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Pathology
Pathology
Arthur S. Schneider, MD
Professor and Vice-chair
Department of Pathology
Chicago Medical School
Rosalind Franklin University of Medicine and Science
North Chicago, Illinois

Philip A. Szanto, MD
Associate Professor of Pathology (retired)
Chicago Medical School
Rosalind Franklin University of Medicine and Science
North Chicago, Illinois

With Special Contributions by

Anne M. Mills, MD
Sandra I. Kim, MD, PhD
Todd A. Swanson, MD, PhD
Publisher: Michael Tully
Acquisitions Editor: Sirkka Howes
Product Manager: Stacey Sebring
Marketing Manager: Joy Fisher-Williams
Vendor Manager: Alicia Jackson
Designer: Holly Reid McLaughlin
Manufacturing Coordinator: Margie Orzech
Compositor: Integra Software Services Pvt. Ltd.
5th Edition
Copyright © 2014, 2009, 2006, 2002, 1993 Lippincott Williams & Wilkins, a Wolters Kluwer business.
351 West Camden Street Two Commerce Square
Baltimore, MD 21201 2001 Market Street
Philadelphia, PA 19103
Printed in China
All rights reserved. This book is protected by copyright. No part of this book may be reproduced or
transmitted in any form or by any means, including as photocopies or scanned-in or other electronic
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contact Lippincott Williams & Wilkins at 2001 Market Street, Philadelphia, PA 19103, via email at
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Not authorized for Sale in North America or the Caribbean.
9 8 7 6 5 4 3 2 1

Library of Congress Cataloging-in-Publication Data

Schneider, Arthur S.
Pathology / Arthur S. Schneider, Philip A. Szanto ; with special contributions by Anne Mills, Sandra I.
Kim, and Todd A. Swanson. — 5th ed.
   p. ; cm. — (BRS)
Includes index.
ISBN 978-1-4511-8889-9
I. Szanto, Philip A. II. Title. III. Series: Board review series.
[DNLM: 1. Pathology—Examination Questions. QZ 18.2]
RB32
616.07’076—dc23
2013010441

DISCLAIMER

Care has been taken to confirm the accuracy of the information present and to describe generally
accepted practices. However, the authors, editors, and publisher are not responsible for errors or
omissions or for any consequences from application of the information in this book and make no
warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents
of the publication. Application of this information in a particular situation remains the professional
responsibility of the practitioner; the clinical treatments described and recommended may not be
considered absolute and universal recommendations.
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set forth in this text are in accordance with the current recommendations and practice at the time of
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(FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care
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As always and with great love and affection,
To Edie (of cherished memory)
To Anne
 Preface

As in prior editions, we have updated the format and, we hope, the utility of this work
by substituting and adding even more color illustrations. In the selection of images,
we have held to the principle that the medical school pathology course should be
aimed at building an understanding of the processes of disease and that identifica-
tion of images is not an objective unto itself, but rather an important tool to illustrate
mechanisms.
While attempting to keep this fifth edition as short as possible, we have added
what we consider to be significant material needed for updating. As before, the end-
of-chapter study questions and the comprehensive examination at the end of the
book are entirely cast in vignette format. This should be helpful for students preparing
for similar examinations administered by national accrediting groups.

Format

First, as indicated by the series title, Board Review Series, one of the prime purposes
of the book is to serve as a source of review material for questions encountered on
the USMLE and similar qualifying examinations. A certain part of such preparation
consists of recognition of “key associations” that serve as the basis for many such
examination questions. Accordingly, in this edition, we have again indicated such
associations throughout the text with a symbol resembling a key. Even though we
are strongly committed to the view that pathology is a conceptual field consisting of
much more than “buzz words,” we also believe that recognition of such material is
part of learning and that it helps students gain confidence in dealing with voluminous
material, such as the content of standard pathology courses. The graphic designator
used here should serve to identify these “high-yield” items and should be useful to the
student in final preparation for board-type examinations.

Organization

The chapter organization continues to parallel that of most major texts, beginning
with an initial 8 chapters covering basic or general pathology, followed by 15 chap-
ters covering the pathology of the organ systems. A final chapter deals with statistical
concepts of laboratory medicine. Each chapter ends with a set of review questions,
and the text concludes with a Comprehensive Examination designed to emulate the
content of national licensing examinations.

vi
 Preface vii

How to Use This Book

We recommend that this book not be used as a primary text, but rather, as the series
title suggests, as a supplement for study and for review. Following the initial study of
a unit in a pathology course, many students will find that review of the correspond-
ing material in this book will aid in the identification of major concepts that deserve
special emphasis. Also, this book can serve as a source for end-of-year review and for
review for national examinations.
Special attention is again directed to the Answers and Explanations that follow
the end-of-chapter Review Test questions and the Comprehensive Examination
questions at the end of the text. Much of the teaching material is emphasized in these
discussions, and it is recommended that these sections be reviewed carefully as part
of examination preparation.

Arthur S. Schneider, MD
Philip A. Szanto, MD
 Acknowledgments

We again welcome back and thank our associates and former students, Drs. Sandra I.
Kim and Todd A. Swanson, who contributed much to the vignette-style sample ques-
tion sections throughout this edition. We also thank Dr. Anne Mills for her insightful
additions to this new edition. Also, we express appreciation to our students and our
many readers throughout the world who have used the preceding editions of this
book over the past years. Their overwhelming response and helpful comments have
been immensely gratifying and deeply appreciated. We again quote William Osler,
who pointed out many years ago that “to study the phenomena of disease without
books is to sail an uncharted sea,” and “it is easier to buy books than to read them.”
Our gratification is increased since we have repeatedly heard from our readers that
our book has not only been bought, but has also been thoroughly read, annotated,
and read again.
We express our sincere gratitude to Dr. Emanuel Rubin, Dr. Raphael Rubin,
Dr. Bruce Fenderson, and their group of colleagues who collected the great majority
of the illustrations generously provided to us by our publisher.
We again acknowledge the continuing contributions of the editorial staff at
Lippincott Williams & Wilkins, especially those of Mrs. Stacey Sebring, managing edi-
tor during the development of this edition and Mrs. Sirkka Howes, acquisitions editor.
We thank them all for their hard work and patience. The final product owes a great
deal to their efforts.

viii
 Contents

Preface  vi
Acknowledgments  viii

1. Cellular Reaction to Injury 1

I. Adaptation to Environmental Stress 1
II. Hypoxic Cell Injury 3
III. Free Radical Injury 4
IV. Chemical Cell Injury 4
V. Necrosis 5
VI. Apoptosis 6
VII. Reversible Cellular Changes and Accumulations 8
VIII. Disorders Characterized by Abnormalities of Protein Folding 11
Review Test  12

2. Inflammation 17
I. Introduction 17
II. Acute Inflammation 17
III. Chronic Inflammation 24
IV. Tissue Repair 26
Review Test  28

3. Hemodynamic Dysfunction 33
I. Hemorrhage 33
II. Hyperemia 33
III. Infarction 34
IV. Thrombosis 34
V. Embolism 39
VI. Edema 40
VII. Shock 41
Review Test  43

ix
x Contents

4. Genetic Disorders 48
I. Chromosomal Disorders 48
II. Modes of Inheritance
of Monogenic Disorders 52
III. Mendelian Disorders 53
IV. Balanced Polymorphism 60
V. Polygenic and Multifactorial Disorders 60
VI. Disorders of Sexual Differentiation 61
Review Test  62

5. Immune Dysfunction 67
I. Cells of the Immune System 67
II. Cytokines 68
III. Complement System 68
IV. Human Leukocyte Antigen System 69
V. Innate versus Acquired Immunity 69
VI. Mechanisms of Immune Injury 69
VII. Transplantation Immunology 72
VIII. Immunodeficiency Diseases 73
IX. Autoimmunity 76
X. Connective Tissue (Collagen) Diseases 77
XI. Amyloidosis 80
Review Test  82

6. Neoplasia 87
I. General Considerations 87
II. Classification and Nomenclature of Tumors 87
III. Properties of Neoplasms 89
IV. Carcinogenesis and Etiology 92
V. Other Neoplastic Disorders with Known DNA Defects 97
VI. Grading and Staging 98
Review Test  99

7. Environmental Pathology 103

I. Physical Injury 103
II. Chemical Abuse 105
III. Environmental Chemical Injuries 107
IV. Adverse Effects of Therapeutic Drugs 108
Review Test  110