You are on page 1of 55
Inflammation- case studies Dr suvarna nalapat
Inflammation- case studies Dr suvarna nalapat
Inflammation- case studies Dr suvarna nalapat

Inflammation- case studies

Dr suvarna nalapat

Inflammation- case studies Dr suvarna nalapat
CASE 1:
CASE 1:

A 19-year-old woman presented to the emergency room with severe left lower quadrant abdominal pain. She had fever, BP 100/70 mm Hg. Physical examination revealed extreme tenderness in the

left lower quadrant. Her WBC count showed a

leukocytosis (19,200) with a "left shift" (75% segs and 10% bands). She was taken to surgery and a laparotomy revealed that the left fallopian tube and ovary were adherent and dilated and filled

with yellow purulent material that was spilling into

the peritoneal cavity from a site of rupture. Culture of this material grew Neisseria gonorrheae.

CASE 1: • A 19-year-old woman presented to the emergency room with severe left lower quadrant
HP microscopic

HP microscopic

HP microscopic
HP microscopic
High power The high power microscopic appearance of the fallopian tube is shown here. What is

High power

High power The high power microscopic appearance of the fallopian tube is shown here. What is

The high power

microscopic appearance of the fallopian tube is shown here. What is the predominant cell type filling the

lumen?

High power The high power microscopic appearance of the fallopian tube is shown here. What is
Tuboovarian mass gross appearance of the tube and ovary, and sectioning reveals what fills them

Tuboovarian mass

Tuboovarian mass gross appearance of the tube and ovary, and sectioning reveals what fills them

gross appearance

of the tube and

ovary, and sectioning reveals what fills them

Tuboovarian mass gross appearance of the tube and ovary, and sectioning reveals what fills them
What is the diagnosis? questions 1. Grossly the tube and ovary are adherent. What is demonstrated
What is the diagnosis? questions 1. Grossly the tube and ovary are adherent. What is demonstrated
What is the diagnosis? questions 1. Grossly the tube and ovary are adherent. What is demonstrated
What is the diagnosis? questions 1. Grossly the tube and ovary are adherent. What is demonstrated
What is the diagnosis? questions 1. Grossly the tube and ovary are adherent. What is demonstrated

What is the diagnosis?

What is the diagnosis? questions 1. Grossly the tube and ovary are adherent. What is demonstrated

questions

  • 1. Grossly the tube and ovary are adherent. What is demonstrated on sectioning?

  • 2. A microscopic cross section shows tube with a thickened wall and dilated lumen. What is the predominant inflammatory cell type seen in the wall and filling lumen?

  • 3. What has happened to the vascular structures (blood vessels, lymphatics) in the tube?

1. The lumen is dilated and filled with purlent exudate. 2. These cells are neutrophils (PMN's,
  • 1. The lumen is dilated and filled with

purlent exudate.

  • 2. These cells are neutrophils (PMN's, polys). They are forming a purulent exudate. The localized collection of pus is an abscess

  • 3. They are dilated. The blood vessels are congested (filled with blood). Lymphatics are not normally seen unless there is inflammation or obstruction

1. The lumen is dilated and filled with purlent exudate. 2. These cells are neutrophils (PMN's,
2 • Over an 18 hour period, a 24-year-old man noticed increasing abdominal pain which was

2

Over an 18 hour period, a 24-year-old man noticed increasing abdominal pain which was first centered in the periumbilical region, but later localized in the right lower abdominal quadrant.

Physical examination demonstrated involuntary

guarding and rebound tenderness in the right lower quadrant. A CBC revealed a WBC count of 18,550/microliter with a left shift. He was taken to

surgery and an appendectomy was performed.

The appendix examined in surgical pathology was swollen and covered with a purulent exudate.

2 • Over an 18 hour period, a 24-year-old man noticed increasing abdominal pain which was
peripheral blood smear What type of leukocyte is increased in number?

peripheral blood smear

peripheral blood smear What type of leukocyte is increased in number?

What type of

leukocyte is increased in number?

peripheral blood smear What type of leukocyte is increased in number?
Gross and microscopic

Gross and microscopic

Gross and microscopic
Gross and microscopic
Gross and microscopic
questions 1. Sections of the appendix show what predominant inflammatory cell type in the wall? 2.

questions

  • 1. Sections of the appendix show what predominant inflammatory cell type in the wall?

  • 2. Through what series of steps are these inflammatory cells undergoing to reach the wall?

  • 3. In some places the wall shows disruption of the tissue. What is this process?

  • 4. How does the CBC relate to the findings in the appendix?

questions 1. Sections of the appendix show what predominant inflammatory cell type in the wall? 2.
1. There are numerous PMN's present, typical of acute inflammation. Also seen are marked vascular dilation
1. There are numerous PMN's present, typical of acute inflammation. Also seen are marked vascular dilation

1. There are numerous PMN's present, typical of acute inflammation. Also seen are marked vascular dilation with congestion and tissue edema (leading to the swollen appearance of the appendix). A fibrinopurulent exudate is present on the surface, producing

the gross appearance noted in surgical

pathology

1. There are numerous PMN's present, typical of acute inflammation. Also seen are marked vascular dilation
2 .Chemotactic factors (such as C5a and leukotriene) are drawing in the neutrophils. The neutrophils are

2 .Chemotactic factors (such as C5a

and leukotriene) are drawing in the neutrophils. The neutrophils

are undergoing margination in

blood vessels (mainly venules) and emigrating into the tissues.

2 .Chemotactic factors (such as C5a and leukotriene) are drawing in the neutrophils. The neutrophils are
3. This is suppurative necrosis (a form of liquefactive necrosis) resulting from the action of the
3. This is suppurative necrosis (a form of liquefactive necrosis) resulting from the action of the

3. This is suppurative necrosis (a form of liquefactive necrosis) resulting from the action of the

PMN's on the tissue.

4.Leukocytosis and a left shift are typical of many acute inflammatory processes.

3. This is suppurative necrosis (a form of liquefactive necrosis) resulting from the action of the
3 • Following left anterior descending coronary artery thrombosis with an acute myocardial infarction involving most

3

Following left anterior descending coronary artery thrombosis with an acute myocardial infarction involving most of the free wall of the left ventricle, a 73-year-old man

experienced partial paralysis of his right

side. He also developed acute renal failure and hematuria. He died a short time later. gross appearance of the cardiac lesion; of

the renal lesion, and microscopic findings are seen as follows

3 • Following left anterior descending coronary artery thrombosis with an acute myocardial infarction involving most
cardiac

cardiac

cardiac
renal

renal

renal
renal
Microscopic findings kidney

Microscopic findings kidney

Microscopic findings kidney
Microscopic findings kidney
Higher power

Higher power

Higher power
Higher power
questions 1. Describe the lesion in the heart at autopsy. 2. Diagnose and describe the lesion

questions

  • 1. Describe the lesion in the heart at autopsy.

  • 2. Diagnose and describe the lesion in the kidney removed at autopsy. What would be

the typical gross appearance?

  • 3. How did the renal lesion result from the myocardial infarction?

  • 4. What was the probable cause of his paralysis

questions 1. Describe the lesion in the heart at autopsy. 2. Diagnose and describe the lesion
answers 1. An area of coagulative necrosis is present in the anterior left ventricular free wall

answers

  • 1. An area of coagulative necrosis is present in the anterior left ventricular free wall and septum.

2.The section of kidney shows a triangular-shaped zone, with its base at the capsular surface and its apex pointed at the medulla, that has loss

of cellular detail: the nuclei are gone

(karyolysis) and the cytoplasm shows enhanced red staining (eosinophilia

answers 1. An area of coagulative necrosis is present in the anterior left ventricular free wall
4. The inflammation has led to exudation. The pink material is fibrin. Thus, there is
  • 4. The inflammation has led to exudation. The pink material is fibrin. Thus, there is a fibrinous exudate

  • Diagnosis:Acute salpingitis with tubo- ovarian abscess. N. gonorrheae can lead to chronic inflammation of the tube with scarring, upon which an acute process can be superimposed.

4. The inflammation has led to exudation. The pink material is fibrin. Thus, there is
microscopic 1. Note that the ghosts of tubules and glomeruli are preserved. One small branch of

microscopic

  • 1. Note that the ghosts of tubules and

glomeruli are preserved. One small branch of a renal artery actually show the cause, a thrombus in an artery near the apex of the area of necrosis. This necrosis is the result of ischemia, leading to an infarction (coagulative

necrosis). It is very recent, so that

little inflammatory infiltrate is present.

microscopic 1. Note that the ghosts of tubules and glomeruli are preserved. One small branch of
answer 3 A mural thrombus developed on the endocardium overlying the area of myocardial infarction. A

answer

  • 3A mural thrombus developed on the endocardium overlying the area of myocardial infarction. A portion of this thrombus broke off and was sent out into the systemic circulation, eventually going out the renal artery and lodging in a small branch to occlude the blood supply to a cortical segment and cause an infarct

  • 4A thrombus probably travelled to a cerebral artery, leading to brain

answer 3 A mural thrombus developed on the endocardium overlying the area of myocardial infarction. A

infarction (a "stroke").

4 • An 83-year-old woman experienced cough, fever, and shaking chills for two days prior to

4

An 83-year-old woman experienced cough, fever, and shaking chills for two days prior to admission. Physical examination revealed rales in the right lung base. She was coughing up a small amount

of yellowish sputum. Chest x-ray initially showed a

right lower lobe infiltrate, but several days later showed infiltrates throughout the right lung. Sputum culture grew Streptococcus pneumoniae.

(gross appearance of the lung, and the

microscopic findings).

4 • An 83-year-old woman experienced cough, fever, and shaking chills for two days prior to
gross 1. How would you describe the gross appearance of the lung?

gross

gross 1. How would you describe the gross appearance of the lung?
  • 1. How would you

describe the gross appearance of the lung?

gross 1. How would you describe the gross appearance of the lung?
microscopic What do you see in the alveolar spaces in the lung?

microscopic

microscopic What do you see in the alveolar spaces in the lung?

What do you see

in the alveolar spaces in the lung?

microscopic What do you see in the alveolar spaces in the lung?
microscopic

microscopic

microscopic
microscopic
microscopic
questions 3.How would this differ from a causative agent such as influenza virus? 4.What chemical mediators

questions

3.How would this differ from a causative

agent such as influenza virus? 4.What chemical mediators are responsible for fever? 5.What is the diagnosis?

questions 3.How would this differ from a causative agent such as influenza virus? 4.What chemical mediators
answers 1. Patchy areas of yellowish tan consolidation are present, consistent with bacterial pneumonia. 2. The

answers

  • 1. Patchy areas of yellowish tan

consolidation are present, consistent with bacterial pneumonia.

  • 2. The alveolar spaces are filled with an exudate containing numerous neutrophils along with some macrophages and pink strands of fibrin generated by the coagulation system initiated by the inflammatory process. Alveolar capillaries are congested and filled with RBC's

answers 1. Patchy areas of yellowish tan consolidation are present, consistent with bacterial pneumonia. 2. The
answers 3. Inflammation caused by viruses is typically interstitial and mostly composed of mononuclear cells. However,
answers 3. Inflammation caused by viruses is typically interstitial and mostly composed of mononuclear cells. However,

answers

3. Inflammation caused by viruses is typically interstitial and mostly composed of mononuclear cells. However, the damage done by viral

inflammation in the lung can

predispose to bacterial infection

  • 1. Interleukin-1 (IL-1) and tumor necrosis factor (TNF) are the mediators most associated with development of fever.

answers 3. Inflammation caused by viruses is typically interstitial and mostly composed of mononuclear cells. However,
diagnosis 1. This is an acute pneumonia. Streptococcus pneumoniae is a bacterial organism that typically produces

diagnosis

  • 1. This is an acute pneumonia.

Streptococcus pneumoniae is a bacterial organism that typically

produces a lobar pattern of

pulmonary involvement. A more virulent organism (usually seen in hospitalized patients) is Staphylococcus aureus which can cause abscess formation.

diagnosis 1. This is an acute pneumonia. Streptococcus pneumoniae is a bacterial organism that typically produces
case5 • A 35-year-old man had a history of intravenous drug use. Over several days' time,

case5

A 35-year-old man had a history of intravenous drug use. Over several days' time, he developed a high fever, then dyspnea. On physical examination, his temperature was 39.4 C (103 F),

and a heart murmur was heard. Needle tracks and

a red, tender, fluctuant area were noted near the left antecubital fossa. A blood culture grew Staphylococcus aureus. Despite antibiotic therapy, he died three days later. The aortic valve is

shown. Sectioning of the myocardium revealed

multiple small soft yellow foci .The epicardium showed a shaggy appearance .

case5 • A 35-year-old man had a history of intravenous drug use. Over several days' time,
Myocardial lesion

Myocardial lesion

Myocardial lesion
Myocardial lesion
Pericardial surface

Pericardial surface

Pericardial surface
Pericardial surface
questions 1. What is the appearance of the aortic valve 2. Note the dark purple focus

questions

  • 1. What is the appearance of the aortic valve

  • 2. Note the dark purple focus in this section of myocardium. Describe what you see in these foci How do these foci in the myocardium relate to the lesions on the aortic valve?

  • 3. Bacteria are being phagocytozed because

what agents are acting as opsonins?

  • 4. What is the diagnosis? What is the pathogenesis of this process?

answers 1. At autopsy, the aortic valve showed extensive necrosis with vegetations composed of yellowish-red, friable

answers

  • 1. At autopsy, the aortic valve showed extensive necrosis with vegetations composed of yellowish-red, friable material.

  • 2. These foci are small abscesses filled with neutrophils. The myocardium and adjacent epicardial fat show suppurative necrosis.

answers 1. At autopsy, the aortic valve showed extensive necrosis with vegetations composed of yellowish-red, friable
answers 3. The vegetations on the aortic valve break off and embolize. Some may go out

answers

answers 3. The vegetations on the aortic valve break off and embolize. Some may go out

3. The vegetations on the aortic valve break off and embolize. Some may go out the coronary

arteries to myocardium. These

are "septic" emboli because they contain bacteria.

  • 1. Immunoglobulin (IgG) and complement C3b.

answers 3. The vegetations on the aortic valve break off and embolize. Some may go out
answers 5. This is acute bacterial endocarditis with septic emboli and myocardial and epicardial abscesses. Most
answers 5. This is acute bacterial endocarditis with septic emboli and myocardial and epicardial abscesses. Most

answers

5. This is acute bacterial endocarditis with septic emboli and myocardial and epicardial

abscesses. Most IV drug users do

not use sterile needles, so are at risk for infection (his antecubital

lesion was an abscess at the site

of injection).

answers 5. This is acute bacterial endocarditis with septic emboli and myocardial and epicardial abscesses. Most
case6 • A 53-year-old man was the driver of a car involved in a head-on collision

case6

A 53-year-old man was the driver of a car involved in a head-on collision with another vehicle at 45 mph. He was not wearing a seat belt and his vehicle did not have an airbag. He sustained blunt

trauma to the upper abdomen. On admission to

hospital, he complained of severe abdominal and mid-back pain. He appeared gravely ill. A peritoneal lavage revealed bloody abdominal fluid.

Serum lipase was 7500 U/L. At surgery, multiple

liver lacerations were noted, and there were flecks of white, chalky material in adipose tissue adjacent to a slightly swollen pancreas.

case6 • A 53-year-old man was the driver of a car involved in a head-on collision
pancreas

pancreas

pancreas
pancreas
microscopic

microscopic

microscopic
microscopic
questions 1. Diagnose and describe what you see grossly (and microscopically .How does this lesion occur?

questions

  • 1. Diagnose and describe what you see

grossly (and microscopically .How does this lesion occur?

  • 2. Name another site at which trauma

can produce this lesion

questions 1. Diagnose and describe what you see grossly (and microscopically .How does this lesion occur?
answers 1. This is fat necrosis. Scattered tan areas are seen throughout the pancreas. There is

answers

  • 1. This is fat necrosis. Scattered tan areas are seen throughout the pancreas. There is not much of a

neutrophilic exudate, but the

adipose tissue shows areas of

necrosis that are smudgy, amorphous, and pink to violaceous (compared with normal adipose tissue)

answers 1. This is fat necrosis. Scattered tan areas are seen throughout the pancreas. There is
answers 2. The blunt force traumatic injury (probably from the steering wheel) damaged the pancreas so
answers 2. The blunt force traumatic injury (probably from the steering wheel) damaged the pancreas so

answers

2. The blunt force traumatic injury (probably from the steering wheel) damaged the pancreas so that pancreatic enzymes (lipases) were

released and began to digest

surrounding tissues. Thus, fatty acids released from triglycerides combined with calcium to produce the white,

chalky, soap-like material typical of fat necrosis

  • 1. Trauma to the breast may produce fat

answers 2. The blunt force traumatic injury (probably from the steering wheel) damaged the pancreas so

necrosis.

case7 • A 42-year-old woman underwent hysterectomy because of pelvic pain and irregular menstrual cycles associated

case7

A 42-year-old woman underwent hysterectomy because of pelvic pain and irregular menstrual cycles associated with heavy menstrual bleeding. She also complained of an intermittent, whitish mucoid vaginal discharge between periods for several months.

case7 • A 42-year-old woman underwent hysterectomy because of pelvic pain and irregular menstrual cycles associated
Gross cervix

Gross cervix

Gross cervix
Gross cervix
microscopic

microscopic

microscopic
microscopic
microscopic
microscopic

microscopic

microscopic
microscopic
What is the diagnosis 1. What is the gross appearance of the cervix 2. Microscopically, the
What is the diagnosis 1. What is the gross appearance of the cervix 2. Microscopically, the
What is the diagnosis 1. What is the gross appearance of the cervix 2. Microscopically, the
What is the diagnosis 1. What is the gross appearance of the cervix 2. Microscopically, the
What is the diagnosis 1. What is the gross appearance of the cervix 2. Microscopically, the

What is the diagnosis

What is the diagnosis 1. What is the gross appearance of the cervix 2. Microscopically, the
  • 1. What is the gross appearance of the cervix

  • 2. Microscopically, the uterine cervix at the squamocolumnar junction has ectocervix lined by glycogen rich, non-keratinizing stratified squamous epithelium. The endocervical canal is lined by a layer of columnar mucinous epithelial cells. At the

squamocolumnar junction, the mucinous

epithelium exhibits focal squamous metaplasia. What do you see adjacent to this area in the fibromuscular stroma

What is the diagnosis 1. What is the gross appearance of the cervix 2. Microscopically, the
1. The epithelium is red (hyperemic) with dilated blood vessels. 2. There is a moderate chronic
  • 1. The epithelium is red (hyperemic) with dilated blood vessels.

  • 2. There is a moderate chronic inflammatory cell infiltrate. This infiltrate consists of lymphocytes, plasma cells, macrophages, and a few neutrophils

  • 3The columnar epithelium has undergone squamous metaplasia in response to the chronic irritation. This process is reversible

1. The epithelium is red (hyperemic) with dilated blood vessels. 2. There is a moderate chronic
chronic cervicitis. This inflammation led to the discharge noted by the patient. Etiologic agents could include:

chronic cervicitis. This

inflammation led to the discharge noted by the patient. Etiologic

agents could include: yeast

(Candida), trichomonas, Gardnerella, chlamydia, or N.

gonorrheae

chronic cervicitis. This inflammation led to the discharge noted by the patient. Etiologic agents could include:
Thank you

Thank you

Thank you
Thank you