Non infective infective granulomas Soheir Mahfouz SARCOIDOSIS Like

Non infective & infective granulomas Soheir Mahfouz

SARCOIDOSIS Like TB granuloma without the caseation Chapter 7 p 102 -103

Sarcoidosis n Definition A non infective granuloma characterized by tubercle –like lesions n Aetiology ? Sarcoidosis is not contagious.

Pathology of sarcoidosis n n n n Multisystem affection by multiple lesions Skin lesions LNs Spleen Lung Bones eyes

Microscopic picture sarcoidosis Tubercles with no caseation surrounded by FT n Epitheloid cellslymphocytes and giant cells n 2 types of GC + crystalline inclusions a) asteroid bodies b) Schauman bodies n

How is sarcoidosis diagnosed? There is no single way to diagnose sarcoidosis, since all the symptoms and laboratory results can occur in other diseases. The main tools your doctor will use to diagnose sarcoidosis include: n Chest x-rays--to look for cloudiness (pulmonary infiltrates) or swollen lymph glands (lymphadenopathy) n CT scan--to provide an even more detailed look at the lungs and lymph glands than provided by a chest x-ray n Pulmonary function (breathing) tests--to measure how well the lungs are working n Bronchoscopy-The purpose of this test is to inspect the bronchial tubes and to extract a biopsy (a small tissue sample) to look for granulomas and to obtain material to rule out infection. n Keviem test

What can happen as the disease progresses? Course of the disease n n In many people with sarcoidosis, the disease appears briefly and then disappears without the person even knowing they have the disease. Twenty to 30 percent of people have some permanent lung damage. For 10 to 15 percent, sarcoidosis is a chronic condition resulting in the deterioration of the affected organ. Sarcoidosis can be fatal in 5 to 10 percent of patients.

LEPROSY Chapter 7 p 103 -104

LEPROSY DEFINITION: Infective granuloma caused by Mycobacterium leprae ETIOLOGY & PATHOGENESIS Organism: Mycobacterium leprae Acid-alcohol fast bacillus Source: prolonged close contact Site: skin and nerves

MANIFESTATIONS ACCORDING TO TYPE 1)Tuberculoid (mild) Maculo-anaesthetic leprosy n Good immunity n 2)Lepromatous (severe) Nodular leprosy— leonine facies n Low immunity n

GROSS n 1)Tuberculoid (mild) Macules (flat hypopigmented patches) n + nerve Inflammation (thickening) n 2)Lepromatous (severe) Nodules or erythematous macules n + nerve Inflammation (Thick, cord-like) n

MICROSCOPIC 1)Tuberculoid (mild) n 2)Lepromatous (severe) Granuloma (leproma) + n Granuloma + many few organisms Lymphocytes + plasma cells +Giant cells+ foamy macrophages (clear cells or foam cells) called lepra cells

MICROSCOPIC

Clinical Picture 1)Tuberculoid (mild) 2)Lepromatous (severe) n Loss of sensation loss of sensation & sweating n Trophic changes n severe trophic (ulcers) changes n Deformities and loss of parts of limbs due of parts limbs severe to loss of sensation & n leonine facial low blood supply) disfigurement n

SYPHILIS Chapter 7 p 104 -112

SYPHILIS DEFINITION: Venereal Infective spirochetal granulomatous disease caused by Treponema pallidum

AETIOLOGY & PATHOGENESIS Organism: spirochete Treponema pallidum Diagnosed by: Silver stains Immunofluorescence-Dark field illumination microscopy n Route & Site of entry: 1. Skin by intimate contact (venereal) : genital organs (male-female) – extragenital sites: lips-breasts etc…. 2. Non- venereal (transplacental: spirochetes spread via placenta to fetus). n

AETIOLOGY & PATHOGENESIS Types: 1. Congenital syphilis: baby born to syphilitic mother with lesions 2. Venereal type: n Primary (1 ry) lesion at time of first contact n Secondary (2 ry) lesions all over body due to blood spread n Tertiary (3 ry) lesions due to hypersensitivity

AETIOLOGY & PATHOGENESIS Mechanism: Spirochete enters (by intimate contact) → IP 2 wks → 1 ry proliferative lesion (granuloma) 33%cases undergo healing Rest of cases spread by blood & lymphatics & after 2 months → 2 ry lesions 3 ry lesions (gumma) 2 - 10 years later

MORPHOLOGY Basic reaction 1 ry GROSS n Nodule (early) n Ulcer (hard sore/chancre) 1. edges punched out & straight 2. floor clean smooth 3. base: syphilitic GT n Regional lymphadenitis

1 ry Microscopic ( syphilitic GT) plasma cells > lymphocyte n macrophages & FT n early endarteritis obliterans + gummatous necrosis central n

MORPHOLOGY Basic reaction 2 ry Gross n Rash in mucous membranes & skin -macular rash -papular rash n +/- Ulcerations n Generalized lymphadenopathy Microscopic n syphilitic GT

MORPHOLOGY Basic reaction 3 ry Gross a-Gumma Hypersensitivity type IV firm –yellow-rubbery surrounded by FT. It occurs in: heart septumliver – bone-brain b-Diffuse inflammation Aorta & meninges bones, testis & tongue * Hepar lobatum

MORPHOLOGY Basic reaction 3 ry Microscopic a-Gumma is a localized area of necrosis surrounded by syphilitic GT b-Diffuse inflammation n Chronic diffuse inflammation + fibrosis (syphilitic GT) n Hypersensitivity necrosis

Cvs syphilis Heart 1. Gumma of septum 2. Diffuse syphilitic myocarditis 3. Diffuse Syphilitic pericarditis n BV 1. Syphilitic arteritis 2. Syphilitic aortitis n

Syphilitic aortitis Microscopic n gross n 1. 2. 3. n Intima: Proliferation of CT opposite media lesions Atherosclerotic plaques Wrinkling of intima Media: mononuclears & end arteritis obliterans VV necrosis of musculoelastic tissue FIBROSIS Adventitia mononuclears & end arteritis obliterans VV and fibrosis

Syphilitic aortitis gross n n n n Aortic cusps thick and rolled up Dilated aorta (ascending) Raised atheroscl plaques TV wrinklings (furrrows) Media thin white (fibrotic Adventitia thickened by FT Coronary ostia narrowed

Syphilitic aortitis complications n 1. 2. n n 1. 2. Aortic incompetence Stretched aortic ring (dilatation of aorta Shrunken cusps with incomplete closure Resulting in LHF Aortic aneurysm: weak fibrotic wall Stenosis of coronary artery Gradual ischemia: Myocardial fibrosis & angina Sudden ischemia : sudden death VF / infarction

Syphilis of bones n 1. 2. 3. n Gumma Worm eaten skull Saddle nose perforated septum Gumma of hard palate perforated palate Diffuse osteomyelitis NB syphilitic osteitis causes osteosclerosis NO PATHOLOGIC FRACTURE

neurosyphilis Meningovascular Gumma or diffuse syphilitic meningitis 2. Syphilitic arteritis n Parenchymatous a. General paralysis of the insane (dementia paralytica) infl + necrosis of frontal lobes with flattening of convolutions b. Tabes dorsalis producing Charcot joint & chronic ulcers due to: posterior column nerve demyelination meningitis followed by gliosis n 1.

Congenital syphilis Transplacental spread→abortion or still birth. If fetus survives: EARLY MANIFESTATIONS (during 1 st 2 years of life)(like 2 ry syphilis) n Skin condylomata: papillary skin projections-desquamationmacules n Mucous patches n Generalized lymphadenopathy n Rhagades: radiating scars at the angle of the mouth

Congenital syphilis EARLY MANIFESTATIONS contin n n 1. 2. Syphilitic osteochondritis: epiphysial line appears yellow , broad & irregular due to infiltration by Syphilitic GT resulting in growth retardation Syphilitic inflammation of organs Pneumonia alba Syphilitic cirrhosis (monocellular cirrhosis)

Congenital syphilis Late MANIFESTATIONS (2 -30 years) n n n n Hutchinson’s teeth: The permanent central incisors are notched & widely separated. Deafness due to 8 th cranial nerve affection Eye: keratitis Saber tibia: thickening and bending of tibia (sword like i. e. curved) diffuse periosteitis Gumma of palate with perforation Gumma nasal septum→saddle nose Effusion large joints

ACTINOMYCOSIS Chapter 7 p 112 -123

ACTINOMYOCOSIS DEFINITION: Infective suppurative granulomatous disease caused by the filamentous bacteria, Actinomyces Israeli.

ETIOLOGY & PATHOGENESIS n Organism: filamentous anaerobic gram+ve organism. It is a Commensal found in oral cavity & intestines. Long blue filaments, having red nobby tips. The filaments branch. n Sites: Cervico-oral (jaw)intestine (ileocoecal) , lungs (pulmonary) & less commonly skin

MANIFESTATIONS GROSS Multiple pus containing cavities n surrounded by FT n multiple sinuses opening onto skin n releasing granular yellow material (sulfur granules) which is pus containing organism n

MICROSCOPIC n Central zone of pus + irregular blue clump of organism with a red periphery n PNLs & macrophage Outer zone of lymphocytes-plasma cells -macrophages n endarteritis obliterans & FT (chronic inflammation) n

LECTURE RESOURCES BOOKS & Lecture notes �Textbook : Basic Pathology by Kumar, Cotran & Robbins �General & systemic pathology J. C. E Underwood 3 d edition Livingstone�Gamal Nada's General Pathology �Gamal Nada's General Museum of Pathology �Soheir Mahfouz's Guidlelines in General Pathology WEBSITES Important web sites from which many images or text were taken. NB. Those not mentioned may be found on web searches: google , Yahoo & ask. com http: //www. pathmax. com/ http: //www-medlib. med. utah. edu/Web. Path/LABS/LABMENU. html#2 http: //www. med. uiuc. edu/Path. Atlasf/title. Page. html http: //www. medscape. com/pathologyhome http: //www. gwumc. edu/dept/path/2 F. HTM http: //ampat. amu. edu. pl/czasopis/contents. htm http: //www. urmc. rochester. edu/smd/pathres/long. html http: //www. medscape. com/pathology/cme n n n n n

LECTURE RESOURCES http: //www. medscape. com/pathology/cme http: //www. mic. ki. se/Diseases/C 23. html http: //dir. yahoo. com/Health/medicine/pathology/ http: //www. iaphomepage. org/ http: //search. msn. com/results. aspx? q=Pathology+lectures+on+line&FORM=QBRE 2 http: //dpalm. med. uth. tmc. edu/faculty/bios/hunter/pathlinks. htm http: //www. pathmax. com/main. html http: //www. pathguy. com http: //www. emedicine. com/oncology/ http: //www. thedoctorsdoctor. com/diseases/liposarcoma. htm#histo http: //www. humpath. com/article. php 3? id_article=3532 http: //www. ec. upstate. edu/path/ http: //peir. net/ http: //medstat. med. utah. edu/Web. Path/webpath. html ATLAS http: //www. emedicine. com/asp/image_search. asp? query=actinomycosis&offset=12 http: //erl. pathology. iupui. edu/C 604/INDEX. HTM http: //www. path. uiowa. edu/virtualslidebox/ http: //www. mic. ki. se/MEDIMAGES. html#G 02. 403. 776. 600 http: //www. palms. med. usyd. edu. au/pathology_museum/ http: //www. med. uiuc. edu/Path. Atlasf/title. Page. html n n n n n n

LECTURE RESOURCES http: //www. med. uiuc. edu/Path. Atlasf/title. Page. html http: //images. google. com/imgres? imgurl=http: //www. images. md/intermedia/imgagent/mediage t/getwatermarked/ACNCR 01 -09 -55001&imgrefurl=http: //www. images. md/users/explore_chapter. asp%3 FID%3 DACNCR 01 -0955%26 col. ID%3 DACNCR 0109%26 coltitle%3 DBreast%2 BCancer&h=80&w=120&sz=11&tbnid=EZu 7 ub. DWDd. UUIM: &tbnh=5 5&tbnw=83&hl=en&start=67&prev=/images%3 Fq%3 DFine%2 BNeedle%2 BAspiration%2 Bof%2 BBreast%26 start%3 D 60%26 svnum%3 D 10%26 hl%3 Den%26 lr%3 D%26 sa%3 DN http: //images. google. com/imgres? imgurl=http: //www. hopkinsbreastcenter. org/pathology/benign /1 j. jpg&imgrefurl=http: //www. hopkinsbreastcenter. org/library/educational_information/benign. s html&h=380&w=492&sz=289&tbnid=NTEc. MCp 3 m. Ru. Zb. M: &tbnh=98&tbnw=127&hl=en&start=1 &prev=/images%3 Fq%3 DFine%2 BNeedle%2 BAspiration%2 Bof%2 BBreast%26 svnum%3 D 10%2 6 hl%3 Den%26 lr%3 D http: //images. google. com/imgres? imgurl=http: //www. webpathology. com/slides/thumbnails/Test es_Sex. Cord_Granulosa. Cell. Tumor 2 TN. jpg&imgrefurl=http: //www. webpathology. com/case. cfm% 3 Fcase%3 D 38&h=76&w=101&sz=6&tbnid=yup 1 zv. PUIS 1 u 3 M: &tbnh=58&tbnw=78&hl=en&start =21&prev=/images%3 Fq%3 Dgranulosa%2 Bcell%2 Btumour%2 Bovary%26 start%3 D 20%26 svnu m%3 D 10%26 hl%3 Den%26 lr%3 D%26 sa%3 DN http: //screening. iarc. fr/index. php http: //web. med. unsw. edu. au/pathology/Pathmus/pathmus. htm#Interactive. Images http: //www. hopkinsbreastcenter. org/library/educational_information/benign. shtml http: //eulep. anat. cam. ac. uk/Search_Pathbase/index. php? actiontype=search&mpath= http: //www. diesis. com/fabrizio/atlas/ Dermatopath http: //www. derm. ubc. ca/pathology/micrneurann. htm n n n

LECTURE RESOURCES Dermatopath http: //www. derm. ubc. ca/pathology/micrneurann. htm http: //tray. dermatology. uiowa. edu/DPTutor. htm n n Reproductive http: //images. google. com/imgres? imgurl=http: //www. path. sunysb. edu/coursemat/reproimages/ thumbs/4 thumb. jpg&imgrefurl=http: //www. path. sunysb. edu/coursemat/reproslides. htm&h=86& w=120&sz=5&tbnid=a. VSQELIji. Wf. BAM: &tbnh=59&tbnw=83&hl=en&start=25&prev=/images%3 Fq%3 Dgranulosa%2 Bcell%2 Btumour%2 Bovary%26 start%3 D 20%26 svnum%3 D 10%26 hl%3 Den %26 lr%3 D%26 sa%3 DN n n n Respiratory http: //iris. nyit. edu/~edoran/Course/Resp 1 lect 01. htm#NORMAL%20 ANATOMY%20 LUNGS n n

Lectures will be available next week on the net http: //www. kasralainy. edu. eg/ english/departments/pathology/