INFLAMMATION LABINFLAMMATION LAB

Amira F. Gohara, MDAmira F. Gohara, MDDept. of PathologyDept. of Pathology

Thursday, October 18, 2012Thursday, October 18, 2012

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ObjectivesObjectives

By the end of the exercise, the student By the end of the exercise, the student should be able to identify:should be able to identify:

• Morphology of cell types in acute, chronic Morphology of cell types in acute, chronic and granulomatous inflammation.and granulomatous inflammation.

• Differences in clinical presentation in acute Differences in clinical presentation in acute and chronic inflammation.and chronic inflammation.

• Histologic characteristics of granulation Histologic characteristics of granulation tissue.tissue.

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Case 1Case 1Clinical PresentationClinical Presentation

A 12-year-old boy presents to the Emergency Room with A 12-year-old boy presents to the Emergency Room with acute right lower quadrant abdominal pain associated with acute right lower quadrant abdominal pain associated with nausea and vomiting. The pain started 6 hours ago in the nausea and vomiting. The pain started 6 hours ago in the periumbilical area but quickly localized in the right lower periumbilical area but quickly localized in the right lower quadrant. On physical examination his temperature was 102quadrant. On physical examination his temperature was 102 F, F, pulse 100/minute regular, respiration 20/minute, BP 100/70. The pulse 100/minute regular, respiration 20/minute, BP 100/70. The rest of the physical exam was negative rest of the physical exam was negative exceptexcept for guarding and for guarding and rebound tenderness in the right lower quadrant. CBC revealed a rebound tenderness in the right lower quadrant. CBC revealed a WBC count of 18,000 with 70% neutrophils, 12% bands and 18% WBC count of 18,000 with 70% neutrophils, 12% bands and 18% lymphocytes.lymphocytes.

1.1. What is your differential diagnosis?What is your differential diagnosis?

2.2. What is the next step in managing this patient?What is the next step in managing this patient?

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

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

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•There are numerous PMN's present, There are numerous PMN's present, typical of acute inflammation.typical of acute inflammation.

•Also seen are marked vascular dilation Also seen are marked vascular dilation with congestion and tissue edema with congestion and tissue edema (leading to the swollen appearance of the (leading to the swollen appearance of the appendix). appendix).

•A fibrinopurulent exudate is present on A fibrinopurulent exudate is present on the surface, as can be noted grossly.the surface, as can be noted grossly.

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Case 1: Image 2.4Case 1: Image 2.4The medium power microscopic appearance of the The medium power microscopic appearance of the appendix removed at surgery is shown here.appendix removed at surgery is shown here.

Point out ulcer, exudate, neutrophils in wall

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

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2. How did the inflammatory cells reach the 2. How did the inflammatory cells reach the wall of the appendix?wall of the appendix?

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3. In some places the wall shows disruption of 3. In some places the wall shows disruption of the tissue. What is this process?the tissue. What is this process?

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

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4. How does the CBC relate to the 4. How does the CBC relate to the findings in the appendix?findings in the appendix?

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Case 2Case 2Clinical PresentationClinical Presentation

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

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

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1. How would you describe the gross 1. How would you describe the gross appearance of the lung?appearance of the lung?

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Case 2: Image 4.2Case 2: Image 4.2The low power microscopic appearance of the The low power microscopic appearance of the lung is shown here.lung is shown here.

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Case 2: Image 4.3Case 2: Image 4.3The medium power microscopic appearance of The medium power microscopic appearance of the lung is shown here.the lung is shown here.

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Case 2: Image 4.4Case 2: Image 4.4The high power microscopic appearance of The high power microscopic appearance of the lung is shown here.the lung is shown here.

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2. What do you see in the alveolar spaces 2. What do you see in the alveolar spaces in the lung?in the lung?

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3.3. How would this differ from a causative How would this differ from a causative agent such as influenza virus?agent such as influenza virus?

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4. What chemical mediators are 4. What chemical mediators are responsible for fever?responsible for fever?

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5. What is the diagnosis?5. What is the diagnosis?

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Case 3Case 3

Clinical PresentationClinical PresentationA 42-year-old woman underwent hysterectomy A 42-year-old woman underwent hysterectomy because of pelvic pain and irregular menstrual because of pelvic pain and irregular menstrual cycles associated with heavy menstrual bleeding. cycles associated with heavy menstrual bleeding. She also complained of an intermittent, whitish She also complained of an intermittent, whitish mucoid vaginal discharge between periods for mucoid vaginal discharge between periods for several months. several months.

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Case 3:Case 3: Image 7.1Image 7.1The gross appearance of the cervix is shown here.The gross appearance of the cervix is shown here.Note the inflammation.Note the inflammation.

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• The epithelium is red (hyperemic, The epithelium is red (hyperemic, congested) with dilated blood vessels. congested) with dilated blood vessels.

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Case 3: Image 7.2Case 3: Image 7.2The low power microscopic appearance of the The low power microscopic appearance of the cervix is shown here. It reveals ulceration and cervix is shown here. It reveals ulceration and chronic inflammationchronic inflammation

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

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

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• There is a moderate chronic inflammatory cell infiltrate. This infiltrate consists of lymphocytes, plasma cells, macrophages, and a few neutrophils.

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Why is there metaplasia (image 7.4)?Why is there metaplasia (image 7.4)?

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4. What is the diagnosis?4. What is the diagnosis?

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Case 4Case 4

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

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Case 4: Image 9.1Case 4: Image 9.1The low power microscopic appearance of the The low power microscopic appearance of the lymph node is shown here.lymph node is shown here.

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Case 4: Image 9.2Case 4: Image 9.2The medium power microscopic appearance The medium power microscopic appearance of the lymph node is shown here.of the lymph node is shown here.

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Case 4: Image 9.3Case 4: Image 9.3The high power microscopic appearance of the The high power microscopic appearance of the lymph node is shown here.lymph node is shown here.

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1. What general type of inflammatory 1. What general type of inflammatory process is seen in the section of lymph process is seen in the section of lymph node?node?

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2. What inflammatory cell types are 2. What inflammatory cell types are present?present?

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3. What is the diagnosis?3. What is the diagnosis?

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Case 5Case 5

• This is a case of recurrent ulcerative colitisThis is a case of recurrent ulcerative colitis

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Case 5: Gross picture of colonCase 5: Gross picture of colon

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1. What does the fact that this is a 1. What does the fact that this is a recurrent problem suggest to you?recurrent problem suggest to you?

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2. Since this is a recurrent problem, how 2. Since this is a recurrent problem, how will this impact on the dynamics of the will this impact on the dynamics of the inflammatory process?inflammatory process?

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3. Define an ulcer.3. Define an ulcer.

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

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Case 5: Image 1Case 5: Image 1

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Case 5: Image 2Case 5: Image 2

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Case 5: Image 3Case 5: Image 3