1. Left ventricular hypertrophy. The common causes of left ventricular hypertrophy are:
Systemic hypertension.
Aortic stenosis and insufficiency.
Mitral insufficiency.
Coarctation of the aorta.
Occlusive coronary artery disease.
Congenital anomalies like septal defects and patent ductus arteriosus.
Conditions with increased cardiac output: thyrotoxicosis, anemia, and arteriovenous fistulae.
2. Right ventricular hypertrophy. Most of the causes of right ventricular hypertrophy are due to pulmonary arterial hypertension. These are:
Pulmonary stenosis and insufficiency.
Tricuspid insufficiency.
Mitral stenosis and/or insufficiency.
Chronic lung diseases: chronic emphysema, bronchiectasis, pneumoconiosis, pulmonary vascular diseases, etc.
Left ventricular hypertrophy.
Compensatory dilation. Quite often, hypertrophy of the heart is accompanied by cardiac dilation.
Causes:
Valvular insufficiency (mitral and/or aortic insufficiency in left ventricular dilatation, tricuspid and/or pulmonary insufficiency in right ventricular dilatation).
Conditions with high cardiac output e.g. thyrotoxicosis, arteriovenous shunt.
Myocardial diseases: cardiomyopathies, myocarditis.
Systemic hypertension.
Hypertrophy of the myocardium without dilatation is referred to as concentric, and when associated with dilatation is called eccentric. The weight of the heart is increased above the normal, often over 500 gm.
Macroscopically, the thickness of the left ventricular wall above 15 mm is indicative of significant hypertrophy. In concentric hypertrophy, the lumen of the chamber is smaller than usual, while in eccentric hypertrophy the lumen is dilated. In pure hypertrophy, the papillary muscles and trabeculae cameae are rounded and enlarged, while in hypertrophy with dilatation these are flattened.
Microscopically, there is increase in size of individual muscle fibres. There may be multiple minute foci of degenerative changes and necrosis in the hypertrophied myocardium.
RHEUMATIC DISEASES
Rheumatic diseases are group of collagen or systemic connective tissue diseases including rheumatic fever, rheumatoid arthritis, systemic lupus erythematosus, scleroderma, dermatomyositis and polyarteriitis nodosa, and Bechterew’s disease.
They are characterized by affect of collagen or connective tissue due to disturbances of immune homeostasis.
Disturbances of immune homeostasis, development of autoimmune reactions, formation of the toxic immune complexes and sensibilizated cells, injury of microcirculation with following systemic progressive disorganization of connective tissue are main links of pathogenesis of rheumatic diseases.
General characteristic of rheumatic diseases
Presence of chronic infectious focus.
Presence of early systemic changes of microcirculation.
Presence of hypersensitivity of immediate type with development of exudative – necrotic reactions and hypersensitivity of delayed type with formation cellular infiltration.
Systemic progressive disorganization of connective tissue includes mucoid swelling, fibrinoid changes, cellular reactions, sclerosis. Combination of different phases of connective tissue disorganization, which indicates the chronic character of the diseases.
Chronic recurrent diseases with alternation of periods of exacerbation and remission
Genetic and environmental factors are important for development of these diseases. Thus, rheumatic arthritis has less severe course in the residents of Africa than in those of Europe, Lupus erythematosus is more frequent in Europian countries and USA than in Great Britain.
RHEUMATIC FEVER (RF) and RHEUMATIC HEART DISEASE (RHD)
RF is an acute, inflammatory, recurrent disease mainly of children (ages 5 to 15) that typically occurs 1 to 5 weeks after a group A streptococcal infection (usually sore throat).
Acute RF occurs after the infection with beta-hemolytic streptococci group A. The various manifestations of the disease in the heart and other regions of the body, excluding the initial infection (tonsillitis, nasopharyngitis), are not the result of a direct infection.
Most evidence suggests is secondary to host antistreptococcal antibodies that are cross-reactive to cardiac antigens, but microbe initiated autoimmune reactivity is not ruled out.
Rheumatic Fever is thus a disease that involves many regions of the body, but it is not serious import to the patient unless it involves the heart. It has been said, “rheumatic fever licks the joints but bits the heart”.
Death is rare during acute RF, being secondary usually to the myocarditis. Typically, the myocarditis and arthritis are transient and largely resolve, but the valvular involement may lead to deformed, scarred valves with permanent dysfunction (chronic RHD) and subsequent CHF.
Chronic RHD is more likely to occur when the first attack is in early childhood, when the first bout of RF is severe, or with recurrent attacks.
Diagnosis rests on the clinical history and the presence of five major (Jones) criteria:
Erythema marginatum. Seen in children more often than adults. There is specific skin “rush”, typically in a bathing suit distribution, macular lesions with erythematous rims and central clearing.
Sydenhams chorea. A neurologic disorder with rapid, involuntary, purposeless movements.
Carditis. It may be myo-, endo-, or pericarditis.
Subcutaneos nodules. Seen in children more often than adults. Histologically, giant Aschoff bodies are noted.
Migratory large joint polyarthritis.
Minor criteria:
1. Fever.
2. Arthralgia.
3. Longer PR interval in the ECG.
4. Leukocytosis.
Also may develop:
Rheumatic glomerulonephritis, rheumatic pneumonia is visceral changes.
Hyperplasia of lymphatic tissue, marked plasmatization is observed in the immune system.
Rheumatic vasculitis with fibrinoid changes of the walls. In the capillaries, there is endothelium proliferation followed by desquamation, so-called rheumatic endotheliosis. Vascular permeability increases sharply. The disease results in vascular sclerosis (arteriolosclerosis, arteriosclerosis, capillarosclerosis).
Pathogenesis and Morphology of RF
A widely accepted concept of the nature of RF is that it is one of the so-called immune disorders of connective tissue, the principal lesions being in the connective tissues throughout the body, especially in the heart. RF has four stages.
Mucoid swelling. In the early phase of development of the lesions, edema of the connective tissues is associated with an increase of mucopolysaccharide. The collagen fibers are pushed apart by the accumulating of basophilic ground substance, and subsequently they undergo swelling, fraying, fragmentation, and disintegration.
Fibrinoid changes. The affected areas, including collagen fibers and the ground substance, are altered considerably and take on a deeply eosinophilic appearance resembling fibrin; thus, the change is referred to as fibrinoid degeneration or necrosis.
Cellular reactions. The early exudative and degenerative features are followed by proliferation, that is, an infiltration by lymphocytes, plasma cells, histiocytes, and fibroblasts. The most distinctive proliferative lesion is the granulematous phase of the Aschoff body.
Sclerosis. Aschoff bodies or diffuse inflammatory cellular infiltration are slowly replaced by fibrous scar mainly about the vessels.
Pathognomonic focal inflammatory nodules called Aschoff bodies are the most characteristic in the heart, but similar lesions may occur elsewhere. Three phases or stages in the development of the Aschoff body are recognized:
Early (exudative, degenerative, or alterative) phase. These constitute foci of fibrinoid necrosis, initially surrounded by lymphocytes, macrophages and a few plasma cells. The early phase of the life cycle of the Aschoff body occur up to the fourth week of acute RF.
Intermediate (proliferative or granulematous) phase. In the intermediate phase, which is evident during the fourth to the thirteenth week of the disease, cellular proliferation is the dominant feature. Distinctive plump histiocytes (Aschoff or Anitschkow cells), some of which are multinucleated (Aschoff multinucleated giant cells with abundant basophilic cytoplasm), appear in periphery of nodules. Anitschkow cells are mononuclear cells. They have a moderate amount of faintly stained cytoplasm with vaguely defined borders. Their nuclei are large and vesicular and contain a prominent central chromatin mass that longitudinal section is serrated (caterpillar-like). In cross section a halo is observed about the chromatin bar so that the nucleus has an “owl-eye” appearance.
Late (senescent, fibrous, healing, or healed) phase. In 3 to 4 months, the healing phase is reached, characterized by regression and fibrosis of the nodule. The collagenous fibers fuse to form dense collagenous bindles, resulting in small scars between the muscle bundles, frequently perivascularly.
Clinical-anatomical forms of Rheumatic Fever:
Cardiovascular form occurs endocarditis, myocarditis, pericarditis.
Polyarthritic form occurs migratory large joint polyarthritis (knee, cubital, humeral, hip joint, ankle-joint). It is characterized by serous or serous-fibrinous inflammation. In the synovial membrane the mucoid swelling develops. Articular cartilage is safe, therefore deformation and ankylosis is absent.
Nodular (nodules around vessels) form occurs deposition of giant Aschoff bodies under skin and may develop perivascular sclerosis.
Cerebral form occurs chorea. The damage of the brain is connected with rheumatic vasculitis. Nervous cells degeneration, brain destruction and hemorrhages occur in the brain. If these changes are clearly marked, they may cause chorea minor (in children).
Cardiovascular form
The cardiac involvement in RF is that of a pancarditis; that is, there is endocarditis, myocarditis, and pericarditis.
Endocarditis (valvulitis)
The most prominent changes develop in mitral and aortic valves. Lesions may also be present on the chordae tendineae, particularly at their attachment to the leaflets, and are rarely on the papillary muscles of the left ventricle.
According to A.I. Abrikosov, valvular endocarditis is classified as follows:
Diffuse or valvulitis. In the active acute stage of the disease the valve leaflets or cusps are thickened and lose their transparency. Edema with swelling of the leaflet, an increased number of capillaries, and an infiltration by lymphocytes and occasionally by neutrophils are seen. Plasma cells and fibroblasts may be present. In some instances, this nonspecific inflammatory reaction may be all that occurs. Usually, however, there is also an increase in acid mucopolysaccharide, with alteration of collagen and the fibrinoid change near the surface of the valve and with surface deposition of fibrin from the blood in the ventricular cavity.
Acute verrucous endocarditis. This is followed by the appearance of characteristic wartlike nodules (verrucae) ranging from 1 to 3 mm in diameter, mainly along the line of closure of the cusps. It may lead to thickening, shortening, and blunting of valvular leaflets. Microscopically: fibrinoid necrosis with thrombotic masses.
Fibroblastic or healing of the rheumatic valvulitis. The following changes take place:
Fibroblastic proliferation and collagen formation throughout the valve with scarring, thickening, and rigidity of the leaflets.
Organization of the vegetations, with greater thickening along the line of closure.
Adhesions between the lateral portions of the cusps, particularly in the region of the commisures.
Thickening, shortening, and fusion of the chordae tendineae.
Frequently, calcification, with contributes to the rigidity of the valve.
Relapsing verrucous endocarditis.
The result is deformity of one or more valves, especially mitral or aortic.
In the chronic or recurrent condition, the functionally important lesions are those of the valves, which result in heart failure because of the increased work of the heart caused by the valvular stenosis of insufficiency.
Mitral insufficiency
The pathophysiology of mitral regurgitation is complex.
Proper closure of the mitral valve depends not only on the mitral valve leaflets by themselves but also on several additional functional components of the mitral valve apparatus, namely, the chordae tendineae, the papillary muscles, and the left ventricle.
Valvular insufficiency may result because of retraction of the scarred leaflets in the vertical direction leading to shortening of the cusps.
Changing hemodynamic conditions may dramatically improve or worsen the degree of mitral regurgitation.
Mitral insufficiency and stenosis are commonly combined.
When mitral insufficiency is the main alteration, the effects are the follows:
Dilatation and hypertrophy of the left ventricle.
Dilatation and hypertrophy of the left atrium, often greater than in mitral stenosis.
Effects on the right side of the heart as in mitral stenosis after left-sided failure.
Mitral stenosis
The most characteristic type of deformity causes mitral stenosis.
Mitral stenosis is the result of rheumatic endocarditis or bacterial endocarditis.
The gross appearance of the stenotic valve varies greatly according to the degree of involvement.
Fibrous adhesion at the comissures may be slight or extensive.
The leaflets are fibrotic and thickened, especially toward the closing edges.
Contraction of scar tissue takes place, the valve leaflets become more rigid, and calcification of the mitral cusps and ring frequently is present to a greater or lesser degree.
Ulceration of the thickest part of deformed valve is a common occurrence.
The orifice becomes considerably narrowed.
When the valves are less extensively involved and the bases of the leaflets are still somewhat pliable, the narrowed opening is surrounded but puckered, thickened tissue, so-called purse-string puckering. As the entire valve becomes more rigid it takes on appearance of a fixed diaphragm with a narrow oval or curved opening, a “buttonhole” or “fish-mouth” orifice.
The effects of mitral stenosis develop as a consequence of obstruction to the outflow of blood from the left atrium and include the following:
Dilatation and hypertrophy of the left atrium, which occasionally appears as a huge saclike structure (so-called giant left atrium).
Endocardial fibrous thickening of the left atrium.
Pronounced chronic passive congestion of the lungs; eventual pulmonary-arteriolar thickening.
Hypertrophy and dilatation of the right ventricle as a result of pulmonary hypertension
Dilatation of the right atrium as a right-sided heart failure develops.
A normal-sized left ventricle or, in prolonged mitral stenosis, atrophic left ventricle caused by reduced inflow of blood, with possible hypertrophy of this ventricle if mitral insufficiency or aortic stenosis is present.
One of the complications that may occur in mitral stenosis and the consequent atrial dilatation is atrial fibrillation. Atrial fibrillation contributes to blood stasis and predisposes to development of thrombosis, especially in the left atrial appendage; systemic embolism may result.
Myocarditis
Rheumatic myocarditis is characterized by the presence of
Granulematous myocarditis. It is characterized by the presence of specific Aschoff bodies. There is gradual subsidence of the inflammatory reaction, and the Aschoff bodies are converted into small scars.
Nonspecific exudative interstitial myocarditis. It is characterized by diffuse or focal lymphohistiocytic infiltration and vasculitis. In the later stages of the disease may diffuse small-focal cardiosclerosis.
Parenchymal damage may lead to acute cardiac insufficiency and to death in early stages of disease or to chronic ischemic heart disease.
Pericarditis
The tendency to affect serous membranes is one of the distinctive features of RF, and fibrinous pericarditis is a prominent part of the picture of acute rheumatic heart disease.
The exudate varies from a thin film of fibrin to a shaggy coat with adhesions between the layers of the pericardium, thus the designation of “shaggy” heart, or “cor villosum”.
Microscopically, fibrin is seen as a shaggy layer on the surface of the epicardium and an infiltrate of lymphocytes, plasma cells, histiosytes, and occasionally neutrophils are present.
Subsequently, organization of the fibrin by vascularized connective tissue may be observed. This may lead to fibrous thickening and adhesions of the visceral and parietal layers, to partial or complete obliteration of the pericardial cavity, and to a “chronic adhesive pericarditis”.
Although pericarditis may be the most prominent gross manifestation of the acute disease, it is usually a little physiologic significance and does not usually affect the clinical course of the patient.
Postmorten diagnosis of old rheumatic disease is based on the following marks:
Chronic adhesive pericarditis, especially circumscribed obliteration of the cardiac sac nears the apex.
Fibrous thickening of the valve leaflets, especially at the line of closure.
Valvular deformities, especially aortic or mitral stenosis of insufficiency and, more significantly, involvement of both the aortic and mitral valves.
Thickening, shortening, and adhesions of the chordal tendineae.
Microscopic changes, including foci of perivascular interstitial fibrosis and vascularization of the valves.
The chief causes of death in RF patients are cardiac failure, infective endocarditis, and embolism. Death may, however, be attributable to various conditions such as pneumonia.
RHEUMATOID ARTHRITIS
Rheumatoid arthritis (RA) is a chronic progressive inflammatory arthritis of unknown origin involving multiple joints and characterized by disorganization of connective tissue of the synovial membrane and articular cartilarge and development of their deformation. RA is likely an autoimmune disease.
RA is basically a severe form of chronic synovitis that can lead to destruction and ankylosis of affected joints. The small joints of hands and feet are usually the first and most common to be involved, with lesions of the large joints appearing later in the course of the disease.
Although the skin, eyes, heart, lungs, spleen, lymph nodes, sceletal muscle, central and peripheral nervous system, and other organs can be affected.
Females are affected three times more often than males and there is peak prevalence in the third to fourth decades of life.
Pathogenesis of RA
Rheumatoid disease is often accompanied by characteristic immunoglobulin (often IgM), called rheumatoid factosr (RF), in affected person serum. These factors are against the own immunoglobulins (often IgG) and are of considerable complexity; they are capable of acting as antiglobulins and of forming complexes with abnormal antigenic gammaglobulins in vivo and in vitro.
RF forms locally in joint fluid; an immune complex binds complement and forms the intra-articular chemotactic factors C3a and C5a. The resultant accumulation of neutrophils contributes to the pathogenesis of the joint disease.
Other autoantibodies are also found in RA, and in addition to circulating immune complexes, cell-mediated immune systems also contribute to the pathogenesis of the articular and extra-articular manifestations of RA.
The cells and mediators that likely play a role in the RA include neutrophils, synovial lining cells, lymphocytes, and macrophages. The last-mentioned produce IL-1 and tumor necrosis factor, cytokines known to stimulate release of collagenases and other lytic enzymes.
The trigger for these immunologic reactions remains unknown; some authors have suggested Epstein-Barr virus (EBV) infection.
Morphology of RA
Main morphological appearance of RA is synovitis
RA generally first affects the small, proximal joints of the hands and feet, but then may involve, usually symmetrically, the wrists, elbows, ankles, and knees.
Stages of synovitis:
1. First stage
Acute inflammatory reaction with development of edema, hyperemia, and infiltration by small and large lymphocytes, plasma cells, plasmoblasts, mast cells, and macrophages, indicating the presence of both humoral and cellular immune response arises.
There often are small areas of superficial necrosis of synovial lining cells with formation of superficial erosions covered by fibrinoid deposits; these deposits are composed of fibrin and small amounts of gamma globulin and complement components.
An exudate containing polymorphonuclear leukocytes, may with ingested immune complexes, accumulates in joint cavity.
Not infrequently, 2 to 3 mm “rice” bodies, composed of fibrin, fibronectin, collagen and immunoglobulin are present in joint cavities of seropositive patients.
2. Second stage
Hypertrophy of the synovium, synoviocytic hyperplasia, and an intense lymphoplasmacytic and hystiocytic infiltrate take place.
Granulation tissue composed of synovial fibroblasts and capillaries causes grossly recognizable villous thickening of the synovium, whose lining cells become hypertrophic and hyperplastic.
In some of these lining cells as well as lymphocytes and plasma cells of the synovium and in leukocytes of the synovial fluid occur.
This exuberant synovium is known as pannus, which eventually fills the joint space, encroaching upon the articular surfaces.
Release of destructive enzymes (proteases and collagenases) and cytokines (particularly IL-1) and pannus formation destroy cartilage, leading to changes very reminiscent of degenerative joint disease.
3. Third stage
Fibrous and bony ankylosis can result.
As the pannus ages, vascularity decreases, the fibrosis and collagenization lead to shrinkage of the capsule, progressive narrowing of the joint space, and displacement or increasing approximation of the ends of the bones.
Closely opposing bones may become fused by bone bridges developing in the scar tissue, or they may be telescoped into each other, with complete elimination of the joint.
Other features include rheumatoid nodules (or rheumatoid granuloma) in subcutaneous tissues (areas of necrosis surrounded by palisade of fibroblasts and white cells at pressure points such as elbows), acute vasculitis (in patients with high rheumatoid factors), and nonspecific, fibrinous inflammatory lesions of lungs, pleura, pericardium, myocardium, peripheral nerves, and eyes.
The most common extra-articular lesion
The most common extra-articular lesion is the subcutaneous nodule, a granuloma of a few millimeters to several centimeters in size, developing usually in areas close to the joints and subject to minor mechanical insults.
Vasculitis associated with deposition of immune complexes in vessel walls is seen especially in patients with high serum titers of IgM-RF complex; occlusion of the vessel may result in ischemia and microinfarcts. Occlusion of the large vessels can cause gangrene of the terminal phalanges of fingers or toes.
Cardiac lesions may involve the pericardium, myocardium, and endocardium, with focal accumulation of lymphocytes and plasma cells, vasculitis, granulomas, fibrosis, and amyloidosis.
Pulmonary lesions may be focal and granulematous or diffuse, interstitial, or intraalveolar. The result is focal fibrosis.
Lymph nodes show hyperplasia and, less commonly, granulomas. Several types of scleritis and retinopathy have been described in about 1% of patients with rheumatoid disease.
Amyloidosis is a late complication of RA with data on the frequency varying from 25% to 60%.
Clinical features
Variable. Most patients experience a prodrome of malaise, fever, fatigue, and musculoskeletal pain before joint involvement occurs.
The lucky patient experiences mild transient disease without sequelae, but most has fluctuating disease with the greatest progression during the initial 4 to 5 years. In a minority the onset in acute, with rapidly progressive development of joint deformities.
Characteristic deformities are radial deviation of the wrist with ulnar deviation of the fingers.
Extra-articular manifestations (mentioned above), although infrequent, are rarely the presenting features of the disease, and tend to develop in patients with high RF titers.
Some of the total morbidity of RA is caused by GI bleeding from long-term aspirin therapy, infections from steroid use, or amyloidosis in long-term severe disease.
The death is caused by uremia.
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
SLE (Libmnan-Sacks disease) is the classic prototype of the multisystem disease of autoimmune origin, characterized by a bewildering array of autoantibodies, particularly antinuclear antibodies. Acute or insidious in its onset, it is chronic, remitting and relasping, often febrile illness characterized principally by injury to the skin, joints, kidney, and serosal membranes.
Likely most autoimmune diseases, SLE is predominantly a disease of women, with frequency of 1 in 700 among women between ages of 20 and 64 and female to-male ratio of 9:1.
The cause of SLE remains unknown, but the existence of a seemingly limitless number of antibodies in these patients against self-constituents indicates that the fundamental defect in SLE is a failure of the regulatory mechanisms that sustain self-tolerance. Some authors consider that RNA virus may cause it.
Antibodies have been identified against an array of nuclear and cytoplasmic components of the cell that are either organ or species specific. Apart from their value in the diagnosis and management of patients with SLE, these antibodies are of major pathogenetic significance, as, for example, in the immune complex-mediated glomerulonephritis so typical of this disease.
Antinuclear antibodies are directed against several nuclear antigens and can be grouped into four categories: (1) antibodies to DNA, (2) antibodies to histones, (3) antibodies to nonhistone proteins bound to RNA, and (4) antibodies to nuclear antigens.
SLE appears to be a complex disorder of multifactorial origin resulting from interactions among genetic, hormonal, and environmental factors acting in concert to cause activation of helper T cells and B cells that results in the secretion of several species of autoantibodies. In this complex web, each factor may be necessary but not enough for clinical expression of the disease; the relative importance of various factors may vary from individual to individual.
Morphology
The morphologic changes in SLE are extremely variable, reflecting the variability of the clinical manifestations and the course of the disease in individual patients. It can also be said that none of these morphologic changes is pathognomic. The constellation of clinical, serologic, and morphologic changes is essential for diagnosis.
SLE is characterized by different cellular and tissue changes which can be divided into 5 groups:
Acute necrotic and degenerative changes of the connective tissue (all stages of disorganization).
Subacute interstitial inflammation of all organs including nervous system with involvement of microcirculation (capillaritis, arteriolitis, vasculitis).
Changes of sclerotic character caused by the above changes. This group is characterized by onion-like sclerosis in the spleen.
Changes of the immune system. Focal accumulations of leukocytes with marked plasmatization are present in the central and peripheral organs. Macrophagic activity is increased.
Nuclear pathology in the cells of all organs and tissues, particularly in the lymph nodes. The shape of the nuclei does not change but they gradually lose DNA and look pale after stain. After the death of the cell, the nucleus disintegrates into granules, i.e. hematoxylin bodies. This phenomen characterizes LSE. Neutrophils and macrophages phagocytize hematoxylin bodies and form so-called “lupus cells”. Their presence in the blood is a significant sign of SLE. Except for the blood, they can be found in the bone marrow, spleen, lymph nodes and the vascular walls.
Visceral manifestations of LSE
The most characteristic lesions result from the deposition of immune complexes and are found in the blood vessels, kidneys, connective tissue, and skin.
An acute necrotizing vasculitis involving small arteries and arterioles may be present in any tissue although skin and muscles are most commonly affected. Fibrinoid deposits characterize the vessel walls of arteries. In chronic stages, vessels undergo fibrous thickening with narrowing lumen. In the spleen, these vascular lesions involve the central arteries and are characterized by marked perivascular fibrosis, producing so-called “onion-skin” lesions.
Kidney. On light microscopic examination, the kidney appears to be involved in 60 to 70% of cases, but if immunofluorescence and electron microscopy are included in the examination of biopsy material, almost all cases of SLE show some renal abnormality. According to WHO morphologic classification of lupus nephritis, five patterns are recognized:
Normal by light, electron, and immunofluorescent microscopy (class 1), which is quite fare.
Mesangial lupus glomerulonephritis (class 2).
Focal proliferative glomerulonephritis (class 3).
Diffuse prolirefative glomerulonephritis (class 4).
Membranous glomerulonephritis (class 5).
It should be noted, however, that none of these patterns are specific for lupus.
Skin. The skin is involved in the majority of patients. Characteristic erythema in the bridge of the nose and cheeks (facial “butterfly”) occurs, but a similar rash may also be seen on the extremities and trunk. Urticaria, bullae, maculopapular lesions, and ulcerations also occur. Exposure to sunlight incites or accentuates the erythema. Histologically, the involved areas show liquefactive degeneration of the basal layer of the epidermis together with edema at the dermal junction. In the dermis, there is variable edema and perivascular mononuclear infiltrates. Vasculitis with fibrinoid necrosis of the vessels may be prominent.
Joints. Joint involvement is frequent, the typical lesion being a nonserosive synovitis with little deformity. The latter fact distinguishes this arthritis from that seen in rheumatoid disease. In the acute phases of arthritis in SLE, there is exudation of neutrophils and fibrin into the synovium and a perivascular mononuclear cell infiltrate in the synovial tissue.
Serosal cavities. Inflammation of the serosal lining membranes may be acute, subacute, or chronic. During the acute phase, the mesothelial surfaces are sometimes covered with fibrinous exudate. Later they become thickened, opaque, and coated with a shaggy fibrous tissue that may lead to partial or total obliteration of the serosal cavity.
Cardiovascular system. Involvement is manifested primarily in the form of pericarditis. Valvular endocarditis may occur, but it is clinically insignificant. In the era before the widespread use of steroids, so-called Libman-Sacks endocarditis was more common. The nonbacterial verrucous endocarditis takes the form of single or multiple irregular 1-to3-mm warty deposits on any valve in the heart, distinctively on either surface of the leaflets. Myocarditis, manifested as nonspecific mononuclear cell infiltration, may also be present but is less common.
Spleen. The spleen may be moderately enlarged.
Lungs. In lungs the pneumanitis, fibrosing alveolitis and diffuse interstitial fibrosis are found out.
The most common causes of death are renal failure (uremia) and intercurrent infections, followed by diffuse central nervous system disease. Patients treated with steroids and immunosuppressive drugs incur the usual risks associated with such therapy.
BECHTEREW’S DISEASE
Bechterew's disease is a chronic disease involving joints and ligaments of the spine causing its immobility. Involvement of peripheral joints and inner organs is possible.
Etiology: infectious-allergic factor, spine injury and hereditary factors. The disease mainly occurs in men with antigen histocompatibility HLA-B27.
Morphology. Destructive inflammatory changes in the tissues of small joints of the spinal column resembling those in rheumatoid arthritis with destruction of articular cartilages, growth of stroma in the cavity of the joint and its-bony metaplasia with development of bone ankylosis and limitation of their mobility. The same process with bone formation develops in intervertebral disks, which results in complete immobility of the spinal column. Visceral changes: chronic inflammation and sclerosis of aorta, heart, lungs; amyloidosis in kidneys.
SYSTEMIC SCLERODERMA
Systemic scleroderma is chronic disease with skin involvement and visceral manifestations.
Etiology. Viruses, genetic factors causing disturbances in collagen synthesis cannot be excluded. Abnormal collagen disintegrates quickly and is followed by sclerosis.
Morphology. All stages of connective tissue disorganization against the background of slight cellular reaction are noted in the skin and internal organs. The condition results in sclerosis and hyalinosis. The skin becomes dense; its mobility is poor. Cortical necrosis may develop when the vessels of the kidneys are involved. It manifests by acute renal failure, termed “true sclerodennic kidney”. Development of large-focus cardiosclerosis, fibrosis of the lungs and subpleural cavities (basal pneumosclcrosis) are possible.
The complications and the causes of death depend on the visceral lesions (kidneys, heart, lungs).
DERMATOMYOSITIS
Dermatomyositis is a chronic rheumatic disease involving striated and in rare cases smooth muscles and skin. If the skin is not damaged, the disease is called polymyositis. It may occur at any age, mainly in women.
Morphology. Striated muscles, the muscles of the pharynx, larynx, and diaphragm, ocular muscles are involved. Degeneration, calcinosis, necrosis, edema, cellular reactions are observed. Degenerative, inflammatory and sclerotic changes are observed in the heart, lungs, and alimentary tract. Hyperplasia against the background of plasmatization is observed in the immune organs.
Clinico-morpholbgical forms:
1) Primary (idiopathic). Primary form in children is caused by genetic factor.
2) Secondary (tumor). Secondary form is frequently observed in cancer of ovaries, stomach, lungs, and breast.
Each form may be acute, subacute, constantly relapsing and chronic.
DISEASES OF RESPIRATORY SYSTEM
ACUTE BACTERIAL INFECTIONS OF THE LUNGS
Occur when normal lung or systemic protective mechanisms are impaired. Pulmonary protective mechanisms include nasal, tracheobronchial, and alveolar mechanisms to filter, neutralize, and clear inhaled organisms and particles.
Important factors interfering with normal lung defenses are
1. Decreased cough reflex leading to aspiration (seen in coma, anesthesia, drug effects).
2. Injury to mucociliary apparatus (as with cigarette or other smoke / gaseous inhalations).
3. Decreased phagocytic /bactericidal function of the alveolar macrophage (as a result of alcohol, tobacco, oxygen toxicity).
4. Edema/congestion (CIHD).
5. Accumulation of secretions.
There are a lot of diseases, of pulmonary system as well as the etiologic factors, which cause these diseases. Acute and chronic bronchitis, pneumonia, destructive processes (abscess and gangrene), bronchial asthma, chronic non-specific pulmonary diseases and cancer of lungs are the most common.
Pathogenic organisms gain access to the lung through the airways, through the bloodstream, by traumatic implantation, or by direct spread across the diaphragm from the subphrenic source, probably through the lymphatics. The most common route is the airways.
Pneumonias
Pneumonia is acute inflammation of the respiratory tract with deposition of intraalveolar exudates.
Etiologic classification of pneumonia:
Bacterial pneumonia.
Viral and mycoplasmal pneumonia.
Other types of pneumonias:
Pneumocystis carini pneumonia.
Legionella pneumonia.
Aspiration pneumonia.
Hypostatic pneumonia.
Lipid pneumonia.
Clinical-morphological classification:
Lobar pneumonia.
Bronchopneumonia (lobular pneumonia).
Interstitial pneumonia.
Lobar pneumonia
Synonyms: crupous, lobular, fibrinous, pleurapneumonia.
Croupous pneumonia is infectious-allergic infection and involves a lobe of lung.
Most lobar pneumonias are caused by pneumococci and Klebsiella pneumonia which enter the lungs via the airways.
The pneumococcus continues to be responsible for 30% to 80% or more of community-acquired pneumonias.
Groups at particular risk include the very young and very old, alcoholics, diabetics, spleenectomized subjects, and patients with multiple myeloma or circle cell disease.
Hypersensivity of immediate type plays an important role in pathogenesis.
Pleural involvement occurs commonly in lobar pneumonia Pneumococcal pneumonia typically presents the picture of lobar pneumonia. One or occasionally several lobes of the lung are involved. Fibrinous exudates in alveoli are presence.
Traditionally the progress of the disease is divided into four stages:
Congestion and Edema predominates in the first 24 hours. The initial response to the organism is edema, which spreads throughout the lobe through pores of Kohn and bronchioles. At this stage an involved lobe appears distended, moist, and deep red of purple. The pleura are shiny, and fluid exudes from the cut surface.
Red hepatization (2 days) describes lung tissue with confluent acute exudate containing neutrophils and red cells, giving a red, firm. Lobe is liver-like.
Gray hepatization (4-6 days) follows, as the red cells disintegrate and the remaining fibrinous-suppurative exudates persist, giving a gray-brown gross appearance.
Resolution (9-11 days) is the favorable final stage in which consolidated exudates undergoes enzymatic and cellular degradation and clearance. Normal structure is restored.
Complications:
Carnification is organization of fibrinoid exudate.
Abscess formation. Lung abscess results from the breakdown of alveolar walls.
Empyema (spread of infection to pleural cavity).
Gangrene.
Bacteremic spread leads to purulent meningitis, bacterial endocarditis, arthritis, pericarditis and other organs.
Causes of death are acute cardiac-respiratory insufficiency and purulent complications.
Bronchopneumonia (focal pneumonia)
Bronchopneumonia is marked by patchy exudative consolidation of lung parenchyma
Polyetiologic. The most often agents are bacterias: pneumococci, staphylococci, streptococci, hemophylus influenzae, pseudomonas aeruginosa, and coliform bacteria.
Bronchopneumonia often arises due to autoinfection. Depending pathogenesis autoinfectional bronchopneumonia may be aspirationous, hypostatic, postoperative, immunodificiency.
Bronchopneumonia often is a complication of others disease.
According to extent may be acynous, lobular, segmental, and miliary.
Morphology
Initially bronchi are affected. Then, inflammation spreads to parenchyma of lungs with accumulation of exudates in the alveoli.
Grossly, the lungs show dispersed, elevated, focal areas of palpable consolidation and suppuration.
Histological features consist of acute (neutrophilic) suppurative, serous, hemorrhagic or mixed exudates filling airspaces and airways, usually about bronchi and bronchioles.
Outcomes and complications: resolution of the exudates usually restores normal lung structure, but organization may occur and result in fibrous scarring in some cases. Aggressive disease may produce abscess, pleurisy, and empyema.
Streptococcal pneumonia
Beta-hemolytic streptococci are an uncommon cause of pneumonia at the present time. In adults streptococcal pneumonia like other pneumonias usually occurs in elderly, severely debilitated patients. Diabetes is also a risk factor. Infections caused by this microbe in the newborn are discussed elsewhere.
The lower lobe is usually the site of major involvement.
The airways appear thickened and are filled with a hemorrhagic or purulent exudate.
The pneumonia is lobular with consolidated patches clearly centered on terminal bronchioles. The distinctive microscopic feature of streptococcal pneumonia is greater interstitial involvement than in other bacterial pneumonias. There is necrosis of the epithelium of distal airways with infiltration of the bronchial walls by neutrophils and mononuclear cells. The interstitial infiltrate also extends into the adjacent alveolar walls.
Staphylococcal pneumonia
Staphylococcal pneumonia usually occurs either in the presence of a source of bacteremia or after viral infection.
Hematogenous pneumonia is seen in those with soft-tissue infections, in patients undergoing long-term dialysis. The lesions may appear as septic infarcts that are yellow and purulent but preserve to some degree the wedge-shaped configuration of infarcts and are associated with thrombosed vessels, or they may be rounded patches of necrotizing pneumonia that break down, giving rise to abscesses.
Staphylococcal pneumonia also results from spread of organisms from the colonized nasopharynx. The lesions are those of bronchopneumonia accompanied by a hemorrhagic and necrotizing bronchitis. Purulent exudate fills the bronchioles and spreads into the adjacent acini.
Staphylococcal bronchopneumonia is not rare in children less than 6 months of age. A notable feature of staphylococcal pneumonia in small children is development of abscesss.
Local complications of staphylococcal pneumonia include empyema and bronchopleural fistula.
Aspiration pneumonia
Aspiration pneumonia results from inhaling different agents into the lungs. These substances include food, gastric contents, infected material from oral cavity, amniotic fluid or meconium in infants, etc.
Hypostatic pneumonia
Hypostatic pneumonia is the term used for the collection of edema fluid and secretions in the dependent parts of the lungs in bed-patients.
Interstitial pneumonia
Infections by viruses, mycoplasma pneumonia, pneumocystis carinii, etc. result in varied clinical and pathologic patterns, ranging from relatively mild upper respiratory tract involvements to severe lower respiratory tract disease.
Morphology
Patchy or lobar areas of congestion without the consolidation of bacterial pneumonias.
A predominance of interstitial pneumonitis with widened, edematous alveolar walls containing a mononuclear inflammatory cell infiltrates.
The formation of hyaline membranes, reflecting diffuse alveolar damage.
Pneumocystic pneumonia is characterized by desquamation of alveolar epithelium. Alveoli filled by foamy fluid and pneumocysts, and also hyperemia and inflammatory infiltration of the alveolar septs. It may pattern in AIDS.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
The term Chronic Obstructive Pulmonary disease (COPD) refers to a group of conditions that share a major symptom – dyspnea - and are accompanied by chronic or recurrent obstruction to air flow within the lung.
Obstructive diseases are characterized by increased resistance to airflow because of chronic or recurring expiratory obstruction.
In their prototypical forms, these individual disorders – chronic bronchitis, bronchiectasis, asthma, emphysema – have distinct anatomic and clinical characteristic.
Hypertension of pulmonary circulation and “cor pulmonale” develops in all Chronic Obstructive Pulmonary diseases.
Amyloidosis of kidneys and chronic renal insufficiency may develop often.
Death of the most patients with COPD is due to
1) Respiratory acidosis and coma,
2) Right-sided failure,
3) Massive collapse of the lung secondary to pneumothorax.
Chronic Bronchitis
The widely accepted definition of chronic bronchitis is a clinical one – chronic bronchitis (CB) is present in any patient who has persistent cough with sputum production for at least 3 months in at least 2 consecutive years.
This disorder, so common among habitual smokers and inhabitants of smog-laden cities, is not nearly so trivial as was once thought.
The role of infection appears to be secondary. It is not responsible for the initiation of CB but is probably significant in maintaining it and may be criterial in producing acute exacerbations.
Pathogenesis. Two sets of factors are important in the genesis of chronic bronchitis:
1. Chronic irritation by inhaled substances.
2. Microbiologic infections.
Morphology
The hallmark and earliest failure of CB is hypersecretion of mucus in the large airways, and is associated with hypertrophy of the submucosal glands in the trachea and bronchi.
As CB persists, there is also a marked increase in goblet cells of small airways – small bronchi and bronchioles – leading to excessive mucus production that contributes to airway obstruction.
Although mucus hypersecretion in large airways is the cause of sputum overproduction, it is now thought that accompanying alterations in the small airways of the lung can result in physiologically important and early manifestations of the chronic airway obstruction.
Histological features of the small airways:
1. Goblet cell metaplasia with mucus plugging of the lumen.
2. Clustering of pigmented alveolar macrophages.
3. Inflammatory infiltration.
4. Fibrosis of bronchiolar wall.
Outcomes and complications
Lead to “cor pulmonale” and heart failure.
Cause atypical metaplasia and dysplasia of the respiratory epithelium, providing a possible soil for cancerous transformation.
Amyloidosis of kidneys.
Lead to bronchiectasis.
Bronchiectasis (BE)
BE is chronic necrotizing infection of the bronchi and bronchioles leading to or associated with abnormal dilation of these airways.
BE has many origins and usually develops in association with following conditions:
Bronchial obstruction, due to tumor, foreign bodies, and occasionally mucous impaction, in which the BE are localized to the obstructed lung segment; or due to diffuse obstructive airway disease, most commonly atopic asthma and chronic bronchitis, measles.
Congenital or hereditary conditions, including congenital BE, cystic fibrosis, intralobar sequestration of the lung states, and immune cilia and Kartagener’s syndromes.
Necrotizing pneumonia, most often caused by tubercle bacillus or staphylococci or mixed infections.
Morphology
BE usually affects the lower lobes bilaterally, particularly those air passages that is most vertical, and is most severe in the more distal bronchi and bronchioles.
When tumors or aspiration of foreign bodies leads to BE, the involvement may be sharply localized to a single segment of the lungs.
The pleura is usually fibrotic and thickened with adhesions to the chest wall. Cut surface has honey-combed appearance. The walls of bronchi are thickened and the lumen arc filled with mucus.
The airways are dilated; sometime up to four times normal size. These dilations may produce:
1. Long, tube-like enlargements (cylindroid BE) in 1 to 4 type of bronchus.
2. May cause fusiform or even sharply saccular distention (saccular BE) in 6-10 types of bronchus.
The histologic findings vary with the activity and chronicity of the disease:
1. In the full-down active case, there in an intense acute and chronic inflammatory exudation within the walls of bronchi and bronchioles, associated with desquamation of the lining epithelium and extensive areas of necrotizing ulceration. There may be squamous metaplasia of the remaining epithelium.
2. In some instances, the necrosis completely destroys the bronchial or bronchiolar walls and forms a lung abscess.
3. Fibrosis of the bronchial and bronchiolar walls and peribronchial fibrosis develop in the more chronic cases.
Outcomes and complications
1. Obstructive ventilatory insufficiency can lead to marked dyspnea and cyanosis.
2. Pulmonary hemorrhage.
3. Pulmonary abscess.
4. Empyema of the pleura.
5. Metastatic brain abscess.
6. “Cor pulmonale” and chronic cardiac-pulmonary insufficiency.
7. Amyloidosis are less frequent complications of BE.
Emphysema
Emphysema is a condition of the lung characterized by abnormal permanent enlargement of the airspace distal to the terminal bronchiole, accompanied by destruction of their walls, and without obvious fibrosis. In contrast, the enlargement of airspaces unaccompanied by destruction is termed overinflation, for example, the distention of airspaces in the opposite lung following unilateral pneumonectomy.
Pathogenesis
While details of the genesis of the two common forms of emphysema – centiacinar and panacinar – remain unsettled, the most plausible hypothesis to account for the destruction of alveolar walls is the protease-antiprotease mechanism. Thus, emphysema is seen to result from the destructive effect of the high protease activity in subjects with low antiprotease activity.
The protease-antiprotease hypothesis also explains the deleterious effect of cigarette smoking.
Smokers have greater numbers of neutrophils and macrophages in their alveoli. The increased recruitment of neutrophils into the lung is likely to result, in part, from the release by activated alveolar macrophages of neutrophil chemotactic factors, this release being stimulated by smoking. In addition, nicotine is chemotactic for neutrophils, and cigarette smoke activates the alternative compliment pathway.
Smoking stimulates release of elastase from neutrophils.
Smoking enhances elastolytic proteases activity in macrophages; macrophage elastase is not inhibited by alpha-1 –AT and, indeed, can proteolytically digest this enzyme.
Oxidants in cigarette smoke and oxygen free radicals secreted by neutrophils inhibit alpha-1-AT and thus decrease net antielastase activity in smokers.
It is thus postulated that impaction of smoke particles in the small bronchi and bronchioles, with the resultant influx of neutrophils and macrophages, and increased elastase and decreased alpha-1-AT activity causes to the centriacinar emphysema seen in smokers.
Classification
Although the term “emphysema” is sometimes loosely applied to diverse conditions, there are four types:
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