CHRONIC INFLAMMATION DR RABIA RATHORE ASSISTANT PROFESSOR WEST

CHRONIC INFLAMMATION DR RABIA RATHORE ASSISTANT PROFESSOR WEST MEDICAL WARD MAYO HOSPITAL/K. E. M. U

DEFINITION • An inflammation that may begin with a relatively rapid onset or in a slow, insidious, and even unnoticed manner, and that tends to persist for several weeks, months, or years.

• PATHOPHYSIOLOGY: • Chronic inflammation has a vague and indefinite termination; occurs when the injuring agent persists in the lesion, and the host's tissues respond in a manner that is not sufficient to overcome completely the continuing effects of the injuring agent.

• It is characterized histopathologically by infiltrates of lymphocytes, plasma cells, and histiocytes; fibrosis; and granuloma formation.

CAUSES OF CHRONIC INFLAMMATION • • PERSISTANT INFECTION: Trepenoma Pallidum infection(Syphilis) Mycobacterium tuberculosis(Tuberculosis) PROLONGED EXPOSURE TO TOXIC AGENTS: • Exogenous(Silicosis) • Endogenous(Atherosclerosis)

• AUTOIMMUNITY: • Autoimmune disorders(SLE)

TYPES OF CHRONIC INFLAMMATION • Non Specific Inflammation • Granulomatous Inflammation

NONSPECIFIC INFLAMMATION • A diffuse accumulation of macrophages and lymphocytes at the site of injury. Fibroblasts proliferate with subsequent scar formation that may replace functional connective tissue or the parenchymal tissues.

GRANULMATOUS INFLAMMATION • A cluster of T cell activated modified macrophages (epithelioid cells) that engulf and surround indigestible foreign bodies. *Epithelioid cells may coalesce to form a large, multinucleated giant cell that attempts to surround the foreign agent and eventually becomes encapsulated by dense connective tissue.

GRANULMATOUS INFLAMMATION • *These clusters of macrophage "epithelioid cells" are surrounded by lymphocytes *Clumping of the epithelioid cells (macrophages) into a mass produce a granuloma.

OUTCOME OF CHRONIC INFLAMMATION • The destruction of tissue. • Thickening and scarring of connective tissue (fibrosis). • Death of cells or tissues (necrosis).

CLINICAL PRESENTATION

CASE SCENARIO NO: 1 • A 35 years female comes to OPD with complaints of pain and symmetric swelling of multiple joints especially the proximal interphalangeal joints and wrists for more than 6 months. There is morning stiffness persisting for > 30 minutes, stiffness may recur after daytime inactivity. She also complains of small rounded swellings over the extensor surface of the forearms.

• What is the diagnosis?

• RHEUMATOID ARTHRITIS

• How will you investigate her?

• • ESR C-REACTIVE PROTEINS RA FACTOR ANTI CCP ANTIBODIES( anti-cyclic citrullinated peptide antibody)

CASE SCENARIO NO: 2 • A College student seeks medical advice due to off and on cramps, abdominal pain, fecal urgency, and tenesmus for the last 45 months and now complaining of bloody diarrhea 7 -8 episodes/day for 2 days. He had similar episode of bloody diarrhea 2 months back. • What is the differential diagnosis?

DIFFERENTIAL DIAGNOSIS • • Inflammatory Bowel disease Infectious colitis Amebic colitis Diverticulitis Psuedomembranous colitis Hemorrhoids Anal fissure Rectal carcinoma/Ca colon.

• How will you investigate him?

INVESTIGATIONS • Stool specimens for routine bacterial cultures (to exclude Salmonella, Shigella, and Campylobacter, as well as specific assays for Ecoli O 157) • Ova and parasites (to exclude amebiasis) • Stool toxin assay for C difficile. • Per rectal examination and proctoscopy • Colonoscopy • p. ANCA • Blood complete examination • ESR and C- reactive protein

ULCERATIVE COLITIS AND CHRONIC INFLAMMATION

CASE SCENARIO NO. 3 • A woman brings her maid to hospital as she was having hemoptysis for one day. On inquiring her it was found that the maid was having fatigue, weight loss, fever with evening rise, night sweats, and productive cough since 3 months for which she has been taking off and on medication from the local doctor. On physical examination, the patient appears chronically ill and malnourished. Chest examination revealed posttussive apical rales and few pan inspiratory coarse crepts.

• What could be the cause of hemoptysis?

CAUSES OF HEMOPTYSIS • • • COMMON CAUSES: Pulmonary Tuberculosis Bronchiectasis Chronic Bronchitis Bronchogenic Carcinoma Pneumonia (Acute)

• • • LESS COMMON CAUSES: Idiopathic pulmonary haemosiderosis, Goodpasture’s syndrome, Microscopic polyangiitis, Wegner , s Granulomatosis Trauma Blood disorders Benign tumours.

• How will you investigate her?

• BLOOD EXAMINATION : To assess both the hematocrit, the platelet count as well as coagulation studies. • ESR • Sputum Examination for AFB/Gram staining , culture • Chest X-RAY • CT Scan Chest

• Renal Fuction test • Antineutrophil cytoplasmic antibody Antiglomerular basement membrane antibody.

CASE SCENARIO NO: 4 • A 55 years old diabetic , hypertensive smoker suddenly developed severe crushing chest pain while he was working at his office. This pain was radiating to the left arm , neck and jaw. He also complained of palpitation, cold sweating and 1 episode of vomiting. • What could be the cause of his chest pain. ?

• Unstable angina • Non ST Segment elevation Myocardial Infarction. • ST Segment elevation Myocardial Infarction.

How will you investigate him?

• Electrocardiogram • Biochemical markers: 1. Cardiac troponin 2. Creatine-kinase-MB 3. SGOT 4. LDH • Angiogram • Echocardiogram

• Fasting Lipid profile • Blood sugar(Fasting-Random) • Hb. A 1 C

• FINAL DIAGNOSIS: • Inferior Wall Myocardial Infarction

CASE SCENARIO NO: 5 • The patient is a 56 -year-old man with chronic hepatitis C infection diagnosed 15 years back. He had never had an evaluation of his HCV. He was diagnosed as a case of chronic liver disease 1 year back, now complains of worsening right upper quadrant abdominal pain of approximately 1 week's duration, increased abdominal distension and jaundice.

• What complication might have occurred in this patient?

• HEPATO-CELLULAR CARCINOMA

• How will you investigate him?

• • • LFTS PT/APTT ULTRASOUND ABDOMEN ALPHA-FETOPROTEIN TRIPHASHIC CT –SCAN ABDOMEN