General PATHOLOGY

Yohannes A.

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 Definition of pathology…

 It is the “Scientific study of disease"

 "scientific study of the molecular, cellular, tissue,
or organ system response to injurious agents.“
 Pathology serves as a "bridge" or "link"
between the preclinical sciences and the
courses in clinical medicine.

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 The core of pathology
• Pathology gives explanation of a disease
by studying the four aspects of the disease
 1. Etiology
 2. Pathogenesis
 3. Morphological changes
 4. Functional derangement & clinical
significance

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 Diagnostic modalities
• Most are based on morphologic changes
• Diagnostic techniques:
1. Histopathology
2. Cytopathology
3. Hematopathology
4. Immunohistochemistry
5. Microbiological examination
6. Biochemical examination
7. Cytogenetics
8. Molecular techniques
9. Autopsy

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 Histopathology
• Studies the tissue under the microscope
• Tissues are obtained by biopsy
 Biopsy – tissue sample from living person
• Biopsy – Incisional
- Excisional
• Tissue examined grossly (macroscopically) &
microscopically
• It is usually the gold standard for pathologic
diagnosis
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 Ctd…
• Once the tissue is removed from the pt, it
has to be immediately fixed by putting it
into adequate amount of 10% formalin
before sending it to the pathologist
• Once the tissue arrives at the pathology
department, the pathologist will examine
macroscopically

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 Ctd…
• Then the tissue is processed to make it ready for
microscopic examination. The whole purpose of
the tissue processing is to prepare a very thin
tissue which can be clearly seen under the
microscope
• The tissue is processed by putting it into
different chemicals. It is then impregnated
(embedded) in paraffin, sectioned (cut) into thin
slices, & is finally stained.
• The stains can be Hematoxylin/Eosin stain or
special stains such as PAS,
immunohistochemistry, etc…

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 Ctd…
• The Hematoxylin/Eosin stain is usually
abbreviated as H & E stain. It is routinely
used.
• It gives the nucleus a blue color, the
cytoplasm & the extracellular matrix a
pinkish color

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 Cytopathology
• Study the cells
• Used in:
Screening for early detection of cancer
Diagnosis of symptomatic cancer
Diagnosis of inflammatory condition,
infectious
Surveillance of pts treated with cancer

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 Ctd…
• Its advantage:
• Cheap
• Takes less time
• Needs no anesthesia
Cytopathological methods:
1. FNAC
2. Exfoliative cytology
3. Abrasive cytology

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 Ctd…
1. FNAC
• Easy in superficial organs
• May need guidance in deep seated mass
2. Exfoliative cytology
• From cells that are shed from spontaneously into
body fluids or secretion
3. Abrasive cytology
• Cells are dislodged from skin or mucous
membrane by various tools
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 Hematological examination

• This is a method by which abnormalities of

the cells of the blood & their precursors in
the bone marrow are investigated to
diagnose the different kinds of anemia &
leukemia.

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 Immunohistochemistry

• This is a method used to detect a specific

antigen in the tissue in order to identify the
type of the disease

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 Microbiological examination

• This is a method by which body fluids,

excised tissue, etc… are examined by
microscopical, cultural, serological
techniques to identify microorganisms
responsible for many diseases

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 Biochemical examination

• This is a method by which the metabolic

disturbances of disease are investigated
by assay of various normal & abnormal
compounds in the blood, urine, etc…
Eg. High serum HCG level - choriocarcinoma

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 Diseases
• Disease is defined as an abnormal
variation in structure or function of any part
of the body
 Causes of disease
 Environmental
 Genetic or
 Both

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 Environmental factors
Are many & are classified into:-
1. Physical agents
2. Chemicals
3. Nutritional deficiencies & excesses
4. Infections & infestations
5. Immunological factors
6. Psychogenic factors

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 Out come of diseases

• Resolution can occur leaving no sequelae

• The disease can settle down, but sequelae
are left, or
• It may result in death

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 Biological death
• Biological death (sure signs of death),
which sets in after clinical death, is an
irreversible state of cellular destruction
• It manifests with irreversible cessation of
circulatory & respiratory functions, or
irreversible cessation of all functions of the
entire brain, including brain stem

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Cellular Adaptations,
Cell injury &
Cell death

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 CELLULAR RESPONSES TO STRESS AND
NOXIOUS STIMULI

• Cells maintain their intracellular milieu

within narrow range of physiologic
parameters(homeostasis).
• In physiologic stresses or pathologic
stimuli, they can undergo adaptation,
achieving a new steady state and
preserving viability and function.

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• The adaptive responses :
hypertrophy, hyperplasia, atrophy, and
metaplasia.
• If the adaptive capability is exceeded or if
the external stress is inherently harmful,
cell injury develops which may be
reversible or irreversible (cell death) .

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 Cell death
• The most crucial events in the evolution of
disease.
• Causes: ischemia ,infections, toxins, and
immune reactions.
• Normal and essential process in
embryogenesis, the development of
organs, and the maintenance of
homeostasis.

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26
 Hypertrophy
• Is an increase in the size of the cell resulting in
the enlargement of the organs
• It results from an increase functional demand or
due to a specific hormonal stimulation.
• By undergoing hypertrophy, the cell achieve
equilibrium between its demand & functional
capacity
• The increase in size is due to synthesis of more
structural components

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 Ctd…
• Hypertrophy commonly seen in cardiac &
skeletal muscle tissues.
• Hypertrophy can be:-
 Physiological
eg. Muscular hypertrophy due to exercise
 Pathological
eg. myocardial hypertrophy due to
hypertension

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 Hyperplasia
• Is an increase in the number of cells of a
tissue or an organ.
• Occurs in those cells that are capable of
synthesizing DNA or undergo mitotic
division
• Nerve cells, skeletal cells & cardiac cells
do not divide, hence an increase work load
to skeletal & cardiac cells respond only by
hypertrophy.

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 Ctd…
• Hyperplasia can be:-
 Physiologic hyperplasia
1. Hormonal hyperplasia which increases
the functional capacity of a tissue when
needed.
– Exemplified by the proliferation of the glandular
epithelium of the female breast at puberty and during
pregnancy

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 Ctd…
2. Compensatory hyperplasia, that is,
hyperplasia that occurs when a
portion of the tissue is removed or
diseased.
– For example, when a liver is partially
resected, mitotic activity in the remaining cells
begins as early as 12 hours later, eventually
restoring the liver to its normal weight

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 Ctd…
 Pathologic hyperplasia
• Most are caused by excessive hormonal
stimulation or growth factors acting on
target cells.
Eg. Endometrial hyperplasia
• Pathologic hyperplasia constitutes a fertile
soil in which cancerous proliferation may
eventually arise

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 Atrophy
• Is a decrease in the size of the cell, which
might result in shrinkage of the organs.
• There is loss of cellular substance
• In an atrophic cell, the cell consists of
fewer mitochondria, myofilaments &
endoplasmic reticulum
• Due to decrease in the work load, demand

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 Ctd…

• Atrophy can be:-

 Physiological
Eg. During embriogenesis
 Pathological

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 Causes of atrophy
 Disuse
 Denervation
 Decreased blood supply
 Inadequate nutrition
 Loss of endocrine stimulation
 Aging
 Pressure

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 Metaplasia
• Is an adaptive substitution of one type of cell in
to another type that is able to tolerate the stress.
• It is a reversible condition
• The most common metaplasia is columnar to
squamous.
• An example is the conversion of columnar
epithelium of the respiratory tract into squamous
type in habitual cigarette smokers.

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 Ctd…
• The influences that predisposes metaplasia, if
persistent, may induce malignant transformation
in metaplastic epithelium
• Metaplasia from squamous to columnar type
may also occur. Esophageal squamous
epithelium is replaced by intestinal – like
columnar under the influence of refluxed gastric
acid
• Cancers may arise that are typically glandular
carcinoma (adenocarcinoma)

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 Ctd…
• Connective tissue metaplasia is the
formation of cartilage, bone or adipose
tissue (mesenchymal tissue) in tissue that
normally do not contain these elements
• Myositis ossificans – bone formation in
muscle after bone fracture

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 Cell injury & cell death
• The cell may acquire a reversible injury or may
obtain an irreversible injury & may die.
• The factor influencing cell injury & cell death
depends on
 Intensity of stimulus
 Duration of the injury
 Type of injury
 Type of cell involved

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 Ctd…

Normal cells
(homeostasis)
stress↓ ↓ injurious agent
↓ ↓
Adaptation → → Cell injury
enable to
adapt

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 Causes of cell injury
• Oxygen deprivation
• Physical agents
• Chemical agents & drugs
• Infectious agents
• Immunologic reactions
• Genetic derangements
• Nutritional imbalance

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Targets of cell injury

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Ctd…

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 Cell injury

• Reversible cell injury

• Irreversible cell injury

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 Reversible cell injury
• When cell come back to normal after removal of
the injurious agent
• Two patterns can be recognized under the light
microscopy
 Cellular swelling
• First manifestation of injury
• It appears whenever the cells are incapable of
maintaining ionic & fluid homeostasis & is result
of loss of function of plasma membrane energy
dependant ion pumps

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 Ctd…
 Fatty change
• Manifested by the appearance of small &
large lipid vacuoles in the cytoplasm &
occurs in hypoxic & various toxic injury
• Principally seen in cells involved in &
dependant on fat metabolism such as
hepatocytes & myocardial cells

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 Irreversible cell injury
• With persistent stimuli ---- cell can not
recover so irreversible cell injury.
• Irreversibly injured cells undergo changes
that are recognized as cell death.

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Example

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 Ctd…
Cell death – is the ultimate result of cell injury &
 Is one of the crucial event in the development of
disease
 With cell death, there are marked changes with
in the cell.
• There are two types of cell death:-
Necrosis
Apoptosis

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 Necrosis
• Is death of a cell or tissue
• A spectrum of morphologic changes that
follow cell death in a living tissue resulting
from the progressive degenerative action of
enzymes in lethally injured cells
• It is always pathological
• Necrosis can be followed by release of
intracellular enzymes into the blood,
inflammation or dystrophic calcification.

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 Nuclear changes
• Karyolysis – the basophilia of the nucleus
fades
• Pyknosis – nuclear shrinkage & increased
basophilia
• Karyorrhexis – nuclear fragmentation

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 TYPES OF NECROSIS
1. Coagulative necrosis
 Most often results from sudden
interruption of blood supply to an organ
 It is , in early stage, characterized by
general preservation of tissue
architecture

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 Ctd…
2. Liquefactive necrosis
 It is characterized by digestion of tissue. It
shows softening & liquefaction of tissue.
 It characteristically results from
ischemic injury to the CNS
 It also occurs in suppurative infections
characterized by formation of pus

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 Ctd…
3. Gangrenous necrosis
 When considerable mass of tissue
undergo necrosis
 Two types gangrene
- Dry
- Wet

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 Dry gangrene
• Is associated with obstruction of the arterial
blood supply with out interference of the venous
return
• Is confined to the extremities
• The involved part become dry, skin wrinkle
• The color change to dark brown or black
• The spread is slow
• There is a line of demarcation
• Can be changed to wet gangrene, if bacterial
infection
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 Wet gangrene
• Is primarily due to interference of the venous
return
• There is bacterial invasion
• Can affect the extremities or even the internal
organs
• The involved part is cold, swollen & pulseless
• The skin is moist, foul smelling & black
• No line of demarcation
• Spread of tissue is rapid
• Can be fatal

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 Ctd…
4. Caseous necrosis
– It is type of necrosis most often seen in foci
of tuberculous infection
– The term caseous is derived from the
cheesy white gross appearance of the area
of necrosis.
– On microscopic examination, the necrotic
focus appears as amorphous granular
debris

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 Ctd…
5. Fat necrosis
– Focal areas of fat destruction, typically occurring as
a result of release of activated pancreatic lipases in
to the substance of the pancreas & the peritoneal
cavity. This occurs in acute pancreatitis.
– The activated enzymes liquefy fat cell membranes &
the lipases split the triglyceride contained with in fat
cells. The released fatty acids combine with calcium
to produce grossly visible chalky white areas
(fat saponification)

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 Apoptosis
– It is a pathway of cell death that is induced by
tightly regulated intracellular program in which
cells destined to die activate enzymes that
degrade the cells own nuclear DNA & nuclear
& cytoplasmic proteins
– Can be physiologic or pathologic

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Apoptosis in physiologic situations
• Programmed destruction of cells during
embryogenesis
• Hormone dependent involution in the adult
• Cell deletion in proliferating cell
populations
• Death of host cells that have served their
useful purpose
• Elimination of potentially harmful self
reactive lymphocytes
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 Apoptosis in pathologic situations

• Cell death produced by a variety of

injurious stimuli such as radiation &
cytotoxic anticancer drugs
• Cell injury in certain viral diseases such as
viral hepatitis
• Pathologic atrophy in parenchymal organs
after duct obstruction
• Cell death in tumors

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 Morphology
• The following morphologic features
characterize cells undergoing apoptosis
– Cell shrinkage
– Chromatin condensation
– Formation of cytoplasmic blebs & apoptotic
bodies
– Phagocytosis of apoptotic cells or cell bodies
usually by macrophages

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 Mechanisms of Apoptosis
– Apoptosis is an active enzymatic process in
which nucleoproteins are broken down and
then the cell is fragmented.
– The fundamental event in apoptosis is the
activation of enzymes called caspases
1. The Mitochondrial (Intrinsic) Pathway of
Apoptosis
2. The Death Receptor (Extrinsic) Pathway of
Apoptosis

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Clearance of Apoptotic Cells
– Apoptotic cells undergo several changes in
their membranes that promote their
phagocytosis. In normal cells
phosphatidylserine is present on the inner
leaflet of the plasma membrane, but in
apoptotic cells this phospholipid "flips" out and
is expressed on the outer layer of the
membrane, where it is recognized by
macrophages.
– Cells that are dying by apoptosis also secrete
soluble factors that recruit phagocytes

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Ctd…

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Features of necrosis & apoptosis

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 Intracellular accumulations
 There are three main pathways of abnormal intracellular
accumulations
1. A normal substance is produced at a normal or an
increased rate, but the metabolic rate is inadequate
to remove it.
2. A normal or an abnormal endogenous substance
accumulates because of genetic or acquired defects
in its folding, packaging, transport, or secretion.
3. An abnormal exogenous substance is deposited and
accumulates because the cell has neither the
enzymatic machinery to degrade the substance nor
the ability to transport it to other sites.

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1. Fatty Change (Steatosis)
– Fatty change refers to any abnormal accumulation of
triglycerides within parenchymal cells.
– It is most often seen in the liver but it may also occur
in heart, skeletal muscle, kidney, and other organs.
– Steatosis may be caused by
- toxins
- protein malnutrition
- diabetes mellitus
- obesity, and
- anoxia

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 Ctd…
– The significance of fatty change depends on
the cause and severity of the accumulation
– When mild it may have no effect on cellular
function
– Fatty change is reversible. In the severe form,
fatty change may precede cell death, and may
be an early lesion in a serious liver disease
called nonalcoholic steatohepatitis.

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 2. Cholesterol and Cholesteryl
Esters
– Cellular cholesterol metabolism is tightly regulated to
ensure normal cell membrane synthesis without
significant intracellular accumulation
– Phagocytic cells
– Macrophages may be filled with minute, membrane-
bound vacuoles of lipid, imparting a foamy
appearance to their cytoplasm (foam cells).
• In hereditary and acquired hyperlipidemic
syndromes, macrophages accumulate
intracellular cholesterol; when present in the
subepithelial connective tissue of skin or in
tendons, clusters of these foamy macrophages
form masses called xanthomas

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 3. Proteins
– Morphologically visible protein accumulations are
much less common than lipid accumulations.
– Example:- the marked accumulation of newly
synthesized immunoglobulins that may occur in the
RER of some plasma cells, forming rounded,
eosinophilic Russell bodies.
• Mallory body, or "alcoholic hyalin," is an
eosinophilic cytoplasmic inclusion in liver cells
that is highly characteristic of alcoholic liver
disease

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 4. Glycogen
– Excessive intracellular deposits of glycogen
are associated with abnormalities in the
metabolism of either glucose or glycogen.
• Glycogen also accumulates within cells in
a group of closely related genetic
disorders collectively referred to as
glycogen storage diseases, or
glycogenoses

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 5. Pigments
• Are colored substances, some of which
are normal constitutes of cells (eg.
Melanin) whereas others are abnormal
• Pigments can be endogenous or
exogenous

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 Exogenous pigments
• Accumulation of carbon or coal dust
blacken lung tissue & involved LNs –
antracosis. When inhaled, it is picked up
by alveolar macrophages & transported
into the regional LNs
• Tattooing is a form of localized exogenous
pigmentation of the skin. The pigments
inoculated are phagocytosed by dermal
macrophages

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 Endogenous pigments
A. Melanin
• Is a brownish-black pigment produced by
the melanocytes found in the skin.
• Increased melanin pigmentation is caused
by sun tanning & certain disease
Eg. Nevus, or malignant melanoma &
decreased melanin pigmentation is seen in
albinism & vitiligo

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 Ctd…
B. Bilirubin
• Is a yellowish pigment, mainly produced
during the degradation of hemoglobin.
• Excessive accumulation of bilirubin causes
yellowish discoloration of the sclera,
mucosa, & internal organs
• Such a yellowish discoloration is called
jaundice

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 Ctd…
C. Hemosiderin
• Is an iron-containing pigment derived from
ferritin. It appears in tissue as a golden
brown amorphous aggregates & is
identified by its staining reaction (blue
color) with the Prussian blue dye.
• Small amount normally found in bone
marrow, liver & spleen
• It can be local or systemic derangement

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 Ctd…
– Excess accumulation is divided into 2 types
I. Hemosiderosis
- When accumulation of hemosiderin is primary
within tissue macrophages & is not associated
with tissue damage
II. Hemochromatosis
- When there is more extensive accumulation of
hemosiderin, often within parenchymal cells,
which leads to tissue damage, scarring &
organ dysfunction

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 PATHOLOGIC CALCIFICATION

• It implies the abnormal deposition of

calcium salts, together with smaller
amounts of iron, magnesium, and other
minerals.
• Two types
– Dystrophic calcification
– Metastatic calcification

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 I. Dystrophic calcification
• When the deposition occurs in dead or dying tissues, it is
called dystrophic calcification; it occurs in the absence of
calcium metabolic derangements (i.e., with normal
serum levels of calcium).
• Dystrophic calcification is encountered in areas of
necrosis of any type.
• Although dystrophic calcification may be an incidental
finding indicating insignificant past cell injury, it may also
be a cause of organ dysfunction.
• For example, calcification can develop in aging or
damaged heart valves, resulting in severely
compromised valve motion

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 II. Metastatic Calcification
• Metastatic calcification can occur in normal
tissues whenever there is hypercalcemia.
• The four major causes of hypercalcemia are
1. Increased secretion of parathyroid hormone
2. Destruction of bone due to the effects of
accelerated turnover (e.g., Paget disease),
immobilization, or tumors
3. Vitamin D-related disorders including vitamin D
intoxication and sarcoidosis and
4. Renal failure, in which phosphate retention
leads to secondary hyperparathyroidism

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 Inflammation
• Inflammation –
Protective response intended to eliminate the
initial cause of cell injury and the necrotic
cells and tissues arising from the injury
• Inflammation is intimately associated with
the repair process which includes
parenchymal cell regeneration and
scarring

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 Inflammation
• Acute - minutes to days
– Characterized by fluid and protein
– PMN’s EXUDATE
– Exudate SG > 1.020
• Chronic - weeks to years
– Lymphocytes and macrophages
– Inflammation of prolonged duration (weeks or months) in
which active inflammation, tissue destruction, and attempts
at repair are proceeding simultaneously

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Five classic local signs of acute
inflammation

– Heat – Calor – vasodilatation

– Redness – Rubor – vasodilatation
– Swelling – Tumor – vascular permeability
– Pain – Dolor – mediator release/PMNs
– Loss of function – Functio laesa – loss of function

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 Vascular changes

• Transient vasoconstriction
• Vasodilation
• Exudation of protein rich fluid
• Blood stasis
• Margination
• Emigration/Transmigration

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 Leukocyte Cellular Events

• Margination and Rolling

• Adhesion and Transmigration
• Migration into interstitial tissue

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 SLOWING CONCENTRATION

Margination Rolling Adhesion

Transmigration
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Fig 3-6
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 Chemotaxis

• Movement toward the site of injury along

a chemical gradient
– Chemotactic factors include
• Complement components (20 serum proteins)
• Arachadonic acid (AA) metabolites
• Soluble bacterial products
• Chemokines, cytokines

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Phagocytosis & Degranulation
Phagocytosis (engulf and destroy)
Degranulation and the oxidative burst
destroy the engulfed particle
• Recognition & attachment
– Opsonins coat target and bind to leukocytes
• Engulfment
• Killing/degradation
– O2 dep: Reactive O2 species in lysosomes &
EC
– O2 indep: Bactericidal permeability agents,
lysozyme, MBP, lactoferrin
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 Leukocyte-induced tissue
injury
• Lysosomal enzymes are released into the
extracellular space during phagocytosis
causing cell injury and matrix degradation
• Activated leukocytes release reactive
oxygen species and products of arachidonic
acid metabolism which can injure tissue and
endothelial cells
• These events underlie many human
diseases (e.g. Rheumatoid arthritis)
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 Chemical mediators of
inflammation
• Plasma-derived
– Circulating precursors
– Have to be activated
• Cell-derived
– Sequestered intracellular
– Synthesized de novo
• Most mediators bind to receptors on cell
surface but some have direct enzymatic or
toxic activity
• Mediators are tightly regulated
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93
 Plasma Mediator Systems - Interaction
 

1. Kinin
2. Clotting
3. Complement
4. Fibrinolytic

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95
 Kinin cascade

• Leads to formation of bradykinin

• Bradykinin causes
– Increased vascular permeability
– Arteriolar dilatation
– Smooth muscle contraction
• Bradykinin is short lived (kininases)
• Vascular actions similar to histamine
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 Complement system

• Role in immunity (C5-9 complex)

– Membrane Attack Complex (MAC C5-9)
– Punches a hole in the membrane

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 Complement system

• Role in inflammation (c3a and c5a)

– Vascular effects
• Increase vascular permeability and vasodilation
• Similar to histamine
– Activates lipoxygenase pathway of
arachidonic acid metabolism (c5a)

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 Complement system

– Leukocyte activation, adhesion and chemotaxis (c5a)

– Phagocytosis
• c3b acts as opsonin and promotes phagocytosis
by cells bearing receptors for c3b

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 Inflammatory Mediators from
Complement
Anaphylatoxins:
C3a, C5a, & C4a trigger mast cells to release
histamine and cause vasodilatation
C5a also activates the lipoxygenase system in
PMNs and monocytes  release of
inflammatory mediators
Leukocyte activation, adhesion, & chemotaxis:
C5a activates leukocytes, promotes leukocyte
binding to endothelium via integrins and is
chemotactic for PMNs, monos, eos, & basos 100
 Inflammatory Mediators from
Complement
Phagocytosis:
C3b and C3bi are opsonins
Control:
Convertases are destabilized by "decay
accelerating factor" (DAF)
Inability to express DAF causes paroxysmal
nocturnal hemoglobinuria
C1 inhibitor (C1INH) deficiency causes
hereditary angioneurotic edema 101
 Vasoactive amines
• Histamine
– Found in mast cells, basophils and platelets
– Released in response to stimuli
– Promotes arteriolar dilation and venular
endothelial contraction
• results in widening of interendothelial cell
junctions with increased vascular permeability
• Serotonin
– Vasoactive effects similar to histamine
– Found in platelets
– Released when platelets aggregate

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 Arachidonic Acid (AA)

• Where is it located?
– AA is a component of cell membrane phospholipids
• The breakdown of AA into its metabolites
produces a variety of biologic effects

103
 Arachidonic Acid
• AA is released from the cell membrane by
phospholipases which have themselves
been activated by various stimuli and/or
inflammatory mediators
• AA metabolism occurs via two major
pathways named for the enzymes that
initiate the reactions; lipoxygenase and
cyclooxygenase

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Fig 3-17

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 Outcomes of Acute
Inflammation
• Resolution
• Fibrosis
• Abscess formation
• Progression to chronic inflammation

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 Chronic inflammation
• Difficult to define
• Inflammation of prolonged duration in which
active inflammation, tissue injury and the
healing proceed simultaneously
• Occurs in:
– Persistent infections - AFB, fungi, Treponemes
• Low toxicity
• Delayed hypersensitivity
• Granulomatous inflammation
– Prolonged exposure potentially toxic agents
• Silica
• Toxic plasma lipids  atherosclerosis
– Autoimmunity - RA, lupus 
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 Chronic inflammation is
characterized by:

• Infiltration with mononuclear cells

(macrophages, lymphocytes & plasma
cells)
• Tissue destruction
• Repair involving angiogenesis and fibrosis
• Macrophage is the prima donna of chronic
inflammation
108
 Lymphocyte
Fig 3-30

IL-1
TNF-

Antigen
Antigen
Presentation
Presentation
totoTTcells
cells
Activated IFN-
Lymphocyte
Activated
macrophage

Other
Other
inflammatory
inflammatory Macrophage
mediators
mediators
109
 Granulomatous Inflammation
• Aggregations of • Fungi
activated, modified – Histoplasmosis
(epitheliod) appearance – Blastomycosis
• Granuloma – focal
• Metal/Dust
collection of
granulomatous – Berylliosis
inflammation – Silicosis
• Bacteria • Foreign body
– Tuberculosis – Splinter
– Leprosy – Suture
• Parasites – Graft material
– Schistosomiasis • Sarcoidosis
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Granuloma

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 Repair
• Refers to the restoration of tissue
architecture and function after an injury.
• It occurs by two types of reactions .
1. Some tissues are able to replace the
damaged components and essentially
return to a normal state; this process is
called regeneration.

112
2. If the injured tissues are incapable of
complete restitution, or if the supporting
structures of the tissue are severely
damaged, repair occurs by laying down of
connective (fibrous) tissue, a process
termed healing that results in scar
formation.

113
• The capacity of a tissue for regeneration
depends on:
1. Proliferative ability
2. The degree of damage to stromal
framework
3. Type and severity of damage

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 Healing by regeneration
Proliferative Potential
• Labile cells - continuously dividing
– Epidermis, mucosal epithelium, GI tract
epithelium etc
• Stable cells - low level of replication
– Hepatocytes, renal tubular epithelium,
pancreatic acini
• Permanent cells - never divide
– Nerve cells, cardiac myocytes, skeletal muscle

115
 repair(healing by connective
tissue
• Repair-orderly process in which lost tissue
is replaced by scar.
• Tissues with permanent cells and stromal
extending injury heal by scar.
• Begin with granulation tissue formation

116
• Granulation tissue- is characterized by
proliferation of fibroblasts and in growth of
blood vessels in to the area of injury with
number of inflammatory cells.
• In granulation tissue formation there are 3
phases:
• 1. Phase of inflammation-exudation
• 2. Phase of demolition-digesting or removing
necrotic tissue

117
3. in growth of granulation tissue
• Fibroblasts-produce extra cellular matrix
e.g. fibronectine , proteoglycans, collagen
• These form scaffolding for the matrix.
• type 1 collagen is the major collagen of
mature scar tissue
• -it provides tensile strength of the matrix in
a scar.
118
• The tensile strength of the wound
continuous to increase many months after
the collagen content has reached a
maximum.
• Wound contraction
• mechanical reduction in the size of the
defect to 70-80% of original size.
• it is done by myofibroblasts

119
 Components of the process
of fibrosis

• Angiogenesis - New vessels budding from

old
• Emigration and proliferation of fibroblasts
and deposition of ECM
• Scar remodeling, tightly regulated by
proteases and protease inhibitors

120
 Cutaneous Wound healing
  Healing by first intention
(primary union)
Clean, uninfected, surgical incision with sutures:

1. Blood clot forms

2. < 24 hours – PMNs appear
3. 24-48 hrs cut edges of epidermis thicken from
basal cell hyperplasia, and epithelium migrates
for union
4. By day 3 – PMN’s replaced by macrophages.
Granulation tissue invades & collagen at margins.

121
 Healing by first intention
 
(primary union)
5. Incision filled with granulation tissue.
Maximal neovascularization & collagen bridges
gap. Epidermis covers & is mature.
6. One week – After suture removal wound
strength only 10% (compared with unwounded
skin)
7. Second week – Continued collagen deposition
and fibroblast proliferation. PMNs gone.
8. First month – Scar with cellular connective
tissue and no inflammatory cells. Regressed
vascular channels.
9. Third month – 70-80% of maximum strength. 122
Healing by first
intention

123
  Healing by second intention
(separated)
• Large tissue defect to fill common
denominator
• Differs from primary union in several ways:
– More fibrin, more debris  more intense
inflammation
– More granulation tissue is formed
– Wound contraction aided by myofibroblasts

124
 Healing by second
intention:
Larger injury, abscess,
infarction.
Process is similar but
results in much larger
scar and then primary
union

125
126
Factors that influence healing
• local factors
• systemic factors
1.Local factors:
• type, size and location of the wound
• vascular supply
• infectionexcessive granulation tissue
formation (proud flesh)large deformed
scar

127
• movement
• ionizing radiation

2.Systemic factors:
• circulatory status
• infection

128
• metabolic status
E.g-poorly controlled dm delayed wound
healing
• nutritional deficiencies
-ed proteined collagen formation
-vitamin deficiency
• e.g. Vitamin C decreased collagen
synthesisscurvy
129
-zinc deficiencydecreased cell proliferation
(fibroblasts)ed collagen
• hormones
E.g. corticosteroids -impair wound healing
-ed collagen synthesis
-anti-inflammatory effect
• anti-inflammatory drugs e.g.- aspirin

130
Complications wound healing
• abnormalities in repair, regeneration and
contractioncomplication
1. Infection
2. Deficient scar formation
a. ulceration
• trophic or neuropathic ulcers-in
varicose,dm,leprosy,30 syphilis(spinal
involvement, tabes dorsalis)
131
b. wound dehiscenceincisional hernias
• -dehiscence occurs in 0.5-5% of
abdominal surgeries
• dehiscence can be due to:-
inappropriate surgical techniques,
stress, or infection

132
3. Excessive scar formation
-failure in 'maturation arrest' or block in
the healing process
a. keloid-exuberant scar that tends to
progress and recur after excision
• -frequent after burns
• -common on neck & earlobes.

133
b. Hypertrophic scar
-structurally similar to keloid but never gets
worse after 6 months
-doesn't recur
4. Excessive contraction
-exaggeration of
contractioncontracture(cicatrisation)

134
• Results in sever deformity
• Palms, soles, and anterior thorax are
prone for contracture (why?)
• follows burn injuries
• it can occur in hollow viscerastricture
E.g-urethra, esophagus
• palmar contracture-dupuytren disease

135
1. DEFICIENT SCAR FORMATION
Ulceration Wound dehiscence
137
138
 Fracture healing

Read!!

139
Hemodynamic Disorders,
Thromboembolic disease,
and Shock

140
 EDEMA
– Edema signifies increased fluid in the interstitial tissue
spaces &
– Fluid collections in different body cavities
• hydrothorax
• hydropericardium
• hydroperitoneum (commonly called ascites)
• Anasarca is a severe and generalized edema
with profound subcutaneous tissue swelling.

141
Mechanisms for edema formations

1. Increased Hydrostatic Pressure

Causes
• Localized increases in intravascular
pressure can result from impaired venous
return example, lower extremity DVT
• Generalized increases in venous
pressure
Eg. CHF

142
 Ctd…
2. Reduced Plasma Osmotic Pressure
Albumin is the serum protein most responsible for
maintaining intravascular colloid osmotic pressure
Causes
– nephrotic syndrome
– protein malnutrition
– diffuse liver diseases etc…

3. Lymphatic Obstruction
Impaired lymphatic drainage and consequent
lymphedema

143
 Morphology
• Most easily recognized grossly
• Microscopically, edema fluid is reflected
primarily as a clearing and separation of the
extracellular matrix elements with subtle cell
swelling.
• Edema is most commonly encountered in
subcutaneous tissues, lungs, and brain
• Subcutaneous edema can be diffuse or more
prominent in regions with high hydrostatic
pressures

144
 Ctd…
• Gravity-dependent distribution is referred
to as dependent edema
• Finger pressure over significantly
edematous subcutaneous tissue displaces
the interstitial fluid and leaves a finger-
shaped depression called pitting edema

145
HYPEREMIA AND CONGESTION
– The terms hyperaemia and congestion both indicate
a local increased volume of blood in a particular
tissue
– Hyperaemia is an active process resulting from
augmented blood flow due to arteriolar dilation. The
affected tissue is redder than normal because of
engorgement with oxygenated blood
– Congestion is a passive process resulting from
impaired venous return out of a tissue. It may occur
systemically or local. The tissue has a blue-red
colour (cyanosis)

146
 HEMORRHAGE
• is extravasation of blood from vessels into the
extravascular space
• An increased tendency to hemorrhage (usually
with insignificant injury) occurs in a wide variety
of clinical disorders collectively called
hemorrhagic diatheses
• can be external or can be confined within a
tissue; any accumulation is referred to as a
hematoma
• Minute (1- to 2-mm) hemorrhages into skin,
mucous membranes, or serosal surfaces are
called petechiae
147
 Ctd…
• Slightly larger (3- to 5-mm) hemorrhages are
called purpura
• Larger (1- to 2-cm) subcutaneous hematomas
(bruises) are called ecchymoses
• Large accumulations of blood in one or another
of the body cavities are called hemothorax,
hemopericardium, hemoperitoneum, or
hemarthrosis
• clinical significance of hemorrhage depends on
the volume and rate of blood loss & site of
bleeding

148
 THROMBOSIS
• Three primary factors predispose to
thrombus formation – Virchow triad

1. Endothelial injury
2. Stasis or turbulence of blood flow
3. Blood hypercoagulability

149
Ctd…

150
 Endothelial injury
– it is particularly important for thrombus
formation occurring in heart or in arterial
circulation
– physical loss of endothelium will lead to
exposure of subendothelial ECM, adhesion of
platelets, release of tissue factor & local
depletion of prostacyclin but dysfunctional
endothelium also may lead to thrombosis
eg. Endocardial injury, ulcerated atherosclerotic
artery
151
 Stasis or turbulence of blood
flow
– turbulence results in arterial & cardiac
thrombosis by causing endothelial injury or
dysfunction
– stasis is major factor in development of
venous thrombosis

eg. Aortic or arterial aneurism – stasis

Myocardial infarction - stasis
Mitral valve stenosis
Hyper viscosity syndrome (polycytemia)
152
 Hypercoagulability
– it is defined as any alteration of the
coagulation pathways that predispose to
thrombosis
– the cause can be primary (genetic) or
secondary (acquired)

153
 Secondary causes
-immobilization
– myocardial infarction
– atrial fibrillation
– tissue damage (surgery, fracture, burn..
– cancer
– prosthetic cardiac valves
– DIC

154
 Morphology of thrombi
• Thrombi may develop any where in the CVS
• A thrombus both microscopically or grossly has apparent
laminations called lines of zahin. This is produced by an alternating
pale layers containing platelets admixed with some fibrin & a darker
layer containing red cells
• Most common sites of arterial thrombi in descending order are
- Coronary artery
- Cerebral artery
- Temporal artery
• Bacterial or fungal infections may cause valvular damage of the
heart as it occurring infective endocarditis lead to the development
of thrombotic mass or vegetation
• Sterile vegetation inhypercoagulable state with no infection called
non bacterial thrombotic endocarditis

155
 Fate of thrombus

– propagation
– embolization
– dissolution
– organization & recanalization

Clinical correlations
– Thrombi are significant clinically in that:
• cause obstruction of arteries & veins
• they are possible source of emboli

156
Fate of thrombosis

157
 Venous thrombosis
(phlebothrombosis)
• affects veins of the lower extremity in 90% of cases
1. superficial venous thrombosis
– usually occur in saphenous system particularly
when there are varicosities
– cause local edema, pain, & tenderness, become
symptomatic but rarely embolize
– local edema due to impaired venous drainage,
predispose the involved overlying skin to
infection after slight trauma developing a
condition known as varicose ulcer

158
 Ctd…
2. Deep venous thrombosis
- Are more serious as they may emboli
- Usually starts in deep veins within the calf
muscles
- Although they may cause local pain &edema,
unlike superficial vein thrombosis, they are
entirely asymptomatic in approximately 50%of
patient, since deep veins obstruction rapidly
offset of relived by collateral bypass channels

159
Conditions associated with DVT
• Trauma, surgery, burns result in
a) Reduced physical activity leading to stasis
b) Injury to vessels
c) Release of procoagulant substance from the
tissue
• Pregnancy & puerperal state increase
coagulation factors & reduced synthesis of
antithrombotics
• Malnutrition, debilitating conditions & wasting
diseases such as cancer. DVT due to these
conditions known as MARANTIC thrombosis

160
 Ctd…
• Migrating thrombophlebitis which affects
various veins throughout the body is
usually of obscure etiology, but sometimes
associated with cancer particularly
pancreatic cancer. It is also known as
TROSSEAU syndrome

161
Arterial & cardiac thrombosis
• Atherosclerosis is major initiator of thrombosis
related to abnormal vascular flow & loss of
endothelial integrity
– Myocardial infarction is related to dyskinetic contraction
of the myocardium as well as damage to the adjacent
endocardium & cardiac thrombi can arise
• RHD may result in atrial mural thrombi due to
mitral valve stenosis followed by left atrial dilation
– In addition to obstructive features, arterial thrombi may
embolize to any tissue, but particularly common in the
brain, kidney, spleen because of their large volume of in
flow of blood

162
 Disseminated intravascular
coagulation (DIC)
• It is an acute or chronic
thrombohemorragic disorder occurring as
a result of progressive activation of
coagulation pathway beyond physiologic
set point secondary to a variety of
diseases resulting in failure of all
components of hemostasis.
• It is also called consumption coagulopathy

163
 Etiology & pathogenesis
• DIC is not a primary disease but coagulopathy
that occurs in the course of variety of clinical
condition
• It may result from pathologic activations of
extrinsic &/or intrinsic pathways of coagulation or
impairment of clot inhibiting influences
Two mechanisms that trigger DIC
– Release of tissue factor or thromboplastin
– Wide spread injury to the endothelial cells

164
 Major disorders associated with
DIC
Acute
Obstetric conditions
• Placenta abruption
• Septic abortion
• Retained dead fetus
• Amniotic fluid embolism
• Toxemia

165
 Ctd…
Infections
• Gm –ve sepsis
• Meningococcemia
• Malaria
Burn, accidental trauma
Chronic
– Neoplasm
– Chronic illness

166
 Clinical course
• The consequences of DIC are two fold:-
• First, widespread deposition of fibrin with in the
microcirculation. This may lead to ischemia of
more severely affected or more vulnerable
organs & hemolytic anemia resulting from
fragmentation of red cells as they squeeze
through narrowed microcirculature
(microangiopatic hemolytic anemia)
• Second, hemorrhagic diathesis may dominate
the clinical picture because of consumption of
platelets & clotting factors & increase in
fibrinolysis

167
 EMBOLISM
Definition
• Is a detached intravascular solid, liquid or
gaseous mass that is carried by blood to sites
distant from its point of origin
• 99% source is thrombus
• Rare forms of emboli includes fat globules &
bubbles of air, amniotic fluid, infected foreign
material, bits of bone marrow, platelets
aggregation, fragment of material from ulcerating
atheromatous plaque or fragments of a tumor

168
 Ctd…
• Emboli lodge in vessels too small to permit
further passage, resulting in a partial or
complete vascular occlusion. The potential
consequence of this is the ischemic
necrosis of distal tissue known as
infarction
• Depending on site of origin, emboli may
lodge in the pulmonary or systemic
circulations

169
Pulmonary thromboembolism
• In more than 95% instance venous emboli
originate from deep leg vein thrombosis
• The effect of pulmonary embolism
depends on the size of the embolus & on
the state of pulmonary circulation
• More pulmonary emboli i.e 60%-80% are
clinically silent b/c they are very small

170
 Systemic thromboembolism
• Refers to emboli traveling with in arterial
circulation
• Most (80%) arise from intra cardiac mural
thrombi, 2/3 of which are associated with left
ventricular wall infarcts & another quarter with
dilated left atria secondary to rheumatic VHD
• Remainder from aortic aneurysm, thrombi on
ulcerated atherosclerotic plaques or
fragmentation of valvular vegetation

171
 Ctd…
• Unlike venous emboli, which tend to lodge
primarily in one vascular bed (lung),
arterial emboli can travel to a wide variety
of sites
• The major sites for arteriolar embolization
are the lower extremities (75%) & the brain
(10%), with the rest in the intestines,
kidney & spleen

172
 Crossed embolism
• Crossed or paradoxical embolism occurs
in the presence of patent foremen ovale
when an embolus is transferred from the
right to the left side of the heart, then to
the systemic circulation

173
 Fat embolism
• Usually follows fracture of bones & other
types of tissue injury, globules of fat
frequently enter the circulation.
• Although traumatic fat embolisms occur,
usually it is asymptomatic in most cases &
fat is removed.
• Fat embolism syndrome is characterized
by pulmonary insufficiency, neurological
symptoms, anemia &thrombocytopenia

174
 Infarction
• Is an area of ischemic necrosis caused by
occlusion of either the arterial supply or
venous drainage in a particular tissue.
• Nearly 99% of all infarcts result from
thrombotic or embolic events & almost all
result from arterial occlusion

175
 Other mechanisms include
– Local vasospasm
– Expansion of atheroma due to hemorrhage in to the
atheromatous plaque
– External compression of the vessels eg. Trauma
– Twisting of vessels as in sigmoid volvulus
– Entrapment of vessels in hernial sacks …
• Infarction caused by venous thrombosis is more
likely to occur in organs with single venous out
flow channels eg. Testis or ovaries

176
Factors that determine the size &
development of an infarct
A. The nature of vascular supply
- The presence of dual blood supply as it
occur in the lung, liver, hand & forearm
may also offset the occurrence of
infarction rapidly unlike renal & splenic
circulation, which have end arterial
supply

177
 Ctd…
B. Rate of development occlusion;
slowing developing occlusion are less
likely to cause infarction since they
provide time for the development of
collaterals
C. Vulnerability susceptibility to hypoxia
D. Oxygen content of blood

178
 Types of infarcts
• Infarcts are classified depending on:
A) The basis of their color (reflecting the amount
of Hemorrhage)
1) Hemorrhage (red)
2) White (anemic)
B) The presence or absence of microbial infection
1) Septic
2) Bland

179
 Red infarcts
• It occurs
– venous occlusion as in ovarian torsion
– In loose tissues such as lung which allow blood to
collect in infarcts zone.
– Tissues with dual circulation (eg, lung), permitting flow
of blood from unobstructed vessel in to necrotic zone
– In tissues that were previously congested b/c of
sluggish blood flow
– When blood flow is established to a site of previous
arterial occlusion & necrosis

180
 White infarcts
It occurs
• In arterial occurs in or in solid organs such
as heart, spleen, kidney, where the
solidity of the tissue limits the amount of
hemorrhage that can percolate or seep in
to the area of ischemic necrosis from the
nearby capillaries

181
 SHOCK
– A state in which the failure of the circulatory
system to maintain adequate cellular
perfusion resulting in widespread reduction in
delivery of oxygen & other nutrients to tissues
– Regardless of the underlying pathology,
shock constitutes systemic hypoperfusion
owing to reduction either in cardiac out put or
in the effective circulating blood volume. The
end results are hypotension followed by
impaired tissue perfusion & cellular hypoxia
182
 1. Hypovolumic shock
• Reduction in circulating blood volume
which result in reduction in preload lead to
inadequate left ventricular filling, reflecting
as a decreased in left & right Ventricle end
diastolic volume & pressure, culminating in
decreased cardiac out put
• Causes include hemorrhage, fluid loss
from burns, diarrhea & vomiting

183
 2. Cardiogenic shock
• It results from myocardial pump failure (severe
depression of cardiac performance)
Causes
A. Myopathic
• Acute myocardial infarction i.e usually occur if >
40% left ventricle mass & more on right ventricle
is involved by infarction
• Myocarditis
• Dilated & hypertrophic cardiomyopathy
• Myocardial depression in septic shock

184
 Ctd…
B. Mechanical
→ Intracardiac
– Left ventricle out flow obstruction eg. Aortic stenosis
– Reduction in forward cardiac out put eg. AR, MR
– arrhythemia
→ Extracardiac
– it is an obstructive shock
– pericardial tamponade
– tension pneumothorax
– acute massive pulmonary embolism
– severe pulmonary HTn

185
 3. Distributive shock
• refers to a group of shock subtypes
caused by profound peripheral
vasodilatation despite normal or high
cardiac out put
cause
• Septic shock
• Anaphylactic shock
• Neurogenic shock
186
 Septic shock
Sepsis
• definition: is a systemic response to severe infection
mediated via macrophage derived cytokines that target end
organ receptors in response to infection or SIRS that has
suspected or proven microbial etiology
• Septic shock: a kind of shock caused by systemic
microbial infection, most commonly by Gm negative
infection (end toxic shock) but can also occur with Gm +ve
or fungal infections.
Or
• Sepsis with
- Hypotension
- Organ dysfunction
- Unresponsive to fluid administration

187
 Neurogenic shock
• Shock may occur in setting of anesthetic
accident or spinal cord injury due to loss of
vascular tone & peripheral pooling of blood
Anaphylactic shock
• It is initiated by a generalized IgE
mediated hypersensitivity response, is
associated with systemic vasodilation &
increased vascular permeability
188
 Stages of shock
• Uncorrected shock passes through 3 important
stages;
1. An initial non progressive phase:
– It is also called a period of early compensatory period,
during which a compensatory mechanisms are
activated & perfusion of vital organs maintained.
Mechanisms
i. A variety of neurohumoral mechanisms operate
• A decrease of a cardiac output will stimulate
peripheral & central bar receptors with
subsequent intense sympathoadrenal
stimulation
189
 Ctd…
• The net effect is
→ Tachycardia, ↑HR→ ↑CO
→ Peripheral vasoconstriction →↑ABP, is
a major auto compensatory response
→Renal conservation of fluid
ii. The fall in renal perfusion stimulate the
renin – aldosterone secretion mechanism

190
 2. Progressive stage
• Characterized by tissue hypoperfusion with
onset of worsening circulatory & metabolic
imbalances including acidosis.
- There is a wide spread tissue hypoxia.
- Anaerobic glycolysis results in excessive lactic
acid production. The lactic acid reduces tissue
PH &blunts vasomotor response. Anoxic injury
to endothelial cells results in DIC.
- Clinically, the patient may become confused &
the urine output declines

191
 3. An irreversible stage
• A stage at which, even if hemodynamic
disorders are corrected, survival is not possible
• widespread cell injury is caused by lysosomal
enzyme leakage
• Myocardial contractile function worsens due to
nitric oxide synthesis
• If ischemic bowel allows intestinal flora to inter
the circulation, endotoxic shock may be
superimposed
• At this point, the pt has complete renal shut
down due to acute tubular necrosis

192
NEOPLASIA

193
 Neoplasia
• Literally means “new growth”
• It is defined as
“abnormal mass of tissues the growth of
which exceeds & is uncoordinated with
that of the normal tissue & persists in the
stimulus which evoked the change”

194
Neoplasms are named based upon
two factors

• On the histologic type : mesenchymal &

epithelial
• On behavioral patterns : benign &
malignant

195
 Ctd…
• Benign tumor of mesenchymal cells are
designated by attaching the suffix –oma to
the cell of origin
• Malignant tumor arising in mesenchymal
tissue are usually called sarcoma
• Benign epithelial tumors are variously
classified, some based on their cell of
origin, others on microscopic architecture
& on their macroscopic pattern

196
 Ctd…
• Adenoma – term applied for benign
epithelial neoplasm that form glandular
pattern
• Papillomas – benign neoplasms
producing microscopically or
macroscopically visible finger like
projection or warty projection from
epithelial surface
• Benign tumors that form large cystic
masses are referred as cystadenoma

197
Papilloma

198
 Ctd…
• Some tumors produce papillary patterns
that protrude in to cystic spaces are called
papillary cystadenoma
• When tumor produces macroscopically
visible projection above a mucosal
surface, called polyp
• Malignant neoplasms of epithelial cell
origin are called carcinomas

199
Ctd…

200
 Ctd…
• Teratoma – are made up of a variety of
parenchymal cell types representative of more
than one germ layer
• They arise from totipotent cells, so mostly are
found in gonads
• Choristoma – an ectopic rest of normal tissue
• Hamartoma – a mass of disorganized but
mature specialized cells or tissue indigenous to
the particular site

201
 Characteristics of benign &
malignant neoplasms
A. Differentiation & anaplasia
• Differentiation refers to the extent to which
parenchymal cells resemble comparable normal
cells both morphologically & functionally
• In general, benign neoplasms are well
differentiated. Malignant neoplasms in contrast,
range from well differentiated, moderately
differentiated to poorly differentiated type
• Malignant neoplasm composed of
undifferentiated cells are said to be anaplastic,
literally anaplasia means to form backward

202
Morphological changes which mark
anaplasia
• Pleomorphism – both cells & nuclei show
variation in size & shape
• Abnormal nuclear morphology – nuclei
contain abundant chromatin & are
extremely dark staining, high nuclear
cytoplasmic ratio 1:1
• Large nucleoli with mitosis
• Tumor giant cells
• Necrosis
203
 Dysplasia
• Disordered cell growth which result in altered
cell structure
• Changes may vary in size. Shape & appearance
• Smokers often have dysplastic changes in their
respiratory tract
• Is an abnormal condition but can be reversible if
stimulus is withdrawn
• Has potential to undergo neoplastic change

204
 Characteristics ctd…
B. Rate of growth
C. Local invasion
D. Metastasis
• Tumor implants discontinuous with the
primary tumor

205
 Pathway of spread
Transcoelomic spread
• Seeding of body cavities & surfaces
• It may occur whenever a malignant neoplasm
penetrates in to a natural “open field”
• Most often involved is the peritoneal cavity but
other cavities – pleura, pericardial,
subarachinoid & joint space may be affected
• It is often characteristics of ovarian carcinoma

206
 Ctd…
Lymphatic spread
• Lymphatic route is the most common
pathway for the initial dissemination of
carcinomas
• The pattern of lymph node involvement
follows the natural routes of drainage

207
 Ctd…
Hematogenous spread
• It is typical for sarcoma but also seen with
carcinoma
• Liver & lung are most frequently involved
in hematogenous spread

208
 Epidemiology
Geographic factor
• Specific differences in incidence rates of
cancers are seen world wide
• For example
Stomach carcinoma – Japan
Lung cancer – USA
Skin cancer – New zeland & Australia
Liver cancer – Ethiopia

209
 Ctd…
Environmental factor
• Asbestosis – lung ca, mesothelioma,
esophagus & gastric ca
• Vinyl chloride – angiosarcoma of liver
• Benzene – leukemia
• Cigarette – bronchogenic ca
• Venereal infection – cervical ca

210
 Ctd…
Age
• Most cancer in adult occur in those over
55yrs of age
• Children under 15 yrs of age however, are
susceptible to acute leukemia, CNS
tumors, neuroblastoma, wilm’s tumor,
retinoblastoma, rhabdomyosarcoma &
etc…

211
 Ctd…
• Genetic predisposition
• It can be divided in to
 Autosomal dominant inherited cancer
syndromes
• It includes several well defined cancers in
which inheritance of a single mutant gene
greatly increases the risk of developing a
tumor eg. Familial retinoblastoma

212
 Familial cancers
• Cancers may occur at higher frequency in
certain families without a clearly defined
pattern of transmission
• These includes carcinoma of colon,
breast, ovary & brain, melanoma
• Features that xize familial cancers include
early age at onset, tumors arising in two or
more close relatives of the index case &
some times, multiple or bilateral tumors

213
 Nonhereditary predisposing
conditions
• Regenerative, hyperplastic & dysplastic
proliferations are fertile soil for the origin of
malignant neoplasm
Endometrial hyperplasia – endometrial ca
Cervical dysplasia – cervical ca
Bronchial dysplasia – bronchogenic ca
Regenerative nodules – liver ca

214
 Ctd…
• Certain non- neoplastic disorders may
predispose to cancers
Chronic atrophic gastritis – gastric ca
Solar keratosis of skin – skin cancer
Chronic ulcerative colitis – colonic ca
Leukoplakia – squamous cell ca

? Does benign tumor become a malignant

tumor????
215
 Molecular basis of cancer
• The fundamental principles in cancer
genetics include
 Non- lethal genetic damage lies at the
heart of carcinogenesis.
 A tumor is formed by the clonal expansion
of a single precursor cell that has incurred
the genetic damage ( tumors are
monoclonal)

216
 Regulator gene
• The four class of normal regulator genes are the
principal targets of genetic damage
1. The growth promoting proto-oncogenes
• Proto-oncogenes activation give rise to
oncogenes (cancer causing genes)
2. Growth inhibiting tumor suppressor genes
• Its physiologic role is to regulate cell growth
however, the inactivation of tumor suppressor
genes is the key event in cancer genesis

217
 Ctd…
3. Genes that regulate programmed cell
death (apoptosis)
4. Genes that regulate DNA repair
• These genes affect cell proliferation or
survival indirectly by influencing the ability
of the organism to repair non lethal
damage in other genes. It predisposes to
mutation & to neoplastic transformation

218
219
 Carcinogenesis
• A large number of agents cause genetic
damages & induce neoplastic
transformation of cells
• They fall in to three categories
Chemical carcinogens
Radiant energy
Oncogenic viruses & some other microbes

220
 Chemical carcinogenesis
• Fall in to two categories
Direct acting compound – these do not
require chemical transformation for their
carcinogenicity
Indirect-acting compounds or
procarcinogenes – require metabolic
conversion to produce ultimate
carcinogens capable of transforming cells

221
 These includes
• Therapeutic agents such as cyclophosphamide
-lymphoid neoplasms & leukemia
 Aromatic amines & Azo dyes
 Nitrosamines & amides
 Naturally occurring carcinogens
– Eg. Aflatoxin B1 is a potent hepatic
carcinogen → Aspergillus flavus

222
 Radiation carcinogenesis
• Radiation energy whether in form of UV
sun light or ionizing electromagnetic (X
rays & gamma rays) & particulates (ß, α,
protons & neutrons) radiation can
transform & induce neoplasm in both
humans & experimental animals

223
 Viral & microbial carcinogesis
• Large groups of DNA & RNA viruses have
proved to be oncogenic & there is an association
between infections by the bacterium H. pylori &
gastric lymphoma
DNA oncogenic viruses
Includes
• HPV
• EBV
• HBV

224
 HPV
• Definitely causes benign squamous
papilloma (warts) - type 1,2,3,4,7
• It also implicated in the genesis of
squamous cell ca of cervix & anogenital
region – type 16,18 & also 31,33,35,51
(found in 85% SCC)
• Also linked to the causation of oral &
laryngeal ca

225
 EBV
• Participates in the pathogenesis of four
tumors
 African form Burkitt’s lymphoma
 B- cell lymphomas in immuno suppressed
individuals
 Some cases of Hodgkin’s disease
 Nasopharyngeal carcinoma

226
 HBV
• Strong epidemiologic association prevails
b/n HBV & HCC
RNA oncogenic virus
• Only one retrovirus is firmly implicated in
the causation of cancer & it is Human T
cell leukemia/lymphoma virus type 1
(HTLV-1)

227
 Helicobacter pylori
• There is an association b/n gastric
infection with H. pylori as a cause of
gastric lymphoma. The strong link is with B
cell lymphoma of stomach
• Treatment of bacteria with antibiotics
results in regression of the lymphoma in
most cases

228
 Clinical features of tumors
• Both benign & malignant neoplasms may
cause problems because of
1. Location & impingement on adjacent structures
2. Functional activities such as hormone
synthesis
3. Bleeding & secondary infection when they
ulcerate through adjacent natural surfaces
4. Initiation of acute symptoms caused by either
rupture or infarction

229
 Local & hormonal effects
• Pituitary adenoma –endocrinopathies
• Cancers arising with or metastatic to an
endocrine organ - endocrine insufficiency
• B-cell adenoma of pancreatic islets less than
1cm in diameter may produce sufficient
insulin to cause fatal hypoglycemia
• Neoplasms in the gut may cause obstruction
as they enlarge

230
 Cancer cachexia
• Cachexia is a progressive loss of body fat & lean
body mass accompanied by profound weakness,
anorexia, & anemia.
• The origin of cancer cachexia is obscured
 Reduced food intake
 TNF produced by macrophages & possibly by
some tumor cells is the mediator of wasting
syndrome that accompanies cancer. Other
cytokines such as IL-1 & IFN α can synergize
with TNF α

231
 Paraneoplastic syndrome
• It is an aggregate of symptom complexes
in cancer – bearing pts that can not readily
be explained either by the local or distant
spread of the tumor or by the elaboration
of hormones indigenous to the tissue from
which the tumor arose
• It occurs in about 10% of pts with
malignant disease

232
 Ctd…
• The endocrinopathies are frequently
encountered paraneoplastic syndromes because
the cancer cells are not of endocrine origin, the
functional activity is referred as ectopic hormone
production
• Cushing syndrome is the most common
endocrinopathy. 50% of pts have carcinoma of
lung, chiefly the small cell type. It is caused by
excessive production of corticotropin

233
 Grading & staging of cancers
• Grading denotes the level of differentiation
• Staging expresses the extent of tumor
spread & forecast the clinical gravity of
cancer

234
 Ctd…
• Grading of cancer is based on the degree
of differentiation of tumor cells & number
of mitoses with in the tumor & presumably
correlates to aggressive character of the
neoplasm
• Cancers are classified in to grades I to IV
with increasing anaplasia. Criteria for
individual grades vary with each form of
neoplasm

235
 Ctd…
• The staging of cancers is based on the
size of primary lesions, its extent of spread
to regional lymph nodes & the presence or
absence of blood born metastasis

236
 Ctd…
Two major staging system are currently in use
• Union internationale contre cancer (UICC) which
utilizes the so called TNM system
• The TNM staging varies for each specific form of cancer
but there are general principles
• With increasing size, the primary lesion is xized as T1 to
T4. T0 is added to indicate an insitu lesion
• N0 for no nodal involvement whereas, N1-N3 would
denote involvement of an increasing number & range of
nodes
• M0 signifies no distant metastasis whereas M1 or
sometimes M2 indicates presence of metastasis

237
 Ctd…
• American joint committee (AJC)
employs a some what different
nomenclature & divides all cancers into
stages to IV, incorporating within each of
these stages the size of the primary lesion
as well as the presence of nodal spread &
the distant metastasis

238
 Ctd…
• The staging of neoplastic disease has
assumed great importance in the selection
of the best form of therapy for the pt.
indeed staging has proved to be of greater
clinical value than grading

239
 Laboratory diagnosis of cancer
• Histologic & cytologic methods
Several sampling approaches are available
1. Biopsy
2. FNA
3. Cytologic smears
• PAP smear
• Fluid cytology
– Advanced techniques
• Immunohistochemistry
• Molecular diagnosis
• Flow cytometry
• Tumor markers

240
 Immunepathology
Defense against infection
1.Nonspecific mechanisms
-Skin barrier, sebum (fatty acid), sweat contains IgA
-Mucosal surfaces (IgA, microflora, mucins, lysozyme,
lactoferrin and peroxidase)
lysozyme-found in tears, nasal secretions ,breast milk acts
directly on bacterial cell wall
lactoferrin –in milk
-Respiratory tract-mucociliary blanket ,pulmonary
secretions contain IgG and IgM, complement
-GIT-acids , bile salts , enzymes

241
2.Specific mechanisms –
Essential features of immune system include
-specificity
-diversity
-memory

242
243
 Hypersensitivity reactions
• Immune responses to antigens can cause tissue damage
• The reactions are called hypersensitivity reactions, the
resultant tissue lesions are called hypersensitivity
diseases
• Hypersensitivity diseases are classified into four
according to the immunologic mechanism mediating it
-Type I hypersensitivity (anaphylactoid)
-Type II hypersensitivity (antibody dependent/cytotoxic)
-Type III hypersensitivity (immune complex mediated)
-Type Iv hypersensitivity (cell mediated/delayed )
244
Type I hypersensitivity (Anaphylaxis)
-an immediate immune reaction occurring within minutes of
exposure to the causative antigen with antibody bound to
mast cells or basophils in previously sensitized individuals
-the commonest examples of type I hypersensitivity are hay
fever, childhood eczema and extrinsic asthma
-has two well defined phases
initial response characterized by vasodilatation, vascular
leakage, smooth muscle spasm
becomes evident 5-30 minutes after exposure to an allergen
and tends to subside within 60 minutes

245
late phase reaction –sets 2-24 hrs later without additional
exposure to antigen and lasts for several days.
e.g allergic rhinitis, bronchial asthma
occurs in only about 50% of individuals
Mechanism
Exposure to antigen
induction of CD4(TH2) cells
B cell activation IgE
IgE antibodies have strong tendency to attach to mast cells and
basophils

246
247
248
-may occur as systemic disorder or local reaction
• Systemic anaphylaxis
-may occur after administration of heterogenous proteins,
hormones, drugs (penicillin)
-severity of disorder varies with sensitization
-within minutes after exposure itching ,hives and skin erythema
appear
-other effects like respiratory distress ,laryngeal edema ,vomiting,
diarrhea, shock

249
• Local anaphylaxis
-atopic allergy
-about 10% of the population suffers from local
anaphylaxis to inhaled or ingested allergens
-eg include pollen ,animal dander ,house dust . . .
-positive family history of allergy is found in
50%

250
Type II hypersensitivity
-is mediated by antibodies directed toward antigens
present on the surface of cells or other tissue
components (ECM)
-the antigen can be intrinsic or extrinsic
-three different antibody dependent mechanisms are
involved
1.Complement dependent reactions
-antibodies react with cell surface antigens leading to
fixation of complement and to cell lysis by MAC
-additionally cells coated with antibodies become
susceptible to phagocytosis (opsonization) 251
252
-2.Antibody dependent cell mediated cytotoxicity (ADCC)
-many cell types that bear receptors for the Fc portion of IgG
cause the lysis of target cells coated with IgG antibody(without
complement fixation
-these cells include neutrophils ,eosinophils ,monocytes and NK
cells ;eg –graft rejuction
3.Antibody mediated cellular dysfunction
-antibodies directed against cell surface receptors impair or
dysregulate function without causing cell injury or
inflammation

253
Eg. Myasthenia gravis ,antibodies reactive with
ACH receptors( motor end plate) impair
neuromuscular transmission and cause muscle
weakness

254
255
Type III hypersensitivity reactions
-mediated by antigen-antibody (immune) complexes
-Ag + Ab complexes produce tissue damage mainly by
eliciting inflammation
-the formation of immune complexes can be initiated by
exogenous antigens such as bacteria, foreign protein and
viruses or endogenous antigens such as DNA
-immune complexes are either formed in the circulation and
then deposited in tissues or are formed at extravascular
sites

256
Two patterns of immune complex mediated injury
1.The complexes are deposited in various tissues of the
body causing a systemic pattern of injury
2.The injury is localized to the site of formation within
a tissue or organ
Systemic immune complex disease (
e.g serum sickness -prototype)
-three phases(for discussion sake)
1.Formation of Ag-Ab complexes in the circulation
2.Deposition of the complexes in various tissues
3.Initiation of inflammatory reaction
257
258
-two general types of antigens cause immune
complex mediated injury
1.The antigen may be exogenous such as foreign
protein a bacterium or a virus
2. Under some circumstances the individual can
produce antibody against self components
endogenous

259
-the favored sites of immunecomplex deposition are kidneys,
joints ,skin ,heart , serosal surface, and small vessels

-once complexes are deposited in the tissues they initiate acute

inflammatory reaction(~10 days after injection)

-clinically-urticaria,fever,arthralgias,proteinuria

260
Local immune complex disease (Arthus
reaction)
-localized area of tissue necrosis resulting from
acute immunecomplex vasculitis-in skin
-develop after 4-10hrs of injection of Ag

261
262
Type IV hypersensitivity (cell mediated)
-mediated by T-cells
-two types of reactions are mediated by different
T cells
1.Delayed type of hypersensitivity initiated by
CD4 T cells
2.Cellular cytotoxicity mediated by CD8 T-cells

263
Delayed type of hypersensitivity initiated by CD4 T cells
-classical example is tuberculin test elicited in an individual
already sensitized to the tubercle bacilli by a previous
infection
After intracutaneous injection of tuberculin ,a local area of
erythema and induration begins to appear 8-12 hrs and reaches
peak in 2-7 days
Histologically it is characterized by immigration of lymphocytes
and monocytes
Then macrophages appear in 2-3 weeks , GRANULOMA

264
265
T-cell mediated cytotoxicity
-sensitized CD8 kill antigen bearing target cells
-play a role in graft rejection and resistance to
virus infection

266
 Autoimmune Diseases

• an immune reaction against self antigens

• Cause of certain diseases in humans-but the
evidence is not firm
• Auto antibodies can be found in the serum of a
remarkably large number of apparently normal
individuals particularly in older ages.

267
Immunologic Tolerance
• Immunologic tolerance is a state in which the
individual is incapable of developing an immune
respons e to a specific antigen

268
• Self tolerance –lack of responsiveness to
an individuals antigen
• Tow mechanisms –central &peripheral
tolerance
• 1. Central tolerance –clonal deletion of
self reactive T&B- lymphocytes during
their maturation in the central lymphoid
organs (i.e thymus for T-cells & bone
marrow for B-cells)
269
• 2. Peripheral tolerance –those self reactive T-cells
that escape intrathymic negative selection can inflict
tissue injury unless they are deleted.(i.e back up
mechanism):-
• a. clonal deletion by activation induced cell death-
CD4 T-cells as well as B-cells ;that recognize self
antigens may receive signal that promote their
apoptosis
• b. clonal anergy-refers to prolonged or irreversible
functional inactivation of lymphocytes induced by
the encounter with Ags under certain conditions

270
c. peripheral suppression of T-cells

• -suppressor T-cells(TH2) with the ability to down

regulate the function of other auto reactive T-
cells(TH1).
• Therefore, tolerance of self-reactive T-cells is
extremely important for prevention of autoimmune
diseases.

271
Mechanisms of Autoimmune Ds
• Pathogenesis of autoimmune Ds
appears to involve immunologic,
genetic,& microbial factors interacting
through complicated mechanisms that
are poorly understood.
• Terminating unresponsive state to auto
antigens

272
• The initiating mechanisms :
-failure of peripheral tolerance
• -breakdown of T-cell anergy
• -failure of activation induced cell death
• -failure of T-cell mediated suppression
-molecular mimecry-some infectious agents
share epitops with self antigens .an immune
response against such microbes may produce
tissue damaging reactions against the cross-
reacting self-antigen.
eg ,Acute rheumatic fever following streptococcal
pharygitis –Ab produced for streptococcal M-
protein cross react with cardiac muscle

273
• CLINICAL Examples of autoimmune diseases
• SLE
• autoimmune hemolytic anemia
• thrombocytopenia
• autoimmune thyroditis
• ankylosing spondylitis
• rehomatoid arthritis

274
• Discoid lupus
These are red,
raised patches
with scaling of the
overlying skin
277
• IMMUNODEFICEINCY DISEASES
– group of disorders of specific immune
responses, neutrophils ,macrophages,&
natural killer cells function, as well as
defect in the complement system that
leads to impaired resistance to microbial
infections
– classification- crudely in to 10&20 types

278
• 1.10 immunodeficiency diseases (rare)
-genetically determined, present early life
-divided into
a. deficiencies of antibodies(B-cell immunity)

e.g- infantile x-linked agammaglobinemea

b. deficiencies of cell mediated (T-cell) immunity
e.g- Digeorg's syndrome
c. combined T-cell &B-cell deficiency diseases
e.g -sever combined immunodeficiency
diseases(SCID)

279
2. 20 IMMUNODEFICIENCY STATES
(ACQUIRED)
• protein deficiency e.g-malnutrition
• hematological malignancies e.g -leukemia,
lymphoma -replacement of normal immune
cells by neoplastic cells
• acute viral infections e.g -infectious
mononucleosis, measlestemporary
impairment of the CMI
280
• chronic renal failure-due to toxic effects of wastes
on B &T-cell function
• iatrogenic -e.g- steroids, cytotoxic drugs,
radiothrapy
• splenectomy  patients will be predisposed to
pyogenic infections esp.pnemococal pneumonia
• acquired immunodeficiency syndrome(AIDS)
• AIDS is a prototype-20 immunodeficiency
diseases

281
Genetic diseases

282
human diseases into three categories:
(1)those that are genetically determined,
(2)those that are almost entirely
environmentally determined, and
(3)those to which both nature and nurture
contribute

283
• Surveys indicate that as many as 20% of
the pediatric inpatients in university
hospitals suffer from disorders of genetic
origin
• Chromosomal aberrations have been
identified in as many as 50% of
spontaneous abortuses during the first
trimester, and many more abortuses
probably had gene mutations

284
fundamental concepts
MUTATIONS :
 mutation refers to permanent changes in
the DNA. Those that affect germ cells are
transmitted to the progeny and may give
rise to inherited diseases. Mutations in
somatic cells are not transmitted to the
progeny but are important in the causation
of cancers and some congenital
malformations

285
 Classification
1) Genome mutation – loss or gain of
whole chromosome (monosomy, trisomy)
2) Chromosome mutation – rearrangement
of genetic material & give rise to visible
structural changes in chromosome
3) Gene mutation – majority of mutation
with hereditary disease
– Results in partial or complete deletion of
gene, more often affect single gene

286
• Point mutations result from the
substitution of a single nucleotide base by
a different base, resulting in the
replacement of one amino acid by another
in the protein product

287
• Mutations involving single genes follow
one of three patterns of inheritance:
1.Autosomal dominant
2.Autosomal recessive
3. X-linked

288
 Disorders associated with defects in
structural proteins
Marfan syndrome
• Disorder of connective tissue of the body,
manifested principally by changes in skeleton,
eye & CVS.

• Prevalence- 1:1500, 70-80% familial ADD

• Pathogenesis – defects in an extracellular

glycoprotein called fibrillin 1
289
 Morphology
• Skeletal abnormality
– Tall exceptionally long extremities & long tapering fingers &
toes
– Ratio upper segment to lower segment is lower
– Long head.
– Spinal deformities (kyphosis, scoliosis…)
– Chest (pectus excavatum or pigeon chest)
• Ocular changes – out ward & upward lens
(ectopia lentis)
• CVS – mitral valve prolapse & dilation of
ascending aorta
290
CYTOGENETIC DISORDERS
It is estimated that approximately one of 200
newborn infants has some form of
chromosomal abnormality
It is estimated that in 50% of first-trimester
abortions, the fetus has a chromosomal
abnormality
Cytogenetic disorders may result from
alterations in the number or structure of
chromosomes and may affect autosomes or
sex chromosomes

291
Numeric Abnormalities :Alteration in the
number of chromosomes
-Aneuploidy:trisomy(2n+1),monosomy(2n-1)
-polyploidy
-mosaicism: presence of more than one
population of cells, one with normal
chromosomes the other with extra or
missing chromosomes

292
• Syndromes associated with sex chromosomes
abnormalities
1)klinefelter’s syndrome: male with
karyotype(47,xxy):the syndrome is
characterized by infertility, atrophic testis,
gynecomastia
2)turner’s syndrome: female with
karyotype(45,x),the syndrome is characterized
by atrophic ovaries, infantile external genitalia,
lack of secondary sexual characteristics

293
Turner’s syndrome

294
 Syndromes associated with Autosome
abnormalities
Trisomy 21 (Down syndrome)
• Most common & major cause of mental
retardation
• Chromosome count is 47, most other has
normal chromosome with translocation
• Maternal age influence in the incidence of
Down’s
• 1% cases, mosaics – no maternal age
influence
295
 Diagnosis
• Flat facial profile, oblique palpebral fissures &
epicantal fold
• Mental retardation
• Congenital heart disease --- endocardial
cushion
• GI atresia
• ALL --- 20 fold ↑
• Infection

296
297
 PEDIATRIC DISEASES
• Many diseases of infancy and childhood
are of genetic origin

• Others, though not genetic, either are

unique to children or take distinctive forms
in this stage of life and so merit the
designation pediatric diseases

298
 CONGENITAL ANOMALIES
• It is estimated that about 3% of newborns
have a major anomaly, defined as a birth
defect having either cosmetic or functional
significance.
• Known causes of errors in human
malformations can be grouped into three
major categories: genetic, environmental,
and multifactorial

299
300
 PERINATAL INFECTIONS
• Infections of the fetus and neonate may be
acquired
-transcervically (ascending infections) or
-transplacentally (hematologic infections)
• Most bacterial infections (e.g., α-hemolytic
streptococcal infection) and a few viral
infections (e.g., herpes simplex) are
acquired by ascending infections

301
• The most important transplacental infections
can be conveniently remembered by the
acronym TORCH. The elements of the
TORCH complex are the following:
– Toxoplasma (T), rubella virus (R),
cytomegalovirus (C), herpesvirus (H), and any of
a number of other (O) microbes such as
Treponema pallidum
• Grouped together as they may evoke similar
clinical and pathologic manifestations

302
• Fetal infection is usually associated with
inflammation of the placental membranes
(chorioamnionitis) and inflammation of the
umbilical cord (funisitis)

• Result in Pneumonia, sepsis, meningitis

303
• TORCH occurring early in gestation may
cause chronic sequel in the child, including
growth restriction, mental retardation,
cataracts, and congenital cardiac anomalies.

• Infections later in pregnancy result primarily

in tissue injury accompanied by
inflammation (encephalitis, chorioretinitis,
hepatosplenomegaly, pneumonia, and
myocarditis)

304
 PREMATURITY AND FETAL
GROWTH RESTRICTION
• Prematurity is the second most common
cause of neonatal mortality (second only
to congenital anomalies), and is defined by
a gestational age less than 37 weeks

305
• The major risk factors for prematurity
include -premature rupture of membranes;

-intrauterine infection leading to

inflammation of the placental membranes
(chorioamnionitis);

-and multiple gestation (e.g., twin

pregnancy)

306
• Fetal growth restriction may result from
fetal, maternal, or placental abnormalities,
although in many cases the specific cause
is unknown
• fetal conditions are chromosomal
disorders, congenital anomalies, and
congenital infections

307
• Fetal infection should be considered in all
growth-restricted neonates, with the
TORCH group of infections being a
common cause
• When the causation is intrinsic to the
fetus, growth retardation is symmetric (i.e.,
affects all organ systems equally)

308
• Placental causes include any factor that
compromises the uteroplacental supply line.
This may result from placenta previa (low
implantation of the placenta), placental
abruption (separation of placenta from the
decidua by a retroplacental clot), or
placental infarction
• With placental (and maternal) causes of
growth restriction, the growth retardation is
asymmetric (i.e., the brain is spared relative
to visceral organs such as the liver
309
• Maternal factors are by far the most
common cause of the growth deficit in
SGA infants. These include vascular
diseases such as preeclampsia ("toxemia
of pregnancy") and chronic hypertension,
drugs (phenytoin), alcohol, smoking

310
 RESPIRATORY DISTRESS
SYNDROME OF THE NEWBORN
• causes of respiratory distress in the
newborn includ:
-excessive sedation of the mother,
-fetal head injury during delivery,
-aspiration of blood or amniotic fluid,
-intrauterine hypoxia brought about by
coiling of the umbilical cord about the neck

311
• However, the most common cause is
respiratory distress syndrome (RDS), also
known as hyaline membrane disease
because of the formation of "membranes"
in the peripheral air spaces of infants who
succumb to this condition

312
 FETAL HYDROPS
• Fetal hydrops refers to the accumulation of
edema fluid in the fetus during intrauterine
growth
Causes
1. Immune eg. Rh incompatibility
2. Non immune eg. cardiovascular defects,
fetal anemia

313
314
• The circulating unconjugated bilirubin is
taken up by the brain tissue, on which it
apparently exerts a toxic effect.

• The basal ganglia and brain stem are

particularly prone to deposition of bilirubin
pigment, which imparts a characteristic
yellow hue to the parenchyma (kernicterus)

315
 TUMORS AND TUMOR-LIKE
LESIONS OF INFANCY AND
CHILDHOOD
• Malignant neoplasms are the second most
common cause of death in children
between the ages of 4 and 14 years; only
accidents exact a higher toll
• Benign tumors are even more common
than are cancers

316
• Benign Tumors :any tumor may be
encountered in the pediatric age group,
but three- hemangiomas,
lymphangiomas, and sacrococcygeal
teratomas -deserve special mention here
because they occur commonly in
childhood

317
• Hemangiomas are the most common
tumors of infancy
• Both cavernous and capillary
hemangiomas may be encountered
• In children most hemangiomas are located
in the skin, particularly on the face and
scalp, where they produce flat to elevated,
irregular, red-blue masses.
• Hemangiomas may enlarge as the child
gets older, but in many instances they
spontaneously regress
318
319
• Sacrococcygeal teratomas are the most
common germ cell tumors of childhood,
accounting for 40% or more of cases
• Lymphangiomas represent the lymphatic
counterpart of hemangiomas. They are
characterized by cystic and cavernous
spaces lined by endothelial cells and
surrounded by lymphoid aggregates; the
spaces usually contain pale fluid

320
321
Malignant Tumors
• The organ systems involved most
commonly by malignant neoplasms in
infancy and childhood include the
hematopoietic system, neural tissue, and
soft tissues

322
Table 7-12. Common
Malignant Neoplasms of
Infancy and Childhood

0-4 Age yr 5-9 Age yr 10-14 Age yr

Leukemia Leukemia Hepatocellular carcinoma

Retinoblastoma Retinoblastoma Soft tissue sarcoma

Neuroblastoma Neuroblastoma Osteogenic sarcoma

Wilms' tumor Hepatocellular carcinoma Thyroid carcinoma

Hepatoblastoma Soft tissue sarcoma Hodgkin disease

Soft tissue sarcoma CNS tumors  

(especially Ewing tumor
rhabdomyosarcoma)

Teratomas Lymphoma  

CNS tumors  
323
• Because of their primitive histologic
appearance, many childhood tumors have
been collectively referred to as small,
round, blue cell tumors
• These are characterized by sheets of cells
with small, round nuclei

324
• Neuroblastoma: The term "neuroblastic
tumor" includes tumors of the sympathetic
ganglia and adrenal medulla that are
derived from primordial neural crest cells
populating these sites.

• It is the second most common solid

malignancy of childhood after brain
tumors, accounting for 7% to 10% of all
pediatric neoplasms, and as many as 50%
of malignancies diagnosed in infancy
325
Morphology
• In childhood, about 40% of neuroblastomas
arise in the adrenal medulla
• The remainder occur anywhere along the
sympathetic chain, with the most common
locations being the paravertebral region of
the abdomen (25%) and posterior
mediastinum (15%)
• Macroscopically, neuroblastomas range in
size from minute nodules (the in situ lesions)
to large masses weighing more than 1 kg.

326
Clinical Course
• Children younger than 2 years with
neuroblastomas generally present with
protuberant abdomen resulting from an
abdominal mass, fever, and weight loss

• In older children the neuroblastomas may

remain unnoticed until metastases cause
hepatomegaly, ascites, and bone pain

327
Retinoblastoma
• is the most common malignant eye tumor of
childhood
-frequently occurs as a congenital tumor, it can
be multifocal and bilateral
-it undergoes spontaneous regression, and
patients have a high incidence of second
primary tumors
-The incidence decreases with age, most cases
being diagnosed before the age of 4 years

328
Clinical Features
• The median age at presentation is 2 years,
although the tumor may be present at birth
• The presenting findings include poor
vision, strabismus, a whitish hue to the
pupil ,and pain and tenderness in the eye
• Untreated, the tumors are usually fatal, but
after early treatment with enucleation,
chemotherapy, and radiotherapy, survival
is the rule
329
Wilms' Tumor
• nephroblastoma, is the most common
primary tumor of the kidney in children

• Most cases occur in children between 2

and 5 years of age

• Is the result of disorders associated with

abnormalities with Wilms' tumor 1 (WT1)
gene, located on chromosome 11

330
Clinical Course
• Patients' complaints are usually referable to
the tumor's enormous size
• Commonly, there is a readily palpable
abdominal mass, which may extend across
the midline and down into the pelvis
• Less often, the patient presents with fever
and abdominal pain, with hematuria, or,
occasionally, with intestinal obstruction as a
result of pressure from the tumor

331