYTIC LEUKEMIA(CLL)

University Exams
Long questions
1. Define and classifyleukemias. Discus peripheral blood smear, bone marrow biopsy and Immunophenotyping associated with
Chronic Lymphocytic leukemia (CLL)
2.
Define and classify leukemias. Describe the clinical features and laboratory diagnosis of Chronic Lymphocytic leukemia (CLL)
Short questions
1. Peripheral blood smear of CLL
2 Bone marrow biopsy of CLL
3. Immunophenotyping of CLL
Laboratory diagnosis of Chronic Lymphocytic leukemia
5 Poor Prognostic factors of CLL
6. Small Lymphocytic Lymphoma (SLL)
Very Short questions
1. Smudge cells

PAGE 244 | WBC DISORDERS

 PATHOLOGY PROF
BUSTER m
Overview
Introduction (00:01:33)
Age (00:01:33)
Pathogenesis (00:03:40)
Clinical features (00:04:19)
Lab diagnosis (00:05:03)
Treatment (00:13:41)

Introduction
CLL and SLL are identical neoplasms arise due to an abnormal neoplastic proliferation of B cells.
Age >
Median age of50 years)
Pathogenesis
a) Deletion of 13g (Most common)
b) Deletion of 11g
c) Deletion of 1Zp
d) Trisomy 2gi

Clinical Features
1. Due To Bone Marrow Failure
a) Anemia_ pallor, lethargy, dyspnea
b) Bleeding manifestations > spontaneous bruises, petechiae, bleeding from gums
c) Infections
2. Enlargement of superficial lymph nodes
3. Splenomegaly and hepatomegaly
0
Lab Diagnosis
Lab diagnosis|

Blood |Immunophenotyping Lymph Node Biopsy

a) Hb a) CD19 a) Diffuse proliferation

b) Platelets b) CD20 eb) Pseudo follicles
c) WBC 4 c) CD 23
d) CD5
e) Surface lgM and IgD

1) Blood Picture
a) Anemia Normocytic normochromic
b) Thrombocytopenia
c) White blood cells >
baSket Ce l

Leukocytosis (50,000-200,000/ pl).

90% of leucocytes mature small lymphocytes.
are tnt Smudge or basket cells (degenerated forms) are present due to
onl4de damaged nuclei of fragile malignant lymphocytes.
CHRONIC LYMPHOCYTIC LEUKEMIA

Smudge cells

Small lymphocytes
WBC DISORDERS |PAGE
245
m DR. PRIYANKA SACHDEV

2) Immunophenotyping
CLL is a tumor of B

cells
Therefore, it expresses
the B-cell markers such Pseudo
as CD19, CD20 and follicles
surface lgM and lgD
In addition, CD 23 and
CD5 are also present

Lymph node blopsy in CLL

3) Lymph Node Biopsy

Effacement of normal nodal architecture by a diffuse prollforatlon of small, round lymphoid
cells with coarse chromatin, indistinct nucleoli, and scant cytoplasm
Scattered nodules (pseudofolicles) composed of medium sized and large lymphoid cells with
dispersed chromatin and distinct nucleoliare observed.
The diffuse proliferation of smalllymphoid cells with pseudofollicles is pathognomonic for SLL.

Treatment
Palliative and symptomatic

MYELOBAST
Lorge cel th round to oval LYMPHOBLAST
hudeus, with fine chromatin,
and 2 to 4 nucleol and Kanty Large cell with round to oval
cytoplasm with fine ganules nucdeus, with coarse, cdumped
chromatín, and inconspicuous
nucleoli and scanty cytoplasm

AUER RODS
Cytatine toplasmic incdusons
sressAabnomal fuson of
aturophdic granles

AML ALL

Promyelocyte

Metamyelocyte

BasophiI
-Smudge cells
Neutrophil
-Eosinophll

Band forms
Small lymphocytes

CML CLL

(11.08) POLYCYTHEMIA VERA

>
Mutatbon ot gAK-2 gennD1ath3
4 Panoo si
University Exams
Short questions
1 Diagnostic criteria, Clinical features and Lab Diagnosis of Polycythaemia Vera
2. Pathophysiology of Polycythaemia Vera

PAGE 246 | WBC DISORDERS

 BUSTER
PATHOLOGY PROF

Overvlew
Definition (00:01:26)
Pathophysiology (00:04;48)
Diagnostic criteria (WHO) Major and Minor
Clinical features (00:14:00) (00:09:00)
Lab Diagnosis (00:15:24)

Definition
Clonal disordercharacterised by increased production of all myeloid
resulting in (Pancytosis
elements
Increased red cells
Increased granulocytes
Increased Platelets

Pathophysiology

Tyrosine kinaseJAK2 mutation

Removes autoinhibitory control

kinases
Activates

Increased production of all myeloid elements

Pancytosis|

Erythropoletin No Erythropoletin

Erythropoletin Receptor
Erythropoletin Receptor

Lipld Layer
LIpld Layer

JAK2
JAK2 mutant

JAK2 SIgnallng pathway

JAK2 SIgnaling pathway Negatlve
Negative
feedback i
feedback regulatlon
regulatlon Dysregulated genes actlvatlon
Actlvatlon of genes for
growth and prollferatlon

Nucleus
Nucleus

Diagnostic criteria (WHO)

a) 3 major criteria
b) 1
minor criterion

W8C DISORDERS |PAGE 247

 m DR.PRIYANKA SACHDEV

a) Major criteria
1. Hb >16,5 q/dL in men, >16,0 g/dL in women or
Hct >49% in men, >48% in women or
Red cell mass >25% above mean normal predicted value.
2. Bone marrowbiopsy showing hypercellularity for age with(trillineage growth\panmyelosis)
including prominent erythroid, granulocytic, and megakaryocytic proliferation with pleomorphic
mature megakaryocytes
3. Presence ofJAK2 exon 12 mutation

b) Minor criteria
1. Subnormal serum erythropoietin level. €PO (Lo)

Diagnostic criteria (WHO)

All3 major criteria
OR
First 2 major criteria and minor criterion
Clinical features
t 6GC>1. Erythrocytosis
redness
Plethoric and cyanotic due to vascular stagnation and deoxygenation.
Headache, dizziness and hypertension
s
2. Basophilia with histamine release> gastrointestinal symptoms like peptic ulceration and intense
pruritus.
3. High cell turnover> hyperuricemia, symptomatic gout and urate stones
n
plake4. Platelet dysfunction and abnormal blood flow > Bleeding and thrombotic events.

Lab Diagnosis
1. Raised Hb. concentraion (above 17.5 g/dl in males and 15.5 g/dl in
females).
2. Erythrocytosis (above 6 million/ul in males and 5.5 million/ul in females).
3. Haematocrit (PCV) above 55% in males and above 47% in females.
4. Mild to moderate Leukocytosis (15,000 - 25,000/ul) with basophilia and raised NAP scores.
5. Thrombocytosis with defective platelet function.
6. Bone marrow examination > erythroid hyperplasia or panhyperplasia.

Plasma

Buffy coat
(WBCs &
platelets)

Packed RBCs

Anemla Normal Polycythemia vera

PAGE 248 |WBC DISORDERS

 BUSTER M
PATHOLOGY PROF

roperts,
Jneftetive eryth mdr
(11.09) MYELODYSPLASTIC SYNDROME Panrýtopenia bene

ms
Unlvers ity Exa
Short questlons
Etiology, clinical features and Lab Dlagnosis of Syndromes
Types and Morphology of MyelodysplastieGdlodysplastic
1

2.

Overvlew
Definition (00:02:41)
Etiology (00:05:24)
Types (00:06:10)
OO
Clinical Features (00:06:43)
Lab diagnosis (00:06:58)
Morphology (00:07:07)

Definition
Hematopoietic clonal stem cell disorders having >
Maturation defects associated with ineffective haematopoiesis
Progressive cytopenia
Dysplasia in one or more cell lines
Risk of development of AML
Also known as preleukaemic syndromes or dysmyelopoietic syndromes.

Etiology
a) Monosomy 5 and 7
b) Deletion of chromosome 5g, 7q and 20g.
8
c) Trisomy

Remember >
Most common cytogenetic change in pediatric MDS is monosomy _7
Most common cytogenetic change in adult MDS is deletion of 5q
of 5ql
Most common cytogenetic change in MDS (overall) is deletion

Types.
1. Primary or ldiopathic MDS patients older than 50 years.
seen in
2. Secondary or therapy related MDS (t-MDS)
appears 2 to 8 years after myelo suppressive
chemotherapy or radiotherapy> poor prognosis

Remember
of MDS can transform to AML
All types
AML transformed from MDS will carry bad prognosis

Clinical Features
1. Anemia appreciated by pallor, fatigue and weakness.
2. Feyer.
3. Weight loss.
4. Splenomegaly seen in20% cases of MDS.

WBC DISORDERS |PAGE 249

m DR. PRIYANKA SACHDEV

Lab diagnosis
Cytoponia poripheral blood
1. modorate degroe of macrocytic or dimorphic anemla.
RBOCs: Mild to
2. WBCs: low total leukocyte count. or giant platolets.
3. Platelets: thrombocytopenia, large hypogranular

Morphology
Hypercellular bone marrow.
Most characteristic finding is dysplastic differentiation
of all 3 lineages>

1) Erythroid lineage
a) Ringed erythroblast:
Perinuclear Iron
accumulation in a ring
like pattern due to iron
inside mitochondria.
b) Oval macrocytes in
peripheral blood.
c) Erythrocyte precursor Ringed erythroblast Oval macrocytes Erythrocyte precurscr
with nuclear bridging.

2) Granulocytic lineage
a) Dohle bodies
Coarse blue granule of
cytoplasm made up of
dilated rough
endoplasmic
reticulum.
b) Neutrophil with hyper
segmented nucleus
c) Pseudo Pelger Huet Dohle hyper segmented Pseudo Pelger
Neutrophil nucleus Huet anamaly
anomaly bodies
with bilobed nucleus.

3) Megakaryocyte lineage
Pawn-Ball Megakaryocyte- Separated lobes of nuclei
in

megakaryocytes.

Pawn-Ball Megakaryocyte
(11.10) HODGKIN'S LYMPHOMA (HL) LYMPHbAA

University Exams (wHL)

Long questions
Classify lymphomas and write on Hodgkin's lymphoma.
1 of nodalár scleiosis Hodgkin's disease.
Classify Hodgkin's disease. Describe the pathologlcal foatures
Classify Hodgkin's lymphoma. List two important features
of mixed cellularity
yeand depletion Hodgkin's disease
Classify Hodgkin's disease. Describe the pathological features of lymphocytic ricand lymphocyld
ly

A 45-year-old lady presented with painless neck swelling since 3 months assoqjasr-with losseos Wldht and
of fever. Fine needl
a polymorphous population of lyphoeyls, Tsma cells and large
aspiration cytology (FNAC) of the same showed
cells with nucleus having owl-eye appearance. What is
binucleate
your diagnosis? Clagsify the disease question and write its
in

staging Non-classica
Short questions cla šsical H
Define & classify Hodgkin Lymphoma.
1,
Describe types of ro cell.
Ann Arbor StagingReed*ints
of HodgKins
Lvmphoma.
Morphology of Hodgkin's lymphoma mixed cellularity type.
Lyphoyt rik
4

PAGE 250 | WBC DISORDERS

Lyephoyk dlchon
 BUSTER
PATHOLOGY PROF

Morphology of Hodgkin's lymphoma Nodular sclerosis type.

5. Morphology of lymphocytic rich Hodgkin's disease
6. Morphology of lymphocytic depletion Hodgkin's lymphoma
7
Morphology of Non classical Hodgkin's lymphoma
8.
Very Short questions
Classification of Hodgkin's disease,
Appearance of diagnostic cell of Hodgkin lymphoma (morohology of Reed-Sternberg cell).
1

Reed-Sternberg cell and its variants. types of Hodakin's Iymphoma where they
Name the different types of Reed Sternberg cells, Mention the

Overview
Introduction (00:01:17)
Types of RS Cells (00:03:10)
WHO CIlassification (00:07:27)
Ann Arbor Staging (00:25:36)
Differences between Hodgkin's Iymphoma and Non-hodakin's lymphoma (00:27:19)

Introduction to anatomically contiguous

lymphoid tissue
and follow orderlv spread
Arises n single lymph node
a

Presence of Reed-Sternberg (RS) cells

Types of RS Cells

bilobed acunr cel

Having
Classical RS Cell > nuc leus eyes
kook tike ouls
appeqrance

Smal nucler tnt

multiple
, muttiple Lobe Pleomorphic
RS
cell
Lymphohistiocytic
ach lbbe has
variant
nucleí

WHO Classification
of RS cells
Based on Immunophenotyping CD 15 and CD 30
1. Classical HD RS cells positive for type
lymphocytic predominance
2. Non-classical /Nodular BCL-6 but are
20 and
RS cells positive for CD 30.
CD 15 and CD - ve
negative for +ve CD 45R30
CD 15A 30
Non classlcal
Classic subtypes
• Lymphocyte predominant
•
Nodular sclerosis
•
Mixed cellularity ysocneA
•Lymphocyte-richg
• Lymphocyte depletion
WBC DISORDERS | PAGE 251
 €BV £bscin bar virus
DR. PRIYANKA SACHDEV

MIxed cellularity Lymphocyto Lymphocyto Lymphocyte

Nodular deplotod prodomlnant
sclerosis rlch
(non-classical HL)

MC type MC type in India Associated

with HIV
M =F - M>F M>F M>F M>F
Classlcal Pleomorphic LH (popcorn
Lacunar cell Classical RS
RS cell. cells RS cells RS celI cells) RS cell
CD15 + CD30+ CD15 +
CD15 + CD20 + BCL6 t,
CD15 t
CD30+ CD30 + CD30+ EMA +
CD15-, CD30
No Associated with Associated Associated Not associated
association EBV with EBV with EBV with EBV
with EBV
Excellent Prognosis very Good to Poor Excellent
prognosis good excellent prognosis prognosis
prognosis
Old age Old age Young males
Adolescent Biphasic
incidence (young group group
and > 55 years)

Macrophages Lacunar Lymphocytes Histiocytes Neutrophils classlc RS Cells

Lymphocytes Bands of collagen
RS cells

(olou r
Pink band
Sclerotic

Nodular sclerosis Mixed cellularity

Hodgkin's cells DIfuse flbrosls

Depleted Pleomorphic
tymphold cells RS cells

Lymphocyte rich Lymphocyte depleted

PAGE 252 | WBC DISORDERS

 BUSTER
PATHOLOGY PROF

tymphona

Ann Arbor Staging » sg' of

Stage l Involvement of single

Iymph node or single extra
Iymphoid site
Stage II Involvement of 2 or
more lymph node on same side
of diaphragm
Stage lIl > Involvement of both
sides of diaphragm
Stage lV Diffuse or
disseminated involvement of one
or more extra lymphoid organs
or tissue with or without
associated Iymph node Stage lll Stage IV
I Stago ll
involvement Stage

Differences between lymphoma

Hodgkin's lymphoma and Non-hodgkin's
Hodgkin's Non-hodgkin's
Feature
B-cell 90%
1. Cell derivation 10% T
Localized, may Disseminated nodal
2. Nodal involvement Spread
spread to
contiguous nodes
Uncommon Common
3. Extranodal spread
Uncommon Common
4. Bone marrow involvement
Common Uncommon
5. Constitutional symptoms
ca Aneuploidy Translocations, deletions
6. Chromosomal defects
Never May spread to blood
7. Spill-over
Better Bad
8. Prognosis (75-85% cure) (30-40% cure)

LYMPHOMA (NHL)
(11.11) NON-HODGKIN'S
University Exams
Long questlons Burkite's Lymphoma In detall in detail
classify Non-Hodgkin's Lymphoma. Discuss DIffuse large B cell lymphoma (DLBCL) Lymphoma
1. Define and Non-Hodgkin''s Lymphoma. Discuss Folllcular Lymphoma In detall
2. Define and classify Non-Hodgkin's Lymphoma. Discuss in detall
3 Define and classify Non-Hodgkin's Lymphoma. Discuss halry cell Leukemla
4 Define and classify
Short questions
Burkitt lympno lymphoma
1
Immunophenotyping of Burkitt
2 Microscopy folllcular lymphoma.
of
Molecular pathogenesis center
3 cell lymphoma. Leukemla
4 Morphology of follicular
marrow blopsy In halry cell
5 Peripheral andbone
6 PathogenesisImmunophenotyping of DLBCL
7 Blopsy and

WBC DISORDERS | PAGE 253

 Follieutar
m Hodgkin lymphom
DR.PRIYANKA SACHDEV

Overview
Diffuse Large B-cell Lymphoma (DLBCL) (00:04:17)
Follicular Lymphoma (00:08:58) Introduction, Age,
Burkitt lymphoma (00:11:46) Clinical features,
Hairy Cell Leukemia (00:20:38) Pathogenesis, Biopsy.
Immunophenotype

Diffuse Large B-cell Lymphoma (DLBCL)

Introduction >
Most common type of NHL in world and India
Worse prognosis amongst all types of NHL.
Mature B-cell tumour
(e14)
CHROHOSOME(9) CHROMOSOME(a)
Age
60 years
Clinical features
Presents as Rapidly enlarging mass at a single or
multiple nodal or extranodal sites.
TRANSLOCATION
Pathogenesis
a) Translocation of BCL2 gene t (14; 18)
translocation ncogtrolled
mitosis of e-lymphoyk
ymphoma
b) Mutations of the BCL6 gene.

Biopsy
Lymph node biopsy
Composed of large cleaved cells spread in a diffuse pattern.
Cytoplasm in these tumour cells is pale and abundant
Nuclei have prominent 1-2 nucleoli.

Immunophenotype->
Tumor cell wall express
CD19
CD20
CD10
BCL6

Follicular Lymphoma
Introduction >
B-cell lymphoma arising from germinal centre.
Age
Middle-aged adults.
Clinical features >
Presents as painless,generalized lymphadenopathy

PAGE 254 |WBC DISORDERS

 PATHOLoGY PROF
BUSTER m
CHROMOsOME 19
Pathogenesis CHROMoSOME 14
t(14:18)
30 to 50% of cases will transform to diffuse
large B-cell lymphoma (DLBCL).

TRANSLOCATION
Biopsy
Lymph node biopsy
Follicular (nodular) growth pattern
composed of 2 principal cell types>

a) Centrocytes (predominant) small cell with cleaved

nuclear contours and scant cytoplasm (Buttock cells).
b) Centroblasts large cell with open nuclear chromatin,
several nucleoli, and modest amount of cytoplasm.

Immunophenotype>
Tumor cells will express >
Cenrooe
CD10
CD19 Ceritroblst
CD20
BCL6 Folllcular
dendritic cell
Surfacelg
BCL2 (90% of tumor cells)

Burkitt lymphoma
Introduction >
Mature B-cell lymphomas
tumour but chemoseristive.
Very aggressive type of
syndrome
Most common cause of tumor lysis

Age and clinical features

3 categories >
1. African (endemic) BL
or young adults.
Seen in children
mandible (face)
Most commonly affects
All cases will be latently
infected with EBV, 100e

2. Sporadic
(nonendemic) BL
children or young adults.
Seen in mass
occurs as an ileocecal or peritoneal African ( endemia
Mos commonly
are latently infected by EBV
15% to 20% of the patients
3. HIV associated
aggressive lymphomas
are latently infected by EBV.
25% of the patients

WBC DISORDERS |PAGE 255

m DR. PRIYANKA SACHDEV

Pathogonesis Chromosome 8 Chromosome 14

C-MYC gene normal location on
chromosome 8

translocated to chromosome 14

Fuses with lgG gene

overexpression of MYC protein

lg
Uncontrolled mitosis MYC Gene
Gene Cochang
Burkitt lymphoma Translocatlon
5g14 translocaion
Biopsy enterimg inslde
AUHOUY
4he
4eat Ake

Lymph node biopsy

Noptat bodie
Macrophage
Loss of architecture.
Involved tissues show diffuse infiltrate of monotonous lymphoid
cells
Appearance of neoplastic Ilymphoid cells:
Medium-sized cells.
Round or oval nuclei with several (2-5) nucleoli.
MItotlc flgure
Moderate amount of deeply basophilic cytoplasm,
Multiple, small, round lipoid (clear) vacuoles
Numerous mitotic figures.
macraphage

Starry sky pattern >

Tumor cells undergo apoptosis
Nuclear remnants of these apoptotic cells are phagocytosed and
cleared by benign macrophages.
These macrophages in the background of lymphoid cells creates
"starry sky" appearance

BackgroUdtumoY Cells
Starry-sky Macrophages Mitotlc flgure Non-cleaved Color
Nucleoll lymphold cells blve
appearance

PAGE 256 | WBC DISORDERS

 BUSTER
PATHOLOGY PROF

Immunophenotypo
Tumor cells will express
CD19
CD20
CD10
Surface lgM
BCL6
BCL2 is absent

Hairy CellLeukemia
Introduction
s
Neoplasm of small mature B cells Growth
having abundant cytoplasm with fine factors
hair-like cytoplasmic projections when
viewed under the phase-contrast
microscope> hence name hairy cell
leukemia
Chemosensitive RAS
Overall prognosis is excellent.
BRAKV6o0E BRAF INHIBITORS:
RAF -Vemurafenlb
- Dabrafenib
Age
MEK INHIBITORS:
Median age > 55 MEK • Trametínib
Cobimnetínib

Clinical features P
ERK
Most common presentation > Hairy cell
massive splenomegaly
Lymphadenopathy is rare. Growth, Proliferation
Pancytopenia occurs in more than
50% of cases due to marroW
infiltration and splenic sequestration.

Pathogenesis
BRAF
Point mutations in serin/threonine kinase cetl
Halry
Peripheral smear
reniform nuclei
Hairy cells are B-cells with
and hair like cytoplasmic projections
which is best seen by phase
contrast
microscopy
Pancytopenia and tear drop RBC due to
bone marrow fibrosis.

Biopsy
Bone marrow biopsy > marrow fibrosis. Hon
Dry tap due to extensive tumor cell arrangement.
Honeycomb appearance of tumor cell due to perinuclear halo.
Fried egg cell appearance of
Immunophenotype
Tumor cells express>
CD20 and surface lg cif
Pan-B-cell markers CD19, CD11c, CD25, CD103 and annexin A1 Spemarken
Other distinctive markersmost specific marker for hairy cell leukemia.
Annexin A1 is best and
WBC DISORDERS | PAGE 257
 DR. PRIYANKA SACHDE
Associatk
4UNOr
syadone
Features DLBCL Folllcular Butkit's Hairy Celf
Lymphoma Iymphoma Leukemia
Introduction |-e tymphea GRAFmutaHo
arising ron gerand
Age iddle
Clinical features |Painlest splenomeg alq;
aHeneplh 9STaka5tOVant topnsa
Pathogenesis 8 14 tronstaa the
Biopsy Lars leqved cel Fellicolg letoyt appraramu
S4a1YNleture
in do Ffostd attengr ceniobl4s
Immunophenotype co, to-0, (o-/s, Cb+9,(090, (oo, n-t
Anngun Ag

bestcmst
speltie mrter
(11.12) PLASMA CELL DISORDERS MULTIPLE MYELOMA
University Exams
Long questions
1 A 60-year-old man was admitted with pathological fracture. On examination he was
found to be anemic. Laboratory
showed erythrocyte sedimentation rate (ESR): 100 mm/hr., X-ray-multiple lytic lesions. Peripheral smear showed examination
Rouleaux formation of the red cells and thrombocytopenia. Bone marrow examination confirmed the diagnosis. Increased
a) Whal is your probable diagnosis?
Whal the other hematological and urinary findings that would be positive in this condition?
c) Describe the bone marrOw findings in this condition.
2. Discuss Morphological fe atures, clinical features, laboratory investigations and prognostic factors of multiple myeloma.
Short questions
1 Revised Multiple Myeloma Diagnostic Criteria
2 Radiological appearance in multiple myeloma.
3 Write the bone marrow findings in multiple myeloma.
4 Morphology of plasma cells in multiple myeloma.
5 M protein.
6 Urinary findings in multiple myeloma.
7 Bence Jones proteins and its demonstration/importance.
8 Describe the investigations in multiple myeloma
Types of Plasma Cell Disorders

Overview
Introduction (00:01:20)
Types (00:05:14)
Multiple myeloma
Definition (00:05:58)
Etiology (00:07:17)
Pathogenesis (00:11:15)
Morphological features (00:13:57)
a) Osseous lesions Gross, microscopy
b) Extraosseous lesions
Clinical Features (00:29:25)
Diagnosis (00:31:50)
Revised Multiple Myeloma Diagnostic Criteria (00:34:55)
Prognostic factors (00:39:07)

Introduction

Abnormal proliferation of immunoglobulin-producing

cells (Plasma cells)

Accumulation of monoclonal immunoglobulin in serum

and urine

paraproteinaemias =
=
Plasma cell dyscrasias
dysproteinaemias = monoclonal gammopathies

PAGE 258 |WBC DISORDERS

 PATHOLOGY PROF
BUSTER m
Mallgnant plasma cell
PCD synthesise excess of proteins
Complete immunoglobulins
Light chains (kappa or lambda) > M
Bence-Jones proteins
Heavy chains of a single class
(alpha, gamma, or mu)

Types Free Ught chalns

Immunoglobutln

1. Monoclonal gammopathy of
Target of serum FLC Disulphlde bonds
undetermined significance (MGUS)
2. Smoldering multiple myeloma Immunoassay
3. Multiple myeloma
A Waldenstrom's macroglobulinemia K (kappa)
5. Heavy chain disease LIght chaln Hidden epitopes

Multiple myeloma A (lambda)

Heavy chaln
Definition>
.
Multifocal malignant proliferation of plasma cells derived from a single clone of cells e

monoclonal).
Peak incidence 5th-6th decades
M>F
Etiology
1. Radiation exposure > For eg. survivors of nuclear attack in World War-ll developed myeloma
about 20 years later.
in blacks. Certain occupations such as
2. Epidemiologic factors > Myeloma has hiaher incidence
farmers, wood workers and leather workers are more prone.
3. Karyotypic abnormalities >
t(11;14)
t(4;14)
Deletion of 13q
4. Oncogenes-antioncogenes lon
adhes
Overexpression of MYC and RAS growth promoting oncogenes moleculy
Abnorma
Mutation in p53 and RB growth-suppressing antioncogene
gtCM proteins
Pathogenesis
Cell-surface adhesion molecules*
Plasma cell
Bind myeloma cells to bone marrow BM stromal cell
stromal cells and ECM proteins. Adheslon molecules

-
Triggers adhesion mediated signalling Adheslon•medlated
slgnallng
Production of cytokines by fibroblasts of
marrow IL-6, VEGF, TGF-B, Produetlon pf cytoklnes
TNF-a IL-1, lymphotoxin, macrophage
inhibitory factor-1a (MIP-1a) and Cyto kine-medlated signallng
receptor activator of nuclear
factor-kB (RANK) ligand
IL-1, Lymphotoxln, Macrophage IL-6
IL-6 proliferation and cell survival of Inhlbltory factor-1,
RANK lgand, TNF"a
VEGF,
tumor cells IL-1, lymphotoxin, Actlvatlon of çellc
pathway(Cyclin-b
ligand, and TNF
MIP-1a, RANK
osteoclast-activating factor
(OAF) > bony destruction Osteoclast actlvating factor Prollferatlon and survlval
and bony destructlon of tumour cells

WBC DISORDERS | PAGE 259

 m
DR. PRIYANKA SACHDEV

DsscDUS
Morphologic Features osseeus.
LEetr Skull
-
a) Osseous (bone marrow) lesions
b) Extraosseous lesions
a) Osseous (Bone Marrow) Lesions
Multiple myelomabegins in bone marrow. RIbs

Most affected bones are those with red marrow skull,

Splne
spine, ribs and pelvis, long bones of the limbs
Pelvls
Lesions begin in medullary cavity erode cancellous Upper llmb bones
bone destruction of bony cortex. (raro)

Gross
Normal bone marroW Lower limb boneg
(rare)
Replaced by soft, Tunched
gelatinous, reddish-grey oUt roUnded
tumours
Focal or diffuse
osteoporosis

Radiographically punched out, rounded, 1-2 cm sized defects

ecentuS
Myeloid cells Cytoplasmic vacuoles Binucleate cell
Microscopy Myelom a Cells Myeloma cells

Hypercellularity of bone marrow

Myeloma cells >10% of marrowcellularity
Form clumps or sheets
Binucleate and multinucleate cells
Nucleus of myeloma cell is eccentric but usually
lacks cart-wheel chromatin pattern (seen in
classical plasma cells)
Cytoplasm > abundant and basophilic
Perinuclear clear area (Hof area) corresponding to
Golgi apparatus
Contains vacuolisation

PLASMA CELLS MYELOMA CELLS

(cartwheel chromatin pattern) (Lack of cartwheelchromatin pattern)
ine

Perinuclear halo due to

prominent Golgl
called HOF are a

Eccentric nucleus with

Spoke Wheel or
Cart Wheel or
Clock llke Chromatin
Oval cells with
BASOPHILIC Cytoplasm Cytoplasmlc vacuoles Nucleoll Russell bodles
Blnucleate cell

PAGE 260 | WBC DISORDERS

 PATHOLOGY PROF
BUSTER m
Flame cells
plasma cells with fiery red cytoplasm.

f lam

Mott cells Morular cells>

plasma cells with multiple grapeabundnt vacUole ptienk
like bluish cytoplasmic
droplets

Russell bodies Tc
Globular cytoplasmic inclusions ytoploin/
in cytoplasm (endoplasmic
reticulum) nilon
bodies
bodies
Jhctusion
+nt icles
N

Dutcher bodies
Nuclear inclusions.

Traun
Rouleaux formation >
Rouleaux
Due to RBCs sticking by M proteins.
RBCs are arranged in rows like
stacks of coins.

Erythrocytes

b) Extraosseous Lesions
1. Blood
50% of patients have atypical
plasma cells in blood
Normocytic normochromic
anemia
marked RBC rouleaux
formation
Hyperviscosity of blood
Elevated ESR.

2. Myeloma kidney or myeloma

nephrosis >
Dutcher bodles
By filtration of light chain
proteins (Bence Jones proteins)
precipitated in DCT in
combination with Tamm-Horsfall
Russell bodles

proteins as tubular casts.

MOTT CELL

WBC DISORDERS | PAGE 261

 m
DR. PRIYANKA SACHDEV

3. Myeloma neuropathy
Infiltration of nerve trunk roots by tumour cells
Nonspecific polyneuropathy
4.. Liver, spleen
Hepatomegaly
Splenomegaly
5. Systemic amyloidosis >
Generalized amyloidosis (AL amylold)
Clinical Features
Bone pain
1.
most common symptom.
Involves back and ribs.
Pathological fractures may occur
2. Susceptibility to infections
2nd most common clinical
feature.
Common bacterial infections pneumonias and pyelonephritis.
Due to hypogammaglobulinaemia
3. Renal failure >
Causes hypercalcaemia, glomerular deposits of amyloid, hyperuricaemia and infiltration of
the kidney by myeloma cells.
4. Anaemia >
Marrow replacement by tumour cells Inhibition of haematopoiesis.
5. Bleeding tendencies
Due to thrombocytopenia, deranged platelet function and interaction of component with
the M
coagulation factors.
6. Hyperviscosity syndrome >
Due to hyperglobulináemia
Headache, fatigue, visual disturbances and hemorrhages.
7. Neurologic symptoms
Due to hyperviscosity, cryoglobulins and'amyloid deposits
8. Biochemical abnormalities >
Hypercalcaemia due to destruction of bone
Hyperuricaemia from necrosis of tumour and from uraemia related to renal failure
Increased b-2 microglobulins in urine and serum.
9. POEMS simultaneous manifestations of >
syadrae
Polyneuropathy
Organomegaly Monoclonal Myeloma(M)-band
Endocrinopathy
Multiple myeloma
Skin changes

Diagnosis
Classic triad >
1. Marrow plasmacytosis of more than 10%
2. Radiologic evidence of lytic bony lesions
3. Demonstration of serum and/or urine M
I domponent.
E lectrophaeuy
Albumin a4
PAGE 262 | WBC DISORDERS
2
 PATHOLOGY PROF
BUSTER m
Rise in total serum protein due to
paraproteinaemia
Normal serum immunoglobulins (lgG, lgA
andlaM) and albumin are depressed.
Paraproteins abnormal
immunoglobulins circulating in plasma
and excreted in urine.

On serum electrophoresis paraprotein usuallv annoare ne a cingla narrow homogeneoUS M•DaHO

component in g-globulin region
Most frequent paraprotein >
lgG 50%
lgA 25%
IgD > 1%
Only light chains 20%

Revised Multiple Myeloma Diagnostic Criteria:

New definition of active multiple myeloma >
Clonal bone marrow plasma cells > 10% or biopsy-proven bony or extramedullary plasmacytoma and
any one or more of

Related organ or tissue impairment ROTI/CRAB features ->4

Myeloma-defining events (MDE) 3
Related organ or tissue impairment ROTIor CRAB Features
1. Hypercalcemia > serum calcium >0.25 mmol/L (>1 mg/dL) higher than upper limit of normalor
>2.75 mmol/L (>11 mg/dL)
2. Renal insufficiency creatinine clearance <40mL per minute or serum creatinine >177pmollL
(>2mgldL).
3. Anemia> Hb value of >20g/L below lowest limit of normal or a Hb value <100g/L
4. Bone lesions one or more osteolytic lesion on skeletal radiography > CT or PETICT
Myeloma Defining Events (MDE)
1. 60% or greater clonal plasma cells on bone marrow Examination.
2. Serum involved / uninvolved free light chain ratio of 100 or greater
or lambda is the one that is above the normal
(a patient's "involved" free light chain-either kappa
one that is typically In or below the normal
reference range; the "uninvolved" free light chain is the
range). or greater in size.
3. More than one focal lesion on MRI that is at least 5mm

Prognostic factors
Poor Prognostic factors>
marker)
Serum B-2 microglobulin 6 mg/dl (best prognostic
1
>

2 C-reactive protein>6 mg/dl.

3 Presence of plasmablastic morphology.
4. Serum LDH raised
5. Plasma cellI labelling index >3%
6. Serum creatinine> 2 mg/dl.
7. Cytogenetics showing:
a) Deletion of 13g9; 119; 17p
b) Monosomy 13;
c) Hypodiploidy

WBC DISORDERS |PAGE 263

 m DR. PRIYANKA SACHDEV

I(11.13) SPLEENOMEGALY
UnlyersÍty Exams
Short questlons 2
Causes of splenomegalylsplenic enlargement.
Causes for massive splenomegaly.
Hypersplenism.
Enumerate.causes of splenomegaly.
Classification of splenomegaly.
6
List tho disorders associated with Splenomegaly.
7 Gross and Microscopy in splenomegaly.

Overylow
Definition (00:00:58)
Causes (00:01:28)
Degree Mild, Moderale, Massive (00:04:51)
Gross (00:06:35)
Microscopy (D0:08:15)
Hypersplenism (00:09:05)

Definition
Occurs in disorders which increase cellularity
vascularity of Spleen

Causes
1. Infections
2. Disorders Of Immunoregulation AlHered spenic
3. Disorders-Of Hmmunoregulation bloo klow
4. Haematolymphoid Malignancies
5. Diseases With Abnormal Erythrocytes
6. Storage Disease
7. Miscellaneous beneath transverse
blood
1grvalescs ymphoy te drqvel io viscera Normal Spleen Splenomegaly
1)Infections >rvv1
a) Malaria
b) Leishmaniasis
c) Typhoid
d) Infectious mononucleosis
e) Bacterial septicaemia
f) Bacterial endocarditis
g) Tuberculosis
h) Viral hepatitis

2) Disorders Of Immunoregulation
a) Rheumatoid arthritis
b) Systemic lupus erythematosus
c) Immune haemolytic anaemias
d) Immune thrombocytopenias

3) Altered Splenic Blood Flow

a) Cirrhosis of Iliver
b) Portal vein obstruction
c) Splenic vein obstruction
d) Congestive heart failure.

PAGE 264 | WBC DISORDERS

 m

PATHOLOGY PROF
BUSTER

4) Haematolymphoid Malignancies
a) Hodgkin disease
b) Non-Hodgkin lymphomas
c) Multiple myeloma
d) leukemias
e) Myeloproliferative neoplasms

5) Diseases With Abnormal Erythrocytes Costal margin Tlp enlargement

a) Thalassaemia 12cm)
cell disease
b) Sickle
Spherocytosis Moderate
c) enlargement
d) Ovalocytosis (3-7 cm)

Marked
enlargement
cm)
6) Storage Disease Y
a) Gaucher's disease
b) Niemann-pick's disease

7) Miscellaneous
a) Amyloidosis
b) Primary and metastatic splenic tumours

Degree of splenomegaly
Mild enlargement
Moderate enlargement
Massive enlargement

Moderate Massive
Mild
500-1000 gm More than 1000 gm
Up to gm
500 Palpable below umbilicus
Palpable up to 5cm below costal Palpable up to umbilicus
margin Causes
Causes
Hepatitis CML
Causes > Storage diseases
Cirrhosis
CVCof the spleen in CHF Thalassaemia major
Lymphomas
Acute malaria Infectious Chronic malaria
Typhoid fever mononucleosis Leishmaniasis
Bacterial endocarditis Haemolytic anaemia Portal vein obstruction.
SLE Splenic abscesses
Rheumatoid arthritis Amyloidosis.
Thalassaemia minor.

Gross
Grossly
Congested, tense and cyanotic
gray tan
Sectioned surface

WBC DISORDERS | PAGE 265

 DR, PRIYANKA SACHDEV

Microscopy Gamna-Gandy Congested Thlckened

capsule
Red pulp > enlarged due to marked sinusoidal body slnusolds
dilatation
Capillarization of sinusoids > Sinusoids may
get converted into capillaries
White pulp atrophic.
Fibrous tissue get deposits of haemosiderin
pigment Gamna-Gandy bodies

Hypersplenism
Altered splenic blood flow or production of antibodies against blood cells

Increased sequestration of RBCs, WBCs or platelets in spleen

drapfd
excessive removal from circulation

Hyperfunctioning spleen

Hypersplenism

Criteria for hypersplenism

1. Splenomegaly
2. Splenic destruction of one or more of cell types causing anaemia, leucopenia,
thrombocytopenia, or pancytopenia
3. Normal or hyperplastic bone marrow cellularity
4. Splenectomy is followed by improvement in severity of blood cytopenia.

PAGE 266 | WBC DISORDERS

 CHAPTER

PLATELET DISORDERS 12
(12.01) BLEEDING DISORDERS
(DEFINITION AND CLASSIFICATION)
University Exam
Short questions
1. Define and classify Bleeding disorders
Steps of Hemostasis
3. Platelet adhesion
4. Platelet aggregation
Very Short questions
5. Coagulation cascade.
6. Primary and secondary clot

Overview
Definition (00:00:55)
Hemostasis (00:03:36)
Steps of Hemostasis (00:05:44)
1. Arteriolar vasoconstriction
2 Primary hemostasis
3. Secondary hemostasis
4. Clot stabilization and resorption
Classification of Bleeding disorders (00:28:22)

Definition
Also known as Hemorrhagic Diathesis
Characterized by defective haemostasias with abnormal bleeding.
Spontaneous
Excessive external or internal bleeding following trivial trauma

Hemostasis
Physiological process bleeding is stopped after injury > protecting integrity of vascular system
after tissue injury.

Steps of Hemostasis
1) Arteriolar vasoconstriction
Occurs immediately and is translent
 DR. PRIYANKA SACHDEV

Basement Artericle
Endotheum srmooth muscle
membrane

Site of Injury

Reflex ECM (collagen)

cal (Vasoconstrlction

2) Primary hemostasis
Formation of the platelet plug

shapechange Granute release ORecrultment

3) (ADP, TXA:)
OPlatelet adheslon Aggregation
(hemostatic plug)
VWF

Endothelium Base ment membrane Collagen

SUb-endolheliug
Plaklets
von Willebrand factor
Injury
Gplb-IX
Gpla-lla
Disruption of the endothelium

Exposes subendothelial collagen

Platelet adhesion
Platelets
Platelet activation Gpllb-llla

Platelet aggregation/recruitment
FIbrinogen
Primary hemostatic plug

1. Platelet adhesion Platelets adhere tocollagen in sub endothelium due to presence of receptor
(Gp) la-ll andGp lb-1X
vWF forms a bridge between collagen of endothelium and platelet

2. Platelet activation 2 types of granules

a) Alpha -granules
b) Dense granules

3. Platelet aggregation Adherence of platelets to one another due to presence of receptor

Gp llb-llla

PAGE 268 | PLATELET DISORDERS

 PATHOLOGY PROF
BUSTER M
Extrtnslc pathway
3) Secondary hemostasis |Intrnslc pathway
TIssue factor
Deposition of fibrin
Injury to
blood vessels
Injury

Tissue factor binds and activates factor VIl or

factor X|
A
cascade starts (Intrinsic, extrinsic, common)
Fibrinogen into insoluble fibrin

Fibrin meshwork is formed Prothronhid hromblr

2
(0)
Secondary hemostasis / Fibiopgen
Cros
(0 nking
10

3Thrombln actlvatlon
2
Phosphollpld complex
expresslon 4 FIbrin polymerlzatlon
2 TÍssue
1TIssue factor factor

Flbrin

4) Clot stabilization and resorption Fibrinolye

Counterregulatory mechanisms (tissue plasminogen activator,
t-PA, thrombomodulin) Clot resorption

Trapped
Release of: neutrophll
-t-PA (Flbrinolysls) Trapped
thrombomoduln RBCs
(blocks coagulatlon
cascade) Polymerized
fIbrin

Classification of Bleeding disorders Turpura

1. Hemorrhagic diathesis due to vascular abnormalitles
2. Hemorrhagic diathesis related to platelet abnormalltles
3. Disorders of coagulation factors
4. Hemorrhagic diathesis due to fibrinolytic defects
5. Combination of all these as occurs In dissemlnated intravascular coagulation (DIC)

PLATELET DISORDERS
|PAGE 269
 m DR. PRIYANKA SACHDEV

I (12.02) THROMBOCYTOPENIA (|TP, TTP, HUS)

Unlversity Exam
Long questlons
Classify bleeding disorders. Describe the pathogenesis and laboratory findings of idiopathic thrombocytopenic purpura
(ITP).
Describe and classify bleeding disorders. Describ0 etiology, hematological featutes, clinical foatures and laboratory diagnosis
Thrombotic Thrombocytopenic Purpura (TTP) of
Short questlons
1
Describe ldiopathic thrombocytopenic purpura (|TP). rite itss eropathogenesis and laboratory findings
Describe Thrombotic Thrombocytenene pe etiopathogenesls and latboratory findings
3 Describe Hemolytic uremic syndrome (HUS). Write its etlopathogen SIs and laboratoty findings
4 Megakaryocytic thrombocytopenia and non-megakaryocylic thrombocytopenla
5. Differentiate TTP and HUS
Very Short questions
1. Enumerate the causes of thrombocytosis.
Causes of megakaryocytic thrombocytopenla
Etiopathogenesis of ITP
A one marrow findings in ITP.
5 Opathogenesis of TTP
6 Etio enesis of Hemolytic uremic syndrome (HUS).
7 Pentard of
8. Triad of HUS

Overview
Introduction (00:01:31)
Definition (00:07:43)
Types (00:10:15)
Causes (00:14:57)
ITP (00:18:38)
TTP (00:25:55) Introduction, Pathogenesis,
HUS (00:38:29) Clinical features, Laboratory findings

Introduction
Hemorrhagic diatheses due to Platelet Disorders >
Quantitative Due to reduction in no. of platelets
>thrombocytopeniake
Qualitative Due to defective platelet functions

Definition
Reduction in peripheral
blood platelet count below lower limit of normal i.e. below 150,000/ul
Spontaneous bleeding seen usually when count falls below 20,000 cells/ ul
is
Prolonged BT with normal| P and aPTT
sledin Proihrqbn
timel
4 platel eds
Types Functlon

1. Megakaryocytic thrombocytopenia-> BM BM Peripheral

If thrombocytopenia is associated Reduced functlon Normal function destruction
with compensatory increase in
megakaryocytes in bone marrow HSC HSC

seen in peripheral destruction of

platelets.
2. Amegakaryocytic o

thrombocytopenia If
thrombocytopenia associated with
is
NO compensatory increase in
BM Blood Vessel BM Blood Vessel
megakaryocytes in bone marrow
due to defect in bone marrow itself Amegakaryocytlc Thrombocytopenla Megakaryocytle Thrombocytopenla

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Causes
Causes

If bonemarrow is functlonal If bone narrow Is haying reduced function

Non-megakaryocytlc thrombocytopenla
Megakaryocyte thrombocytopenla
1,, Bone marrow failure
Immune mediated Non-lmmune 2. 012 and folate deficiency
3. Leukemla ;
disserninated
Coombstest
modlated
Cancor
1. Coombs test 4. Myelodysplastic syndrome
2, SLE 1. 5, Orugs (cytotolc drugs,
3, B cellcancers 2. Alcohol)
4. Drugs (Qulnidine, 3. DIC
Heparin) 4, Glant
5. Miscellancous : Dengue hemangloma

Immune Thrombocytopenic Purpura (1TP)

Introductlon
Immunologic dostructlon of platolots by autoantibodlos,of cla0s lgG
Type ll hypersonsitivity roaction
Duo to peripheral platolot destruction, thoro ls componsatory Incronso In mogakaryocytos In
bono marrow

Pathogonosis
2 Types
1. Acute
2. Chronic

1) Acuto /TP
In children (2-6 yoar)
M=F
Following recovory from a viral Infectlon

Viral antlgons

Formatlon of
(Igantibodlos agalnst vlral antlgons

Antibodlos Cross rooct with platoloto

Immunologlc dostructlon of platolots

Thrombocytoponia
2) Chronlc ITP
More commonly In adults
F> M
Pathogenosls By formatlon of antl-platolot autoantibodles

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m DR. PRIYANKA SACHDEV

Clinical Features
Petechial hemorrhages
Easy bruising mucosal bleeding
Menorrhagia in women
Nasal bleeding
Bleedingfrom gumsn beromln
Melaena > bleeding Stool
Haemaluria
Intracranial haemorrhage

Laboratory Findings
1 Platelet count Reduced Nofmal clump Large platelet Reduced platelets
of platelets
2. BT locreased
3. Blood film Occasional platelets
4. Bone marrow Increased no. of
megakaryocytes serum of
5. Anti-platelet lgG antibody in
patients

Thrombotic Thrombocytopenic PSoNORMAL ITP

Purpura (TTP) / Moschcowitz Peripheral Smear

disease
Introduction due
Cotloid
Pentad anemia MAH A) throybus
1. Microangiopathic hemolytic
2. Thrombocytopenia
3. Neurological symptoms
4. Renal dysfunction
5. Fever

Pathogenesis
Deficiency of enzyme called
vWF
ADAMTS.13 (vWF metalloprotease) that degrades

Multimers of vWF accumulate in plasma

Promote platelet thrombus formation

throughout the microcirculation

TTP

Clinlcal Features
Petechial hemorrhages
Easy bruising mucosal bleeding
Menorrhagia in women
Nasal bleeding
Bleeding from gums
Melaena
Hematuria
Intracranial hemorrhage
Formation of microthrombi Neurological symptoms and Renal dysfunction and Microangiopathic
haemolytic anaemia

PAGE 272 | PLATELET DISORDERS

 m

PATHOLOGY PROF BUSTER

Laboratory Findings
1. Platelet count Reduced
2. BT Increased
3. Blood film
Occasional platelets
4. Bone marrow
Increased no. of megakaryocytes
5. Biopsy Typical microthrombi in arterioles, capillarios
and venules
Hemolytic uremic syndrome (HUS)
Introduction
Triad

1. Microangiopathic hemolytic anemia

2. Renal failure
3. Thrombocytopenia

Pathogenesis
2 Types
1. Typical (epidemic, classical, diarrhea-positive) HUS
2. Atypical (non-epidemic, diarrhea-negative) HUS
1. Typical (epidemic, classical, diarrhea-positive) HUS

Acute gastroenteritis caused

by E. colistrain 0157: H7

Shiga-like toxin into circulation

Alters endothelial cell function

Platelet activation and aggregation
whaut fngu.
Typical HUS
2) Atypical (non-epidemic, diarrhea-negative)

Normally Factor H, Factor I, and CD46 prevent excessive

activation of alternative complement pathway
Deficiency of these regulatory proteins

excessive complement activation

Platelet activation
Thrombosis
Atypical HUS

Laboratory Findings
of
Peripheral smear of HUS and TTP shows features
microangiopathic hemolytic anemia:
Schlstocyto
1. Fragmented RBCs (Schistocytes)
2. Helmet cells
3. Burr cells
4. Target cells

PLATELET DISORDERS | PAGE 273

m DR. PRIYANKA SACHDEV

TTP HUS

ADAMT 13 Normal
CNS involvement Not affected
Renal involvement +++

(12.03) FUNCTIONAL PLATELET DISORDERS

(BERNARD SOULIER SYNDROME, GLANZMANN'S SNDROME)
University Exam
Short questlons
Enumerate functional platelet disorders.
2 Bernard-Soulier evndr
drome
Glanzmann's disease

Overview
Introduction (00:00:34)
Classification (00:07:00)
Bernard-Soulier syndrome (00:07:20)
Glanzmann's disease (00:08:52)

Introduction
Normal platelet count with defect in function of platelet
Bleeding time prolonged but platelet count will be normal

Classification
Classification
Disorders of adhesion
Inherited Acquired
Bernard-Soulier syndrome Uremia
Acquired vWD
Disorders of aggregation
Inherited Acquired
Glanzmann thrombasthenia FDP inhibition
Dysproteinaemias
Drugs-Ticlopidine, Gp llb/llla
Inhibitors
Disorders of granule release
Inherited Acquired
Oculocutaneous albinism Cardiopulmonary bypass
Chediak-Higashisyndrome Myeloproliferative disease
Isolated dense granule deficiency Drugs- NSAIDs
Gray platelet syndrome
(combined a and b granule deficiency)

PAGE 274 |PLATELET DISORDERS

 BUSTER
PATHOLOGY PROF

Deflclency
Bernard-Soulier syndrome BERNAR0-SOULIER
SYNDROME
Autosomal recessive disorder
Due to deficiency or dysfunction of glycoprotein Glb
Deficlency
lb-|X GLANZMANN Patelet
THROMBAsTHENIA
Defect in platelet adhesion
Gpllb-lla complex FIartnogn.

Glanzmann's disease> Endothellum

Gplb
Autosomal recessive disorder ADP Induces
Due to deficiencyldysfunction of glycoprotein conformatlonal
change von witlebrand
|lb-llla factor

Thus there is defective platelet aggregation Deflelency

vON WLLESRANO
At birth present with increased bleeding from DISLASe
umbilical cord stump. Subendothellum

(12.04) COAGULATION DISORDERS

HEMOPHILIA AND VON WILLEBRAND'S DISEASE
University Exams
Long questions
1. Define hemophilia. Describe briefly a case of Hemophilia A B (Christmas DiseasSe)
2. Define hemophilia. Describe pathogenesis, Clinical features and lab diagnosis of Hemophilia
Short questions
1 Write a note on hemophilia.
2. Pathogenesis of Hemophilia
3. Von Willebrand's disease (clinical feature and laboratory diagnosis).

Overview
Classification (00:12:16)
1. Classic Hemophilia (Hemophilia A) (00:12:32)
Christmas Disease (Hemophilia B) (00:15:37) Introduction,
3 Von Willebrand's Disease (00:17:33) Pathogenesis,
Laboratory Findings

Classification
1. Classic hemophilia or hemophilia A > due to inherited deficiency of factor Vll
2. Christmas disease or hemophilia B due to inherited deficiency of factor IX
3. Von Willebrand's disease due to inherited defect of von Willebrand's factor

1) Classic Hemophilia (Hemophilia A)

Introduction >
Inherited deficiency of factor VIlI
X linked recessive trait

(Males) Manifests clinically

Females carriers

PLATELET DISORDERS PAGE

275
m DR. PRIYANKA SACHDEV

Pathogenesis
Quantitative reduction of factor VIll
Functions of factor VIll
a) Regulates activation of factor X in intrinsic coagulation pathway
b) Factor Vllcirculates in blood complexed to another larger protein von Willebrand's factor (vWEy
Laboratory Findings
a) BT is prolonged
b) PT is normal
c) APTT prolonged > defeed
is assay in etiafatto an
d) Specific for factor Vll shows lowered activity.
2) Christmas Disease (Hemophilia B)eArer)
Introduction
Inherited deficiency of factor IX (Christmas factor or plasma thromboplastin component)
Hemophilia B is rarer than hemophilia A
X linked recessive trait
Males Manifests clinically
Females carriers
Pathogenesis
Quantitative reduction of factor IX

Laboratory Findings
a) BT is prolonged
b) PT is normal
c) APTT is prolonged
d) Specific assay for factor lIX
shows lowered activity.

Endothellum
3) Von Willebrand's-olc
amolj alt
Disease factor vlll
Introduction > VWF Xa
Clotting Activated, aggregated
Most Clrculating vWF
common.hereditary with Factor VIlI
cascade platelets

coagulation disorder (plateiet

Due to qualitative or quantitative Fibrinogen
defect in von Willebrand's factor Gplb/tlla
(vWF) (Platelet Gplb

vWF helps in >

1. Platelet adhesion
2. Factor VIllcarrier in plasma.
Subendothellal vWF
Endothellal defect Collagen

Pathogenesis
Platelet Adhesion defects
Deficiency of vWF results in defect in the
adhesion of platelets to collagen preventing the
formation of hemostatic plug.
Leads to mucus and cutaneous bleeding in the
form of epistaxis, menorrhagia and GIbleeding.
Coagulation defect
Reduced half-life of factor VIll leading to its deficiency
Results in hemorrhages and intramuscular hematoma.

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BUSTER
PATHOLOGY PROF

Laboratory Findings
a) BT Prolonged
b) Normal platelet count.
c) Reduced plasma vWF concentration
d) Synthesis of factor VIIlremains normal but half-life of decreases due to reduced vwr (Goo
-
levels> secondary VIll Intrinsic pathway is affected aPTT s increased L)
e) Positive Hess Capillary Resistance Test (Torniquet Test)

Hess Capillary Resistance Test (Torniquet

Test)
Pressure in it between diastolic and
systolic for 5 minutes.
After deflation number of petechiae
appearing in next 5 minutes in 3-cm²
area over cubital fossa are counted.

Presence of more than20 petechiaelis considered a positive test.

(ensomcobagi
I(12.04) DISSEMINATED INTRAVASCULAR COAGULATION (DIC) >h,rovbe-hadiserld
Trlad
University Exams AHA,
Long questions
Bleeding
1shaeN9
Discuss Etiology, Pathogenesis, Clinical Features and Laboratory Findings of Disseminated Intravascular Coagulation (01C)
1.
Short questions
1. Pathogenesis of DIC

Overview
Introduction (00:01:06)
Etiology (00:04:11)
.. Pathogenesis (00:05:07)
Clinical Features (00:13:21)
Laboratory Findings (00:13:55)

Introduction
DIC is a common acquired coagulation disorder resultingdue to excessive activation of the
coagulation system, due to massive tissue injury or sepsis.
The normal anticoagulants and fibrinolytic systems are overwhelmed and cannot control the
coagulation activation which becomes systemic, resulting in disseminated microvascular thrombi
formation. :
Massive tissue injury or sepsis

Excessive activation_of coagulation system

Normal anticoagulants and fibrinolytic systems are

overwhelmed and cannot control coagulation activation

Becomes systemic

Disseminated microvascular
thrombi formation

DIC|

PLATELET DISORDERS|PAGE
277
 m
DR. PRIYANKA SACHDEV

Also known as
Defibrination syndrome Con suN
factor
Consumption coagulopathy rlatelels k tongulaton
Thrombo-haemorrhagic disorder

Etiology
1.Massive tissue injury In obstetrical syndromes (e.g. abruptio placentae, amniotic fluid embolism,
retained dead fetus), massive trauma, metastatic malignancies, surgery.
2. Infections Endotoxaemia, Meningococcal septicemia, malaria, aspergillosis.
3. Widespread endothelial damage In aortic aneurysm, haemolytic-uraemic syndrome, severe
burns, acute glomerulonephritis.
4 Carcinoma Pancreas, Stomach, Prostate, Lung, Acute promyelocytic leukemia

Pathogenesis

Any of above cause

Activation of coagulation pathway

Formation of thrombus Ischemia and MAHA

Consumption of coagulation factors

Bleeding Activation of protective fibrinolytic system

Produe
Formation of FDP's > Fibronglytie degradatoh

lCoagulatlon
factors CONSUMPTION THROMBOTIC Endothelial damage
PHASE PHASE

Platelet aggregates
MICROTHROMBI:
J Platelets IN CIRCULATION Activation
Secondary of coagulation
fibrinolysls
FDPs
present

PAGE 278 | PLATELET DISORDERS

 PATHOLOGY PROF BUSTER m
Masslve tissue destruction Products of conception Endothelial injury
Sepsis

Release of tissue
factor Platelet
aggregation
Widespread
microvasculat
thrombosis
Activation of
plasmin
Microanglopathic Vascular
Hemolytic Anemla occlusion

Fibrinolyslis Proteolysis of Consumptíon of

Ischemic tssue
clotting factors damage clotting factors
and platelets
Fibrin split products

Inhibition of thrombin, platelet Bleeding

aggregation, and fibrin polymerization

Clinical Features Triad Bleeding

Tschomia
1. Bleeding MAHA
2. Organ damage due to ischemia caused by thrombosis
mAHA

Laboratory Findings
1 Platelet count Low
2. BT, PT, APTT, TT Prolonged
3. Plasma fibrinogen levels > Reduced
4. Fibrin degradation products (FDPs) raised
5. Blood film shows MAHA schistocytes

PLATELET DISORDERS | PAGE 279