1. INFLAMMATION LAB Amira F. Gohara, MD Dept. of Pathology Thursday, October 18, 2012

2. 9/12/20112 Objectives By the end of the exercise, the student should be able to identify: Morphology of cell types in acute, chronic and granulomatous inflammation.Morphology of cell types in acute, chronic and granulomatous inflammation. Differences in clinical presentation in acute and chronic inflammation.Differences in clinical presentation in acute and chronic inflammation. Histologic characteristics of granulation tissue.Histologic characteristics of granulation tissue.

3. 9/12/20113 Case 1 Clinical Presentation A 12-year-old boy presents to the Emergency Room with acute right lower quadrant abdominal pain associated with nausea and vomiting. The pain started 6 hours ago in the periumbilical area but quickly localized in the right lower quadrant. On physical examination his temperature was 102  F, pulse 100/minute regular, respiration 20/minute, BP 100/70. The rest of the physical exam was negative except for guarding and rebound tenderness in the right lower quadrant. CBC revealed a WBC count of 18,000 with 70% neutrophils, 12% bands and 18% lymphocytes. 1.What is your differential diagnosis? 2.What is the next step in managing this patient?

4. 9/12/20114 Case 1: Image 2.2 The gross appearance of the appendix removed at surgery is shown here. Point out swelling, erythema and exudate.

5. 9/12/20115 Case 1: Image 2.3 The low power microscopic appearance of the appendix removed at surgery is shown here. (point out ulceration, exudate, loss of wall)

6. 9/12/20116 There are numerous PMN's present, typical of acute inflammation.There are numerous PMN's present, typical of acute inflammation. Also seen are marked vascular dilation with congestion and tissue edema (leading to the swollen appearance of the appendix).Also seen are marked vascular dilation with congestion and tissue edema (leading to the swollen appearance of the appendix). A fibrinopurulent exudate is present on the surface, as can be noted grossly.A fibrinopurulent exudate is present on the surface, as can be noted grossly.

7. 9/12/20117 Case 1: Image 2.4 The medium power microscopic appearance of the appendix removed at surgery is shown here. Point out ulcer, exudate, neutrophils in wall

8. 9/12/20118 Case 1: Image 2.5 The high power microscopic appearance of the appendix removed at surgery is shown here. What inflammatory cell is abundant?

9. 9/12/20119 2. How did the inflammatory cells reach the wall of the appendix?

10. 9/12/201110 3. In some places the wall shows disruption of the tissue. What is this process?

11. 9/12/201111 Case 1: Image 2.1 The peripheral blood smear is shown here. What type of leukocyte is increased in number?

12. 9/12/201112 4. How does the CBC relate to the findings in the appendix?

13. 9/12/201113 Case 2 Clinical Presentation An 83-year-old woman was transferred from a nursing home to an acute care facility because of a history of fever, chills and productive cough for 2 days. Physical examination revealed temperature of 103  F, pulse 110/minute regular, respiration 24/minute. Chest exam revealed rales in the right lung base. Chest x-ray showed a right lower lobe infiltrate. Sputum culture grew streptococcus pneumoniae.

14. 9/12/201114 Case 2: Image 4.1 The gross appearance of the lung is shown here. (Point to areas of consolidation, then go to question)

15. 9/12/201115 1. How would you describe the gross appearance of the lung?

16. 9/12/201116 Case 2: Image 4.2 The low power microscopic appearance of the lung is shown here.

17. 9/12/201117 Case 2: Image 4.3 The medium power microscopic appearance of the lung is shown here.

18. 9/12/201118 Case 2: Image 4.4 The high power microscopic appearance of the lung is shown here.

19. 9/12/201119 2. What do you see in the alveolar spaces in the lung?

20. 9/12/201120 3.How would this differ from a causative agent such as influenza virus?

21. 9/12/201121 4. What chemical mediators are responsible for fever?

22. 9/12/201122 5. What is the diagnosis?

23. 9/12/201123 Case 3 Clinical Presentation A 42-year-old woman underwent hysterectomy because of pelvic pain and irregular menstrual cycles associated with heavy menstrual bleeding. She also complained of an intermittent, whitish mucoid vaginal discharge between periods for several months.

24. 9/12/201124 Case 3: Image 7.1 The gross appearance of the cervix is shown here. Note the inflammation.

25. 9/12/201125 The epithelium is red (hyperemic, congested) with dilated blood vessels.The epithelium is red (hyperemic, congested) with dilated blood vessels.

26. 9/12/201126 Case 3: Image 7.2 The low power microscopic appearance of the cervix is shown here. It reveals ulceration and chronic inflammation

27. 9/12/201127 Case 3: Image 7.3 The higher power microscopic appearance of the cervix is shown here. (lymphocytes, plasma cells, dilated blood vessels)

28. 9/12/201128 Case 3: Image 7.4 The appearance of an endocervical gland is shown here. What type of epithelium is present?

29. 9/12/201129 There is a moderate chronic inflammatory cell infiltrate. This infiltrate consists of lymphocytes, plasma cells, macrophages, and a few neutrophils.

30. 9/12/201130 Why is there metaplasia (image 7.4)?

31. 9/12/201131 4. What is the diagnosis?

32. 9/12/201132 Case 4 Clinical Presentation A 30-year-old African-American female presents to her physician’s office with a history of dyspnea and dry cough for 6 months as well as low grade fever and night sweats. Physical examination reveals a temperature of 100.4  F, pulse 80/minute regular, respiration 18/minute, BP 120/75. Bilateral non tender cervical lymphadenopathy was noted. Chest x-ray revealed prominent bilateral hilar lymphadenopathy. CBC revealed eosinophilia, serum calcium was 11 mgm/dl. A cervical node biopsy was done; culture of the node was negative.

33. 9/12/201133 Case 4: Image 9.1 The low power microscopic appearance of the lymph node is shown here.

34. 9/12/201134 Case 4: Image 9.2 The medium power microscopic appearance of the lymph node is shown here.

35. 9/12/201135 Case 4: Image 9.3 The high power microscopic appearance of the lymph node is shown here.

36. 9/12/201136 1. What general type of inflammatory process is seen in the section of lymph node?

37. 9/12/201137 2. What inflammatory cell types are present?

38. 9/12/201138 3. What is the diagnosis?

39. 9/12/201139 Case 5 This is a case of recurrent ulcerative colitisThis is a case of recurrent ulcerative colitis

40. 9/12/201140 Case 5: Gross picture of colon

41. 9/12/201141 1. What does the fact that this is a recurrent problem suggest to you?

42. 9/12/201142 2. Since this is a recurrent problem, how will this impact on the dynamics of the inflammatory process?

43. 9/12/201143 3. Define an ulcer.

44. 9/12/201144 4. A biopsy of the colon reveals the follow- ing morphologic changes (see image series). Identify each of the following:

45. 9/12/201145 Case 5: Image 1

46. 9/12/201146 Case 5: Image 2

47. 9/12/201147 Case 5: Image 3