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QIO: 3585 ..L ar Pre v ious Next Lab~lues Notes Calcula t o r

•1 •
A 54-year-old woman with a heart murmur for 20 years visits her physician complaining of shortness of breath, fatigue, and edema. on physical
.2 examination the physician notes that the patient's late diastolic murmur and her 51 have become fainter than before. ca rdiac biopsy reveals the
presence of Aschoff bodies.
•3

Which of the following histologic findings would most likely be seen if one viewed the Aschoff bodies at high power?

A. Anitschkow cells

B. Cali-Exner bodies

c. Howell-Jolly bodies

o. Pseudorosettes

E. Reinke crystals

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1 •
Th e co rrect an sw er i s A. 750/o ch ose this.
.2
Given the presence of a late diastolic murmur, this patient likely has mitral stenosis.
•3 Rheumatic heart disease is the most common cause of mitral stenosis. She Is experiencing
symptoms because it is getting worse. A classic sign of worsening stenosis Is the decreasing
volume of heart murmurs, because the valve is getting more stenotic and opens less during
each beat. Rheumatic mitral stenosis is histologically associated with Aschoff bodies, shown
In the Image. Aschoff bodies consist ofT lymphocytes, plasma cells, and activated
macrophages called Anitschkow cells, which are pathognomonic for rheumatic heart disease.
These macrophages have abundant cytoplasm and a nucleus in which the chromatin
condenses Into a wavy ribbon, earning them the nickname "caterpillar cell s. •
Aschoff body Rneumatic fever Pathognomonic Chromatin Cytoplasm Heart murmo Macrophage

Cardiovascular disease Plasma cell Mitral valve stenosis Stenosis Histology Diastole Lymphocyte
Mitral valve

Image courtesy of Wikimedia Commons

6 is not co rrect. 60/o chose this.

Cali-Exner bodies are found in granulosa cell tumors of the ovary and are pathognomonic for this condition. They are eosinophilic, fluid -filled spaces.
Cali-Exner bodies Granulosa cell Pathognomonic Ovary Eosinophilic

C is not co rrect. 60fo ch ose this.

Howell-Jolly bodies are small, dark basophilic inclusions in red cells that represent nuclear remnants. They are normally removed during filtration by the
spleen and are most commonly seen in patients with splenectomy or autosplenectomy in sickle cell disease.
Autosplenectomy Splenectomy Sickle-cell disease Spleen Basophilic Howell-Jolly bodies Howell-Jolly body Red blood cell

0 i s n ot correct. 60/o ch ose this.

Pseudorosettes are typically found in neuroblastomas or other tumors, such as medulloblastoma. They contain a central region of neuropil surrounded by
a halo of tumor cells.
Medu loblastoma Neuropi Neoplasm

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- . T- I:.: I l l - - I "I II 'J I - · - - 1 -- 'J - - - :.: - I :.: - e:.: - 1 l'f I I 1:.: -
1 spleen and are most commonly seen in patients with splenectomy or autosplenectomy in sickle cell disease.
.2 Autosplenectomy Splenectomy Sickle-cell disease Spleen Basophilic Howell-Jolly bodies Howell-Jolly body Red blood cell

•3 D is not correct. 6 % chose this.

Pseudorosettes are typically found in neuroblastomas or other tumors, such as medulloblastoma. They contain a central region of neuropil surrounded by
a halo of tumor cells.
Medulloblastoma Neuropil Neoplasm

E is not correct. 7 % chose this.

Reinke crystals are found in Leydig cell tumors of the testis. They are plump, rod-like cytoplasmic inclusions.
Leydig cell Reinke crystals Leydig cell tumour Testicle Cytoplasm

Bottom Line:
Pathologic features of rheumatic heart disease include Aschoff bodies, which contain multinucleated giant cells and large Anitschkow cells.
Aschoff body Rheumatic fever Anitschkow cell Giant cell Pathology Rheumatism

I ill ;fi 1!1 I•J for year:[ 2017 ..

FI RST AI D FA CTS

FA17 p 300.1

Rheumatic fever A consequence of pharyngeal infection with J'INES (major criteria):

group A ~-hemolytic streptococci. Late Joint (migratory polyarthritis)
sequelae include rheumatic heart disease, 'I (carditis)
wh ich affects heart valves-mitral > aortic >> Nodules in skin (subcutaneous)
tricuspid {high-pressure valves affected most). Erythema marginatum
F'.;~rl v IP.sion is mitr;~ l v;~ l vP. rP..crm.crit::rtion: S\I(IP. n h~1m r.horP~l

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1
. .. •
Treatment/prophylaxis: penicill in.
.2
•3
FA17p279.1
Heart murmurs
Systolic
Aortic stenosis Crescendo-decrescendo systolic ejection murmur (ejection click may be present).
LV>> aortic pressure during S}Stole. Loudest at heart base; radiates to carotids.
Sl S2
'·Pulsus pan·us et tardus''- pulses are weak with a delayed peak. Can lead to
~I Syncope, \ ngina, and Dyspnea on exertion (S.\0). ~ lost commonly due to age-
related calcification in older patients (> 60 years old) or in younger patients with
early-onset calcification of bicuspid aortic Yah-e.
Mitral/tricuspid regurgitation Holosystolic, high-pitched "blowing murmur.''
Sl S2 Mitral - loudest at apex and radiates toward axilla. ,fR is often due to ischemic heart
disease (post-MI), MVP, LV dilatation.
~ Tricuspid- loudest at tricuspid t~rea . T R commonly caused by RV dilatation.
Rheumatic fever and infective endocarditis can cause either IR or 'I'R.
Mitral valve prolapse Late systolic crescendo murmur with midsystolie click (MC; due to sudden tensing
Sl MC S2 of chordae tendineae). Most frequent ,·ah-ular lesion. Best heard over apex. Loudest
just before S2. Usually benign. Can predispose to infective endocarditis. Can be
I LwH~vl caused by myxomatous degeneration (l 0 or 2° to connecti,·e tissue disease such as
Ylarfan or Ehlers-Dan los syndrome), rheumatic fe,·er, chordae rupture.
Ventricular septal defect llolosystolic, harsh-soundi ng murmur. Loudest at tricuspid area.

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1 •
A 74-year-old woman with a history of orthopnea and paroxysmal nocturnal dyspnea develops respiratory distress and dies en route to a hospital. A
.2 slide of the lung at autopsy is shown in the image.

•3

Image courtesy of Dr. Daniel Wasdahl

What type of cell Is the arrow pointing to in this image?

A . Club cell

B. Lymphoblast

c. Macrophage

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 Image courtesy of Dr. Daniel Wasdahl

What type of cell is the arrow pointing to in this image?

A . Club cell

B. Lymphoblast

c. Macrophage

D. Type I alveolar pneumocyte

E. Type II alveolar pneumocyte

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1 The co rrect a nswer is c. 66% cho se this.

2 The autopsy slide demonstrat es pulmonary edema with scattered hemosiderin-laden macrophages, a common finding in patients with congestive heart
failure (CHF). The diagnosis of CHF is suggested in this vignette by the patient's history of orthopnea and paroxysmal nocturnal dyspnea . In the lungs,
•3 hemosiderin produced from the breakdown of extravasat ed RBCs is phagocytosed by macrophages, giving the vacuolat ed cytoplasm of these large,
irregularly shaped cells a brownish hue. These hemosiderin-laden macrophages are sometimes called "heart failure cells."
Dyspnea Hemosiderin Heart failure Pulmonary edema Congestive heart failure Cytoplasm Orthopnea Paroxysmal nocturnal dyspnoea Autopsy Edema Phagocytosis
Macrophage lung

A is no t co rrect. 9 % cho se this.

Club cells (formerly called Clara cells) are dome-shaped with microvilli, and line the bronchioles of the lungs. They secret e a surfactant-like solution to
protect the bronchiole lining.
Bronchiole Microvillus Club cell lung

B is no t co rrect. 1 0 % cho se this.

Lymphoblasts are the first committed cell in the lymphoid series. Malignant lymphoblasts are present in the bone marrow and blood in acute
lymphoblastic leukemia.
Acute lymphoblastic leukemia leukemia lymphoblast lymphatic system Bone marrow Cancer Malignancy Bone

D is no t co rrect. 6 % cho se this.

Type I alveolar pneumocytes are the large, thin squamous cells that form the structure of the alveolar wall and are responsible for gas exchange. They
cover > 95 % of the alveolar surface area .
Alveolar cells Pulmonary alveolus Squamous epithelial cell Gas exchange

E is no t co rrect. 9 % cho se this.

Type II alveolar pneumocytes are responsible of the secretion of surfactant, which decrea ses the alveolar surface t ension. They also replicat e to form
more type I cells. They represent < 5 % of the alveolar surface area and are small and cuboid in shape.
Surfactant Surface tension Pulmonary alveolus Alveolar cells

Botto m Li ne:
Hemosiderin-laden macrophages ("heart failure cells") are a characteristic histologic finding in patients with left-sided heart failure.
Macrophage Histology Heart failure

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Alveolar cells Pulmonary alveolus Squamous epithelial cell Gas exchange
lab 'Vfl1 ues Notes Calculator

2 E is not correct. 9 % chose this .

•3 Type II alveolar pneumocytes are responsible of the secretion of surfactant, which decreases the alveolar surface tension . They also replicate to form
more type I cells. They represent <5% of the alveolar surface area and are small and cuboid in shape.
Surfactant Surface tension Pulmonary alveolus Alveolar cells

Bottom Line:
Hemosiderin-laden macrophages ("heart failure cells") are a characteristic histologic finding in patients with left-sided heart failure.
Macrophage Histology Heart failure

lijj ;fi IJ l•l for year:l 2017 ..

FIRST AID FAC T S

FA17 p298.1

Heart failure C li nical syndrome of cardiac pump dysfunction - congestion and low perfusion. Symptoms
include dyspnea, orthopnea, fatigue; signs include S3 heart sound, rales, jugular venous distention
(JVD}, pitting edema rzt.
Systolic dysfunction-reduced EF', t EDV; ~ con t ractility often zoto ischemia/M I or dilated
cardiomyopathy.
Diastolic dysfunction- preserved EF, normal EDV; l compliance often zoto myocardial
hypertrophy.
Right HF most often results from left I IF. Cor pulmonale refers to isolated right I IF due to
pulmonary cause.
.. ,.........., . ' ., •. •• .... .. t . . . ....... \

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1
The Image Is from a 51-year-old man at autopsy. Prior to his death he suffered from an illness characterized by increa sing shortness of breath, lower
extremity edema, and a loud holosystolic heart murmur. In childhood he suffered from several bouts of an illness with polyarthritis, rash, chorea, and
IA•A] •
2
fever.
•3

...
Image courtesy of Dr. Ed Uthman

In the pathologic slide of affected tissue from the patient shown above, which of the following would have been identified by the pathologist?

A. Caseous granuloma

B. Degenerative calcification

C. Fibroblast infiltrate and collagen deposition

D. Lymphocytic infiltrate

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 2
•3

...
Image courtesy of Dr. Ed Uthman

In the pathologic slide of affected tissue from the patient shown above, which of the following would have been identified by the pathologist?

A. Caseous granuloma

B. Degenerative calcification

c. Fibroblast infiltrat e and collagen deposit ion

D. Lymphocytic infiltrat e

E. Multinucleated giant cells

F. Myxoid degeneration

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1 The co rrect a nswer is E. 38% cho se this.

2 The constellation of symptoms including valvular damage, chorea, fever; and polya rthritis is characteristic of rheumatic fever; which lea ds to rheumatic
heart disea se. Pa tients often develop congestive heart failure caused by valvular damage, especially to the mitral and aortic valves. This patient's
3 shortness of brea th, lower extremity swelling, and murmur were likely long-t erm sequelae from rheumatic fever in childhood . Rheumatic heart disea se is
most commonly associat ed with Aschoff bodies, which are noncasea ting granulomas with multinuclea t ed giant cells as seen in the image in the vignette.
Aschoff bodies are considered pathognomonic for rheumatic heart disea se.
Rheumatic fever Aschoff body Heart failure Pathognomonic Congestive heart failure Chorea Polyarthritis Fever Granuloma Dyspnea Cardiovascular disease
Heart murmur Sequela Rheumatism Aortic valve

A is no t co rrect. 6 % cho se this.

Caseous granulomas are found in tuberculosis, not rheumatic heart disea se. Multinuclea t ed giant cells with horsheshoe nuclei and foreign body giant cells
will be visible, and a central region of necrosis and cell debris is always present.
Caseous necrosis Rheumatic fever Tuberculosis Granuloma Necrosis Giant cell Multinucleate Cardiovascular disease

B is no t co rrect. 9 % cho se this.

Degenerative calcification is a common finding in elderly patients with aortic stenosis, not rheumatic heart disea se. Nodular calcific masses may be visible.
Rheumatic fever Aortic stenosis Stenosis Calcification Cardiovascular disease Rheumatism

c is no t co rrect. 24% cho se this.

Fibroblast infiltration and collagen deposition is often found in the weeks following a myocardial infarction in which the necrotic myocardium is replaced by
scar tissue. Macrophages and granulation tissue at the margins may be visible.
Fibroblast Collagen Granulation tissue Cardiac muscle Myocardial infarction Macrophage Scar Necrosis

D is no t co rrect. 1 2% cho se this.

Lymphocytic infiltrat es are most commonly associat ed with viral infections, not rheumatic heart disea se. Viral infections such as those caused by coxsackie
B virus can lea d to myocarditis.
Myocarditis Rheumatic fever Coxsackie B virus Coxsackievirus Virus Cardiovascular disease

F is no t co rrect. 11% cho se this.

Myxoid degeneration is associat ed with mitral valve prolapse, not rheumatic heart disea se. Although mitral va lve prolapse can also cause a systolic
murmur and ultimat ely congestive heart failure, this patient's childhood illness is more consistent with rheumatic fever. This pathology involves thickening,
fibrosis, and the development of rubber -like consistency.
Mitral valve prolapse Rheumatic fever Heart failure Congestive heart failure Mitral valve Systole Cardiovascular disease Prolapse Fibrosis Pathology Fever

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1 Myocarditis Rheumatic fever Coxsackie B virus Coxsackievirus Virus Cardiovascular disease

2 F is not correct. 11% chos e this .

Myxoid degeneration is associated with mitral valve prolapse, not rheumatic heart disease. Although mitral va lve prolapse can also cause a systolic
3
murmur and ultimately congestive heart failure, this patient's childhood illness is more consistent with rheumatic fever. This pathology involves thickening,
fibrosis, and the development of rubber -like consistency.
Mitral valve prolapse Rheumatic fever Heart failure Congestive heart failure Mitral valve Systole Cardiovascular disease Prolapse Fibrosis Pathology Fever

Rheumatology Rheumatism Mucous membrane Heart murmur

Bottom Line:
Rheumatic fever follows a pharyngeal infection with group A streptococci and is characterized by a constellation of symptoms including fever; erythema
marginatum, polyarthritis, and chorea. Long-term sequelae due to va lvular damage include myocarditis and congestive heart failure.
Erythema marginatum Rheumatic fever Myocarditis Heart failure Congestive heart failure Group A streptococcal infection Erythema Polyarthritis Chorea
Streptococcus Fever Pharynx Rheumatism Sequela Infection

lijj ;fi IJ l•l for year:l 2017 ..

FI RST AID FAC T S

FA17 p 300.1

Rheumatic fever A consequence of pharrngeal infection with J'INES (major criteria):

group A ~-hemolytic streptococci. Late Joint (migratory polyarthritis)
sequelae include rheumatic heart disease, '1 (carditis)
wh ich affects heart valves-mitral > aortic>> Nodules in skin (subcutaneous)
tricuspid {high-pressure valves affected most). Erythema marginatum
Early lesion is mitral valve regurgitation; Sydenham chorea
),tQ. l.:.c-;1"\n ;c n,i .. r"ll c ..Pnnt'ic Accnr-i'ltPrl

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