14

4. F A B classification of leukemia.LeukemiasDefinition: Group of malignant diseases arising from hematopoietic cells;1.Etiology:1. Herditory:a. Hodgkins disease is 99% more in identical twins b. Leukemias more common in same families2. Genetic disorders: Inherited genetic factors with genomic instability:eg:a. Fanconi anemiab. Ataxia telangiectasiac. Down syndromed. Wiscott Aldrich syndrome 3. Viral infection:a. Human T cell Leukemia Virus-1(HTLV): T cell leukemiab. Ebstein Bar virus: lymphomac. Herpes virus-8: Kaposis sarcomad. Hepatitis C: lymphomae. HIV: B-cell and Burkitts lymphomasf. Helecobacter pylori: lymphoma of stomach4. Environmental agents:a. Ionizing radiation: Leukemiasb. Drugs:i. Phenytoin: lekemias and lymphomasii. Cancer chemotherapy-leukemiac. Gluten sensitivity: intestinal lymphomad. HIV: B cell lymphomas5. Immune deficiency:a. Congenital or acquired immune deficiency: leukemia and lymphoma 6. Iatrogenic Factors:a. Radiotherapy- leukemia2. Pathogenesis:1. Malignant transformation of a single clone of cells belonging to lymphoid or myeloid series due to a genetic damage to DNA; this is followed by proliferation of affected clone2. Chromosomal translocation: eg: Philedelphia Chromosome t(9;22) in CML3. Maturation defect: i.e failure to mature beyond myeloblast or lymphoblast;4. Myelosupression: bone marrow is suppressed by the excessive cancer cells5. Infiltration: bone marrow and liver, spleen, lymphnodes and CNS are infiltrated by leukemic cells

ClassificationTypes of classification:1. Historical classification2. French American British classification (FAB)3. WHO classification I. Historical classification:

1. Leukemias: Acute in the sense the disease progresses rapidy and blast cells predominate in blood smear; chronic in which disease progresses slowly and blast cells are not seen in early smearsa. Acute myeloblastic leukemia (AML)b. Acute lymphoblastic leukemia(ALL)c. Chronic myeloid(myelocytic) leukemia(CML)d. Chronic lymphocytic leukemia(CLL)2. Lymphomas:a. Hodgkinb. Non HodgkinII. Present major classification:1. Lymphoid neoplasm: arise from precursors of lymphocytes:2. Myeloid neoplasm: arise from hematopoietic stem cells that give rise to:3. Histiocytic neoplasms

FAB Classification:

1. WHO Classification of Lymphoid neoplasms:1. Acute lymphoblastic leukemia, ALLa. Precursor B cell neoplasm( blast cells): i. Precursor B Lymphoblastic leukemia/lymphomab. Peripheral B cell neoplasm (mature cells):i. Chronic lymphocytic leukemia (CLL)ii. Follicular lymphomasiii. Hairy cell leukemiaiv. Burkits lymphoma etcc. Plasma cell neoplasms: 1. Plasmocytoma/Plasma cell myelomad. Precursor T cell neoplasm( blast cells): (Acute lymphoblastic leukemia, ALL)i. Precursor T Lymphoblastic leukemia/lymphomaii. Peripheral T cell and NK cell neoplasm (mature cells):iii. Adult T cell leukemia/lymphomaiv. NK/T cell lymphomav. NK cell leukemia etce. Hodgkin lymphoma (Reed Sternberg cells + ve):i. Classical:1. Nodular sclerosis2. Mixed cellularity3. Lymphocyte rich4. Lymphocyte depletionii. Lymphocyte predominance2.WHO classification of Classification of Myeloid neoplasm: 5 groups:1. Myeloproliferative diseases2. Myelodysplastic / Myeloproliferative diseases3. Myelodysplastic syndromes (MDS)4. Acute myeloid leukemia5. Acute biphenotypic leukemia

1.Myeloproliferative diseases:1. Chronic myeloid leukemia2. Chronic neutrophilic leukemia3. Chronic eosinophilic leukemia4. Chronic idiopathic myelofibrosis5. Polycythemia veera6. Essential thrombocytosis7. Chronic myeloproliferative diseases2.Myelodysplastic / Myeloproliferative diseases:1.Chronic myelomonocytic leukemia3.Myelodysplastic syndromes (MDS):1. Refractory anemia2. Refractory anemia with sideroblasts3. Refractory anemia with excess blasts4. Myelodysplastic syndrome unclassified4.Acute myeloid leukemia:1. AML with recurrent cytogenetic abnormalities2. AML with multilineage dysplasia3. AML with MDS4. AML, not otherwise classified:a. AML minimally differentiated b. AMLwithout differentiationc. AMLwith maturationd. Acute monoblastic and monocytic leukemia e. Acute erythroid leukemiaf. acute megakaryocytic leukemiag. acute basophilic leukemiah. Acute panmyelosis with myelofibrosisi. Myeloid sarcoma5. Acute biphenotypic leukemia

Blood and bone marrow pictures:1.Acute lymphoblastic leukemia ALL: peak incidence at 2-5 years of age, and another peak in old age1. Blood and Peripheral smear:a. Changes in WBC:i. Total count may be very high 50-100x10or less than 10,000/microLii. Lymphoblasts:1. Are seen in large no. (Convent party appearance)2. The cells are round and small,3. Cytoplasm is scanty and homogeneous;4. Granules are absent;5. Nucleus one or two nucleoli.6. The cells are PAS/Sudan Black negative; acid phosphatase positive; 7. Some Markers:a. CD 19 positive in B cell typeb. CD 7 positive in T cell typeiii. RBC: normochromic and normocytic anemiaiv. Platelets: thrombocytopenia2. Bone marrow changes in ALL: 1. Lymphoblasts:a. Are seen in large no. Counts more than 20% (WHO) and 30% (FAB) are diagnostic of ALLb. Lymphoblasts are large cells; contain large round or indended nucleus; stippled with nuclear chromatin; nuclear membrane is dense; nucleoli 1-2 are seen; cytoplasm is scanty; it is basophilic and without granules;c. Lymphoblasts are TdT and adenosine deaminase positive;2. Erythropoietic series:reduced in no; megaloblasts and ring sideroblasts may be seen.3. Megakaryocytes are reduced or absent.4. Cytogenetics :a. Aneuploidy in 75%b. Philadelphia chromosome in 15%5. Cell markers seen ALL:a. Leukocyte common antigenb. Positive sheep erythrocyte rosette test in B cell types

2. Acute Myeloblastic (myelogenous; myeloid) Leukemia (AML): median age 50 years; may rarely occur in childhood.1. Blood Picture:a. Total Leukocyte count is raised; occasionally normalb. Plenty of blast cells:i. Blast cells are large in sizeii. Round or oval nucleus nearly filling the celliii. Abundant granular cytoplasmiv. Auer rods are seen sometimes which are abnormal derivatives of primary azurophilic granulesv. Nuclear chromatin is delicatevi. Nucleoli 3-5vii. Cytochemistry:1. Peroxidase and sudan black positive2. Phosphatase negativeviii. Markers:1. CD 19 negative2. CD 7 Negative3. CD 13 and 33 positivec. Polymorphs and few lymphocytes are seend. RBC: normochromic normocytic anemiae. Platelets: severe thrombocytopenia2. Bone Marrow:a. Maroow is hypercellular; occasionally hypocellularb. Myeloblasts are predominant; > 20%(WHO) or > 30% FAB is diagnostic of ALLc. Immature granulocytes, erythroblasts, megaloblastic erythroblasts and sideroblasts are seend. Plasma cells and monocytes are moderately elevatede. Megakaryocytes are reduced or absentf. Cytogenetics:i. Presence of cells with aneuploidy; translocation or inversions ii. Philadelphia chromosome in 3% casesg. Cytochemistry:i. Myeloperoxidase, sudan black, PAS are positive in M6 cellsii. Non specific esterase positive in M4 and M5iii. Acid phosphatase positive in M4 and M5h. Biochemistry:i. Serum muramidase elevated in M4 and M5ii. Serum uric acid elevated in general

3. Chronic lymphocytic (lymphatic)leukemia (CLL):over 50 years of age with male preponderance; hepatosplenomegaly, lymphadenopathy and anemiaa. Blood picture:i. Normochromic and normocytic anemia; mild reticulocytosis; 20% coombs have positive hemolytic anemiaii. Absolute neutrophil count is within normal range; granulocytopenia in advanced stageiii. Marked leukocytosis(50,000-200,000/l)iv. 90% of leukocytes is mature small lymphocytes; degerated lymphocytes are called smudge or basket cellsv. Platelets is normal or moderately reducedb. Bone marrow:i. Increased lymphocyte countii. Reduced myeloid precursorsiii. Reduced erythroid precursorsc. Other tests:i. Lymph node: Replacement of lymphnode with diffuse small lymphocytes ii. Erythrocyte rosette test: positive with mouse RBCsiii. Markers: CD5 is positive for immunoglobulinsiv. Coombs +ve in 20%4. Chronic Myeloid (myelocytic) leukemia (CML): peak in 3-4 decades of life; juvenile form in children; anemia, weight loss, bleeding, priapism, lymphadenopathy and splenomegaly.a. Blood: 3 phases: chronic, accelerated and blast crisis phasesi. RBC: Normocytic normochromic anemiaii. WBC: 1. General: Marked leukocytosis: 200 000/L; myelocites present2. Chronic Phase: a. Myeloblast 10%3. Accelerated phase:a. Increasing anemiab. Blasts 10-20%c. Low platelet count4. Blast crisis:a. Blasts > 20%iii. Platelet: normal or raised in the casesb. Bone marrow:i. Hypercellular marrowii. Myeloid predominanceiii. Increased myeloid erythroid ratioiv. Myelocytes predominancev. Erythropoiesis: reduction in erythropoietic seriesvi. Megakaryocytes: more and smallervii. Cytogenetics:1. Philedelphia chromosome in 90 to 95%; it is reciprocal translocation of long arm of 22 and long arm of chromosome 9viii. Cytochemistry:1. Neutrophil alkaline phosphatase is reduced; increased in leukaemoid reactionix. Other findings:1. Serum B 12 elevated2. Serum uric acid elevated

S.N: Philadiphia chromosome: The Philadelphia chromosome is made when the Abl gene on chromosome 9 is mistakenly transferred to chromosome 22 and attaches to the Bcr gene. This creates a new fusion gene called Bcr-Abl which leads to leukemic process.

S.N: Leukemoid reaction: The term leukemoid reaction describes an elevated white blood cell count, that is a physiologic response to stress or infection (as opposed to a primary blood malignancy, such as leukemia) Leukemoid reaction may be myeloid (more common) or lymphoid Causes:1. Infections: Staphylococcal pneumonia Meningitis Diphtheria Any sepsis Endocarditis Septic abortion2. Toxins: Eclampsia Mercury poisoning Burns3. Malignancy: Multiple myeloma Myelofibrosis Hodgkin CLL4. Severe Hemorrhage and hemolysis Lab:1. Myleloid luekemoid reaction: Leukocytosis upto 100,000/L Blasts < 5% Toxic granulation or Dohle bodies in Neutrophils in infections Philadelphia chromosome negative No organ infiltrations2. Lymphoid leukemoid reaction: Infections: Pertusis Infectious mononucleolus Cytomegalo virus Chickenpox Measles Tuberculosis Lab: Leukocyte count upto 100,000/L Mostly mature lymphocytes Mimics CLLDifference between leukaemoid reaction and leukemiaS.NoLeukaemoid reaction Leukemia

1 The infection leading to leukemoid reaction will be presentSplenomegaly, lymphadenopathy and bleeding tendency are evident

2Leukocyte count upto 100,000/L

Leukocyte count often more than 100,000/L

3Immature cells are lessImmature cells are more

4WBC may show toxic granulation due to infectionAbsent

5Anemia is lessMore

6Bone marrow: less hypercelluarMore hypercellular

7Autopsy: no organ infiltration of blastsPresent in liver, spleen, CNS etc

4. A 35 years, old man was admitted with history of painless cervical and axillary lymphadenopathy. He had history of loss of weight, fever and night sweating and was found to have cutaneous anergy. No hepatosplenomegaly.a) What is your most probable diagnosis?b) Give the classification of the condition.c) Describe the morphology of any two types.Lymphomas 1.These are malignant neoplasm derived from lymphocytes, usually in lymph nodes but also in other organs or in soft tissue.Unlike the leukemia the tumor cells do not appear in the blood in detectable numbers2.TYPES OF LYMPHOMAS: The lymphomas are broadly grouped into two types:A. Non-Hodgkins lymphomas (60%)B. Hodgkins lymphoma (also known as Hodgkin's disease) (40%)3.Cells of origin:The non- Hodgkins lymphomas are derived from either B or T lymphocytes. The cell of origin in Hodgkins lymphoma is now known to be of B-cell origin

Hodgkins disease1.Neoplasm (lymphoma) arising from lymph node with secondary involvement of extra nodal sites2.Age 15-35 yrs with male preponderance; another peak at 5th decade3. Symptoms include painless swelling of the lymph nodes in the neck, armpits, or groin fever and chills night sweats weight loss loss of appetite itchy skin nodes are painful after alcohol consumption4.Classifications:1. Conventional:a. Non Hodgkin- heterogynous groupb. Hodgkin (Reed Sternberg cell +ve)2. Rye classification:1. Lymphocyte predominant type2. Nodular sclerosis3. Mixed cellularity4. Lymphocyte depletion type3. Modified WHO classification:1. Classic Hodgkin Disease:a. Lymphocyte predominant typeb. Nodular sclerosisc. Mixed cellularityd. Lymphocyte depletion type2. Nodular lymphocyte predominant Hodgkin disease6.Reed-Sternberg cell:1. These are neoplastic cells of HD2. 10% are myeloma cells: similar to plasma cells but vary in size; nuclus is eccentric; unlike normal plasma cell its nuclear chromatin does not show car-wheel pattern3. Nucleoli are present4. Cytoplasm is abundant with perinuclear halo; vacuolation and Russel bodies containing antibodies5. Variants of plasma cells: Flame cells: red cytoplasm Mott cells: contain grapelike cytoplasmic droplets

Plasma cell Myeloma cell: eccentric nucleus with halo; no cart weel

Normal Protein electrophoresis Myeloma- M spike in Gamma region2. Extra osseous:1. Atypical plasma cells in blood2. Anaemia3. Hyperviscocity of blood4. Nephrosis due to Bence-Jones proteinuria5. Polyneuropathy6. Pathologic fractures of bones7. Systemic amyloidosis myeloma proteins8. Hepato splenomegaly due to myeloma cellsBence Jones Protein:1. Multiple myeloma cells produce excessive monoclonal proteins - M proteins, which are classified as heavy amino acid chains and light amino acid chains2. The light amino acid chains are of two types: kappa and lambda. Kappa is twice as prevalent as lambda. When detected in the urine the light chain fragments are called Bence-Jones proteins3. Light chains (molecular weight 22,000 d) are polypeptides synthesized by plasma cells and assembled with heavy chains to form the various classes of immunoglobulins, for example, immunoglobulin G (IgG), immunoglobulin M (IgM), and immunoglobulin A (IgA). 4. Plasma cells normally produce a slight excess of light chains that are either excreted or catabolized by the kidney5. 1% of myeloma are nonsecretory: no Bence-Jones proteins in urine6. Kappa light chains usually exist as monomers (22,000 d) and are therefore small enough to be filtered through the glomerulus, but they may exist as dimers. Lambda light chains usually exist as dimers (44,000 d) and, therefore, are less likely to be filtered and appear in urine. 7. Light-chain proteins appear in urine in high concentration either when the production of light-chain proteins is markedly increased or when the ability of the proximal tubules to reabsorb all the filtered protein is exceeded.8. Since mostly excreted in urine they are not present in detectable amount in blood except in renal failure.9. They on heating precipitate at 40-60 C and redissolve at higher temperature10. Causes:1. Multiple myeloma2. Plasmacytoma3. Waldenstrom macroglobulinemia11. Tests:1. 5 ml of urine is mixed with 2-3 drops of acetic acid and heated in a water bath; at 40-60C there will be cloudiness and precipitation; on further heating over 70C the precipitate dissolves and reappear when cooling below 60 C2. Serum electrophoresis demonstrates M-bandMultiple myeloma affecting kidney:1. Tumour invasion: ureteric obstruction and renal hypertension2. Hypercalcemia3. Hyperurecemia4. Amyloidosis 5. BJ proteinuria6. Glomerular diseaseMyeloma kidney (cast nephropathy)1. Myueloma kidney is one of the several renal dysfunctions due to light chain proteinuria2. Light chains bind with Tamm-Horsfall mucoprotein, which is secreted by tubular cells in ascending loop of Henle, forming casts3. Light chains can precipitate in the tubules, leading to obstructing, dense, intratubular casts in the distal and collecting tubules that may initiate a giant cell reaction 4. Multinucleated giant cells surround the casts which produces nephropathy5. Light chain proteins also have direct toxic effect on renal epithelial cells6. It may also be deposited in basement membrane to produce glomerulopathy

LABORATORY INVESTIGATION OF SUSPECTED MYELOMA1. Diagnostic triad:1. myeloma cells >10% in bone marrow2. Lytic lesions in bones3. M proteins in serum and urine 2. Serum proteins:1. Rise in total serum proteins due to paraproteinemia (M proteins or abnormal immunoglobulin e.g. Bence Jones proteins)2. Normal IgG, IgA, IgM and albumin levels are low3. Serum electrophoresis:1. Spike produced by M proteins; in the region of IgG in 50%; IgA in 25%2. Another 20 have only light chains in serum3. No M-bands in non secretary myeloma(1%)

4. Serum viscocity: Hyperviscocity in myeloma The normal reference range is 1.4-1.8 Centipoises ; >5 in myeloma Rouleaux formation is often present with increased serum viscosity.5. Hypercalcemia6. Hyperurecemia3. Urine: Bence Jones proteins are present in urine; >6 gms/dL4. Bone marrow:1. Hyper cellular2. >10% are myeloma cells: similar to plasma cells but vary in size; nuclus is eccentric; unlike normal plasma cell its nuclear chromatin does not show car-wheel pattern3. Nucleoli are present4. Cytoplasm is abundant with perinuclear halo; vacuolation and Russel bodies which contain antibodies5. Variants of plasma cells: Flame cells: red cytoplasm Mott cells: contain grapelike cytoplasmic droplets

1. Polycystic kidney disease: PKD(short notes)1. Renal parenchyma is converted into cysts of varying sizes2. Two types:1. Adult type: autosomal dominant (ADPKD)2. Infantile type: autosomal recessive (ARPKD)3. Adult type:1. Incidence 1 in 400 to 10002. PKD gene is located is in chromosome 16 and rarely in 43. Bilateral and diffuse4. Symptoms appear in 30-50 years of age5. Morphology:1. Bilaterally enlarged; lobulated; may weigh up to 4 kg2. Cut surface show cysts in different size; contain straw yellow to reddish brown material3. Renal pelvis is distorted by cysts; do not communicate with each other( contrast to hydronephrosis)6. Histology:1. Cysts are parts of nephrons2. Epithelial lining of cysts are that tubules3. Parts of glomerulus could be recognized among the cysts4. Intervening normal renal parenchyma may be seen5. Acquired inflammation due to pyelonephritis, nephrosclerosis etc may be seen

7. Clinical:1. Manifest in 30-50 years of age2. Presents as hematuria and renal pain3. Hypertension is common4. Associated cystic changes in liver, panctreas and spleen etc may be present5. Berry aneurysm of circle of Willis present in 15%6. Acquired infections may further damage the kidney2. Infantile type:1. Autosomal recessive2. 1 in 20,000 incidence3. Mutation in chromosome 6-6p-214. Bilateral5. Manifest at birth and renal failure in early childhood6. Morphology:1. Bilateral enlargement2. Smooth surface and shape not distorted3. Cut surface: small cysts extend radially to cortex; mostly normal parenchyma; pelvis and ureters normal7. Histology:1. Total no of nephrons are normal2. Sponge like cysts develop from collecting tubules and show cylindrical and secular dilatation lined by cuboidal or columnar epithelium3. Many glomeruli undergo cystic dilatation

8. Clinical:1. Gross enlargement may interfere normal delivery2. Renal failure occurs early3. Associated cystic disease in liver may lead to congenital fibrosis, portal hypertension and splenomegaly 4. Severely affected infants are often born with pulmonary hypoplasia and suffer from respiratory compromise

Glomerulonephritis

Glomerulonephritis (Bright disease; nephritic syndrome)1.Definition:Renal diseases in which an immunologic mechanism triggers inflammation and proliferation of glomerular tissue that can result in damage to the basement membrane, mesangium, or capillary endothelium.2.Classification:1. Primary: 1. Acute:1. Post streptococcal2. Non streptococcal2. Rapidly progressive3. Minimal change disease4. Membranous5. Membrano proliferative6. Focal proliferative7. Focal segmental glomerulosclerosis8. IgA nephropathy9. Chronic GN2. Secondary: 1. SLE2. Diabetic nephropathy3. Amyloid nephropathy4. Polyarteritis nodosa5. Wageners granulomatosis6. Goodpasture syndrome7. Henoch-Schonlein purpura8. Systemic infection: Bacterial endocarditis; Falciform malaria etc9. Idiopathic mixed cryoglobulinemia3. Hereditary nephritis:1. Alports syndrome2. Fabrys disease3. Nail-patella syndrome3.Etiopathogenesis of post streptococcal glomerulonephritis (PSGN):1. Glomeruli consists of: endothelium, epithelium,mesangium and basement membrane(GBM)2. Acute glomerulonephritis follows infection with certain strains of group A beta-hemolytic streptococci (GABS). The ones that produce a clear zone of hemolysis around the colony are called beta hemolytic streptococci; 3. GABS contain M, T and R proteins. Of these, the M protein is the nephritogenic antigen. It is located in the bacterial cell wall 4. Among the M types, commonly identified nephritogenic strains are 12,4,1 5. It follows mostly skin infection but can also occur after throat infection with nephritogenic strains 6. Evidence: 1. Low serum complement (C3) levels in the acute phase 2. High serum levels of antibodies to streptococcal antigens3. Electron microscopy reveals lumpy-bumpy deposits on glomerular membrane and in mesangium7. Immune-mediated renal injury is a result of renal deposition of circulating immune complexes or due to their in-situ formation or both8. Glomerular inflammation follows which leads to complement (C3) activation by classic or more probably alternate pathway 9. The immune complexes are deposited in the glomerulus produce structural and functional changes by destruction of basement membrane and accumulation of inflammatory cellsPathology:1. Morphology:1. Kidneys enlarge symmetrically2. Petichial hemorrhages on the cortical surface give flea-bitten appearance2. Light microscopy:1. Glomeruli: Enlarged and hypercellular glomeruli Proliferation of mesangial, endothelial and occasionally epithelial cells Infiltration of polymorphs and sometimes monocytes2. Tubule: Deposition of fibrin in tubular lumen and mesangium RBCs in tubular lumen3. Interstitium: Edema and leukocytic infiltration in renal interstitium4. Vessels: No changes in blood vessels

3. Clinical:1. Age incidence is 5-12 years2. Symptoms develop 1-2 week following streptococcal infection3. Oliguria and smoky urine4. Edema is the most frequent manifesting symptom5. Gross hematuria occurs at onset6. Hypertension is the third cardinal feature7. Salt and water retention 8. Complications:1. CCF2. Hypertensive encephalopathy3. Acute renal failure4. Progressive glomerulonephritis9. Prognosis:1. Complete recovery if there are no complications4. Lab Diagnosis:Urine 1. Urine output most is often reduced 2. proteinuria 3. Hematuria 4. Polymorphonuclear leukocytes and renal epithelial cells 5. Hyaline and/or cellular casts are almost always present.6. RBC casts have been found in 60-85% Streptococcal infection 1. Cultures from either the pharynx or skin may be positive 2. ASO, AH, anti-DNase B are positive3. An ASO titter of 250 U or higher is highly suggestive of recent streptococcal infection.Complement 1. The concentration of C3 has been found to be decreased in more than 90% of patients Renal 1. The elevation in the serum concentrations of creatinine and BUN is usually modest, although some patients may have severe azotemia (Blood urea nitrogen) at onset.2. The electrolyte profile is usually normal;3. Hyperkalemia and metabolic acidosis are in patients with significant renal functional impairment. The same applies to hyperphosphatemia.Blood 1. A mild anemia (normocytic, normochromic) is 2. WBC and platelet counts are usually normal, although an occasional patient exhibits a leukocytosis; rarely, a mild thrombocytopenia may be present.

Short notes:1. Definition: Primary glomerular diseases are disorders in which the kidneys are the only or predominant organ involved 2. Examples of Primary glomerular disease:1. Post streptococcal GN2. Cresentric GN3. Membranous glomerulopathy4. Focal segmental glomerulosclerosis5. Memranoproliferative GN6. IgA nephropathy7. Chronic GN3. Classification of types of glomerular disease:1. Antibody mediated : Three forms of antibody mediated injuries:1. In situ immune complex deposition: 1. Fixed or in situ : Intrinsic glomerular antigens2. Planted: Antigens planted within the glomerulus 2. Circulating antigen antibody complexes: 1. Endogenous: a. DNA, tumor antigens2. Exogenous:Infectious products 3. Cytotoxic antibodies 2. Cell mediated 3. Alternate complement pathway

Normal Post streptococcal

Membranous

4.In situ Immune complex disease1. Fixed or in situ immune complex: Anti GBM antibody induced nephritis: two experimental models: i. Masugi model;a. Antibodies are formed against antigens which are normal components of GBMb. Diffuse linear pattern of immune complex deposition along GBMc. 5% of Nephritis belong to this modeld. Eg: Good pasture syndrome ii. Heymann model:a. Antibodies react with antigens in the basal surface of visceral epithelial cellsb. This is followed by complement activationc. Immune complexes are formed and deposited along the sub epithelial aspect of basement membrane in a granular patternd. Eg: membranous glomerulonephritis2. Planted antigen antibody complex:i. Bacterial, viral and parasitic products and other such antigens may get deposited in glomerulus ii. Antibodies bind to these antigens and induce complement activation leading to immune complex formation and glomerular inflammation.iii. Eg. Post streptococcal GN3. Circulating antigen antibody complexes: i. Endogenous: eg: SLEi. Antigen from host tissue form antibody complexes and then get trapped in glomeruliii. Complements are activatediii. Glomerular injury occursiv. Eg: nephritis in SLEii. Exogenous:i. Antigens are formed against infections like streptococci, Hepatitis B, Treponema, Plasmodium etcii. Trapped in glomeruli followed by inflammationiii. Eg: Nephritis associated with streptococci, Hepatitis B, Treponema, Plasmodium etc4. Cytotoxic antibodies:i. Glomerular cells themselves may act as antigensii. Antibodies develop and immune complexes are formediii. Injury is caused by cytotoxic mechanism5. Cell mediated injury:iv. T cells get sensitized and together with activated macrophages can cause glomerular injuryv. Cytokines and other mediators from T cells are responsible for this cytotoxic injuryvi. Example: pauci-immune glomerulonephritis6. Alternate complement pathway:1. The normal complement system consists of the classic and alternative pathways. The classic pathway is activated by the interaction of C1 with an antigen-antibody complex. This interaction results in the formation of C4b2a, which is the classic pathway C3b convertase. The alternative pathway utilizes C3 and factors B and D to form the alternative pathway convertase C3b,Bb.2. Mainly Complement- 3 contributes to this type of injury3. Immune complexes are found in the mesangium and subendothelial spaces, and they trigger complement activation and the release of cytokines and chemokines. The release of inflammatory mediators causes an influx of inflammatory cells and leads to mesangial and endothelial cell proliferation. 4. Example : Memranoproliferative glomerulonephritis7. Mediators of glomerular injury:5. Cells:1. Neutrophils and monocytes: release proteases which cause GBM degradation;2. Macrophages and T lymphocytes and NK cells: produce variety of lymphokines and other mediators3. Platelets: release eicosanoids and growth factors4. Mesangial cells: release cytokines, chemokines, eicosanoids and growth factors etc6. Soluble mediators:1. Formation of C5b-C9 causes cell lysis2. Interleukin-1 and TNF produce leukocyte adhesion and other effects3. Fibrin leaks into Bowmans space and induce crescent formation4. Plasminogen activator inhibitors induce thrombosis and fibrosis 8.Glomerular localization of antigen antibody complexes:1. Immune complexes get deposited in mesangium, subenotheilal space, sub epithelial space2. The deposits may be granular or diffuse linear pattern3. Localization depends on molecular charge: 1. anionic : sub endothelial2. cationic: sub epithelial3. neutral: mesangium9. The injury process due to antigen antibody complexes:1. There are histologic and functional changes2. Histologic:1. Histologic changes may be diffuse, global or segmental or masangial2. Leukocytic infiltration at the site and hypercellularity3. Proliferation of measangial and epithelial cells4. Formation of crescent5. Basement membrane thickening6. Hyalinization and sclerosis10 . Functional changes:1. Proteinuria2. Hematuria 3. Renal failure

Short notes:

Synonym: rapidly progressive glomerulonephritis:1. Definition: 1. A syndrome of severe glomerular injury2. Does not denote any specific etiology3. Rapid and progressive loss of renal function4. Classic histology is presence of crescents in most glomeruli;2. Classification:1. Group I:1. Anti GBM antibody induced glomerulonephritis2. Linear deposits of Ig.G and C3 in GBM3. In some similar lesions in lungs (Good pasture syndrome)2. Group II:1. Immune complex mediated disease2. Granular pattern of immune complex deposits3. Eg. Post infectious, SLE, IgA, Henoch-Schonlein nephropathies3. Group III:1. Pauci immune type2. No immune complex or anti GBM antibody deposits3. Antineutrophil cytoplsamic or perinuclear antibodies are present in serum4. Mostly idiopathic5. Probably a manifestation of small vessel vasculitis limited to glomerulus 3. Pathology:1. Kidneys are enlarged, pale with petichiae2. Crescents are present in Bowman capsule; they are formed by proliferation of parietal cells, monocytes, macrophages, Neutrophils and lymphocytes in a fibrin meshwork;3. Rupure of GBM and passage of proteins, inflammatory cells into Bowmans space which form crescents.4. Clinical:1. Hematuria2. Hypertension and edema3. Hemoptysis in Good-pasture syndrome4. Presence of serum anti-GBM, antinuclear, ANCA antibodies depending on the type5. Plasma exchange, steroids, cytotoxic agents may help in recovery.

1. Definition: It is a membranous glomerulopathy with diffuse thickening of glomerular capillary wall, immune complex deposits along the sub epithelial side of GBM 1. Massive proteinuria >3.5 gm/day2. Hypoalbuminemia < 3 gm/dL3. Edema4. Hyperlipidemia and lipiduria2. Age: 6-8 years3. Etiology and Classification:1. Idiopathic2. Drug induced: gold, NSAID3. Malignancy: Hodgkin, Ca Lung, colon and melanoma4. SLE5. Infections: Hepatitis B,C, syphilis, malaria etc6. Autoimmune : thyroiditis4. Pathogenesis:1. Immune complex mediated2. Idiopathic form: the in situ antigen is an unidentified antigen due to a genetic susceptibility3. C5b-C9 complex induce mesangial and epithelial cells to liberate proteases and oxidants which cause capillary wall injury and increased protein leakage.4. No circulating immune complex5. In secondary forms specific antigens could be identified5. Pathology:1. Kidneys are enlarged and pale2. Glomeruli: 1. Diffuse thickening of capillary wall2. Thickening of GBM3. No cellular proliferation3. Tubule:1. Normal4. Interstitium:1. Fine Fibrosis and scanty inflammatory cells5. Vessels:1. Hypertensive changes in late stage6. Electron microscopy:1. Immune complex deposits in subepithelial location2. GBM appear as spikes between deposits 7. Immunoflorescence:1. Granular deposits of immune complex (IgG+C) 6. Complications:1. Hypertension2. End stage renal disease and renal failure3. Azotemia 4. Renal vein thrombosis

1. In 1919, Good pasture described a syndrome characterized by hemoptysis, alveolar hemorrhage and necrosis, and proliferative glomerulonephritis in a patient during an influenza epidemic. Autopsy revealed that the patient had a vasculitis2. Definition:Is a triad of diffuse pulmonary hemorrhage (as seen in the images below), glomerulonephritis, and circulating anti glomerular basement membrane (anti-GBM) antibodies.3. It is a type I of crescentric glomerulonephritis4. It is a immune complex disease due to anti GBM antibodies which also cross react with pulmonary alveolar basement membrane producing both pulmonary and renal lesions5. The antigen called Goodpasture antigen is a component of alpha 3 chain of collagen type IV 6. Pathology:a. Kidneys are enlarged, pale with petichiaeb. Crescents are present in Bowman capsule; they are formed by proliferation of parietal cells, monocytes, macrophages, Neutrophils and lymphocytes in a fibrin meshwork;c. Rupture of GBM and passage of proteins, inflammatory cells into Bowmans space which form crescents.d. Diffuse linear pattern of immune complex deposition along GBM 1. It is a tubulo interstitial diseasae resulting from repeated attacks of inflammation and scarring.2. Etiopathogenesis: two typesa. Reflux nephropathyb. Obstructive pyelonephritis3. Reflux nephropathy:a. Congenital absence or shortening of intravesical portion of ureter leading to reflux during micturition as the valvular mechanism is lostb. Urine reflux into ureter and pelvisc. One or both kidneys are damaged with scarringd. Urinary infection is also common4. Obstructive pyelonephritis:a. Obstruction can occur at variable levels( eg. Pelvi ureteric junction or posterior urethral valve or renal calculi) b. Unilateral or bilateralc. Infections superimpose obstructiond. Inflammations lead to chronic pyelonephritis5. Morphology:a. Gross: i. Kidneys are irregularly scarredii. Small and contractediii. Capsule is adherent with scarsiv. If bilateral the involvement is asymmetrical as opposed to chronic glomerulonephritis which is symmetricalv. The diseased cortex is dilated, blunted, and deformed.vi. The overlying cortex is represented by scar which show U shaped depressions on the cortical surfacevii. Pelvis is dilatedb. Microscopic:i. Interstitium:1. Chronic inflammation is seen2. Varying degrees of inflammation in the cortex and medulla3. Neutrophilic infiltrations4. Pus casts in the tubules5. Xanthogranulomatous pyelonephritis occurs in proteus infections6. Fibrotic changes in cortex, medulla and calyx7. ii. Tubules:1. Tubules show atrophy, hypertrophy and dilatations2. Dilated tubules are filled with colloid casts (throidization)iii. Glomerulus:1. Periglomerular fibrosis may be present2. Focal segmental glomerulosclerosis may be seeniv. Blood vessels:1. Show obliterative endarteritis 2. Secondary changes may occur due to hypertensionv. Pelvi calyceal system:1. Pelis and calyx are dilated2. Walls show chronic inflammation with lymphoid follicles3. Epithelium undergoes squamous metaplasia

HaematopathologyAnemia:1. Definition:a. Defined as a reduction below normal limits of the total circulating red cell mass (or)b. Hg% > 2 standard deviations below the mean for age, sex and racec. Characterized by:i. Reduced HB%ii. Reduced PCViii. Reduced RBC countiv. Anaemia is a sign of an underlying pathology (it is not a diagnosis)2. Classification:a. Blood loss:i. Acute: Traumaii. Chronic: peptic ulcer; haemorrhoids, Menorraghiab. Hemolytic:i. Intrinsic: (within RBC)1. Hereditary a. RBC Memrane disorders:i. Spherocytosis ii. Increase in membrane lecithinb. RBC Enzyme disorders:i. Pyruvate kinase deficiencyii. Hexokinase deficiencyiii. G6P Deficiencyiv. Glutathione synthetase deficiency c. Hemoglobin disorders:i. Reduced Globin: Thalassemiasii. Abnormal globins: Sickle cell; unstable hemoglobins2. Acquired:a. Membrane defect: paroxysmal nocturnal hemoglobinuriaii. Extrinsic: (outside RBC)1. Antibody mediated:a. Isohemagglutinins:i. Transfusion reactionii. ABO incompatibilityiii. Rh incompatibilityb. Autoantibodies:i. Idiopathicii. Drug induced- eg. penicilliniii. SLEiv. Neoplasmsv. Mycoplasma infection- paroxysmal cold hemoglobinuria2. Mechanical trauma:a. MIcroangiopathic:i. Thrombotic thrombocytopenic purpuraii. Disseminated intra vascular coagulationb. Cardiac:i. Prosthetic valve replacement3. Infections:a. Malariab. Hook worm4. Chemical injury:a. Lead poisoning5. Sequestration:a. Hypersplenismc. Impaired production:i. Defect ion proliferation and maturation of stem cells:1. Aplastic anemia2. Pure red cell anemia3. Renal failure ( erythropoietin deficiency)4. Endocrine ( Hypothyroidism)ii. Defect ion proliferation and maturation of erythroblasts:1. Defect in DNA synthesis: a. B12 deficiencyb. Folic acid deficiency2. Defect in Hb synthesis:a. Iron deficiencyd. Unknown or multiple mechanism:i. Sideroblastic anemiaii. Chronic infections: osteomyelitis; lung abscessiii. Chronic inflammation: Rheumatoid arthritisiv. Marrow infiltration: Myelophthisic anemia3. Morphologic classification:a. Microcytic hypochromicb. Normocytic normographicc. Machrocytic normochromic

a. Hemolytic:i. Intrinsic: (within RBC)1. Hereditary a. RBC Memrane disorders:i. Spherocytosis ii. Increase in membrane lecithinb. RBC Enzyme disorders:i. Pyruvate kinase deficiencyii. Hexokinase deficiencyiii. G6PD Deficiencyiv. Glutathione synthetase deficiency c. Hemoglobin disorders:i. Reduced Globin: Thalassemiasii. Abnormal globins: Sickle cell; unstable hemoglobins2. Acquired:a. Membrane defect: paroxysmal nocturnal hemoglobinuriaii. Extrinsic: (outside RBC)1. Antibody mediated:a. Isohemagglutinins:i. Transfusion reactionii. ABO incompatibilityiii. Rh incompatibilityb. Autoantibodies:i. Idiopathicii. Drug induced- eg. penicilliniii. SLEiv. Neoplasmsv. Mycoplasma infection- paroxysmal cold hemoglobinuria2. Mechanical trauma:a. MIcroangiopathic:i. Thrombotic thrombocytopenic purpuraii. Disseminated intra vascular coagulationb. Cardiac:i. Prosthetic valve replacement3. Infections:a. Malariab. Hook worm4. Chemical injury:a. Lead poisoning5. Sequestration:a. Hypersplenism

Hemolytic anemias:1. Hereditory Spherocytosis:a. Inherited disorder of red cell membraneb. Autosomal dominat; autosomal recessivec. Mutation of red cell ankyrin, a-spectrin, band-3 etc with abnormal protein complex responsible for stability to RBC;d. Membrane instability leads to loss of fragments of membrane in circulation of blood and the RBC adopts a spherical shape which is a microcyte;e. Spheroidal shape ands reduced membrane plasticity leads to sluggish movement within the spleenf. Spleen captures spherocytes which are phagocytosed by RE cells; g. Splenectomy prevents hemolysis h. Morphology:i. Spherocytes are smaller, hyperchromic, lacking central pallorii. Marrow hyperplasiaiii. Reticulocytosisiv. Hemosiderosisv. Mild jaundicevi. Gall stones due Hb pigmentsvii. Splenomegaly2. G6PD:a. It is an X-linked recessive trait; males are affected while female are carriersb. G6PD A and G6PD mediteranian variants are the most common defective enzymes c. Glucose 6 phosphate dehydrogenase in RBC reduces NADP to NADPH; NADPH is essential for reducing glutathione; reduced glutathione is essential for neutralizing H2O2 and other oxidant radicals.d. Absence of G6PD leads to accumulation of oxidant radicals within RBCs and RBC metabolism is deranged leading to formation of Heinz bodies which damage the membrane and lead to haemolysise. Spleen tries to remove Heinz bodies and the the remaining part of RBC appear as bite cellsf. The oxidant stress is produced by liberating free radical by leukocytes during infections like viral hepatitis, pneumonia, typhoid etcg. Drugs like primaquine, chloroquine, sulphonamides also induce oxidant stressh. Young RBCs are resistant to oxidant stress and recovery is due to attainment of increased young RBC population3. Sickle cell disease:a. Intorduction:i. It is a hereditary hemoglobinopathy; autosomal recessiveii. Sickle cells are resistant to malarial infection- a factor for increased S gene concentration in malaria endemic placesiii. Normal Hb consists of:1. Hb A ( 2 alpha and 2 beta chains)2. Hb A 2 ( 2 alpha and 2 delta)3. Hb F ( 2 alpha and 2 gamma)iv. Sickle cell Hb defect:1. In Beta chain at 6 th position there is substitution of valine for glutamic acid- HbSv. When deoxygenated HbS undergo polymerization and RBC aquires the shape of a sicklevi. Sickle cells undergo membrane changes: allow more K and H2O efflux; they become dehydrated and sticky.vii. Sickling and stickiness cause vascular occlusion- eg. Bones and penisviii. Sickle cell disease occurs in 3 states:1. Homozygous: severe disease2. Heterozygous: carrier state; disease may manifest in severe hypoxia3. Double heterozygous: HbS is associated with HbC or thalassaemia traite b. Clinical feautures:i. Anemia: there is severe anemia due to hemoplysisii. Vaso occlusive diseases: 1. Bones, lungs, penis, liver, spleen etc are involved2. Bone pain and priapism (persistant erection of penis) are common3. Dactylitis of hands and bones called hand foot syndrome4. Acute chest syndrome in which lung inflammation leads to pulmonary dysfunction5. CNS: seizures can occur6. Ulcres over legsiii. Hyperbilrubinemia: mild haemolytic jaundice ( indirect bilirubinnemia)iv. Acute Crisis events:a. Sequestration crisis: Sickele cells trapped in spleen lead to splenomegaly, hypovolemia, and shockb. Aplastic crisis: transient bone marrow failure due to parvovirus B19 infection of RBC progenitor cells; there is severe anemiac. Vasoocclusive crisis: acute chest syndrome, priapism, seizures and strokev. Chronic hypoxia: this leads to stunted growth, developmental retardation and damage to renal medulla leading to dehydration1. Impaired splenic function leads to infection by capsulate organisms Pneumococcal and H.influenza produce septicemis and meningitisvi. Pulmonary hypertension is a complication of chronic intravascular hemolysisc. Morphology:i. Hyperplstic bone marrow; ii. Extra medullary erythropiesis in liver and spleeniii. Splenomegaly:1. Congestion of red pulp2. Sickle cells in splenic cords3. Thrombosis, infarction and fibrosis in spleen4. Spleen becomes fibrotic and small- autosplenectomyiv. Vascular occlusions seen in lungs, kidney, bonesv. Pigment gall stones d. Lab Diagnosis:i. Sickle cells in peripheral smear; target cells and RBC with Howell-Jolly bodiesii. Sickling test:1. Test I:Patiens blood is mixed with metabisulfite which consumes oxygen and anoxia induces sickling of RBCs2. Test II:a. A freshly prepared sodium dithionate and disodium hydrogem phosphate are mixed with 2:3 proportionb. 5 drops of this mixture is taken on glass slidec. A drop of patients blood is addedd. The specimen is covered by cover slip and sealed with Vaselinee. The slide is examined under microscope for sickling, periodically over 24 hoursf. A control is used for comparisoniii. Hb electrophoresis demonstrates HbSiv. Prenatal diagnosis is done by DNA analysis from amniocentesise. Treatment:i. Hydroxyurrea:1. Causes increase in HbF which prevents polymerization2. Acts as anti inflammatory agent by suppressing leukocytosis and inflammation3. Increases red cell volume and HbS concentration is lowered4. It gets oxidised to form Nitric oxideii. Nitric Oxide:1. Nitric oxide is a potent vasodilator and inhibit platelet aggregation2. Nitric oxide therapy3. iii. Antibiotic prophylaxis against sepsisiv. Vaccination against H.inf and pneumococciv. RBC transfusionvi. Adequate hydrationvii. Stem cell transplantation Thalassemias: (Mediteranian anemia)1. Unlike hemoglobinopathies which are qualitative defects, thallasemias are quantitative defects of globin chain synthesis2. It is an autosomal recessive disease with a spectrum manifestations3. The defective genes are either in alpha ( Chr 11) or beta (Chr 16) chains4. There are 4 major types of globins labelled as alpha (), beta (), gamma (), and delta (). The dominant haemoglobin in adults (haemoglobin A) is composed of 2 alpha and 2 beta chains. Thalassemia refers to a spectrum of diseases characterized by reduced or absent production of one or more globin chains.5. Relative excess of beta chains due to impaired production of alpha globin results in less stable chains. This leads to the clinical disease known as alpha thalassemia. Similarly, impaired production of beta globin chains manifests with a more severe disease known as beta thalassemia.6. Classification:a. -thalassemia:i. Major (Cooleys anemia): is homozygous; alpha chains are reduced; HbA is less; severe anemiaii. Trait: heterozygous; clinically normaliii. Hb Barts hydrops fetalis: all four alpha chains are suppressed; Hb consist only of 4 chains called HbBarts; severe intrauterine hemolysis and fetal deathiv. HbH disease: deletion of 3 alpha chains leads to HbH(4) disease; severe hemolysisb. B-thalassemia:i. Major: homozygous; Beta chains are less; alpha chains are in excess; HbF is more; severe anemia due to hemolysisii. Trait: mild symptoms7. - Thalassemia:a. Reduced synthesis of globin chains; and globin chains are synthesized more leading to excess production of HbH (4) and Hb Barts (4)b. Silent carrier: asymptomatic carriers; one chain gene is deletedc. Trait: 2 chain genes are deleted; asymptomaticd. HbH: deletion of 3 chain genes; HbH(4) is in excess; HbH has severe affinity for O2 and tissue hypoxia and severe anemiae. Hydrops fetalis: all 4 chain genes are deleted; Hb Barts are more; in utero tissue hypoxia and anemia lead to hydrops and fetal death8. -Thalassemia: a. Disease due to Impaired synthesis of chains & excess synthesis of chainsb. Molecular lesions:i. 0: complete absence of chainsii. +: partial synthesis of chains c. Types of mutations:i. Transcription defect: promoter sequence is defectiveii. Translation defect: defect coding sequence with creation of stop codonsiii. Splicing defect: mutation affect splice junctions and normal splicing does not occurd. Mechanism of anemia:i. Deficiency of chains and decreased Hb A : produce hypochromic microcytic red cellsii. Excessive chain synthesis produce soluble inclusions within RBC and a membrane damage results leading to apoptosis and further destruction in spleeniii. Ineffective erythropoiesisiv. Increased erythropoietin produce medullary and extra medullary hyperplasia of hematopoietic tissuev. Excessive iron absorption from gut leading to hemochromtosise. Clinical syndromes:i. Thalassemia major: homozygous; absence of chains; severe hemolysis; severe anemia requiring repeated transfusions;ii. Thalassemia minor:heterozygous; partial absence of chains; mild microcytic anemia; no symptomsiii. Thalassemia intermedia:Genetically heterozygous but more severe than Thalassemia minorf. Morphology:i. Thalassemia major 1. Genotypes are +/ +; 0/0; o/+2. Anemia from 6-9 months; Hb F protects young infants;3. Hb 3-6 gm/dL4. Smear: a. anisocytosis, poikilocytosis, microcytosis, hypochromiab. target cells, basophilic stifling, fragmented red cellsc. Reti count is elevatedd. Normoblasts with poor hemoglobinzation5. HbF is markedly elevated as it does not require chains6. HbA2 may be normal or high or low 7. Increase in marrow of facial bones gives malar prominence and wide separation teeth8. Hemosiderisis and hemochomotosis in several organs9. Growth retardation10. Hepato splenomegalyii. Thalassemia minor:1. More common than major2. Heterozygous and carriers of the defective genes3. Mild anemia: hyochromic, microcytic, target cells, basophilic stifling4. Mild hyperplasia of marrow5. HbA2 is increased as it contains and and no chains6. HbF is normal or slightly increased

Megaloblastic anemia:1. Definition: It is a type of anemia due to impaired DNA synthesis; maturation of nucleus is delayed while cytoplasm increase normally leading to megaloblasts in bone marrow and macrocytes in peripheral smear.2. Biochemical basis:a. Folate and B12 are essential for synthesis of thymidine one of 4 bases of DNA; b. B12 is essential cofactor for methionine synthase which converts homocysteine to methionine.c. In the same reaction N- methyl FH4 is converted to tetra hydro folic acid (FH4)d. In B12 deficiency FH4 is trapped as N- methyl FH4e. FH4 is crucial for convertion of deoxyurine monophosphate to deoxythymidine monophosphate which is the immediate precursor of DNA3. Etiologic classification:a. B12 deficiency:i. Inadequate in take: vegetarians and exclusive breast feedingii. Malbsorption:1. intrinsic factor deficiency2. Tropical sprue3. Regional ileitis4. Fish tapeworm infestationiii. Increased demand:1. Pregnancy2. Hyperthyroidism3. cancerb. Folate deficiency:i. Inadequate intake: alcoholism, old ageii. Malabsorption:1. Tropical sprue2. Regional ileitisiii. Excess demand:1. Pregnancy, lactation, infancy2. Malignancy, 3. TB4. Rheumatoid arthritisc. Other causes:i. DHF reductase inhibitors: methotrxateii. Unknown: Di Guglielmos syndrome4. B12 deficiency anaemia: Pernicious anaemia:a. Causes:i. Inadequate in take: vegetarians and exclusive breast feedingii. Malbsorption:1. intrinsic factor deficiency2. Tropical sprue3. Regional ileitis4. Fish tapeworm infestationiii. Increased demand:1. Pregnancy2. Hyperthyroidism3. Cancerb. Metabolism:i. Microorganism is the primary source of Vit.B12ii. Human derive it only from animal food productsiii. Daily requirement is 2-3 mgiv. Absorption require intrinsic factor from gastric fundusv. Absorption is mainly from ileumvi. 1% absorption occurs in alternate pathway which does not require intrinsic factor c. Incidence: common in 5th to 8th decades 0f life; d. Pathogenesis:i. Initaial event in pernicious anemia is autoimmune destruction of gastric mucosaii. Type I and II antibodies prevents binding of B12 to intrinci factor and to ileual mucosae. Morphology:i. Alimentary tarct:1. Toungue is glassy2. Stomach shows atrophy; epithelium has more goblets cells and is called intestinalization 3. Some cells show megaloblastic changes4. CNS:a. Degeneration of myelin in dorasal and lateral tractsb. Some degeneration in posterior ganglio and dorasal and latral roots- subacute combined degerationf. Lab diagnosis:g. B12:i. Blood picture:1. Hb% is decreased2. Red Cells: a. Macrocytosisb. Anisocytosisc. Poikilocytosisd. Macroovalocytese. Basophilic stiplingf. Occasional normoblasts3. Reticulocytes: low or normal4. Values:a. MCV and MCH are elevatedb. Normal or reduced MCHCc. Leukocytes: reduced in no and hypersegmented polymorphsd. Occasional myelocytese. Platelets: reduced and some bizarre formsii. Bone Marrow:1. Hypercellular with decreased myeloid-erythroid ratio2. Megaloblasts:a. Abnormal, large, nucleated erythroid precursor;b. Less mature nucleus but more cytoplasmic material- nuclear cytoplsmic asynchronyc. Nuclei are large, fine reticulum, lighther stainingd. Some cells may show mitosise. Degenerated erythroid precursors may be seen3. Giant metamyelocytes and band cells may be seen4. Megakaryocytes are normal in no; occasional cell with hypersegmented nucleus5. Prussian blue staining may show increase in iron granules in erythroid precursors6. Chromosomes may show breaksiii. Biochemistry:1. Unconjugated bilirubin is raised due to ineffective eryhtropoiesis2. Serum iron and ferritin are normal or elevatediv. Special tests:1. Serum B12 assay: microbiological and radioassay2. Schilling test: A Schilling test may be given in two parts. Part one measures the amount of vitamin B12 passed in urine after a known amount of the vitamin tagged with a radioactive substance is swallowed. If the intestines absorb vitamin B12 normally, a certain amount of the vitamin (up to 25% of the amount swallowed) will be passed in the urine. If the intestines cannot absorb the vitamin normally, very little or no vitamin B12 will be present in the urine. A Schilling test with abnormal results (no vitamin B12 in the urine) may be repeated after giving an oral dose of intrinsic factor and radioactive B12. This is called part two of the test, and it tells whether the vitamin deficiency is caused by a lack of intrinsic factor or from a problem with the intestines. Folic acid deficiency:1. Sources: green vegetables, fruits, animal proteins; heating may reduce folic acid content of food2. Lab investications:v. Normal serum level is 6-18 ng/mlvi. Urinary excretion of FIGLU (formiminoglutamic acid): addition of oral histidine increases urinary excretion of FIGLU in folate deficiencyvii. Serum folate assay:1. Microbiological assay2. Radiassay viii. Red cell folate assay: RBC contain 20-50 times more folate; decrease in folate deficiency.

Iron Deficiency Anemia:1. Definition of anemia:a. Defined as a reduction below normal limits of the total circulating red cell mass (or)b. Hg% > 2 standard deviations below the mean for age, sex and racec. Characterized by:iii. Reduced HB%iv. Reduced PCVv. Reduced RBC countvi. Anemia is a sign of an underlying pathology (it is not a diagnosis)2. Metabolism:a. No regulated pathway for iron metabolismb. 1-2 mg lost by shedding mucosal and skin epithelial cellsc. 20% of heme iron in animal source and 1-2% non heme iron from vegetable sources are absorbedd. VitC enhances absorptione. Both nonheme iron and heme iron have 6 coordinating bonds; however, 4 of the bonds in heme bind pyrroles, making them unavailable for chelation by other compounds. Therefore, ascorbic acid chelates nonheme iron to enhance absorption but has no effect upon heme iron. Many dietary components, such as phytates, phosphates, oxalates, and tannates, bind nonheme iron to decrease nonheme iron absorption. They do not affect heme. This explains why heme is so effectively absorbed with foods containing these chelators. Iron hemoglobin structure.[ CLOSE WINDOW ]

Both nonheme iron and heme iron have 6 coordinating bonds; however, 4 of the bonds in heme bind pyrroles, making them unavailable for chelation by other compounds. Therefore, ascorbic acid chelates nonheme iron to enhance absorption but has no effect upon heme iron. Many dietary components, such as phytates, phosphates, oxalates, and tannates, bind nonheme iron to decrease nonheme iron absorption. They do not affect heme. This explains why heme is so effectively absorbed with foods containing these chelators. Iron hemoglobin structure.

f. Total Iron content of men 6gm and women 2 gm; 80% in haemoglobin, myoglobin and iron containing enzymes as functional iron and rest in ferritin and hemisiderin as storage iron.3. Etiology of anemia:a. Iron requirement is 7-10 mg for men and 7-20 mg in women per dayb. 10% - 15% is absorbed out of daily requirement i.e 1 mg is absorbed everydayc. Deficiency occurs due to :i. Dietary lackii. Impaired absorptioniii. Increased requirementiv. Chronic blood lossd. Dietary lack:i. Infants take only milk which has less iron; breast milk contains .3mg/Lii. Iron in cows milk has poor bioavailabiltyiii. Cereals have iron ; non introduction of weaning food also leads to iron deficnecy after 6 months of ageiv. Adults:1. Not consuming iron rich food2. Taking tea, coffee which contain iron chelators3. Consuming large quantity of milk in the place of iron rich food4. Faddism e. Impaired absorption:i. Tropical sprueii. Steatorrheaiii. Chronic diarrhoeaiv. Gastrectomyf. Increased requirement:i. Infants and childrenii. Adolescentsiii. Premenopausal womeniv. Repeated pregnanciesg. Chronic blood loss:i. Peptic ulcerii. Haemorrhoidsiii. Cancer GITiv. Hookwormv. Dysmenorrheavi. Renal tumors4. Morphology:a. Bone marrow:i. Moderate increase in erythroid precursors(more normoblasts)ii. Disappearance of stainable iron from mononuclear phagocytic cells in the bone marrow by Prussian blue stainingb. Peripheral smear:i. Small red cells (microcytes) and pale(hypochromic)ii. The zone of pallor in RBC is enlarged to give pessary signiii. Poikilocytes containing small elongated cells are present5. Lab tests:a. Haemoglobin is reduced b. Hematocrit (PCV) is loweredc. Serum iron and ferritin are lowd. Total plasma iron binding capacity is highe. Reduction in transferring Saturation below 15%f. Serum level of hepcidin is lowg. Free erythrocyte protoporphyrin is elevated

Aplastic anemia:1. Definition: a syndrome of marrow failure associated with pancytopenia which includes anemia, neutropenia and thrombocytopenia.2. Classification:a. Acquired:i. Idiopathic:1. Primary stem cell defect2. Immune mediatedii. Chemical agents:1. Dose related:a. Alkylating agentsb. Antimetabolitesc. Benzened. Chloremphenicole. Inorganic arsenicals2. Idiosyncratic:a. chloramphenicolb. phenylbutazonec. organic arsenicalsd. chlorpromazinee. DDTiii. Physical agents:1. Irradiationiv. Viral infections:1. Hepatitis2. CMV3. EB virus4. Herpesv. Miscelaneous:1. Drugs and chemicalsb. Inherited:i. Fanconi anemia3. Pathogenesis:a. Not fully understoodb. Two suggested mechanisms:i. Immune suppression of marrow :The causal agent antigenically alter the stem cell followed by activation of T cells; cytokines and TNF prevent normal stem cell growth.ii. Intrinsic abnormality of stem cells:Insult to marrow causes genetic damage to stem cells leading to aplstic anemia4. Morphology:i. Bone marrow preferably from Marrow biopsy:1. Hypocellular marrow2. Devoid of hematopietic cells3. Only fat cells, plasma cells and lymphocytes are seenii. Blood smear:1. Normocytic normochromic rbc2. Reticulocytopenia5. Clinical findings:i. Any age either sexii. Anemia: pallor and fatiqueiii. Thrombocytopenia: petichiae and echymosisiv. Granulocytopenia: persistant or recurrent infectionsv. No splenomegaly6. Treatment:a. Withdrwl of affending agentb. Bone marrow transplant7. Prognosis: unpredictable

Shortnotes:

1. Reticulocytes are immature red blood cells, typically composing about 1% of the red cells in the human body. 2. Reticulocytes develop and mature in the red bone marrow and then circulate for about a day in the blood stream before developing into mature red blood cells.3. Like mature red blood cells, reticulocytes do not have a cell nucleus. They are called reticulocytes because of a reticular (mesh-like) network of ribosomal RNA that becomes visible under a microscope with certain stains such as new methylene blue.4. Reticulocyte production index:a. The idea of the RPI is an index of erythropoietic activity of bone marrowb. RPI should increase in response to any loss of red blood cells. c. If reticulocyte production is not raised in response to anemia, then the anemia may be due to an acute cause with insufficient time to compensate, or there is a defect with red blood cell production in the bone marrow.d. Marrow defects include nutritional deficiencies (i.e. iron, folate, or B12) or insufficient erythropoietin, the stimulus for red blood cell production.e. Reticulocytopenia, or "aplastic crisis", is the term for an abnormal decrease of reticulocytes in the bodyf. Reticount is increased following hemorrhage and following anemia treatment with iron

1. It results from passage of IgG from mother to fetus2. IgG develop due to:a. Rh sensitization:Rh ve Mother sensitized by fetal Rh +ve RBC by feto maternal transfusion that occurs during pregnancy and labour More than 60 antigens in RBC Rh factor is one Rh factor has many antigens: D, C,E, Kell, Kidd, K, M, Duffy 90 % Rh disease due to D antigen C&E 10% 1 ml of fetal blood can produce adequate sensitization Ig M and IgG antibodies are produced Ig G crosses placenta into fetal circulation Adheres to fetal RBC Produce haemolysis by compliment activation Increasing severity by successive pregnancies ABO incompatibility will reduce severity of Rh incompatibility b. ABO incompatibilty:When mother is one blood group of a,b,O group and the baby is different group A1 more antigenic; o group mother and A1 group fetus O - A1 severe incompatibility due to Ig.G ABO in 20 % pregnancies Among them 20 % develop icterus Overall incidence is 1-2 % First pregnancy can be affected Less jaundice but anemia may be significant < 10% MAY GO FOR EXCHANGE TRANSFUSION 3. The blood group incompatibility produce hemolysis and unconjugated hyperbilirubinemia in NB4. High levels exceeding 20 mg/dL may produce kernictreus5. Phototherapy and exchange transfusions are the treatments

7. F A B classification of leukemia.

LeukemiasGroup of malignant diseases arising from hematopoietic cells;1.Etiology:7. Herditory:a. Hodgkins disease is 99% more in identical twins b. Leukemias more common in same families8. Genetic disorders: Inherited genetic factors with genomic instability:eg:a. Fanconi anemiab. Ataxia telangiectasiac. Down syndromed. Wiscott Aldrich syndrome 9. Viral infection:a. Human T cell Leukemia Virus-1(HTLV): T cell leukemiab. Ebstein Bar virus: lymphomac. Herpes virus-8: Kaposis sarcomad. Hepatitis C: lymphomae. HIV: B-cell and Burkitts lymphomasf. Helecobacter pylori: lymphoma of stomach10. Environmental agents:a. Ionizing radiation: Leukemiasb. Drugs:i. Phenytoin: lekemias and lymphomasii. Cancer chemotherapy-leukemiac. Gluten sensitivity: intestinal lymphomad. HIV: B cell lymphomas11. Immune deficiency:a. Congenital or acquired immune deficiency: leukemia and lymphoma 12. Iatrogenic Factors:a. Radiotherapy- leukemia2. Pathogenesis:6. Malignant transformation of a single clone of cells belonging to lymphoid or myeloid series due to a genetic damage to DNA; this is followed by proliferation of affected clone7. Chromosomal translocation: eg: Philedelphia Chromosome t(9;22) in CML8. Maturation defect: i.e failure to mature beyond myeloblast or lymphoblast;9. Myelosupression: bone marrow is suppressed by the excessive cancer cells10. Infiltration: bone marrow and liver, spleen, lymphnodes and CNS are infiltrated by leukemic cells

ClassificationTypes of classification:4. Historical classification5. French American British classification (FAB)6. WHO classification I. Historical classification:

3. Leukemias: Acute in the sense the disease progresses rapidy and blast cells predominate in blood smear; chronic in which disease progresses slowly and blast cells are not seen in early smearsa. Acute myeloblastic leukemia (AML)b. Acute lymphoblastic leukemia(ALL)c. Chronic myeloid(myelocytic) leukemia(CML)d. Chronic lymphocytic leukemia(CLL)4. Lymphomas:a. Hodgkinb. Non HodgkinII. Present major classification:4. Lymphoid neoplasm: arise from precursors of lymphocytes:5. Myeloid neoplasm: arise from hematopoietic stem cells that give rise to:6. Histiocytic neoplasms

FAB Classification:

1. WHO Classification of Lymphoid neoplasms:2. Acute lymphoblastic leukemia, ALLa. Precursor B cell neoplasm( blast cells): i. Precursor B Lymphoblastic leukemia/lymphomab. Peripheral B cell neoplasm (mature cells):i. Chronic lymphocytic leukemia (CLL)ii. Follicular lymphomasiii. Hairy cell leukemiaiv. Burkits lymphoma etcc. Plasma cell neoplasms: 1. Plasmocytoma/Plasma cell myelomad. Precursor T cell neoplasm( blast cells): (Acute lymphoblastic leukemia, ALL)i. Precursor T Lymphoblastic leukemia/lymphomaii. Peripheral T cell and NK cell neoplasm (mature cells):iii. Adult T cell leukemia/lymphomaiv. NK/T cell lymphomav. NK cell leukemia etce. Hodgkin lymphoma (Reed Sternberg cells + ve):i. Classical:1. Nodular sclerosis2. Mixed cellularity3. Lymphocyte rich4. Lymphocyte depletionii. Lymphocyte predominance2.WHO classification of Classification of Myeloid neoplasm: 5 groups:6. Myeloproliferative diseases7. Myelodysplastic / Myeloproliferative diseases8. Myelodysplastic syndromes (MDS)9. Acute myeloid leukemia10. Acute biphenotypic leukemia

1.Myeloproliferative diseases:8. Chronic myeloid leukemia9. Chronic neutrophilic leukemia10. Chronic eosinophilic leukemia11. Chronic idiopathic myelofibrosis12. Polycythemia veera13. Essential thrombocytosis14. Chronic myeloproliferative diseases2.Myelodysplastic / Myeloproliferative diseases:1.Chronic myelomonocytic leukemia3.Myelodysplastic syndromes (MDS):5. Refractory anemia6. Refractory anemia with sideroblasts7. Refractory anemia with excess blasts8. Myelodysplastic syndrome unclassified4.Acute myeloid leukemia:6. AML with recurrent cytogenetic abnormalities7. AML with multilineage dysplasia8. AML with MDS9. AML, not otherwise classified:a. AML minimally differentiated b. AMLwithout differentiationc. AMLwith maturationd. Acute monoblastic and monocytic leukemia e. Acute erythroid leukemiaf. acute megakaryocytic leukemiag. acute basophilic leukemiah. Acute panmyelosis with myelofibrosisi. Myeloid sarcoma10. Acute biphenotypic leukemia

Blood and bone marrow pictures:1.Acute lymphoblastic leukemia ALL: peak incidence at 2-5 years of age, and another peak in old age2. Blood and Peripheral smear:a. Changes in WBC:i. Total count may be very high 50-100x10or less than 10,000/microLii. Lymphoblasts:1. Are seen in large no. (Convent party appearance)2. The cells are round and small,3. Cytoplasm is scanty and homogeneous;4. Granules are absent;5. Nucleus one or two nucleoli.6. The cells are PAS/Sudan Black negative; acid phosphatase positive; 7. Some Markers:a. CD 19 positive in B cell typeb. CD 7 positive in T cell typeiii. RBC: normochromic and normocytic anemiaiv. Platelets: thrombocytopenia3. Bone marrow changes in ALL: 6. Lymphoblasts:a. Are seen in large no. Counts more than 20% (WHO) and 30% (FAB) are diagnostic of ALLb. Lymphoblasts are large cells; contain large round or indended nucleus; stippled with nuclear chromatin; nuclear membrane is dense; nucleoli 1-2 are seen; cytoplasm is scanty; it is basophilic and without granules;c. Lymphoblasts are TdT and adenosine deaminase positive;7. Erythropoietic series:reduced in no; megaloblasts and ring sideroblasts may be seen.8. Megakaryocytes are reduced or absent.9. Cytogenetics :a. Aneuploidy in 75%b. Philadelphia chromosome in 15%10. Cell markers seen ALL:a. Leukocyte common antigenb. Positive sheep erythrocyte rosette test in B cell types

2. Acute Myeloblastic (myelogenous; myeloid) Leukemia (AML): median age 50 years; may rarely occur in childhood.5. Blood Picture:a. Total Leukocyte count is raised; occasionally normalb. Plenty of blast cells:i. Blast cells are large in sizeii. Round or oval nucleus nearly filling the celliii. Abundant granular cytoplasmiv. Auer rods are seen sometimes which are abnormal derivatives of primary azurophilic granulesv. Nuclear chromatin is delicatevi. Nucleoli 3-5vii. Cytochemistry:1. Peroxidase and sudan black positive2. Phosphatase negativeviii. Markers:1. CD 19 negative2. CD 7 Negative3. CD 13 and 33 positivec. Polymorphs and few lymphocytes are seend. RBC: normochromic normocytic anemiae. Platelets: severe thrombocytopenia6. Bone Marrow:a. Maroow is hypercellular; occasionally hypocellularb. Myeloblasts are predominant; > 20%(WHO) or > 30% FAB is diagnostic of ALLc. Immature granulocytes, erythroblasts, megaloblastic erythroblasts and sideroblasts are seend. Plasma cells and monocytes are moderately elevatede. Megakaryocytes are reduced or absentf. Cytogenetics:i. Presence of cells with aneuploidy; translocation or inversions ii. Philadelphia chromosome in 3% casesg. Cytochemistry:i. Myeloperoxidase, sudan black, PAS are positive in M6 cellsii. Non specific esterase positive in M4 and M5iii. Acid phosphatase positive in M4 and M5h. Biochemistry:i. Serum muramidase elevated in M4 and M5ii. Serum uric acid elevated in general

7. Chronic lymphocytic (lymphatic)leukemia (CLL):over 50 years of age with male preponderance; hepatosplenomegaly, lymphadenopathy and anemiaa. Blood picture:i. Normochromic and normocytic anemia; mild reticulocytosis; 20% coombs have positive hemolytic anemiaii. Absolute neutrophil count is within normal range; granulocytopenia in advanced stageiii. Marked leukocytosis(50,000-200,000/l)iv. 90% of leukocytes is mature small lymphocytes; degerated lymphocytes are called smudge or basket cellsv. Platelets is normal or moderately reducedb. Bone marrow:i. Increased lymphocyte countii. Reduced myeloid precursorsiii. Reduced erythroid precursorsc. Other tests:i. Lymph node: Replacement of lymphnode with diffuse small lymphocytes ii. Erythrocyte rosette test: positive with mouse RBCsiii. Markers: CD5 is positive for immunoglobulinsiv. Coombs +ve in 20%v. 8. Chronic Myeloid (myelocytic) leukemia (CML): peak in 3-4 decades of life; juvenile form in children; anemia, weight loss, bleeding, priapism, lymphadenopathy and splenomegaly.a. Blood: 3 phases: chronic, accelerated and blast crisis phasesi. RBC: Normocytic normochromic anemiaii. WBC: 1. General: Marked leukocytosis: 200 000/L; myelocites present2. Chronic Phase: a. Myeloblast 10%3. Accelerated phase:a. Increasing anemiab. Blasts 10-20%c. Low platelet count4. Blast crisis:a. Blasts > 20%iii. Platelet: normal or raised in the casesb. Bone marrow:i. Hypercellular marrowii. Myeloid predominanceiii. Increased myeloid erythroid ratioiv. Myelocytes predominancev. Erythropoiesis: reduction in erythropoietic seriesvi. Megakaryocytes: more and smallervii. Cytogenetics:1. Philedelphia chromosome in 90 to 95%; it is reciprocal translocation of long arm of 22 and long arm of chromosome 9viii. Cytochemistry:1. Neutrophil alkaline phosphatase is reduced; increased in leukaemoid reactionix. Other findings:1. Serum B 12 elevated2. Serum uric acid elevated

S.N: Philadiphia chromosome: The Philadelphia chromosome is made when the Abl gene on chromosome 9 is mistakenly transferred to chromosome 22 and attaches to the Bcr gene. This creates a new fusion gene called Bcr-Abl which leads to leukemic process.

S.N: Leukemoid reaction: The term leukemoid reaction describes an elevated white blood cell count, that is a physiologic response to stress or infection (as opposed to a primary blood malignancy, such as leukemia) Leukemoid reaction may be myeloid (more common) or lymphoid Causes:1. Infections: Staphylococcal pneumonia Meningitis Diphtheria Any sepsis Endocarditis Septic abortion2. Toxins: Eclampsia Mercury poisoning Burns3. Malignancy: Multiple myeloma Myelofibrosis Hodgkin CLL4. Severe Hemorrhage and hemolysis Lab:1. Myleloid luekemoid reaction: Leukocytosis upto 100,000/L Blasts < 5% Toxic granulation or Dohle bodies in Neutrophils in infections Philadelphia chromosome negative No organ infiltrations2. Lymphoid leukemoid reaction: Infections: Pertusis Infectious mononucleolus Cytomegalo virus Chickenpox Measles Tuberculosis Lab: Leukocyte count upto 100,000/L Mostly mature lymphocytes Mimics CLLDifference between leukaemoid reaction and leukemiaS.NoLeukaemoid reaction Leukemia

1 The infection leading to leukemoid reaction will be presentSplenomegaly, lymphadenopathy and bleeding tendency are evident

2Leukocyte count upto 100,000/L

Leukocyte count often more than 100,000/L

3Immature cells are lessImmature cells are more

4WBC may show toxic granulation due to infectionAbsent

5Anemia is lessMore

6Bone marrow: less hypercelluarMore hypercellular

7Autopsy: no organ infiltration of blastsPresent in liver, spleen, CNS etc

2. A 35 years, old man was admitted with history of painless cervicaland axillary lymphadenopathy. He had history of loss of weight,fever and night sweating and was found to have cutaneous anergy.No hepatosplenomegaly.a) What is your most probable diagnosis?b) Give the classification of the condition.c) Describe the morphology of any two types.Lymphomas 1.These are malignant neoplasm derived from lymphocytes, usually in lymph nodes but also in other organs or in soft tissue.Unlike the leukemia the tumor cells do not appear in the blood in detectable numbers2.TYPES OF LYMPHOMAS: The lymphomas are broadly grouped into two types:A. Non-Hodgkins lymphomas (60%)B. Hodgkins lymphoma (also known as Hodgkin's disease) (40%)3.Cells of origin:The non- Hodgkins lymphomas are derived from either B or T lymphocytes. The cell of origin in Hodgkins lymphoma is now known to be of B-cell origin

Hodgkins disease1.Neoplasm (lymphoma) arising from lymph node with secondary involvement of extra nodal sites2.Age 15-35 yrs with male preponderance; another peak at 5th decade3. Symptoms include painless swelling of the lymph nodes in the neck, armpits, or groin fever and chills night sweats weight loss loss of appetite itchy skin nodes are painful after alcohol consumption4.Classifications:4. Conventional:a. Non Hodgkin- heterogynous groupb. Hodgkin (Reed Sternberg cell +ve)5. Rye classification:5. Lymphocyte predominant type6. Nodular sclerosis7. Mixed cellularity8. Lymphocyte depletion type6. Modified WHO classification:3. Classic Hodgkin Disease:a. Lymphocyte predominant typeb. Nodular sclerosisc. Mixed cellularityd. Lymphocyte depletion type4. Nodular lymphocyte predominant Hodgkin disease6.Reed-Sternberg cell:7. These are neoplastic cells of HD8. 10% are myeloma cells: similar to plasma cells but vary in size; nuclus is eccentric; unlike normal plasma cell its nuclear chromatin does not show car-wheel pattern3. Nucleoli are present4. Cytoplasm is abundant with perinuclear halo; vacuolation and Russel bodies containing antibodies5. Variants of plasma cells: Flame cells: red cytoplasm Mott cells: contain grapelike cytoplasmic droplets

Plasma cell Myeloma cell: eccentric nucleus with halo; no cart weel

Normal Protein electrophoresis Myeloma- M spike in Gamma region8. Extra osseous:1. Atypical plasma cells in blood2. Anaemia3. Hyperviscocity of blood4. Nephrosis due to Bence-Jones proteinuria5. Polyneuropathy6. Pathologic fractures of bones7. Systemic amyloidosis myeloma proteins8. Hepato splenomegaly due to myeloma cells

Bence Jones Protein:12. Multiple myeloma cells produce excessive monoclonal proteins - M proteins, which are classified as heavy amino acid chains and light amino acid chains13. The light amino acid chains are of two types: kappa and lambda. Kappa is twice as prevalent as lambda. When detected in the urine the light chain fragments are called Bence-Jones proteins14. Light chains (molecular weight 22,000 d) are polypeptides synthesized by plasma cells and assembled with heavy chains to form the various classes of immunoglobulins, for example, immunoglobulin G (IgG), immunoglobulin M (IgM), and immunoglobulin A (IgA). 15. Plasma cells normally produce a slight excess of light chains that are either excreted or catabolized by the kidney16. 1% of myeloma are nonsecretory: no Bence-Jones proteins in urine17. Kappa light chains usually exist as monomers (22,000 d) and are therefore small enough to be filtered through the glomerulus, but they may exist as dimers. Lambda light chains usually exist as dimers (44,000 d) and, therefore, are less likely to be filtered and appear in urine. 18. Light-chain proteins appear in urine in high concentration either when the production of light-chain proteins is markedly increased or when the ability of the proximal tubules to reabsorb all the filtered protein is exceeded.19. Since mostly excreted in urine they are not present in detectable amount in blood except in renal failure.20. They on heating precipitate at 40-60 C and redissolve at higher temperature21. Causes:1. Multiple myeloma2. Plasmacytoma3. Waldenstrom macroglobulinemia22. Tests:1. 5 ml of urine is mixed with 2-3 drops of acetic acid and heated in a water bath; at 40-60C there will be cloudiness and precipitation; on further heating over 70C the precipitate dissolves and reappear when cooling below 60 C2. Serum electrophoresis demonstrates M-bandMultiple myeloma affecting kidney:1. Tumour invasion: ureteric obstruction and renal hypertension2. Hypercalcemia3. Hyperurecemia4. Amyloidosis 5. BJ proteinuria6. Glomerular diseaseMyeloma kidney (cast nephropathy)7. Myueloma kidney is one of the several renal dysfunctions due to light chain proteinuria8. Light chains bind with Tamm-Horsfall mucoprotein, which is secreted by tubular cells in ascending loop of Henle, forming casts9. Light chains can precipitate in the tubules, leading to obstructing, dense, intratubular casts in the distal and collecting tubules that may initiate a giant cell reaction 10. Multinucleated giant cells surround the casts which produces nephropathy11. Light chain proteins also have direct toxic effect on renal epithelial cells12. It may also be deposited in basement membrane to produce glomerulopathy

LABORATORY INVESTIGATION OF SUSPECTED MYELOMA5. Diagnostic triad:1. myeloma cells >10% in bone marrow2. Lytic lesions in bones3. M proteins in serum and urine 6. Serum proteins:1. Rise in total serum proteins due to paraproteinemia (M proteins or abnormal immunoglobulin e.g. Bence Jones proteins)2. Normal IgG, IgA, IgM and albumin levels are low3. Serum electrophoresis:1. Spike produced by M proteins; in the region of IgG in 50%; IgA in 25%2. Another 20 have only light chains in serum3. No M-bands in non secretary myeloma(1%)

4. Serum viscocity: Hyperviscocity in myeloma The normal reference range is 1.4-1.8 Centipoises ; >5 in myeloma Rouleaux formation is often present with increased serum viscosity.5. Hypercalcemia6. Hyperurecemia7. Urine: Bence Jones proteins are present in urine; >6 gms/dL8. Bone marrow:1. Hyper cellular2. >10% are myeloma cells: similar to plasma cells but vary in size; nuclus is eccentric; unlike normal plasma cell its nuclear chromatin does not show car-wheel pattern3. Nucleoli are present4. Cytoplasm is abundant with perinuclear halo; vacuolation and Russel bodies which contain antibodies5. Variants of plasma cells: Flame cells: red cytoplasm Mott cells: contain grapelike cytoplasmic droplets

1. Polycystic kidney disease: PKD(short notes)4. Renal parenchyma is converted into cysts of varying sizes5. Two types:1. Adult type: autosomal dominant (ADPKD)2. Infantile type: autosomal recessive (ARPKD)6. Adult type:1. Incidence 1 in 400 to 10002. PKD gene is located is in chromosome 16 and rarely in 43. Bilateral and diffuse4. Symptoms appear in 30-50 years of age5. Morphology:1. Bilaterally enlarged; lobulated; may weigh up to 4 kg2. Cut surface show cysts in different size; contain straw yellow to reddish brown material3. Renal pelvis is distorted by cysts; do not communicate with each other( contrast to hydronephrosis)6. Histology:1. Cysts are parts of nephrons2. Epithelial lining of cysts are that tubules3. Parts of glomerulus could be recognized among the cysts4. Intervening normal renal parenchyma may be seen5. Acquired inflammation due to pyelonephritis, nephrosclerosis etc may be seen

7. Clinical:1. Manifest in 30-50 years of age2. Presents as hematuria and renal pain3. Hypertension is common4. Associated cystic changes in liver, panctreas and spleen etc may be present5. Berry aneurysm of circle of Willis present in 15%6. Acquired infections may further damage the kidney2. Infantile type:9. Autosomal recessive10. 1 in 20,000 incidence11. Mutation in chromosome 6-6p-2112. Bilateral13. Manifest at birth and renal failure in early childhood14. Morphology:1. Bilateral enlargement2. Smooth surface and shape not distorted3. Cut surface: small cysts extend radially to cortex; mostly normal parenchyma; pelvis and ureters normal15. Histology:1. Total no of nephrons are normal2. Sponge like cysts develop from collecting tubules and show cylindrical and secular dilatation lined by cuboidal or columnar epithelium3. Many glomeruli undergo cystic dilatation

16. Clinical:1. Gross enlargement may interfere normal delivery2. Renal failure occurs early3. Associated cystic disease in liver may lead to congenital fibrosis, portal hypertension and splenomegaly 4. Severely affected infants are often born with pulmonary hypoplasia and suffer from respiratory compromise

Glomerulonephritis

Glomerulonephritis (Bright disease; nephritic syndrome)1.Definition:Renal diseases in which an immunologic mechanism triggers inflammation and proliferation of glomerular tissue that can result in damage to the basement membrane, mesangium, or capillary endothelium.2.Classification:1. Primary: 10. Acute:1. Post streptococcal2. Non streptococcal11. Rapidly progressive12. Minimal change disease13. Membranous14. Membrano proliferative15. Focal proliferative16. Focal segmental glomerulosclerosis17. IgA nephropathy18. Chronic GN2. Secondary: 10. SLE11. Diabetic nephropathy12. Amyloid nephropathy13. Polyarteritis nodosa14. Wageners granulomatosis15. Goodpasture syndrome16. Henoch-Schonlein purpura17. Systemic infection: Bacterial endocarditis; Falciform malaria etc18. Idiopathic mixed cryoglobulinemia4. Hereditary nephritis:1. Alports syndrome2. Fabrys disease3. Nail-patella syndrome3.Etiopathogenesis of post streptococcal glomerulonephritis (PSGN):10. Glomeruli consists of: endothelium, epithelium,mesangium and basement membrane(GBM)11. Acute glomerulonephritis follows infection with certain strains of group A beta-hemolytic streptococci (GABS). The ones that produce a clear zone of hemolysis around the colony are called beta hemolytic streptococci; 12. GABS contain M, T and R proteins. Of these, the M protein is the nephritogenic antigen. It is located in the bacterial cell wall 13. Among the M types, commonly identified nephritogenic strains are 12,4,1 14. It follows mostly skin infection but can also occur after throat infection with nephritogenic strains 15. Evidence: 1. Low serum complement (C3) levels in the acute phase 2. High serum levels of antibodies to streptococcal antigens3. Electron microscopy reveals lumpy-bumpy deposits on glomerular membrane and in mesangium16. Immune-mediated renal injury is a result of renal deposition of circulating immune complexes or due to their in-situ formation or both17. Glomerular inflammation follows which leads to complement (C3) activation by classic or more probably alternate pathway 18. The immune complexes are deposited in the glomerulus produce structural and functional changes by destruction of basement membrane and accumulation of inflammatory cellsPathology:5. Morphology:1. Kidneys enlarge symmetrically2. Petichial hemorrhages on the cortical surface give flea-bitten appearance6. Light microscopy:1. Glomeruli: Enlarged and hypercellular glomeruli Proliferation of mesangial, endothelial and occasionally epithelial cells Infiltration of polymorphs and sometimes monocytes2. Tubule: Deposition of fibrin in tubular lumen and mesangium RBCs in tubular lumen3. Interstitium: Edema and leukocytic infiltration in renal interstitium4. Vessels: No changes in blood vessels

7. Clinical:1. Age incidence is 5-12 years2. Symptoms develop 1-2 week following streptococcal infection3. Oliguria and smoky urine4. Edema is the most frequent manifesting symptom5. Gross hematuria occurs at onset6. Hypertension is the third cardinal feature7. Salt and water retention 8. Complications:1. CCF2. Hypertensive encephalopathy3. Acute renal failure4. Progressive glomerulonephritis9. Prognosis:1. Complete recovery if there are no complications8. Lab Diagnosis:Urine 1. Urine output most is often reduced 2. proteinuria 3. Hematuria 4. Polymorphonuclear leukocytes and renal epithelial cells 5. Hyaline and/or cellular casts are almost always present.6. RBC casts have been found in 60-85% Streptococcal infection 4. Cultures from either the pharynx or skin may be positive 5. ASO, AH, anti-DNase B are positive6. An ASO titter of 250 U or higher is highly suggestive of recent streptococcal infection.Complement 2. The concentration of C3 has been found to be decreased in more than 90% of patients Renal 4. The elevation in the serum concentrations of creatinine and BUN is usually modest, although some patients may have severe azotemia (Blood urea nitrogen) at onset.5. The electrolyte profile is usually normal;6. Hyperkalemia and metabolic acidosis are in patients with significant renal functional impairment. The same applies to hyperphosphatemia.Blood 3. A mild anemia (normocytic, normochromic) is 4. WBC and platelet counts are usually normal, although an occasional patient exhibits a leukocytosis; rarely, a mild thrombocytopenia may be present.

Short notes:4. Definition: Primary glomerular diseases are disorders in which the kidneys are the only or predominant organ involved 5. Examples of Primary glomerular disease:1. Post streptococcal GN2. Cresentric GN3. Membranous glomerulopathy4. Focal segmental glomerulosclerosis5. Memranoproliferative GN6. IgA nephropathy7. Chronic GN6. Classification of types of glomerular disease:1. Antibody mediated : Three forms of antibody mediated injuries:1. In situ immune complex deposition: 1. Fixed or in situ : Intrinsic glomerular antigens2. Planted: Antigens planted within the glomerulus 2. Circulating antigen antibody complexes: 1. Endogenous: b. DNA, tumor antigens2. Exogenous:Infectious products 3. Cytotoxic antibodies 2. Cell mediated 3. Alternate complement pathway

Normal Post streptococcal

Membranous

4.In situ Immune complex disease5. Fixed or in situ immune complex: Anti GBM antibody induced nephritis: two experimental models: iii. Masugi model;a. Antibodies are formed against antigens which are normal components of GBMb. Diffuse linear pattern of immune complex deposition along GBMc. 5% of Nephritis belong to this modeld. Eg: Good pasture syndrome iv. Heymann model:a. Antibodies react with antigens in the basal surface of visceral epithelial cellsb. This is followed by complement activationc. Immune complexes are formed and deposited along the sub epithelial aspect of basement membrane in a granular patternd. Eg: membranous glomerulonephritis6. Planted antigen antibody complex:i. Bacterial, viral and parasitic products and other such antigens may get deposited in glomerulus ii. Antibodies bind to these antigens and induce complement activation leading to immune complex formation and glomerular inflammation.iii. Eg. Post streptococcal GN7. Circulating antigen antibody complexes: i. Endogenous: eg: SLEi. Antigen from host tissue form antibody complexes and then get trapped in glomeruliii. Complements are activatediii. Glomerular injury occursiv. Eg: nephritis in SLEii. Exogenous:i. Antigens are formed against infections like streptococci, Hepatitis B, Treponema, Plasmodium etcii. Trapped in glomeruli followed by inflammationiii. Eg: Nephritis associated with streptococci, Hepatitis B, Treponema, Plasmodium etc8. Cytotoxic antibodies:i. Glomerular cells themselves may act as antigensii. Antibodies develop and immune complexes are formediii. Injury is caused by cytotoxic mechanism5. Cell mediated injury:iv. T cells get sensitized and together with activated macrophages can cause glomerular injuryv. Cytokines and other mediators from T cells are responsible for this cytotoxic injuryvi. Example: pauci-immune glomerulonephritis6. Alternate complement pathway:7. The normal complement system consists of the classic and alternative pathways. The classic pathway is activated by the interaction of C1 with an antigen-antibody complex. This interaction results in the formation of C4b2a, which is the classic pathway C3b convertase. The alternative pathway utilizes C3 and factors B and D to form the alternative pathway convertase C3b,Bb.8. Mainly Complement- 3 contributes to this type of injury9. Immune complexes are found in the mesangium and subendothelial spaces, and they trigger complement activation and the release of cytokines and chemokines. The release of inflammatory mediators causes an influx of inflammatory cells and leads to mesangial and endothelial cell proliferation. 10. Example : Memranoproliferative glomerulonephritis7. Mediators of glomerular injury:11. Cells:1. Neutrophils and monocytes: release proteases which cause GBM degradation;2. Macrophages and T lymphocytes and NK cells: produce variety of lymphokines and other mediators3. Platelets: release eicosanoids and growth factors4. Mesangial cells: release cytokines, chemokines, eicosanoids and growth factors etc12. Soluble mediators:1. Formation of C5b-C9 causes cell lysis2. Interleukin-1 and TNF produce leukocyte adhesion and other effects3. Fibrin leaks into Bowmans space and induce crescent formation4. Plasminogen activator inhibitors induce thrombosis and fibrosis 8.Glomerular localization of antigen antibody complexes:4. Immune complexes get deposited in mesangium, subenotheilal space, sub epithelial space5. The deposits may be granular or diffuse linear pattern6. Localization depends on molecular charge: 1. anionic : sub endothelial2. cationic: sub epithelial3. neutral: mesangium9. The injury process due to antigen antibody complexes:3. There are histologic and functional changes4. Histologic:1. Histologic changes may be diffuse, global or segmental or masangial2. Leukocytic infiltration at the site and hypercellularity3. Proliferation of measangial and epithelial cells4. Formation of crescent5. Basement membrane thickening6. Hyalinization and sclerosis10 . Functional changes:4. Proteinuria5. Hematuria 6. Renal failure

Short notes:

Synonym: rapidly progressive glomerulonephritis:5. Definition: 1. A syndrome of severe glomerular injury2. Does not denote any specific etiology3. Rapid and progressive loss of renal function4. Classic histology is presence of crescents in most glomeruli;6. Classification:1. Group I:1. Anti GBM antibody induced glomerulonephritis2. Linear deposits of Ig.G and C3 in GBM3. In some similar lesions in lungs (Good pasture syndrome)2. Group II:1. Immune complex mediated disease2. Granular pattern of immune complex deposits3. Eg. Post infectious, SLE, IgA, Henoch-Schonlein nephropathies3. Group III:1. Pauci immune type2. No immune complex or anti GBM antibody deposits3. Antineutrophil cytoplsamic or perinuclear antibodies are present in serum4. Mostly idiopathic5. Probably a manifestation of small vessel vasculitis limited to glomerulus 7. Pathology:1. Kidneys are enlarged, pale with petichiae2. Crescents are present in Bowman capsule; they are formed by proliferation of parie