NEET MDS Lessons
General Pathology
THYROIDITIS
The more common and clinically significant thyroidites are:
1. Hashimoto thyroiditis
2. Subacute granulomatous thyroiditis
3. Subacute lymphocytic thyroiditis
Hashimoto thyroiditis
Hashimoto thyroiditis (Chronic Lymphocytic Thyroiditis) is the most common cause of hypothyroidism. It results from gradual autoimmune destruction of the thyroid gland. There is striking female predominance (10: 1 to 20:1), and is most prevalent around a mean age of 50 years.
Pathogenesis
• The dominant feature is progressive destruction of thyroid follicular epithelial cells with gradual replacement by mononuclear cell infiltration and fibrosis.
• Sensitization of CD4+ T-helper cells to thyroid antigens seems to be the initiating event.
• The reaction of CD4+ T cells with thyroid antigens produces interferon γ which promote inflammation and activate macrophages. Injury to the thyroid results from the toxic products of these inflammatory cells.
• CD8+ cytotoxic T cells also contribute to epithelial cells killing as are natural killer cells.
• There is a significant genetic component to disease pathogenesis. This is supported by
1. The increased frequency of the disease in first-degree relatives,
2. Unaffected family members often have circulating thyroid autoantibodies.
Gross features
• The thyroid shows moderate, diffuse, and symmetric enlargement.
• The cut surface is pale, gray-tan, firm, nodular and somewhat friable.
• Eventually there is thyroid atrophy
Microscopic features
• There is widespread, diffuse infiltration of the parenchyma by small lymphocytes, plasma cells. The lymphocytes are also form follicles some with well-developed germinal centers
• The thyroid follicles are atrophic and lined by epithelial cells having abundant eosinophilic, granular cytoplasm (Hurthle cells). This is a metaplastic response to the ongoing injury; ultrastructurally the Hurthle cells are stuffed by numerous mitochondria.
• Interstitial connective tissue is increased and may be abundant.
Hashimoto thyroiditis presents as painless symmetrical goiter, usually with some degree of hypothyroidism. In some cases there is an initial transient thyrotoxicosis caused by disruption of thyroid follicles, with secondary release of thyroid hormones ("hashitoxicosis"). As hypothyroidism supervenes T4 and T3 levels progressively fall & TSH levels are increased. Patients often have other autoimmune diseases and are at increased risk for the development of B-cell non-Hodgkin lymphomas.
Subacute Granulomatous (de Quervain) Thyroiditis
Subacute Granulomatous (de Quervain) Thyroiditis is much less common than Hashimoto disease.
- It is most common around the age of 40 years and occurs more frequently in women than in men.
- An upper respiratory infection just before the onset of thyroiditis. Thus, a viral infection is probably the cause.
- There is firm uni- or bilateral enlargement of the gland.
Microscopically, there is disruption of thyroid follicles, with extravasation of colloid. The extravasated colloid provokes a granulomatous reaction, with giant cells.
Thyroid function tests are those of thyrotoxicosis but with progression and gland destruction, a transient hypothyroid phase occurs. The condition is self-limited, with most patients returning to a euthyroid state within at most 2 months.
Subacute Lymphocytic Thyroiditis
Subacute Lymphocytic Thyroiditis may follow pregnancy (postpartum thyroiditis).
- It is most likely autoimmune in etiology, because circulating antithyroid antibodies are found in the majority of patients.
- It mostly affects middle-aged women and present as painless, mild, symmetric neck mass. Initially, there is thyrotoxicosis, followed by return to a euthyroid state within a few months. In a minority there is progression to hypothyroidism.
Microscopically, there is a lymphocytic infiltration and hyperplastic germinal center within the thyroid parenchyma; unlike Hashimoto thyroiditis, follicular atrophy or Hürthle cell metaplasia are not commonly seen.
Riedel thyroiditis
Riedel thyroiditis is a rare disorder of unknown etiology, characterized by extensive fibrosis involving the thyroid and the surrounding neck structures. The presence of a hard and fixed thyroid mass may be confused clinically with thyroid cancer. It may be associated with idiopathic fibrosis in other sites, such as the retroperitoneum. The presence of circulating antithyroid antibodies in most patients suggests an autoimmune etiology.
Histopathological techniques
Histopathological examination studies tissues under the microscope. During this study, the pathologist looks for abnormal structures in the tissue. Tissues for histopathological examination are obtained by biopsy. Biopsy is a tissue sample from a living person to identify the disease. Biopsy can be either incisional or excisional.
Once the tissue is removed from the patient, it has to be immediately fixed by putting it into adequate amount of 10% Formaldehyde (10% formalin) before sending it to the pathologist.
The purpose of fixation is:
1. to prevent autolysis and bacterial decomposition and putrefaction
2. to coagulate the tissue to prevent loss of easily diffusible substances
3. to fortify the tissue against the deleterious effects of the various stages in the preparation of sections and tissue processing.
4. to leave the tissues in a condition which facilitates differential staining with dyes and other reagents.
SHOCK
Definition. It is a clinical state of acute inadequacy of perfusion to tissues due to fall in effective circulating blood volume.
This inadequacy can be caused by :
- Increased vascular capacity
- Decreased blood volume
- Altered distribution of available blood
- Defective pumping system
Causes:
(1) Hypovolemic
- Massive hamorrhage (external or internal).
- Loss of plasma as in bums.
- Dehydration due to severe vomiting, diarrhea diabetic coma.
- Generalized capillary permeability as in anaphylaxis.
(2) Cardiogenic
- Myocardial infarction.
- Pulmonary embolism.
- Cardiac tamponade
(3) Peripheral pooling:
- Endotoxic shock.
- Disseminated intravascular coagulation (DIC).
(4) Neurogenic:
- Syncope.
- Contributory factor in trauma, bums etc.
Metabolic changes in shock
- Hyperglycaemia due to glycogenolysis.
- Increased blood lactate and pyruvate due to anaerobic glycolysis. This results in metabolic acidosis.
- Protein catabolism and increased blood urea.
- Interference with enzyme systems.
Organs involved in shock
(1) Kidneys:
- Renal tubular necrosis.
- Cortical necrosis.
(2) Lungs:
- Oedema, congestion and haemorrhage.
- Microthrombi.
(3) G.I.T. :
- Mucosal oedema.
- Ulceration and haemorrhage
(4) Degeneration and focal necrosis in:
- Heart.
- Liver.
- Adrenals
(5) Anoxic encephalopathy
Cells Of The Exudate
Granulocytes (Neutrophils, eosinophils, and basophils)
Monocytes (and tissue macrophages)
Lymphocytes
Neutrophils (polymorphs).
Characteristics
(1) Cell of acute inflammation.
(2) Actively motile.
(3) Phagocytic.
(4) Respond to chemotactic agents like.
Complement products.
Bacterial products.
Tissue breakdown
Lysosomal enzymes of other polymorphs
Functions
(1) Phagocytosis and intracellular digestion of bacteria.
(2) Exocytosis of lysosomal enzymes to digest dead tissue as the first step in the process of repair.
Eosinophils
Characteristics
(I) Cell of allergjc and immunologic inflammation.
(2) Motile and phagocytic but less so than a neutrophil.
(3) Response to chemotaxis similar to neutrophil. In addition, it is also responsive to antigens and antigen-antibody complexes.
(4) Steroids cause depletion of eosinophils.
Functions
(1) Contain most of the lysosomal enzymes that polymorphs have
(2) control of Histamine release and degradation in inflammation
Basophils (and mast cells)
Characteristics
(1) Contain coarse metachromatic granules.
(2) Contain, histamine and proteolytic enzymes
Functions
Histamine: release which causes some of the changes of inflammation and allergic
reactions. .
Monocytes .
Blood monocytes form a component of. the mononuclear phagocytic system (MPS), the other being tissue macrophages The tissue macrophages may be :
(a) Fixed phagocytic. cells:
- Kuffer cell of liver.
- Sinusoidal lining cells of spleen and lymph nodes.
- Pleural and peritoneal macrophages
- Alveolar macrophages.
- Microglial cells.
(b) Wandering macrophages or tissue histiocytes.
The tissue histiocytes are derived from blood monocytes.
Characteristics
.(1)Seen in inflammation of some duration, as they -outlive polymorphs.
(2) Actively phagocytic and motile.
(3) Fuse readily to from giant cells in certain situations.
Function
(1) Phagocytosis.
(2) Lysosomal enzyme secretion.
(3) Site of synthesis of some components of complement.
(4) Antigen handling and processing before presenting it to the Immune competent cell.
(5) Secretion of lysosyme and interferon.
Giant cells can be
(A) Physiological
Syncytiotrophoblast, megakatyocytes, striated muscle, osteoclast.
(B) Pathological:
Foreign body: in the presence of particulate foreign matter like talc, suture material etc. and in certain infections_e g fungal.
Langhan's type: a variant of foreign body giant cell seen in tuberculosis.
Touton type in lipid rich situations like Xanthomas, lipid granulomas etc.
(iv) Aschoff cell in rheumatic carditis.
(v) Tumour gjant cells e.g. Reid-Sternberg cell in Hodgkin's Lymphoma, giant cells in any malignancy.
Lymphocytes and Plasma cells
These are the small mononuclear cell comprising the immune system
They are less motile than_macrophages and neutrophils and are seen in chronic inflammation and immune based diseases.
Valvular disease
A. Generally, there are three types:
1. Stenosis—fibrotic, stiff, and thickened valves, resulting in reduced blood flow through the valve.
2. Regurgitation or valvular insufficiency— valves are unable to close completely, allowing blood to regurgitate.
3. Prolapse—“floppy” valves; may occur with or without regurgitation. The most common valvular defect.
Immunodeficiency
This may be :-
- Congenital (Primary)
- Acquired (Secondary)
Features : Complete or near complete lack of T & B lymphoid tissue. Fatal early in life Even with marrow grafting, chances of graft versus host reaction is high.
B. T Cell Defects :
- Thymic dysplasia
- Digeorge’s syndrome
- Nazelof’s syndrome
- Ataxia teltngiectaisa
- Wiscott Aldrich’s syndrome
These lessons show predominantly defective cell mediated immunity. But they may also show partial immunoglobulin defects cell mediated immunity. But they may also show partial immunoglobulin defects due to absence og T-B co-operation.
C. Humoral immunity defects.
Bruron type- aggammaglobulinaemia.
- Dysgammaglobulinaemias-variable immunodeficiency’s of one or more classes.
Acquired deficiency
A. Immuno suppression by :
- Irradiation.
- Corticoids.
- Anti metabolites.
- Anti lymphocyte serum.
B. Neaplasia of lymphoid system :
- Hodgkin's and Non Hodgkin's lymphomas.
- Chronic lymphocytic leukaemia..
- Multime myeloma and other paraproteinaemias (normal immunoglobulins reduced in spite of hyperglobulinaemia).
c. excessive protein loss.
- Nephrotic Syndrome.
- Protein losing enteropathy.
Erythema multiforme is a hypersensitivity reaction to an infection (Mycoplasma), drugs or various autoimmune diseases.
- probable immunologic disease
- lesions vary from erythematous macules, papules, or vesicles.
- papular lesions frequently look like a target with a pale central area.
- extensive erythema multiforme in children is called Stevens-Johnson syndrome, where there is extensive skin and mucous membrane involvement with fever and respiratory symptoms.