TOPIC #1: THE HOMEOSTASIS OF THE CELL.

PHYSIOLOGICAL STRESS. THE CONCEPT OF ADAPTATION

AND CELLULAR INJURY

HOMEOSTASIS OF THE CELL

# Homeostasis a process in which the cell regulates its internal environment by
continuous exchange of nutrients, fluids and temperature (heat) with the external
environment.
# Stress any stimulus that interrupts with the homeostasis of the cell, which can
be physiological or pathological.

TYPES OF STRESS
# Hypoxia interferes with aerobic oxidative respiration; it can be caused by
ischemia (loss of blood supply), inadequate oxygenation of the blood(pneumonia),
or reduction of the oxygen carrying capacity (anemia, CO poisoning).
# Chemical agents substances that are osmotically active, such as glucose or salts,
which cause movement of fluids into or out of the cell, others: pollutants, co,
asbestos, high amount of ox.
# Physical agents such as trauma, extreme temperatures, radiation, atmospheric
pressure etc.
# Infectious agents viruses, bacteria, fungi etc.
# Immunologic reactions autoimmune reactions, allergic reactions.
# Genetic defects congenital malformations (sickle cell), damaged DNA,
misfolded proteins.
# Nutritional imbalance when the diet lacks certain nutritional values (proteins,
vitamins).
# Aging leads to alterations in the ability of the cell to replicate and repair itself.

THE CONCEPT OF ADAPTATION

# Adaptation any response of the cell to stimuli (stress) to achieve a new steady
state and preserve its function. Reversible changes
# The responses of the cell can be either physiological or pathological:
Physiological adaptation the responses of the cell to normal stimulation
by hormones or endogenous chemicals.
Pathological adaptation the responses of the cell to stress, allowing the
cell to modulate its structure and function to avoid cell injury.

CELLULAR INJURY
# When the cell is exposed to severe stress that exceeds its adaptive capability, cell
injury may occur.
# Cellular injury can be either acute or chronic.
# Acute cell injury can be divided into: based on nature and severity of stress
AND basal cellular metabolism and nutrient supply
Reversible the cell can return to its normal state if the stress is removed.
Early stages/mild form of injury, functional/morphologic changes are
reversible if stimulus is removed. Significant structural/functional
abnormalities may be present, theres no severe mem damage/nuclear
dissolotion
Irreversible the cell will eventually die. Necrosis (always patho)/apop
(no GF, DNA/proteins damage). Characterized by inability to correct
mitochondrial dysfunction, and profound disturbance in membrane
function.
# Chronic cell injury the causes of cell injury are the various types of stress
mentioned earlier, which induce distinctive alterations that include only the
organelles:
Autophagy lysosomal digestion of the cell's own components,
considered to be a survival mechanism in nutrient deprived cells.
Hypertrophy of sER occurs in cells that are exposed to certain chemical
agents, such as barbiturates 1.
Mitochondrial alterations change in the number, size and shape of
mitochondria.
Cytoskeletal abnormalities occur due to certain drugs that interfere with
the normal function of cytoskeleton (disrupt polymerization, cause
accumulation of fibrillar material, defective mobility of organelles).

1
Processed by cytochrome P-450 in sER of hepatocytes
the drug.

hypertrophy of sER

tolerance to

TOPIC #2: ADAPTATION I ATROPHY, INVOLUTION,

APOPTOSIS
ADAPTATION
# Reversible changes of the cell to stimuli in order to achieve a new steady state
and preserve its function.

PHYSIOLOGICAL

PATHOLOGICAL

responses of the cell to normal

stimulation by hormones or
endogenous mediators

responses of the cell to stress

that allows it to modulate its
structure, thus escape injury

closing/opening of ion
channels, enlargement of the
breast and uterus during
pregnancy

atrophy, hypertrophy,
hyperplasia, metaplasia,
dysplasia

ATROPHY
# Decrease in the size of the individual cells by loss of cell substance, resulting in
the shrinkage of the organ/tissue.
1) These organs may have decreased function.
# Atrophy can be caused by:
Decreased workload immobilization of a broken arm will allow the bone
to heal, but will cause muscle atrophy.
Loss of innervations.
Diminished blood supply.
Inadequate nutrition.
Loss of endocrine stimulation (may be physiological => menopause).
Cell aging (senile atrophy).
# Atrophy results from decreased protein synthesis (due to reduced metabolic
activity), and increased protein degradation, mediated by ubiquitine-proteasome
complexes and lysosomes.
# Atrophy may be accompanied by increased autophagy.

INVOLUTION
# Reduction of the volume of the functional cells by atrophy (simple atrophy)
# Reduction of the number of the functional cells by apoptosis (numerical atrophy)
Examples of involution:
Involution of the uterus after birth the uterus returns from its
hypertrophic state to its normal size.
Involution of the thymus during puberty the gland begins to atrophy,
and is gradually replaced by fat.

APOPTOSIS
# The pathway of programmed cell death, regulated by certain genes, cell
fragments are avid targets for phygocytes, doesnt elicit an inflammatory
response
# Causes of apoptosis:
Physiological used to eliminate cells that are no longer needed, or to
maintain a certain amount of cells in a tissue.
1) Destruction of cells during embryogenesis.
2) Involution of hormone-dependent tissues upon hormone
deprivation. Endometrial cell breakdown during menstrual cycle,
regression of lactating breast
3) Cell loss in proliferating cell populations (intestinal crypt
epithelia).
4) Cells that have served their purpose (RBCs, neutrophils in an acute
inflammatory response deproved of survival signals like GF).
5) Elimination of potentially harmful self-reactive lymphocytes.
6) Cell death initiated by cytotoxic T cells in defense against viruses
or tumors.
Pathological elimination of cells that are genetically altered or injured
beyond repair, keeping extent of tissue damage to a minimum
1) DNA damage that cannot be repaired radiation, cytotoxic
anticancer drugs, extreme temp, hypoxia, directly/through free
radicals
2) Misfolded proteins accumulation of misfolded proteins causes
ER stress that induces apoptosis (unfolded protein response), part
of Alzheimer, Huntington, Parkinson.
3) Cell injury due to infections, mainly by viral infections.
4) Pathologic atrophy in parenchymal organs after duct obstruction
(pancreas, parotid gland, kidney)

#
# Mechanisms of action:
DEATH RECEPTOR (EXTRINSIC)
PATHWAY

MITOCHONDRIAL (INTRINSIC)
PATHWAY

Mediated by cell surface receptors

(FAS(cd95),TNF type I, both belong to
TNF family)

Survival/death is determined by
permeability of mitochondria which is
controlled mainly by Bcl-2

FAS + FAS ligand (on activated T)

activation of the "death domain"
of the receptor and activation of caspase
8

Initiated by loss of stimulation of

growth factors/agents that damage
DNA/acc of misfolded proteins

In many cells, caspase 8 activates Bid

(pro-apop, of Bcl-2 family)
mitochondrial pathway
Involved in:

elimination of self reactive

lymphocytes,
killing target cells by cytotoxic
T

Sensors of Bcl-2 family are activated

BH3 proteins.
Results in the inactivation of antiapoptotic proteins (Bcl-2, Bcl-xL), and
activation of pro-apoptotic proteins
(Bax, Bak).
Activation of Bax and Bak form chanles
in mit. Mem., and cytochrome C is
released + other proteins(inhibit antiapop mol.).
Cytochrome C + Apaf-1 => caspase 9
activation
Nuclear fragmantation

# Regulation of apoptosis is mediated by the Bcl-2 protein family, which includes

both pro- and anti-apoptotic proteins, and by p53 protein 1.
# Caspase antagonist is a protein called FLIP. Some viruses produce a FLIP
homolog and prevent cell apop
# When DNA is damaged, p53 accumulates in cell, arrests cell in G1 phase for
repair, if damage is too great, it triggers apop by activating Bax, Bak and increase
synthesis of pro-apop members of Bcl-2 family

Decreased transcription of Bcl-2, and increased transcription of Bax & Bak activates p53 protein.

TOPIC #3: ADAPTATION II HYPERTROPHY. HYPERPLASIA.

METAPLASIA

ADAPTATION
# Reversible changes of the cell to stimuli in order to achieve a new steady state
and preserve its function.
PHYSIOLOGICAL

PATHOLOGICAL

responses of the cell to normal

stimulation by hormones or
endogenous mediators

responses of the cell to stress

that allows it to modulate its
structure, thus escape injury

closing/opening of ion
channels, enlargement of the
breast and uterus during
pregnancy

atrophy, hypertrophy,
hyperplasia, metaplasia,
dysplasia

HYPERTROPHY
# Increase in the size of the organ/tissue due to increase in the SIZE of cells by
increasing the amount of structural proteins and organelles. Due to increased
functional demand/GF/ hormonal stimuli
PATHOLOGICAL

PHYSIOLOGICAL

Enlargement of the uterus

during pregnancy due to
estrogen stimulation.

Cardiac hypertrophy as a result of hypertension

or aortic valve disease

Striated muscle undergo

hypertrophy due to increased
demand (cells have limited
capacity to divide).

Two types of signals:

Mechanical stretch

Trophic GF/adrenergic hormones

Result in the synthesis of proteins and myofibrils to improve

performance

Beyond certain limit degenerative changes (loss of contractile

elements,fragmentation, [loss of blood supply], limit od vasculature to
adequetly supply enlarged fibers)

Ventricular dilation

heart failure

HYPERPLASIA
# Increase in size of the organ/tissue due to an increase in NUMBER of cells,
usually in cell population of replicating (dividing) cells.
PHYSIOLOGICAL

PATHOLOGICAL

Hormonal proliferation of
glandular epithelium by
prolactin stimulation, such as
female breast during puberty
and pregnancy.

Excessive hormonal
production unbalanced levels
of estrogen and progesterone
leads to endometrial
hyperplasia, causing abnormal
bleeding.

Compensatory occurs when a

portion of a tissue is removed
or diseased (example: liver).
Wound healing GF produces
by WBC

Excessive GF production
papilloma virus causes skin
warts (masses of hyperplastic
epithelium).

# Hyperplasia may disappear if the stimulation is removed; this sensitivity to

normal control mechanisms distinguishes between benign hyperplasia and
cancerous hyperplasia.
# Hyperplasia may accompany hypertrophy (example: uterus growth).

METAPLSIA
# The reversible replacement of one adult (differentiated) cell type by another adult
cell type.
# Occurs when a certain cell type cannot withstand the change in its environmental
conditions, and it is replaced by another, more suitable cell type.
# Examples of metaplasia:
Due to smoking, the normal ciliated columnar epithelium of the trachea
and bronchi is replaced by stratified squamous epithelium; although it had
survival advantages, important protective functions are lost (mucous
secretion, ciliary clearance), if persistent, may predispose to malignant
transformation. Often coexist with lung cancer composed of squamous
cells.
Since vitamin A is essential for normal epithelial differentiation, its
deficiency may also induce squamous metaplasis in respiratory epithelium.
In chronic gastric reflux, the normal stratified squamous epithelium of the
lower esophagous may transform into columnar epithelium => BARRET'S
ESOPHAGOUS

TOPIC #4: DEGENERATION PATHOMECHANISM &

MORPHOLOGY OF REVERSIBLE CELLULAR INJURY (cellular
swelling, fatty change)

CELL INJURY
# Occurs when the adaptive capability of the cell is exceeded.
# Within a certain limit, cell injury is reversible, but a severe or persistent stress
results in irreversible injury and eventually cell death.
# Cellular function may be long lost before cell death occurs, and morphologic
changes of cell injury lag far behind both (myocardial cells become
noncontractile after 1-2min of ischemia, die after 20-30min, appear dead after 23h at least)

REVERSIBLE CELL INJURY

# At early stages, mild form of stress can be handled.
# Functional and morphological changes are reversible if the stimulus is removed.
# Types of reversible cell injury:
Cellular swelling failure of energy dependent ion pumps, leading to
inability to maintain homeostasis.
Fatty change (steatosis) occurs in hypoxic injury and in various forms of
toxic/metabolic injury. Manifested by lipid vacuoles in cytoplasm.
Abnormal accumulation of TAGs within parenchymal cells, observed
most frequently in the liver (major organ of fat metabolism), but also in
the heart and kidney.
# sER is involved in the metabolism of various chemicals. Cells exposed to
these chemicals show hypertrophy of the ER.barbiturates are metabolizes in
liver by cytochrome P-450. Development of tolerance to the drug is due to this
hypertrophy and increased P-450 enzymatic activity. In addition, products
formed by the ox. metabolism include reactive ox. species(ROS) which may
injure the cell
# IC changes:
Plasma membrane alteration: blebbing, blunting, distortion of
microvilli, loosening of IC attachment.
Mitochondrial changes: swelling and appearance of phospholipid-rich
densities.
Dilation of ER with detachment of ribosomes and siddocoation of
polysomes

Nuclear alteration with clumping of chromatin. Plasma may conatin

phospholipid masses myelin figures derived from damaged cellular
membranes

FATTY CHANGE (steatosis)

Manifested by the appearance of lipid vacuoles in the cytoplasm.

Prinicipally encountered in cells participating in fat metabolism
(hepatocytes, myocardial cells), its reversible.
Injured cells become more eosinophillic
# Accumulation of lipids lipid vacuoles appear within the cell, which unite to
form a large lipid droplet, displacing the nucleus to the periphery.
# Some cells may rapture, and their vacuoles unite to form fatty cysts.
# Examples of fatty change:
In the liver, fatty change occurs due to diabetes mellitus 1, and the liver
becomes enlarged (3-6 kg), yellow in color, soft & greasy in consistency.
In the heart, lipid deposition is formed in two patterns:
1) /Specific location results from moderate, prolonged hypoxia,
creating bands of yellow myocardium alternating with bands of
healthy tissue.
2) Uniformly affected myocytes results from profound hypoxia or
toxic injury.

CELLULAR SWELLING
The first manifestation of almost all forms of injury to cells, is a reversible alteration.
When it affects many cells on an organ it causes some pallor, increased turgor, and
increased weight of the organ. Small vacuoles are visible segments of ER. Also
called hydropic change/vacuolar degeneration.

PATHOMECHANISM OF CELL INJURY

# The main targets of harmful stimuli:
Mitochondria responsible for ATP and ROS production , their damage
will lead to depletion of ATP, and as a result cell swelling (accumulation
of Na+, efflux of K+), intracellular pH => enzyme activity , failure of
Ca2+ pumps.
Disturbance in ca homeosasis
Cell membrane (plasm and lysosomal) leads to loss of osmotic balance
(influx/efflux of fluid and ions), and loss of cellular content.
Damage to DNA and misfolding of proteins
1

Secondary to alcoholism, obesity and malnutrition.

 Cytoskeleton maintain shape and integrity of the cell. ?

# Cell responses to injurious stimuli depends on:
Low doses of toxins or brief duration of stimuli =>
Type of injury
reversible cell injury
Duration
Severity
High doses of toxins or long duration of stimuli =>
irreversible cell injury => cell death
# The consequence of injurious stimuli depends on:
Type of cell
An identical injury may have different outcomes
Status
in different cell types => skeletal muscle can last
Adaptability
2-3 hours of complete ischemia without
Genetic makeup
developing irreversible cell injury, while cardiac
muscle dies after 20-30 minutes.
Nutritional status has an effect => glycogen rich
cells will tolerate ischemia better than cells that
depleted their energy source.
Genetic diversity in metabolic pathways
(cytochrome P-450 polymorphism may provide
some protection against toxins).

DEPLETION OF ATP

# Decreased supply of O2 and nutrients

# Mitochondrial damage
# Toxins (example: cyanide)

Reduced activity of Na+/K+ pump

-

[Na+]i
[K+]o

Water osmosis into the cell =>

CELL SWELLING, dilation of ER

Increase in anaerobic glycolysis

-

Depletion of glycogen stores

Accumulation of lactic acid => pH => enzymatic activity

Ca2+ pump failure

-

Influx of Ca2+ => damage to cellular components by activation of

enzymes (proteases, caspases, phospholipases).

Detachment of ribosomes from rER

-

Reduced protein synthesis

DAMAGE TO MITOCHONDRIA

#
#
#
#
#

[Ca2+]i
Reactive oxygen species (ROS)
Hypoxia
Toxins
radiation

High-conductance channel formation

-

Called mitochondrial permeability transposition pore.

Loss of mitochondrial membrane potential, pH changes.
Failure of oxidative phosphorylation => ATP depletion =>
NECROSIS

Leakage of cytochrome C into cytosol

-

Due to permeability of mitochondrial membrane.

Activation of intrinsic pathway of apoptosis.

Failure of oxidative phosphorylation

-

Depletion of ATP
Formation of ROS

Necrosis

INFLUX OF Ca (*depleting EC Ca delays cell death in case of hypoxia/toxins)

Activates Enzymes
-

# Ischemia
# Toxins

Phospholipase (mem. Damage)

Proteases (breakdown mem and cytoskeleton proteins)
Endonucleases (DNA and chromatin fragmentation)
ATPase (ATP depletion)

Apoptosis
-

By activation of caspases
Increasing mitochondrial permeability

ACCUMULATION OF FREE RADICALS (Oxidative stress)

-

Lipid peroxidation of membranes: reaction of mem polyunsaturated lipids

with radicals creates peroxides autolytic chain
Cross linkage and changes in proteins: radicals promote protein crosslinkageloss of enzymatic activity/enhanced deg.
DNA damage

Accumulation of free radicals, determined by rates of production

and removal.

Rate of spontaneous decay,

glutathione (GSH) peroxidase,
catalse (2H2O2 => O2 + 2H2O),
antioxidants(vitamins E,A,C).

Redox reactions during

mitochondrial respiration,
ionizing radiation, metabolism
of chemicals, in neutrophils
and macrophages (respiratory
burst), NO produced by WBC

DEFECTS IN MEMBRANE PERMEABILITY

Decreased phospholipid syn:
Due to fall in ATPdecreased enzymatic activity
Increased phospholipid breakdown:

# Ischemia
# Toxins
# Lytic complement
components

Due to Ca increae activation of phospholipase

ROS
Cytoskeleton abnormalities
Due to Ca increae activation of phospholipase
Lipis breakdown products:
Unesterified FFA acyl carnitine, lysophospholipid phospholipis
deg

3 most imp mem: mit, plasma (osmotic changes, loss of cellular contents), lysosomal
mem (activation of acid hydrolase, contain DNase, RNase)

TOPIC #5: THE MECHANISMS OF IRREVERSIBLE HYPOXIC

CELLULAR INJURY. THE MORPHOLOGY OF HYPOXIC
NECROSIS

HYPOXIC CELL INJURY

# Causes of hypoxic cell injury:
Ischemia diminished blood flow to a tissue, usually due to obstruction of
arterial blood.
Anemia reduction in number of RBCs or Hb molecules.
CO poisoning diminished O2 carrying capacity due to affinity of CO
to Hb.
Decreased perfusion in CHF, shock, hypertension.
Poor oxygenation of blood in pulmonary diseases.
# Hypoxic cell injury primarily affects the mitochondria, resulting in reduced
oxidative phosphorylation and diminished production of ATP
Failure of ion pumps (Na+/K+ pump, Ca2+ pump).
1) IC [Na+] , IC [K+] , IC [Ca2+]
2) Water accumulation results in cell swelling.
3) Swelling of rER and mitochondria.
Detachment of ribosomes from rER.
1) Failure of protein synthesis.
Depletion of glycogen stores.
1) Stimulation of phosphofructokinase (PFK-1), resulting in
glycolysis and IC pH => inactivation of enzymes.
# Hypoxic cell injury eventually results in membrane damage:
Mitochondrial membrane damage reduction in ATP production, and
release of pro-apoptotic enzymes to the cytosol.
Plasma membrane damage loss of osmotic balance, influx of fluids and
ions, loss of cellular contents.
Lysosomal membrane damage leakage of digestive enzymes into the
cytoplasm.

CELL DEATH
# Occurs when severe injury or prolonged stimulus are applied.
Swelling of mitochondria and lysosome.
Extensive damage to plasma membrane.
Massive Ca2+ influx.
# IC enzymes are released from necrotic cells into the circulation due to loss of
membrane integrity:

Myocardial enzymes

AST aspartate aminotransferase

LDH lactate dehydrogenase
CK creatine kinase
troponin

Liver enzymes

Alanine aminotransferase
Alkaline phosphatase(bile)
Gamma glutamyl transferase

# The vulnerability of cells to hypoxic injury varies among different cell types:
Neurons 3-5 minutes; purkinje cells of cerebellum & hippocampus are
much more sensitive.
Myocardial and hepatic cells 1-2 hours.
Skeletal muscle cells several hours.

MORPHOLOGY OF HYPOXIC NECROSIS

# Hypoxic necrotic cells show increased eosinophilia => eosin binds to denatured
cytoplasmic proteins, loss of basophilia doe to lack of RNA in cytoplasm.
# The cell may have a more glassy homogenous appearance due to loss of glycogen
particles.
# When enzymes have digested the cytoplasmic organelles, the cytoplasm becomes
vaculated.
# Dead cells may be replaced by large masses of phospholipids => myelin figures,
derived from damaged cellular membranes.
# Eventually, dead cells may become calcified.
# By electron microscopy, necrotic cells are characterized by:
Discontinuous membranes (plasma, organelles).
Mitochondrial dilation.
Lysosomal disruption.
Cytoplasmic myelin figures.
Nuclear changes:
1) Pyknosis nuclear shrinkage and increased basophilia due to DNA
condensation.
2) Karyorrhexis fragmentation of pyknotic nucleus.
3) Karyolysis fading of chromatin basophilia due to DNAse activity.

TOPIC #6: THE MORPHOLOGICAL FORMS OF NECROSIS

NECROSIS
# A form of cell injury that results in the premature death of cells in the living
tissue, and may lead to the death of the organ.
# This type of cell death is characterized by loss of membrane integrity and leakage
of cellular contents elicit inflammation
# It is the net result of degradation action of enzymes on lethally injured cells.
# Necrosis is mediated by two processes:
Protein denaturation due to low pH formed by hypoxia-induced
glycolysis.
Enzymatic digestion by intracellular enzymes, derived from lysosomes,
and by enzymes derived from extrinsic sources (leukocytes => the dying
cells induce an inflammatory reaction).
# Morphology:
Cytoplasmic changes: increased eosinophilia (loss of basophilic RNA,
attachement of eosin to denaturated proteins)
Nuclear changes: basophilia of chromatin may fade (karyolysis),
nucleus may shrink and increased basophilia (pyknosis), nucleus may
undergo fragmentation (karyorrhexis)
Necrotoc cells may be replaced by myelin which will be phagocytosed/degrade to FA.
FA may be calcified.
FORMS OF NECROSIS
# Coagulative necrosis
Characteristic of infarcts in solid organs => NOT BRAIN
Tissue cells are dead, but the architecture is preserved (for several days).
Firm texture.
Denaturation of proteins predominates (of both structural proteins and
enzymes => NO PROTEOLYSIS => eosinophilia (eosin binds to denatured
proteins).
Cells digested by leukocytes, cellular debris removed by phagocytes
# Gangrenous necrosis
Usually affects lower limbs, initiated due to loss of blood supply,
secondary to coagulative necrosis.
Wet gangrene in moist tissues => when bacterial infection develops
coagulative necrosis is modified by the liquefactive action of the bacteria.
Dry gangrene in lower extremities => caused by coagulative necrosis
without liquefaction.

# Liquefactive necrosis
Characteristic of bacterial/fungal infections => stimulates the
accumulation of inflammatory cells => enzymes of leukocytes digest the
tissue.
Hypoxic death of cells in CNS evokes liquefactive necrosis (unknown
reason).
Dead cells are completely digested, resulting in the transformation of the
tissue into a liquid viscous mass.
Loss of basophilia due to degradation of proteins and RNA.
Acute inflammation => pus formation.
# Caseous necrosis
Most commonly caused by tuberculosis.
"cheese-like" consistency => the tissue appears white and friable.
Tissue architecture is completely obliterated, has amorphous granular
appearance (cells are not completely digested), enclosed within a
distinctive inflammatory border.
Cellular outlines cannot be distinguished.
Granulomatous reaction the necrotic area is composed of cellular decries
enclosed by multinucleated giant cells (fused macrophages); may also
contain epithelial cells, T cells and fibroblasts.
# Fat necrosis
Caused by the release of activated pancreatic lipases into the pancreatic
tissue => pancreatitis => leakage of pancreatic enzymes to the peritoneal
cavity.
Digestion of TAGs (in cell membrane) => FFAs are released and combine
with Ca2+ => formation of soap (SAPONIFICATION).
Visible chalky-like appearance.
# Fibrinoid necrosis
Usually seen in immune reactions involving blood vessels damage.
Complexes of antigen-antibody are deposited on the wall of the vessel,
together with fibrin (leaked out of the vessel due to increased
permeability).
Appears eosinophilic and glandular.

TOPIC #7: ACCUMULATION OF PROTEINS, LIPIDS AND

CARBOHYDRATES

ABNORMAL INTRACELLULAR ACCUMULATIONS

# Inadequate removal of the substance that is produced in a normal or increased
rate (example: fatty change in liver).
# Genetic or acquired defects in folding, packaging, transport or secretion of a
normal or abnormal endogenous substance 1.
# Accumulation of an exogenous substance since the cell lacks the enzymatic
machinery to degrade it, or the ability to transport it out of the cell 2.

LIPID ACCUMULATION (fatty change steatosis) *..

# Any abnormal accumulation of TAGs within parenchymal cells of organs of fat
metabolism, mainly in the liver, can also be seen in the heart, kidney and skeletal
muscle.
# May be caused by: toxins, malnutrition, diabetes mellitus, obesity or anoxia.
# FFAs are usually transported into hepatocytes, where they:
Esterified into TAGs.
Converted into cholesterol or phospholipids.
Oxidized into ketone bodies.
# TAGs exit hepatocytes by forming complexes with apolipoproteins, creating the
lipoprotein complexes that can enter circulation; defects at any stage of this
process result in lipid accumulation:
Hepatotxins (alcohol) => Alter mitochondrial and sER function
Inhibit FA oxidation

CCl 4 /protein malnutrition => Decreased synthesis of apoproteins

Anoxia (extreme hypoxia) => Total decrease in oxygen level

Inhibit FA oxidation

# Morphology => Appears as clear vacuoles within parenchymal cells

Can be visualized by special staining
1

Sudan IV/oil red O => far appears orange-red

PAS => glycogen appears red-violet

Alpha1-antitripsin deficiency, in which alpha1-antitripsin protein, a protease inhibitor, is accumulated

in hepatocytes.
2
Accumulation of carbon or silica particles.

# Liver appears yellow in color, enlarged (3-6 kg), and soft & greasy in consistency.
# In the heart, lipid deposition can appear in two forms:
Specific => zebra-like pattern of yellow myocardium, alternated by bands
of healthy, red-brown myocytes; usually as a result of prolonged,
moderate hypoxia (anemia).
Uniformly affected myocytes => produced due to profound hypoxia.
# Cholesterol:
Important component of cell membrane.
Ensures synthesis of steroids, bile acids and vitamin D.
When there is cholesterol overload, macrophages phagocytose the lipids,
and become filled with small lipid vacuoles to form FOAM CELLS.
Xanthomas => clusters of foamy macrophages found in subepithelial c.
tissue of the skin or in tendons.
Atherosclerosis => smooth muscle cells and macrophages within the
intimal layer of the aorta and large arteries are filled with lipid vacuoles,
Such cells have a foamy appearance (foam cells). Some of these fat-laden
cells may rupture, releasing lipids into the extracellular space.
Cholesterolosis => This refers to the focal accumulations of
cholesterol-laden macrophages in the lamina propria ofthe gallbladder.
Niemann-Pick disease, type C. This lysosomal storage disease is caused
by mutations affecting an enzyme involved in cholesterol trafficking.
PROTEIN ACCUMULATION
# usually appear as eosinophilic droplets of abnormal proteins deposit primarily in
extracellular spaces
# In the kidney, protein filtered through the glomerulus are normally reabsorbed by
pinocytosis in the proximal tubule. In disorders with heavy protein leakage across
the glomerular filter there is increased reabsorption of the protein into vesicles,
and the protein appears as pink hyaline droplets within the cytoplasm of the
tubular cell. The ER becomes hugely distended, producing large, homogeneous
eosinophilic inclusions called Russell bodies.
# Liver Mallory bodies ("alcoholic hyaline") => eosinophilic cytoplasmic
inclusion (crystals) in hepatocytes, composed of aggregated intermediate
filaments that are resistant to degradation.
# 1-antitrypsin deficiency, results in the buildup of partially folded intermediates,
which aggregate in the ER of the liver and are not secreted. The resultant
deficiency of the circulating enzyme causes emphysema.
# Brain Alzheimer's disease => neurofibrillary compounds of aggregated proteins,
containing microtubule-associated proteins and neurofilaments.

CARBOHYDRATES ACCUMULATION

# Excessive IC deposits of glycogen due to abnormalities in glucose or glycogen

metabolism.
# Glycogen masses appear as clear vacuoles within the cytoplasm. Staining with
PAS reaction imparts a rose-to-violet color to the glycogen
# Glycogen storage disease enzymatic defects in the synthesis or breakdown of
glycogen, result in massive storage with secondary cell injury and death.
# In untreated diabetes mellitus, glycogen accumulates in renal tubules, hepatocytes,
cardiac myocytes and pancreatic B cells.

TOPIC #8: PATHOLOGIC CALCIFICATION

PATHOLOGIC CALCIFICATION
# The abnormal deposition of Ca2+ salts together with small amounts of other
minerals, such as iron and Mg2+.
# Two forms of calcification exist:
1) Dystrophic calcification occurs in the absence of Ca2+ derangement
(normal level of serum Ca2+).
2) Metastatic calcification deposition of Ca2+ salts due to hypercalcemia.

DYSTROPHIC CALCIFICATION
# The calcification occurring in dying/dead cells as a response to cell injury.
(common in caseous necrosis)
# Ca2+ levels in the serum are NOT elevated.
# Pathogenesis formation of crystalline Ca2+-phosphate.
Initiation
Extracellular occurs in membrane-bound vesicles, accumulating
Ca2+ and phosphate, derived from degenerating cells.
Intracellular occurs in the mitochondria of cells that have lost
their ability to regulate IC Ca2+.

Propagation of crystal formation depends on [Ca2+] and [PO 4 -] in the

extracellular space, presence of mineral inhibitors, and rate of
collagenization.
Seen in aortic valves (aortic stenosis) and athrosclerosis

METASTATIC CALCIFICATION
# Occurs due to hypercalcemia that can be cuased by:
Endocrine dysfunction increased secretion of PTH due to tumors.
Bone destruction due to increased turnover (Paget's disease),
immobilization, and tumors 1.
Vitamin D related disorders intoxification (hypervitaminosis),
sarcoidosis (macrophages that activate vitamin D precursors).
Renal failure phosphate retention leads to secondary
hyperparathyroidism.
Excess Ca2+ intake.
# Morphology occurs throughout the body, mainly affecting kidneys 2, lungs 3 and
gastric mucosa.

Increased bone catabolism is associated with multiple myeloma and leukemia.

May cause renal damage, seen as white fine granules (nephrocalcinosis).
3
Produce respiratory deficits, well seen in radiography.
2

TOPIC #9: PIGMENTS

EXOGENOUS PIGMENTS
# Carbon

Phagocytosed by alveolar macrophages, and transported to the

lymph nodes (tracheobronchial)
Anthracosis blackening of the lymph nodes and pulmonary
parenchyma.
Heavy accumulation may indicate emphysema (destruction of
tissue responsible for maintaining physical shape of the alveoli and
lungs), or fibroblastic reaction (coal workers' pneumonia).

ENDOGENOUS PIGMENTS
# Lipofucson

Brownish-yellow, insoluble pigment, derived from peroxidation of

lipids of membranes.
Mostly accumulates in elderly people, mainly in the heart, liver and
brain.
Not harmful to the cell.
Indication for past free radical injury.
Brown atrophy large amount of lipofucsin in atrophied tissue.

# Melanin

Brown-black pigment, produced in melanocytes in epidermis by

tyrosinase enzyme.
Once synthesized, melanin is transferred to keratinocytes, which
accumulate it.
Serves as a screen against harmful UV radiation.
Sun tanning will cause increased pigmentation; albinism and
vitiligo will cause decreased pigmentation.

# Billirubin

Yellowish pigment, end product of heme degradation.

When accumulated, stains mucous membranes, sclera and organs
(under pathological conditions) => JAUNDICE

# Hemosiderin

Golden-yellow to brown pigment, derived from Hb and contains

iron.
Consists of aggregates of ferritin (hemosiderin granules)
Identified by Purssian blue staining
Local excess of iron => hemosiderin results from hemorrhage
(example: common bruise)
Colors of the bruise reflect metabolism of Hb:
-

Red-blue: hemoglobin, as a result of RBCs lysis.

Green-blue: Hb is catabolized by lysosomes to
billiverdin (green-blue) and billirubin,
Golden-yellow: hemosiderin (the iron of Hb).

Hemosiderosis => when there is systemic overload of iron,

hemosiderin is deposited in many organs (first seen in liver, bone
marrow, spleen, and lymph nodes).
Occurs due to:
1)
2)
3)
4)

Increased absorption of dietary iron.

Impaired utilization of iron.
Hemolytic anemia.
Transfusions.

Hereditary hemosiderosis => mutation in Hfe gene (chromosome 6)

"bronzed diabetes" occurs in micronuclear cirrhosis,
diabetes mellitus and skin pigmentation

TOPIC #10: AMYLOIDOSIS

AMYLOIDOSIS
# A condition in which extracellular deposits of fibrillar proteins are responsible for
tissue damage and functional compromise.
# These abnormal fibrils are produced by the aggregation of misfolded proteins,
which are soluble in their normal configuration.
# Fibrillar deposits binds to PG, GAG (heparin/dermatan sulfate) and serum
amyloid P component (SAP).
# Amyloid an insoluble fibrous protein, formed by aggregation of over 20
different misfolded proteins, which has some characteristics of starch (amylase).
Composed of non-branching fibrils, each has -pleated sheet
configuration.
Amorphous eosinophilic appearance in H&E.
Staining with congo red dye will give apple-green birefringence
coloration in polarized light.
# IC degradation by proteosomes failed allowing the formation of amyloidosis
# 3 distinct forms of amyloid proteins:
AL protein (Amyloid Light-chain)
Produced by plasma cells.
Composed of immunoglobulin light chains (defective deg of
light chain)
Associated with some forms of monoclonal B-cell proliferation
(multiple myeloma).
AA protein (Amyloid-Associated)
Derived from a serum precursor SAA => serum amyloidassociated.
SAA id synthesized in the liver, and increased during acute
phase response (under influence of IL-1, IL-6).
Associated with chronic inflammatory disorders.
Defective proteolysis of SAA leads to its aggregation as AA
fibrils.
A amyloid
Derived from TM GP amyloid precursor protein (APP)
Found in cerebral lesions of Alzheimer disease
Deposits in cerebral blood vessels
# Other proteins associated with amylois deposits:
Transthyretin (TTR) related to familial amyloid polyneuropathies,
deposits in the heart of aged people
2-MG component of MHC-I, identified as amyloid fibril subunit
(A2m) high cc in patoents with renal disease

SYSTEMIC AMYLIODOSIS
# Primary = associated with monoclonal plasma cell prolif
Deposition of amyloid fibrils derived from immunoglobulin light chains
(AL type).
Most common form.
Monoclonal plasma cell prolif (5-15% in patients with multiple myeloma)
Syn of abnormal ampunt of Ig (monoclonal gammaopathy), producing M
protein.
Plasma cells may also produce either the (lambda) or (kappa) light
chains => BENCE JONES PROTEINS.
Deposition of AL in kidneys, heart, PNS, GI tract. (?)
# Secondary = complication of an underlying chronic inflammatory process
Deposition of fibrils composed of AA protein.
Deposition occurs due to association with:
inflammatory condition tuberculosis, bronchiatitis, chronic
osteomyelitis
autoimmune state RA, bowel disease
renal carcinoma, Hodgkin lymphoma

HEREDITARY AMYLOIDOSIS
# Familial Mediterranean fever:
Autosomal recessive
Pyrin => the gene responsible for this condition, regulates acute
inflammation by inhibiting the function of neutrophils.
Patients have gain-of-function mutation overproduction of IL-1
Amyloid deposition AA protein.
This condition is characterized by periodic attacks of fever accompanied
by inflammation of serosal membranes (peritoneum, pleura).
# Familial amyloidotic polyneurophathies:
Autosomal dominant.
Deposition of amyloid in the peripheral and autonomic nerves.
Amyloid deposition mutant TTR (transthyretin, a plasma protein).
# Senile systemic amyloidosis (amyloid of aging):
Systemic deposition of amyloid in elderly people.
Usually involves the heart.
The amyloid is composed of normal TTR molecules.

LOCALIZED AMYLOIDOSIS
# Amyloid deposition is limited to a single organ => produce nodular masses.
# Affects mainly the lungs, larynx, skin, urinary bladder and tongue.
# In some cases amyloid deposits are AL
# Endocrine amyloidosis amyloid deposits in certain endocrine tumors
Deposition of amyloid in islet cells of pancreas, derived from insulin or
glucagon, called amylin 1 => interferes with insulin sensing by cells.
Modullary carcinoma of thyroid amyloid is derived from calcitonin.
Undifferentiated carcinoma of the stomach

MORPHOLOGY
# No distinctive pattern of organ distribution, but generalizations can be made.
Primary amyloidosis (heart, GI tract, respiratory tract, peripheral nerves,
skin, tongue), perivascular and vascular localization are common.
Amyloidosis secondary to chronic inflammation (kidneys, liver, spleen,
lymph nodes, adrenal glands, thyroid).
Familial Mediterranean fever (kisney, blood vessels, spleen, respiratory
tract, rarely liver)
# When amyloid is accumulated (always in EC) in large amount, the organ is
frequently enlarged, with firm consistency and gray in color.
# Major organs involved:
- Most common and severe involvement.
Kidneys
- Abnormally large, pale, gray and firm.
- Deposition mainly in glomeruli.

Spleen

Enlarged (200-800 gr).

Deposits are limited to the splenic follicles, but may affect
the splenic sinusoids and extend to the splenic pulp.
Firm, pale, gray, waxy appearance.

Liver

Massive enlargement, up to 9 kg.

Deposits first appear in the space of Disse, then on hepatic
parenchyma and sinusoids.

Heart

Minimal to moderate enlargement.

Gray-pink subendocardial elevations, mainly between
myocardial fibers

Other organs

Most commonly in adrenal, thyroid and pituitary.

Starts at epithelial cells and progresses to parenchyma.
No disturbance of function

IAPP = insulin amyloid polypeptide.

TOPIC #11: EDEMA

EDEMA
# The abnormal accumulation of fluids in the interstitium, characterized by tissue
swelling.
# Extravascular fluids can accumulate in body cavities (hydrothorax,
hydropericardiun, hydroperitoneum/ascites).
# Ansarca severe edema, selling of subcutaneous tissue and fluid accumulation in
body cavities
# Edematous fluid can be either transudate or exudates:
Trabsudate results from increased hydrostatic or decreased oncotic
pressure of plasma; non-inflammatory fluid with low protein content,
specific gravity<1.012.
Exudates results from increased permeability of blood vessels caused by
inflammation; viscous, yellowish-white fluid with high protein content
and inflammatory leukocytes, specific gravity>1.012.

EDEMA FORMATION
# Increased hydrostatic pressure
Systemic edema mostly due to congestive heart failure :
CO => renal perfusion => activation of RAS => retention of Na+, water =>
heart cannot increase CO (due to failure) => extra fluid will increase
hydrostatic pressure in veins => edema. Treated with anti-aldosteron/diuretics
Venous obstruction (example: thrombosis) will result in local edema distal to
the site of thrombus (Pc => absorption is impaired).
# Decreased plasma oncotic pressure
Albumin is the serum protein most responsible for maintaining intravascular
oncotic pressure.
Reduced synthesis of albumin/albumin is lost decreases oncotic pressure of the
plasma, which leads to net movement of fluid from the plasma into the
interstitium.
Nephritic syndrome (glomerular permeability ).
Causes of albumin loss Diffuse liver diseases, such as cirrhosis (synthesis ).
Protein malnutrition.
Reduced intravascular volume => same manifestations as congestive heart
failure (20 hyperaldosteronism, renal hypoperfusion)

# Lymphatic obstruction
Impaired lymphatic drainage => localized lymphoedema.
Can be cause by Inflammatory or neoplastic obstruction (parasites =>
fibrosis of lymphatics and lymph nodes).
Surgical removal of lymph nodes (as therapy for breast
cancer) => arm edema.
# Na+ and water retention
Primary => associated with renal dysfunction.
Water accompany Na+
Increased hydrostatic pressure due to intravascular expansion
Decreased oncotic pressure (within the vessels)
Secondary => due to congestive heart failure.

MORPHOLOGY OF EDEMA
Microscopically => appears as a clearing and separation of ECM elements
with cell swelling.
Edema is most commonly encountered in subcutaneous tissues, lungs and
brain.
# Subcutaneous edema in regions with high hydrostatic pressure.
Dependent edema => a gravity-dependent distribution, also a prominent
feature of cardiac failure, appears mostly on legs.
Edema due to renal dysfunction is more severe than cardiac edema, and
affects body parts equally.
Pitting edema => finger pressure over edematous subcutaneous tissue
displaces the fluid and creates a finger-shape depression.
# Pulmonary edema most frequently seen in left ventricular failure, with lungs
weigh 2-3 times their normal weight.
# Brain edema may be localized to site of injury (infarct, abscess, neoplasm), or
generalized 1 (encephalitis, obstruction of venous outflow).

Gross swelling, narrow sulci, distended gyri => brain can herniated via foramen magnum.

TOPIC #12: HYPEREMIA AND CONGESTION. HEMORRHAGE

HYPEREMIA
# Active process of increased blood flow to different tissues due to vasodilation, as
occurs in inflammation/exercising skeletal muscle.
# Redder than normal due to accumulation of oxygenated blood
# Hyperemia occurs when a tissue increases its activity, thus utilizing caerain
substances and releasing metabolites => pO 2 , pCO 2 , pH , temperature ,
utilization of glucose, FAs and other nutrients.
# The presence of certain metabolites (CO 2 , adenosine) will initiate vasodilation in
order to increase the blood flow; thus, waste products are cleared from the tissue,
and new blood, rich in oxygen and nutrients, supplies the tissue.
# Vasodilation can also be caused by: Sympathetic tone
Vasodilators (histamine, bradykinin)
inflammation

CONGESTION
# Passive process refers to impaired venous flow out of the tissue, usually occurs
when the heart is unable to provide sufficient pump action to distribute the blood
(=>systemic), or when there is an obstruction of the vein (=>local).
# The tissue becomes cyanotic due to accumulation of deoxygenated blood.
# Congestion can be acute or chronic.
# In chronic congestion hypoxia may lead to parenchynal death and 20 tissue
fibrosis. Intravascular pressue may cause edema/vessel rupture focal
hemorrhage
CHRONIC
ACUTE
PULMONARY CONGESTION
PULMONARY CONGESTION

More blood in alveolar capillaries

Alveolar septal edema
Intra-alveolar hemorrhage

HEPATIC CONGESTION

Caused by LV failure, mitral stenosis

Congestion & distension of capillaries lead to
rapture => blood in alveoli
Degeneration & phagocytosis of RBCs =>
intra-alveolar phagocytes full of hemosiderin
=> heart failure cells
Fibrosis of interalveolar septa and hemosiderin
deposition => brown lung
HEPATIC CONGESTION

Right ventricular failure

More blood in central vein

Central hepatocytes degenerate (due to
hypoxia)
Peripheral hepatocytes undergo less
severe hypoxia (closer to hepatic
arteries)

The central regions of the lobules are

red-brown, surrounded by brownyellowish fatty cells => nutmeg liver.
Hepatocyte necrosis &hemosiderin-laden
macrophage
Severe hepatic congestion is due to heart
failyre, heptic fibrosis (cardiac cirrhosis
may develop

HEMORRHAGE
# Extravasation of blood from the vessels into the extravascular space.
# Caused by: Trauma (most common cause)
Atherosclerosis
Inflammatory or neoplastic erosion of vessel wall
Chronic congestion
# Hemorrhage can be external to the tissue or confined within it (hematoma).
# Sizes of hemorrhages:
Petechia => minute (1-2 mm) hemorrhage into skin, mucous membrane or
serosal surface, associated with thrombocytopenia, defective platelet function
and loss of vascular wall support vitamin C deff
Purpura => 3-5 mm, can occur with trauma, vasculitis, vascular fragility.
Ecchymoses => 1-2 cm subcutaneous hematoma; RBCs are phagocytosed and
degraded by macrophages (Hb
billirubin
hemosiderin).
# Large accumulations of blood in a body cavity are named according to the cavity:
hemothorax, hemopericardium, hemoperitoneum, hemoarthrosis (joints).
# Patients with extensive hemorrhage may develop jaundice due to [billirubin] .
# Recurrent external bleedings (ulcers, menstruation) can lead to iron loss and to
iron deficiency anemia.
# Blood loss of over 20% may cause hemorrhagic shock

TOPIC #13: THROMBOGENESIS. MORPHOLOGY OF

THROMBI. FATE OF THE THROMBUS. DISSEMINATED
INTRAVASCULAR COAGULATION

THROMBOSIS
# The pathologic form of homeostasis, involves blood clot (thrombus) formation in
an uninjured vessel, or thrombotic occlusion of a vessel after relatively minor
injury.
# Thrombosis include the 3 components of homeostasis (Virchow's triad):
Endothelial injury
Stasis/turbulence of blood flow
Blood hypercoagulability
# Endothelium exposure of subendothelial ECM release TF, reduces production
of PGI 2 and plasminogen activators.
Endothel may be dysfunctional (not only damaged) and create an imbalance
between the anticoagulant and procoagulant activities of the endothelium may
induce thrombosis => hypertension, bacterial endotoxins, vasculitis.
# Turbulence any alterations in the laminar blood flow that causes endothelial
injury/dysfunction, as well as forming countercurrents and local pockets of stasis
(the flow stops allowing platelets and leukocytes to come in contact with endothel)
=>
hyperviscosity syndromes(polycytemia)
sickle cell anemia
bed-care patients
ulcerated atherosclerosis
aneurysm (arterial dilation)
acute myocardial infraction
mitral valve stenosis (after RA) results in atrial dilation
# Hypercoagulability alterations of the coagulation pathways that predispose to
thrombosis (primarily venous)
Primary => inherited
Mutations in the gene of factor V and the gene of prothrombin.
May cause resistance to protein C(anti-thrombic) or overexp of
prothrombin
Less common, mutations in anticoagulant genes of antithrombin III,
protein C and protein S.
Secondary => acquired
Heparin-induced thrombocytopenia (HIT): autoantibodies that bind
complexes of heparin and platelets (platelet factor-4). Platelet binding
activates them and agg them .
Antiphospholipid antibody syndrome: manifestations are recurrent
thrombosis and miscarriages and thrombocytopenia. Caused by
antibodies to phospholipids of cell membrane which induce endothel

injury. Some patiemts may have secondary Antiphospholipid

syndrome due to another autoimmune disease (SLE), patients without
an underlying autoimmune disease are classified as primary.
Associated with oral contraceptive use: contain estrogen, stimulate
the liver to produce plasma proteins, including coagulation factors
and reduced syn of antithrobmin III; upon smoking, the contained
compounds may induce endothelial wall injury => collagen exposure
=> promotion of coagulation cascade.
May also be associated with age increased platelet agg and PGI 2

MORPHOLOGY OF THROMBI
# Thrombi can develop anywhere in the cardiovascular system.
# The size and shape of the thrombus depends on the site of origin and the cause:
Arterial/cardiac thrombi begin at the sites of endothelial injury or turbulence.
Venous thrombi occur at sites of stasis.
# Thrombi are attached to the vascular surface:
Arterial grows in a retrograde direction
Both tend to
from the point of attachment.
propagate toward the
Venous extends in the direction of blood
heart
flow.
# The propagation portion of the thrombus tends to be poorly attached to the
surface, and therefore prone to fragmentation, generating an embolus.
# Lines of Zahn laminations on the thrombi (gross or microscopical), representing
pale platelet & fibrin layers alternating with darker erythrocyte-rich layers =>
help distinguish antemortem thrombosis from postmortem state (no laminations
after death).
# Types of thrombi:
Mural thrombi occur in heart chambers or aortic lumen, caused by
abnormal myocardial contraction 1 or endomyocerdial injury 2.
Arterial thrombi occlusive, produced by platelets and coagulation
activation, composed of meshwork of platelets, fibrin, erythrocytes and
leukocytes.
Venous thrombi (phlebothrombosis) occlusive, caused by activation of
coagulation cascade and platelets (minor role), contain more erythrocytes
and are called red thrombi.
Postmortem clots gelatinous composition, with a dark red portion (red
cells have settles by gravity), and a yellow "chicken fat" portion; usually,
they are not attached to the vessel surface.
Vegetations thrombi on heart valves due to damage caused by bacterial
or fungal infections 3.

Arrhythmias, dilated cardiomyopathy, myocardial infarction.

Myocarditis, catheter, trauma.
3
Sterile vegetations develop on non-infected valves in hypercoagulable state.
2

FATE OF THE THROMBUS

# Propagation thrombus enlarges due to accumulation of more platelets and finrin
increasing odds of obstructiob/embolism.
# Embolization the thrombi are fragmented and transported elsewhere in the
vasculature.
# Dissolution thrombi are removed by fibrinolytic activity. In older thrombi, lysis
is inefficient.
# Organization and recanalization older thrombi become organized by thr
ingrowth of endothelial cells, smooth muscle cell and fibroblasts. In time,
capillary chnaels are formed reestabilishing the continuity of the lumen.
recanilization may occuer without organization due to enzymatic digestion due to
entrapped WBC.

DISSEMINATED INTRAVASCULAR COAGULATION

#
#
#
#

Acute, subacute or chronic widespread thrombosis within microcirculation

Forms particulaty in barin, lung, heart and kidney.
Secondary complication in a variety of diseases.
As a result there is a consumption of platelets and coagulation factors, and
secondarily activation of fibrinolysis
# DIC gives rise to tissue hypoxia and microinfarcts, or to bleeding disorder related
to pathologic activation of fibrinolysis and the depletion of hemostatic elements.
# Major mechanisms of action:
The release of tissue factor or thromboplastic substances into the
circulation from the placenta or granules of leukemic cells.
Widespread endothelial cell damage causing release of TF and exposure
of subendothelial collagen and vWF => promote platelets aggregation and
activation of intrinsic coagulation pathway.
# In G(-) and G(+) sepsis, endo- or exotoxins cause increased synthesis and release
of TF from monocytes release IL-1 and TNF, both increase the expression of TF and
decrease the expression of thrombomodulin (anticoagulator, activates protein C) =>
activation of extrinsic coagulation pathway.

# DIC outcomes
1) Widespread fibrin deposition within the microcirculation, leading to
ischemia and hemolysis (RBCs are traumatized while passing through
vessels narrowed by thrombi).
2) Bleeding diathesis results from depletion of platelets and clotting factors,
and secondary release of plasminogen activators => hemostatic failure
(reduced concentration of factor V and factor VII and inhibition of platelet
aggregation.

TOPIC #14: EMBOLISM TYPES AND CONSEQUENCES

EMBOLISM
# Any intravascular solid, liquid or gaseous mass that is carried by the blood to a
site distant from its point of origin.
# Most emboli arise from thrombi (thromboembolism), results in ischemic necrosis
(infarction) of downstream tissue.
# May cause occlusion
# Primary consequence of systemic embolization is ischemic necrosis (infraction),
while in the pulm circ it may lead to hypoxia, hypotension and right sided heart
failure

TYPES OF EMBOLISM
# Pulmonary thromboembolism
Originates from deep vein thrombi, above the knee level.
Passes through the right side of the heart into the pulmonary circulation.
May cause the occlusion of: Main pulmonary artery
Impact across the bifurcation of right
and left pulm arterirs => saddle embolus
arterioles

Consequences of occlusion:
Increase in pulm artery pressure, vasosasm, release of
thrombaxane, serotonin
Ischemia of downstream pulm parenchyma, diminished CO,
right sided heart failutr
Hypoxia redirection to well oxygenated alveoli
Right to left shunting through foramen ovale in 30% of patients
The more peropherial the occlusion, the higher the risk of
infraction (hemorrhagic), adjacent pleura is covered by fibrous
exudate
Paradoxical embolism venous embolus that gains access to the systemic
circulation by passing from right to left side of the heart through septal
defect.
Pulmonary obstruction of medium sized arteries can cause pulmonary
hemorrhage, but usually pulmonary infarction because the lung has dual
blood supply.

# Systemic thromboembolism
Emboli in the systemic circulation, most of them arise from intracardial
mural thrombi.
Most associated with left ventricular wall infarcts.
The major sites for embolization are lower extremities and CNS, and to
lesser extent the kidneys, intestine and spleen.
# Fat embolism
Caused by fractures of long bones (contain fatty marrow), or by soft tissue
trauma.
Involves mechanical obstruction and biochemical injury.
Fat enters the circulation by rapture of marrow vasculature.
Fat embolism syndrome(10%): - Pulmonary insufficiency
- Neurologic symptoms
- Anemia
- Thrombocytopenia

Appear after 1-3 days after injury with sudden onset of

tachypnea (rapid breathing), dyspnea (shortness of
breathing), tachycardia (rapid HR).
Occlude pulmonary and cerebral vasculature directly and by platelet agg
FFA released from the fat globules cause local toxic injury to endothelium.
# Gas (air) embolism
Gas bubbles in circulation physically obstruct vascular flow.
Air => 100ml are required to produce clinical effects, caused by
penetrating chest injury or during obstetric procedures.
Nitrogen (decompression sickness) => occurs when deep sea divers
ascend rapidly, thus exposed to sudden change in atmospheric pressure.
when air is breathed in high pressure, increased amounts of gas (mainly
nitrogen) become soluble and dissolve on blood; if sudden pressure
change occurs, insoluble nitrogen bubbles are formed.
# Amniotic fluid embolism
Escape of amniotic fluid into maternal circulation.
Sudden severe dyspnea, cyanosis and hypotensive shock.
Pulm edema develops
Amniotic fluid contains large amount of TF, and may induce coagulation
cascade (causes DIC).

TOPIC #15: THE DEFINITION AND CAUSES OF SHOCK.

SHOCK RELATED MORPHOLOGICAL CHANGES

SHOCH
# A condition of circulatory collapse that results in hypoperfusion and decreased
oxygenation of tissues.
# Can be caused by CO or by reduced circulatory blood volume
# Consequences are impaired tissue perfusion and cellular hypoxia

CATEGORIES OF SHOCK
# Cardiogenic shock due to severe CO (failure of pump in LV).
Caused by: Myocardial infarction
Ventricular arrhythmias
Extrinsic compression (cardiac tamponade)
Outflow obstruction
# Hypovolemic shock results from loss of blood or plasma volume.
Caused by: Hemorrhage
Severe burns
Trauma
Vomit, diarrhea
# Septic shock caused by microbial infection, usually G(+) followed but G(-) and
fungi.
Initial vasodilation => pooling of blood => hypovolemia, perfusion
Bacterial products induce cytokine cascade => complement activation
Endothelial injury => coagulation => DIC
# Neurogenic shock anesthetic accident or spinal injury => loss of vascular tone.
# Anaphylactic shock systemic vasodilation and vascular permeability .
Caused by type I hypersensitivity reaction (IgE)
Results in tissue hypoperfusion and cellular hypoxia

STAGES OF SHOCK
# Non-progressive stage = compensatory mechanisms
Sympathetic tone => TPR
Release of catecholamines and ADH, activation of RAS, stress hormones
=> vasoconstriction, BP, renak fluid conservation=> maintenance of
perfusion, coronary and cerebral vessels are not affected.
Activation of rennin-angiotensin system => retain Na+ => volume
# Progressive stage compensatory mechanisms are no longer adequate.
Tissue perfusion cell will go from aerobic to anaerobic metabolism.
As a result => metabolic lactic acidosis, not enough ATP dilatin
Confusion, consciousness
# Irreversible stage
Tissue and organ damage cannot be repaired => death
NO increased syn worsen myocardial contraction
Lysosomal enzyme leakage

MORPHOLOGY
# Tissue changes occur as a result of hypoxic cell injury.
Brain => ischemic encephalopathy
Liver => fatty change, nutmeg liver
Kidney => tubular ischemic injury electrolyte imbalance, fibrin thrombi
Adrenals => cortical cell depletion decrease in cortical production, lead to
decreased perfusion
GI => focal mucosal hemorrhage and necrosis
Heart => areas of ischemic coagulative necrosis

TOPIC #16: ACUTE INFLAMMATION. CELLULAR AND

VASCULAR CHANGES

INFLAMMATION
# A protective response intended to eliminate the initial cause of cell injury, as well as
the necrotic cells and tissues resulting from it.
# The components of the inflammatory reaction, which destroy and eliminate microbes
and dead tissues, are also capable of injuring normal tissues.
# Inflammation can be acute or chronic:
Acute inflammation rapid onset, short duration; characterized by fluid and
plasma proteins exudation and leukocytes (mainly neutrophils) accumulation
to clear invader and digest necrotic tissue
Chronic inflammation longer duration; characterized by influx of
lymphocytes and macrophages, associated with vascular proliferation and
fibrosis.

ACUTE INFLAMMATION
# Stimuli for acute inflammation:
1) Infections by pathogens bacteria, viruses, fungi, parasites.
2) Trauma thermal injury (burn), irradiation, toxic chemicals)
3) Tissue necrosis.
4) Foreign bodies.
5) Hypersensitivity reactions.
# Signs of inflammation:
Rubor
dilation of vessels => redness
Dolor
accumulation of interstitial fluid => pressure => pain
Calor
increased blood flow => heat
Tumor
accumulation of extravascular fluid => swelling
Functio laesa
loss of function
# The major components of acute inflammation are:
! Vascular changes vasodilation, resulting in increased blood flow, and
increased permeability resulting in departure of plasma proteins.
! Cellular events emigration of leukocytes, mainly neutrophils, from
microcirculation, and their accumulation at the site of injury.
# Recognition of microbes, necrotic cells and forigen substances are accomplished by
Pattern recognition receptors:
TLR located on plasma membrane and endosomes, so they can recognize
EC and ingested microbes. Recognition will initiate production of
inflammatory mediators and antiviral chemokimes(IFN).
Inflammasome recognizes products of dead cells (uric acid, EC ATP)
activates caspase-1IL-1 most imp WBC recruitment

VASCULAR CHANGES
# Changes in vascular caliber and flow:
Short lasting vasoconstriction (few seconds), then arteriolar vasodilation =>
increased local blood flow, causing redness and warmth.
Protein-rich fluid moves to extravascular tissues => [RBCs] => viscosity =>
flow => STASIS
Accumulation of leukocytes, mainly neutrophils, along the endothelial wall
(margination)
# Increased vascular permeability protein accumulation in ECM (exudate)
Immediate transient response
! Contraction of endothelial cells => only in postcapillary venules,
leading to formation of intercellular gaps.
! This reaction is elicited by => histamine, bradykinin, leukotriens.
! Prolonged retraction of endothelial cells due to changes in
cytoskeleton is mediated by cytokines (TNF, IL-1).
Endothelial injury
! Endothelial cells undergo necrosis and detachment due to vascular
leakage => immediate sustained response.
! Venules, capillaries and arterioles can be affected.
! Occurs as a result of: leukocyte aggregation along the endothelial wall,
releasing toxic mediators (O 2 species, proteolytic enzymes) or trauma.
Increased transcytosis
! VEGF (vascular endothelial growth factor) increases vascular
permeability by inducing channels formation (fusion of intracellular
vesicles).
Leakage from renewed blood vessels
! Repair of tissue => formation of new blood vessels (angiogenesis).
! These vessels remain leaky until maturation of endothelial cells.
# Movement of transudate (protein-poor fluid) to interstitium or movement of exudate
(protein-rich fluid) to ECM creates EDEMA.
Increased lympth flow helps drain edema fluids, leukocytes and debris.
CELLULAR CHANGES
Leukocytes kill bacteria/microbes and eliminate necrotic tissue
LEKOCYTE RECRUITMENT
# Migration and rolling
Small RBCs move faster than large WBCs => leukocytes are pushed aside on
the periphery of the blood vessel => MARGINATION
Leukocytes transiently stick along the activated endothelial wall => ROLLING.
Mediated by selectins => E-selectin (IL-1,TNF) and P-selectin
(histmain/thrombin) on endothelium (upregulate on activated entoehl);
L-selectin(IL-1, TNF) on leukocytes.

# Firm adhesion
Mediated by integrins, which undergo conformational change upon activation
of leukocytes by chemokines.
Endothelial cells increase their expression of ligands for integrins, mainly
ICAM and VCAM due to IL-1, TNF
Integrins => heterodimers containing and chains on leukocyte membrane.
# Diapedesis (transmigration)
Mediated by CD31 (PECAM-1), on both leukocytes and endothelium.
Leukocytes squeeze between cells at intercellular junctions, through the
basement membrane (by secretion of collagenases), mainly in venules.
Leukocytes secrete collagenase to pass through BM
# Chemotaxis
Leukocytes migrate toward the site of inflammation along a chemical gradient
of chemokines (bacterial products, cytokines, components of complement sys
C5)
Neutrophils predominant infiltrate mainly due to their number, attach more firmly to
adhesion molecules. After 24-48 h replaced by macrophages
ACTIVATION OF LEUKOCYTES
# Phagocytosis
Recognition and attachment of the particle to the leukocyte, done PRR or by
opsonins (cover the pathogen) such as IgG, C3b, collectins.
Engulfment and formation of phagocytic vacuoles, which will fuse with lysosome
forming a phagolysosome
Killing and degradation of the ingested material.
Stimulation of oxidative burst => sudden increase in O 2 and production of
superoxide ion by NADPH oxidase, which generates H 2 O 2 (ROS).
In neutrophils, azorophilic granules contain MPO which converts H 2 O 2 to
a powerful oxidant
Lysosomal enzyme elestase
# Neutrophils produce EC fibrillar network to trap antimicrobial substances in site of
infection and prevent spread of microbes0
# Leukocytes also cause injury to normal cells:
Injury of "by stander" tissue as part of normal defense.
Inflammatory responses may be longer than needed, autoimmune disease,
allergic reaction, phagolysosme may stay transiently open, frustrated
phagocytosis lysosomal enzyme are released.

TERMINATION
#
#
#
#

Decay (short half-life) or enzymatic degradation of chemical mediators.

Normalization of vascular permeability.
Leukocytes produce inhibitory mediators => limit their own reaction.
Lymphatic drainage and macrophage ingestion clear debris of necrotic cells, edema
fluid, inflammatory cells etc.

MEDIATORS OF INFLAMMATION
# Vasoactive amines
Histamine => permeability , epithelial cells contraction
Serotonin => similar to histamine, derived from platelets
# Amino acids metabolites
Cycloxygenase pathway => thromboxane A 2 vasoconstrictor, platelet aggregator;
prostaglandins vasodilator, platelet inhibitor
Lipoxygenase pathway => leukotriens
# Cytokines
Soluble proteins, signaling molecules
Macrophages secrete TNF, IL-1
# Kinin system
Factor XII limks kinin, coagulation, plasminogen, complement
# Complement system
C3a and C5a => anaphylatoxins mediate degranulation
C3b => opsonization

TOPIC #17: MORPHOLOGIC PATTERNS IN ACUTE

INFLAMMATION

SEROUS INFLAMMATION
# Outpouring of watery, protein-poor fluid = transudate.
# Fluid derived either from serum or from secretions of mesothelial cells lining
serous cavities (peritoneum, pericardium, pleura).
! Fluid found in serous cavities is called effusion.
# Example: skin blister fluid accumulates beneath or within the epidermis.
# Fluid in a serous cavity is called effusion

FIBROUS INFLAMMATION
# Greater vascular permeability => larger molecules, such as fibrinogen, cross the
endothelial barrier.
# Fibrinous exudate => characteristic of inflammation in the lining of body cavities
(meninges, pericardium, pleura).
# The fibrinous exudate may undergo degradation by fibrinolysis, and cell debris
are removed by macrophages => RESOLUTION (restoration of normal tissue
structure).
# Failure to completely remove fibrin results in scar tissue formation =>
ORGANIZATION scar

# Example: organization of fibrinous pericardial exudate results in fibrous scar

tissue that obliterates the pericardial space.

PURULENT/SUPPURATIVE INFLAMMATION
# Characterized by presence of pus (purulent exudate), containing neutrophils,
fibrin, necroting cells, edema fluid, cell debris and bacteria.
# Organisms that are more likely to induce pus formation are called pyogenic
(staphylococci).
# Abscess focal collections of pus caused by seeding of pyogenic organisms into
the tissue; usually composed of central necrotic region and a peripheral region of
preserved neutrophils, surrounded by dilated vessels and fibroblastic proliferation.
With time abscess will be replaced by connective tissue

ULCERATIVE INFLAMMATION
# Local defect on the surface of an organ, produced by necrosis of cells and
shedding of inflammatory necrotic tissue.
# Most commonly seen in:
Inflammatory necrosis of mucosa of the mouth, stomach, intestine and
urogenital tract.
Tissue necrosis and subcutaneous inflammation of lower extremities in
older patients who have circulatory disturbances.
# Can be acute or chronic:
Acute intense PMN infiltration and vascular dilation in the margins of
the defect.
Chronic margins and base of the ulcer develop scarring with
accumulation of lymphocytes, macrophages and plasma cells.

TOPIC #18: OUTCOMES OF ACUTE INFLAMMATION.

MORPHOLOGIC PATTERNS OF CHRONIC INFLAMMATION

OUTCOMES OF ACUTE INFLAMMATION

# Resolution
When injury is limited with minimal damage, and the tissue is capable of
replacing irreversibly injured cells, the outcome is restoration of the tissue
to normal structure and function.
Termination of acute inflammation involves elimination of chemical
mediators, normalization of vascular permeability and stop leukocyte
emigration.
Leukocytes produce inhibitory mediators that limit the inflammatory
reaction.
Lymphatic drainage and macrophages ingestion lead to clearance of
edema fluid and inflammatory cells.
Leukocyte secrete cytokines that initiate repair process blood vessels
grow into injured tissue, fibroblast lay down collagen.
# Scarring (fibrosis)
Occurs after substantial tissue destruction.
The tissue is not able to regenerate itself.
Extensive CT deposition occurs in attempt to heal damage or as
consequence of chronic inflammation.
Outcome is fibrosis
# Chronic inflammation
Occurs if:
! Pathogen causing the inflammation is not removed.
! May be present from onset of injury
May be followed by normal restoration/scarring
Characterized by infiltration of mononuclear cells, consist of macrophages,
lymphocytes (both T and B), and plasma cells.
Mediated by cytokines produced by macrophages (TNF, IL-1) and by
lymphocytes (mainly T cells => INF).
Often includes proliferation of fibroblasts and new blood vessels, with
resultant fibrosis and disturbance of architecture.

CHRONIC INFLAMMATION
# Can arise by:
Persistent infections by microbes lead to T cell mediated immune
response.
Hypersensitivity diseases caused by excessive and inappropriate
activation of the immune system.
Prolonged exposure to toxic agents non-degradable exogenous agents
(silica particles), or endogenous ([lipid] ).
# Granulomatous inflammation
Characterized by aggregations of activated macrophages with scattered
lymphocytes.
Granulomas are formed as a response of:
! Persistant T-cell response to certain microbes (TB/fungi). Tcell derived cytokines are responsible for chronic macrophage
activation
! Immune mediated disease (chron)
! Disease of unknown etiology sarcoidosis, foreign body
granulomas
# Morphology of chronic inflammation:
Epitheloid cells in granulomas => pink granular cytoplasm with indistinct
cell boundries.
Aggregations of epitheloid macrophages are surrounded by a collar of
lymphocytes, which secrete cytokines that continuously activate
macrophages.
Older granulomas may have a rim of fibroblasts and CT
Multinucleated giant cells (40-50m) can be found in granulomas, consist
of large mass of cytoplasm and many nuclei.
! They are derived from the fusion of over 20 macrophages.
In granulomas that are associated with certain infectious organisms,
hypoxia and free radical injuries lead to a central zone of necrosis, with a
granular cheesy appearance => CASEOUS NECROSIS
Microscopically => amorphous, structureless, granular debris with
complete loss of cellular details.

TOPIC #19: TISSUE RECONSTRUCTION. WOUND HEALING

PROLIFERTAIVE CAPACITIES OF TISSUES
The ability of tissues to repair themselves is critically influenced by their intrinsic
proliferative capacity. Tissues of the body are divided to 3 groups:

Labile (continuously dividing) tissues cells are continuously replaced by

maturation of stem cells. Include hematopoietic cells in BM and majority of
surface epithelia (skin, oral cavity, vagina ,cervix, ducts of exocrine organs, GI
and urinary tract)
Stable tissues- minimal replacative activity in normal state, yet can proliferate
in response to injury/loss of tissue mass. Can reconstruct parenchyma of liver,
kidney and pancreas
Permanent tissues cells of these tissues are permanently differentiated and
nonproliferative, such as neurons and cardiac muscle.

REPAIR BY CONNECTIVE TISSUE

# Cannot be accomplished by regeneration alone, but involves replacement of the
non-regenerated cells with CT
# Stages of repair:
Repair begins within 24 hours of injury by emigration of fibroblasts and
their induction, as well as endothelial cell proliferation.
3-5 days: granulation tissue is apparent
Granulation tissue accumulates CT matrix, resulting in scar formation.
# There are 4 components of CT repair:
1) Angiogenesis formation of new blood vessels; endothelial precursor
cells migrate from bone marrow to areas of injury.
2) Migration and proliferation of fibroblasts.
3) Scar formation deposition of CT together with vassels and leukocytes
is called granulation tissue.
4) Maturation and reorganization of the fibrous tissue.

ANGIOGENESIS (topic 41)

# Steps of blood vessel formation:
Vasodilation by NO and permeability of existing blood vessels by VEGF
(vascular endothelial growth factor).
Migration of endothelial cells to the site of injury.
Proliferation and remodeling of endothelial cells => tube formation.
Recruitment of pericytes and smooth muscle cells to form mature vessel.
# Newly formed vessel is leaky during angiogenesis since the interendothelial
junctions are not completely formed, and because VEGF increases permeability.

# Structural ECM proteins participate in the process by interactions with

endothelial cells through integrin receptors.

ACTIVATION OF FIBROBLASTS AND DEPOSITION OF CT

# Scar formation (deposition of CT) occurs in 2 steps:
1) Migration of fibroblasts into the site of injury and their proliferation there.
2) Deposition of ECM produced by these cells.
# The recruitment and stimulation of fibroblasts are driven by growth factors:
PDGF platelet derived growth factor; promotes proliferation of
fibroblasts and smooth muscle cells.
FGF2 fibroblast growth factor.
TGF transforming growth factor; controls proliferation and differentiation.
# Macrophages are important cellular components of granulation tissue that clear
the tissue debris, and also secrete mediators that induce fibroblast proliferation
and ECM production.

ECM DEPOSITION
# Collagen synthesis by fibroblasts at day 3-5 from the onset of injury.
# The same GFs that induce fibroblasts proliferation, mediate collagen synthesis.
# Net collagen accumulation depends on increased synthesis along diminished
degradation of collagen.
# The granulation tissue evolves into a scar composed of inactive, spindle-shaped
fibroblasts, dense collagen and ECM components.
# As the scar matures, there is progressive vascular regression, which transforms
the vascularized granulation tissue into a pale, avascularized scar.

TISSUE REMODELING
# Transition from granulation tissue into scar tissue involves a shift in composition
of the ECM.
# Collagen and ECM components are degraded by metalloproteins (MMPs) that are
dependent on zinc ions for their activity.
# MMPs are produced by many cell types => fibroblasts, macrophages, neutrophils.
! Production is inhibited by TGF or by steroids.

WOUND HEALING

# Involves both epithelial regeneration and the formation of c. tissue scar.

# Based on the nature of the wound, healing can occur by 1st or 2nd intention.

HEALING BY FIRST INTENTION => clean, uninfected surgical incision

# Incision causes only minor disruption of epithelial basement membrane
continuity, and death of relatively few epithelial and c. tissue cells => epithelial
regeneration predominates over fibrosis => small scar is formed.
# Day 1
Incision is filled with fibrin-clotted blood, followed by infiltration of
neutrophils.
Increased mitotic activity is seen in basal cells at the cut edge of the epidermis.
# Day 2
Epithelial cells from both edges begin to migrate and proliferate along the
dermis, depositing basement membrane components as they go.
The cells meet in the midline, giving a thin, continuous epithelial layer.
# Day 3
Neutrophils are replaced by macrophages.
The granulation tissue invades the incision space.
Collagen fibers are vertically oriented => DO NOT bridge over the incision.
Proliferation of epithelial cells continues => thickened epidermal covering.
# Day 5
Maximal blood vessel formation (neovascularization).
Granulation tissue fills the incisial space.
Collagen fibers start to bridge the incision.
Epidermis recovers its normal thickness.
# Week 2
Continued collagen accumulation and fibroblast proliferation.
Diminish of WBC infiltration, edema and vascularity.
Increased collagen deposition and regression of vascular channels.
# Week 4
The scar comprises cellular c. tissue devoid of inflammatory cells, and
covered by normal epidermis.

HEALING BY SECOND INTENTION => tissue loss is more extensive (large wound,
abscess, ulceration, ischemic necross)
#
#
#
#

The inflammatory reaction is more intense => necrotic exudate

Abundant development of granulation tissue
Wound contraction by action of myofibroblasts.
Differences between 1st and 2nd intention:

LARGE
SCAR
FORMATION

1) At the surface of the wound, a larger clot will be formed, rich in fibrin and
fibronectin.
2) Intense inflammation due to greater volume of necrotic debris, exudate
and fibrin that must be removed.
3) Larger amount of granulation tissue is formed.
4) 2nd intention involves wound contraction, due to myofibroblasts

WOUND STRENGTH
# Sutures give wounds up to 70% of the strength of unwounded skin due to their
location.
# When sutures are removed, the wound strength is 10% of the strength of
unwounded skin, but increases rapidly as wound healing continues.
# The recovery of tensile strength results from collagen synthesis exceeding its
degradation, and from structural modifications of collagen.
# Wound strength reaches up to 70%-80% of the strength of unwounded skin.

TOPIC #20: IMMUNE MECHANISMS OF TISSUE INJURY.

TYPE I HYPERSENSITIVITY (anaphylactic type). TYPE II
HYPERSENSITIVITY (antibody type)

IMMUNE MECHANISMS OF TISSUE INJURY

# Innate immunity known as non-specific immune system, recognizes pathogens
and elicits a rapid response to provide immediate defense against infection.
The innate immune system consists of anatomical barriers, induction of
inflammation to attract phagocytes and trigger the immune system and the
complement system that helps in removal of pathogens.
Phagocyted, DC and other cell types secrete cytokines which promote
inflammation.
NK will kill virus infected cell and will procude IFN-
Cytokines involved in innate immunity TNF, IL-1,2,6
# Complement system consists of soluble proteins produced by the liver, which
coat the surface of pathogens, making them more susceptible to phagocytosis.
Many bacteria resist phagocytosis (they are encapsulated), and without
this coat of proteins cannot be phagocytosed.
The components of the complement system are proteolytic enzymes,
circulating in the blood in their inactivate form (zymogens).
Upon activation, a series of proteolytic cleavage occurs, resulting in the
cleavage of complement component 3 (C3) into:
1) C3a acts as chemo-attractant to recruit effector cells.
2) C3b covalently binds to the surface of the pathogen.
Another component, C5, is also cleaved and forms:
1) C5a also acts as chemo-attractant.
2) C5b participates and initiates the formation of the membrane
attack complex, which forms transmembrane pores.
The complement system can be activated in 3 pathways:
1) Alternative pathway based on the cleavage of C3 and activation
of C3 convertase that cleaves more C3 molecules.
2) Lectin pathway initiates by mannose-binding lectin (MBL) that
binds to mannose containing carbohydrates on the surface of
pathogens, activated and cleaves C4 and C2; their fragments will
activate C3 convertase.
3) Classical pathway triggered by C reactive protein (CRP) that
upon pathogen binding can interact with C1, which is similar in
structure to MBL, and eventually activates C3 convertase.
# Adaptive immunity recognizes pathogens by using cell-surface receptors of just
one type => B-cell receptor or T-cell receptor.

Cytokines involved in diff of lymphocytes are IL-2,4; in activation of

effector cell IFN-, IL-5).
B-cell receptor (BCR) known as immunoglobulin, and their soluble
form, antibodies, is secreted by effector B-cells (plasma cells); their
structure is of a Y, consisting of 2 heavy chains and 2 light chains, with a
constant region (binds to the B-cell) and a variable region (binds to the
pathogen).
Production of functionally different AB is made by isotype switch.
AB neutralize the microbe
T-cell receptor (TCR) expressed on T-cells, consists of an chain and a
chain, both of which are anchored to the surface and consist of a constant
region and a variable region, nave T are activates by an antigen aand a
costimulator (B7).
Upon activation T-cell secrete cytokines which function as growth diff
factor for lymphocytes.
EC molecules are represented by APC through MHC-II to CD4+ T helper
IL-2 sec T H 1 active macrophage and AB prolif
T H 2 IL-4 IgE
CD40L on T and CD40 on B/macrophages IFN-
IC molecules are represented by APC through MHC-I to CD8+ T helper

HYPERSENSITIVITY REACTIONS
# The reactions produced by the normal immune system, which may cause tissue
injury.
# Hypersensitivity reactions are caused by autoimmune diseases, excessive reaction
against microbes or an immune response against common environmental
substances.
# Types of hypersensitivity:
Type I results from the formation of immune complexes.
Type II alterations in cell-surface components elicit an immune response.
Type III soluble immune complexes formation.
Type IV caused by products of T helper cells.

TYPE I HYPERSENSITIVITY
# Occurs within minutes after interaction of Ag and IgE AB on mast cells
# The interaction of the immune complexes with mast cells initiates their
degranulation and the release of inflammatory mediators.
# Steps of sensitization:

#
#

Upon exposure to antigen, B-cells are stimulated by T H 2 cells to produce

IgE antibodies.
After the antigen is cleared from circulation, IgE antibodies that have not
encountered an antigen, bind to Fc receptors found on mast cells,
eosinophils and basophils.
! IgE have high affinity to their receptor, so they bind it tightly.
Upon second encounter with the antigen, the mast cells are activated and
release granules content
Mast cells found in mucosal and epithelial tissues, and serve to recruit the
immune system upon infection; their cytoplasm is filled with granules that
contain:
Histamine & heparin increase vascular permeability, cause smooth
muscle contraction, and vasodilation.
TNF promotes inflammation, and stimulates cytokine production, recruit
eosinophils
Cytokines IL-3 => eosinophils production and activation, T H 2 response;
IL-4 => T H 2 response; IL-5 => eosinophils production and activation.
Chemokines CCL3 => chemotactic for monocytes, macrophages and
neutrophils.
Eosinophils their granules contain arginine-rich basic proteins; upon activation,
they release enzymes (peroxidase, collagenase) and toxic proteins that directly
kill microorganisms, and they also release prostaglandins, leukotriens and
cytokines that amplify the immune response by activating epithelial cells and
leukocytes.
Basophils their granules are similar in content to those of mast cells, and they
are the key cells that initiate the T H 2 response by secreting IL-4 and IL-3; they
are also recruited during innate immune response by their TLRs.
Type I hypersensitivity is usually evoked by allergens, such as drugs, food etc.
IgE-mediated allergic reaction consists of 2 phases:
1) Immediate reaction upon exposure to an allergen, a characteristic
inflammatory reaction, called "wheal and flare", is induced; release of
histamine by mast cells causes blood vessels to increased permeability =>
fluid leaves the blood vessels => local swelling (wheal); increased blood
flow to the area produces redness (flare).
2) Late-phase reaction about 6-8 hours after the initial reaction has
subsided, a second reaction occurs, in which the swelling is more
widespread. Dominant cells neutrophils, eosinophils,T H 2
Pathologic manifestations of allergic reactions:
Systemic anaphylaxis shortly after exposure, activation of mast cells
causes increased blood flow and permeability of blood vessels resulting in
edema and inflammation, bronchoconstriction and hypersecretion of
mucous, laryngeal edema,
Gut reactions activation of mucosal mast cells in the GI tract causes
increased permeability of blood vessels => release of fluid into the lumen,

and increased peristalsis resulting in expulsion of gut content (diarrhea,

vomit).
Local reactions Ag confined to a particular site skin, GI or lung (hay
fever). asthma is evoked by submucosal mast cells, resulting in
bronchoconstriction and mucous secretion.
Has a strong genetic component

TYPE II HYPERSENSITIVITY
# Antibody-mediated reaction, caused by antibodies produced against molecules
found on cell surface.
# These molecules can be intrinsic to the cell surface, and undergo configuration
alterations, or they can be exogenous (drug metabolites).
# These reactions may induce:
Opsonization and phagocytosis the antibodies bind the cell surface
antigens, and their constant region serves as a ligand for receptors found
on macrophages, neutrophils and NK cells; thus, the antibodies "bridge"
the interaction of these cells and promote phagocytosis.
! Examples: hemolytic anemia, thrombocytopenia.
Opsonized cells are usually eliminated in spleen splenectomy may be
beneficail

Inflammation the antibodies bind to cell surface antigens and activate

the complement system through the classical pathway recruit
neutrophils and macrophages
! Example: Good pasture syndrom
Antibody-mediated cellular dysfunction the antibodies bind to cell
surface antigens, thus block the binding site of their normal ligand and
interfere with signal transduction of the cell.
! Example: myastemia gravis => antibodies are directed against
AchR of the motor units, this inhibiting neuromuscular
transmission, which result in muscle weakness.

TOPIC #21: TYPE III HYPERSENSITIVITY (immune complex

mediated). TYPE IV HYPERSENSITIVITY (cell mediated)

TYPE III HYPERSENSITIVITY

# Complexes of soluble proteins (antigens) and their high affinity IgG antibodies
are generated during an immune response; when produced in large amount,
persist and deposited in tissues, they become pathogenic.
# Large aggregations of proteins-antibodies fix complement components, and are
being phagocytosed, while small aggregations are less efficient in fixating
complement, and circulate in the blood to be deposited on the walls of blood
vessels, or in certain organs (kidney, joints, and skin).
# When such aggregations accumulate on the wall, they become large enough to fix
complement, initiating tissue damaging inflammatory response by interacting
with circulating leukocytes and mast cells.
# Platelets also accumulate around the site of deposition, forming clots, and the
blood vessel may burst => hemorrhage in the skin.
# The development of type III hypersensitivity depends on:
1) The size of the immune complex.
2) The concentration of both antigen and antibody:
- Antigen in excess => small complexes (each binding site of a
single Ab molecule binds one Ag).
- Antibody in excess => large complexes (each Ag binds several
Ab).
3) Affinity if the antibody to its isotope.
# Immune complex mediated diseases
Arthus reaction an immune reaction in the skin, caused by injection of
antigen into the dermis; the antigen reacts with specific IgG in the ECM,
activating complement and phagocytic cells to produce local
inflammatory response.
Acute serum sickness the collection of symptoms caused by the
injection of large amount of foreign molecules, such as serum proteins,
causing the formation of immune complexes composed of the injected
proteins and the antibodies produced against them; was used to treat
diphtheria, scarlet fever, letanus etc. in the 19th century.
Farmer's lung caused by interaction og IgG with large particles of
inhaled allergens; the resulting inflammation compromises gas exchange
by the lung.
Systemic lupus erythematosus an immune reaction caused by circulating
IgG that are specific for "self" cell constituents, such as nucleic acids and
nuclear proteins, as well as cell surface constituents.

TYPE IV HYPERSENSITIVITY
# Caused by effector T cells (T-helper); also called delayed-type hypersensitivity
reactions (DTH) since they occur 1-3 days after contact with the antigen.
# The amount of antigen required to elicit a reaction is much greater than in
antibody-mediated (type II) hypersensitivity.
# Tuberculin test small amount of protein antigen, extracted from Mycobacterium
tuberculosis, is injected to the dermis (or subcutaneous tissue), and elicits an
inflammatory reaction in people who were exposed or immuned against
tuberculosis; this response is mediated by T H 1 cells reacting to MHC-II presented
by macrophages and dentritic cells (CDs).
# DTH can also be developed in response to contact sensitizing agent, such as
poison ivy (causing dermatitis):
When a person comes in contact with the plant, pentadecacatechol
penetrates the skin, and degraded by macrophages and Langerhans cells.
MHC-II-antigen complexes are presented to T H 1 cells that secrete
cytokines (IFN-, TGF-), which initiate inflammation.
Pentadecacatechol also penetrates the plasma membrane of cells, modifies
intracellular proteins that are degraded and presented by MHC-I (activates
cytotoxic T-cells).
# T-cell mediated hypersensitivity diseases:
Type I diabetes mellitus destruction of pancreatic cells.
Rheumatoid arthritis WBCs infiltrate synovial joints and produce
antibodies against the constant region of human IgG.

TOPIC #22: TRANSPLANT REJECTION. GRAFT VERSUS HOST

REACTION

TRANSPLANT REJECTION
# Rejection of allografts 1 is an immunologic reaction to MHC molecules, which are
highly polymorphic (no 2 individuals are likely to express exactly the same set of
MHC).
# There are 2 main mechanisms by which the host immune system recognizes and
responds to grafts:
1) Direct recognition the graft is recognized by T-cells of the recipient,
which are stimulated by direct interaction with MHC molecules expressed
on the graft.
DCs of the donor are present in the graft, and are most likely the APCs in
this recognition.
2) Indirect recognition the APCs of the host pick up the MHC molecules of
the donor, process and present them to T-helper cells of the recipient; in
this case, cytotoxic T cells are not involved in killing the graft, but
production of antibodies occur.

Organ transplant between two individuals of the same species.

# The rejection of the graft is made by:

T-cell mediated rejection cytotoxic T cells directly kill cells of the
grafted tissue; helper T cells secrete cytokines that trigger DTH reaction,
with increased vascular permeability and local accumulation of
lymphocytes and macrophages.
Antibody-mediated rejection the antibodies of the host are directed
against graft MHC and activate complement as well as recruitment of
leukocytes.
# Categories of graft rejection:
Hyperacute rejection occurs within minutes to a few hours after
transplantation due to pre-existing humoral immunity (antibodies); the
graft is characterized by acute arteritis, vessel thrombosis and ischemic
necrosis.
Acute rejection may occur within days to weeks after transplantation in
a non-immunosuppressed host; it is caused by both cellular and humoral
immunity:
Acute cellular rejection extensive interstitial infiltration of helper
and cytotoxic T cells, accompanied by edema and mild
hemorrhage, and renal failure.
Acute humoral rejection characterized by necrotizing vasculitis
with endothelial cell necrosis, deposition of antibodies,
complement and fibron.
Chronic rejection occurs late after transplantation with increased
creatinine in serum (indicates renal dysfunction), dominated by vascular
changes, interstitial fibrosis and loss of renal parenchyma.

GRAFT VS. HOST REACTION

# Occurs when immunologically competent T cells are transplanted into
immunologically compromised recipients during bone marrow transplantation, or
solid organs rich in lymphoid tissue.
# The host cannot reject the graft, but the T cells of the donor recognize the tissues
of the recipient as "foraign" and react against them.
# There are 2 types of GVHD:
1) Acute occurs days to weeks after transplantation, causes epithelial cell
necrosis in the liver, skin and gut => destruction of small bile ducts
(results in jaundice), mucosal ulcerations (results in bloody diarrhea), and
generalized rash.
2) Chronic may follow the acute form or may occur on its own; patients
develop skin lesions and manifestations mimicking other autoimmune
diseases.
# GVHD is a potentially lethal complication that can be minimized by MHC
matching or by depletion of donor T cells before transplantation.

TOPIC #23: TUBERCULOSIS

TUBERCULOSIS
# Caused by Mycobacterium tuberculosis.
# Typically attacks the lungs; air-borne, chronic granulomatous disease.
# Two forms of tuberculosis:
PULMONARY FORM

NON-PULMONARY FORM

Spreads by inhalation of droplets

containing the organism
(Mycobacterium tuberculosis)

Most often is caused by ingestion of

infected milk (Mycobacterium
bovis).

Tubercle bacillus
# Mycobacteria species are obligate aerobes, slowly growing; growth is inhibited
by low pH (<6.5) and by long chain fatty acids.

PRIMARY TUBERCULOSIS

# Develops in previously unexposed, and therefore unsensitized, persons.

# Inhaled bacilli in distal airspaces of the middle portion of the lung, close to the
pleura.

# As sensitization develops, an area of 1-1.5 cm of gray-white inflammatory dense

mass appears => Ghon focus, its center usually undergoes caseous necrosis.
# The bacilli then drain into regional nodes => Ghon complex the combination of
parenchymal lesion and nodal involvement.
# Ghon complex indergoes progressive fibrosis, followed by calcification =>
Ranke complex.
# Histologicall appearance granulomatous inflammation, with the presence of
giant cells.
# Implications of primary TB:
Induces hypersensitivity (DTH).
The foci (locations) of scarring may harbor viable bacilli for years, and
serve as a source for reactivation (when host defenses are compromised).
Progressive primary TB occurs in individuals who are
immunocompramised (AIDS), elderly people or malnourished children.

SECONDARY TUBERCULOSIS
# Arises in a previously sensitized host, by activating Ghon complexes, with spread
to a new pulmonary or extra pulmonary site.
# Secondary pulmonary tuberculosis is classically localized to the apex of one or
both upper lobes.
# Due to pre-existing hypersensitivity, the bacilli excite a large tissue response that
tends to wall off the focus => regional lymph nodes are less involved.
# Cavitations occur more frequently, resulting in dissemination along the airways.
# Increased risk of TB exists in all stages of HIV, the manifeatation differ
depending on the degree of immunosuppression:
Less severe immunosuppression(CD4+ count>300 cells/mm3) present
with "usual" secondary TB => apical disease with cavitations.
Advanced immunosuppression (DC4+ count<200 cells/mm3) present with
symptoms similar to primary TB => middle lobes, lymph nodes
involvement.
# Morphology
Small focus of solid mass, ~2cm, next to apical pleura.
Sharply defined, firm, gray-white to yellow areas that have a variable
amount of central caseous necrosis and peripheral fibrosis.
Histologically, granulomatous inflammation can be seen.
# Secondary TB (localized, apical) may heal either spontaneously or after therapy,
or it may progress along several pathways:
Progressive pulmonary TB the apical lesion enlarges with expansion of
the area of cessation; erosion into a bronchus allows the evacuation of the

caseous center, creating an irregular cavity lined by caseous material, and

the erosion of blood vessels results in hemoptysis.
Miliary pulmonary disease occurs when organisms drain through the
lymph vessels that drain into lymphatic ducts and from there to the venous
system => right side of the heart => pulmonary arteries; small, yellowwhite solid masses are scattered through the lung parenchyma.
Systemic miliary TB when infective foci in the lung spread through
pulmonary veins to the left heart and to systemic circulation.
Isolated-organ TB usually involves the meninges, kidneys, adrenal
glands, bones and fallopian tubes; in vertebrae it is called Pott disease.
Lymphadenitis most frequent form of extra pulmonary TB, usually
occurring in the cervical region.
Intestinal TB by drinking of contaminated milk; organisms are trapped
in the lymphoid tissue of large and small intestine.

PATHOGENESIS
# The Mycobacteria are ingested by macrophages, but inhibit their normal
bactericidal responses by manipulation of endosomal pH => impaired
phagolysosome formation.
# The bacteria proliferate within the alveolar macrophages, resulting in bacteremia
and seeding in multiple sites.
# After 3 weeks, cell-mediated immunity develops => bacterial antigens reach the
lymph nodes, and presented bound to MHC-II by DCs to CD4+ T-cells.
# Under the influence of IL-12 (secreted by macrophages), CD4+ T-cells
proliferate into T H 1 subset, capable of secreting IFN => activating macrophages.
# Activated macrophages release mediators such as TNF (recruitment of
monocytes), NO (by inducible nitric oxide synthase), and reactive oxygen species.

CLINICAL COURSE
# Onset is asymptomatic.
# Systemic symptoms related to cytokine release (TNF, IL-1) by activated
macrophages, include malaise (nausea), anorexia, weight loss and fever.
# With progression of the disease => increasing amount of sputum (first mucoid,
later purulent); when cavitations appear, the sputum will contain tubercle bacilli.
# Some degree of hemoptysis.
# Pleuritic pain when the infection reaches pleural surface.

TOPIC #23: TUBERCULOSIS

TUBERCULOSIS
# A chronic granulomatous disease caused by various strains of Mycobacteria, mainly Mycobacterium
tuberculosis.
# Typically attacks the lungs; air-borne, chronic granulomatous disease.
# Typically, the centers of tubercular granulomas undergo caseous necrosis.
# Two forms of tuberculosis:
PULMONARY FORM

NON-PULMONARY FORM

Spreads by inhalation of droplets

containing the organism
(Mycobacterium tuberculosis)

Most often is caused by ingestion of

infected milk (Mycobacterium
bovis).

Tubercle bacillus
# Mycobacteria species are obligate aerobes, slowly growing; growth is inhibited by low pH (<6.5) and
by long chain fatty acids.
# It is important that infection be differentiated from disease. Infection may or may not cause clinically
tissue damage. Such people are infected but do not have active disease and therefore cannot transmit
to others.
# The Mantoux test (DHR)- a positive tuberculin skin test signifies cell mediated hypersensitivitiy to
tubercular antigens. It does not differentiate btw infection and disease. False negative may be
produce by viral infection, Hodgkin lymphoma ect.
# Only a small fraction of those who contract an infection develop active disease.
PRIMARY TUBERCULOSIS
# Develops in previously unexposed, and therefore unsensitized, persons.
# Inhaled bacilli in distal airspaces of the middle portion of the lung, close to the pleura.
# As sensitization develops, an area of 1-1.5 cm of gray-white inflammatory dense mass appears =>
Ghon focus, its center usually undergoes caseous necrosis.
# The bacilli then drain into regional lymph nodes => Ghon complex the combination of
parenchymal lesion and nodal involvement.
# Ghon complex undergoes progressive fibrosis, followed by calcification => Ranke complex.
# Histologicall appearance granulomatous inflammation, with the presence of giant cells and
epitheloid histiocytes.
# The major consequences of primary TB:
Induces hypersensitivity (DTH).
The foci (locations) of scarring may harbor viable bacilli for years, and serve as a source for
reactivation (when host defenses are compromised).
Progressive primary TB occurs in individuals who are immunocompramised (AIDS),
elderly people or malnourished children.

SECONDARY TUBERCULOSIS (reactivation tuberculosis)

# Arises in a previously sensitized host, by activating Ghon complexes, with spread to a new
pulmonary or extra pulmonary site or by exogenous reinfection.
# Secondary pulmonary tuberculosis is classically localized to the apex of one or both upper lobes.
# Due to pre-existing hypersensitivity, the bacilli excite a large tissue response that tends to wall off the
focus => regional lymph nodes are less involved.
# Cavitations occur more frequently, resulting in dissemination along the airways.
# Increased risk of TB exists in all stages of HIV, the manifeatation differ depending on the degree of
immunosuppression:
Less severe immunosuppression(CD4+ count>300 cells/mm3) present with "usual" secondary
TB => apical disease with cavitations.
Advanced immunosuppression (DC4+ count<200 cells/mm3) present with symptoms similar
to primary TB => middle lobes, lymph nodes involvement.
# Morphology
Small focus of solid mass, ~2cm, next to apical pleura.
Sharply defined, firm, gray-white to yellow areas that have a variable amount of central
caseous necrosis and peripheral fibrosis.
Histologically, granulomatous inflammation can be seen.
# Secondary TB (localized, apical) may heal either spontaneously or after therapy, or it may progress
along several pathways:
Progressive pulmonary TB the apical lesion enlarges with expansion of the area of
cessation; erosion into a bronchus allows the evacuation of the caseous center, creating an
irregular cavity lined by caseous material, and the erosion of blood vessels results in
hemoptysis (coughing out blood).
Military pulmonary disease occurs when organisms drain through the lymph vessels that
drain into lymphatic ducts and from there to the venous system => right side of the heart =>
pulmonary arteries; small, yellow-white solid masses are scattered through the lung
parenchyma. With progressive pulmonary TB, the pleural cavity is involved and serous
pleural effusions, tuberculous empyema (pus) or fibrous pleuritis may develop.
Systemic miliary TB when infective foci in the lung spread through pulmonary veins to the
left heart and to systemic circulation (liver, BM, spleen ect..)
Isolated-organ TB usually involves the meninges, kidneys, adrenal glands, bones and
fallopian tubes; in vertebrae it is called Pott disease.
Lymphadenitis most frequent form of extra pulmonary TB, usually occurring in the
cervical region.
Intestinal TB by drinking of contaminated milk; organisms are trapped in the lymphoid
tissue of large and small intestine.

PATHOGENESIS
# The Mycobacteria are ingested by macrophages, but inhibit their normal bactericidal responses by
manipulation of endosomal pH => impaired phagolysosome formation.
# The bacteria proliferate within the alveolar macrophages, resulting in bacteremia and seeding in
multiple sites. Despite the bateremia, most persons at this stage are asymptomatic or have a mild flu
like illness. [ in some people with NRAMPI gene- natural resistance ssociated macrophage protein I,
the disease may progress from this point without immune response].
# After 3 weeks, cell-mediated immunity develops (tissue hypersensitivity) => bacterial antigens reach
the lymph nodes, and presented bound to MHC-II by DCs to CD4+ T-cells.
# Under the influence of IL-12 (secreted by macrophages), CD4+ T-cells proliferate into T H 1 subset,
capable of secreting IFN => activating macrophages.
# Activated macrophages release mediators such as TNF (recruitment of monocytes which go through
activation and differentiate into epitheloid histiocytes that characterize the granulomas response),
NO (by inducible nitric oxide synthase- antibacterial), and reactive oxygen species.
# Immunity to a tubercular infection is primarly mediated by T H I cells, which stimulate
macrophage to kill bacteria!

CLINICAL COURSE
# Onset is asymptomatic.
# Systemic symptoms related to cytokine release (TNF, IL-1) by activated macrophages, include
malaise (nausea), anorexia, weight loss and fever.
# With progression of the disease => increasing amount of sputum (first mucoid, later purulent); when
cavitations appear, the sputum will contain tubercle bacilli.
# Some degree of hemoptysis.
# Pleuritic pain when the infection reaches pleural surface.
# Extrapulmonary manifestation depend on the organ.
# Amyloidosis may develop in persistent cases.

Topic 24
Opportunistic infections (viruses, bacteria, fungi) and predisposing conditions.

Opportunistic infections Definition:

An infection by a microorganism that normally does not cause disease but becomes pathogenic when the
body's immune system is impaired and unable to fight off infection.
account for the majority of deaths in AIDS and in other diseases with immunosuppression.
Major opportunistic infections:

Fungal infections:
Fungi may cause superficial or deep infections:

Superficial infections involve the skin, hair and nails. They are called dermatophytes.
Deep fungal infections can spread systematically and invade tissues, destroying vital organs in
immunocompromised hosts.

Fungi are divided into endemic and opportunistic species:

Endemic are invasive species that are limited to particular geographic region.
Opportunistic fungi (e.g. Candida, Aspergilus, Mucor, Cryptococcus) they either colonize
individuals or are encountered from environmenta sources. In immunodeficient individuals
opportunistic fungi give rise to life threatening invasive infections characterized by tissue necrosis,

hemorrhage ect.. patiants with AIDS often are infected by opportunistic fungus Pneomocystis
jiroveci (=carinii).
Examples:

Pneumocystosis:
caused by P. jiroveci
pneumonia or disseminated disease
OI that causes most often death in AIDS
treatable; prophylaxis possible
transmission: via respiratory tract
Candidiasis (Thrush)
caused by C. albicans
oral cavity, trachea, lung, oesophagus
Cryptococcosis
caused by cryptococci (fungi!)
enters via respiratory tract / lung
spreads to lepromeninges -> meningitis
may also affect skin, skeletal system, urinary tract
high mortality
can be treated
Histoplasmosis
caused by H. Capsulatum
by inhalation (birds, bat dropping)
intracellular parasite in macrophages
epitheloid cell granulomas with necrosis; later fibrosis, calcification; yeasts detectable by silver
impregnation
Diff. Dg: TB, sarcoidosis, coccidioidomycosis
in fulminant (imunosuppressed): no granulomas, macrophages filled with fungal yeasts throughout the
body.

Bacterial infections:
Mycobacteriosis
TB pulmonary or extrapulmonary. M. tuberculosis block the fusion of of the phagolysosome
allowing the bacteria to proliferate unchecked within the macrophage.
atypical: M. avium intracellulare often disseminated
Usual pathogens
S. aureus, S. pneumoniae, H. influenzae, Salmonella
pneumonia; entiritis; meningitis; disseminated (sepsis)

Viral infections:

Viruses are obligate intracellular.

Cytomegalovirus (CMV)- infected cells are enlarged and show a large eosinophilic nuclear inclusion
and smaller basophilic cytoplasmic inclusion.
very common, most people had CMV by 40y; stays dormant
via saliva, blood, semen
throat, lung, GI, meningoencephalitis, retinitis

Herpes simplex virus (HSV 1,2)- large nuclear inclusion surrounded by a clear halo.
very common
gingivostomatitis (HSV-1); genital herpes (HSV-2)
keratitis, encephalitis, hepatitis, pneumonia
disseminated to viscera
KSHV/HHV-8
Kaposi sarcoma
EBV
B-cell lymphomas (e.g. Burkitt lymphoma)

Varicella Zoster Virus (VZV)

cause of chickenpox and shingles
in immunosuppressed: encephalitis, transverse myelitis, necrotising visceral lesions

TOPIC #25: SELF-TOLERANCE. MECHANISMS OF

AUTOIMMUNE DISEASE

SELF-TOLERANCE
# Immunological tolerance the lack of response of the immune system to an
antigen.
# Self tolerance the immune system of an individual does not develop an immune
response toward self antigens.
# During development of B and T lymphocytes, antigen receptors are produced,
some of them are a match to the body's own antigens.
# In order to eliminate self-reactive lymphocytes, 2 groups of mechanisms arise:
Central tolerance
The elimination of self-reactive B and T cells during their
maturation on bone marrow and thymus. Use AID (antigeninduced death)
In the thymus => self antigens are processed and presented by
APCs (AIRE gene autoimmune regulator), and any developing T
cell that expresses a receptor to those antigens is negatively
selected and eliminated by apoptosis.
In the bone marrow => B cells that react with membrane bound
antigens are eliminated by apoptosis; some self-reactive B cells
undergo rearrangement of receptor genes to express new, non selfreactive receptors => receptor editing.
Peripheral tolerance
Self-reactive T cells that escape negative selection and reach the
periphery.
There are several mechanisms in peripheral tissues to silence these
autoreactive cells: anergy, suppression by regulatory T cells, and
activation-induced cell death.
Anergy is the functional inactivation of lymphocytes
Activation of T cells demands recognition of antigen-self-MHC
complex, and costimulatory signals provided by APCs.
When a T cell encounters its specific antigen on a non-APC, it
becomes anergic since there are no costimulatory signals.
B cells can also become anergic if they encounter their antigen in
the absence of specific helper T cell.
Suppression by regulatory T cells is done by secretion of
immunosuppressive cytokines (IL-10, TGF); regulatory T cells
express CD25 and require IL-2 for their survival and generation.

 AICD (activation-induced cell death) is a mechanism that involves

apoptosis of mature lymphocytes as a result of self-antigen
recognition.
Autoreactive T cells that undergo repeated and persistent
activation eventually induce their Fas receptor and undergo
apoptosis.

MECHANISMS OF AUTOIMMUNE DISEASE

# Lack of cell angry due to over expression of costimulatory molecules (necrosis,
inflammation).
! Multiple sclerosis, diabetes type II.
# Lack of AICD defect in the interaction of Fas and Fas ligand.
! Systemic lupus erythematosus.
# Modification of an antigen in drug induced situations, the drug metabolites
initiate conformational change of the antigen.
# Failure of T cell suppression insufficient production of IL-10.
# Molecular mimicry microbes may express epitopes similar to self antigens, thus
responses of the immune system to these microbes may induce an attack on self
tissues => rheumatic heart disease Streptococcus pyogenes has similar proteins
to cardiac antigens.
# Lymphocyte activation antigen independent activation of self-reactive anergic
clones.
# Genetic factors several autoimmune diseases are linked to HLA locus; in
addition, 2 genetic polymorphisms are associated with autoimmunity => PTPN22
encodes for phosphatase and is associated with rheumatoid arthritis, and NOD2

encodes for intracellular receptor of microbial peptides, associated with Crohn

disease.
# Epitope spreading in the thymus, T cells are not exposed to all self antigens,
each antigen has several epitopes, and only the most dominant ones are presented
to T cells in the thymus; this, T cells are reactive to the less dominant epitopes are
NOT eliminated.

TOPIC #26: SYSTEMIC LUPUS ERYTHEMATOUS

SLE
# A multisystem autoimmune disease that can affect any part of the body, but
mostly affects the skin, kidneys, serosal membranes, joints and heart.
# Associated with the presence of ANAs (anti-nuclear antibodies).
# The diagnosis is established if the patient shows at least 4 symptoms:
Malar rash (butterfly)
Discoid rash
Photosensitivity
Renal disorders
Neurological disorders
Arthritis
Serositis
ANA
Hematologic disorders
Oral ulcers

PATHOMECHANISM
# The major defect in SLE is the failure to maintain self-tolerance.
# Tissue damage occurs in 2 pathways:
1) Deposition of antigen-antibody complexes (type III hypersensitivity).
2) Production of large number of autoantibodies (type II hypersensitivity).
# Spectrum of antibodies:
Anti-nuclear antibodies (ANAs) produced against nuclear antigens
(DNA => Smith antibodies, histones, non-histone proteins, nucleolar
antigens).
Anti-phospholipid antibodies directed against phospholipids of cell
membrane, but also disturb coagulation process, since phospholipids are
important in the formation of blood clots ("lupus antibodies").
Antibodies against blood cells RBCs => hemolytic anemia, platelets =>
thrombocytopenia, lymphocytes => lymphopenia.

ETIOLOGY
# Immunologic factors combination of increased generation or defective
clearance of nuclear antigens released from apoptotic cells, and failure of T cells
and B cells tolerance to those self antigens.
Tolerance has failed in both helper T cells and B cells specific for nuclear
self antigens.
# Genetic factors
High rate of incidence in monozygotic twins.
Increased risk of family members to develop SLE.
Association with HLE type II, mainly HLA-DQ.
May be associated with complement system deficiencies.
# Non-genetic factors
UV radiation => apoptosis and increased release of nuclear antigens.
Drugs => against hypertension.
Sex hormones => seems to have an influence since SLE affects women
more than men.

MORPHOLOGY
# Acute necrotizing vasculitis affects small arteries and arterioles; characterized
by necrosis and fibrinous depositions within vessel walls, resulting in fibrous
thickening and lumen narrowing.
# Joint involvement swelling and non-specific mononuclear cell infiltration in
synovial membranes.
# Skin involvement malar rash (butterfly pattern), worsened by UV light
(photosensitivity) due to liquefactive degeneration of basement membrane and
edema in dermis-epidermis junction.
# CNS involvement focal neurologic deficits, often related to vascular lesions
causing focal cerebral microinfarctions.
# Spleen moderately enlarged with capsular fibrous thickening and follicular
hyperplasia.
# Serous membranes pericardium and pleura show inflammatory changes from
serous effusions to fibrous exudation.
# Heart manifested in the form of endocarditis, myocarditis and valvular lesions
(Libman-Sacks endocarditis).
# Kidney involvement most important clinical feature of SLE, causing renal
failure which is the most common; the pathogenesis of all forms of
glomerulonephritis in SLE involve deposition of antigen0antibody complexes
within the glomeruli:
Class I (5%) rare, looks normal by light, electron and
immunoflorescence microscopy (no histological signs of inflammation).

Class II mesangial lupus glomerulonephritis (10%-25%) immune

complexes are deposited in the mesangium (increased mesangial matrix).
Class III focal proliferative glomerulonephritis (20%-35%) in an
otherwise normal glomerulus, 1-2 areas show swelling and proliferation of
endothelial and mesangial cells, with neutrophils infiltration and fibrinoid
deposits; associated with hemturia and proteinuria.
Class IV diffuse proliferative glomerulonephritis (35%-60%) most
severe form, most glomeruli show endothelial and mesangial proliferation
affecting the entire glomerulus; subendothelial immune complexes
deposition; patients suffer from hemturia, proteinuria, hypertension, and
renal insufficiency.
Class V membranous glomerulonephritis (10%-15%) characterized by
widespread thickening of the capillary wall caused by deposition of
basement membrane like material, and accumulation of immune
complexes; patients have severe proteinuria.

TOPIC #27: RHEUMATOID ARTHRITIS

RHEUMATOID ARTHRITIS
# Systemic, chronic inflammatory disease affecting primarily the synovial joints.
# Characterized by non-suppurative synovitis that leads to destruction of articular
surfaces (cartilage + underlying bone), with resultant disabling arthritis.
# Extra articular involvement develops in the skin, heart, blood vessels, muscles
and lungs.

MORPHOLOGY
# Symmetric arthritis affecting small joints of the hands, feet, wrist, anckles,
elbows, and shoulders.
# Histologically, the affected joints show chronic synovitis, characterized by:
Synovial cell hyperplasia and proliferation.
Infiltration of inflammatory cells, forming lymphoid follicles in the
synivium composed of helper T cells, plasma cells and macrophages.
Increased vascularity due to angiogenesis.
Aggregates of fibrin on synovial surface.
Increased osteoclasts activity.
# Formation of pannus a membrane of granulation tissue, fibrous c. tissue,
inflammatory cells and synovial-lining cells, which cover the articular surface;
overgrowth of this tissue creates edematous villus projections.
# Eventually, the pannus fills the joint space; subsequent fibrosis and calcification
result in permanent ankylosis (stiff joint).
# Destruction of tendons, ligaments and joint
capsules produce the characteristic
deformities => radial deviation of the wrist,
ulnar deviation of the fingers.
# Rheumatoid subcutaneous nodules are firm,
non-tender oval/rounded masses that usually
appear along the forearm in 25% of patients.

PATHOGENESIS
# Immunologically mediated, RA is a joint inflammation with interplay of genetic
and environmental factors.
# Activation of helper T cells by unknowm arthritogenic agent (microne, virus)
leads to release of cytokines.
# The role of the cytokines:
Activate macrophages in the joint space that release degenerative enzymes
and cytokines (IL-1, TNF) => keep inflammation going.
Activate B cells to produce antibodies (mainly IgM) that are
autoantibodies, binding self IgG; the autoantibodies are called rheumatoid
factor, and they may form immune complexes with self IgG to be
deposited on joints.
Promote leukocytes recruitment.
Activate T cells that produce RANK ligand (cytokine), which induces
osteoclast differentiation and activation.

GENETIC FACTORS
# Genetic predisposition among 1st degree relatives and monozygotic twins.
# Associated with HLA-DR4, and polymorphism in PTPN22 gene.

CLINICAL COURSE
# Weakness, malaise, fever.
# Swelling of joints, stiffness especially in the morning.
# As the disease advances, joints become enlarged and limited in movement until
complete ankylosis appears.

TOPIC #28: SJGREN'S SYNDROME

THE SYNDROME
# An autoimmune disease characterized by dry eyes (keratoconjuctivitis sicca), and
dry mouth (xerostomia), resulting from destruction of lacrimal and salivary
glands.
# 90% occur in woman between the ages of 35 to 45 years
# High risk of develop non-Hodgkin B cell lymphoma (Marginal zone)
# Has 2 forms:
1) Primary known as sicca syndrome, occurs as an isolated disorder where
autoantibodies are produced against 2 nuclear antigens => SS-A (Ro) and
SS-B (La).
2) Secondary associated with another autoimmune disease (rheumatoid
arthritis most common).

PATHOGENESIS
# Mediated by loss of tolerance in the helper T cells population.
# It is an autoimmune disease in which the ductal epithelial cells of exocrine glands
are the primary target.
# The disease is initiated by an autoimmune reaction to an unknown self antigen.

MORPHOLOGY
# Intense infiltration of lymphocytes (mainly activated helper T cells), and plasma
cells.
# Lymphoid follicles with germinal centers may be formed.
# The native architecture is destroyed.
# Destruction of lacrimal gland => dry cornea, inflammation, erosion, ulceration
(keratoconjuctivitis).
# Loss of salivary glands => dry mucosa, mucosal atrophy, inflammation,
ulceration (xerostomia).
# Nasal dryness => ulceration, septum perforation.
# Respiratory tract => laryngitis, bronchitis, pneumonitis.

TOPIC #29: SYSTEMIC SCLEROSIS (scleroderma)

SYSTEMIC SCLEROSIS
# An autoimmune disease characterized by excessive fibrosis throughout the body,
including the skin, GI tract, lungs, kidneys, heart and skeletal muscle.
# Can be classified into 2 groups:
Diffuse scleroderma initial widespread skin involvement, with rapid
progression and early visceral involvement.
Limited scleroderma mild skin involvement (fingers, face), relatively
benign course with late visceral involvement; also called CREST
syndrome.
Calcinosis => calcification of fingertips
Raynaud syndrome => vasospastic disorder causing fingers
discoloration
Esophageal dysmotility => acid reflux
Sclerodactyly => claw hands
Telangiectasia => dilation of superficial vessels

PATHOGENESIS
# Fibroblasts activation with excessive fibrosis.
# Helper T cells are activated by an unknown trigger => accumulate in the skin and
release cytokines that activate mast cells and macrophages => release fibrogenic
cytokines (IL-1, PDGF, TGF, FGF).
# B cells are also activated => indicated by the presence of
hypergammaglobulinemia and ANAs.
# 2 types of ANAs are produced:
Anti-DNA topoisomerase I (anti-Scl70) highly specific for diffuse
scleroderma, present in 70% of patients.
Anti-centromere antibodies highly specific for limited scleroderma
(CERST), present in 90% of patients.
# Microvascular disease is present early in the course of systemic sclerosis, caused
by local T cells reaction, followed by platelets aggregation and release of platelet
factors that trigger fibrosis of the adventitia, thus narrowing the microvasculature.

MORPHOLOGY
# Skin
Diffuse sclerotic atrophy with edema (doughy consistency); with progression,
replaced by fibrosis of the dermis tightly boubd to subcutaneous structures
Increase in compact collagen in the dermis along with thinning of the
epidermis.
Small vessels show thickening of basement membrane, endothelial cell
damage and partial occlusion; arterioles also thicken.
# GI tract
Progressive atrophy, collagenous replacement of the muscular layers (most
severe in esophagus) => dysfunction of the esophageal sphincter resulting in
gastric reflux
Ulceration of the mucosa, excessive collagenization of lamina propria and
submucosa
Loss of microvilli and villi in small intestine => malabsorption
# Musculoskeletal system
Synovial hyperplasia and inflammation
At later stage => fibrosis
# Lungs
Fibrosis of small pulmonary vessels => pulmonary hypertension
Pulmonary vascular endothelial dusfunction
# Kidneys
Thickened wall of intertubular arteries => cell proliferation with deposition of
glycoproteins and mucopolysaccharides
Hypertension not always occur, but when it does, it is associated with fibrinoid
necrosis, thrombosis and infarction of arterioles
No glomerular change
# Heart
Patchy myocardial fibrosis
Thickening of intramyocardial arterioles, caused by microvascular injury
Changes in lungs result in right ventricular hypertrophy and failure
CLINICAL COURSE
# SS affects woman x3 then man (peak btw 50-60)
# Distinctive feature of SS is the striking cutaneous involvement
# Almost all patient exhibit Raynaud phenomenon

TOPIC #30: CONGENTIAL AND ACQUIRED

IMMUNODEFICIENCIES (Bruton's agammaglobulinemia, isolated
IgA deficiency, DiGeorge's syndrome, SCID)

BRUTON'S DISEASE X-LINKED AGAMMAGLOBULINEMIA

# X-linked disease, characterized by the failure of pre-B cells to differentiate into B
cells, resulting in the absence of -globulins in the blood =>
AGAMMAGLOBULINEMIA.
# During normal B cells maturation, Ig heavy chain genes are rearranged first,
followed by rearrangement of the light chain genes.
# In X-linked agammaglobulinemia (XLA), cell maturation stops after the
rearrangement of the heavy chain genes due to a mutation in tyrosine kinase that
is responsible for signal transduction in pre-B cells during maturation => Bruton
tyrosine kinase (BTK).
# The disease is characterized by:
Absent/decreased number of B cells in circulation and depressed serum
level of all classes of immunoglobulins.
Underdeveloped germinal centers in lymph nodes, Payer's patches,
appendix, and tonsils.
Absence of plasma cells.
Normal T cell mediated responses.
# XLA is not apparent until maternal immunoglobulins are depleted (~6 months).
# Recurrent bacterial infections, mainly by those that are antibody-mediated 1.
# Treatment => replacement therapy with intravenous Ig.

ISOLATED IgA DEFICIENCY

# Relatively mild immunodeficiency in which IgA is absent.
# IgA can be found in mucosal secretions, and is involved in airways and GI
defense.
# This condition is caused by an inherited inability to produce IgA due to blockage
in the final differentiation of B cells, producing IgA, into plasma cells.
# Patients with this deficiency are usually asymptomatic.

Haemophilus influenzea, Streptococcus pneumoniae, Staphylococcus aureus.

DIGEORGE SYNDROME
# Developmental failure of the 3rd and 4th pharyngeal pouches, Due to 22qll
microdeletion
# Results in defect in thymic development with deficient T-cell maturation.
# T cells are absent from lymph nodes (interfollicular area), spleen (PALS), and
peripheral blood (adaptive immunity).
# B cells and serum immunoglobulins are unaffected.
# Symptoms include:
Cardiac abnormalities.
Abnormal feces.
Thymic hypoplasia.
Cleft palate.
Hypocalcemia/Hypoparathyroidism.

SEVERE COMBINED IMMUNODEFICIENCY (SCID)

# Genetic disorder in which both humoral and cell-mediated immunities are
impaired.
# Caused by mutations in the gene encoding the common -chain of the receptors
for different cytokines (IL-2, 4, 7, 9, 15).
# IL-7 is very important since it is responsible for stimulating the survival and
expansion of immature B cells and T cells precursors.
# SCID can be either X-linked or autosomal recessive.
# In the autosomal recessive inheritance, adenosine deaminase (ADA) mutations
are common, resulting in the accumulation of adenosine, which inhibits DNA
synthesis, and is also toxic to lymphocytes.
# In both forms (ADA, -chain deficiencies), thymus is hypoplastic, lymphoid
tissues are atrophic, and lack B cell germinal centers and paracortical T cells.
# Defect in MHC II deficiency (defect CD4+ T-cell) or RAG1/RAG2 mutation
(DNA Rearrangement)
# Treatment => bone marrow transplantation and gene therapy.

TOPIC #31: ACQUIRED IMMUNODEFICIENCY (AIDS)

AIDS
# It is caused by the human immunodeficiency virus (HIV), a retrovirus, and is
characterized by infection and depletion of helper T cells, as well as profound
immunusuppression, leading to opportunistic infections, secondary neoplasms
and neurologic manifestations.
# Risk factors:
Homosexual or bisexual males.
Intravenous drug abusers.
Heterosexual contacts with members of high risk groups.
Recipients of blood transfusions (risk has been greatly diminished by
screening donor's blood).
Infants of high risk patients.

MODE OF TRANSMISSION
# Sexual transmission the virus is found in semen, both extracellularly and within
mononuclear inflammatory cells, and in vaginal and cervical cells; sexual
transmission is aided by other STDs that cause genital ulceration (syphilis, herpes
simplex), or increase content of inflammatory cells (gonorrhea, chlamydia).
# Parenteral transmission intravenous drug abusers, hemophiliacs that receive
factor VIII or IX concentrates, and random recipients of blood.
# Mother-to-infant transmission in the uterus (transplacental), during delivery and
via ingestion of contaminated breast milk.

ETIOLOGY
# There are 2 types of HIV:
HIV type 1 more common type associated with AIDS in US, Europe and
Central Africa.
HIV type 2 cause similar disease principally in West Africa
# Both types are genetically different, but antigenically similar.
# Structure spherical, composed of viral core surrounded by lipid envelope.
Virus core contains: P24: the protein shell (caspid protein)
P7: nucleocaspid protein
2 copies of RNA strands
Viral proteins (protease, reverse transcriptase, integrase)

The core is surrounded by matrix, composed of P17 protein, which is

surrounded by lipid envelop => contains gp120 and gp41 glycoproteins.
# Viral genome consists of 9 genes, encoding 19 proteins; there are several major
genes:
Tat codes for 2 proteins that
are transactivators, which
increase gene transcription
and are critical for virus
replication.
Nef codes for nef protein,
which leads to the down
regulation of CD4 and MHC
molecules.
Gag, Pol & Env contain information needed for the production of
structural proteins of the viral particle.
# The HIV-1 form can be divided into 2 groups, designated M (major) and O
(outlier); group M viruses are more common, and are further divided into
subtypes (A-J), which differ in their geographic distribution and their mode of
transmission 1.

PATHOGENESIS
# Life cycle of HIV
CD4 acts as a high affinity receptor for HIV
The gp120 is non-covalently attached to gp41; gp120 initially binds CD4,
resulting in its conformational changes and exposure of new recognition sites
for CCR5 2 and CXCR4 3 (cell surface chemokines), which serve as coreceptors.
Then, gp41 undergoes conformational change that allows it to be inserted into
the target cell membrane, a process which facilitates the fusion of the virus
with the cell.
Once internalized, the viral genome undergoes reverse transcription, leading to
the formation of complementary DNA (cDNA) that may stay in the cytoplasm
or transfer into the nucleus to be integrated into the host genome (in dividing T
cells).
After integration, the viral DNA may remain non-transcribed for months or
years, and the infection becomes latent; transcription and formation of viral
particles will eventually lead to cell death.

For example: E subtype by heterosexual contact, B subtype by lymphocytes and monocytes.

Found on macrophages, used by R5 virus.
3
Found on T cells, used by X4 virus.
2

# Progression of HIV infection

Acute phase
First cell type to be infected is memory CD4+ T cells (express CCR5)
in mucosal lymphoid tissue => largest reservoir of T cells.
DCs in epithelia at sites of virus entry capture te virus and migrate to
lymph nodes, where they pass the virus onto CD4+ T cells through
direct cell-cell contact.
As a result, viral replication can be seen in lymph nodes within days,
leading to viremia => high number of particles in the blood.
Viremia is accompanied by a variety of non-specific symptoms (sore
throat, fever, rash etc.).
The infection spreads through the body and infects CD4+ T cells
(helper T cells, macrophages, DCs).
Chronic phase
Lymph nodes and spleen are the sites of continuous HIV replication
and cell destruction.
During this phase, the immune system remains competent at handling
most opportunistic infections => CLINICAL LATENCY PERIOD
Although most T cells do not harbor the virus, destruction of CD4+ T
cells steadily progresses, and their number steadily declines.
In early stages, the body may produce new CD4+ T cells therefore
those cells are replaced almost as quickly as they are destroyed.
Eventually, the continuous cycle of virus infection leads to steady
decline in T cells number.
Crisis phase
Breakdown of host defenses, marked increase in viremia and clinical
disease.
Low CD4+ T cells count (<500 cells/L).
Patients develop serious opportunistic infections, secondary neoplasms,
and neurologic manifestations.
# Mechanisms of T cells depletion
Lytic HIV infection of CD4+ T cells, and cell death during viral
replication and production of virions.
Loss of immature precursor cells of CD4+ T cells => decreased CD4+ cell
production, due to direct infection of thymic progenitor cells, and
infection of accessory cells that secrete cytokine essential for maturation
of CD4+ T cells.
Chronic activation of uninfected cells by HIV antigens, which leads to
apoptosis of T cells.
Disruption of lymphoid tissue normal architecture, leading to impaired
immune response.
Fusion of infected and uninfected cells causes the formation of giant cells.
Infected CD4+ T cells may be destroyed by specific cytotoxic T cells.

# Qualitative defects in T cells function

Reduced antigen-induced T cells proliferation.
Impaired T H 1 cytokine production.
Abnormal intracellular signaling.
# Macrophages/Monocytes in HIV infection
Most infected cells are found in the tissues and not in the blood.
HIV-1 can multiply in non-dividing, terminally differentiated
macrophages.
Macrophages are quite resistant to cytopathic effects of HIV, and can
harbor the virus for longer period; infected macrophages bud a small
amount of virus from their cell surface, and therefore contain large
amount of virus particles within intracellular vesicles.
HIV infections are transmitted to macrophages by R5 strains (CCR5).
# Dentritic cells in HIV infection
Mucosal DCs capture the virus and transport it to lymph nodes, where
they infect CD4+ T cells.
Follicular DCs serve as reservoirs of HIV.
The virus particles are found on the surface of dendritic processes, bound
to Fc receptors via HIV/anti-HIV complex.
# Lymphocytes and B cells in HIV infection
Patients present hypergammaglobulinemia and circulating immune
complexes due to polyclonal B cell activation; may result from viral
infections (EBV), gp41 itself, and IL-6 produced by infected macrophages.
There is no ability to control antibody-mediated responses to new antigens.
Responses against T-independent antigens are suppressed.
Impaired humoral immunity leaves these patients susceptible to
opportunistic infections.
# CNS involvement
Microglia, of the macrophages lineage, are the predominant cell types in
the brain.
Monocytes carry the virus to the brain => almost exclusively R5 strains
are present in brain HIV.
Infected microglia release toxic cytokines to recruit neuron damaging
inflammatory cells.

CLINICAL FEATURES

# Opportunistic infections pneumonia, herpes simplex, Mycobacterium

tuberculosis, Streptococcus pneumoniae, Haemophilus influenza.
# Neoplasms Kaposi sarcoma, non-Hodgkin lymphoma, cervical cancer.
# CNS involvement aseptic meningitis, vascular myelopathy, progressive
encephalopathy.

TOPIC #32: AUTOSOMAL DOMINANT MENDELIAN

INHERITANCE. MARFAN SYNDROME. EHLERS-DANLOS
SYNDROME

AUTOSOMAL DOMINANT INHERITANCE

# Dominance is a relationship between alleles of a gene in which one allele masks
the expression (phenotype) of another allele at the same locus.
# Autosomal dominant inheritance affects both males and females, expressed in
heterozygote.
# Autosomal dominant diseases may include the following features:
Some patients do not have affected parents => new mutations occurred in
the egg or sperm; their siblings are not affected.
Some individuals inherit the mutant gene but are phenotypically normal
=> REDUCED PENETRANCE
Some individuals may inherit the same mutant gene, but they expressed
differently => VARIABLE EXPRESSIVITY.
Age of onset is delayed.
50% reduction in the normal gene product is associated with clinical
symptoms.
# Reduction of 50% in enzymatic activity can be compensated; therefore the
involved genes usually do not encode enzyme proteins.
# Two major categories of non-enzymes proteins are affected:
1) Regulatory proteins involved in regulation of complex metabolic
pathways, such as membrane receptors and transport proteins.
2) Structural proteins such as collagen and cytoskeletal components.
# Dominant negative when a mutated allele impairs the function of the normal
allele => when the gene encoding one subunit of a multimeric protein, the
product of one mutant allele can interfere with the assembly of a functional
normal multimer.

MARFAN SYNDROME
# Autosomal dominant disorder of c. tissue, affecting
fibrillin-1.
# Fibrillin-1 is a glycoprotein secreted by fibroblasts and
is the major component of microfibrils found in ECM.
# Microfibrils serve as scaffoldings for the deposition of
elastic fibers.
# Fibrillin-1 is encoded by FBN1 gene found on
chromosome 15.

# Mutant FBN1 gene acts as a dominant negative by preventing the assembly of

normal microfibrils.
# In addition to FBN1 mutation, dysregulation of TGF production occurs, which
results in similar features to Marfan syndrome.
# Most cases of Marfan syndrome are familial (75%), the rest are sporadic (arising
from mutations in germ cells).
# Morphology:
Skeletal abnormalities patients are tall and thin with abnormally long
legs, arms and fingers (arachnodactyly), high arch palate, hyper-extensible
joints, and spinal and chest deformities.
Ocular changes bilateral dislocation of the lens (weak suspensory
ligaments).
Cardiovascular system fragmentation of elastic fibers in tunica media of
the aorta, leading to aneurysm and death due to aortic rupture; cardiac
valves, mainly the mitral, may be extensively distended and result in
regurgitation.

EHLER-DANLOS SYNDROME
# Characterized by defects in collagen synthesis or
structure; all are single gene disorders, and can be
inherited as autosomal recessive, autosomal
dominant or X-linked.
# Tissues affected are rich in collagen (skin, joints,
ligaments etc.).
# Morphology:
Skin is hyper-extensible, extremely fragile and lacks the normal tensile
strength.
Joints are hyper-mobile and prone to dislocations.
Internal organs may rupture (colon, large vessels), cornea may rupture.
# Classification of EDSs divides them into 6 groups.
# The molecular bases of three of the most common EDS are:
1) Deficiency of lysyl hydroxylase kyphoscoliosis (type VI)
Hydroxylasion of lysyl residues decreases in collagen types I & III,
interferes with normal cross-links of collagen molecules; inherited as
autosomal recessive disorder.
2) Deficient synthesis of type III collagen vascular (type IV)
Resulting from mutations affecting COL3A1 gene (structural); inherited
as an autosomal dominant disorder, characterized by weakness of vessels
and intestinal wall
3) Deficient synthesis of type V collagen due to mutations in
COL5A1 and COL5A2 is inherited as an autosomal dominant
disorder and results in classical EDS..

TOPIC #33: AUTOSOMAL RECESSIVE INHERITANCE.

CYSTIC FIBROSIS

AUTOSOMAL RECESSIVE INHERITANCE

# Occurs when both alleles at a given locus are mutants.
# Recessive disorders are characterized by:
Parents are usually not affected, siblings may show the disease.
Siblings have 25% chance of being affected.
If the mutant gene occurs at low frequency in the population, it is most
likely that the affected patient was born as a result of relatives' marriage.
# Most autosomal recessive disorders have the following features:
1) The expression of the defect tends to be more uniform.
2) Complete penetration is common.
3) Onset of the disease is usually at an early age.
4) Although new mutations for recessive disorders occur, they are rarely
detected clinically.
5) In many cases, enzyme proteins are affected.

CYSTIC FIBROSIS
# Widespread disorder of epithelial transport characterized by abnormal transport
of Cl- and Na+ across epithelium, leading to thick viscous secretions.
# This disorder affects most critically the lungs, but also the GI tract, exocrine
glands and reproductive system.
# Pathogenesis the primary defect of CF is the abnormal function of an epithelial
Cl- channel protein encoded by CF transmembrane conductance regulator (CFTR)
gene, located on chromosome 7;
# The most common severe CFTR mutation is a deletion of three nucleotides
coding for phenylalanine at amino acid position 508 (F508). This causes
misfolding and total loss of the CFTR.
# mutations in this gene leave the epithelium relatively impermeable to Cl- ions.
# The impact of this defect is tissue specific:
Sweat glands main function of CFTR is reabsorbing luminal Cl-;
mutations will lead to decreased NaCl reabsorption, and result in the
production of hypertonic sweat (increased concentration of salt).
Respiratory and intestinal epithelium CFTR is responsible for active
luminal secretion of Cl-; mutations results in reduced Cl- secretion, but
active Na+ absorption still occurs, thus passive water reabsorption occurs.
This dehydration leads to defective mucociliary action, and accumulation
of concentrated secretions that obstruct air passage.

# Morphology:
Pancreas abnormalities are present in 85%-90% of patients.
In mild cases => accumulation of mucous in the small ducts with some
dilation of the exocrine glands.
In advanced cases => the ducts are completely plugged, causing
atrophy of the exocrine glands and progressive fibrosis.
Absence of exocrine secretions lead to impaired fat absorption and causes
fat soluble vitamins deficiency.
Intestine meconium ileus => thick viscid plugs of mucous obstruct the
small intestine of infants.
Pulmonary changes viscous mucous secretion of the submucosal glands
of the respiratory tree; bronchioles are distended and blocked due to this
secretion, associated with hyperplasia and hypertrophy of mucoussecreting cells (superimposed infections give rise to chronic bronchitis).
Liver bile canaliculi are plugged; hepatic steatosis 1 is common, and may
develop into cirrhosis.
Vas deference absent, or obstructed by thick secretion.

1
Fatty change abnormal accumulation of TAGs within parenchymal cells, observed most frequently
in the liver.

TOPIC #34: LYSOSOMAL STORAGE DISEASES (Tay-Sachs

disease. Niemann-Pick disease. Gaucher disease.
Mucopolysaccharidoses). Glycogen Storage Diseases

LYSOSOMAL STORAGE DISEASES

# A group of autosomal recessive metabolic diseases that result from the defect in
lysosomal function.
# When a lysosomal enzyme malfunctions, it will lead to accumulation of the
partially degraded insoluble metabolites within the lysosome.
# Many disorders have been identified, each resulted from the functional absence of
a specific lysosomal enzyme, or proteins involved in their function.

TAY-SACHS DISEASE
# Deficiency 1 in hexoaminidase A enzyme, responsible for breakdown of
phospholipids found in neurons, named gangliosides.
# When hexoaminidase A is malfunctioning, gangliosides are stored within
lysosomes of neurons and glial cells throughout the CNS.
# The disease is categorized to several forms according to the onset age:
Infantile for the first 6 months, infants appear to develop normally; as
neurons become swollen due to gangliosides accumulation, a mental and
physical deterioration occurs, and the infant becomes blind, deaf, unable
to swallow and paralytic => death before the age of 4.
Juvenile rare, seen in children 2-10 years of age; develop cognitive and
motor skill deterioration, motor speech disorder (dysarthria), swallowing
difficulties (dysphagia), and lack of coordination (ataxia) => death
between 5-15 years old.
Adult (late onset) first symptoms appear during 30s and 40s; usually not
fatal since progress can be stopped, characterized by loss of walking
coordination and neurological deterioration, dysphagia, dysarthria,
cognitive decline and psychiatric illnesses.

Resulted from mutations in HEXA gene on chromosome 15.

NIEMANN-PICK DISEASES
# A group of metabolic disorders caused by mutations in SMPD1 gene (types A
and B), and NPC1/2 gene (type C).
# They are considered as lipid storage diseases in which lipids are accumulated in
the liver, spleen, lungs, bone marrow and brain.
# zebra bodies - lamellated myelin figures seen in electron microscopy
# Niemann-Pick type A & B characterized by deficiency of acid
sphingomyelinase, and as a result accumulation of sphingomyelin.
Type A severe deficiency in sphingomyelinase, and the accumulation of
sphingomyelin in neurons and phagocytic cells; due to their high content
of phagocytic cells, the organs most affected are spleen, liver, bone
marrow, lymph nodes and lungs, resulting in massive visceromegaly and
severe neurologic deterioration => death by the age of 3.
Type B suffer from visceromegaly but no neurologic deterioration.
# Niemann-Pick type C caused by defect in lipid transport; affected cells
accumulate cholesterol and gangliosides.
marked by ataxia, vertical supranuclear gaze palsy, dystonia, dysarthria,
and psychomotor regression.
GAUCHER DISEASE
# Results from mutations in the gene encoding for glucocerebrosidase (a glucosylceramidase activity) found on chromosome 1, resulting in accumulation of
glucosyl-ceramide in phagocytic cells => Gaucher cells.
# Classification of Gaucher disease:
Type I (99% of cases) symptoms include enlarged liver and spleen
(hepatosplenomegaly), skeletal weakness, bone disease, NO CNS
INVOLVEMENT.
Type II (Acute) begins within 6 months of birth, symptoms include liver
and spleen enlargement, extensive brain damage, spasticity, and limb
rigidity => death by the age of 2.
Type III (chronic) characterized by slowly progressive, but milder
neurologic symptoms, including enlarged spleen and/or liver, anemia, and
respiratory problems.

MUCOPOLYSACCHARIDOSES
# Characterized by defective degradation of mucopolysaccharides (GAGs) in
various tissues.
# Mucopolysaccharides are part of ground substance, and are synthesized by
fibroblasts.
# Accumulation (of Heparan/Dermatan/Keratan Sulfate) results in roughness of
facial features, clouding of cornea, joint stiffness, and mental retardation.
# MPS is classified from 1 to 7, all of which are autosomal recessive, except type 2
(Hunter syndrome) which is X-linked.

GLYCOGEN STORAGE DISEASES

# Results from deficiency of any of the enzymes involved in glycogen synthesis or
degradation => lead to accumulation of glycogen or abnormal form of glycogen.
# Glycogen is most often stored in the cytoplasm, and sometimes within nuclei.
# Glycogen storage diseases can be categorized:
Hepatic type the liver contains enzymes that synthesize glycogen, and
also enzymes that break it down; this type of disease is characterized by
liver enlargement due to accumulation of glycogen, and by hypoglycemia
due to failure of glucose production.
! Von Gierke disease => lack of G-6-phosphatase
Myopathic type (McArdle syndrome defected muscle phosphorylase)
glycogen is an important energy source in skeletal muscles, so when
glycolytic enzymes are defected, glycogen is accumulated, resulting in
muscle weakness; characterized by cramps after exercise and failure to
produce lactate during exercise.
Pompe disease caused by deficiency of lysosomal acid maltase and
associated with deposition of glycogen in different organs, but
cardiomegaly is most prominent.
Brancher disease deposition of abnormal glycogen.

TOPIC #35: X-LINKED INHERITANCE. POLYGENIC

INHERITANCE. GOUT

X-LINKED DISORDERS
# Recessive X-linked inheritance
Transmitted by heterozygous female carriers only to sons, who are
hemizygous.
Males will express the disorder, while females will be carriers, and will
only express the disorder if they are homozygous to the defected X
chromosome.
Affected males will not transmit the disorder to sons, but all daughters
will be carriers.
Examples: Duchenne muscular dystrophy, hemophilia, SCID.
# Dominant X-linked inheritance
Rare variant of inheritance.
Transmission of the disease to 50% of the sons and daughters of
heterozygous females.
An affected male cannot transmit the disease to sons, but all daughters
will be affected.
Examples: Rett syndrome, vitamin D resistant rickets.

POLYGENIC INHERITANCE
# Refers to inheritance of phenotypic trait, attributed to 2 or more genes, and may
be affected by the environment.
# Polygenic inheritance is characterized by:
The risk of expressing a polygenic (multifactorial) disorder depends on
the number of mutant genes inherited.
The rate of recurrence of a disorder in first degree relatives is the same as
of the affected individual => the risk is always 2%-7% that parents with
an affected child will have another affected child.
# This form of inheritance is characteristic for diabetes mellitus, hypertension, gout,
schizophrenia and bipolar disorders.

GOUT
# Caused by excessive amounts of uric acid, characterized by recurrent attacks of
acute arthritis.
# There are two forms of gout:
Primary accounts for 90% of the cases, in which the enzymatic defect is
unknown (common), or it is due to a metabolic defect causing
hyperuricemia, e.g., partial HGPRT deficiency. (Rare).
Secondary in which the cause of hyperuricemia is known, but gout is
NOT the main clinical disorder. e.g.

# Pathogenesis elevated uric acid levels can result from over production, reduced
excretion, or both.
Uric acid is the end product of purine catabolism.
Purine production involves:
The de novo pathway synthesis if purine from ribose-5phosphate, regulated by negative feedback.
The salvage pathway synthesis of purine from free purine bases,
derived from dietary intake and catabolism of nucleic acids.
# Lesch-Nyhan syndrome an X-linked disorder in which the enzyme HGPRT is
deficient, results in hyperuricemia, severe neurologic disorder and self mutilation;
as a result, purine synthesis via the salvage pathway is blocked.
# Gout is more common in men, and includes 4 stages:
1) Asymptomatic hyperuricemia.
2) Acute arthritis.
3) Asymptomatic inter-critical period (no attacks during this time).
4) Chronic tophaceous gout.
# Morphology dense neutrophilic infiltration, monosodium urate crystals found in
the cytoplasm of neutrophils, and tophi => large crystalline aggregates on
articular surfaces (during attack).

TOPIC #36: CYTOGENETIC DISORDERS. DOWN SYNDROME

CYTOGENETIC DISORDERS
# Chromosomal abnormalities that reflect an atypical number of chromosomes, or a
structural abnormality in one or more chromosomes.
# These chromosomal abnormalities usually occur when there is an error in cell
division following mitosis or meiosis.
# Karyotype a photographic representation of a stained metaphase stage, in which
chromosomes are arranged in order of decreasing length.
# Numerical abnormalities also called aneuploidy, caused by:
Non-disjunction of a homologous pair of chromosomes at the 1st meiotic
division.
Non-disjunction of sister chromatids during the 2nd meiotic division.

NORMAL DIVISION

DISJUNCTION AT 1ST
MEIOTIC DIVISION

DISJUNCTION AT 2ND
MEIOTIC DIVISION

# The gametes formed this way have either an extra chromosome, or one less
chromosome.
# Fertilization of such gametes by normal gametes will result in 2 types of zygotes:
trisomic (3 copies of the chromosome), and monosomic (1 copy of the
chromosome).
# Structural abnormalities:
Translocations occur when chromosomes are broken and the broken
elements reattach to other chromosomes, 2 types:
Reciprocal: translocations occur when genetic material is
exchanged between nonhomologous chromosomes.

These translocations are much more common than reciprocal

translocations and are estimated to occur in approximately 1 in
1,000 live births. They occur only in the acrocentric chromosomes
(13, 14, 15, 21, and 22) and involve the loss of the short arms of
two of the chromosomes and subsequent fusion of the long arms.
An example of a Robertsonian translocation involving
chromosomes 14 and 21

Isochromosome when the centromer divides horizontally rather than

vertically, resulting in the loss of one arm.
Deletion a portion of the chromosome is removed.
Inversion a portion of the chromosome has broken off, turned upside
down and reattached.
Insertion a portion of DNA was inserted in the chromosome.

DOWN SYNDROME
# Caused by the presence of a 3rd copy of chromosome 21, or part of it.
# The presence of an extra chromosome 21 can be caused by:
Translocation of the long arm of chromosome 21 to chromosome 22 or 14.
Non-disjunction during meiosis.
# Some patients can be mosaic => their cells consist of a mixture of cells, either
with 46 or 47 chromosomes.
# Clinical features flat facial profile, mental retardation, cardiac malformations.
Approximately 40% of the patients have congenital heart disease, most
commonly defects of the endocardial
Children with trisomy 21 have a 10- to 20-fold increased risk of
developing acute leukemia. Both acute lymphoblastic leukemias and acute
myeloid leukemias occur
Virtually all patients with trisomy 21 older than age 40 develop
neuropathologic changes characteristic of Alzheimer disease
Patients with Down syndrome demonstrate abnormal immune responses
that predispose them to serious infections, particularly of the lungs, and to
thyroid autoimmunity

TOPIC #37: PATHOMECHANISMS OF CONGENITAL

MALFORMATION

CONGENITAL MALFORMATIONS
# Congenital abnormalities are structural defects that are present at birth.
# Malformation primary errors of morphogenesis resulting from intrinsic
abnormal developmental process due to multifactorial gene defect.
# Disruption secondary destruction of an organ that was previously normal in
development, usually arise from extrinsic disturbance in morphogenesis
(environmental agents).
# Deformation caused by an extrinsic disturbance of development due to
biomechanical forces (when the uterus does not grow as fast as the fetus).
# Sequence congenital anomalities resulting from secondary effects of another
organ's defect.

ETIOLOGY
# Genetic causes chromosomal syndromes, single gene mutations etc.
# Environmental influences viral infections, drugs, irradiation to which the
mother is exposed during pregnancy 1.
# Multifactorial inheritance the combination of environmental influence on the
expression of 2 or more genes.

PATHOGENESIS
# The timing of the prenatal defect during the first 3 weeks, injurious agents can
damage enough cells to cause an abortion, or just a few cells from which the
embryo can recover; between 3rd-9th weeks the embryo is extremely susceptible
to injuries since organs are being crafted out of germ cells layers; after the 9th
week, fetal period starts. Characterized by growth and maturation of organs, less
susceptible to injuries, but more sensitive to growth retardation.
# Genes that regulate morphogenesis these genes are responsible for normal
growth and development of the fetus.
o Valproic acid is an antiepileptic disrupts expression of HOX genes
leading to abnormalities
o The vitamin A (retinol) derivative all-trans-retinoic acid is essential
for normal development and differentiation (cleft lip and cleft palate)
1
For example: maternal hyperglycemia => fetal hyperinsulinemia =>enlarged organs, and increased
body fat and muscle mass

TOPIC #38: DEFINITION OF NEOPLASIA. NOMENCLATURE.

GROWTH CHARACTERISTICS OF BENIGN AND MALIGNANT
TUMORS

NEOPLASIA
# Literally means "new growth" an abnormal mass of tissue, its growth is faster
and uncoordinated with that of a normal tissue.
# Growth persists even after the stimulation ceases, and is independent of
regulatory signals; therefore these cells have some degree of autonomy.
# Nevertheless, neoplasias depend on blood supply and some on endocrine support
from the host.

TUMOR
# Benign tumor
Localized, lacks the ability to spread to other sites.
Removed by surgical procedure.
Cells bear strong resemblance to the normal cells in their organ of origin.
# Malignant tumor
Referred to as cancer.
Can invade and destroy adjacent structures and spread to distant sites
(metastasis).
Rapidly growing.
Often contains central area of ischemic necrosis because the tumor's blood
supply fails to keep up with the rate of growth.
# Basic components of tumors:
1) Parenchyma made up of transformed cells, or neoplastic cells, from
which the tumor originates; determines the biologic behavior of the
neoplasm.
2) Stroma supporting, non-neoplastic c. tissue of the host, which is crucial
to the growth of the neoplasm since it carries blood vessels.

NOMENCLATURE
# For benign names end with the suffix "-oma", attached to the name of the cell
type from which the tumor arises => lipoma, fibroma.
The names of benign epithelial tumpors are based on their histiogenesis and
architecture => adenoma (neoplasm producing glands or derived from glands, not

necessarily producing a glandular pattern), papilloma (forms projections),

cystadenoma (forms cysts).
For malignant follows that of benign tumors, with certain additions and
exceptions:
Sarcoma malignant neoplasms arising in mesenchymal tissue, or its
derivatives => fibrosarcoma (a cancer of fibrous tissue origin),
chondrosarcoma (a cancer of chondrocytes).
Leukemia/Lymphoma malignant neoplasms arising from mesenchymal
cells of the blood
Carcinoma malignant neoplasms of epithelial cells, derived from all
germ-cell layers (endoderm, mesoderm, ectoderm) => adenocarcinoma
(cancer of glandular epithelium), squamous cell carcinoma.
Mixed tumors derived from one germ-cell layer that differentiates into more
than one cell type => mixed tumor of salivary glands contains epithelial cells as
well as stroma and cartilage-like tissue (pleomorphic adenoma),
fibroadenoma(femal breast, mixed tumor)
Teratoma special type of mixed tumor, derived from totipotent germ cells,
originating from all germ-cell layers; has the capacity to differentiate into any cell
type at any location.
Choristoma congenital anomality in which perfectly functional cells belonging
to a certain organ, are found in the wrong place => nodule of well developed
pancreatic tissue is found in the submucosa of the stomach.
Hemartoma disorganized masses of mature tissue, with characteristic
differentiation of the normal surrounding tissue => disorganized hepatic cells,
blood vessels and bile ducts are found within the liver.

GROWTH CHARACTERISTICS OF TUMORS

# Rate of growth depends on blood supply, hormonal influences and level of
differentiation => benign tumors grow slower than malignant, malignant tumors
grow so rapidly that they are poorly differentiated.
! Leiomayoma is a benign tumor of smooth muscle in the uterus, influenced
by levels of estrogen (may increase rapidly during pregnancy).
# Invasiveness
Benign localized, c. tissue (host and of tumor itself) capsule not all are
encapsuled like leiomyoma, cannot infiltrate or metastasize.
Malignant no defined borders, grows by progressive invasion, able to
metastasize.
# Differentiation and anaplasia
Benign resembles the normal tissue, less mitotic figures.
Malignant vary in differentiation. Some resemble the normal tissue and
some dont. undifferentiated neoplasms are called anaplastic, display

pleomorphism. Mitoses are numerical and distinctly atypical these are

less likely to have a specialized functional acticity (unlike benign)
Dysplasia: disorderly but non-neoplastic prolif. Mainly in epithelial
lesions, mitotic figures are more abundant. When dysplastic changes are
marked and involve the entire thickness of the epithelium, the lesion is
reffered to as carcinoma in situ preinvasive stage of cancer
# Metastasis
Benign localized.
Malignant gives off metastases
Basal cell carcinoma of skin and CNS are highly invasive but rarely
metastasize; osteogenic sarcomas extremely metastasize
Malignant neoplasm spread in one of three ways:
Seeding within body cavities (ovary)
Lymphatic spread (carcinoma)
Hematogenous spread (sarcomas, liver & lung are most involved
secondary site)
# Responsiveness to drugs benign tumors response poorly to drugs than
malignant tumors (drugs work better on dividing cells).

TOPIC #39: DIFFERENTIATION AND ANAPLASIA.

PLEOMORPHISM. GRADING OF CANCER

DIFFERENTIATION
# Refers to parenchymal cells that constitute the neoplasm.
# Differentiation of parenchymal cells is the extent to which they resemble their
normal cells of origin, both morphologically and functionally.
# The stroma carrying the blood supply is crucial to the growth of tumors, but has
no role in differentiation between benign and malignant tumors.
# The amount of stromal tissue determines the consistency of the neoplasm =>
certain cancers induce the formation of a dense, abundant fibrous stroma
(desmoplasia), thus the tumor is hard (scirrhous tumor).
BENIGN TUMORS
-

Well differentiated cells that

resemble the normal tissue
Lipoma => made of mature fat
cells filled with lipid vacuoles
Chondroma => made of
mature chondrocytes that
synthesize cartilage matrix
Low mitotic figures (in normal
configuration!!)

MALIGNANT TUMORS
-

Wide range of parenchymal

differentiation, from well defined
cells to completely
undifferentiated cells
Resemble primitive undesignated
cells

# The better the differentiation of the cell, the more it retains the functional
capabilities of its normal cell of origin.
# The more rapidly growing and the more undifferentiated a tumor is, the less
likely it is to have specialized functional activity.

ANAPLASIA
# It is the abnormal lack of differentiation of cells, refers to the reversal in cell
differentiation or to the failure of cells to differentiate in the first place.
# Anaplasia is the characteristic of malignant tumors, and implies loss of the
structural and functional differentiation of normal cells.
# Anaplastic cells display pleomorphism.

PLEOMORPHISM
# Variations in the size and shape of cells throughout the tumor.
# In anaplastic cells:
Nucleus/cytoplasm ratio approaches 1:1 instead of the normal 1:4 or 1:6.
The nucleus is very large and hyperchromatic (darkly stained); there can
be either enormous nucleus or several nuclei.
Chromatin appears rough and clumped.
Numerous and atypical mitotic figures.
Loss of normal cell polarity (the organization and orientation of a certain
cell type in comparison with its neighboring cells).
Large nucleoli may appear.
# Dysplasia describes disorderly but non-neoplastic proliferation, and is the loss
in the uniformity of individual cells and in their architectural orientation; usually
appears in epithelium.
Display pleomorphosm
! Carcinoma in situ (CIN-III) => when dysplastic changes involve the entire
thickness of the epithelium.

GRADING OF CANCER
# Attempts to estimate the aggressiveness, or level of malignancy of the tumor,
based on:
Cytologic differentiation of tumor cells.
Number of mitoses within the tumor cells.
# Grading is in order of increasing anaplasia
I (benign) => well-differentiated (low grade)
II => moderately differentiated (intermediate grade)
III => poorly differentiated (high grade)
IV (malignant) => undifferentiated (high grade)
# Grading varies with each form of neoplasia:
Gleason system used to grade adenocarcinoma cells in prostate cancer.
Bloom-Richardson system for breast cancer.
Fuhrman system for kidney cancer.
LOW GRADE TUMOR
-

Low mitotic rate

Less aggressive => less mitotic
figures, reduced metastaltic
capability
Bad prognosis => more difficult to
treat (chemotherapy works on
dividing cells)
Well differentiated (minimal
pleomorphism)
Less favorable => usually non
curable

HIGH GRADE TUMOR

-

High mitotic rate => lots of mitotic

figures, little differentiation,
increased pleomorphism
Very aggressive => spreads very
fast
Good prognosis => dividing cells
are more easily destroyed, fast
treatment results
More favorable => even that it is
more violent and dangerous, it is
evaluated better and can be cured
faster and easier

TOPIC #40: THE CELL CYCLE. BIOLOGY OF TUMOR CELL

GROWTH. PROLIFERATIVE POTENTIAL IN NEOPLASIA

THE CELL CYCLE

# The sequence of events that take place in the cell, leading to its replication and
division (proliferation), to form copies of itself.
# Phases of cell cycle:
Presynthetic growth phase 1 (G1) during which the biosynthetic
activities of the cell resume at a high rate, mainly production of proteins
necessary for DNA replication.
DNA synthesis phase (S) during which the DNA is replicated, forming
two sister chromatids for each chromosome (one for the parental copy,
and one for the maternal copy of the chromosome).
Premitotic growth phase 2 (G2) continuation of protein production
needed for division.
Mitosis (M) a brief phase consists of nuclear division (karyokinesis),
organelles distribution and cytoplasm division (cytokinesis).
# Stages of mitosis:
Prophase chromatin is condensed into distinct chromosomes and their
sister chromatids, bound at the centromere by cohesion protein complex;
centrosomes and microtubules appear next to the nucleus.
Metaphase nuclear membrane disintegrates; formation of kinetochores
at the centromere, to which microtubules attach, and the chromosomes are
convened along the equatorial plane.
Anaphase sister chromatids are separated, and pulled apart by the
microtubules connected to the kinetochore.
Telophase formation of nuclear membrane, appearance of nucleoli,
chromosomes "relax" and decondense to form chromatin.
# Non-dividing cells can be found in either cell cycle arrest at G1, or they exit the
cycle to enter a phase called G0 => resting phase.
# The progression of cell cycle through the different stages depends on the ability
of the cell to perform an intrinsic quality control => cell cycle checkpoints, thus
preventing the replication of damaged DNA, or the mitosis of abnormal cells
(arrest cell cycle to allow repair, or induce apoptosis).
# The regulation and transition between stages of cell cycle are done by proteins
called cyclins; these protein complexes bind to CDKs (cyclin-dependent kinases),
which promote the mitotic process.
# CDKs are inhibited by CDIs (cyclin-dependent kinase inhibitors).
# The transition between cell cycle stages depends on the amount of CDKs and
cyclins of the specific stage (G1/S transition => cyclin D/CDK4).

BIOLOGY OF TUMOR CELL GROWTH

# Carcinogenesis is the process by which normal cells are transformed into cancer
cells.
# Tumors arise from clonal growth of cells that have inflicted mutations in 4
classes of genes:
Growth-promoting proto-oncogenes.
Growth-inhibiting tumor suppressor genes.
Genes that regulate apoptosis.
Genes involved in DNA repair.
# Each cancer gene has a specific function, the dysregulation of which contributes
to the origin or progression of malignancy.
NORMAL CELL

Failure of DNA repair

DNA damage

Successful DNA repair

Mutation in the genome of somatic cells (genes

affecting DNA repair, growth or apoptosis)

Activation of growth
promoting oncogenes

Inactivation of tumor
suppressor genes

Alterations in genes that

regulate apoptosis

Decreased apoptosis

Unregulated cell
proliferation

Clonal expansion

Tumor progression

Malignant neoplasm

# There are 7 fundamental changes in cell physiology that dictate malignancy:

1) Self-sufficiency in growth signals.
2) Insensitivity to growth-inhibitory signals.
3) Evasion of apoptosis.
4) Limitless replecative potential.
5) Development of sustained angiogenesis.
6) Ability to invade and metastasize.
7) Genomic instability resulting from defects in DNA repair.
# Self-sufficiency in growth signals mutations in proto-oncogenes result in the
formation of oncogenes, whose products are oncoproteins that resemble the
normal products of proto-oncogenes but lack regulatory elements.
Oncogenes function autonomously, and promote uncontrolled cell proliferation
by:
Expression of growth factor and its receptor, independent of an
appropriate stimulus, setting an autocrine loop of cell proliferation.
! PDGF and its receptor in brain tumors.
Over expression of GF receptor, making the cell hypersensitive to the
presence of GF, or mutation of the receptor itself, which delivers
mitogenic signals even in the absence of GF.
! EGF (epidermal GF) receptor family, including ERBB1 and
HER2/NEU in breast, lung and epidermal cancers.
Mutations in genes encoding signaling molecules, which target GF
receptors to their nuclear target.
! RAS a small GTPase, flips between resting GDP-bound state and
active GTP-bound state (upon GF binding); mutations block the
hydrolysis of GTP to GDP, leading to unchecked signaling.
! ABL proto-oncogenes encodes for tyrosine kinase; its activity is
unregulated when the ABL gene is translocated from chromosome
9 to chromosome 22 where is fuses with part of the breakpoint
cluster region (BCR), resulting in the production of a hybrid
protein with unregulated tyrosine kinase activity.
Over production or unregulated activity of transcription factors.
! Translocation of MYC gene leads to the over expression of its
encoded transcription factor, leading to unregulated expression of
its target genes (involved in cell proliferation).
Nutations that activate cyclin genes, or inactivate the regulators of cyclins
and CDKs.
! Cyclin-CDK complexes promote cell cycle; unregulation of
cyclins, CDKs and CDIs results in uncontrolled cell cycle
progression.

# Insensitivity to growth-inhibitory signals tumor suppressor genes encode

proteins that inhibit cellular proliferation; both copies of the gene must be lost for
tumor development.
Retinoblastoma gene RB is in its active state (hypo-phosphorylated) and
inhibits E2F transcription factor by binding it, thus preventing the
transcription of cyclin E (required for G1/S transition => cyclin E-CDK2
complex).
GF signaling leads to cyclin D expression, activation of cyclin D-CDK4/6
complex and the inactivation of RB by phosphorylation => mutations in
RB gene render it nonfunctional.
P53 gene tumor suppressor gene that is activated by anoxia, oncogene
signaling or DNA damage, lead to activation of p53 protein by
phosphorylation, which drives the transcription of p21 => prevents the
phosphorylation of RB, thus blocks G1/S transition to allow DNA repair;
p53 induces apoptosis if the cell is unable to repair itself.
TGF pathway inhibits proliferation by activating growth-inhibiting
genes (CDIs), and suppression of growth-promoting genes (MYC,
cyclins); compromising its function leads to cancer.
# Evasion of apoptosis can be initiated by extrinsic pathway (death receptor) or
intrinsic pathway (BCL2 gene), both results in the activation of proteolytic
cascade of caspases.
Extrinsic pathway activation of death receptor by Fas ligand.
Intrinsic pathway increase permeability of mitochondrial membrane (to
allow the release of cytochrome C and formation of Apaf-1), by disturbing
the balance between pro-apoptotic genes (bax, bak) and anti-apoptotic
genes (bcl2, bcl-xl).
# Limitless replicative potential in normal (somatic) cells, telomerase enzyme is
not expressed, and the telomere regions of the chromosomes are shortened until
they activate cell cycle checkpoints, leading to the limitation of cell division; in
cancerous cells, telomerase prevents the activation of apoptosis by adding DNA
sequences to the telomere region, thus preventing activation of checkpoints.
# Development of sustained angiogenesis tumors require blood supply, and
trigger the formation of new blood vessels (sprouts) from rxisting blood vessels
in a process of angiogenesis, usually due to hypoxia
Hypoxia => activation of hypoxia-induced factor 1 (HIF1) =>
transcription of VEGF
In normal cells, VHL protein binds to HIF1 and leads to its destruction,
while in cancerous cells, HIF1 is not destroyed, leading to transcription
of VEGF (vascular endothelial growth factor), and angiogenesis.
# Ability to invade and metastasize occurs in 4 steps that include loosening of
cell-cell contacts, degeneration of ECM, and migration of tumor cells.
# Genomic instability individuals who are born with inherited defects in DNA
repair proteins are more likely to develop cancer.

PROLIFERATIVE POTENTIAL IN NEOPLASIA

# Dividing cells continuously proliferate to replace cells that eventually die.
! Hematopoietic cells in bone marrow, cells of surface epithelia (skin, oral
cavity, vagina, GI tract).
# Quiescent cells dividing cells found in G0 state; these cells may enter cell cycle
in response to stimulus.
! Parenchymal cells of most solid glandular tissues (liver, kidneys,
pancreas).
# Non-dividing cells cannot undergo division in post-natal life (neurons, skeletal
and cardiac muscle).

TOPIC #41: LOCAL INVASION IN MALIGNANCY. ROLE OF

STROMA. ANGIOGENESIS

LOCAL INVASION IN MALIGNANCY

# Malignant neoplasm grows by progressive infiltration, invasion, destruction and
penetration of the surrounding tissue, and does not develop a capsule; in some
cases, malignant tumors appear to be encased by the stroma of the surrounding
tissue, when actually small extensions of the tumor penetrate and infiltrate into
the surrounding tissue, making it necessary to remove some of the normal tissue
when removing the malignant tumor.
# Role of stroma:
o carrying blood supply, crucial to the growth of the tumor.
o Determine the consistency of the neoplasm; certain cancers induce a
dense, abundant fibrous stroma(desmoplasia)
o in general, encapsulation is the rule in benign tumors (benign)

ANGIOGENESIS
# Blood vessels are formed in 2 processes:
1) Vasculogenesis the formation of primitive vascular system from
angioblasts during embryonic development.
2) Angiogenesis (neovascularization) existing vessels send out capillary
sprouts to produce new vessels.
# Steps of angiogenesis:
Vasodilation in response to NO, increased permeability due to VEGF.
Migration of endothelial cells to the site of injury.
Proliferation of endothelial cells.
Inhibition of endothelial cells proliferation and remodeling into capillary
tubes.
Recruitment of periendothelial cells (pericytes for capillaries, smooth
muscle cells for larger vessels), to form mature vessels.
# New vessels formed during angiogenesis are leaky due to incompletely formed
interendothelial junctions, and due to the presence of VEGF.
# GFs involved in angiogenesis:
VEGF induced by hypoxia, TGF/ stimulates the proliferation and
motility of endothelial cells, bind to a family of tyrosine kinase receptor.
Promotes vasodilation by stimulate the production of NO, and contribute
to the formation of vascular lumen

Angiopoietins 1 & 2, PDGF, TGF participate in the stabilization of the

newly formed vessels by the recruitment of pericytes, smooth muscle cells
and deposition of connective tissue
FGF2 stimulates the proliferation of endothelial cells, promotes the
migration of macrophages and fibroblasts to the damaged area, and
stimulates epithelial cells migration to cover epidermal wounds.

Growing cancers stimulate neoangiogenesis, during which

vessels sprout from previously existing capillaries.
Neovascularization has a dual effect on tumor growth:
perfusion supplies needed nutrients and oxygen, and
newly formed endothelial cells stimulate the growth of
adjacent tumor cells by secreting growth factors, such as
insulin-like growth factors (IGFs) and PDGF.
the
vessels are leaky and dilated, features that can be appreciated on angiograms.
By permitting tumor cells access to these abnormal
vessels, angiogenesis also contributes to metastasis.
The molecular basis of the angiogenic
involves increased production of angiogenic factors and/
or loss of angiogenic inhibitors. These factors may be produced
by the tumor cells themselves or by inflammatory
cells (e.g., macrophages) or other stromal cells associated
with the tumors. Many proteases can release proangiogenic
basic fibroblast growth factors (bFGF) that are
stored in the ECM; conversely, the angiogenesis inhibitors
angiostatin and endostatin are produced by proteolytic
cleavage of plasminogen and collagen, respectively.
The local balance of angiogenic and antiangiogenic
factors is influenced by several factors: Relative lack of oxygen activates the transcription of the
proangiogenic
cytokines VEGF and bFGF. These factors
create an angiogenic gradient that stimulates the proliferation
of endothelial cells and guides the growth of
new vessels toward the tumor. VEGF also increases the
expression of ligands that activate the Notch signaling
pathway, which regulates the branching and density of
the new vessels.
Mutations involving tumor suppressors and oncogenes
in cancers also tilt the balance in favor of angiogenesis.
For example, p53 can stimulate expression of antiangiogenic
molecules, such as thrombospondin-1, and repress
expression of proangiogenic molecules such as VEGF.
Thus, loss of p53 in tumor cells not only removes cell
cycle checkpoints and alters tumor cell metabolism but
also provides a more permissive environment for
angiogenesis.
The transcription of VEGF is also influenced by signals
from the RAS-MAP kinase pathway, and gain-of-function
mutations in RAS or MYC upregulate the production
of VEGF.

TOPIC #42: MECHANISMS OF LOCAL AND DISTANT SPREAD.

MOLECULAR BASCIS OF METASTASES. STAGING OF CANCER
The metastatic cascade can be divided into two phases:

Invasion of ECM
Vascular spread and homing of tumor cells

MECHANISM OF LOCAL INVASION

There are two types of ECM which separate the cells from each other basement membrane and
interstitial connective tissue.
Steps:

Loosening of tumor cells:

E-cadherin keep cells together and can transmit anti-growth signals.
E-cadherin function is lost in almost all epithelial cancers.

Degradation of the BM and interstitial CT.

Tumor may secrete proteolysis enzymes or induce stromal cells(fibroblast &
inflammatory cells) to elaborate proteases (e.g. matrix metalloproteinase, urokinase
plasminogen activator).
MMP also release growth factors may stimulate VEGF.

Change in attachment of tumor cells to ECM proteins

Normal cells posses integrin for BM laminin and collagen receptors that maintain cells
in its differentiated state. While in normal cells loss of these receptor initiates apoptosis,
tumor cells are resistant to this form of cell death.

Locomotion, propelling tumor cells through the degraded BM. The tumor cells secrete
autocrine motility factors and GF (insulin-like GF).

MECHANSM OF DISTAL SPREAD

Some tumor cells form emboli by aggregating and adhering to circulating WBC, mainly platelets
thus achieve protection from anti-tumor host effector cells.
Extravasation of tumor cells involves using adhesion to vascular endothel followed by egress
through BM into organs parenchyma by mechanism similar to invasion.
Some tumors (lung cancer) tend to involve a specific distal tissue (adrenals), they do so by:
Expression of adhesion molecules whose ligands are expressed preferentially on endothel
of target cells

Expression of chemokines and their receptors. For example, breast cancer express high
levels of CXCR4/7 chemokine receptors, the ligand of these receptors (CXCR12/21) are
expressed only on those organs to which the cancer metastasize.
Once reaching the target, the stroma must supply the growth demands of the tumor. In
some cases te tissue may be a nonresponsive environment for example skeletal muscle
are rarely site of metastases.
MOLECULAR BASIS OF METASTASIS
Suggested hypothesis:
The clonal evolution model suggests that as mutations accumulate in cancer cells, rare
subset of tumor cell subclones acquires a pattern of gene expression that is permissive for
all steps involved in metastasis.
A subset of breast cancers has a metastatic gene expression signature similar to that found
in metastases, although no clinical evidence for metastasis is apparent. It is hypothesized
that in these tumors with a metastasis signature most if not all cells develop a
predilection for metastatic spread during early stages of carcinogenesis
A third idea that combines the two above supposes that the metastatic signature is
necessary but not sufficient for metastasis, and that additional mutations are needed for
metastasis to occur.
Candidates for metastasis oncogenes which could promote/suppress metastase are SNAIL
and TWIST, which promote epithelial-to-mesenchymal transition (EMT). In EMT,
carcinoma cells downregulate certain epithelial markers (e.g., E-cadherin) and upregulate
certain mesenchymal markers (e.g. smooth muscle actin). These changes are believed to
favor the development of a promigratory phenotype that is essential for metastasis.
STAGING
Based on the size of the primary lesion, its extent of spread to regional lymph nodes, and the
presence or absence of bloodborne metastases. The major staging system uses a classification
called the TNM system:
T for primary tumor
The primary lesion is characterized as T1 to T4 based on increasing size
T0 is used to indicate an in situ lesion.
N for regional lymph node involvement
N0 would mean no nodal involvement.
N1 to N3 would denote involvement of an increasing number and range of nodes.
M for metastases
M0 signifies no distant metastases
M1 or sometimes M2 indicates the presence of metastases and some judgment as to their number.

TOPIC #43: HEREDITY IN CANCER. CANCER SYNDROMES

HEREDITY IN CANCER
# Autosomal dominant
Inheritance of a single mutant gene greatly increases the risk of
developing a tumor
Most common cancer in this mode of transsmition ic RB.
40% of RB are familial (others are sporadic) carry an inherited disabling
mutation in a tumor suppressor gene.
Familial rB develop bilateral tumors, and are at high risk of developing a
secondaty cancer (osteosarcoma)
Specific marker phenotype => multiple benign tumors in affected tissue.
! Familial polyposis of the colon, multiple endocrine neoplasia.
# Autosomal recessive syndromes of defective DNA repair characterized by
chromosomal or DNA instability, greatly increases the predisposition to
environmental carcinogens (for example, xeroderma pigmentosum).
# Familial cancers of uncertain inheritance characterized by onset at early age in
2 or more close relatives:
Transmission pattern is not clear.
No specific marker phenotype => for example, familial colonic cancers do
not arise in pre-existing benign polyps.
Carcinomas of colon, breast, ovary, and brain.

GENES CHARACTERISTICS
# Proto-oncogenes normally functioning genes that encode for products having a
major role in proliferation; convert into oncogenes by mutation (gain of function).
! Excess in GF => PDGF; receptor alteration => tyrosine kinase; nuclear
TF => MYC; cell cycle elements => cyclin D.
# Tumor suppressor genes encode for proteins that have inhibitory role by
holding back proliferative processes; mutations cause uncontrolled growth (loss
of function).
! RB gene => regulates G1/S transition; p53 gene => regulates DNA repair
and apoptosis (Li-Fraumeni syndrome).
# Genes that regulate apoptosis bcl2 family (anti- and proapoptotic factors).
# Genes that regulate DNA repair occurs due to mutations in cells that are
sensitive to DNA damage.

CANCER SYNDROMES
# In addition to genetic influences, some clinical conditions may predispose to
development of malignant neoplasms => PRENEOPLASTIC DISORDERS
# Such conditions may increase the likelihood of developing cancer.
# Chief predisposing conditions:
Persistent regenerative cell replication
Hepatocellular carcinomas in liver cirrhosis, squamous endometrial
hyperplasia, bronchogenic carcinoma in dysplastic bronchial mucosa
of smokers
Hyperplastic and dysplastic proliferations
Endometrial carcinoma in atypical endometrial hyperplasia,
bronchogenic carcinoma in dysplastic bronchial mucosa of smokers
Chronic atrophic gastritis
Gastric carcinoma in pernicious anemia, or following long-standing
Helicobacter pylori infection
Chronic ulcerative colitis
Colorectal carcinoma in long-standing gastric diseases
Leukoplakia of oral cavity, vulva or penis
Adhere to white plaques on mucous membranes, increases the risk of
squamous cell carcinoma
Villous adenomas of the colon
High risk of transforming into colorectal carcinoma

TOPIC #44: CLONALITY IN NEOPLASIA. GENETIC

PROGRESSION IN CANCER. TUMOR-CELL
HETEROGENEITY

CLONALITY IN NEOPLASIA
# Tumor results from non-lethal genetic damage.
# Tumor mass develops from clonal expansion of a single progenitor cell that has
acquired genetic damage => tumors are monoclonal.
# Target genes of genetic damage:
Proto-oncogenes transform into oncogenes due to mutation in only one
allele, therefore they are considered dominant.
Tumor suppressor genes require both alleles to be mutated in order to lose
their function (considered recessive); can be either promoters ("release the
breaks" on cellular proliferation), or they can be caretakers (ensure
integrity of genome).
Genes that regulate apoptosis may be dominant, or act as tumor
suppressor genes.
Genes that regulate DNA repair affect cell proliferation by influencing the
ability of the cell to repair non-lethal damage in other genes.

GENETIC PROGRESSION IN CANCER

# Carcinogenesis multistep process at phenotypic and genotypic levels, resulting
from the accumulation of multiple mutations => creating sub-populations of
clones.
# Malignant neoplasms have several phenotypic characteristics, such as excessive
growth, local invasiveness, and the ability to form distant metastases.
# Tumor progression the ability of the tumor to become more aggressive and
acquire greater malignant potential; at the molecular level, tumor progression
results from mutations that accumulate independently in different cells,
generating sub-clones with different characteristics.
# Those characteristics are:
Ability to invade.
Rate of growth.
Metastatic ability.
Hormonal responsiveness.
Responsiveness to anti-neoplastic drugs.

TUMOR CELL HETEROGENEITY

# Malignant tumors are monoclonal in origin, but become extremely heterogenous
by the time they are clinically evident.
# Heterogeneity results from continuous multiple mutations that accumulate in
different cells, generating new sub-clones.
# These new sub-clones are subjected to host defenses (immune and non-immune);
some will be destroyed and some will survive and become "experts" in survival,
growth, invasion and metastasis.

TOPIC #45: LABORATORY DIAGNOSIS OF CANCER

(histopathology, cytopathology and molecular methods)

MORPHOLOGIC METHODS
# Sampling techniques
Excision or biopsy removal of the tumor with margin, or of a large mass
of the tumor, preserve in fixation and microscopically analyzed.
Frozen section a sample is quick frozen and sectioned, permits
immediate histologic evaluation.
Fine-needle aspiration used with palpable lesions (breast, thyroid, lymph
nodes, salivary glands); involves aspiration of cells from a mass, followed
by cytologic examination of the smear.
Cytologic smears neoplastic cells are less adhesive and shed into fluids
or secretions; these cells are then evaluated for anaplastic features.
# Specimen evaluation and classification
Immunocytochemistry detection of characteristic proteins by specific
monoclonal antibodies, labeled with peroxidase.
! Detection of cytokeratin in case of undifferentiated carcinoma;
detection of PSA in metastatic deposits allow the diagnosis of
primary tumor in the prostate.
Flow cytometry used in classification of leukemias and lymphomas; a
method in which antibodies against cell surface molecules and against
differentiation markers are labeled with fluorescence dye, and are used to
obtain the phenotype of malignant cells.

TUMOR MARKERS
# Tumor markers associated with enzymes, hormones etc.; cannot be used for
definitive cancer diagnosis, but contribute to determination of therapy
effectiveness or recurrent appearance.
# Common markers are:
PSA (prostate specific antigen)
Screen for prostetic adenocarcinoma
Elevated in carcinoma, but also in benign prostetic hyperplasia
PSA test shows low sensitivity and low specificity
CEA (carcino-embryonic antigen)
Increases in cancers of colon, pancreas, breast and stomach
Also produced in non-neoplastic conditions
Low sensitivity and low specificity
AFP (alpha-fetoprotein)
Produced by hepatocellular carcinoma, and yolk sac remnants in
gonads
Elevated in cancers of testes, ovary, pancreas and stomach
Also elevated in non-neoplastic conditions
Low sensitivity and low specificity

TOPIC #46: SYSTEMIC EFFECTS OF NEOPLASIA

(paraneoplastic syndromes, immunosuppression, cachexia)

SYSTEMIC EFFECT OF NEOPLASIA

# Both malignant and benign tumors can cause morbidity and mortality.
# Clinical features:
Location and impingement on adjacent structures
- Small tumor in the pituitary gland, either malignant or benign, may
compress and destroy the gland. (hypopituitarism)
- Leiomyoma in the renal artery may lead to ischemia and
hypertension.
Functional activity (e.g: hormone synthesis/paraneoplastic syndrome)
- Seen in neoplasms of endocrine glands.
- Adenoma/carcinoma in beta cells of the pancreatic islets of
Langerhans can cause hyperinsulinism
- Adenoma/carcinoma of adrenal cortex can affect aldosterne
secretion (Na retention), hypertension, hypokalemia
Ulceration
- Tumors may cause ulceration through a surface, leading to bleeding
and infection.
Cancer cachexia
- Loss of body fat, wasting, profound weakness.
Rupture/infraction

PARANEOPLASTIC SYNDROMES
# Refers to symptoms that are not directly related to the spread of the tumor or to
hypersecretion of hormones caused by the tumor.
# Paraneoplastic (10-15% of patients) syndromes are important because:
1) They may represent early manifestations of neoplasm.
2) They may cause significant clinical problems, and may be lethal.
3) They may mimic metastatic disease, confounding treatment
# Most common syndromes:
Hypercalcemia multifactorial, main effector is PTH-like peptide
produced by tumor cells. Other tumor-derived factors are TGF which
activates osteoclasts and vitamin D
Cushing syndrome abnormal production of ACTH, or ACTH-like
peptides, by tumor cells, as occurs in small cancer cells of the lung =>
stimulates production of glucocorticoids (stress hormones).
Bronchogenic carcinomas produce mol identical to ACTH, anti-diuretic,
PTH, serotonin, hCG
Non-bacterial thrombotic endocarditis in heart valves.

Hypercoagulability venous thrombosis

Neoplasm most often associated with these syndromes are lung, breast &
hematologic malignancies.

CACHEXIA
# Progressive loss of body fat accompanied by profound weakness and anemia.
# Cachexia is NOT caused by nutritional demands of the tumor, but it is caused by
the action of cytokines produced by the tumor.
# In cancer patients, calorie expenditure and BMR are high, despite reduced food
intake.
# The basis of these metabolic abnormalities is unknown, but it is suspected that
TNF and IL-1 produced by macrophages in response to tumor cells (or by the
tumor itself), may mediate cachexia.
# TNF suppresses appetite and inhibits lipoprotein lipase, thus inhibits the release
of FFAs from lipoproteins.
# Central loss of apetite (hypothalamus)
# Mobilizing factor proteolysis-inducing factor, which causes breakdown on
skeletal muscle protein has been detected in the serum of cancer patients.
IMMUNOSUPRESSION
# Bone marrow suppression by tumor factors (leukemia? Monoclonal expansion of
AB?)
# Toxicity of chemotherapy, irradiation of BM
# Malnutrition, anorexia

TOPIC #47: DEFINITION OF DYSPLASIA. PRECANCEROUS

LESIONS

DEFINITION OF DYSPLASIA
# Disordered cellular growth
# Most often refers to proliferation of precancerous cells
o cervical intraepithelial neoplasia (CIN) represents dysplasia and is a
precursor to cervical cancer
# Often arises from longstanding pathologic hyperplasia (e.g., endometrial
hyperplasia) or metaplasia (e.g., Barrett esophagus)
# Dysplasia is reversible, in theory, with alleviation of inciting stress
o If stress persists, dysplasia progresses to carcinoma (irreversible).

PRECANCEROUS LESIONS
# Identifiable local signs (abnormalities) that, with time, have an increased risk of
developing into cancer.
# These consist of genetically and phenotypically altered cells that exhibit a higher
risk to develop to malignant tumors.
# arise in the setting of chronic tissue injury or inflammation, which may increase
the likelihood of malignancy by stimulating continuing regenerative proliferation
or by exposing cells to byproducts of inflammation, both of which can lead to
somatic mutations1
# Early removal may prevent the development of a cancer
# These lesions include:
Squamous metaplasia and dysplasia of the bronchial mucosa, seen in
habitual smokers - a risk factor for lung cancer
Endometrial hyperplasia and dysplasia, seen in women with unopposed
estrogenic stimulation - a risk factor for endometrial carcinoma
Leukoplakia of the oral cavity, vulva, or penis, which may progress to
squamous cell carcinoma
Villous adenomas of the colon, associated with a high risk of
transformation to colorectal carcinoma

A change in the genetic structure that is not inherited from a parent, and also not
passed to offspring

Topic #48: VASCULITIS. DEFENITION, PATHOGENESIS, CLASSIFICATION.

Vasculitis, inflammation of vessel walls. Besides the findings referable to the specific tissue(s)
involved, general signs and symptoms such as fever, muscle pain(myalgia) and joint pain
(arthralgias) also appear.
Vessels of any type in virtually any organ can be affected, and most form of vasculitis affect
small vessels (arterioles, capillary, venules). Nevertheless, several of the vasculitis tend to
affect large vessels(medium sized muscular arteries).
Some 20 primary forms of vasculitis are recognized, and classifications schemes attempt to
group them according to:
vessel size
role of immune complexes
presence of specific autoantibodie
granuloma formation
tissue tropism
population demographics.

The two most common pathogenic mechanisms of vasculitis are:

immune-mediated inflammation
direct invasion of vascular walls by infectious pathogens.

Infections can also indirectly induce a noninfectious vasculitis, for example, by generating
immune complexes or triggering cross-reactivity.
It is critical to distinguish between infectious and immunologic mechanisms, because
immunosuppressive therapy is appropriate for immune-mediated vasculitis but could be
harmful for infectious vasculitis. Physical and chemical injury can also cause vasculitis.
Noninfectious Vasculitis
The main immunologic mechanisms that initiate noninfectious vasculitis are:

(1)

immune complex deposition

antineutrophil cytoplasmic antibodies (ANCAs)
anti-endothelial cell antibodies.
Autoreactive T cells
Immune complex-associated vasculitis:

Seen in systemic immunologic disorder such as SLE, that are associated with
autoantibody production.
Immune complexes deposition is implicated in the following vasculitis:
- Drug hypersensitivity vasculitis: (e.g. penicillin/streptokinase). Antibodies directed
against the drug modified proteins result/foreign mol in immune complex formation.
Skin lesions are main manifestation.
- Vasculitis secondary to infections: antibody to microbial constituents can produce
immune complexes that deposit in vascular lesions. E.g. hepatitis B surface Ag and
anti HB Ab.
(2) Antineutrophil cytoplasmic antibodies:
Circulating Ab that react with neutrophil cytoplasmic Ag called anti-neutrophil
cytoplasmic antibodies ANCAs (autoantibodies). ANCAs serve as useful quantitative
diagnostic markers for the ANCA-associated vasculitides, and their levels can reflect the
degree of inflammatory activity.
Two are most important:
-

Antiproteinase-3 (PR3- ANCA), a neutrophil granule constituent that shares

homology with numerous microbial peptides. Associated with Wegener
granulomatosis.
Anti-myeloperoxidase (MPO-ANCA), a lysosomal granule constitute involved in
oxygen free radical generation. MPO-ANCA are inducaed by several therapeutic
agents(propylthiouracil). It is associated with, microscopic polyangiitis and Churg
Strauss syndrome.

A possible mechanism for ANCA vasculitis involves the following sequence:

-

Drug or microbial Ag induces ANCA formation; alternatively, leukocytes surface

expression or release of PR3 and MPO incites ANCA development.
Infection, endotoxin exposure or inflammatory stimulus elicits cytokines such as TNF
that upregulate the surface expression of PR3 and MPO on neutrophil.
ANCA bind these cytokine-activated cells, causing further activation of neutrophils.
ANCA activated neutrophils cause endothelial cell injury by releasing granule
contents and reactive oxygen species.

The ANCA autoantibodies do not form circulating immune complexes! It is often

describe as " pauci immune".
(3) Antiendotheloal cell antibodies: Ab to endothelial cells, for example in Kawasaki
disease.
Infectious Vasculitis
Localized arteritis may be caused by the direct invasion of infectious agents, usually bacteria
or fungi (Aspergillus and Mucor spp.). Vascular infections can weaken arterial walls and give
rise to mycotic aneurysms, or they can induce thrombosis and infarction.
Thus, involvement of meningeal vessels in bacterial meningitis can cause thrombosis and
infarction, ultimately extending a subarachnoid infection into the brain parenchyma.

Topic #49: SMALL-VESSELS VASCULITIS

(Microscopic polyangiitis, Churg-Strauss syndrome, Wegner
granulomatosis).
Microscopic Polyangiitis
#
#
#

#
#

#
#
#

This is a necrotizing vasculitis that generally affects capillaries as well as

arterioles and venules of a size smaller than those involved in PAN.
It is also called hypersensitivity vasculitis.
Unlike PAN, all lesions of microscopic polyangiitis tend to be of the same age
in any given patient. The skin, mucous membranes, lungs, brain, heart, GI
tract, kidneys, and muscle can all be involved
necrotizing glomerulonephritis (90% of patients) and pulmonary capillaritis
are particularly common.
Pathogenesis - In many cases, an antibody response to antigens such as drugs,
microorganisms or tumor proteins. This can result in immune complex
deposition, or it may trigger causal secondary immune responses.
o Henoch-Schnlein purpura - Vasculitis due to IgA immune complex
deposition; most common vasculitis in children
P-ANCAs are present in more than 70% of patients.
Recruitment and activation of neutrophils within a particular vascular bed are
probably responsible for the manifestations of the disease.
Morphology- Characterized by segmental fibrinoid necrosis of the media with
focal transmural necrotizing lesions; granulomatous inflammation is absent.
Little or no immunoglobulin can be seen in most lesions (so-called "pauciimmune" injury).
Clinical Course- Depending on the location, clinical features include
hematuria, and proteinuria; bowel pain or bleeding; muscle pain or weakness.
Most patients respond to simple removal of the offending agent.

Wegener Granulomatosis
#

Wegener granulomatosis is a necrotizing vasculitis characterized by a triad of

Granulomas of the lung and / or upper respiratory tract (ear, nose, sinuses,
throat)
Vasculitis affecting small to medium-sized vessels, most prominent in the
lungs and upper airways.
Glomerulonephritis.

Clinically, this resembles PAN except that there is also respiratory involvement.
#

Pathogenesis- Wegener granulomatosis probably represents some form of cellmediated hypersensitivity response. C-ANCAs are present in up to 95% of
cases; they are a useful marker of disease activity, and may participate in
disease pathogenesis.

Morphology
o upper respiratory tract lesions range from inflammatory sinusitis to
ulcerative lesions of the nose, palate, or pharynx.
o Lung finding range from diffuse parenchymal infiltrates to
granulomatous nodules
o Multifocal necrotizing granulomatous vasculitis with a surrounding
fibroblastic proliferation
o Renal lesions focal and segmental necrotizing glomerulonephritis, or
more advanced glomerular lesion with diffuse necrosis and parietal cell
proliferation (crescentic glomerulonephritis)
Clinical Features- Males are affected more than females. The average age is
40 years. Classical features include bilateral pneumonitis with nodular and
cavitary lesion (95%), chronic sinusitis (90%) and evidence of renal disease
(80%).
If untreated 80% of patients die within 1 year.
Treatment steroids, cyclophosphamide, TNF inhibitors and anti-B cell
antibody (Rituximab)

Churg-Strauss syndrome
#

#
#

Allergic granulomatosis and angiitis (Churg-Strauss syndrome) is a condition

related to Wegener granulomatosis, distinguished by a strong association with
allergic rhinitis and bronchial asthma
Cutaneous involvement (with palpable purpura), gastrointestinal bleeding, and
renal disease (primarily as focal and segmental glomerulosclerosis) are the
major associations.
Cytotoxicity produced by the myocardial eosinophilic infiltrates often leads to
cardiomyopathy; cardiac involvement is seen in 60% of patients and is a major
cause of morbidity and death
Churg-Strauss syndrome may stem from hyperresponsiveness to some
normally innocuous allergic stimulus
The vascular lesions differ from those of polyarteritis nodosa or microscopic
polyangiitis by virtue of the presence of granulomas and eosinophils.

Topic #50: MEDIUM-VESSELS VASCULITIS.

(polyarteriitis nodosa, Kawasakis disease, Buergers disease)
Polyarteritis Nodosa
#

#
#

#
#

Polyarteritis nodosa (PAN) is a systemic vasculitis of small or medium-sized

muscular arteries (but not arterioles, capillaries, or venules), typically
involving renal and visceral vessels but NOT the pulmonary circulation.
Not associated with ANCA, 1/3 of patients have chronic hepatitis B infection
which leads to formation of immune complexes.
Morphology
Classic PAN is characterized by segmental transmural necrotizing
inflammation often with thrombosis. Vessels of the kidneys, heart,
liver, and GI tract are involved. Lesions usually involve only part of the
vessel length, with a preference for branch points. The inflammatory
process weakens the arterial wall and can lead to aneurysms or even
rupture. Impaired perfusion with ulcerations, infarcts, ischemic
atrophy, or hemorrhages in the distribution of affected vessels may
be the first sign of disease.
During the acute phase there is transmural inflammation of the
arterial wall with a mixed infiltrate of inflammatory cells, frequently
accompanied by fibrinoid necrosis. Luminal thrombosis can occur.
Later, the acute inflammatory infiltrate is replaced by fibrous
thickening of the vessel wall that can extend into the adventitia.
Characteristically, all stages of activity (from early to late) may coexist
in different vessels or even within the same vessel, suggesting
ongoing and recurrent pathogenic insults.
Clinical Course
PAN is a disease primarily of young adults, but can occur at all ages.
The course can vary from acute to chronic but is typically episodic,
with long symptom-free intervals. Vascular involvement is widely
scattered. The most common manifestations are malaise, fever, and
weight loss; hypertension caused by renal artery involvement;
abdominal pain and bloody stool caused by vascular GI lesions;
muscular pains; peripheral neuritis.
Renal (arterial) involvement is common and a major cause of death,
although glomerulonephritis is absent.
Biopsy is often necessary to confirm the diagnosis.
If untreated, the disease is fatal in most cases; (therapy with corticosteroids )
immunosupression drugs results in remissions or cures in 90%.

Kawasaki Disease
Kawasaki disease is an acute high fever, usually self-limited illness of infancy
and childhood (80% of patients are younger than 4 years) associated with an
arteritis affecting large to medium-sized, and even small vessels. Its clinical
significance stems from the involvement of coronary arteries; coronary
arteritis can result in aneurysms that rupture or thrombose, causing acute
myocardial infarctions.
# Kawasaki disease is the leading cause of acquired heart disease in children.
# The vascular damage is primarily mediated by activated T cell and
macrophages
# Pathogenesis
The etiology is uncertain, but thought to result from a delayed-type
hypersensitivity response of T cells. This leads to cytokine production,
B-cell activation and the formation of autoantibodies to Endothelial
cells and Smooth muscles cells.
The autoantibodies precipitate the acute vasculitis.
#

Morphology - The vasculitis is PAN-like, theres a dense transmural

inflammatory infiltrate with inflammation affecting the entire thickness of
the vessel wall; Fibrinoid necrosis is usually less prominent than in PAN.
Although the acute vasculitis subsides spontaneously or in response to
treatment, aneurysm formation, or thrombosis and myocardial infarction,
can appear.
Healed lesions may have obstructive intimal thickening.
# Clinical Course Typically presents with conjuctival and oral erythema and blistering, edema
of hands and feet, rash and cervical lymph node enlargement. 20% of
untreated patients devolpe cardiovascular disease. Intravenous
immunoglobulin or aspirin therapy sharply reduces the rate of coronary
artery disease.
#

Thromboangiitis Obliterans (Buerger Disease)

Buerger disease is a distinctive disease that often leads to vascular
insufficiency. Characterized by segmental, thrombosing acute and chronic
inflammation of medium-sized and small arteries, principally the tibial and
radial arteries with occasional secondary extension into the veins and nerves
of the extremities. Occurs almost exclusively in heavy smokers of cigarettes,
usually beginning before age 35.
# Pathogenesis - The strong relationship to cigarette smoking is thought to
involve direct toxicity to endothelium by some tobacco products. Most
patients have hypersensitivity to intradermally injected tobacco extracts, and
#

their vessels show impaired endothelium-dependent vasodilation. Genetic

influences are suggested by an increased prevalence in certain ethnic groups
(Israeli, Japanese) and a association with particular HLA haplotypes
# Morphology
Theres acute and chronic inflammation, accompanied by luminal thrombosis.
The thrombus can contain small microabscesses composed of neutrophils
surrounded by granulomatous inflammation. The thrombus may eventually
organize and recanalize. The inflammatory process extends into contiguous
veins and nerves (rare with other forms of vasculitis), and with time all three
structures can be encased in fibrous tissue.
#

Clinical Features the vascular insufficiency tends to be accompanied by severe pain,

even at rest, related to the neural involvement.
Chronic ulcerations of the toes, feet, or fingers may appear.
Quitting cigarette smoking in the early stages of the disease often
brings dramatic relief from further attacks.

Topic #51: LARGE-VESSELS VASCULITIS.

(Giant-cell arteritis, Takayashus arteritis). Infectious vasculitis.

Giant-Cell (Temporal) Arteritis

#
#
#
#

Giant-cell (temporal) arteritis is the most common of the vasculitis. It is a chronic,

typically granulomatous inflammation of large to small-sized arteries.
Principally affects the arteries in the head-especially the temporal arteries-but also the
vertebral and ophthalmic arteries, as well as the aorta (giant-cell aortitis).
Ophthalmic artery involvement can lead to sudden and permanent blindness.
Pathogenesis -thought to be T cell-mediated immune response to an unknown vessel
wall antigen. Pro-inflammatory cytokines (especially TNF) and anti-endothelial cell
antibodies also contribute. The good response to steroids also tell us that it is an
immune etiology
Morphology- Nodular intimal thickening with reduction of the lumen and occasional
thrombosis. Classical lesions show granulomatous inflammation within the inner
media centered on the internal elastic membrane; there is a lymphocyte (CD4+ more
than CD8+) and macrophage infiltrate, with multinucleated giant cells, and
fragmentation of the internal elastic lamina. Inflammatory lesions are not continuous
along the vessel, and long segments of relatively normal artery may separate areas of
inflammation.
Healed area is marked by collagenous thickening of the vessel wall; organization of a
luminal thrombus can transform the artery into a fibrous cord.
Clinical Features :
Usually occurs in patients over 50 years of age. Symptoms may be
unspecific- fever, fatigue, weight loss-or may involve facial pain or headache,
most intense along the course of the superficial temporal artery, which is
painful to palpation.
Ocular symptoms (ophthalmic artery) appear in about 50% of patients; may
cause complete vision loss.
Diagnosis depends on biopsy and histologic confirmation.
However, because temporal arteritis is extremely segmental, adequate biopsy
requires at least a 2- to 3-cm length of artery; even then, a negative biopsy
result does not exclude the diagnosis. Treatment with corticosteroids is
generally effective.

Takayasu Arteritis
#

#
#

This is a granulomatous vasculitis of medium and larger arteries characterized

principally by ocular disturbances and weakening of the pulses in the upper
extremities (hence its other name, "pulseless disease").
It causes transmural fibrous thickening of the aorta-particularly the aortic arch and
great vessels-with severe luminal narrowing of the major branch vessels.
Similar to giant cell aortitis, the distinction is by the age of the patient. <50 Takayasu
> 50 giant cell

Morphology
Takayasu arteritis classically involves the aortic arch but in a third of cases
also affects the remainder of the aorta and its branches;
Pulmonary arteries are involved in 50% of patients. Gross changes include
intimal hyperplasia and irregular thickening of the vessel wall;
When the aortic arch is involved, the origin for the great vessels can be
markedly narrowed or even obliterated. Such narrowing explains the
weakness of the peripheral pulses;
Coronary and renal arteries may be similarly affected.
Clinical Features:
Initial symptoms are nonspecific, including fatigue, weight loss, and fever.
With progression, vascular symptoms appear and dominate the clinical
picture. These include reduced blood pressure and weaker pulses in the upper
extremities relative to the lower extremities, with coldness or numbness of
the fingers;
Ocular disturbances, including visual defects, retinal hemorrhages, and total
blindness and neurologic deficits.
Pulmonary artery involvement may cause pulmonary hypertension.
Narrowing of the coronary orifice may lead to myocardial infarction.
Involvement of the renal arteries leads to systemic hypertension.

Infectious Vasculitis
Localized arteritis may be caused by the direct invasion of infectious agents, usually bacteria
or fungi (Aspergillus and Mucor spp) .
Vascular invasion can be part of a more general tissue infection (e.g., bacterial pneumonia or
adjacent to abscesses), or less commonly arise from hematogenous spread of bacteria during
septicemia or embolization from infective endocarditis.
Vascular infections can weaken arterial walls and give rise to mycotic aneurysms, or they can
induce thrombosis and infarction. Thus, involvement of meningeal vessels in bacterial
meningitis can cause thrombosis and infarction, ultimately extending a subarachnoid infection
into the brain parenchyma.

TOPIC #52: GENERAL FEATURES OF ANEMIA. BLOOD LOSS

ANEMIA. HEMOLYTIC ANEMIAS
GENERAL FEATURES OF ANEMIA
# Anemia the reduction of oxygen transport capacity of the blood, resulting from
decrease in number of RBCs (bleeding, increased destrucrion/decreased
production), or reduced concentration of hemoglobin.
# Decreased tissue ox tension triggers increased production of erythropoietin from
specialized cells in kidney compensatory hyperplasia of erythroid precursors
in BM and, in severe anemias, the appearance of extramedullary hematopoiesis
within secondary hematopoietic organs (liver, spleen, lymph nodes).
Reticulocytes can be detected in peripheral blood (anemias due to decreased
production are associated with reticulocytopenia).
# Anemias can be also classified on the basis of RBC morphology:
Microcytic (iron def, thalassemia)
Macrocytic (folate/B12 def)
Normocytic with abnormal shape (hereditary sherocytosis, sickle cell)
and by color (normo/hyper/hypo-chromic)
#

Possible tests:
iron (anemia due to iron def/chronic disease/thalassemia)
plasma unconjugated bilirubin, LDH, haptoglobin (hemolytic anemias)
folate/b12 cc (low in megaloblastic anemias)
Hb electrophoresis
Coombs test (immunohemolytic anemia)
In case anemia occurs along thrombocytopenia/granulocytopenia,
likely to be associated with BM aplasia/infiltration BM examination
Clinical consequence are determined its by severity, rapidity of onset and
underlying pathogenic mechanism. If onset is slow, compensatory mechanism by
increase plasma volume, CO, respiratory rate, level of red cell 2,3diphosphoglycerate (enhance release of O2 from Hb).
Pallor, fatigue are common to all forms of anemia. Anemias that result from
ineffective hematopoiesis are associated with inappropriate increase in iron abs,
damage to endocrine and heart.
The lowered oxygen content of the circulating blood leads to dyspnea on mild
exertion. Hypoxia can cause fatty change in the liver, myocardium, and kidney.
myocardial hypoxia manifests as angina pectoris, particularly when complicated
by pre-existing coronary artery disease. With acute blood loss and shock. Central
nervous system hypoxia can cause headache, dimness of vision, and faintness.

BLOOD LOSS ANEMIA

# Acute (>20% of blood volume)
Immediate threat => hypovolemic shock.
The anemia is normocytic and normochromic.

Characterized by elevated erythropoietin level, which stimulates RBCs

production. (5-7 days)
If the bleeding is sufficiently massive to cause a decrease in blood
pressure, the compensatory release of adrenergic hormones mobilizes
granulocytes and results in leukocytosis
# Chronic
induces anemia only when the rate of loss exceeds the regenerative
capacity of the marrow or when iron reserves are depleted and iron
deficiency anemia appears
Iron is needed for heme synthesis and effective erythropoiesis.
Iron deficiency leads to chronic anemia of underproduction of RBCs.
The anemia is microcytic and hypochromic.

HEMOLYTIC ANEMIA
# Anemia that is associated with accelerated destruction of RBCs.
# Destruction can be caused by either inherent defects (intra-corpuscular), which
are usually inherited, or by external factor (extra-corpuscular), which are usually
acquired.
# All hemolytic anemias are characterized by:
1) Increased rate of RBCs destruction.
2) Compensatory increase in erythropoiesis that results in reticulocytosis.
3) Retention of the products of RBCs destruction (iron hemosiderosis)
# Hemolytic anemias are associated with erythroid hyperplasia within the bone
marrow, and an increased reticulocyte count in peripheral blood.
# Hemolysis can occur in:
Intravascular (within vascular compartments)
Caused by mechanical trauma (cardiac valves, thrombotic narrowing
of microcirc.) ,
Biochemical or physical agents that damage the membrane
(parasite/toxins)
Leads to hemoglobinemia, hemoglobinuria, and hemosiderinuria
Heambilirubin results in unconjugated hyperbilirubinemia and
jaundice.
massive hemolysis may lead to acute tubular necrosis
Haptoglobin (clears free hb) is depleted from plasma, high levels of
LDH. Free hemoglobin oxidizes to methemoglobin, which is brown in
color, some passes out in the urine, imparting a red brown color.

Extravascular (within phagocytic cells)

More common
Occurs in spleen and liver
Phagocytes remove damaged cells from circulation
Leads to systemic hemosiderosis
Not associated with hemoglobinemia/hemoglobinuria, yet produces
jaundice, if long-lasting leads to formation of bilirubin-rich gallstones.

Haptoglobin is decreased (some hb escapes macrophage to plasma),

LDH elevated
Reactive hyperplasia of mononuclear phagocytessplenomegaly
# Intra-corpuscular hemolytic anemias:
Hereditary membrane defects
Hereditary spherocytosis
Hemoglobin synthesis defects
Sickle cell anemia
Thalassemias
Enzyme deficiency of RBCs
G6PD deficiency
Acquired membrane defects
Paroxysmal nocturnal hemoglobinuria
# Extra-corpuscular anemias
Immunohemolytic anemias
Warm antibody immunohemolytic anemia
Cold antibody immunohemolytic anemia
Erythrocytosis fetalis
Mechanical trauma to RBCs
Infections
Mechanical damage
INTRA-CORPUSCULAR HEMOLYTIC ANEMIAS
# Hereditary membrane defects
Abnormality of spectrin and ankrin, proteins of the RBC skeleton, which
reduces membrane stability.
In circulation, the cells are exposed to circulatory stress, making them lose
membrane fragments.
This reduces membrane surface area, forces the cells to assume spherical
shape.
These spherical cells cannot leave the cords of the spleen (cannot undergo
deformation like discoid RBCs), and eventually are destroyed.
Morphology small spheric RBCs, splenomegaly, hyperplasia of red cell
progenitor cells, increased number of macrophages in splenic cords.
# Hemoglobin synthesis defects
Sickle cell anemia
Characterized by mutation in -globin chain, glutamate is replaced by
valine at the 6th position, creating hemoglobin S (HbS).
Upon deoxygenation, RBC shifts to sickle form, oxygenation
transforms it back to normal; eventually, irreversible change to sickle
shape.
The sickling of RBCs is affected by the presence of other hemoglonib
types, the concentration of HbS, and the amount of time RBCs are
exposed to O 2 .

Morphology splenomegaly at early stage, splenic scarring and

shrinkage at later stage; capillary stasis => ischemia, infarction fatty
change and hemolysis.
Thalassemias autosomal dominant
-THALASSEMIA

-THALASSEMIA

Lack or decreased synthesis of - Lack or decreased synthesis of globin chain.

globin chain.
- Encoded by 4 genes, mutation due
- Encoded by 2 genes, mutation due
# Enzyme
deficiency
of RBCs
to gene
deletions.
to sungle base change.
G6PD
deficiency
=> X-linked.
- 1 gene
deletion
=> silent
carrier.
- Results in accumulation of normal
- 2 genes
=> trait,to injury by oxidants,ofwhich
-globin
and theirinactivated
precipitation
RBCsdeletion
are vulnerable
are usually
on RBC membrane.
asymptomatic.
by reduced glutathione (GSH).
- 3 genes
deletion
=>
severe
LeadsoftoGSH
increased
erythropoiesis
G6PD produces NADPH needed for reduction
(if GSH
is not
and iron overload.
anemia.
reduced, it cannot inactivate oxidants).
- 4 gene deletion => death.
- Results in spleno- and

No
symptoms
unless
RBCs
are
subjected
to
oxidants injury.
- Formation of -tetrameres (HbH),
hepatomegaly,
and severe
characterized
Oxidative stress
=> O
hemoglobin
and denaturation =>
by high
2 affinity, oxidation hemosiderosis.
intracellular
precipitations
(Heinz bodies) => cell membrane flexibility
making
it ineffective
in delivering
to tissues.=> hemolysis.
O2decreases
# Acquired membrane defects
Paroxysmal nocturnal hemoglobinuria caused by membrane defects due
to mutation in myeloid stem cells.
The mutation occurs in proteins that block complement activation,
resulting in spontaneous activation and hemolysis.
-

EXTRA-CORPUSCULAR ANEMIA
# Immunohemolytic anemias
Warm antibody immunohemolytic anemia
Caused by IgG (rarely by IgA), active at 37oC
Primary in most cases, but can be secondary (associated with a disease
affecting the immune system)
Hemolysis results from the opsonization of RBCs => phagocytosis in
the spleen
Cells become spheroidal due to failed phagocytosis
Cold antibody immunohemolytic anemia
Caused by IgM, active only at 30oC (distal parts of the body)
IgM fixes complement system components, BUT the cells are not
lysed at this temperature
The opsonized RBCs travel to warmer places where IgM is released,
complement becomes active and causes phagocytosis
Erythroblastosis fetalis
Hemolysis induced by antibodies in newborns
Antigens of fetal RBCs enter maternal circulation during labor, thus
sensitize the mother => increases the risk of harmful outcomes during
next pregnancies (Rh incompetability, ABO incompetability)

# Mechanical trauma to RBCs

Infections (Malaria)
Multiplies within liver cells, enters RBCs and goes through
reproduction for 48 hours
Newly formed organisms escape RBCs by destroying them
Mechanical damage
Cardiac valve prosthesis => turbulent flow => cell damage
Vessels obstruction due to fibrin deposition => cells are destroyed
when passing through

# Decreased RBCs production:

Hematopoietic cell damage.
Deficiency of factors needed for heme synthesis (iron), or DNA synthesis
(vitamin B12, folic acid).
# Increased RBCs loss:
External blood loss (hemorrhage).
RBC destruction (hemolytic anemia).
Can be caused by:
1) -thalassemia => deletion of -globin genes.
2) -thalassemia => deletion of -globin genes.
3) Sickle cell anemia => base point mutation, resulting in the
replacement of glutamine by valine.
4) G6PD deficiency => failure of erythrocytes under oxidative stress.

TOPIC #53: ANEMIAS OF REDUCED ERYTHROPOIESIS (iron

deficiency anemia, megaloblastic anemias, aplastic anemia, anemias
of chronic disease)

IRON DEFICIENCY ANEMIA

# The most common form of nutritional deficiency anemia.
# Total body iron content => women 2.5g, men 3.5g.
~80% of functional iron is found in hemoglobin.
The rest (~20%) is found in myoglobin and iron-containing enzymes.
# Iron storage pool is represented by hemosiderin and ferritin-bound iron, found
mainly in the liver, spleen, bone marrow and skeletal muscle.
Serum ferritin => indicator of body iron stores. (33% ~)
# Iron is absorbed in the duodenum:

# The transfer between transferring receptor and ferritin expression is regulated by

hepcidin, which is synthesized in the liver and secreted in an iron-dependent
fashion (iron => hepcidin ).
# Hepcidin binds to ferroportin and induces its internalization, thus less iron is
transported out of the enterocytes to plasma transferring.
# Negative iron balance can be caused by:
1) Low dietary intake, especially vegetarians.
2) Malabsorption due to celiac disease (an autoimmune disease that causes
inflammation of the small intestine).
3) Increased demands of iron, not met by normal dietary intake, like during
pregnancy and infancy.
4) Chronic blood loss may occur from GI tract (ulcer, colonic cancer, and
hemorrhoids), or from the female genital tract (menorrhagia 1,
metrorrhagia 2, and cancer).

1
2

Heavy and prolonged menstrual period at regular intervals.

Uterine bleeding at irregular intervals, usually between menstrual periods.

# Morphology
RBCs are microcytic (small cells), and hypochromic (paler than usual) =>
MCV , MCHC
Iron deficiency is accompanied by increase in platelet count.
Erythropoietin level increases due to hypoxia (results from reduced
number of RBCs), but the bone marrow cannot meet the demands of RBC
production because of iron deficiency.
# Clinical course in most cases asymptomatic, but manifestations such as
weakness and pallor (paleness) may appear; pica is characteristic (consumption of
non-foodstuff such as dirt or clay).
# Diagnostic criteria anemia, microcytic and hypochromic RBCs, ferritin in
serum, iron in serum, transferring saturation , good response to iron treatment.

ANEMIA OF CHRONIC DISEASE

# Originates from inflammation-induced depletion of iron, such as chronic
microbial infections (osteomyelitis, bacterial endocarditis etc.), chronic immune
disorders (rheumatoid arthritis), and neplasms (Hodgkin lymphoma, carcinomas).
# Characterized by low serum iron level, and RBCs that are either normocytic and
normochromic, or microcytic and hypochromic.
# Associated with increased storage of iron in the bone marrow, high serum ferritin
level and reduced iron-binding capacity.
# Major cause of these findings is high level of hepcidin, resulting from the
presence of cytokines produced during inflammation (IL-6).
# Effective treatment of the underlying condition can cure the anemia.

MEGALOBLASTIC ANEMIA
# Caused by folate deficiency and vitamin B12 deficiency 3, both are required for
DNA synthesis.
# Pathogenesis
Enlargement of erythroid precursors (megaloblasts), which give rise to
abnormally large RBCs (macrocytes).
Granulocyte precursors are also enlarged (giant metamyelocytes), which
give rise to hyper-segmented neutrophils.
The cellular gigantism is caused by impairment of DNA synthesis
resulting in the delay of cell division, BUT the synthesis of RNA and
cytoplasmic elements proceeds as normal, thus outpaces that of the
nucleus => nuclear-cytoplasmic asynchrony.

Some megaloblasts undergo apoptosis in the bone marrow (ineffective

hematopoiesis), others are released into the blood stream, but have shorter
than usual lifespan.
# Morphology hypercellular bone marrow, nuclear-cytoplasmic asynchrony of
megaloblasts and granulocyte precursors; in peripheral blood => hypersegmented neutrophils (>5 lobes), and macrocytes (giant RBCs).
# Folate Deficiency Anemia
Not common cause for megaloblastic anemia
Poor diet or increased metabolic need (pregnant woman)
Absorption be block by drug (Phenytoin) or by malabsorptive
disorders (Celiac disease)
Metabolism can be block by drugs (Methotrexate used in
chemotherapy, and autoimmune disease)
Tetrahydrofolate (created from Dihydrofolate using the enzyme
Dihydrofolate reductase) act as donor or acceptor of carbon in purines
synthesis
Clinical features same as B12 deficiency but NO neurological
abnormalities
# Vitamin B12 Deficiency (Cobalamin) Anemia (Pernicious Anemia)
Same as Folate but also cause demyelinating disorder of peripheral
nerves and spinal cords.
absorption through intrinsic factor (parietal cells of fundus mucosa) in
the ileum
delivery to the liver by transcobalamins
malabsorption due to gastric mucosal atrophy
autoimmune reaction against
parietal cells
intrinsic factor
malabsorption in the distal ileum (Crohn, Whipple)

APLASTIC ANEMIA
# A disorder in which multipotent myeloid stem cells are suppressed, leading to
marrow failure and pancytopenia.
# In most cases, aplastic anemia is idiopathic; in other cases, it is caused by
exposure to myelotoxic agents (drugs and chemicals).
# Pathogenesis
It seems that autoreactive T cells play an important role 4.
The events that trigger the T cell attack are unclear.
Rare genetic conditions that may predispose for aplastic anemia have
inherited defects in telomerase (needed for maintenance and stability of
chromosomes).
# Morphology the bone marrow is HYPOcellular, more than 90% of intertrabecular spaces are occupied by fat.
4

In 70%-80% aplastic anemia responds to immunosuppressive therapy aimed to T cells.

# Clinical course
Affects persons of all ages and both sexes.
It is a slowly progressive anemia causing weakness, pallor and dyspnea.
Thrombocytopenia and granulocytopenia may occur.
NO splenomegaly.

TOPIC #54: GENERAL FEATURES OF ACUTE LEUKEMIAS.

ACUTE MYELOID LEUKEMIAS. MYELODYSPLASTIC
SYNDROMES (WHO 2008)

GENERAL FEATURES OF LEUKEMIAS

# Leukemia a group of malignancies of either lymphoid or myeloid origin, which
primarily involves the bone marrow with spillage of neoplastic cells into the
blood.
! Leukemic cells may go through circulation to lymphoid tissues and make
a solid mass => lymphoma.
# Leukemia can be either acute or chronic:
Acute leukemia characterized by rapid increase in the number of
immature blood cells (blasts >20%); their accumulation within the bone
marrow suppresses the normal hematopoietic stem cells, resulting in the
decreased number of WBCs, RBCs and platelets.
Chronic leukemia characterized by the excessive build up of relatively
mature, but abnormal, leukocytes, and by slow progression.
# General features of acute leukemia:
Rapidly growing tumors.
Occurs due to block in differentiation, leading to accumulation of
immature leukemic blasts in the bone marrow => suppresses the function
of normal hematopoietic stem cells by physical displacement.
Clinical features abrupt onset, characterized by fatigue, fever, bleeding
(petechiae, ecchymoses, epistaxis)
lymphadenopathy, hepatomegaly and splenomegaly (more prominent in
ALL)
Bone pain resulting from marrow expansion.
Diagnosis of acute leukemias rests on the identification of blast forms in
peripheral blood, WBC count is variable, and anemia is usually present.
Acute leukemias can be classified according to their lineage, either AML
(acute myeloid leukemia), or ALL (acute lymphoid leukemia).

ACUTE MYELOID LEUKEMIA

# AML abnormal proliferation and accumulation of blast cells from the myeloid
lineage, characterized by bone marrow failure.
# Usually affects older adults (>50 y)
# Associated with acquired mutations in transcription factors that inhibit normal
myeloid differentiation, leading to accumulation of cells at earlier stages of
development. (15:17 translocation in acute promyelocytic leukemia, analogue to

vitamin A can overcome blockage in diff and induce diff into neutrophils
treatment by ATRA imp example of therapy targeted at a tumor specific mol
defect)
# Morphology myeloblasts and promyelocytes constitute large percentage of the
bone marrow cellularity; Auer rods, distinctive red-staining rod-like structures,
may be present in myeloblasts (numerous in acute promyelocytic leukemia) .
# Classification of AML (according to WHO):
I AML with recurrent chromosomal translocations
Translocation between chromosomes 8 & 21 (M2)
Inversion in chromosome 16 (M4)
Translocation between chromosomes 15 & 17 => acute
promyeloblastic leukemia (M3)
Translocation between chromosomes 9 & 11
! Generally, it has high rate of remission and better prognosis.
II AML with multilineage dysplasia
Appears in patients with prior myelodysplastic syndrome, or with prior
myeloproliferative disease
Prognosis is very poor
III AML therapy related
Occurs in patients who had prior chemotherapy or radiations treatment
IV AML not otherwise classified
Subclasses that do not fall into the above categories; defined by the
extent and type of differentiation (M0 => M7)

MYELOPLASTIC SYNDROMES
# Pre-leukemic condition with increased chance to develop AML.
# The bone marrow is replaced by clonal progeny of mutant multipotent stem cell
that retains its capacity to differentiate into RBCs, granulocytes or platelets => all
are defective (mainly megaloblastoid erythroid precursor)
# The abnormal stem cell clone is genetically unstable => additional mutations
occur, and transformation into AML develops in 10%-40% of the cases.
# Karyotype abnormalities include loss of chromosome 5 or 7, or deletion of their
long arm, and trisomy 8.
# Response to chemotherapy is poor.

TOPIC #55: CHRONIC MYELOPROLIFERATIVE DISEASES

(chronic myeloid leukemia, polycythemia vera, essential
thrombocytemia, primary myelofibrosis)

CHRONIC MYELOPROLIFERATIVE DISEASES

# Marked by hyper proliferation of myeloid precursors that retain the capacity for
terminal differentiation, resulting in an increase of one or more formed elements
of peripheral blood.
# These neoplastic progenitors tent to seed secondary hematopoietic organs,
resulting in hepatosplenomegaly and mild lymphadenopathy.
# These disorders are commonly associated with mutated tyrosine kinases.
# The disorders include:
Chronic myeloid leukemia (CML).
Polycythemia vera (PCV).
Primary myelofibrosis.
Essential thrombocythemia.

CHRONIC MYELOID LEUKEMIA

# Affects adults between 25 and 60 years of age
# Associated with the translocation of ABL gene from chromosome 9, to fuse with
BCR gene on chromosome 22 => PHILADELPHIA CHROMOSOME.
# BCR-ABL fusion gene is present in the precursor cells of granulocytes,
erythrocytes, megakaryocytes and B cells.
# The BCR-ABL gene encodes for a tyrosine kinase that generates continuous
signals mimicking the effect of GF receptor activation on progenitor cells.
# The course of CML is of slow progression, but after a variable period of time,
CML enters an accelerated phase, during which there is gradual failure in the
response to treatment.
# Morphology
o Elevated leukocyte count (often > 100,000 cell/L)
o The circulating cells are predominantly neutrophils, metamyelocytes,
and myelocyte, but also basophils, eosinophils, and platelets are
increase
o Bone marrow is hypercellular, spleen enlargement because of
extensive extramedullary hematopoiesis
o This burgeoning proliferation often compromises the local blood
supply, leading to splenic infarcts

# Clinal Features
o The course of CML is of slow progression, but after a variable period
of time, CML enters an accelerated phase
o First line treatment is imatinib, which blocks tyrosine kinase activity
# Diagnosis
o Search for the presence of BCR-ABL fusion gene by karyotyping,
FISH or PCR assay.
POLYCYTHEMIA VERA
# Excessive neoplastic proliferation and maturation of erythroid, granulocytic and
megakaryocytic elements, resulting in panmyelosis.
# The main clinical sign of PCV is the absolute increase in RBCs mass, but is
associated with low levels of erythropoietin in the serum.
# PCV cells carry a specific mutation in JAK2, a tyrosine kinase that acts through
the activation of erythropoietin receptor => this mutation results in the
hypersensitivity of the cells to erythropoietin.
# Morphology increased volume of blood, resulting in increased viscosity and
vascular stasis, creating thromboses and infarctions (heart, spleen, kidneys);
hypercellularity of bone marrow is also seen.
# Clinical features abnormal histamine release (causes itching), tendencies to
thrombosis and hemorrhage.
# Diagnosis
o elevated RBC count (> 6 million/l), hematocrit > 60%, high platelet
count (can be giant)
o basophila is common
# Budd-Chiari syndrome hepatic vein thrombos
# Treatment - Phelbotomy

PRIMARY MYELOFIBROSIS
# Bone marrow is replaced by collagen fibers, resulting in the shift of
hematopoiesis to the spleen, liver and lymph nodes, causing extreme enlargement
of these organs.
# Megakaryocytes produce excess platelet-derived growth factor (PDGF) causing
marrow fibrosis
# Hematopoiesis becomes disordered and insufficient, and together with bone
marrow fibrosis, results in anemia and thrombocytopenia.
# The same JAK2 mutation that is found in PCV is present in most cases of
primary myelofibrosis.
# Leukoerythroblastic smear (tear-drop RBCs, nucleated RBCs, and immature
granulocytes)

ESSENTIAL THROMBOCYTHEMIA
# The pathologic basis is unknown, but it resembles PCV in that the cells of the
megakaryocytic series are more sensitive to GFs.
# Platelets do not function normally, leading to bleeding and thrombosis.
# Associated with JAK2 mutation.
# Slowly progressive disorder with long asymptomatic periods, which may evolve
into acute myeloid leukemia or myelofibrosis.
# Symptoms are related to an increased risk of bleeding and/or thrombosis.
o Rarely progresses to marrow fibrosis or acute leukemia
o No significant risk for hyperuricemia or gout

TOPIC #56: REACTIVE LYMPHADENOPATHIES (acute

lymphadenitis, follicular and paracortical hyperplasia, sinus
histiocytosis, toxoplasma lymphadenitis, dermatopathic
lymphadenopathy)

REACTIVE LYMPHADENITIS
# Infections and nonbacterial inflammatory stimuli involve the lymph nodes.
# Any immune response against foreign antigens is often associated with lymph
node enlargement => lymphadenopathy.
# Lymphadenitis is the inflammation of lymph node that can be acute or chronic.
# Acute lymphadenitis
Confined to a local group of nodes draining the area of infection (can also
be generalized in case of systemic infection).
Inflamed nodes are swollen and engorged (filled with blood).
Large germinal centers containing numerous mitotic figures.
In severe infections, the centers of the follicles may undergo necrosis,
resulting in the formation of abscess.
# Chronic lymphadenitis can assume one of three patterns, dependeing on the
causative agent
Follicular hyperplasia associated with inflammatory processes that
activate B cells and create germinal centers; can be caused by rheumatoid
arthritis, toxoplasmosis and at early stages of HIV infections
Distinguished from follicular lymphoma by:
preservation of lymph node architecture
variation in shape and size of the follicles
mixed population of lymphocytes at various stages of
differentiation
prominent phagocytic and mitotic activity in germinal centers
Paracortical hyperplasia characterized by reactive changes in T cell
regions of the lymph node, and the transformation of T cells to
immunoblasts that can affect B cell follicles; caused by viral infections,
certain vaccinations (smallpox), and immune reaction induced by drugs.
Sinus histiocytosis characterized by distension and prominence of
lymphatic sinusoids due to hypertrophy of the lining endothelial cells;
caused by the draining of cancers.
# Toxoplasma lymphadenitis caused by parasitic disease due to infection by the
protozoan Toxoplasma gandii; symptoms are often influenza-like, and include
swollen lymph nodes with poorly demarcated reactive germinal centers.
# Dermatopathic lymphadenopathy inflammation of lymph nodes due to drainage
of infected area of the skin; characterized by the presence of melanin-fllied
macrophages, eosinophils and plasma cells.

TOPIC #57: CLASSIFICATION OF MALIGNANT LYMPHOMAS

(WHO 2008)

LYMPHOMA VS. LEUKEMIA

LYMPHOMA
1) Solid, cohesive neoplasms of the
immune system.
2) Mostly originate from lymphoid
tissue.
3) Some lymphomas can go into
leukemic phase => due to mutation
the cells can lose their adhesive
property.

HODGKIN & NON-HODGKIN

LYMPHOMA

LEUKEMIA
1) Malignancies of hematopoietic
precursor cells, usually transfer from
bone marrow into circulation.
2) Not so cohesive as lymphomas,
therefore in leukemia there is
increased WBC count.
3) Leukemic cells may go through
circulation into lymphoid tissue and
make a solid mass => lymphoma
4) Pluripoietic cell
Myeloid stem cell => MYELOID
leukemia
Lymphoid stem cell =>
LYMPHOID leukemia

LYMPHOCYTIC LEUKEMIA
WHO CLASSIFICATION
# A system that defines lymphomas according to several features: morphology, cell
of origin, clinical features and genotype.
# The classification divides lymphomas into 3 categories:
1) Tumor of B cells
Precursor B cell neoplasms (B cell ALL)
Peripheral B cell neoplasms (mantle cell lymphomas, follicular
lymphoma, Burkitt lymphoma)
2) Tumor of T cells and NK cells
Precursor T cell neoplasms (T cell ALL)
Peripheral NK cell neoplasms (NK cell leukemia, mycosis fangoides)
3) Hodgkin lymphomas
Low grade => small lymphocytic, follicular, small to large cleaved
cells, bad prognosis
Intermediate => follicular, large cells, diffuse
High grade => large cells, immunoblastic, lymphoblastic, better
prognosis

TOPIC #58: PRECURSOR LYMPHOBLASTIC LYMPHOMAS

AND LEUKEMIAS

# Aggressive tumors composed of immature lymphocytes (lymphoblasts), occurs

mainly in children/young adults.
# Pre-B cell lymphocytic tumors develop in the bone marrow (leukemia), while
pre-T cell tumors develop in the thymus, pre-T lymphoma rapidly progress to
leukemia.
# Both take on the clinical appearance of an acute lymphoblastic leukemia (ALL).
# Pathogenesis
Rapidly growing tumors.
Acquired mutation in specific TF that regulate the diff of immature
lymphoid/myeloid origion
Complementary acquired mutation allow tumor cell to prolif in a GFindependent manner.
Block in differentiation leading to accumulation of immature precursor
cells.
In B-ALL most imp mutation is BCR-ABL (9:22) Philadelphia
chromosome constitutively stmulate pathway which is normally
stimulated by GF
# Clinical features
Abrupt onset.
Symptoms related to depression of normal bone marrow function (fatigue
due to anemia, fever due to absence of mature leukocytes, bleeding due to
lack of platelets).
Bone pain and tenderness.
# Morphology
Lymphoblasts compose 25% of bone marrow cellularity.
Rough, dense chromatin with 1-2 mucleoli.
Cytoplasm contains large aggregates of PAS positive material (sugars).
# Phenotype
Presence of deoxytransferase in both T and B precursor cells.
Lineage specific markers => CD19 (B cell), CD3 (T cell).

TOPIC #59: PHYSIOLOGICAL B-CELL MATURATION

(germinal centers). FOLLICULAR LYMPHOMA

B-CELL MATURATION
# Peripheral lymph node is composed of a cortex and a medulla => the cortex
contains lymphocytic nodules (follicles).
# The lymph follicle contains mainly B cells, and can be either primary (not
activated) or secondary (met with an antigen).
# Upon activation, B cells start to proliferate and differentiate, creating the
germinal center of the lymph follicle.
# Process of B cell differentiation:

BONE MARROW

CIRCULATION

Lymphoid precursor cell

Lymphoblast

Nave B cell

LYMPH NODE

(mantle
zone)

(germinal
center)

B cell with
irregular
nucleus

Follicular
blast cell

(marginal
zone)

Centroblast

Centrocyte

Marginal
zone
lymphocyte

Plasma cell
# In the germinal center, the differentiating and proliferating B cells undergo:
Somatic hypermutation rearrangement of DNA of the variable region
genes to form variations of antibodies.
Class switching rearrangement of the heavy chain genes to switch the
class of the antibody.

FOLLICULAR LYMPHOMA
# A type of non-hodgkin lymphoma, constitute 40% of NHLs.
# Morphology
Well differentiated follicles.
Centrocyte-like cells and centroblast-like cells.

#
#

#
#
#

Cleaved nucleus

Large nucleus

Prominent indentations

Prominent nucleoli

Dense chromatin
Immunophenotype B cell markers CD10, CD19, CD20; cells show somatic
hypermutation.
Karyotype characteristic translocation of BCL2 gene from chromosome 18 to
the loci of IgH gene on chromosome 14, resulting in the overexpression of BCL2
gene, which produces anti-apoptotic proteins (prevent release of cytochrome C
=> no apoptosis).
Clinical features painless lymphadenopathy, bone marrow contains lymphoma
(RBC , WBC , platelets ), poor response to chemotherapy.
Follicular lymphoma may progress to a diffuse large B cell lymphoma.
Treatment is reserved lot patients who are symptomatic and involves low-dose
chemotherapy or rituximab (anti-CD20 antibody).

TOPIC #60: MANTLE CELL LYMPHOMA. MARGINAL CELL

LYMPHOMA

MANTLE CELL LYMPHOMA

# Composed of B cells found in the mantle zone (corona) of lymphatic follicle.
# A type of non-Hodgkin lymphoma, constitute 4% of NHLs.
# Morphology
Irregular nucleus, slightly larger than normal lymphocytes
Bone marrow is involved in most cases, peripheral blood is involved in 20%
of cases.
Nucleoli are not well defined.
May arise in GI, usually manifesting as multifocal submucosal nodules.
No somatic hypermutation.
# Immunophenotype
B cell markers CD19, CD20, IgM, IgD.
T cell markers CD5.
Cyclin D1 presence.
Distinguished from CLL/SLL by the absence of prolif centers and
presence of cyclin D1
# Karyotype translocation of cyclin D1 gene from chromosome 11 to the locus of
IgH gene on chromosome 14, resulting in overexpression of cyclin D1 and the
promotion of G1/S transition => over proliferation => aggressive, incurable
tumors.
# Clinical features nonspecific symptoms (fatigue, fever, weight loss),
lymphadenopathy, generalized disease involving the liver, spleen, bone marrow
and GI tract.

MARGINAL CELL LYMPHOMA********

# Composed of cells that originate from the marginal zone of lymphatic follicles
(the transition zone between the follicle and interfollicular region).
# Immunophenotype
B cell markers CD19, CD20, CD21.
No CD5, CD10.
# Karyotype translocation of BCL10 gene from chromosome 1 to the locus of
IgH gene on chromosome 14.
# There are 3 types of marginal zone lymphomas:
1) Splenic marginal zone lymphoma B cells replace the normal resident
cells of the white pulp of the spleen (T cells, macrophages).
2) MALT lymphoma most common form, occurs most frequently in the
stomach (also called extra-nodal marginal zone lymphoma).
3) Nodal marginal zone lymphoma in lymphatic follicles of lymph nodes.

B-cell tumors that arise within lymph nodes, spleen, or extranodal tissues(MALTomas).
In most cases, the tumor cells show evidence of somatic hypermutation and are considered to
be of memory B-cell origin.
Extranodal characteristics:
They often arise within tissues involved by chronic inflammatory disorders of
autoimmune or infectious etiology; ( salivary gland in Sjgren disease, the thyroid gland
in Hashimoto thyroiditis, and the stomach in Helicobacter gastritis.)
They remain localized for prolonged periods, spreading systemically only late in their
course.
They may regress if the inciting agent (e.g., Helicobacter pylori) is eradicated.
lie between reactive lymphoid hyperplasia and lymphoma
(11;18), (14;18), or (1;14) known chromosomal translocations - up-regulate the
expression and function of BCL10 or MALT1, protein components of a signaling
complex that activates NF-B and promotes the growth and survival of B cells

TOPIC #61: DIFFUSE LARGE B-CELL LYMPHOMA. BURKITT

LYMPHOMA

DIFFUSE LARGE B-CELL LYMPHOMA

# A type of non-Hodgkin lymphoma, constitute 50% of NHLs.
# Morphology
Irregular, large nucleus (3-4 times the size of resting lymphocyte nucleus).
Prominent nucleoli.
Pale cytoplasm.
# Immunophenotype
B cell markers CD19, CD20, IgM, IgG.
Somatic hypermutation.
# Karyotype translocation of BCL2 gene from chromosome 18 to chromosome
14 that occurs in 30% of the cases (follicular lymphoma that transforms into
DLBL); in 30% of the cases, BCL6 gene on chromosome 3 is mutated (repressor
of transcription).
# Distinct subtypes of DLBL:
EBV

HHV-8

MEDIASTINAL MASSES

In immunosuppressed
patients (AIDS,
transplantation)

Produce a protein which

is homologous to cyclin
D1

More common in women

Can spread to abdominal

cavity and CNS
-

Over stimulation of B
cells.
Restoration of immunity
may cause regression.

The virus spreads into

cavities, causing primary
effusion lymphomas
(pleural, pericardium or
peritoneum cavity)

# Clinical features aggressive tumors that are rapidly fatal if not treated; can
affect virtually any organ.

BURKITT LYMPHOMA
# Can be classified as:
SPORADIC

ENDEMIC
-

In equatorial Africa.
100% EBV associated.
Lymphoma in the jaw and
face.
"starry sky" appearance: dark
cells infiltrated by nonneoplastic macrophages that
clear the debris of dead
neoplastic cells

Outside Africa.
20% EBV associated.
Lymphoma is mainly in the
ileocecal region.
Same appearance as endemic.

# Immunophenotype
B cell markers CD10, CD19, CD20, IgM (kappa or lmbda).
Somatic hypermutation.
# Karyotype translocation of MYC gene on chromosome 8 to IgH gene on
chromosome 14, resulting in the over expression of MYC => over production of
TF.
# Clinical features affects mainly children, usually arises in extra-nodal sites.

TOPIC #62: THE PLASMA CELL REACTION. PLSMOCYTIC

NEOPLASMS

PLASMA CELL REACTION

# Activated B cells proliferate and differentiate into plasma cells that secrete
soluble immunoglobulins, named antibodies.
# Antibodies are divided into 5 main classes, according to their constant region.
# The plasma cells secrete antibodies that have the same antigen-binding sute as the
immunoglobulins found on the surface of the B cell from which the plasma cells
have developed.
# IgM (and IgD) is the original antigen receptor on circulating B cells; IgM is the
first antibody to be secreted in the immune response.
# The quality of antibodies produced is improved during the immune response by 2
mutational mechanisms:
Somatic hypermutation induces nucleotide substitutions throughout the
genes of the variable region (both light and heavy chains), resulting in the
production of variant antibodies, some with higher affinity to the antigen.
Class-switch recombination the process by which B cells change the
class of the immunoglobulin they make; involves the process of somatic
recombination (the genes of heavy chain constant region are attached to
the already existing variable region exon).
# Plasma cells cannot switch the class of their antibodies, cannot act as APC (do
not own MHC), and cannot take up antigens (insufficient amount of receptors on
their surface).

PLASMOCYTIC NEOPLASMS
# B-cell proliferations contain neoplastic plasma cells that secrete a monoclonal Ig
or Ig fragment. A monoclonal Ig identified in the blood is referred to as an M
component, in reference to myeloma. Neoplastic plasma cells often synthesize
excess light chains (kappa more than lambda), along with complete Igs. Rare
tumors secrete only heavy chains.
Light chains are small in size, they are also excreted in the urine, where they are
referred to as Bence-Jones proteins.
# Terms used to describe the abnormal Igs associated with plasma cell neoplasms
include:
monoclonal gammopathy
Dysproteinemia
Paraproteinemia.
# These abnormalproteins are associated with:
Multiple myeloma (plasma cell myeloma)

Solitary plasmacytoma
lymphoplasmacytic lymphoma
Heavy-chain disease
Primary or immunocyte-associated amyloidosis
Monoclonal gammopathy of undetermined significance

MULTIPLE MYELOMA
# Plasma cell neoplasm commonly associated with lytic bone lesions,
hypercalcemia, renal failure, and acquired immune abnormalities.
# The most common M components are IgG (60%), IgA (20%-25%) and
immunoglobulin light chains (=lambda or =kappa).
# Can spread late in its course to lymph nodes and extranodal sites.
# Pathogenesis:
Recurrent translocations with the Ig heavy-chain gene on chromosome
14 and cyclin D1 on chromosome 11 or cyclin D3 on chromosome 6.

B-cell survival is supported by mutations of the NF-B pathway and

IL-6 which is produced by the tumor cells themselves and by resident
marrow stromal cells (fibroblast and macrophage).
Cytokines up-regulate production of RANK-ligand which in turn
activates osteoclasts.
Patients are immunosuppressed as AB production is defected.
Renal involvement (myeloma nephrosis) proteinaceous casts, which
include M components and Bence Jones proteins, can be found in distal
convoluted tubules.
! Multinucleated giant cells, formed from fusion of macrophages,
surround these casts.
Certain light chains are prone to cause amyloidosis of the AL type ,
which can worsen renal dysfunction
# Morphology:
the marrow contains an increased number of plasma cells(>30%)
most frequent fracture site vertebral column/femur
plasma cells have a prominent Golgi apparatus and an eccentrically
placed nucleus
In advanced disease, plasma cell infiltrates may be present in the
spleen,liver, kidneys, lungs, lymph nodes, and other soft tissues.

# Immunophenotype:
Plasma cell tumors are positive for CD138, an adhesion molecule also
known as syndecan-1, and often express CD56
# Clinical Features:
Decreased production of normal Igs causes recurrent bacterial
infections.
Marrow involvement often gives rise to a normocytic normochromic
anemia, sometimes accompanied by moderate leukopenia and
thrombocytopenia.

SOLITARY PLASMACYTOMA
# Solitary lesions involving the skeleton or soft tissues.
# Skeletal plasmacytoma => occurs at same locations as multiple myeloma, and
most of them develop full multiple myeloma over 5-10 years.
# Moderate elevation of M proteins are present in some cases
# Soft tissue plasmacytoma => occurs mainly in upper respiratory tract
(nasopharynx, sinuses, and larynx).
LYMPHOPLASMACYTIC LYMPHOMA
# Tumor composed of mixed proliferation of B cells => small lymphocytes,
plasmacytic lymphocytes, and plasma cells.
# Behaves like indolent (slow-growing) B cell lymphoma.
# Involves multiple lymph nodes, bone marrow and spleen.
# Produces M component => mostly IgM, causing the blood to become viscous Waldenstrom macroglobulinemia that causes: Visual impairment, Neurologic
problems, Bleeding
# Balanced production of heavy and light chains => there are NO Bence Jones
proteins.
# Responds well to chemotherapy
HEAVY CHAIN DISEASE
# Proliferation of cells that produce only heavy chain proteins, mainly IgA.
# Seen mainly in tissues in which IgA is normally produced => small intestine,
respiratory tract.
# Less common form => IgG heavy chain disease, manifests with diffuse
lymphadenopathy, hepatosplenomegaly.
PRIMARY AMYLOIDOSIS
# Over production of immunoglobulin light chains, forming aggregations => AL
protein.
MONOCLONAL GAMMOPATHY OF UNDETERMINED SIGNIFICANCE
# M components are found in the serum of asymptomatic individuals (>50 years
old).
# Patients may develop plasma cell neoplasia (multiple myeloma,
lymphoplasmacytic lymphoma, amyloidosis).
# MGUS cells usually contain the same chromosomal translocation of multiple
myeloma.
# MGUS patients have <3g/dL of monoclonal proteins in serum => NO Bence
Jones proteins.

TOPIC #63: PHYSIOLOGICAL T-CELL REACTIONS.

PERIPHERAL T-CELL LYMPHOMA

PHYSIOLOGICAL T-CELL REACTIONS

# Thymus derived lymphocytes; the effector cells of cellular immunity.
# Constitute 60%-70% of lymphocytes in peripheral blood, and are the major
lymphocyte population in splenic PALS and interfollicular zones in lymph nodes.
# Cannot detect antigens directly; instead, they recognize fragments of antigenic
proteins presented on the surface of infected cells by the MHC 1 (in humans, it is
called HLA => human leukocyte antigen).
# T cell receptor (TCR) is a heterodimer composed of and chains, connected by
disulfide bonds; each chain has a variable region and a constant region.
# TCR is non-covalently bound to a cluster of 5 polypeptide chains: (gamma),
(delta), (epsilon) which are part of CD3 marker, and 2 (zeta) chains => all of
which interact with the constant region of the TCR and allow intracellular signal
transduction.
# Subsets of T cells:
T helper cells (CD4)
Bind to MHC-II on APCs.
Secrete cytokines that attract other cells of the immune system =>
B cells, macrophages.
T killer cells (CD8)
Bind to MHC-I on all nucleated cells.
Directly kill infected cells.
# T cells also present CD28 marker, which helps them to bind to APCs.

PERIPHERAL T-CELL LYMPHOMA

# Peripheral T-cells are differentiated (post thymic).
# Peripheral T-cell lymphomas of lymph nodes have a variable morphology. The
morphological heterogeneity of these lymphomas are due to cellular interactions
between reactive and neoplastic cell populations (lymphokines and cell to cell
contacts).
# These tumors present different cell types making them difficult to distinguish
form reactive conditions and Hodgkin disease.
# Types:
o Lymphoepitheloid lymphoma (Lennert's lymphoma)
o Angioimmunoblastic lymphadenopathy like T lymphoma.
o T zone lymphoma.
1
MHC-I is found on all nucleated cells => marker for CD8 cells; MHC-II is found on APCs => marker
for CD4 cells

o Pleomorphic T-cell lymphoma.

o Large cell anaplastic lymphoma.
Lymphoepitheloid lymphoma (Lennert's kymphoma)
o Is small cell (lymphocytic) infiltrate intermingled with high amount of
epitheloid cells and some blasts.
o Resembles lymphocyte predominant Hodgkin disease but RS cells are missing.
Angioimmunoblastic lymphadenopathy like T lymphoma
o Mixed infiltrate of small, medium and large immunoblastic cells.
o Resembles mixed cellularity of Hodgkin disease.
o Neoplastic cells show clear cytoplasm and wrinkled nucleus.
o Immunoblasts and plasma cells are basophilic.
o Proliferation of dendritic reticulum cells are the hallmark of this
disease (CD23 positive).
o There is also proliferation of HEV.
T-zone lymphoma
o Spread within the T-cell areas.
o Lymph node follicles with germinal centers are preserved.
o Follicular hyperplasia with CD4 positive T-cells.
Pleomorphic T-cell lymphoma
o Strong nuclear pleomorphism of small, medium and large lymphoid
cells.
o Clear cells are also present.
Large cell anaplastic lymphoma
o T-cells are CD30 positive.
o Shows cohesive spreading.
o Found primarily within sinuses of lymph nodes.
o Often mistaken for carcinomas, malignant melanomas or malignant
histiocytosis (DD: malignant histiocytosis shows CD68 positive)
o Translocation t(2:5) will cause increase in tyrosine kinase.
o Some case of Hodgkin disease and peripheral T-cell lymphoma may
evolve into secondary large cell anaplsatic lymphoma.
o Multinucleated tumor giant cells may be present (suggesting Hodgkin
sarcoma or Hodgkin disease type III).

TOPIC #64: EXTRA-NODAL LYMPHOMAS (lymphomas of the

MALT, cutaneous lymphomas, CNS lymphoma)

EXTRA-NODAL LYMPHOMAS
# Mature B cell tumors, most commonly arise in MALT (salivary glands, small
intestine, large intestine, lungs), and in non-mucosal sites (orbit, breast).
# Tend to develop in the setting of autoimmune diseases or chronic bacterial
infections (Helicobacter pylori, Campylobacter jejuni).

MALT LYMPHOMA
# MALT lymphoma originates in B cells of MALT of the GI tract.
# May arise anywhere in the gut, but most commonly occur in the stomach, usually
due to chronic gastritis caused by H. pylori bacterium.
# The infection leads to polyclonal B cell hyperplasia and eventually to monoclonal
B cell neoplasm.
# MALT lymphoma cells are negative to CD5 and CD10 markers.
# Translocation between chromosomes 11 and 18 is common => creates a fusion
gene between the apoptosis inhibitor BCL2 gene (chromosome 11), and the MLT
gene 1 (chromosome 18).
# ~50% of gastric lymphomas can regress with antibiotic treatment.

CUTANEOUS LYMPHOMA
# There are 2 classes of cutaneous lymphoma affecting the skin:
B cell cutaneous lymphoma.
T cell cutaneous lymphoma.
# T cell cutaneous lymphoma
Several forms, most common is Mycosis fungoides
Caused by mutation of cytotoxic T cells that infiltrate the epidermis and
upper dermis, characterized by infolding of the nuclear membrane
At later stage => Sezary syndrome, characterized by erythroderma
(inflammatory skin disease), and by tumor cells in peripheral blood
# B cell cutaneous lymphoma
Constitute a group of diseases, characterized by B cells similar to those
found in germinal centers => diffuse large B cell lymphoma, primary
cutaneous follicular lymphoma, intravascular large B cell lymphoma

Paracaspases, have proteolytic function on T cells

CNS LYMPHOMA
# Intracranial tumor that appears mostly in patients with severe immunosuppression.
# Highly associated with Epstein-Barr virus infections in immunosuppressed
patients, but rarely so in immunocompitant patients.
# Most CNS lymphomas are diffuse large B cell lymphoma.
# Symptoms include:
Dislopia (double vision).
Dysphagia (difficulty in swallowing).
Dementia.
Systemic symptoms (fever, night sweat, weight loss).

TOPIC #65: HODGKIN'S DISEASE. MOLECULAR BIOLOGY.

MORPHOLOGY & CLASSIFICATION. CLINICAL STAGES OF
HD

HODGKIN LYMPHOMA
# A type of lymphoma that involves lymphocytes, arising from a single node (or a
chain of nodes), and spreads to anatomically continuous lymph nodes.
# It is distinguished from non-Hodgkin lymphoma (NHL) by:
HODGKIN
-

NHL

Reed-Sternberg cells (+)

Arises in lymph nodes, mainly
cervical, supraclavicular and
axillary.
Forms the Waldeter's ring, less
common in GI lymph nodes.
Spread is orderly and continuous
(through lymphatic vessles).

Reed-Sternberg cells (-)

Arises in both lymph nodes and
extra-lymphatic tissue.
Very common in GI lymph nodes.
Random spread (through blood).

# Reed-Sternberg cells
Large cells (15-45m), enlarged multi-lobulated nucleus, prominent
nucleoli, and abundant eosinophilic cytoplasm.
2 mirror image nuclei (or 1 nucleus with 2 lobes), containing large
eosinophilic nucleoli (1 in each nucleus), surrounded by distinctive clear
zone and distinct nuclear membrane => owl eyes appearance.
Variants of RS cells include lacunar cell and popcorn cell.

CD15, CD30

CD15, CD30

CD20

RS cell

Lacunar cell

Popcorn cell

SUBTYPES OF HODGKIN LYMPHOMA

# Nodular sclerosis Hodgkin lymphoma
Most common form equally occurring in males and females (young
adults).
Few RS cells
, many lacunar cells
Collagenous bands divide the lymphoid tissue into nodules.
Cellular component macrophages
, eosinophils , lymphocytes
Prognosis good (RS cell => prognosis , lymphocytes => prognosis ).

# Mixed-cellularity Hodgkin lymphoma

Affects patients >50 years old, predominant in males.
Many RS cells
among small macrophages
, eosinophils
plasma cells , lymphocytes
Diagnosed at advanced stage.
Systemic symptoms.
Associated with EBV.

# Lymphocyte-predominance Hodgkin lymphoma

Large number of lymphocytes , few RS cells (if any)
cells are the main variant.
Usually remains in cervical and axillary lymph nodes.

, popcorn

# Lymphocyte-rich Hodgkin lymphoma

More common in males, older persons (40-50).
Many lymphocytes , few RS cells (no popcorn cells).

# Lymphocyte-depleted Hodgkin lymphoma

Fibrous tissue with few RS cells OR lymphocytes with numerous RS cells.

STAGING OF HODGKIN LYMPHOMA

# Stage I

Involvement of a single lymph node (I)

OR
Involvement of a single extra lymphatic organ (IE)

# Stage II

Involvement of 2 or more lymph node regions on the

same side of the diaphragm alone (II)
OR
Involvement of 2 or more lymph node regions on the
same side of the diaphragm WITH involvement of
limited contiguous ( )extra lymphatic organs (IIE)

# Stage III

Involvement of lymph node regions on both sides of

the diaphragm (III), which may include the spleen
(IIIS), limited contiguous extra lymphatic organ (IIIE),
or both (IIIES)

# Stage IV

Multiple foci (locations) of involvement of one or

more extra lymphatic organs or tissues, with or without
lymphatic involvement