Escolar Documentos
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Anatomical Pathology
1) Describe the gross & microscopic features of sarcoidosis & TB.
SARCOIDOSIS
Sarcoidosis is a multisystem disease of unknown etiology characterized by
noncaseating granulomas in many tissues and organs.
Microscopic:
The diagnostic histopathologic feature of sarcoidosis is the noncaseating
epithelioid granuloma, irrespective of the organ involved. This is a discrete,
compact collection of epithelioid cells rimmed by an outer zone of largely CD4+ T
cells. The epithelioid cells are derived from macrophages and are characterized by
abundant eosinophilic cytoplasm and vesicular nuclei. It is not uncommon to see
intermixed multinucleate giant cells formed by fusion of macrophages.
A thin layer of laminated fibroblasts is present peripheral to the granuloma; over
time, these proliferate and lay down collagen that replaces the entire granuloma
with a
hyalinized scar.
Two other microscopic features are sometimes seen in the granulomas: (1)
Schaumann bodies, laminated concretions composed of calcium and proteins;
and (2) asteroid bodies, stellate inclusions enclosed within giant cells. Their
presence is not required for diagnosis of sarcoidosisthey also may occur in
granulomas of other origins. Rarely, foci of central necrosis may be present in
sarcoid granulomas, suggesting an infectious process. Caseation necrosis typical
of tuberculosis is absent.
Gross:
The lungs are involved at some stage of the disease in 90% of patients. The
granulomas predominantly involve the interstitium rather than air spaces, with
some tendency to localize in the connective tissue around bronchioles and
pulmonary venules and in the pleura (lymphangitic distribution). The
bronchoalveolar lavage fluid contains abundant CD4+ T cells. In 5% to 15% of
patients, the granulomas eventually are replaced by diffuse interstitial fibrosis,
resulting in a so-called honeycomb lung.
Intrathoracic hilar and paratracheal lymph nodes are enlarged in 75% to 90%
of patients, while a third present with peripheral lymphadenopathy. The nodes are
characteristically painless and have a firm, rubbery texture. Unlike in tuberculosis,
lymph nodes in sarcoidosis are nonmatted (nonadherent) and do not ulcerate.
Skin lesions are encountered in approximately 25% of patients. Erythema
nodosum, the hallmark of acute sarcoidosis, consists of raised, red, tender
nodules on the anterior aspects of the legs. Sarcoidal granulomas are uncommon
in these lesions. By contrast, discrete painless subcutaneous nodules can also
occur in sarcoidosis, and these usually reveal abundant noncaseating granulomas.
Involvement of the eye and lacrimal glands occurs in about one fifth to
one half of patients.
TUBERCULOSIS
Tuberculosis is a communicable chronic granulomatous disease caused by
Mycobacterium tuberculosis. It usually involves the lungs but may affect any organ
or tissue in the body. Typically, the centers of tubercular granulomas undergo
caseous necrosis.
Microscopic:
Gross:
Morphology of Granulomas
Sarcoid Granuloma
Small granulomas that mostly consists of epitheloid cells. No necrotizing
center, but fibrosis may be present. The outer layer consists mostly of
collagen. Sarcoid granulomas can occure in:
Sarcoidosis.
Crohn`s disease.
Berylliosis.
Extrinsic Allergic Alveolitis.
Primary Billiary Cirrhosis.
Tuberculous Granuloma
Pseudotuberculous Granuloma
As the name implies, they are quite similar to tuberculous granulomas.
They are ill-defined granulomas consisting of macrophages and epitheloid
cells. Granulocytes (mostly neutrophils) are present in the caseous core.
They may form abscesses. Pseudotuberculous granulomas can occure in:
Yersinia Pseudotuberculosis.
Brucellosis.
Listeriosis.
Histoplasmosis.
Cryptococcosis.
Typhoid fever.
Rheumatic Granuloma
A granuloma with specialized macrophages (called Anitchov cells) around a
core of fibrinoid collagen necrosis. Aschoff cells (a variant of giant cells) are
interspersed between the other cells, while lymphocytes make up the outer
layer. Rheumatic granulomas mostly occure in myocardium and only in
rheumatic fever.
Rheumatoid Granuloma
A granuloma with a core of fibrinoid collagen necrosis, surrounded by a wall
of epitheloid cells. Several centimeters in diameter. Lymphocytes are
present in the outer layer. Often occuring in multiple subcutaneous
locations and articular nocules in rheumatoid arthritis.
Foreign-Body Granuloma
A granuloma with epitheloid cells surrounding a material that cannot be
broken down, or that provides large enough difficulties in doing so. The
foreign body is surrounded by epitheloid cells and giant cells. The outer
layer consists of lymphocytes, fibroblasts and vessels.
Bilateral hilar lymph node enlargement can arise from many causes which include:
sarcoidosis
infection
o tuberculosis
o mycoplasma
o histoplasmosis
o coccidiodomycosis
malignancy
o lymphoma - more common on hodgkin lymphoma than non-hodgkin
lymphoma.
o carcinoma -
inorganic dust disease
o silicosis
o berylliosis
Pharm
6) Describe the mechanism of action of trimethoprim/Sulfamethoxazole.
(toxicity, interaction, side effects)
7) How is TB treated?
Public Health
8) List the risk factors for TB and sarcoidosis
Risk Factors
TB Sarcoidosis
Weakened immune Age and sex. Sarcoidosis often
system occurs between the ages of 20
Has health problems that and 40. Women are slightly more
make it hard for the body to likely to develop the disease.
fight bacteria:
o HIV/AIDS
o Diabetes
o End-stage kidney disease
o Certain cancers
o Cancer treatment, such as
chemotherapy
o Drugs to prevent rejection of
transplanted organs
o Some drugs used to treat
rheumatoid arthritis, Crohn's
disease and psoriasis
o Malnutrition
o Very young or advanced age
Traveling or living in
certain areas. The risk of
contracting tuberculosis is
higher for people who live in
or travel to countries that
have high rates of
tuberculosis and drug-
resistant tuberculosis, such
as:
Sub-Saharan Africa, India,
China, Russia, Pakistan
MicroB
11) How is TB cultured? (special conditions & media)
There are four specimen collection methods for pulmonary TB disease (Table
4.2):
Coughing
Induced sputum
Bronchoscopy
Gastric aspiration
Chem Path
12) What is the significance of the FEV1/FVC ratio? (Give the normal
values)
FVC (Forced Vital Capacity) -- This is the total volume of air expired after
a full inspiration. Patients with obstructive lung disease usually have a normal or
only slightly decreased vital capacity. Patients with restrictive lung disease have
a decreased vital capacity.
FEV1 (Forced Expiratory Volume in 1 Second) -- This is the volume of air
expired in the first second during maximal expiratory effort. The FEV1 is
reduced in both obstructive and restrictive lung disease. The FEV1 is reduced in
obstructive lung disease because of increased airway resistance. It is reduced in
restrictive lung disease because of the low vital capacity.
FEV1/FVC -- This is the percentage of the vital capacity which is expired in
the first second of maximal expiration.
In healthy patients the FEV1/FVC is usually around 80%.
In patients with obstructive lung disease FEV1/FVC decreases and can
be as low as 20-30% in severe obstructive airway disease.
Restrictive disorders have a near normal, or even increased, FEV1/FVC.
Immunology
14) Describe the immune response to TB and Sarcoidosis.
Haematology
15) Review CBS (I dont think we need to present this, it was just mentioned).
16) Review Arterial Blood Gases.