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Flashcards in Pathology Deck (25)
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1

arteriosclerosis

•general term encompassing three forms of arterial disease •general categories -atherosclerosis -arteriosclerosis -Monkeberg medial calcific sclerosis

2

vessels affected by atherosclerosis

•large and medium sized muscular arteries and elastic arteries

3

atherosclerotic plaques

•characterized by atheromatous plaques (atheromas) -fatty lesions involving the intima •pathogenesis "response to injury" - endothelial injury/dysfunction due to 1. hemodynamic disturbance 2. cholesterol -smooth muscle proliferation and migration into intima -macrophage proliferation and migration into intima

4

risk factors for atherosclerosis

•risk factors: -genetic abnormalities (LDL receptor gene mutations) -family history -increasing age -male -hyperlipidemia -hypertension -smoking -diabetes -inflammation (plasma CRP levels)

5

clinical manifestations of atherosclerosis

•elastic arteries (aorta) -thrombosis -embolism -aneurysm -rupture -obstruction •muscular arteries (coronary) -obstruction (stenosis) -ischemia -infarction

6

arteriosclerosis

•disease of arterioles 1. hyaline arteriosclerosis -bland accumulation of hyaline material in walls of arterioles 2. hyperplastic arteriosclerosis -narrowing of lumen by proliferating fibroblasts and smooth muscle cells in an onionskin lamellar pattern •elderly patients or younger hypertensive or diabetic patients

7

Monckeberg Medial Calcific Sclerosis

•small to medium sized arteries •calcification of the media (femoral, tibial, radial, ulnar arteries and arteries of soft tissue around neck) •>50yo, no gender predilection, usually clinically unimportant, but in rare cases may produce ischemia and necrosis of affected tissues

8

aneurysms

•abnormal localized dilation of a tubular structure (beyond its expected borders) •etiologies -atherosclerosis (abdominal aorta) -congenital (berry) -infection ("mycotic", eg syphilitic of ascending aorta) -structural abnormalities (medial degeneration) -vasculitis

9

atherosclerotic aneurysms

•abdominal aorta- below renal arteries but above bifurcation of iliac arteries •complications -rupture with massive hemorrhage - sudden death! -compression of adjacent sturctures -occlusion of arterial branches, esp. renal -embolism from mural thrombus with ischemia or infarction of distal extremities •prognosis related to size - 50% of aneurysms >6 cm eventually rupture

10

syphilitic aneurysms

•ascending aorta •may extend proximally to produce aortic valve annular dilatation and regurgitation •lymphocytic/plasma cell inflammatory reaction principally of aortic adventitia with occlusion of vas vasorum (ischemic injury to media) •clinical symptoms mainly due to compression of adjacent thoracic structures

11

dissecting aneurysms

•characterized by dissection of blood along a plane of cleavage through media of aortic wall (usually within the outer third of the media) and formation of a hematoma in the dissection tract •40-60 yo, males>females, hypertension, congenitally bicuspid aortic valve (ascending aortic aortopathy), aortitis, medial degeneration, or other causes of aortic weakness (Marfans, E-D, Loeys-Dietz) •clinical features -chest pain -occlusion of arterial branches of aorta -aortic valve regurgitation -rupture with hemorrhage into pericardial sac, thorax or retroperitoneum - sudden death!

12

proposed mechanism of dissecting aneurysm

1. weakened media allows intima to "buckle" into lumen 2. pressure wave of blood under systemic arterial pressure (amplification in hypertension) impacts on bulging intima to produce intimal tear 3. blood dissects through intimal teear into media, and elevated BP (hypertension) promotes dissection along weakened media

13

vasculitis

•inflammation of vessel, causing medial injury •common causes -autoimmune diseases and infections •uncommon causes -radiation therapy and toxic substances •generally involves arteries (arteritis) but also affects veins and capillaries (venulitis and capillaritis) •many different clinical syndromes asscociated

14

Giant Cell Arteritis

•temporal arteritis (inaccurate as other large arteries - aorta- can also be involved) •females>males •clinical signs/symptoms -headache -tenderness over artery -visual disturbances (sometimes with acute blindness in ipsilateral eye) -facial pain •diagnostic testing -ESR frequently elevated -temporal artery biopsy (1/3 are falsely negative)

15

Polyarteritis Nodosa

•fibrinoid necrosis and acute inflammation of medium sized muscular arteries, often involving multiple organ systems •clinical signs/symptoms -young adults to middle aged -renal failure (if kidney) -abdominal pain and GI bleeding (if GI tract) -peripheral neuropathy (if nerves) -etc... •diagnosis usually involves biopsy of affected organ (sural nerve if neuropathy)

16

Granulomatosis with Polyangiitis (PGA)

•Wegener granulomatosis •small arteries, arterioles, and/or capillaries 1. acute necrotizing granulomas of nose, sinuses, and upper airways 2. granulomatous arteritis or capillaritis of lung 3. glomerulonephritis •clinical signs/symptoms -middle aged -males > females -inflitrates or masses in lungs -sinusitis -ulceration of nasopharyngeal mucous membranes -renal abnormalities (hematuria, renal failure) •diagnosis -nasal or sinus biopsies -lung, renal biopsy -lab testing for anti-neutrophil cytoplasmic bodies (ANCA)

17

A 56-year-old man complains of shortness of breath, tiredness, and decreasing exercise tolerance. A cardiac exam leads to more tests, culminating in open-heart surgery and excision of the aortic valve. This specimen is sent to Pathology.

A. What is the diagnosis?

B. What 4 gross findings are the basis for this diagnosis?

C. How common is this disease?

D. What is the most common hemodynamic abnormality?

E. What are the most common consequences of this disease (if unoperated)?

A. aortic valve stenosis, failure of separation of leaflets

B. fusion of leaflets, calcifications

C. 1-2 %

D. stenosis

E. LVH, left ventricular dilation --> HF, endocarditis, sudden death

18

An 83-year-old man complains of vague chest pain and dyspnea on exertion. Imaging shows a calcified aortic valve and normal coronary arteries. He is hypertensive. This aortic valve is resected and sent to Pathology.

A. What is your diagnosis?

B. What 4 gross findings are the basis of this diagnosis?

C. What is the most common hemodynamic abnormality?

D. What are common consequences (if unoperated)?

E. What 2 main prosthetic valve options are available?

F. What complications occur with these 2 valve types?

A. degenerative calcific aortic stenosis

B. 3 leaflets- calcifications at base, no fusion o fleaflets, not much fibrosis

C. sortic stenosis

D. endocarditis, LVH --> HF, sudden death

19

A 60-year-old man develops heart failure; he has had mitral valve disease for many years. A murmur is obvious. The mitral valve is surgically excised and sent to Pathology.

A. What is the diagnosis?

B. What 3 gross findings are the basis of this diagnosis?

C. What is the most likely cause of his valve disease?

D. What is the most common hemodynamic abnormality?

E. What are common consequences (if unoperated)?

A. post inflammatory mitral valve damage

B. fish mouth, fusin, fibrosis, thickening, calcification

C. chronic rheumatic heart disease

D. mitral stenosis

E. left atrium dilation, LV is fine!, atrial fibrillation - arrhythmias, thrombus --> embolus

20

A 35-year-old woman and known heroin addict presents to the emergency department with a 3-week history of fever and chills with increasing dyspnea. A holosystolic murmur is noted at the left upper sternal border. The tricuspid valve is eventually surgically excised.

A. What is the diagnosis?

B. What 3 gross findings are the basis of this diagnosis?

C. What is the most common hemodynamic abnormality?

D. Name 3 general complications of this disease:

E. What is the etiology of this disease?

A. infectious endocarditis

B. vegetations, ruptured chordae, holes

C. tricuspid regurgitation

D. septic embolus, immune complex disease --> glomerulonephritis, ring abscess

E. bacteria ---> bloodstream (infection soemwhere else or IV drug use)

21

A 66-year-old diabetic man with no history of cardiac or respiratory disease is found dead in bed by his spouse. He had smoked 2 packs of cigarettes a day for 40 years. An autopsy is performed, and cross sections of the right coronary artery are examined.

A. What is the diagnosis?

B. What 2 gross findings are the basis of this diagnosis?

C. Name 4 possible acute consequences of this disease:

D. Name 4 treatment options for this disease:

A. coronary artery disease

B. thrombus, plaque --> atherosclerosis --> stenosis

C. MI, arrhythmias, angina - unstable, sudden death

D. angioplasty, thrombolytic therapy, stent, bypass

22

A 75-year-old woman is undergoing intestinal surgery for colon cancer. She recalls having a “heart attack” several decades ago but is unclear on the details. She dies suddenly on post-op day 3. An autopsy is performed, and cross sections through the two ventricles are examined.

A. What is the diagnosis?

B. What 3 gross findings are the basis of this diagnosis?

C. Name 7 potential consequences or outcomes:

D. What 2 other cardiac abnormalities are likely present?

A. remote MI

B. fibrosis - old MI --> thinnning of wall, dilation

C. arrhythmia, systolic dysfunction, aneurysm, chronic regurgitation --> dilated LA --> thromus --> emboli, sudden death

D. coronary atherosclerosis, mitral insufficiency

23

A 19-year-old man with no previous medical history collapses suddenly on the basketball court and dies, despite aggressive resuscitation attempts. Interestingly, the man’s uncle died in his early 20s under similar circumstances. An autopsy is performed.

A. What is the diagnosis? 

B. What gross finding is the basis for this diagnosis?

C. Name 3 consequences of this disease:

D. What percentage of cases are due to a genetic abnormality?

E. In familial cases, what is the most common inheritance pattern, and what genes most commonly harbor mutations?

A. hypertrophic cardiomyopathy

B. septal hypertrophy - asymmetric, LVH

C. HF, exercise intolerance, sudden death

D. 100%, though not all are inherited - about 50/50

E. autosomal dominant, penetrance varies, all affect sarcomeres

24

An 80-year-old woman complains of abdominal pain. A large mass is palpated in the abdomen. Exploratory surgery is planned, but the patient collapses and dies while waiting. An autopsy is performed, and the abdominal aorta is examined.

A. What is the diagnosis?

B. What is the etiology of this disease?

C. What segment of the aorta is most commonly involved?

D. What is the likely terminal event?

E. Should all cases of this disease detected in living patients be removed surgically? Why or why not?

A. AAA

B. atherosclerosis

C. below renal arteries

D. ruptures

E. >5 cm, rapidli increasing in size, other symptoms

25

A 67 year old man with no prior medical history develops sudden severe chest/upper abdominal pain 1 hour after eating a very fatty meal. Acute cholecystitis is suspected. While waiting for imaging studies, he suddenly dies. An autopsy is performed, and the heart is examined.

A. What is the diagnosis?

B. What 3 findings are the basis for this diagnosis?

C. What is the likely physiologic mechanism of death?

D. Name 3 diseases that this clinical presentation mimics:

E. If the patient were 31 years old, what is the most common genetic disease that should be considered?

A. aortic dissection - tear #1, cardiac tamponade - tear #2

B. tear #1: intima, into media LVH  tear #2: into pericardial sac

C. hypertension

D. MI, GERD, choleocystitis

E. Marfan's