Essentials of Rubin's Pathology, 5th Edition

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ESSENTIALS of RUBIN’S PATHOLOGY FIFTH EDITION

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ESSENTIALS of RUBIN’S PATHOLOGY FIFTH EDITION

EDITORS: Emanuel Rubin, MD Gonzalo E. Aponte Distinguished Professor of Pathology Chairman Emeritus of the Department of Pathology, Anatomy, and Cell Biology Jefferson Medical College Philadelphia, Pennsylvania Howard M. Reisner, PhD Professor of Pathology and Laboratory Medicine Department of Pathology and Laboratory Medicine The University of North Carolina at Chapel Hill School of Medicine Chapel Hill, North Carolina W I T H 4 4 CO N T R I B U TO R S Illustrations by Dimitri Karetnikov, George Barile, and Kathy Jaeger

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Acquisitions Editor: Betty Sun Developmental Editor: Kathleen Scogna Managing Editor: Kelley Squazzo Copy Editor: Dvora Konstant Marketing Manager: Emilie Moyer Associate Production Editor: Kevin P. Johnson Designer: Risa Clow Compositor: Maryland Composition, Inc. Copyright © 2009 Lippincott Williams & Wilkins, a Wolters Kluwer business 351 West Camden Street Baltimore, MD 21201 530 Walnut Street Philadelphia, PA 19106 All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner. The publisher is not responsible (as a matter of product liability, negligence, or otherwise) for any injury resulting from any material contained herein. This publication contains information relating to general principles of medical care that should not be construed as specific instructions for individual patients. Manufacturers’ product information and package inserts should be reviewed for current information, including contraindications, dosages, and precautions. Printed in China Library of Congress Cataloging-in-Publication Data Essentials of Rubin's pathology / editors, Emanuel Rubin, Howard M. Reisner ; with 44 contributors ; illustrations by Dimitri Karetnikov, George Barile, and Kathy Jaeger. — 5th ed. p. ; cm. Rev ed. of: Rubin's pathology. 5th ed. c2008. Includes bibliographical references and index. ISBN-13: 978-0-7817-7324-9 ISBN-10: 0-7817-7324-5 1. Pathology. I. Rubin, Emanuel, 1928- II. Reisner, Howard M. III. Rubin's pathology. IV. Title: Rubin's pathology. [DNLM: 1. Pathology. QZ 4 E782 2009] RB111.E856 2009 616.07—dc22 2007036036 The publishers have made every effort to trace the copyright holders for borrowed material. If they have inadvertently overlooked any, they will be pleased to make the necessary arrangements at the first opportunity. ISBN: 978-07817-7324-9 To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 824-7390. International customers should call (301) 714-2324. Visit Lippincott Williams & Wilkins on the Internet: http://www.LWW.com. Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to 6:00 pm, EST. 07 08 09 10 11 1 2 3 4 5 6 7 8 9 10

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DEDICATION

We dedicate this book to our wives and families, whose love and support throughout this endeavor sustained us; to our colleagues, from whom we have learned so much; and to students everywhere, upon whose curiosity and energy the future of medical science depends. Also to the memories of Fred Zak and Lotte Strauss, who were my first teachers of pathology. Emanuel Rubin, MD Cui dono lepidum novum libellum Arido modo pumice expolitum? Emily, tibi Howard M. Reisner, PhD

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CONTRIBUTORS

Michael F. Allard, BSc, MD, FRCP(C) Professor and Cardiovascular Pathologist Department of Pathology and Laboratory Medicine University of British Columbia Senior Scientist The James Hogg iCAPTURE Centre for Cardiovascular and Pulmonary Research St. Paul’s Hospital - Providence Health Care Vancouver, British Columbia, Canada Mary Beth Beasley, MD Department of Pathology Providence Portland Medical Center Portland, Oregon Douglas P. Bennett, MD Clinical Fellow of Infectious Diseases Department of Medicine Jefferson Medical College Philadelphia, Pennsylvania Marluce Bibbo, MD, ScD Professor of Pathology Director of Cytopathology Department of Pathology, Anatomy, and Cell Biology Jefferson Medical College Philadelphia, Pennsylvania Thomas W. Bouldin, MD Professor and Vice Chair for Faculty and Trainee Development Department of Pathology and Laboratory Medicine The University of North Carolina at Chapel Hill School of Medicine Chapel Hill, North Carolina Mark Curtis, MD, PhD Assistant Professor of Pathology, Anatomy, and Cell Biology Jefferson Medical College Philadelphia, Pennsylvania Ivan Damjanov, MD, PhD Professor of Pathology The University of Kansas School of Medicine Kansas City, Kansas

Giulia De Falco, PhD Assistant Professor of Human Pathology and Oncology University of Siena Siena, Italy Renee Z. Dintzis, PhD Associate Professor of Cell Biology Director of Organ Histology Johns Hopkins University School of Medicine Baltimore, Maryland Hormoz Ehya, MD Director of Cytopathology of Pathology Fox Chase Cancer Center Philadelphia, Pennsylvania David Elder, MD Professor of Pathology and Laboratory Medicine Director of Anatomic Pathology Hospital of the University of Pennsylvania Philadelphia, Pennsylvania Kevin Furlong, DO Assistant Professor of Clinical Medicine Division of Endocrinology, Diabetes, and Metabolic Diseases Department of Medicine Jefferson Medical College Philadelphia, Pennsylvania Robert M. Genta, MD Professor of Pathology and Medicine (Gastroenterology) University of Texas Southwestern Medical Center Chief, Department of Pathology Dallas VA Medical Center Dallas, Texas Antonio Giordano, MD, PhD Director Sbarro Institute for Cancer Research and Molecular Medicine and Center of Biotechnology College of Science and Technology Temple University Philadelphia, Pennsylvania

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viii CONTRIBUTORS

Barry Goldstein, MD, PhD Director, Division of Endocrinology, Diabetes, and Metabolic Diseases Department of Medicine Jefferson Medical College Philadelphia, Pennsylvania Avrum I. Gotlieb, MDCM, FRCP(C) Professor and Chair of Laboratory Medicine and Pathobiology University of Toronto Toronto, Ontario, Canada Donna E. Hansel, MD, PhD Associate Staff Department of Anatomic Pathology Cleveland Clinic Cleveland, Ohio Benjamin Hoch, MD Assistant Professor of Pathology Director, Orthopaedic Pathology Director, ENT Pathology Mount Sinai School of Medicine New York, New York Serge Jabbour, MD, FACP, FACE Associate Professor Division of Endocrinology, Diabetes, and Metabolic Diseases Department of Medicine Jefferson Medical College Philadelphia, Pennsylvania J. Charles Jennette, MD Kenneth M. Brinkhous Distinguished Professor and Chair Department of Pathology and Laboratory Medicine The University of North Carolina at Chapel Hill School of Medicine Chapel Hill, North Carolina Lawrence C. Kenyon, MD, PhD Associate Professor of Pathology, Anatomy, and Cell Biology Jefferson Medical College Philadelphia, Pennsylvania Anthony A. Killeen, MD, PhD Associate Professor of Clinical Pathology Department of Laboratory Medicine and Pathology University of Minnesota Minneapolis, Minnesota Robert Kisilevsky, MD, PhD, FRCPC Professor Emeritus of Pathology and Molecular Medicine Queen’s University Kingston, Ontario, Canada

Michael J. Klein, MD Professor of Pathology Head, Section of Surgical Pathology University of Alabama School of Medicine Birmingham, Alabama Gordon K. Klintworth, MD, PhD Professor of Pathology and Joseph A.C. Wadsworth Research Professor of Ophthalmology Duke University Medical Center Durham, North Carolina Gregory Y. Lauwers, MD Director, Gastrointestinal Pathology Service Massachusetts General Hospital Associate Professor of Pathology Harvard Medical School Boston, Massachusetts Steven McKenzie, MD, PhD Vice President for Research, Medicine Thomas Jefferson University Philadelphia, Pennsylvania Bruce M. McManus, MD, PhD, FRCPC, FACC, FCAP Professor of Pathology and Laboratory Medicine University of British Columbia Director The James Hogg iCAPTURE Centre for Cardiovascular and Pulmonary Research St. Paul’s Hospital-Providence Health Care Vancouver, British Columbia, Canada Maria J. Merino-Neumann, MD Senior Principal Investigator Laboratory of Pathology National Cancer Institute National Institutes of Health Bethesda, Maryland Mari Mino-Kenudson, MD Assistant Professor of Pathology Harvard Medical School Assistant in Pathology Massachusetts General Hospital Boston, Massachusetts Frank A. Mitros, MD Frederic W. Stamler Professor of Anatomical Pathology Professor of Surgical Pathology Department of Pathology University of Iowa College of Medicine Iowa City, Iowa

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CONTRIBUTORS

Hedwig S. Murphy, MD, PhD Assistant Professor of Pathology University of Michigan Pathologist, Pathology and Laboratory Medicine Veteran’s Affairs Ann Arbor Healthcare System Ann Arbor, Michigan George L. Mutter, MD Associate Professor of Pathology Harvard Medical School Department of Pathology Brigham and Women’s Hospital Boston, Massachusetts Adeboye O. Osunkoya, MD Clinical and Research Fellow Division of Genitourinary Pathology Department of Pathology The Johns Hopkins Hospital Baltimore, Maryland Roger J. Pomerantz, MD, FACP President, Tibotec Senior Vice President, World-Wide Therapeutic Area Head of Virology Johnson and Johnson Corporation Yardley, Pennsylvania Martha M. Quezado, MD Chief, Neuropathology Unit Surgical Pathology Section Laboratory of Pathology National Cancer Institute National Institutes of Health Bethesda, Maryland Howard M. Reisner, PhD Professor of Pathology and Laboratory Medicine Department of Pathology and Laboratory Medicine The University of North Carolina at Chapel Hill School of Medicine Chapel Hill, North Carolina Stanley J. Robboy, MD Professor of Pathology and Obstetrics and Gynecology Vice Chairman for Diagnostic Services Duke University Medical Center Durham, North Carolina Emanuel Rubin, MD Gonzalo E. Aponte Distinguished Professor of Pathology Chairman Emeritus of the Department of Pathology, Anatomy, and Cell Biology Jefferson Medical College Philadelphia, Pennsylvania

Raphael Rubin, MD Professor of Pathology, Anatomy, and Cell Biology Jefferson Medical College Philadelphia, Pennsylvania Jeffrey E. Saffitz, MD, PhD Mallinckrodt Professor of Pathology Harvard Medical School Chief, Department of Pathology Beth Israel Deaconess Medical Center Boston, Massachusetts Alan L. Schiller, MD Irene Heinz Given and John LaPorte Given Professor and Chairman of Pathology Mount Sinai Medical School New York, New York Roland Schwarting, MD Professor and Chair of Pathology Cooper University Hospital Camden, New Jersey David A. Schwartz, MD, MS (Hyg) Associate Clinical Professor of Pathology Vanderbilt University School of Medicine Nashville, Tennessee Gregory C. Sephel, PhD Associate Professor of Pathology Vanderbilt University Medical Center Nashville, Tennessee Craig A. Storm, MD Assistant Professor of Pathology Dartmouth-Hitchcock Medical Center Lebanon, New Hampshire David S. Strayer, MD, PhD Professor of Pathology, Anatomy, and Cell Biology Jefferson Medical College Philadelphia, Pennsylvania Ann D. Thor, MD Professor and Chair of Pathology University of Colorado Health Sciences Center at Fitzsimons Aurora, Colorado William D. Travis, MD Attending Thoracic Pathologist Department of Pathology Memorial Sloan-Kettering Cancer Center New York, New York

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CONTRIBUTORS

John Q. Trojanowski, MD, PhD Professor of Pathology and Laboratory Medicine University of Pennsylvania School of Medicine Center for Neurodegenerative Disease Research Philadelphia, Pennsylvania Jeffrey S. Warren, MD Warthin/Weller Endowed Professor and Director Division of Clinical Pathology Department of Pathology University of Michigan Medical School Ann Arbor, Michigan Bruce M. Wenig, MD Professor of Pathology Albert Einstein College of Medicine Bronx, New York Chairman of Pathology and Laboratory Medicine Beth Israel Medical Center, St. Luke’s-Roosevelt Hospital Center and Long Island College Hospital New York, New York

Stephen C. Woodward, MD Professor Emeritus of Pathology Vanderbilt University Medical Center Nashville, Tennessee Robert Yanagawa, PhD Scholar Faculty of Medicine University of Toronto Toronto, Ontario, Canada

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PREFACE

The enthusiastic reception of the prior edition of Essentials of Rubin’s Pathology motivated us to prepare a new fifth edition. The text is based on the larger fifth edition of Rubin’s Pathology and provides a summary of contemporary general and systemic pathology. We have omitted most of the discussions of normal anatomy, physiology and histology, as well as the descriptions of less frequently encountered diseases, when such do not teach important fundamental concepts. In addition, the clinical and experimental support for statements in the text have been shortened. Thus, our goal for Essentials of Rubin’s Pathology is to present the reader with all the key concepts of the evolution and expression of disease and to assign priorities based on the clinical importance and heuristic relevance of the individual disorders. In revising the manuscript we have updated and modified content that is important in achieving our goal. As in earlier editions, Essentials of Rubin’s Pathology maintains the tradition of dividing the subject matter into general (Chapters 1–9) and systemic (Chapters 10–30) pathology. The text continues to distinguish between pathogenesis, pathology and clinical features of the various diseases discussed. Throughout the text, key terms and definitions

of importance have been highlighted by bullets, italics, bold face and color to add emphasis and aid review. Many of the original drawings and photographs have been revised and new ones have been added. This edition of Essentials of Rubin’s Pathology recognizes the expansion of knowledge relevant to pathology into the molecular realm and contains a considerable amount of new material. It should continue to serve the needs of all students of pathology who wish to integrate the concepts of molecular, cellular and tissue based biology with the study of clinical medicine. Attempting to edit a comprehensive textbook of pathology without missing prior errors, or introducing new ones is like trying to live without sin--worth the effort, but ultimately impossible. The inevitability of human error has not deterred us from the inclusion of new and sometimes still controversial concepts. Some of these will stand the test of time, others will be corrected in the next edition. We stand ready to catch cast stones. Emanuel Rubin, MD Howard Reisner, PhD

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ACKNOWLEDGMENTS

This fifth edition of Essentials of Rubin’s Pathology is based on the hard work and insights of all those who made the fifth edition of Rubin’s Pathology possible. In addition, the editors would like to to thank the managing and editorial staff at the Lippincott Williams & Wilkins division of Wolters Kluwer Health and in particular Betty Sun, Kelley Squazzo, and Kathleen Scogna for their continuing support. Without their help this volume would not have been possible. The editors also acknowledge the contributions made by our colleagues who participated in writing previous editions and those who offered suggestions and ideas for the current edition. Stuart A. Aaronson Mohammad Alomari Adam Bagg Karoly Balogh Sue Bartow Hugh Bonner Patrick J. Buckley Stephen W. Chensue Daniel H. Connor Jeffrey Cossman John E. Craighead Mary Cunnane Joseph C. Fantone

John L. Farber Gregory N. Fuller Stanley R. Hamiliton Terrence J. Harrist Arthur P. Hays Robert B. Jennings Kent J. Johnson Michael J. Klein William D. Kocher Robert J. Kurman Ernest A. Lack Antonio Martinez-Hernandez Wolfgang J. Mergner

Juan Palazzo Robert O. Peterson Timothy R. Quinn Brian Schapiro Stephen M. Schwartz Benjamin H. Spargo Charles Steenbergen, Jr. Steven L. Teitelbaum Benjamin F. Trump Jianzhou Wang Beverly Y. Wang

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CONTENTS

CHAPTER 1:

C H A P T E R 12 :

Cell Injury 1

The Respiratory System 244

David S. Strayer and Emanuel Rubin

Mary Beth Beasley, William D. Travis, and Emanuel Rubin

CHAPTER 2:

C H A P T E R 13 :

Inflammation 18

The Gastrointestinal Tract 274

Hedwig S. Murphy

Frank A. Mitros and Emanuel Rubin

CHAPTER 3:

C H A P T E R 14 :

Repair, Regeneration, and Fibrosis 36

The Liver and Biliary System 309

Gregory C. Sephel and Stephen C. Woodward

Raphael Rubin and Emanuel Rubin

CHAPTER 4:

C H A P T E R 15 :

Immunopathology 53

The Pancreas 341

Jeffrey S. Warren, Douglas P. Bennett, and Roger J. Pomerantz

Gregory Y. Lauwers, Mari Mino-Kenudson, and Raphael Rubin

CHAPTER 5:

C H A P T E R 16 :

Neoplasia 71

The Kidney 350

Antonio Giordano, Giulia De Falco, Emanuel Rubin, and Raphael Rubin

J. Charles Jennette C H A P T E R 17:

Developmental and Genetic Diseases 92

The Lower Urinary Tract and Male Reproductive System 378

Anthony A. Killeen, Emanuel Rubin, and David S. Strayer

Ivan Damjanov

C H A P T E R 7:

C H A P T E R 18 :

Hemodynamic Disorders 117

The Female Reproductive System 396

Bruce M. McManus, Michael F. Allard, and Robert Yanagawa

Stanley J. Robboy, Maria J. Merino, and George L. Mutter

CHAPTER 8:

C H A P T E R 19 :

Environmental and Nutritional Pathology 131

The Breast 425

CHAPTER 6:

Ann D. Thor and Adeboye O. Osunkoya

David S. Strayer and Emanuel Rubin CHAPTER 20: CHAPTER 9:

Hematopathology 432

Infectious and Parasitic Diseases 148

Roland Schwarting, Steven McKenzie, and Raphael Rubin

David A. Schwartz, Robert M. Genta, Douglas P. Bennett, and Roger J. Pomerantz

C H A P T E R 21 :

The Endocrine System 468 C H A P T E R 10 :

Blood Vessels 195

Maria Merino, Martha Quezado, Raphael Rubin, and Emanuel Rubin

Avrum I. Gotlieb CHAPTER 22:

The Heart 216

Obesity, Diabetes Mellitus, and Metabolic Syndrome 489

Jeffrey E. Saffitz

Barry J. Goldstein, Serge Jabbour, and Kevin Furlong

C H A P T E R 11 :

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CHAPTER 23:

CHAPTER 28:

The Amyloidoses 495

The Nervous System 583

Robert Kisilevsky

Donna E. Hansel, Renee Z. Dintzis, John Q. Trojanowski, Lawrence C. Kenyon, and Thomas W. Bouldin

CHAPTER 24:

The Skin 501 Craig A. Storm and David E. Elder

CHAPTER 29:

The Eye 618 Gordon K. Klintworth

CHAPTER 25:

The Head and Neck 522 Bruce M. Wenig

CHAPTER 30:

Cytopathology 628 Hormoz Ehya and Marluce Bibbo

CHAPTER 26:

Bones and Joints 535 Benjamin L. Hoch, Michael J. Klein, and Alan L. Schiller C H A P T E R 27:

Skeletal Muscle 573 Lawrence C. Kenyon and Mark T. Curtis

Figure Acknowledgments 633 Index 634

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Cell Injury David S. Strayer Emanuel Rubin

Reactions to Persistent Stress and Cell Injury Proteasomes Atrophy as Adaptation Hypertrophy Hyperplasia Metaplasia Dysplasia Mechanisms and Morphology of Cell Injury Hydropic Swelling Subcellular Changes Ischemic Cell Injury Oxidative Stress Ischemia/Reperfusion Injury Intracellular Storage

How Exogenous Agents Injure Cells Ionizing Radiation Viral Cytotoxicity Chemicals Abnormal G Protein Activity Cell Death Necrosis from Exogenous Stress Necrosis from Intracellular Insults Apoptosis (Programmed Cell Death) Biological Aging Maximal Life Span The Cellular Basis of Aging Genetic Factors Somatic Damage Summary Hypothesis of Aging

Pathology is the study of structural and functional abnormalities that are expressed as diseases of organs and systems. Classic theories attributed diseases to imbalances or noxious effects of humors on specific organs. In the 19th century, Rudolf Virchow, often referred to as the father of modern pathology, proposed that injury to the smallest living unit of the body, the cell, is the basis of all disease. To this day, clinical and experimental pathology remain rooted in this concept, which is now extended by an increased understanding of the molecular nature of many disease processes. A living cell must maintain the ability to produce energy, much of which is spent in establishing a barrier between the internal milieu of the cell and a hostile environment. The plasma membrane, associated ion pumps, and receptor molecules serve this purpose.

A cell must also be able to adapt to adverse environmental conditions, such as changes in temperature, solute concentrations, oxygen supply, or the presence of noxious agents, and so on. If an injury exceeds the adaptive capacity of the cell, the cell dies. From this perspective, pathology is the study of cell injury and the expression of a cell’s pre-existing capacity to adapt to such injury.

Reactions to Persistent Stress and Cell Injury Persistent stress often leads to chronic cell injury. Whereas permanent organ injury is associated with the death of individual cells, the cellular response to persistent sublethal injury (whether chemical or physical) reflects adaptation of the cell to a hostile environment. Again, these changes are, for the most part, reversible on discontinuation of the stress. The major adaptive responses are atrophy, hypertrophy, hyperplasia, metaplasia, dysplasia, and intracellular stor1

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age of certain endogenous or exogenous materials. In addition, certain forms of neoplasia may follow adaptive responses.

Proteasomes are Key Participants in Cell Homeostasis, Response to Stress, and Adaptation to Altered Extracellular Environment Cellular homeostasis requires mechanisms that allow the cell to destroy certain proteins selectively. Although there is evidence that more than one such pathway may exist, the best-understood mechanism by which cells target specific proteins for elimination is the ubiquitin (Ub)-proteasomal apparatus.

Proteasomes The importance of the proteosome is underscored by the fact that it may comprise up to 1% of the total protein of the cell. Proteasomes are evolutionarily highly conserved and are present in all eukaryotic cells. Mutations leading to interference with normal proteasomal function are lethal. Proteasomes exist in two forms. The 20S proteasomes are important in degradation of oxidized proteins. In 26S proteasomes, ubiquitinated proteins are degraded.

Ub and Ubiquitination Proteins to be degraded are flagged by attaching small chains of Ub molecules to them, thereby serving to identify proteins to be destroyed.

How Ubiquitination Matters The importance of ubiquitination and specific protein elimination is fundamental to cellular adaptation to stress and injury. Defective ubiquitination may play a role in several important neurodegenerative diseases. Mutations in parkin, a Ub ligase, and also a related enzyme, are implicated in two hereditary forms of Parkinson disease. Manipulation of ubiquitination may be important in tumor development. Thus, papilloma virus strains that are associated with human cervical cancer (see Chapters 5 and 18) produce increased p53 ubiquitination and accelerate p53 degradation. Impaired ubiquitination may also be involved in some cellular degenerative changes that occur in aging and in some storage diseases.

Atrophy is an Adaptation to Diminished Need or Resources for a Cell’s Activities Clinically, atrophy is often noted as a decrease in size or function of an organ that occurs under pathologic or physiologic circumstances. Therefore, atrophy may result from disuse of skeletal muscle or from loss of trophic signals as part of normal aging. At the level of an individual cell, atrophy may be thought of as an adaptive response, whereby a cell accommodates to changes in its environment while remaining viable. Reduction in an organ’s size may reflect reversible cell atrophy or irreversible loss of cells. For example, atrophy of the brain in Alzheimer disease is secondary to extensive cell death; the size of the organ cannot be restored (Fig. 1-1). Atrophy occurs under a variety of conditions: • Reduced Functional Demand: For example, after immobilization of a limb in a cast, muscle cells atrophy, and muscular strength is reduced. When normal activity resumes, the muscle’s size and function return. • Inadequate Supply of Oxygen: Interference with blood supply to tissues is called ischemia. Although total cessation of oxygen perfusion results in cell death, partial ischemia is often compatible with cell viability. Under such circumstances, cell atrophy is common.

Atrophy of the brain. Marked atrophy of the frontal lobe is noted in this photograph of the brain. The gyri are thinned and the sulci conspicuously widened. FIGURE 1-1.

• Insufficient Nutrients: Starvation or inadequate nutrition associated with chronic disease leads to cell atrophy, particularly in skeletal muscle. • Interruption of Trophic Signals: The functions of many cells depend on signals transmitted by chemical mediators, of which the endocrine system and neuromuscular transmission are the best examples. Loss of such signals via ablation of an endocrine gland or denervation results in atrophy of the target organ. Atrophy secondary to endocrine insufficiency is not restricted to pathologic conditions. For example, the endometrium atrophies when estrogen levels decrease after menopause (Fig. 1-2). • Aging: The size of all parenchymal organs decreases with age. The size of the brain is invariably decreased, and in the very old, the size of the heart may be so diminished that the term senile atrophy has been used.

Hypertrophy is an Increase in Cell Size and Functional Capacity Hypertrophy is an adaptive change that results in an increase in cellular size to satisfy increased functional demand or trophic signals. In some cases, increased cellular number (hyperplasia, see below) may also result. In organs made of terminally differentiated cells (e.g., heart, skeletal muscle), such adaptive responses are accomplished solely by increased cell size (Fig. 1-3). In other organs (e.g., kidney, thyroid), cell numbers and cell size may both increase. Hypertrophy is associated with an initial increase in the degradation of certain cellular proteins, followed by an increase in the synthesis of proteins needed to meet increased functional demand. Programmed cell death (apoptosis, see below) may be inhibited, thereby resulting in an increase in cell survival.

Hyperplasia is an Increase in the Number of Cells in an Organ or Tissue Hypertrophy and hyperplasia often occur concurrently. The specific stimuli that induce hyperplasia and the mechanisms by which they act vary greatly from one tissue and cell type to the next. Whatever the stimulus, hyperplasia involves stimulating resting cells (G0) to enter the cell cycle (G1) and then to multiply. This may be a response to an altered endocrine milieu, increased functional demand, or chronic injury. These topics are discussed in Chapters 3 and 5.

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C H A P T E R 1 : CELL INJURY

B Proliferative endometrium. A. A section of the uterus from a woman of reproductive age reveals a thick endometrium composed of proliferative glands in an abundant stroma. B. The endometrium of a 75-year-old woman (shown at the same magnification) is thin and contains only a few atrophic and cystic glands. FIGURE 1-2.

• Hormonal Stimulation: Changes in hormone concentrations, whether physiologic or pathologic, can elicit proliferation of responsive cells. The normal increase in estrogens at puberty or early in the menstrual cycle leads to increased numbers of endometrial and uterine stromal cells. Exogenous estrogen administration to postmenopausal women has the same effect. Ectopic hormone production may also result in hyperplasia. Erythropoietin production by renal tumors may lead to hyperplasia of erythrocytes in the bone marrow. • Increased Functional Demand: Hyperplasia, like hypertrophy, may be a response to increased physiologic demand. At high altitudes, low atmospheric oxygen content leads to compensatory hyperplasia of erythrocyte precursors in the bone marrow and increased erythrocytes in the blood (secondary polycythemia). Chronic blood loss, as in excessive menstrual bleeding, also causes hyperplasia of erythrocytic elements. • Chronic Injury: Long-standing inflammation or chronic physical or chemical injury often results in a hyperplastic response. Pressure from ill-fitting shoes causes hyperplasia of the skin of the foot, so-called corns or calluses, which reflects the skin’s protective capacity. Inappropriate hyperplasia can itself be harmful—witness the unpleasant consequences of psoriasis, which is characterized by conspicuous hyperplasia of the skin (Fig. 1-4). Excessive estrogen

stimulation, whether from endogenous or exogenous sources, may lead to endometrial hyperplasia.

Metaplasia is Conversion of One Differentiated Cell Type to Another Metaplasia is usually an adaptive response to chronic persistent injury, in which a tissue assumes the phenotype that provides it with the best protection from the insult. Most commonly, glandular epithelium is replaced by squamous epithelium. Columnar or cuboidal lining cells may be committed to mucus production but may not be adequately resistant to the effects of chronic irritation or a pernicious chemical. For example, prolonged exposure of the bronchial epithelium to tobacco smoke leads to squamous metaplasia. A similar response occurs in the endocervix afflicted by chronic infection (Fig. 1-5). The process is not restricted to squamous differentiation. When highly acidic gastric contents reflux chronically into the lower esophagus, the squamous epithelium of the esophagus may be replaced by stomach-like glandular mucosa (Barrett epithelium). This can be thought of as an adaptation to protect the esophagus from injury by gastric acid and pepsin, to which the normal gastric mucosa is resistant. Metaplasia may also consist of replacement of one glandular epithelium by another. Metaplasia of transitional epithelium to glandular epithelium occurs when the bladder is chronically inflamed (cystitis glandularis). Although metaplasia is often adaptive, it is not necessarily innocuous. For example, squamous metaplasia may protect a bronchus from tobacco smoke, but it also impairs mucus production and ciliary clearance. Neoplastic transformation may occur in metaplastic epithelium; cancers of the lung, cervix, stomach, and bladder often arise in such areas. Metaplasia is usually fully reversible. If the noxious stimulus is removed (e.g., when one stops smoking), the metaplastic epithelium eventually returns to normal.

Dysplasia is Disordered Growth and Maturation of the Cellular Components of a Tissue

Myocardial hypertrophy. Cross-section of the heart of a patient with long-standing hypertension shows pronounced, concentric left ventricular hypertrophy. FIGURE 1-3.

The cells that compose an epithelium normally exhibit uniformity of size, shape, and nuclear structure. Moreover, they are arranged in a regular fashion, as, for example, a squamous epithelium progresses from plump basal cells to flat superficial cells. In dysplasia, this monotonous appearance is disturbed by (1) variation in cell size and shape, (2) nuclear enlargement, irregularity, and hyperchromatism, and (3) disarray in the arrangement of cells within the epithelium (Fig. 1-6). Dysplasia occurs most often in hyper-

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4 Essentials of Rubin’s Pathology

B FIGURE 1-4.

Hyperplasia. A. Normal epidermis. B. Epidermal hyperplasia in psoriasis, shown at the same magnification as in A. The epidermis is thickened, owing to an increase in the number of squamous cells.

plastic squamous epithelium, as seen in epidermal actinic keratosis (caused by sunlight) and in areas of squamous metaplasia, such as in the bronchus or the cervix. It is not, however, exclusive to squamous epithelium. Ulcerative colitis, an inflammatory disease of the large intestine, is often complicated by dysplastic changes in the columnar mucosal cells. Like metaplasia, dysplasia is a response to a persistent injurious influence and will usually regress, for example, on cessation of smoking or the disappearance of human papillomavirus from the cervix. However, it shares many cytologic features with cancer, and the line between the two may be very fine. For example, it may be difficult to distinguish severe dysplasia from early cancer of the cervix. Dysplasia is preneoplastic, in the sense that it is a necessary stage in the multistep cellular evolution to cancer. In fact, dysplasia is included in the morphologic classifications of the stages of intraepithelial neoplasia in a variety of organs (e.g., cervix, prostate, bladder). Severe dysplasia is considered an indication for aggressive preventive therapy to cure the underlying cause, eliminate the noxious agent, or surgically remove the offending tissue. As in the development of cancer (see Chapter 5), dysplasia results from sequential mutations in a proliferating cell population. Dysplasia is the morphologic expression of the molecular disturbance in growth regulation. However, unlike cancer cells, dysplastic cells are not entirely autonomous, and with intervention, tissue appearance may still revert to normal.

Squamous metaplasia. A section of endocervix FIGURE 1-5. shows the normal columnar epithelium at both margins and a focus of squamous metaplasia in the center.

Mechanisms and Morphology of Cell Injury All cells have efficient mechanisms to deal with shifts in environmental conditions. Thus, ion channels open or close, harmful chemicals are detoxified, metabolic stores such as fat or glycogen may be mobilized, and catabolic processes may lead to the segregation of internal particulate materials. It is when environmental changes exceed the cell’s capacity to maintain normal homeostasis that cell injury occurs. If the stress is removed in time or if the cell can withstand the assault, cell injury is reversible, and complete structural and functional integrity is restored. The cell can also be exposed to persistent sublethal stress, as in mechanical irritation of the skin or exposure of the bronchial mucosa to tobacco smoke. In such instances, the cell has time to adapt to reversible injury in a number of ways, each of which has its morphologic counterpart. On the other hand, if the stress is severe, irreversible injury leads to death of the cell. The precise moment at which reversible injury gives way to irreversible injury, the “point of no return,” cannot be identified at present.

Dysplasia. The dysplastic epithelium of the uterine cervix lacks the normal polarity, and the individual cells show hyperchromatic nuclei, a larger nucleus-to-cytoplasm ratio, and a disorderly arrangement. FIGURE 1-6.

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gradient into the cell and prevents a similar efflux of potassium (K+) from the cell. The barrier to Na+ is imperfect, and the relative leakiness to that ion permits its passive entry into the cell. To compensate for this intrusion, the energy-dependent plasma membrane Na+ pump (Na+/K+-ATPase), which is fueled by ATP, extrudes Na+ from the cell. Injurious agents may interfere with this membrane-regulated process by (1) increasing the permeability of the plasma membrane to Na+, thereby exceeding the capacity of the pump to extrude Na+, (2) damaging the pump directly, or (3) interfering with the synthesis of ATP, thereby depriving the pump of its fuel. In any event, the accumulation of Na+ in the cell leads to an increase in water content to maintain isosmotic conditions; the cell then swells.

Subcellular Changes Occur in Reversibly Injured Cells

Hydropic swelling. A needle biopsy of the liver of a patient with toxic hepatic injury shows severe hydropic swelling in the centrilobular zone. The affected hepatocytes exhibit central nuclei and cytoplasm distended (ballooned) by excess fluid. FIGURE 1-7.

Hydropic Swelling is a Reversible Increase in Cell Volume Hydropic swelling is characterized by a large, pale cytoplasm and a normally located nucleus (Fig. 1-7). The greater volume reflects an increased water content. Hydropic swelling reflects acute, reversible cell injury and may result from such varied causes as chemical and biological toxins, viral or bacterial infections, ischemia, excessive heat or cold, etc. By electron microscopy, the number of organelles is unchanged, although they appear dispersed in a larger volume. The excess fluid accumulates preferentially in the cisternae of the endoplasmic reticulum, which are conspicuously dilated, presumably because of ionic shifts into this compartment (Fig. 1-8). Hydropic swelling is entirely reversible when the cause is removed. Hydropic swelling results from impairment of cellular volume regulation, a process that controls ionic concentrations in the cytoplasm. This regulation, particularly for sodium (Na+), involves three components: (1) the plasma membrane, (2) the plasma membrane Na+ pump, and (3) the supply of ATP. The plasma membrane imposes a barrier to the flow of Na+ down a concentration

• Endoplasmic Reticulum: The cisternae of the endoplasmic reticulum are distended by fluid in hydropic swelling. In other forms of acute, reversible cell injury, membrane-bound polysomes may undergo disaggregation and detach from the surface of the rough endoplasmic reticulum. • Mitochondria: In some forms of acute injury, particularly ischemia, mitochondria swell. This enlargement reflects the dissipation of the energy gradient and consequent impairment of mitochondrial volume control. Amorphous densities rich in phospholipid may appear, but these effects are fully reversible on recovery. • Plasma Membrane: Blebs of the cellular plasma membrane— that is, focal extrusions of the cytoplasm—are occasionally noted. These can detach from the membrane into the external environment without the loss of cell viability. • Nucleus: In the nucleus, reversible injury is reflected principally in nucleolar change. The fibrillar and granular components of the nucleolus may segregate. Alternatively, the granular component may be diminished, leaving only a fibrillar core. These changes in cell organelles (Fig. 1-9) are reflected in functional derangements (e.g., reduced protein synthesis and impaired energy production). After withdrawal of an acute stress that has led to reversible cell injury, by definition, the cell returns to its normal state.

Ischemic Cell Injury Usually Results from Obstruction to the Flow of Blood When tissues are deprived of oxygen, ATP cannot be produced by aerobic metabolism and is instead generated inefficiently by anaerobic metabolism. Ischemia initiates a series of chemical and pH

B Ultrastructure of hydropic swelling of a liver cell. A. Two apposed normal hepatocytes with tightly organized, parallel arrays of rough endoplasmic reticulum. B. Swollen hepatocyte in which the cisternae of the endoplasmic reticulum are dilated by excess fluid. FIGURE 1-8.

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Plama membrane bleb

Disaggregated ribosomes

Increased intracellular volume

Dilated, vesicular endoplasmic reticulum

Aggregated cytoskeletal elements

Mitochondrial swelling and calcification

FIGURE 1-9.

Ultrastructural features of reversible cell injury.

imbalances, which are accompanied by enhanced generation of injurious free-radical species. The damage produced by short periods of ischemia tends to be reversible if the circulation is restored. However, cells subjected to long episodes of ischemia become irreversibly injured and die. The mechanisms of cell damage are discussed later.

Oxidative Stress Leads to Cell Injury in Many Organs For human life, oxygen is both a blessing and a curse. Without it, life is impossible, but oxygen metabolism can produce partially reduced oxygen species that react with virtually any molecule they reach.

leaks in mitochondrial electron transport, with an additional contribution from the mixed-function oxygenase (P450) system. The major forms of ROS are listed in Table 1-1.

Superoxide

The superoxide anion (O2–) is produced principally by leaks in mitochondrial electron transport or as part of the inflammatory response (see Chapter 2). Superoxide and other ROS are the princiO2 cytosolic enzymes

Electron transport chain

Reactive Oxygen Species (ROS)

O2-

ROS have been identified as the likely cause of cell injury in many diseases and other damaging events. These include: • The inflammatory process (see Chapter 2) • Chemical toxicity • Ionizing radiation in which injury is the result of the direct formation of hydroxyl (•OH) radicals from the radiolysis of water (H2O) • Chemical carcinogenesis • Aging (see below) Cells may also be injured when oxygen is present at concentrations greater than normal. The lungs of adults and the eyes of premature newborns were at one time the major targets of such oxygen toxicity (retrolental fibroplasia) until recognized. Complete reduction of O2 to H2O by mitochondrial electron transport involves the transfer of four electrons. There are three partially reduced species that are intermediate between O2 and H2O, representing transfers of varying numbers of electrons (Fig. 1-10). They are O2–, superoxide (one electron); H2O2, hydrogen peroxide (two electrons); and •OH, the •OH radical (three electrons). For the most part, these ROS are produced principally by

P450

CoQ 4H+

2H+

2H2O

O2-

SOD

SOD GPX

H2O2

2H2O2 catalase

GPX

H2O

O2 + 2H2O Peroxisome

Mitochondrion

Mechanisms by which reactive oxygen radicals are generated from molecular oxygen and then detoxified by cellular enzymes. CoQ, coenzyme Q; GPX, glutathione peroxidase; H+, hydrogen ion; H2O, water; H2O2, hydrogen peroxide; O2, oxygen; O2– superoxide; SOD, superoxide dismutase. FIGURE 1-10.

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TABLE 1–1

Reactive Oxygen Species

GSSG Molecule

Attributes

Hydrogen peroxide (H2O2)

Forms free radicals via Fe2+-catalyzed Fenton reaction

H2O

Diffuses widely within the cell Superoxide anion (O2–)

Generated by leaks in the electron transport chain and some cytosolic reactions

GSH H2O2 Fe2+

Fe3+

O2-

Produces other ROS

•OH

Does not readily diffuse far from its origin Hydroxyl radical (•OH)

Generated from H2O2 by 2+ Fe -catalyzed Fenton reaction The intracellular radical most responsible for attack on macromolecules

Peroxynitrite (ONOO•)

Formed from the reaction of nitric oxide (NO) with O2 damages macromolecules

Lipid peroxide radicals (RCOO•)

Organic radicals produced during lipid peroxidation

Hypochlorous acid (HOCl)

Produced by macrophages and neutrophils during respiratory burst that accompanies phagocytosis Dissociates to yield hypochlorite radical (OCl–)

Fe2+, ferrous iron; ROS, reactive oxygen species.

pal effectors of cellular oxidative defenses that destroy pathogens, fragments of necrotic cells, or other phagocytosed material. They may also serve as signaling intermediates that elicit the release of proteolytic and other degradative enzymes (see Chapter 2).

Hydrogen Peroxide

O2– anions are catabolized by superoxide dismutase to produce H2O2. Hydrogen peroxide is also produced directly by a number of oxidases in cytoplasmic peroxisomes (see Fig. 1-10). By itself, H2O2 is not particularly injurious, and it is largely metabolized to H2O by catalase or glutathione peroxidase in both the cytosol and the mitochondria (see Fig. 1-10). However, when produced in excess, it is converted to highly reactive •OH. In neutrophils, myeloperoxidase transforms H2O2 to the potent radical hypochlorite (OCl–), which is lethal for microorganisms and cells.

Hydroxyl Radical Hydroxyl radicals (•OH) are formed by (1) the radiolysis of H2O, (2) the reaction of H2O2 with ferrous iron (Fe2+) (Fenton reaction), and (3) the reaction of O2– with H2O2 (Haber-Weiss reaction). The •OH radical is the most reactive molecule of ROS, and there are several mechanisms by which it can damage macromolecules. • Lipid Peroxidation: This process ultimately results in the destruction of the unsaturated fatty acids of phospholipids and a loss of membrane integrity. • Protein Interactions: As a result of oxidative damage caused by •OH, proteins undergo fragmentation, cross-linking, aggregation, and eventually degradation. • DNA damage: DNA is an important target of the •OH. A variety of structural alterations include strand breaks, modified bases, and cross-links between strands. In most cases, the integrity of the genome can be reconstituted by the various DNA

Lipid peroxidation

Proteins

DNA

(inner mitochondrial (oxidative membrane damage) damage)

CELL DEATH Mechanisms of cell injury by activated oxygen species. Fe2+, ferrous iron; Fe2+, ferric iron; GSH, glutathione; GSSG, glutathione; H2O2, hydrogen peroxide; O2, oxygen; O2–, superoxide anion; •OH, hydroxyl radical. FIGURE 1-11.

repair pathways. However, if oxidative damage to DNA is sufficiently extensive, the cell dies. Figure 1-11 summarizes the mechanisms of cell injury by activated oxygen species.

Cellular Defenses against Oxygen-Free Radicals Cells manifest potent antioxidant defenses against ROS, including detoxifying enzymes such as superoxide dismutase, catalase and glutathione peroxidase (see above), and exogenous free-radical scavengers such as vitamins C (ascorbate), vitamin E (␣-tocopherol), and vitamin A precursors (retinoids)

Ischemia/Reperfusion Injury Reflects Oxidative Stress Ischemia/reperfusion (I/R) injury is a common clinical problem that arises in occlusive cardiovascular disease, infection, shock, and many other settings. I/R injury reflects the interplay of transient ischemia, consequent tissue damage, and exposure of damaged tissue to the oxygen that arrives when blood flow is re-established (reperfusion). Initially, ischemic cellular damage leads to the generation of free-radical species. Reperfusion then provides abundant molecular O2 to combine with free radicals to form ROS. The evolution of I/R injury also involves several other factors, including inflammatory mediators (tumor necrosis factor␣ [TNF-␣], interleukin-1 [IL-1]), platelet-activating factor, nitric oxide synthase (NOS), NO•, intercellular adhesion molecules, and many more. Reperfusion injury can be put into perspective by emphasizing that there are three different degrees of cell injury, depending on the duration of the ischemia: • With short periods of ischemia, reperfusion (and, therefore, the resupply of oxygen) completely restores the structural and functional integrity of the cell. Cell injury in this case is completely reversible.

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8 Essentials of Rubin’s Pathology

• With longer periods of ischemia, reperfusion is not associated with restoration of cell structure and function but rather with deterioration and death of the cells. In this case, lethal cell injury occurs during the period of reperfusion. • Lethal cell injury may develop during the period of ischemia itself, in which case reperfusion is not a factor. A longer period of ischemia is needed to produce this third type of cell injury. In this case, cell damage does not depend on the formation of activated oxygen species.

Intracellular Storage Is Retention of Materials Within the Cell The substances that accumulate may be normal or abnormal, endogenous or exogenous, harmful or innocuous and may act as an indicator of cell injury (Fig 1-12). • Degraded phospholipids, which result from the turnover of endogenous membranes, are stored in lysosomes and may be recycled or remain as insoluble pigments (lipofuscin) (Fig. 1-12D). • Substances that cannot be metabolized accumulate in cells. These include (1) endogenous substrates that are not further processed because a key enzyme is missing (hereditary storage diseases) (see Chapter 6), (2) insoluble endogenous pigments, such as lipofuscin (see above) and melanin (Fig. 1-12 E), (3) aggregates of normal or abnormal proteins, and (4) exogenous particulates (e.g., inhaled silica and carbon or injected tattoo pigments). • Overload of normal body constituents, including iron, copper, and cholesterol, injures a variety of cells. • Abnormal proteins may be toxic when they are retained within a cell. Examples are Lewy bodies in Parkinson disease and mutant α1-antitrypsin in liver disease (Fig. 1-12 C).

Fat Abnormal accumulation of fat is most conspicuous in the liver, a subject treated in detail in Chapter 14. When delivery of free fatty acids to the liver is increased, as in diabetes, or when intrahepatic lipid metabolism is disturbed, as in alcoholism, triglycerides accumulate in liver cells. Fatty liver is identified morphologically as lipid globules in the cytoplasm. Other organs, including the heart, kidney, and skeletal muscle, also store fat, as do atherosclerotic plaque macrophage (Fig. 1-12A,B). Fat storage is generally reversible, and there is no evidence that the excess fat by itself interferes with cell function (although such storage may well be associated with disease).

Lipofuscin Lipofuscin is a mixture of lipids and proteins containing a goldenbrown pigment called ceroid. Lipofuscin tends to accumulate by accretion of oxidized, cross-linked proteins and is not digestible. It occurs mainly in terminally differentiated cells (neurons and cardiac myocytes) or in cells that cycle infrequently (hepatocytes) (see Fig. 1-12D). It is often more conspicuous in conditions associated with atrophy of an organ.

Exogenous Substances Anthracosis refers to the storage of carbon particles in the lung and regional lymph nodes (Fig. 1-12F). Virtually all urban dwellers inhale particulates of organic carbon generated by the burning of fossil fuels. These particles accumulate in alveolar macrophages and are also transported to hilar and mediastinal lymph nodes, where the indigestible material is stored indefinitely within macrophages. Although the gross appearance of the lungs of persons with anthracosis may be alarming, the condition is innocuous. Tattoos are the result of the introduction of insoluble metallic and vegetable pigments into the skin, where they are engulfed by dermal macrophages and persist for a lifetime.

Iron and Other Metals Total body iron may be increased by enhanced intestinal iron absorption, as in some anemias, or by administration of iron-containing erythrocytes in a transfusion. In either case, the excess iron is stored intracellularly as ferritin and hemosiderin (Fig. 1-12G). Increasing the body’s total iron content leads to progressive accumulation of hemosiderin (a partially denatured form of ferritin that aggregates easily and is recognized microscopically as yellow-brown granules in the cytoplasm), a condition termed hemosiderosis. Intracellular accumulation of iron in hemosiderosis does not usually injure cells. However, if the increase in total body iron is extreme, we speak of iron overload syndromes (see Chapter 14), in which iron deposition is so severe that it damages vital organs—particularly the heart, liver, and pancreas. Excessive iron storage in some organs is also associated with an increased risk of cancer. Pulmonary siderosis encountered among certain metal polishers is accompanied by an increased risk of lung cancer. Hereditary hemochromatosis (a genetic abnormality of iron absorption) leads to a higher incidence of liver cancer, as well as cirrhosis and cardiac disease. Excess accumulation of lead, particularly in children, causes mental retardation and anemia. In Wilson disease, a hereditary disorder of copper metabolism, storage of excess copper in the liver and brain may produce severe chronic disease of those organs.

Calcification is a Normal or Abnormal Process The deposition of mineral salts of calcium is a normal process in the formation of bone from cartilage. Calcium entry into dead or dying cells occurs, owing to the inability of such cells to maintain a steep calcium gradient. This cellular calcification is not ordinarily visible except as inclusions within mitochondria. Dystrophic calcification refers to the macroscopic deposition of calcium salts in injured tissues. This type of calcification does not simply reflect an accumulation of calcium derived from the bodies of dead cells. Rather it represents an extracellular deposition of calcium from the circulation or interstitial fluid associated with persistent necrotic tissue. Dystrophic calcification may have no functional consequences, but if it occurs in a crucial location, such as a mitral or aortic valve, it may result in disease. Metastatic calcification reflects deranged calcium metabolism, in contrast to dystrophic calcification, which has its origin in cell injury. Metastatic calcification is associated with an increased serum calcium concentration (hypercalcemia).

Melanin Melanin is an insoluble, brown-black pigment found principally in the epidermal cells of the skin but also in the eye and other organs (see Fig. 112E). It is located in intracellular organelles known as melanosomes and results from the polymerization of certain oxidation products of tyrosine. The amount of melanin is responsible for the differences in skin color among the various races, as well as the color of the eyes. It serves a protective function, owing to its ability to absorb ultraviolet light. In white persons, exposure to sunlight increases melanin formation (tanning). Melanin is discussed in detail in Chapter 24.

How Exogenous Agents Injure Cells Ionizing radiation, chemicals, and viral pathogens injure cells by diverse mechanisms, often by direct interactions with and damage to critical cell components. Other agents may require metabolic activation that produces highly reactive free radicals (ROS), or as is the case with ionizing radiation, directly produce reactive •OH radicals. Viruses may subvert intrinsic cell death pathways (apoptotic pathways) to their advantage or provoke immune-mediated injury.

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A. Lipid accumulation in macrophages in a cutaneous xanthoma. B. Abnormal cholesterol accumulation in an atherosclerotic plaque. C. Storage of abnormal, mutant, α1-antitrypsin in the liver (red granules). Periodic acid-Schiff (PAS) stain after diastase treatment to remove glycogen. D. Lipofuscin. Photomicrograph of the liver from an 80-year-old man shows golden cytoplasmic granules, which represent lysosomal storage of lipofuscin. E. Melanin storage (arrows) in an intradermal nevus. F. Carbon pigment storage. A mediastinal lymph node, which drains the lungs, exhibits numerous macrophages that contain black anthracotic (carbon) pigment. This material was inhaled and originally deposited in the lungs. G. Iron storage in hereditary hemochromatosis. Prussian blue stain of the liver reveals large deposits of iron within hepatocellular lysosomes. FIGURE 1-12.

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Ionizing Radiation Damages Cells by Production of Hydroxyl Radicals and Direct Mutagenic Effects The term “ionizing radiation” connotes an ability to cause radiolysis of water, thereby directly forming •OH. As noted above, •OH interact with DNA and inhibit DNA replication. For a nonproliferating cell, such as a hepatocyte or a neuron, the inability to divide is of little consequence. For a proliferating cell, however, the prevention of mitosis is a catastrophic loss of function. Once a proliferating cell can no longer divide, it dies by apoptosis (see below), which rids the body of those cells that have lost their prime function. Direct mutagenic effects of ionizing radiation on DNA are also important. The cytotoxic effects of ionizing radiation are dose dependent. Whereas exposure to significant amounts of radiation impairs the replicating capacity of cycling cells, massive doses of radiation may kill both proliferating and quiescent cells directly. Figure 1-13 summarizes the mechanisms of cell killing by ionizing radiation.

Viral Cytotoxicity is Direct or Immunologically Mediated The means by which viruses cause cell injury and death are as diverse as viruses themselves. Unlike bacteria, a virus requires a cellular host to (1) house it; (2) provide enzymes, substrates, and other resources for viral replication; and (3) serve as a source for dissemination when mature virions are ready to be spread to other cells.

• Direct Toxicity: Viruses may injure cells directly by subverting cellular enzymes and depleting the cell’s nutrients, thereby disrupting the normal homeostatic mechanisms. The mechanisms underlying virus-induced lysis of cells, however, are complex. • Manipulation of Apoptosis (see below): There are many viral activities that can elicit apoptosis. For example, apoptosis is activated when the cell detects episomal (extrachromosomal) DNA replication. Because viruses must avoid cell death before they have produced infectious progeny, they have evolved mechanisms to counteract this effect by upregulating antiapoptotic proteins and inhibiting proapoptotic ones. Some viruses also encode proteins that induce apoptosis once daughter virions are released. • Immunologically mediated cytotoxicity: Both humoral and cellular arms of the immune system protect against the harmful effects of viral infections by eliminating infected cells. These arms of the immune system eliminate virus-infected cells by inducing apoptosis or by lysing the cell with complement (see Chapter 4).

Chemicals Injure Cells Directly and Indirectly Innumerable chemicals can damage almost any cell in the body. The science of toxicology attempts to define the mechanisms that determine both target cell specificity and the mechanism of action of such chemicals. Toxic chemicals either (1) are themselves not toxic but are metabolized to yield an ultimate toxin that interacts with the target cell or (2) interact directly with cellular constituents without requiring metabolic activation. Whatever the mechanism, the result is usually necrotic cell death (see below).

Ionizing Radiation 300-1000 R

Radiolysis of H2O

>2000 R

Energy transfer to macromolecules

All cells Proliferating cells

DNA damage Protein and lipid adducts

Liver Necrosis Caused by the Metabolic Products of Chemicals Acetaminophen, an important constituent of many analgesics, is a well-studied hepatotoxin, which is metabolized by the mixedfunction oxidase system of the endoplasmic reticulum of the hepatocyte and causes liver cell necrosis. The drug is innocuous in recommended doses, but when consumed to excess, it is highly toxic to the liver. Most acetaminophen is enzymatically converted in the liver to nontoxic glucuronide or sulfate metabolites. Less than 5% of acetaminophen is ordinarily metabolized by isoforms of cytochrome P450 to N-acetyl-p-benzoquinone imine (NAPQI), a highly reactive quinone (Fig. 1-14). However, when large doses of acetaminophen overwhelm the glucuronidation pathway, toxic amounts of NAPQI are formed. The conjugation of NAPQI with sulfhydryl groups on liver proteins causes extensive cellular dysfunction and subsequent injury. At the same time, NAPQI depletes the antioxidant glutathione (GSH), rendering the cell more susceptible to free radical-induced injury. Thus, conditions that deplete GSH, such as starvation, enhance the toxicity of acetaminophen. In addition, acetaminophen toxicity is increased by chronic alcohol consumption, an effect mediated by an ethanolinduced increase in the 3A4 isoform of P450, which results in increased production of NAPQI. Other hepatotoxic compounds (such as carbon tetrachloride [CCl4]) produce metabolites that directly peroxidate and damage cell membrane phospholipids.

Chemicals that are Not Metabolized APOPTOSIS

NECROSIS

Mechanisms by which ionizing radiation at low and high doses causes cell death. H20, water; •OH, hydroxyl radical; R, rads. FIGURE 1-13.

Directly cytotoxic chemicals interact with cellular constituents without prior metabolic conversion. The critical cellular targets are diverse and include, for example, mitochondria (heavy metals and cyanide), cytoskeleton (phalloidin from toxic mushrooms), and DNA (chemotherapeutic alkylating agents). The interaction of directly cytotoxic chemicals with glutathione (alkylating agents) weakens the cell’s antioxidant defenses.

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Acetaminophen O HNCCH3 15%

80%

Sulfates Glucuronates

Other detoxification pathways

P450 O HNCCH3

NAPQI O

HNCCH3

GSH transferase S–G

cellular integrity (e.g., ischemia, burns, and toxins). Necrosis occurs when an insult irreversibly interferes with a vital structure or function of an organelle (plasma membrane, mitochondria, etc.) and does not trigger apoptosis. Pathologic cell death, however, can also result from apoptosis, as exemplified by viral infections and ionizing radiation.

Necrosis Results from Exogenous Cell Injury

OH 5%

Covalent binding

Proteins DNA Mitochondria

Oxidative stress

OH Mercapturic acid NECROSIS

Chemical reactions involved in acetaminophen hepatotoxicity. GSH, glutathione; NAPQI, N-acetylp-benzoquinone imine. FIGURE 1-14.

Abnormal G Protein Activity Leads to Functional Cell Injury Normal cell function requires the coordination of numerous activating and regulatory signaling cascades. Hereditary or acquired interference with correct signal transduction can result in significant cellular dysfunction, as illustrated by diseases associated with faulty G proteins. Inherited defects in G protein subunits can lead to constitutive activation of the enzyme. In one such hereditary syndrome, endocrine manifestations predominate, including multiple tumors in the pituitary and thyroid glands. Another G protein mutation appears to predominate in many cases of essential hypertension, in which exaggerated activation of G protein signaling results in increased vascular responsiveness to stimuli that cause vasoconstriction. Certain microorganisms (e.g., Vibrio cholerae and Escherichia coli) produce their effects by elaborating toxins that activate G proteins.

At the cellular level, necrosis is characterized by cell and organelle swelling, ATP depletion, increased plasma membrane permeability, release of macromolecules, and eventually inflammation. Although the mechanisms responsible for necrosis vary according to the nature of the insult and the organ involved (see above), most instances of necrosis share certain mechanistic similarities. Whatever the nature of the lethal insult, cell necrosis is heralded by disruption of the permeability barrier function of the plasma membrane. Normally, extracellular concentrations of Na+ and calcium are orders of magnitude greater than intracellular concentrations. The opposite holds for potassium. The selective ion permeability requires (1) considerable energy, (2) structural integrity of the lipid bilayer, (3) intact ion channel proteins, and (4) normal association of the membrane with cytoskeletal constituents. When one or more of these elements is severely damaged, the resulting disturbance of the internal ionic balance is thought to represent the “point of no return” for the injured cell. The role of calcium in the pathogenesis of cell death deserves special mention. Ca2+concentration in extracellular fluids is in the millimolar range (10–3 M). By contrast, cytosolic Ca2+concentration is 10,000-fold lower, on the order of 10–7 M. Many crucial cell functions are exquisitely regulated by minute fluctuations in the cytosolic free calcium concentration. Thus, a massive influx of Ca2+ through a damaged plasma membrane ensures the loss of cell viability.

Coagulative Necrosis Coagulative necrosis refers to light microscopic alterations in a dead or dying cell (Fig. 1-15). The appearance of the necrotic cell has traditionally been termed coagulative necrosis because of its similarity to coagulation of proteins that occurs upon heating. However, the usefulness of this historical term today is questionable. Shortly after a cell’s death, its outline is maintained. When stained with the usual combination of hematoxylin and eosin, the cytoplasm of a necrotic cell is more deeply eosinophilic than usual.

Cell Death Paradoxically, an organism’s survival requires the sacrifice of individual cells. Physiologic cell death is integral to the transformation of embryonic anlagen to fully developed organs. It is also crucial for the regulation of cell numbers in a variety of tissues, including the epidermis, gastrointestinal tract, and hematopoietic system. Physiological cell death involves the activation of an internal suicide program, which results in cell killing by a process termed apoptosis. By contrast, pathologic cell death is not regulated and is invariably injurious to the organism. It may result from a variety of insults to

Coagulative necrosis. Photomicrograph of the heart in a patient with an acute myocardial infarction. In the center, the deeply eosinophilic necrotic cells have lost their nuclei. The necrotic focus is surrounded by paler-staining, viable cardiac myocytes. FIGURE 1-15.

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In the nucleus, chromatin is initially clumped and then is redistributed along the nuclear membrane. Three morphologic changes follow: • Pyknosis: The nucleus becomes smaller and stains deeply basophilic as chromatin clumping continues. • Karyorrhexis: The pyknotic nucleus breaks up into many smaller fragments scattered about the cytoplasm. • Karyolysis: The pyknotic nucleus may be extruded from the cell or it may manifest progressive loss of chromatin staining. Early ultrastructural changes in a dying or dead cell reflect an extension of alterations associated with reversible cell injury. In addition to the nuclear changes described above, the dead cell features dilated endoplasmic reticulum, disaggregated ribosomes, swollen and calcified mitochondria, aggregated cytoskeletal elements, and plasma membrane blebs. After a variable time, depending on the tissue and circumstances, a dead cell is subjected to the lytic activity of intracellular and extracellular enzymes. As a result, the cell disintegrates. This is particularly the case when necrotic cells have elicited an acute inflammatory response (see Chapter 2). Whereas the morphology of individual cell death tends to be uniform across different cell types, the tissue responses are more variable. This diversity is described by a number of terms that reflect specific histologic patterns that depend upon the organ and the circumstances.

Liquefactive Necrosis When the rate of dissolution of the necrotic cells is considerably faster than the rate of repair, the resulting morphologic appearance is termed liquefactive necrosis. The polymorphonuclear leukocytes of the acute inflammatory reaction contain potent hydrolases capable of digesting dead cells. A sharply localized collection of these acute inflammatory cells, generally in response to bacterial infection, produces rapid cell death and tissue dissolution. The result is often an abscess (Fig. 1-16), which is a cavity formed by liquefactive necrosis in a solid tissue. Eventually, an abscess is walled off by a fibrous capsule that contains its contents. Coagulative necrosis of the brain may occur after cerebral artery occlusion and is followed by rapid dissolution—liquefactive necrosis—of the dead tissue by a mechanism that cannot be attributed to the action of an acute inflammatory response. Liquefactive necrosis of large areas of the central nervous system can lead to an actual cavity or cyst that persists for the rest of the person’s life.

Fat necrosis. A photomicrograph of peripancreatic adipose tissue from a patient with acute pancreatitis shows an island of necrotic adipocytes adjacent to an acutely inflamed area. Fatty acids are precipitated as calcium soaps, which accumulate as amorphous, basophilic deposits at the periphery of the irregular island of necrotic adipocytes. FIGURE 1-17.

Fat Necrosis Fat necrosis specifically affects adipose tissue and most commonly results from pancreatitis or trauma (Fig. 1-17). The unique feature determining this type of necrosis is the presence of triglycerides in adipose tissue. The process begins when digestive enzymes, normally found only in the pancreatic duct and small intestine, are released from injured pancreatic acinar cells and ducts into the extracellular spaces. On extracellular activation, these enzymes digest the pancreas itself as well as surrounding tissues, including adipose cells. Free fatty acids bind calcium and are precipitated as calcium soaps. Grossly, fat necrosis appears as an irregular, chalky white area embedded in otherwise normal adipose tissue. Traumatic fat necrosis is common in the breast, where triglycerides and lipases are released from injured adipocytes as a result of direct cell injury.

Caseous Necrosis Caseous necrosis is characteristic of tuberculosis. The lesions of tuberculosis are compact aggregates of macrophages and other inflammatory cells termed granulomas or tubercles (see Chapter 2). In the center of such caseous granulomas, accumulated mononuclear cells that mediate the chronic inflammatory reaction to the offending mycobacteria are killed. The necrotic cells fail to retain their cellular outlines but do not disappear by lysis, as in liquefactive necrosis. Rather, the dead cells persist indefinitely as amorphous, coarsely granular, eosinophilic debris. Grossly, this debris is grayish white, soft, and friable. It resembles clumpy cheese, hence the name caseous necrosis. This distinctive type of necrosis is generally attributed to the toxic effects of the mycobacterial cell wall, which contains complex waxes (peptidoglycolipids) that exert potent biological effects.

Necrosis Usually Involves Accumulation of a Number of Intracellular Insults

FIGURE 1-16. leukocytes.

Liquefactive necrosis in an abscess of the skin. The abscess cavity is filled with polymorphonuclear

The processes by which cells undergo death by necrosis vary according to the cause, organ, and cell type. The best-studied and most clinically important example is ischemic necrosis of cardiac myocytes, the leading cause of death in the Western world. The mechanisms underlying the death of cardiac myocytes are in part unique, but the basic processes that are involved are comparable to

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Apoptosis, or Programmed Cell Death, Refers to a Cellular Suicide Mechanism

Blood. O2, glucose

ISCHEMIA

Cell membrane

Anaerobic glycolysis

Mitochondria

The Morphology of Apoptosis

Aerobic glycolysis

Krebs cycle

Lactate Na+/H+ exchange

ATP

Na+/K+ exchange

Apoptosis is a prearranged pathway of cell death triggered by a variety of specific extracellular and intracellular signals. It is part of the balance between the life and death of cells and determines that a cell dies when it is no longer useful or when it may be harmful to the larger organism. As a self-defense mechanism, cells that are infected with pathogens or in which genomic alterations have occurred are destroyed. In this context, many pathogens have evolved mechanisms to inactivate key components of the apoptotic signaling cascades. Apoptosis detects and destroys cells that harbor dangerous mutations, thereby maintaining genetic consistency and preventing the development of cancer. By contrast, as in the case of infectious agents, successful clones of tumor cells often devise mechanisms to circumvent apoptosis.

Artery (e.g. coronary)

Thrombus

K+ Na+

H+ Na+

K+ Na+

H+ Na+ Na+/Ca2+ exchange

Na+ Phospholipases

Activates

Na+ Ca2+

Cell membrane damage

NECROSIS

Mechanisms by which ischemia leads to cell death. ATP, adenosine triphosphate; Ca2+, calcium ion; H+, hydrogen ion; K+, potassium ion; Na2+, sodium ion; O2, oxygen. FIGURE 1-18.

those in other organs. Some of the unfolding events may occur simultaneously; others may be sequential This complex series of events is summarized below (Fig. 1-18). • Interruption of blood supply decreases delivery of O2 and glucose. • Anaerobic glycolysis leads to overproduction of lactate and decreased intracellular pH. • Distortion of the activities of pumps in the plasma membrane as a result of lack of ATP and intracellular acidosis skews the ionic balance of the cell. • Ca2+ accumulates in the cell. • Activation of phospholipase A2 (PLA2) and proteases by high intracellular Ca2+ disrupts the plasma membrane and cytoskeleton, thereby causing cell swelling. • The lack of O2 impairs mitochondrial electron transport, thereby decreasing ATP synthesis and facilitating production of ROS. • Mitochondrial damage promotes the release of cytochrome c to the cytosol. • The cell dies. Ample data from experimental and clinical studies indicate that pharmacologic interference with a number of events involved in the pathogenesis of cell necrosis can preserve cell viability after an ischemic insult. Treatments that increase glucose uptake and redress some of the ionic imbalances may preserve myocyte viability during ischemia.

Apoptotic cells are recognized by nuclear fragmentation and pyknosis, generally against a background of viable cells. Importantly, individual cells or small groups of cells undergo apoptosis, whereas necrosis characteristically involves larger geographic areas of cell death. Ultrastructural features of apoptotic cells include (1) nuclear condensation and fragmentation, (2) segregation of cytoplasmic organelles into distinct regions, (3) blebs of the plasma membrane, and (4) membrane-bound cellular fragments, which often lack nuclei (Fig. 1-19). Cells that have undergone necrotic cell death tend to elicit strong inflammatory responses. Inflammation, however, is not generally seen in the vicinity of apoptotic cells. Mononuclear phagocytes may contain cellular debris from apoptotic cells but recruitment of neutrophils or lymphocytes is uncommon (see Chapter 2). In view of the numerous developmental, physiologic, and protective functions of apoptosis, the lack of inflammation is clearly beneficial to the organism. Apoptosis plays multiple vital roles in normal development and physiology including: • Pruning of nonpersistent structures (such as interdigital tissue) during development • Removal of self-reactive clones during the generation of immune diversity • Removal of mature, senescent, and less functional cells in organs continuously repopulated from stem cells (such as the gastrointestinal mucosa, epidermis, and hematopoietic system) • Regression of hyperplasia in organs responding to changing trophic signals (such as postmenopausal atrophy of the endometrium) • Deletion of mutant cells after recognition of irreparable DNA damage, in concert with p53

Apoptosis as a Defense against Dissemination of Infection When a cell “detects” episomal (extrachromosomal) DNA replication, as in a viral infection, it tends to initiate apoptosis. This effect can be viewed as a means to eliminate infected cells before they

Apoptosis. A viable leukemic cell (A) contrasts with an apoptotic cell (B) in which the nucleus has undergone condensation and fragmentation. FIGURE 1-19.

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can spread the virus. Many viruses have evolved protective mechanisms to manipulate cellular apoptosis. Viral gene products that inhibit apoptosis have been identified for many agents, including human immunodeficiency virus, human papillomavirus, adenovirus, and many others. In some cases, these viral proteins bind and inactivate certain cellular proteins (e.g., p53) that are important in signaling apoptosis. In other instances, they may act at various points in the signaling pathways that activate apoptosis.

The Initiation of Apoptosis Apoptosis is a final effector mechanism that can be initiated by many different stimuli and has signals that are propagated by a number of pathways. Unlike necrosis, apoptosis engages the cell’s own signaling cascades. That is, a cell that undergoes apoptosis is an active participant in its own death (suicide). Most intermediate enzymes that transduce proapoptotic signals belong to a family of cysteine proteases called caspases. The best understood initiators of apoptosis at the cell membrane are the binding of TNF-α to its receptor (TNFR) and that of the Fas ligand to its receptor (Fas, or Fas receptor). TNF-␣ is most often a free cytokine, whereas the Fas ligand is located at the plasma membrane of certain cells, such as cytotoxic effector lymphocytes. The receptors for TNF-␣ and the Fas ligand become activated when they bind their ligands. These transmembrane proteins have

specific amino acid sequences, termed death domains, in their cytoplasmic tails that act as docking sites for death domains of other proteins that participate in the signaling process leading to apoptosis (Fig. 1-20A). After binding to the receptors, the latter proteins activate downstream signaling molecules, especially procaspase-8, which is converted to caspase-8. In turn, caspase-8 initiates an activation cascade of other downstream caspases in the apoptosis pathway. These caspases (3, 6, and 7) activate a number of nuclear enzymes (e.g., polyadenosine diphosphate [ADP]-ribosyl polymerase [PARP]) that mediate the nuclear fragmentation of apoptotic cell death. Activation of caspase signaling also occurs when killer lymphocytes, mainly cytotoxic T cells, recognize a cell as foreign. These lymphocytes release perforin and granzyme B. Perforin, as its name suggests, punches a hole in the plasma membrane of a target cell, through which granzyme B enters and activates procaspase-8 directly (see Fig. 1-20B).

Apoptosis and Mitochondrial Proteins The mitochondrial membrane is a key regulator of the balance between cell death and cell survival. Proteins of the Bcl-2 family reside in the mitochondrial inner membrane and are either proapoptotic or anti-apoptotic (prosurvival). The balance between such factors determines the fate of the cell (see Fig. 1-20C). Bcl-2 dimers at the mitochondrial membrane bind the protein Apaf-1. A surfeit of

TNF

TNFR Cell membrane Death domain Procaspases-3, 6, 7 Docking protein

Death domain Binds and activates Pro-C8 Activates Procaspase-8

Caspase-8

Activates

Endonucleases (PARP)

Caspases-3, 6, 7

Nuclear proteins (lamin)

Effector caspases cleave target proteins

Cytoskeletal proteins (α-fodrin)

APOPTOSIS A FIGURE 1-20.

Mechanisms by which apoptosis may be initiated, signaled, and executed. A. Ligand–receptor interactions that lead to caspase activation. TNF, tumor necrosis factor; TNFR, tumor necrosis factor receptor.

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Target Cell

Mitochondrion

CTL

Cyt C

Granzyme Perforin

Procaspase-9

ROS

PTP open

PTP closed Activated caspase-9

Procaspase-9

Apaf-1

Caspase-9

Procaspase-3

Caspase-3

Procaspase-6

Caspase-6

Procaspase-7

Caspase-7

APOPTOSIS B

APOPTOSIS C

Continued. B. Immunologic reactions in which granzyme released by cytotoxic lymphocytes (CTLs) causes apoptosis. C. Opening of the mitochondrial permeability transition pore, leading to Apaf-1 activation, thereby triggering the apoptotic cascade. Cyt C, cytochrome C; PTP, permeability transition pore; ROS, reactive oxygen species. FIGURE 1-20.

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proapoptotic constituents of the Bcl-2 family leads to the release of Apaf-1. At the same time, the mitochondrial permeability transition pore opens, and cytochrome c leaks through the mitochondrial membrane. Cytosolic cytochrome c activates Apaf-1, which in turn converts procaspase-9 to caspase-9. Caspase-9 activates downstream caspases (3, 6, and 7) in the same manner as caspase-8.

Apoptosis Activated by p53 A pivotal molecule in the cell’s life-and-death dance is the versatile protein p53, which preserves the viability of an injured cell when DNA damage can be repaired, but propels it toward apoptosis after irreparable harm has occurred (p53 is discussed in greater detail in Chapter 5). After it binds to areas of DNA damage, p53 activates proteins that arrest the cell in stage G1 of the cell cycle, allowing time for DNA repair to proceed. It also directs DNA repair enzymes to the site of injury. If DNA damage cannot be repaired, p53 activates mechanisms that lead to apoptosis. Stress also leads to accumulation of p53. Activation of certain oncogenes, such as c-myc, hypoxia, depletion of ribonucleotides, and loss of cell–cell adhesion during oncogenesis all promote p53-dependent apoptotic pathways. In summary, cells are continually poised between survival and apoptosis: their fate rests on the balance of powerful intracellular and extracellular forces and have signals that constantly act upon and counteract each other. Often, apoptosis functions as a self-protective programmed mechanism that leads to a cell’s suicide when its survival may be detrimental to the organism. At other times, apoptosis is a pathologic process that contributes to many disorders, especially degenerative diseases. Thus, pharmacologic manipulation of apoptosis is an active frontier of drug development.

Biological Aging Aging must be distinguished from mortality on the one hand and from disease on the other. Death is a random event; an aged person who does not succumb to the most common cause of death will die from the second, third, or tenth most common cause. Although the increased vulnerability to disease among the elderly is an interesting problem, disease itself is entirely distinct from aging.

Maximal Life Span Has Remained Unchanged Millennia ago, the psalmist sang of a natural life span of 70 years, which with vigor may extend to 80. By contrast, it is estimated that the usual age at death of Neolithic humans was 20 to 25 years, and the average life span today in some regions is often barely 10 years more. Interestingly, the maximum life span attained is not significantly altered by a protected environment. With improved safety and sanitation, antibiotics and other drugs, and better diagnostic and therapeutic methods, the age-adjusted death rate in the United States has declined by 40% since 1970. In 2004, life expectancy at the time of birth was 80.4 years for females and 75.2 years for males. Yet the maximum human life span has remained constant at about 110 years. Even if diseases associated with old age, such as cardiovascular disease and cancer, were eliminated, only a modest increase in average life expectancy would be seen.

The Cellular Basis of Aging Although the biological basis for aging is obscure, there is general agreement that its cause lies at the cellular level. Various theories of cellular aging have been proposed, but the evidence adduced for each is at best indirect. Support for the concept of a genetically programmed life span comes from studies of replicating cells in tissue culture. Unlike cancer cells, normal cells in tissue culture have a limited capacity to replicate at about 50 population doublings. If they are exposed to an oncogenic virus or a chemical carcinogen, they may continue to replicate; in a sense, they become immortal. A rough correlation between the number of population doublings in fibroblasts and life span has been reported in several species. Moreover, cells ob-

FIGURE 1-21.

Progeria. A 10-year-old girl shows the typical features of premature aging associated with progeria.

tained from persons afflicted with a syndrome of precocious aging, such as progeria (see below), also display a reduced number of population doublings in vitro. However, there is no demonstrable age-related change in vivo in the replicative capacity of rapidly cycling cells (e.g., epithelial cells of the intestine), leaving one with an apparent paradox. Cellular senescence in vitro is also a dominant genetic trait. Thus, hybrids between normal human cells in vitro, which exhibit a limited number of cell divisions, and immortalized cells with an indefinite capacity to divide, undergo senescence. An attractive explanation for cell senescence in vitro centers on the genetic elements at the tips of chromosomes, termed telomeres. These are series of short repetitive nucleotide sequences (2,000 in human chromosomes). Because DNA polymerase cannot copy the linear chromosomes all the way to the tip, the telomeres tend to shorten with each cell division until a critical diminution in size interferes with replication. Thus, telomere shortening acts as a molecular clock that produces senescence after a defined number of cell divisions in vitro. Most eukaryotic cells have the potential to express a ribonucleoprotein enzyme termed telomerase, which can extend chromosome ends. Expression of telomerase can reverse the senescent phenotype in vitro, and can be demonstrated in immortalized cells, but at the cost of producing a tumor-like phenotype. Hence, the telomeric clock functions as a tumor-suppressing mechanism, limiting cell proliferative capacity in vivo. Telomere shortening-dependent growth arrest suppresses tumorigenesis but at the cost of contributing to aging.

Genetic Factors Influence Aging In humans, the modest correlation in longevity between related persons, the excellent concordance of life span among identical twins, and the presence of heritable disease associated with accelerated aging (progeria) lend credence to the concept that aging is influenced by genetic factors. One of the most striking of such genetic diseases is Hutchinson-Guilford progeria, in which the entire

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Metabolic Activity

Genetic Factors Clock genes DNA repair Stress responses Antioxidant defenses

Oxidative Stress

Environmental Factors Caloric intake Intercurrent diseases Exogenous stresses (radiation, chemicals, etc.)

Somatic Injury DNA damage Protein adducts Lipid peroxidation

Aging FIGURE 1-22.

Factors that influence the development of biological aging.

process of aging, including features such as male-pattern baldness, cataracts, and coronary artery disease, is compressed into a span of less than 10 years (Fig. 1-21). The cause of this form of progeria is a mutation in the LMNA gene; its product is a protein termed lamin A, and the mutant form of this protein is termed progerin. This abnormal protein accumulates in the nucleus from one cell generation to the next, thereby interfering with the structural integrity and organization of the nucleus. A variety of additional mutations of the LMNA gene (termed “laminopathies”), as well as defects of other genes, are associated with the progeric phenotype.

eration of activated oxygen species correlates inversely with body size. Additional evidence for progressive oxidative damage with aging is the deposition of oxidized aggregated proteins and lipofuscin pigment, principally in postmitotic cells of organs such as the brain, heart, and liver (see above) and the accumulation of hydroxyl radical-mediated damage to mitochondrial DNA. Aerobic respiration in mitochondria is the richest source of ROS in the cell.

Aging May Reflect Accumulated Somatic Damage

Current evidence supports the notion that although aging is under some measure of genetic control, it is unlikely that a predetermined genetic program for aging exists (Fig. 1-22). It is likely that the combined effects of a number of genes eventually lead to the accumulation of somatic mutations, deficiencies in DNA repair, the accretion of oxidative damage to macromolecules, and a variety of other defects in cell function, all culminating in the progressive failure of homeostatic mechanisms characteristic of aging. As Maimonides said in the 12th century, “The same forces that operate in the birth and temporal existence of man also operate in his destruction and death.”

Oxidative stress is an invariable consequence of life in an atmosphere rich in oxygen. An important hypothesis holds that the loss of function that is characteristic of aging is caused by progressive and irreversible accrual of molecular oxidative damage. The rate of generation of ROS correlates with an organism’s overall metabolic rate. The theory that aging is related to oxidative stress is based on several observations: (1) larger animals usually live longer than smaller ones; (2) metabolic rate is inversely related to body size (the larger the animal, the lower the metabolic rate); and (3) gen-

Summary Hypothesis of Aging

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Inflammation Hedwig S. Murphy

Overview of Inflammation Acute Inflammation: Vascular Events Plasma-Derived Mediators of Inflammation Hageman Factor Kinins Complement System and the Membrane Attack Complex (MAC) Cell-Derived Mediators of Inflammation Arachidonic Acid and Platelet-Activating Factor Prostanoids, Leukotrienes, and Lipoxins Cytokines Reactive Oxygen Species (ROS) Cells of Inflammation Neutrophils Endothelial Cells Monocyte/Macrophages Mast Cells and Basophils Eosinophils Platelets

Leukocyte Recruitment in Acute Inflammation Leukocyte Adhesion Chemotactic Molecules Leukocytes Traverse the Endothelial Cell Barrier to Gain Access to the Tissue Leukoctye Functions in Acute Inflammation Phagocytosis Neutrophil Enzymes Oxidative and Nonoxidative Bactericidal Activity Outcomes of Acute Inflammation Chronic Inflammation Cells from Both the Circulation and Affected Tissue Play a Role in Chronic Inflammation Injury and Repair in Chronic Inflammation Granulomatous Inflammation Systemic Manifestations of Inflammation Acute Phase Response Fever Shock

Inflammation is the response to injury of a tissue and its microcirculation and is characterized by the elaboration of inflammatory mediators as well as the movement of fluid and leukocytes from the blood into extravascular tissues. Inflammation localizes and eliminates microorganisms, damaged cells, and foreign particles, paving the way for a return to normal structure and function. The clinical signs of inflammation, recognized in Egyptian medical texts before 1000 BC, were codified as the four cardinal signs of inflammation: rubor (redness), calor (heat), tumor (swelling), and dolor (pain) by the Roman encyclopedist Aulus Celsus in the

second century AD. These features correspond to the inflammatory events of vasodilation, edema, and tissue damage. A fifth sign, functio laesa (loss of function), was added in the 19th century by Rudolf Virchow, who recognized inflammation as a response to tissue injury.

Overview of Inflammation Inflammation is best viewed as an ongoing process that can be divided into phases. • Initiation results in a stereotypic, immediate response termed acute inflammation. The acute response is characterized by the rapid flooding of the injured tissue with fluid, coagulation factors, cytokines, chemokines, platelets and inflammatory cells, and neutrophils in particular (Fig. 2-1).

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FIGURE 2-1.

Acute inflammation with densely packed polymorphonuclear neutrophils (PMNs) with multilobed nu-

clei (arrows).

• Amplification depends upon the extent of injury and the activation of mediators such as kinins and complement components. Additional leukocytes and macrophages are recruited to the area. • Destruction of the inciting agent by phagocytosis and enzymatic or nonenzymatic processes reduces or eliminates foreign material or infectious organisms. At the same time, damaged tissue components are also removed, paving the way for repair to begin (see Chapter 3). • Termination of the inflammatory response is mediated by intrinsic anti-inflammatory mechanisms that limit tissue damage and allow for either restoration of tissue, with return to normal physiological function, or repair and the development of a scar in place of normal tissue. Certain types of injury trigger a sustained inflammatory response associated with the inability to clear injured tissue and foreign agents. Such a persistent response (which often has an immune component) is termed chronic inflammation. Chronic inflammatory infiltrates are composed largely of lymphocytes, plasma cells, and macrophages and often have an immune component (Fig. 2-2). Acute and chronic inflammatory infiltrates often coexist.

Acute Inflammation: Vascular Events Among the earliest responses to tissue injury are alterations in the anatomy and function of the microvasculature, which may promote edema (see Figs. 2-3 and 2-4). These responses include: 1. Transient vasoconstriction of arterioles at the site of injury is the earliest vascular response to mild skin injury. This process is mediated by both neurogenic and chemical mediator systems and usually resolves within seconds to minutes. 2. Vasodilation of precapillary arterioles then increases blood flow to the tissue, a condition known as hyperemia.

FIGURE 2-2.

Chronic inflammation. Lymphocytes, plasma cells (arrows), and a few macrophages are present.

Vasodilation is caused by the release of specific mediators and is responsible for redness and warmth at sites of tissue injury. 3. An increase in endothelial cell barrier permeability results in edema. Loss of fluid from intravascular compartments as blood passes through capillary venules leads to local stasis and plugging of dilated small vessels with erythrocytes. These changes are reversible following mild injury: within several minutes to hours, the extravascular fluid is cleared through lymphatics. The vascular response to injury is a dynamic event that involves sequential physiological and pathological changes. Vasoactive mediators, originating from both plasma and cellular sources, are generated at sites of tissue injury (see Fig. 2-4). These mediators bind to specific receptors on vascular endothelial and smooth muscle cells, causing vasoconstriction or vasodilation. Proximal to capillaries, vasodilation of arterioles increases blood flow and can exacerbate fluid leakage into the tissue. Distally, vasoconstriction of postcapillary venules increases capillary bed hydrostatic pressure, potentiating edema formation. By contrast, vasodilation of venules decreases capillary hydrostatic pressure and inhibits movement of fluid into extravascular spaces. After injury, vasoactive mediators bind specific receptors on endothelial cells, causing endothelial cell contraction and gap formation, a reversible process (see Fig. 2-3B). This break in the endothelial barrier leads to extravasation (leakage) of intravascular fluids into the extravascular space. Mild direct injury to the endothelium results in a biphasic response: an early change in permeability occurs within 30 minutes after injury, followed by a second increase in vascular permeability after 3 to 5 hours. When damage is severe, exudation of intravascular fluid into the extravascular compartment increases progressively, peaking 3 to 4 hours after injury. Severe direct injury to the endothelium, such as is caused by burns or caustic chemicals, may result in irreversible damage. In such cases, the endothelium separates from the basement membrane, resulting in cell blebbing (blisters or bubbles between the

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A NORMAL VENULE

Basement membrane Endothelial cell

Tight junction

B VASOACTIVE MEDIATOR-INDUCED INJURY

Electrolytes, fluid, protein

Time course of change in permeability Change in permeability

Endothelial retraction and gap formation

2 3 Hours

C DIRECT INJURY TO ENDOTHELIUM

Gap formation

Time course of change in permeability Change in permeability

Denuded basement membrane

Severe

Mild

Blebbing

2 3 Hours

Responses of the microvasculature to injury. A. The wall of the normal venule is sealed by tight junctions between adjacent endothelial cells. B. During mild vasoactive mediator-induced injury, the endothelial cells separate and permit the passage of the fluid constituents of the blood. C. With severe direct injury, the endothelial cells form blebs (b) and separate from the underlying basement membrane. Areas of denuded basement membrane (arrows) allow a prolonged escape of fluid elements from the microvasculature. FIGURE 2-3.

endothelium and the basement membrane). This leaves areas of basement membrane naked (see Fig. 2-3C), thereby disrupting the barrier between the intravascular and extravascular spaces. Several definitions are important for understanding the vascular components of inflammation: • Edema is the accumulation of fluid within the extravascular compartment and interstitial tissues. • A transudate is edema fluid with a low protein content (specific gravity 1.015), which frequently contains inflammatory cells. Exudates are observed early in acute inflammatory reactions and are produced by mild injuries, such as sunburn or traumatic blisters. • A fibrinous exudate contains large amounts of fibrin as a result of activation of the coagulation system. When a fibrinous exudate occurs on a serosal surface, such as the pleura or pericardium, it is referred to as “fibrinous pleuritis” or “fibrinous pericarditis.”

• A purulent exudate or effusion contains prominent cellular components. It is frequently associated with pathological conditions such as pyogenic bacterial infections, in which the predominant cell type is the polymorphonuclear neutrophil (PMN).

Plasma-Derived Mediators of Inflammation Numerous chemical mediators are integral to the initiation, amplification, and termination of inflammatory processes (Fig. 2-4). Cell- and plasma-derived mediators work in concert to activate cells by (1) binding specific receptors, (2) recruiting cells to sites of injury, and (3) stimulating the release of additional soluble mediators. These mediators themselves are relatively short-lived, or are inhibited by intrinsic mechanisms, effectively turning off the response and allowing the process to resolve. Cell-derived mediators are considered below. Plasma contains the elements of three major enzyme cascades, each composed of a series of proteases. Sequential activation of proteases results in release of important chemical mediators.

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SOURCE

PLASMADERIVED

• Hageman factor activation

MEDIATOR

Clotting/fibrinolytic system

Fibrin split products

Kallikrein-kinin system

Kinins (bradykinin)

• Complement system activation

C3a, C5a Increased vascular permeability

CELLDERIVED

FIGURE 2-4.

• Mast cell/basophil degranulation

Histamine

• Platelets

Serotonin

• Inflammatory cells

• Plateletactivating factor • Prostaglandins • Leukotrienes

• Endothelium

• Nitric oxide • Plateletactivating factor • Prostaglandins

EDEMA

Inflammatory mediators of increased vascular permeability.

These interrelated systems include (1) the coagulation cascade and fibrinolytic system, (2) kinin generation, and (3) the complement system (Fig. 2-4). The coagulation cascade is discussed in Chapters 10 and 20; the kinin and complement systems are presented here.

Hageman Factor is a Key Source of Vasoactive Mediators Hageman factor (clotting factor XII) is generated within the plasma and is activated by exposure to negatively charged surfaces such as basement membranes, proteolytic enzymes, bacterial lipopolysaccharides, and foreign materials. This key component triggers activation of additional plasma protease systems that are important in inflammation, including (1) the “intrinsic” coagulation cascade, (2) fibrinolysis with the concomitant elaboration of plasmin and plasmin-derived bioactive peptides, (3) generation of kallikrein and subsequent production of kinins, and (4) activation of the alternate complement pathway (see Fig. 2-5).

Kinins Amplify the Inflammatory Response Kinins are potent inflammatory agents formed in plasma and tissue by the action of serine protease kallikreins on specific plasma glycoproteins termed kininogens. Bradykinin and related peptides regulate multiple physiological processes, including blood pressure, contraction and relaxation of smooth muscle, plasma extravasation, cell migration, inflammatory cell activation, and inflammatory-mediated pain responses. Kinins amplify the inflammatory response by stimulating local tissue cells and inflammatory cells to generate additional mediators, including prostanoids, cytokines (especially tumor necrosis factor-α [TNF-

α] and interleukins), and nitric oxide (NO•). Kinins are rapidly degraded to inactive products by kininases and, therefore, have rapid and short-lived functions.

Complement is Activated Through Three Pathways to Form the Membrane Attack Complex (MAC) The complement system is a group of proteins found in plasma and on cell surfaces, whose primary function is defense against microbes. The physiological activities of the complement system include (1) defense against pyogenic bacterial infection by opsonization, chemotaxis, activation of leukocytes and lysis of bacteria and cells; (2) bridging innate and adaptive immunity for defense against microbial agents by augmenting antibody responses and enhancing immunological memory; and (3) disposal of immune products and products of inflammatory injury by clearance of immune complexes from tissues and removal of apoptotic cells. The endpoint of complement activation is the formation of the MAC and cell lysis. The cleavage products generated at each step of the way catalyze the next step in the cascade and have additional properties that render them important inflammatory molecules (Fig. 2-6): • Anaphylatoxins (C3a, C4a, C5a): These proinflammatory molecules mediate smooth-muscle contraction and increase vascular permeability. • Opsonins (C3b, iC3b): Bacterial opsonization is the process by which a specific molecule (e.g., IgG or C3b) binds to the surface of the bacterium. The process enhances phagocytosis by enabling receptors on phagocytic cell membranes (e.g., Fc receptor or C3b receptor) to recognize and bind the opsonized bac-

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AGENTS ASSOCIATED WITH INJURY • Negatively charged surfaces (e.g., basement membrane, collagen, elastin, glycosaminoglycans) • Bacterial lipopolysaccharide • Sodium urate crystals • Enzymes (e.g., trypsin, plasmin)

ACTIVATION OF HAGEMAN FACTOR (XII) Plasminogen Plasmin

Fibrinolysis

Activation of kallikrein

Activation of coagulation system

Complement activation

FIBRIN DEGRADATION PRODUCTS

KININ GENERATION

CLOT FORMATION

Hageman factor activation and inflammatory mediator production. Hageman factor activation is a key event leading to conversion of plasminogen to plasmin, resulting in generation of fibrin split products and active complement products. Activation of kallikrein produces kinins, and activation of the coagulation system results in clot formation. FIGURE 2-5.

terium. Viruses, parasites, and transformed cells also activate complement by similar mechanisms, an effect that leads to their inactivation or death. • Proinflammatory molecules (MAC, C5a): These chemotactic factors also activate leukocytes and tissue cells to generate oxidants and cytokines and induce degranulation of mast cells and basophils. The complement system is activated by three convergent pathways termed classical, mannose-binding lectin (MBL), and alternative pathways (see Fig. 2-6).

The Classical Pathway Activators of the classical pathway include antigen-antibody (AgAb) complexes, products of bacteria and viruses, proteases, urate crystals, apoptotic cells, and polyanions (polynucleotides). The proteins of this pathway are C1 through C9, the nomenclature following the historical order of discovery. Ag-Ab complexes activate C1, initiating a cascade that leads to formation of the MAC, which proceeds as shown in Figure 2-6.

The Mannose-Binding Pathway The mannose- or lectin-binding pathway has some components in common with the classical pathway. It is initiated by the binding of microbes bearing terminal mannose groups to mannose-binding lectin, a member of the family of calcium-dependent lectins, termed the collectins. This multifunctional acute-phase protein has properties similar to those of immunoglobulin M (IgM) antibody (binds to a wide range of oligosaccharide structures), IgG (interacts with phagocytic receptors), and C1q. This last property enables it to interact with either C1r-C1s or with a serine protease called MASP (MBL-associated serine protease) to activate complement (see Fig. 2-6).

Alternative Pathway The alternative pathway is initiated by derivative products of microorganisms, such as endotoxin (from bacterial cell surfaces), zymosan (yeast cell walls), polysaccharides, viruses, tumor cells, and foreign materials. Proteins of the alternative pathway are called “factors,” followed by a letter. Activation of the alternative pathway occurs at the level of C3 activation to produce small amounts of C3b, which become covalently bound to carbohydrates and proteins on microbial cell surfaces (see Fig. 2-6).

The Complement System and Disease The importance of an intact and appropriately regulated complement system is exemplified in persons who have acquired or congenital deficiencies of specific complement components or regulatory proteins. Such patients have an increased susceptibility to infectious agents, and in some cases, a propensity for autoimmune diseases associated with circulating immune complexes.

Cell-Derived Mediators of Inflammation Circulating platelets, basophils, PMNs, endothelial cells, monocyte/macrophages, tissue mast cells, and the injured tissue itself are all potential cellular sources of vasoactive mediators. In general, these mediators are (1) derived from metabolism of phospholipids and arachidonic acid (e.g., prostaglandins, thromboxanes, leukotrienes, lipoxins, platelet-activating factor [PAF]), (2) preformed and stored in cytoplasmic granules (e.g., histamine, serotonin, lysosomal hydrolases), or (3) derived from altered production of normal regulators of vascular function (e.g., NO•).

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Alternative Pathway

Classical Pathway

Bacteria, activation surfaces

Antigen-antibody complexes

Mannose on microbe surfaces

bind C1

bind MBL

C1 Activation

C1r/C1s-MBL or MBL-MASP

bind C3b

Plasma C3

Factors D and B

Mannose-Binding Pathway

TABLE 2–1

Biological Activities of Arachidonic Acid Metabolites Metabolite

Biological Activity

PGE2, PGD2

Induce vasodilation, bronchodilation, inhibit inflammatory cell function

PGI2

Induces vasodilation, bronchodilation, inhibits inflammatory cell function

PGF2α

Induces vasodilation, bronchoconstriction

TXA2

Induces vasoconstriction, bronchoconstriction, enhances inflammatory cell functions (especially platelets)

LTB4

Chemotactic for phagocytic cells, stimulates phagocytic cell adherence, enhances microvascular permeability

LTC4, LTD4, LTE4

Induce smooth muscle contraction, constrict pulmonary airways, increase microvascular permeability

C2 C3bBb (C3 convertase)

C4b,2a (C3 convertase) C3 C3a ANAPHYLATOXIN C3b C3b, iC3b OPSONIZATION

C3bBb3b (C5 convertase)

C4b,2a,3b (C5 convertase)

C5 C5a CHEMOTAXIS ANAPHYLATOXIN

C5b

PG, prostaglandin; TXA2, thromboxane A2; LT, leukotriene. C6,7,8,9

C5b-9 MAC (Membrane Attack Complex)

CELL LYSIS

Complement activation. The alternative, classical, and mannose-binding pathways lead to generation of the complement cascade of inflammatory mediators and cell lysis by the membrane attack complex (MAC). MBL, mannose-binding lectin; MBL-MASP, MBL-associated serine protease. FIGURE 2-6.

Arachidonic Acid and Platelet-Activating Factor are Derived from Membrane Phospholipids Phospholipids and fatty acid derivatives released from plasma membranes are metabolized into mediators and homeostatic regulators by inflammatory cells and injured tissues. As part of a complex regulatory network, prostanoids, leukotrienes and lipoxin (derivatives of arachidonic acid), both promote and inhibit inflammation (Table 2-1).

Arachidonic Acid Depending on the specific inflammatory cell and the nature of the stimulus, activated cells generate arachidonic acid by one of two pathways, involving either stimulus-induced activation of phospholipase A2 (PLA2) or phospholipase C. Once generated, arachidonic acid is further metabolized through two pathways: (1) cyclooxygenation, with subsequent production of prostaglandins and thromboxanes; and (2) lipoxygenation, to form leukotrienes and lipoxins (Fig. 2-7). Corticosteroids are widely used to suppress the tissue destruction associated with many inflammatory diseases. These drugs in-

duce synthesis of an inhibitor of PLA2 and block release of arachidonic acid in inflammatory cells. Although corticosteroids (e.g., prednisone) are widely used to suppress inflammatory responses, their prolonged administration can have significant harmful effects, including increased risk of infection, damage to connective tissue, and adrenal gland atrophy.

Platelet-Activating Factor (PAF) Another potent inflammatory mediator derived from membrane phospholipids is PAF, synthesized by virtually all activated inflammatory cells, endothelial cells, and injured tissue cells. PAF is derived from membrane phospholipids by the PLA2 pathway. During inflammatory and allergic responses, PAF stimulates platelets, neutrophils, monocyte/macrophages, endothelial cells, and vascular smooth muscle cells. PAF induces platelet aggregation and degranulation at sites of tissue injury and enhances the release of serotonin, thereby causing changes in vascular permeability. The molecule is also an extremely potent vasodilator, augmenting permeability of the microvasculature at sites of tissue injury.

Prostanoids, Leukotrienes, and Lipoxins are Biologically Active Metabolites of Arachidonic Acid Prostanoids Arachidonic acid is further metabolized by cyclooxygenases 1 and 2 (COX-1, COX-2) to generate prostanoids (see Fig. 2-7). COX-1 is constitutively expressed by most cells and increases upon cell activation. It is a key enzyme in the synthesis of prostaglandins, which in turn (1) protect the gastrointestinal mucosal lining, (2) regulate water/electrolyte balance, (3) stimulate platelet aggregation to maintain normal hemostasis, and (4) maintain resistance to thrombosis on vascular endothelial cell surfaces. COX-2 expression is generally low or undetectable but takes over as the major source of prostanoids as inflammation progresses. Both COX isoforms generate prostaglandin H (PGH2), which is then the substrate for the production of prosta-

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ARACHIDONIC ACID CYCLOOXYGENASE PATHWAY

PGH2

LIPOXYGENASE PATHWAY

T COX-1, COX-2 (NSAIDs)

Aspirin

5-LOX

15R HETE

15S-HETE

HpETE HETE

5-LOX

PGI2 PGD2 PGE2 PGF2α

PROSTAGLANDINS

TXA2

15-epi LX

LXA4 LXB4

LTA4

LTB4

12-LOX LTC4 LTD4 LTE4

THROMBOXANE

LIPOXINS

LEUKOTRIENES

Biologically active arachidonic acid metabolites. The cyclooxygenase pathway of arachidonic acid metabolism generates prostaglandins (PG) and thromboxane (TXA2). The lipoxygenase pathway forms lipoxins (LX) and leukotrienes (LT); COX, cyclooxygenase; HETE, hydroxyeicosatetraenoic acid; HpETE, 5-hydroperoxyeicosatetraenoic acid; NSAIDs, nonsteroidal anti-inflammatory drugs. FIGURE 2-7.

cyclins (PGI2), PGD2, PGE2, PGF2α, and TXA2 (thromboxane). The profile of prostaglandin production (i.e., the quantity and variety produced during inflammation) depends in part on the cells present and their activation state (see Table 2-1). Inhibition of COX is one mechanism by which nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, indomethacin, and ibuprofen, exert their potent analgesic and anti-inflammatory effects. NSAIDS block COX-2–induced formation of prostaglandins, thereby mitigating pain and inflammation. However, they also inhibit COX-1 and lead to adverse effects on the stomach and kidneys. This complication led to the development of COX-2–specific inhibitors (see Fig. 2-7).

Leukotrienes Slow-reacting substance of anaphylaxis has long been recognized as a smooth muscle stimulant and mediator of hypersensitivity reactions. It is, in fact, a mixture of leukotrienes, the second major family of derivatives of arachidonic acid (see Fig. 2-7 and Table 2-1). Leukotriene A4 (LTA4) serves as a precursor to several other leukotrienes. LTB4 is a major product of neutrophils as well as certain macrophage populations and has potent chemotactic activity for neutrophils, monocytes, and macrophages. In other cell types, especially mast cells, basophils and macrophages, LTC4, LTD4, and LTE4 are produced. These three cysteinylleukotrienes (1) stimulate smooth-muscle contraction, (2) enhance vascular permeability, and (3) are responsible for the development of many of the clinical symptoms associated with allergic-type reactions, notably asthma. Leukotrienes exert their action through high-affinity specific receptors, which may prove to be important targets of drug therapy.

Lipoxins Lipoxins, the third class of proinflammatory products of arachidonic acid, are synthesized by platelets and neutrophils within the vascular lumen in a manner dependent on cell–cell interactions (see Fig. 2-7). Neutrophil LTA4 serves as a source for platelet-dependent synthesis of lipoxins. Monocytes, eosinophils, and airway epithelial cells generate 15S-hydroxyeicosatetraenoic acid (15S-HETE), which is taken up by neutrophils and converted to lipoxins.

Cytokines are Cell-Derived Inflammatory Hormones Cytokines constitute a group of low-molecular-weight hormonelike proteins secreted by cells. Many cytokines are produced at sites of inflammation, including interleukins, growth factors, colonystimulating factors, interferons, and chemokines (Fig. 2-8). Cytokines produced at sites of tissue injury regulate inflammatory responses, ranging from initial changes in vascular permeability to resolution and restoration of tissue integrity. These molecules are inflammatory hormones that exhibit autocrine (affecting themselves), paracrine (affecting nearby cells), and endocrine (affecting cells in other tissues) functions. Through production of cytokines, macrophages are pivotal in orchestrating tissue inflammatory responses. Lipopolysaccharide (LPS), a molecule derived from the outer cell membrane of gram-negative bacteria, is one of the most potent activators of macrophages, as well as of endothelial cells and leukocytes (Fig. 2-9). LPS activates cells via specific receptors, either directly or after binding a serum LPS-binding protein (LBP). It is a potent stimulus for the production of TNF-α and interleukins (IL1, IL-6, IL-8, IL-12, and others). Macrophage-derived cytokines modulate endothelial cell leukocyte adhesion (TNF-α), leukocyte recruitment (IL-8), the acute phase response (IL-6, IL-1), and immune functions (IL-1, IL-6, IL-12).

Interleukins IL-1 and TNF-α, produced by macrophages, as well as other cells, are central to the development and amplification of inflammatory responses. These cytokines activate endothelial cells to express adhesion molecules and release cytokines, chemokines, and reactive oxygen species (ROS) (see below). TNF-α induces priming and aggregation of neutrophils. IL-1 and TNF-α are also among the mediators of fever, catabolism of muscle, shifts in protein synthesis, and hemodynamic effects associated with inflammatory states (see Fig. 2-9). IFN-γ, another potent stimulus for macrophage activation and cytokine production, is produced by a subset of T lymphocytes as part of the immune response (see Chapter 4).

Chemokine Structure and Function Chemokines direct cell migration (a process termed chemotaxis). The accumulation of inflammatory cells at sites of tissue

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Interleukins

Growth Factors

Chemokines

Interferons

ProInflammatory Cytokines

IL-1 IL-6 IL-8 IL-13 IL-10

GM-CSF M-CSF

CC CXC XC CX3C

IFNα IFNβ IFNγ

TNFα

• Inflammatory cell activation

• Macrophage • Bactericidal activity

• Leukocyte chemotaxis • Leukocyte activation

• NK and dendritic cell function

FIGURE 2-8.

T cells

Macrophage IFNγ

LPS

TNFα, IL-1

ENDOTHELIAL CELLS

NEUTROPHILS

Adhesion molecules

Aggregation

Fever

Priming

Anorexia

ACUTE PHASE RESPONSE

Eicosanoids

Hypotension

Chemokines

Increased heart rate

Oxygen radicals

Corticosteroid and ACTH release

Central role of interleukin (IL)-1 and tumor necrosis factor (TNF)-␣ in inflammation. Lipopolysaccharide (LPS) and IFN-γ activate macrophages to release inflammatory cytokines, principally IL-1 and TNF-α, responsible for directing local and systemic inflammatory responses. ACTH, adrenocorticotropic hormone. FIGURE 2-9.

• Fever • Anorexia • Shock • Cytotoxicity • Cytokine induction • Activation of endothelial cells and tissue cells

Cytokines important in inflammation. GM-CSF, granulocyte macrophage-colony stimulating factor; IL, interleukin; NK, natural killer; IFN, interferon; TNF, tumor necrosis factor.

Gram negative bacteria

Cytokines

• Antiviral • Leukocyte activation

injury requires their migration from the vascular space into extravascular tissue. Chemokines are a large class of cytokines (over 50 known members) that regulate leukocyte trafficking in inflammation and immunity. For example, chemokines are important chemotactic factors for PMNs in acute inflammation (see later). Chemokines are small molecules that interact with G-protein coupled receptors on target cells. These secreted proteins are produced by a variety of cell types, either constitutively or after induction, and differ widely in biological action. This diversity is based on specific cell types targeted, specific receptor activation, and differences in intracellular signaling. Two functional classes of chemokines have been distinguished, namely inflammatory chemokines and homing chemokines. Inflammatory chemokines are produced in response to bacterial toxins and inflammatory cytokines (especially IL-1, TNF-α, and IFN-γ) by a variety of tissue cells, as well as leukocytes themselves. Homing chemokines are constitutively expressed and upregulated during disease states, they direct trafficking and homing of lymphocytes and dendritic cells to lymphoid tissues during an immune response (see Chapter 4). Chemokines function as immobilized or soluble molecules that generate a chemotactic gradient by binding to proteoglycans of the extracellular matrix or to cell surfaces. As a result, high concentrations of chemokines persist at sites of tissue injury. Specific receptors on the surface of the migrating leukocytes bind the matrix-bound chemokines and associated adhesion molecules, which tend to move cells along the chemotactic gradient to the site of injury. This process of responding to a matrix-bound chemoattractant is termed haptotaxis. As soluble molecules, chemokines control leukocyte motility and localization within extravascular tissues by establishing a chemotactic gradient. The multiplicity and combination of chemokine receptors on cells allows an extensive variety in biological function. Neutrophils, monocytes, eosinophils, and basophils share some receptors but express other receptors exclusively. Thus, specific chemokine combinations can recruit selective cell populations.

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Reactive Oxygen Species are Signal-Transducing, Bactericidal, and Cytotoxic Molecules ROS are chemically reactive molecules derived from molecular oxygen. Normally, they are rapidly inactivated, but when generated inappropriately, they can be cytotoxic (see Chapter 1). ROS create oxidative stress by activating signal-transduction pathways and combining with proteins, lipids, and DNA. Leukocyte-derived ROS, released within phagosomes, are bactericidal. ROS important in inflammation include superoxide (O2–), nitric oxide (NO•), hydrogen peroxide (H2O2), and hydroxyl radical (•OH) (Fig. 2-10) (see below and Chapter 1).

Cells of Inflammation Leukocytes are the major cellular components of the inflammatory response and include neutrophils, T and B lymphocytes, monocytes, macrophages, eosinophils, mast cells, and basophils. Specific functions are associated with each of these cell types, but such functions overlap and vary as inflammation progresses. In addition, local tissue cells interact with one another and with inflammatory cells, in a continuous response to injury and infection.

Neutrophils are the Major Cellular Participants in Acute Inflammation The PMN is the major cellular participant in acute inflammation. It has granulated cytoplasm and a nucleus with two to four lobes. PMNs are stored in the bone marrow, circulate in the blood, and rapidly accumulate at sites of injury or infection (Fig. 2-11A). They are activated in response to phagocytic stimuli, cytokines, chemotactic mediators or antigen–antibody complexes, which bind specific receptors on their surface membrane. In tissues, PMNs phagocytose invading microbes and dead tissue (see below). Once they are recruited into tissue, they do not re-enter the circulation.

Neutrophil Respiratory burst O2

NADPH oxidase O2-

SOD H2O2

Activate neutrophil granules

Fe2+ myeloperoxidase HOCl (OCl-) OH

Endothelial cells comprise a monolayer of cells lining blood vessels and help to separate intra- and extravascular spaces. They produce agents that maintain blood vessel patency and also vasodilators and vasoconstrictors that regulate vascular tone. Injury to a vessel wall interrupts the endothelial barrier and exposes a local procoagulant signal (Fig. 2-11B). Endothelial cells are gatekeepers in inflammatory cell recruitment: they can promote or inhibit tissue perfusion and the influx of inflammatory cells. Inflammatory agents, such as bradykinin and histamine, endotoxin and cytokines, induce endothelial cells to reveal adhesion molecules that (1) anchor and activate leukocytes, (2) present major histocompatibility complex (MHC) class I and II molecules, and (3) generate cytokines and important vasoactive and inflammatory mediators.

Monocyte/Macrophages are Important in Acute and Chronic Inflammation Circulating monocytes (Fig. 2-11C) have a single lobed or kidney-shaped nucleus. They are derived from the bone marrow and can exit the circulation to migrate into tissue and become resident macrophages. In response to inflammatory mediators, they accumulate at sites of acute inflammation where they ingest and process microbes. Monocyte/macrophages produce potent vasoactive mediators, including prostaglandins and leukotrienes, PAF, and inflammatory cytokines. These cells are especially important for maintaining chronic inflammation.

Mast Cells and Basophils are Important in Allergic Hypersensitivity Reactions Mast cell products play an important role in regulating vascular permeability and bronchial smooth muscle tone, especially in allergic hypersensitivity reactions (see Chapter 4). Granulated mast cells and basophils (Fig. 2-11D) contain cell surface receptors for IgE. Mast cells are found in the connective tissues and are especially prevalent along lung and gastrointestinal mucosal surfaces, the dermis, and the microvasculature. Basophils circulate in small numbers and can migrate into tissue. When IgE-sensitized mast cells or basophils are stimulated by antigens, physical agonists such as cold and trauma, or cationic proteins, inflammatory mediators in the dense cytoplasmic granules are secreted into extracellular tissues. These bodies contain acid mucopolysaccharides (including heparin), serine proteases, chemotactic mediators for neutrophils and eosinophils, and histamine, a primary mediator of early increased vascular permeability. Histamine binds specific H1 receptors in the vascular wall, thereby inducing endothelial cell contraction, gap formation, and edema, an effect that can be inhibited pharmacologically by H1-receptor antagonists. Stimulation of mast cells and basophils also leads to the release of products of arachidonic acid metabolism and cytokines, such as TNF-α and IL-4.

Eosinophils are Important in Defense Against Parasites Degradative enzymes Neutrophil granules

Generation of reactive oxygen species in neutrophils as a result of phagocytosis of bacteria. Fe2+, ferrous iron; H2O2, hydrogen peroxide; HOCl, hypochlorous acid; NADPH, nicotinamide adenine dinucleotide phosphate; OCl–, hypochlorite radical; •OH, hydroxyl radical; SOD,superoxide dismutase. FIGURE 2-10.

Endothelial Cells Line Blood Vessels

Eosinophils circulate in the blood and are recruited to tissues in a manner similar to that of PMNs. They are characteristic of IgE-mediated reactions, such as hypersensitivity, allergic, and asthmatic responses (Fig. 2-12A). Eosinophils contain leukotrienes and PAF, as well as acid phosphatase and peroxidase. They express IgA receptors and exhibit large granules that contain eosinophil major basic protein, both of which are involved in defense against parasites.

Platelets Play a Role in Normal Hemostasis Platelets play a primary role in normal hemostasis and in initiating and regulating clot formation (see Chapter 20). They are

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POLYMORPHONUCLEAR LEUKOCYTES CHARACTERISTICS AND FUNCTIONS • Central to acute inflammation • Phagocytosis of microorganisms and tissue debris • Mediates tissue injury

Primary granule Secondary granule Granules (lysosomes)

PRIMARY INFLAMMATORY MEDIATORS • Reactive oxygen metabolites • Lysosomal granule contents Secondary granules Primary granules Lysozyme Myeloperoxidase Lactoferrin Lysozyme Collagenase Defensins Complement activator Bactericidal/permeability Phospholipase A2 increasing protein CD11b/CD18 Elastase CD11c/CD18 Cathepsins Protease 3 Laminin Glucuronidase Mannosidase Tertiary granules Phospholipase A2 Gelatinase Plasminogen activator Cathepsins Glucuronidase Mannosidase

ENDOTHELIAL CELLS CHARACTERISTICS AND FUNCTIONS • Maintains vascular integrity • Regulates platelet aggregation • Regulates vascular contraction and relaxation • Mediates leukocyte recruitment in inflammation PRIMARY INFLAMMATORY MEDIATORS • von Willebrand factor • Nitric oxide • Endothelins • Prostanoids

Capillary lumen FIGURE 2-11.

Cells of inflammation: morphology and function. A. Neutrophil. B. Endothelial cell

sources of inflammatory mediators, including potent vasoactive substances and growth factors that modulate mesenchymal cell proliferation (Fig. 2-12B). The platelet is small (2 ␮m in diameter), lacks a nucleus, and contains three distinct kinds of inclusions:

adhere to vascular endothelium, where they become activated. They then flatten and migrate from the vasculature through the endothelial cell layer into surrounding tissue. In the extravascular tissue, PMNs ingest foreign material, microbes, and dead tissue.

• dense granules, rich in serotonin, histamine, calcium and adenosine diphosphate (ADP) • ␣ granules, containing fibrinogen, coagulation proteins, platelet-derived growth factor, and other peptides and proteins • lysosomes, which sequester acid hydrolases

Leukocyte Adhesion to Endothelium Results from Interaction of Complementary Adhesion Molecules

Platelets adhere, aggregate, and degranulate when they contact fibrillar collagen (e.g., after vascular injury that exposes extracellular matrix [ECM] proteins) or thrombin (after activation of the coagulation system).

Leukocyte Recruitment in Acute Inflammation One of the essential features of acute inflammation is the accumulation of leukocytes, particularly PMNs, in affected tissues. Leukocytes

Leukocyte recruitment to the postcapillary venules begins with the interaction of leukocytes with endothelial cell selectins, which are redistributed to endothelial cell surfaces during activation. This interaction, called tethering, slows leukocytes in the blood flow (Fig. 2-13). Leukocytes then move along the vascular endothelial cell surface with a saltatory movement, termed rolling. PMNs become activated by proximity to the endothelium and by inflammatory mediators, and adhere strongly to intercellular adhesion molecules on the endothelium (leukocyte arrest). As endothelial cells separate, leukocytes transmigrate through the vessel wall and, under the influence of chemotactic factors, they migrate through extravascular tissue to the site of injury.

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MONOCYTE/MACROPHAGE CHARACTERISTICS AND FUNCTIONS • Regulates inflammatory response • Regulates coagulation/fibrinolytic pathway • Regulates immune response (see Chapt. 4) Lysosome

PRIMARY INFLAMMATORY MEDIATORS • cytokines - IL-1 - TNF-α - IL-6 - Chemokines (e.g. IL-8, MCP-1) • lysosomal enzymes - acid hydrolases - serine proteases - metalloproteases (e.g. collagenase) • cationic proteins • prostaglandins/leukotrienes • plasminogen activator • procoagulant activity • oxygen metabolite formation

Phagocytic vacuole

C MAST CELL (BASOPHILS)

CHARACTERISTICS AND FUNCTIONS • Binds IgE molecules • Contains electron-dense granules PRIMARY INFLAMMATORY MEDIATORS • Histamine • Leukotrienes (LTC, LTD, LTE) • Platelet activating factor • Eosinophil chemotactic factors • Cytokines (e.g., TNF-α IL-4) D FIGURE 2-11.

Continued. C. Monocyte/macrophage. D. Mast cell. IL, interleukin; MCP-1, monocyte chemoattractant protein-1; TNF-α, tumor necrosis factor-α.

The events involved in leukocyte recruitment are regulated as follows: (1) Inflammatory mediators stimulate resident tissue cells, including vascular endothelial cells; (2) Adhesion molecules are expressed on vascular endothelial cell surfaces and bind to reciprocal molecules on the surfaces of circulating leukocytes; and (3) Chemotactic factors attract leukocytes along a chemical gradient to the site of injury.

Adhesion Molecules Four molecular families of adhesion molecules are involved in leukocyte recruitment: selectins, addressins, integrins, and members of the immunoglobulin super family. Selectins The selectin family (part of the C-type, calcium-dependent lectin group) includes P-selectin, E-selectin, and L-selectin, expressed on the surface of platelets, endothelial cells, and leukocytes, respectively. Selectins share a similar molecular structure, which includes a chain of transmembrane glycoproteins with an extracellular carbohydrate-binding domain specific for sialylated oligosaccharides. The last is the sialyl-Lewis X moiety on addressins, the binding of which allows rapid attachment and rolling of cells. P-selectin (CD62P, GMP-140, PADGEM) is preformed and stored within Weibel-Palade bodies of endothelial cells and αgranules of platelets. On stimulation with histamine, thrombin, or specific inflammatory cytokines, P-selectin is rapidly transported to the cell surface, where it binds to sialyl-Lewis X on leukocyte surfaces. Preformed P-selectin can be delivered quickly to the cell

surface, allowing rapid adhesive interaction between endothelial cells and leukocytes. E-selectin (CD62E, ELAM-1) is not normally expressed on endothelial cell surfaces but is induced by inflammatory mediators, such as cytokines or bacterial LPS. E-selectin mediates the adhesion of neutrophils, monocytes, and certain lymphocytes via binding to molecules that contain Lewis X. L-selectin (CD62L, LAM-1, Leu-8) is expressed on many types of leukocytes. It was originally defined as the “homing receptor” for lymphocytes. It binds lymphocytes to high endothelial venules in lymphoid tissue, thereby regulating their trafficking through this tissue. L-selectin binds glycan-bearing cell adhesion molecule-1 (GlyCAM-1), mucosal addressin cell adhesion molecule-1 (MadCAM-1), and CD34. Addressins Vascular addressins are mucin-like glycoproteins, including GlyCAM-1, P-selectin glycoprotein-1 (PSGL-1), E-selectin ligand 1 (ESL-1), and CD34. They possess sialyl-Lewis X, which binds the lectin domain of selectins. Addressins are expressed at leukocyte and endothelial surfaces. They regulate the localization of subpopulations of leukocytes and are involved in lymphocyte activation. Integrins Chemokines, lipid mediators, and proinflammatory molecules activate cells to express the integrin family of adhesion molecules (see Chapter 3). Integrins have transmembrane α and β chains arranged as heterodimers. They participate in cell–cell interactions and cell–ECM binding. Very late activation (VLA) molecules include

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EOSINOPHILS CHARACTERISTICS AND FUNCTIONS • Associated with: - Allergic reactions - Parasite-associated inflammatory reactions - Chronic inflammation • Modulate mast cell-mediated reactions PRIMARY INFLAMMATORY MEDIATORS • Reactive oxygen metabolites • Lysosomal granule enzymes (primary crystalloid granules) - Major basic protein - Eosinophil cationic protein - Eosinophil peroxidase - Acid phosphatase - β-glucuronidase - Arylsulfatase B - Histaminase • Phospholipase D • Prostaglandins of E series • Cytokines

Granules

A PLATELETS

Vacuoles

Granules

Microtubules

B FIGURE 2-12.

CHARACTERISTICS AND FUNCTIONS • Thrombosis; promote clot formation • Regulates permeability • Regulate proliferative response of mesenchymal cells PRIMARY INFLAMMATORY MEDIATORS • Dense granules -Serotonin -Ca2+ -ADP • α-granules -Cationic proteins -Fibrinogen and coagulation proteins -Platelet-derived growth factor (PDGF) • Lysosomes -Acid hydrolases •Thromboxane A2

More cells of inflammation: morphology and function. A. Eosinophil. B. Platelet. ADP, adenosine diphosphate.

VLA-4 (α4β1) on leukocytes and lymphocytes that bind VCAM-1 (an immunoglobulin-domain-bearing molecule) on endothelial cells. The β2 integrins (CD18) form molecules by association with α integrin chains: α1β2 (also called CD11a/CD18 or LFA-1) and αmβ2 (also termed CR3, CD11b/CD18 or Mac-1) bind to both ICAM-1 and ICAM-2 (also members of the Ig domain-bearing family, see below). Leukocyte integrins exist in a low-affinity state, but are converted to a high-affinity state when these cells are activated. Immunoglobulin Superfamily Adhesion molecules of the immunoglobulin (Ig) superfamily include ICAM-1, ICAM-2, and VCAM-1, all of which interact with integrins on leukocytes to mediate recruitment. They are expressed at the surfaces of cytokine-stimulated endothelial cells and some leukocytes, as well as certain epithelial cells, such as pulmonary alveolar cells.

Recruitment of Leukocytes Tethering, rolling, and firm adhesion are prerequisites for recruitment of leukocytes from the circulation into tissues. For a rolling cell to adhere, there must first be a selectin-dependent reduction in rolling velocity. The early increase in rolling depends on P-se-

lectin, whereas cytokine-induced E-selectin initiates early adhesion. Integrin family members function cooperatively with selectins to facilitate rolling and subsequent firm adhesion of leukocytes. Leukocyte integrin binding to the Ig superfamily of ligands expressed on vascular endothelium further retards leukocytes, increasing the length of exposure of each leukocyte to endothelium. At the same time, engagement of adhesion molecules activates intracellular signal transduction. As a result, leukocytes and vascular endothelial cells are further activated, with subsequent upregulation of L-selectin and integrin binding. The net result is firm adhesion (see Fig. 2-13).

Chemotactic Molecules Direct Neutrophils to Sites of Injury Leukocytes must be accurately positioned at sites of inflammatory injury to carry out their biological functions. For specific subsets of leukocytes to arrive in a timely fashion, they must receive specific directions. Leukocytes are guided through vascular and extravascular spaces by a complex interaction of attractants, repellants, and adhesion molecules. Chemotaxis is the dynamic and energy-dependent process of directed cell migration. Blood leukocytes are recruited by chemoattractants released by endothelial cells. They then migrate from the en-

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ENDOTHELIAL CELLS

Blood Flow PMN

ENDOTHELIAL ACTIVATION

TETHERING

ROLLING

FIRM ADHESION

EC: P-selectin

EC: E-selectin

EC: ICAM

EC: PECAM-1

PMN: Sialyl-Lewis X

PMN: β1, β2 integrins

PMN: elastase

Inflammatory mediators (Histamine, thrombin, PAF, IL-1, TNF)

TRANSMIGRATION

Inflammatory mediators (Chemokines)

Neutrophil adhesion and extravasation. Inflammatory mediators activate endothelial cells to increase expression of adhesion molecules. Sialyl Lewis X on neutrophil PSGL-1 and ESL-1 binds to P- and E-selectins to facilitate tethering and rolling of neutrophils. Increased integrins on activated neutrophils bind to ICAM-1 on endothelial cells to form a firm attachment. Endothelial cell attachments to one another are released, and neutrophils then pass between separated cells to enter the tissue. EC, endothelial cell; ICAM, intercellular adhesion molecule; IL, interleukin; PAF, platelet activating factor; PMN, polymorphonuclear neutrophil; TNF, tumor necrosis factor. FIGURE 2-13.

dothelium toward the target tissue, down a gradient of one chemoattractant in response to a second more distal chemoattractant gradient. During migration, the cell extends a pseudopod toward increasing chemokine concentrations. At the leading front of the pseudopod, marked changes in levels of intracellular calcium are associated with the assembly and contraction of cytoskeleton proteins. This process draws the remaining tail of the cell along the chemical gradient. Neutrophils must integrate the various signals to arrive at the appropriate site at the correct time to perform their assigned tasks. The most important chemotactic factors for PMNs are: • C5a, derived from complement • Bacterial and mitochondrial products, particularly low-molecular-weight N-formylated peptides (such as N-formyl-methionyl-leucyl-phenylalanine) • Products of arachidonic acid metabolism, especially LTB4 • Chemokines Chemotactic factors for other cell types, including lymphocytes, basophils, and eosinophils, are also produced at sites of tissue injury and may be secreted by activated endothelial cells, tissue parenchymal cells, or other inflammatory cells. They include PAF, transforming growth factor-β (TGF-β), neutrophilic cationic proteins, and lymphokines. The cocktail of chemokines presented within a tissue largely determines the type of leukocyte attracted to the site. Cells arriving at their destination must then be able to stop in the target tissue. Contact guidance, regulated adhesion, or inhibitory signals may determine the final arrest of specific cells in particular tissue locations.

Leukocytes Traverse the Endothelial Cell Barrier to Gain Access to the Tissue Leukocytes adherent to the vascular endothelium emigrate by paracellular diapedesis, (i.e., passing between adjacent endothelial cells). Responding to chemokine gradients, neutrophils extend

pseudopods and insinuate themselves between the cells and out of the vascular space. Vascular endothelial cells are connected by tight junctions and adherens junctions. CD31 (platelet endothelial cell adhesion molecule) is expressed on endothelial cell surfaces and binds to itself to keep cells together. These junctions separate under the influence of inflammatory mediators, intracellular signals generated by adhesion molecule engagement, and signals from the adherent neutrophils. Neutrophils mobilize elastase to their pseudopod membranes, inducing endothelial cell retraction and separation at the advancing edge of the neutrophil. Neutrophils also induce increases in intracellular calcium in endothelial cells, to which the endothelial cells respond by pulling apart. Neutrophils also migrate through endothelial cells by transcellular diapedesis. Instead of inducing endothelial cell retraction, PMNs may squeeze through small circular pores in the endothelial cell cytoplasm. In tissues that contain fenestrated microvessels, such as the gastrointestinal mucosa and secretory glands, PMNs may traverse thin regions of endothelium, called fenestrae, without damaging endothelial cells. In nonfenestrated microvessels, PMNs may cross the endothelium using endothelial cell caveolae or pinocytotic vesicles, which form small, membranebound passageways across the cell.

Leukocyte Functions in Acute Inflammation Leukocytes Phagocytose Microorganisms and Tissue Debris Many inflammatory cells (including monocytes, tissue macrophages, dendritic cells, and neutrophils) recognize, internalize, and digest foreign material, microorganisms, or cellular debris by a process termed phagocytosis. This is now defined as ingestion by eukaryotic cells of large (usually > 0.5 μm) insoluble

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particles and microorganisms. The effector cells are phagocytes. The complex process involves a sequence of transmembrane and intracellular signaling events. 1. Recognition: Phagocytosis is initiated by the recognition of particles by specific receptors on the surface of phagocytic cells (Fig. 2-14). Phagocytosis of most biological agents is enhanced by, if not dependent on, their coating (opsonization) with plasma components (opsonins), particularly immunoglobulins or C3b. Phagocytic cells possess specific opsonic receptors, including those for immunoglobulin Fcγ and complement components. Many pathogens, however, have evolved mechanisms to evade phagocytosis by leukocytes. Polysaccharide capsules, protein A, protein M, or peptidoglycans around bacteria can prevent complement deposition or antigen recognition and receptor binding. 2. Signaling: Clumping of opsonins on bacterial surfaces causes Fcγ receptors on phagocytes to cluster. Subsequent phosphorylation of immunoreceptor tyrosine-based activation motifs, located in the cytosolic domain or γ subunit of the receptor, triggers intracellular signaling events. Tyrosine kinases that associate with the Fcγ receptor are required for signaling during phagocytosis. 3. Internalization: In the case of phagocytosis initiated via the Fcγ receptor or CR3 (CD11b/CD18 receptor), actin assembly occurs directly under the phagocytosed target. Polymerized actin filaments push the plasma membrane forward. The plasma membrane remodels to increase surface area and to form pseudopods surrounding the foreign material. The resulting phagocytic cup engulfs the foreign agent. The membrane then “zippers” around the opsonized particle to enclose it in a cytoplasmic vacuole called a phagosome (see Fig. 2-14). 4. Digestion: The phagosome that contains the foreign material fuses with cytoplasmic lysosomes to form a phagolysosome, into which lysosomal enzymes are released. The acid pH within the phagolysosome activates these hydrolytic enzymes, which then degrade the phagocytosed material. Some microorganisms have evolved mechanisms for evading killing by neutrophils by preventing lysosomal degranulation or inhibiting neutrophil enzymes.

Neutrophil Enzymes are Required for Antimicrobial Defense and Debridement Although PMNs are critical for degrading microbes and cell debris, they also contribute to tissue injury. The release of PMN granules at sites of injury is a double-edged sword. On the one hand, debridement of damaged tissue by proteolytic breakdown is beneficial. On the other hand, degradative enzymes can damage endothelial and epithelial cells, as well as degrade connective tissue.

Neutrophil Granules The armamentarium of enzymes required for degradation of microbes and tissue is generated and contained within PMN cytoplasmic granules. Primary, secondary, and tertiary granules in neutrophils are differentiated morphologically and biochemically: each granule has a unique spectrum of enzymes (see Fig. 2-11A).

Inflammatory Cells Have Oxidative and Nonoxidative Bactericidal Activity The bactericidal activity of PMNs and macrophages is mediated in part by production of ROS and in part by oxygenindependent mechanisms.

Bacterial Killing by Oxygen Species Phagocytosis is accompanied by metabolic reactions in inflammatory cells that lead to the production of several oxygen metabolites

PHAGOSOME FORMATION PMN C3b receptor C3b

Fc Bacterium Fc receptor

Phagolysosome NADPH oxidase

Lysozyme, lactoferrin, PLA2

O-2

Cationic proteins

H2O2 •OH Fe2+

HOCl MPO H2O2

Primary granule Secondary granule

• Degranulation and NADPH oxidase activation • Bacterial killing and digestion

Mechanisms of neutrophil bacterial phagocytosis and cell killing. Opsonins such as C3b coat the surface of microbes, allowing recognition by the neutrophil C3b receptor. Receptor clustering triggers intracellular signalling and actin assembly within the neutrophil. Pseudopods form around the microbe to enclose it within a phagosome. Lysosomal granules fuse with the phagosome to form a phagolysosome into which the lysosomal enzymes and oxygen radicals are released to kill and degrade the microbe. Fe2+, ferrous iron; HOCl, hypochlorous acid; MPO, myeloperoxidase; PLA2, phospholipase A2; PMN, polymorphonuclear neutrophil. FIGURE 2-14.

(see Chapter 1). These products are more reactive than oxygen itself and contribute to the killing of ingested bacteria (see Fig. 2-14). • Superoxide Anion (O2–): Phagocytosis activates a nicotinamide adenine dinucleotide phosphate (NADPH) oxidase in PMN cell membranes. NADPH oxidase is a multicomponent electron transport complex that reduces molecular oxygen to O2–. Activation of this enzyme is enhanced by prior exposure of cells to a chemotactic stimulus or LPS. NADPH oxidase activation increases oxygen consumption and stimulates the hexose monophosphate shunt. Together, these cell responses are referred to as the respiratory burst. • Hydrogen Peroxide (H2O2): O2– is rapidly converted to H2O2 by superoxide dismutase at the cell surface and in phagolysosomes. H2O2 is stable and serves as a substrate for generating additional reactive oxidants. • Hypochlorous Acid (HOCl): Myeloperoxidase (MPO), a neutrophil product with a strong cationic charge, is secreted from granules during exocytosis. In the presence of a halide, usually chlorine, MPO catalyzes the conversion of H2O2 to HOCl. This powerful oxidant is a major bactericidal agent produced by phagocytic cells. HOCl also participates in activating neutrophil-derived collagenase and gelatinase, both of which are secreted as latent enzymes. At the same time, HOCl inactivates α1-antitrypsin.

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• Hydroxyl Radical (•OH): Reduction of H2O2 occurs via the Haber-Weiss reaction to form the highly reactive •OH. This reaction occurs slowly at physiological pH, but in the presence of ferrous iron (Fe2+), the Fenton reaction rapidly converts H2O2 to •OH. Further reduction of •OH leads to formation of H2O (see Chapter 1). • Nitric Oxide (NO•): Phagocytic cells and vascular endothelial cells produce NO• and its derivatives, which have diverse effects, both physiological and nonphysiological. NO• and other oxygen radical species interact with one another to balance their cytotoxic and cytoprotective effects. NO• can react with oxygen radicals to form toxic molecules such as peroxynitrite and S-nitrosothiols. It can also scavenge O2–, thereby reducing the amount of toxic radicals. Monocytes, macrophages, and eosinophils also produce oxygen radicals, depending on their state of activation and the stimulus to which they are exposed. Production of ROS by these cells contributes to their bactericidal and fungicidal activity as well as their ability to kill certain parasites. The importance of oxygen-dependent mechanisms in bacterial killing is exemplified in chronic granulomatous disease of childhood. In this hereditary deficiency of NADPH oxidase, failure to produce O2– and H2O2 during phagocytosis makes these persons susceptible to recurrent infections, especially with gram-positive cocci. Patients with a related genetic deficiency in myeloperoxidase cannot produce HOCl and show increased susceptibility to infections by the fungal pathogen Candida (Table 2-2).

Nonoxidative Bacterial Killing Phagocytes, particularly PMNs and monocytes/macrophages, have substantial antimicrobial activity, which is oxygen independent. This activity mainly involves preformed bactericidal proteins in cytoplasmic granules. These include lysosomal acid hydrolases and specialized noncatalytic proteins unique to inflammatory cells. • Lysosomal hydrolases: Neutrophil primary and secondary granules and lysosomes of mononuclear phagocytes contain hydrolases, including sulfatases, phosphatases, and other enzymes capable of digesting polysaccharides and DNA. • Bactericidal/permeability-increasing protein: This cationic protein in PMN primary granules can kill many gram-negative bacteria but is not toxic to gram-positive bacteria or to eukaryotic cells. • Defensins: Primary granules of PMNs and lysosomes of some mononuclear phagocytes contain this family of cationic proteins, which kill an extensive variety of gram-positive and gram-negative bacteria, fungi, and some enveloped viruses. • Lactoferrin: Lactoferrin is an iron-binding glycoprotein in the secondary granules of neutrophils and in most body secretory fluids. Its iron-chelating capacity allows it to compete with bacteria for iron. It may also facilitate oxidative killing of bacteria by enhancing •OH formation. • Lysozyme: This bactericidal enzyme is found in many tissues and body fluids, in primary and secondary granules of neutrophils, and in lysosomes of mononuclear phagocytes. Peptidoglycans of gram-positive bacterial cell walls are exquisitely sensitive to degradation by lysozyme; gram-negative bacteria are usually resistant to it. • Bactericidal Proteins of Eosinophils: Eosinophils contain several granule-bound cationic proteins, the most important of which are major basic protein and eosinophilic cationic protein. Major basic protein accounts for about half of the total protein of the eosinophil granule. Both proteins are ineffective against bacteria but are potent cytotoxic agents for many parasites.

Defects in Leukocyte Function The importance of protection afforded by acute inflammatory cells is emphasized by the frequency and severity of infections

TABLE 2–2

Congenital Diseases of Defective Phagocytic Cell Function Characterized by Recurrent Bacterial Infections Disease

Defect

LAD

LAD-1 defective β2-integrin expression or function (CD11/CD18) LAD-2 (defective fucosylation, selectin binding)

Hyper-IgE-recurrent infection, (Job) syndrome

Poor chemotaxis

Chediak-Higashi syndrome

Defective lysosomal granules, poor chemotaxis

Neutrophil-specific granule deficiency

Absent neutrophil granules

Chronic granulomatous disease

Deficient NADPH oxidase, with absent H2O2 production

Myeloperoxidase deficiency

Deficient HOCl production

H2O2, hydrogen peroxide; HOCl, hypochlorous acid; Ig, immunoglobulin, LAD, leukocyte adhesion deficiency; NADPH, nicotinamide adenine dinucleotide phosphate.

when PMNs are greatly decreased or defective. The most common such deficit is iatrogenic neutropenia resulting from cancer chemotherapy. Functional impairment of phagocytes may occur at any step in the sequence: adherence, emigration, chemotaxis, or phagocytosis. These disorders may be acquired or congenital. Acquired diseases, such as leukemia, diabetes mellitus, malnutrition, viral infections, and sepsis are often accompanied by defects in inflammatory cell function. Table 2-2 shows representative examples of congenital diseases linked to defective phagocytic function.

Outcomes of Acute Inflammation As a result of regulatory components and the short life span of neutrophils, acute inflammatory reactions are usually self-limited and are followed by restoration of normal tissue architecture and physiological function (resolution). Resolution involves removal of dead cells, clearance of acute response cells, and re-establishment of the stroma. However, inflammatory responses can lead to other outcomes: • Scar: If a tissue is irreversibly injured, the normal architecture is often replaced by a scar, despite elimination of the initial pathological insult (see Chapter 3). • Abscess: If the area of acute inflammation is walled off by inflammatory cells and fibrosis, PMN products destroy the tissue, forming an abscess. • Lymphadenitis: Localized acute inflammation and chronic inflammation may cause secondary inflammation of lymphatic channels (lymphangitis) and lymph nodes (lymphadenitis). The inflamed lymphatic channels in the skin appear as red streaks, and the lymph nodes are enlarged and painful. Microscopically, the lymph nodes show hyperplasia of lymphoid follicles and proliferation of mononuclear phagocytes in the sinuses (sinus histiocytosis). • Persistent inflammation: Failure to eliminate a pathological insult or inability to trigger resolution results in a persistent inflammatory reaction. This may be evident as a prolonged acute response, with continued influx of neutrophils and tissue destruction, or more commonly as chronic inflammation.

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Chronic Inflammation When acute inflammation does not resolve or becomes disordered, chronic inflammation occurs. Inflammatory cells persist, stroma responds by becoming hyperplastic, and tissue destruction and scarring lead to organ dysfunction. This process may be localized but more commonly progresses to disabling diseases such as chronic lung disease, rheumatoid arthritis, asthma, ulcerative colitis, granulomatous diseases, autoimmune diseases, and chronic dermatitis. Acute and chronic inflammation are ends of a dynamic continuum with overlapping morphological features: (1) Inflammation with continued recruitment of chronic inflammatory cells is followed by (2) tissue injury due to prolongation of the inflammatory response, and (3) an often-disordered attempt to restore tissue integrity. The events leading to an amplified inflammatory response resemble those of acute inflammation in a number of aspects: • Specific triggers, microbial products or injury, initiate the response. • Chemical mediators direct recruitment, activation, and interaction of inflammatory cells. Activation of coagulation and complement cascades generates small peptides that function to prolong the inflammatory response. Cytokines, specifically IL6 and RANTES, regulate a switch in chemokines, such that mononuclear cells are directed to the site. Other cytokines (e.g., IFN-γ) then promote macrophage proliferation and activation. • Inflammatory cells are recruited from the blood. Interactions between lymphocytes, macrophages, dendritic cells, and fibroblasts generate antigen-specific responses. • Stromal cell activation and extracellular matrix remodeling occur, both of which affect the cellular immune response. Varying degrees of fibrosis may result, depending on the extent of tissue injury and persistence of the pathological stimulus and inflammatory response. Chronic inflammation is not synonymous with chronic infection, but if the inflammatory response to infectious agents, including bacteria, viruses, and notably parasites, cannot eliminate the organism, infection may persist. Chronic inflammation may also be associated with a variety of noninfectious disease states including: • Trauma: Extensive tissue damage releases mediators capable of inducing an extended inflammatory response. • Cancer: Chronic inflammatory cells, especially macrophages and T lymphocytes, may be the morphological expression of an immune response to malignant cells. Chemotherapy may suppress normal inflammatory responses, thereby increasing susceptibility to infection. • Immune factors: Many autoimmune diseases, including rheumatoid arthritis, chronic thyroiditis, and primary biliary cirrhosis, are characterized by chronic inflammatory responses in affected tissues. This may be associated with activation of antibody-dependent and cell-mediated immune mechanisms (see Chapter 4). Such autoimmune responses may account for injury in affected organs.

Cells from Both the Circulation and Affected Tissue Play a Role in Chronic Inflammation Monocyte/macrophages, lymphocytes, and plasma cells (see Chapter 4), and cells discussed previously under Acute Inflammation play an active role in chronic inflammation. The latter are recruited from the circulation, as well as cells from the affected tissue including fibroblasts and vascular endothelial cells (see Chapter 3).

Monocyte/Macrophages Activated macrophages and their cytokines are central to initiating inflammation and prolonging responses that lead to chronic

CHRONIC INJURY

Activated T lymphocytes Bacterial and tissue-derived monocyte chemotactic factors Chemotactic Growth factors

Recruitment of circulating monocytes

Long-lived tissue macrophages

factors

Proliferation of tissue macrophages

INCREASED MACROPHAGES Epithelioid cells

FIGURE 2-15.

Tissue-derived mitogen

Multinucleated giant cells

Accumulation of macrophages in chronic inflammation.

inflammation. (see Fig. 2-11C). Macrophages produce inflammatory and immunological mediators and regulate reactions leading to chronic inflammation. They also control lymphocyte responses to antigens and secrete other mediators that modulate the proliferation and activities of fibroblasts and endothelial cells. The mononuclear phagocyte system includes blood monocytes and different types of tissue macrophages, particularly Kupffer cells of the liver. Under the influence of chemotactic stimuli, IFN-γ and bacterial endotoxins, resident tissue macrophages are activated and proliferate, while circulating monocytes are recruited and differentiate into tissue macrophages (Fig. 2-15). Within different tissues, resident macrophages differ in their armamentarium of enzymes and can respond to local inflammatory signals. The activity of these enzymes is central to the tissue destruction in chronic inflammation. In emphysema, for example, resident macrophages generate proteinases, particularly matrix metalloproteinases (MMPs) with elastolytic activity, which destroy alveolar walls and recruit blood monocytes into the lung. Other macrophage products include oxygen metabolites, chemotactic factors, cytokines, and growth factors.

Lymphocytes and Plasma Cells Lymphocytes and plasma cells play a central role in the adaptive immune response to pathogens and foreign agents in damaged tissue and are discussed in detail in Chapter 4.

Fibroblasts Fibroblasts are long-lived, ubiquitous cells whose chief function is to produce components of the extracellular matrix (ECM) (Fig. 216). They can also differentiate into other connective tissue cells, including chondrocytes, adipocytes, osteocytes, and smooth muscle cells. Fibroblasts are the construction workers of the tissue, rebuilding the scaffold of the ECM upon which tissue is re-established. Fibroblasts not only respond to immune signals that induce their proliferation and activation but are also active players in the immune response. They interact with inflammatory cells, particularly lymphocytes, via surface molecules and receptors on both cells. For example, when CD40 on fibroblasts binds its ligand on lymphocytes, both cells are activated. Activated fibroblasts pro-

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Collagen fibrils

Endoplasmic Reticuliun

CHARACTERISTICS AND FUNCTIONS • Produce extracellular matrix proteins • Mediate chronic inflammation and wound healing

FIGURE 2-16.

PRIMARY INFLAMMATORY MEDIATORS • IL-6 • PGE2 • IL-8 • CD40 expression • Cyclooxygenase-2 • Matricellular proteins • Hyaluronan • Extracellular proteins

Fibroblast: Morphology and function. IL, interleukin.

duce cytokines, chemokines, and prostanoids, creating a tissue microenvironment that further regulates the behavior of inflammatory cells in the damaged tissue. Fibroblasts function in wound healing in combination with regenerating vascular endothelial cells. Both are discussed more fully in Chapter 3.

Injury and Repair in Chronic Inflammation Chronic inflammation is mediated by both immunological and nonimmunological mechanisms and is frequently observed in conjunction with reparative responses, namely, granulation tissue and fibrosis. Neutrophil products, such as proteases and ROS, protect the host by participating in antimicrobial defense and debridement of damaged tissue. However, these same products may prolong tissue damage and promote chronic inflammation if not appropriately regulated. Persistent tissue injury produced by inflammatory cells is important in the pathogenesis of several diseases, for instance, pulmonary emphysema, rheumatoid arthritis, certain immune complex diseases, gout, and adult respiratory distress syndrome.

Granulomatous Inflammation Granuloma formation is a protective response to chronic infection (fungal infections, tuberculosis, leprosy, schistosomiasis) or the presence of foreign material (e.g., suture or talc). It prevents dissemination and restricts inflammation due to exogenous substances that are not effectively digested during the acute response, thereby protecting the host tissues. Some autoimmune diseases (e.g., rheumatoid arthritis, Crohn disease, and sarcoidosis [a mysterious disease of unknown etiology]) are also associated with granulomas. The principal cells involved in granulomatous inflammation are macrophages and lymphocytes. Macrophages are mobile cells that continuously migrate through the extravascular connective tissues. After amassing substances that they cannot digest, macrophages lose their motility, accumulate at the site of injury, and undergo transformation into nodular collections of pale, epithelioid cells, creating a granuloma (Fig. 2-17A,B). Multinucleated giant cells are formed by the cytoplasmic fusion of

B Granulomatous inflammation. A. Section of lung from a patient with sarcoidosis reveals numerous discrete granulomas. B. A higher-power photomicrograph of a single granuloma in a lymph node from the same patient depicts a multinucleated giant cell amid numerous pale epithelioid cells. A thin rim of fibrosis separates the granuloma from the lymphoid cells of the node. FIGURE 2-17.

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macrophages. When the nuclei of such giant cells are arranged around the periphery of the cell in a horseshoe pattern, the cell is called a Langhans giant cell. If a foreign agent (e.g., silica or a Histoplasma spore) or other indigestible material is identified within the cytoplasm of a multinucleated giant cell, it is termed a foreign body giant cell. Granulomas are further classified histopathologically by the presence or absence of necrosis. Certain infectious agents such as Mycobacterium tuberculosis characteristically produce caseating granulomas, the necrotic centers of which are filled with an amorphous mixture of debris and dead microorganisms and cells. Other diseases, such as sarcoidosis, are characterized by granulomas that lack necrosis.

Systemic Manifestations of Inflammation Under certain conditions, local injury may result in prominent systemic effects that can themselves be debilitating. For example, systemic effects are likely to result when a pathogen enters the bloodstream, a condition known as sepsis. The systemic symptoms associated with inflammation, e.g. fever, myalgia, arthralgia, anorexia and somnolence, are attributable to cytokines, including IL-1α, IL-1β, TNF-α, IL-6, and interferons. The most prominent systemic manifestations of inflammation, termed the systemic inflammatory response syndrome, are leukocytosis and the acute phase response, fever and shock.

The Acute Phase Response is a Systemic Response to Elevated Levels of IL-1, IL-6, and TNF-α The acute phase response is a regulated physiological reaction that occurs in inflammatory conditions in response to elevated levels of IL-1, IL-6, and TNF-α. It is characterized clinically by fever, leukocytosis, decreased appetite, and altered sleep patterns and notably by changes in plasma levels of certain acute phase proteins. These proteins (Table 2-3) are synthesized primarily by the liver and released in elevated amounts into the circulation, where they may serve as markers for ongoing inflammation. For example, increases in acute phase proteins lead to the accelerated erythrocyte sedimentation rate, a qualitative index used clinically to monitor the activity of many inflammatory diseases.

Fever is a Clinical Hallmark of Inflammation Fever is a clinical hallmark of inflammation. Release of pyrogens (molecules that cause fever) by bacteria, viruses, or injured cells may directly affect hypothalamic thermoregulation. More impor-

TABLE 2–3

Acute Phase Proteins Protein

Function

Mannose binding protein

Opsonization/complement activation

C-reactive protein

Opsonization

α1-Antitrypsin

Serine protease inhibitor

Haptoglobin

Binds hemoglobin

Ceruloplasmin

Antioxidant, binds copper

Fibrinogen

Coagulation

Serum amyloid A protein

Apolipoprotein

α2-Macroglobulin

Antiprotease

Cysteine protease inhibitor

Antiprotease

tantly, they stimulate the production of endogenous pyrogens, namely cytokines—including IL-1α, IL-1β, TNF-α, IL-6—and interferons, which produce local and systemic effects. IL-1 stimulates prostaglandin synthesis in hypothalamic thermoregulatory centers, thereby altering the “thermostat” that controls body temperature. Inhibitors of cyclooxygenase (e.g., aspirin) block the fever response by inhibiting IL-1–stimulated synthesis of PGE2. Chills (the sensation of cold), rigor (profound chills with shivering and piloerection), and sweats (to allow heat dissipation) are symptoms associated with fever.

Shock is Characterized by Cardiac Decompensation Under conditions of massive tissue injury or infection that spreads to the blood (sepsis), significant quantities of cytokines, especially TNF-α and other chemical mediators of inflammation, may be generated in the circulation. The sustained presence of these mediators induces cardiovascular decompensation through its effects on the heart and on the peripheral vascular system, a process termed shock. Systemic effects include generalized vasodilation, increased vascular permeability, intravascular volume loss, myocardial depression with decreased cardiac output, and potentially death (see Chapter 7). In severe cases, activation of coagulation pathways may generate microthrombi throughout the body, with consumption of clotting components and subsequent predisposition to bleeding, a condition defined as disseminated intravascular coagulation (see Chapter 20). The net result is multisystem organ dysfunction and death.

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Repair, Regeneration, and Fibrosis Gregory C. Sephel Stephen C. Woodward

The Basic Processes of Healing Migration of Cells Extracellular Matrix Stromal Reorganization Cell Proliferation Integrated Molecular Signals Repair Repair and Regeneration

Wound Healing Regeneration Adult Stem Cells Cell Proliferation Conditions that Modify Repair Local Factors Repair Patterns Suboptimal Wound Repair

The study of wound healing involves a complex interaction among many cell types, matrix proteins, growth factors, and cytokines, which regulate and modulate the repair process. Successful healing maintains tissue function and repairs tissue barriers, preventing blood loss and infection. Optimally, repair is accomplished by regeneration—restoration of the original tissue matrix and architecture. More often, healing proceeds through collagen deposition or scarring (fibrosis). Successful repair relies upon a balance between matrix deposition and matrix degradation. Tissue regeneration is favored when the matrix composition and architecture are unaltered. Thus, wounds that do not heal may reflect damage to the tissue architecture by excess proteinase activity, decreased matrix accumulation, or altered matrix assembly. By contrast, fibrosis and scarring may result either from reduced proteinase activity or increased matrix accumulation. The formation of new collagen during repair is required for increased strength of the healing site. However, excess col-

lagen formation (chronic fibrosis) is a major component of diseases that involve chronic injury.

The Basic Processes of Healing Three key cellular mechanisms are necessary for wound healing: • Cellular migration • Extracellular matrix organization, reorganization, and remodeling • Cell proliferation

Migration of Cells Initiates Repair Cells at the Site of Injury The entry of cells into a wound and the activation of local cells is initiated by mediators that are (1) released from reserves stored in the granules of platelets and basophils at the site of injury or (2) synthesized de novo by tissue resident cells. These mediators (1) control vascular permeability to fluid and cells, (2) degrade damaged tissue, and (3) initiate the repair cascade (see also Chapter 2). • Platelets are activated when bound to collagen exposed by endothelial damage, after which they aggregate and, with fibrin, form a thrombus that limits blood loss. They release plateletderived growth factor (PDGF) and other molecules that facilitate repair (see Fig. 2-12B). • Mast cell granules release heparin and other contents, many of which promote blood vessel formation (angiogenesis). They reside next to small blood vessels (see Fig. 2-11D).

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• Resident macrophages in connective tissue secrete mediators that not only contribute to the early response but also perpetuate it. Their numbers are increased through proliferation and recruitment to the site of injury (see Fig. 2-11C).

Cells that Migrate to the Wound Inflammatory stimuli (see also Chapter 2) and cells activated at the site of injury produce mediators that initiate the migration of the following cells to the site of injury (Fig. 3-1): • Polymorphonuclear leukocytes are rapidly recruited from the bone marrow and invade the wound site within the first day. They degrade and destroy nonviable tissue by releasing their granular contents (see Fig. 2-11A). • Macrophages arrive shortly after neutrophils but persist for days or longer. They phagocytose debris and orchestrate the development of reparative tissue (granulation tissue) by the release of cytokines and chemoattractants. • Fibroblasts, myofibroblasts, pericytes, and smooth muscle cells are recruited by growth factors and matrix degradation products, arriving in a skin wound by day 3 or 4. These cells are responsible for increased collagen synthesis (fibroplasia), synthesis of connective tissue matrix, tissue remodeling, wound contraction, and (indirectly) wound strength. • Endothelial cells form nascent capillaries by responding to growth factors and are visible in a skin wound beyond day 3. The development of capillaries is necessary for the exchange of gases, the delivery of nutrients, and the influx of inflammatory cells (see Fig. 2-11B). • Epithelial cells in the epidermis move across the surface of a skin wound, penetrate the provisional matrix (see below), and migrate upon stromal collagen. • Stem cells from the bone marrow, the bulb of the hair follicle, and the basal layer of the epidermis provide a renewable source of epidermal and dermal cells, which are capable of differentiation, proliferation, and migration. Under appropriate conditions, these cells form new blood vessels and epithelium and regenerate skin structures, such as hair follicles and sebaceous glands.

Mechanisms of Cell Migration Cell migration depends on the response of cells to chemical signals (cytokines) and insoluble substrates of the extracellular matrix. Locomotion of the rapidly migrating leukocytes is powered by broad, wavelike, membrane extensions called lamellipodia. Slower moving cells, such as fibroblasts, extend narrower, finger-like, membrane protrusions labeled filopodia. Cell polarization and membrane extensions are initiated by growth factors or chemokines, which trigger a response by binding to their specific receptors on the cell surface. Actin fibrils polymerize and form a network at the membrane’s leading edge, thereby propelling lamellipodia and filopodia forward, with traction provided via attachments to the extracellular matrix substrate. Actin-related proteins stimulate actin assembly, and numerous actin-binding proteins act like molecular tinker toys, rapidly constructing, stabilizing, and destabilizing actin networks. The leading edge of the cell membrane impinges upon the extracellular matrix and adheres to it through transmembrane adhesion receptors, termed integrins, which recognize matrix components such as collagen, laminin, and fibronectin. Such adhesive interactions between cell body and matrix are critical for cell migration. Integrins also transmit intracellular signals to cells that regulate cellular survival, proliferation, and differentiation. Cytoskeletal connections are involved in cell–cell and cell–matrix connections and determine the shape and differentiation of epithelial, endothelial, and other cells.

The Organization of Extracellular Matrix Sustains the Repair Process Two types of extracellular matrix contribute to the organization, physical properties, and function of both normal and injured tissue, namely connective tissue (interstitial matrix or stroma) and basement membranes.

Connective Tissue (Matrix) Connective tissue forms an interconnected matrix between tissue elements, such as epithelia, muscles, nerves, and blood vessels. This stromal matrix consists of both cells and an extracellular compartment, the latter including structural elements and a proteinaceous ground substance. Connective tissue provides physical protection by conferring resistance to compression or stretching. The stroma also acts as a storage medium for bioactive proteins. The cells in connective tissue are primarily of mesenchymal origin and include fibroblasts, myofibroblasts, adipocytes, chondrocytes, osteocytes, and endothelial cells. Bone marrow–derived cells (e.g., mast cells, macrophages, and transient leukocytes) also populate connective tissue (see above). The extracellular matrix of connective tissue is defined by the type of collagen fibers, selected from a large family of collagen molecules (Table 3-1). Another important structural component of the stroma is elastic fibers, which impart elasticity principally to skin, large blood vessels, and lungs. The fibers are composed of an elastin core, surrounded by microfibrillar proteins, such as fibrillin. The socalled ground substance of the interstitium represents a number of molecules, including glycosaminoglycans (GAGs), proteoglycans, and fibronectin, which provide for many important biological functions of connective tissue, in addition to the support and modulation of cell attachment. Collagens Collagen is the most abundant protein in the animal kingdom; it is essential for the structural integrity of tissues and organs. When collagen synthesis is reduced, delayed, or abnormal, the result is failed wound healing, as seen in scurvy. Mutational alterations of fibrillar collagen are responsible for diseases of bone (osteogenesis imperfecta), cartilage (chondroplasias), skin, joints, and blood vessels (Ehlers-Danlos syndrome) (see Chapters 6 and 26). Excess collagen deposition leads to fibrosis, the basis of several connective tissue diseases and the loss of function that accompanies chronic damage to many organs, including kidneys, lungs, and the liver. Collagens are divided into three types (see Table 3-1): • Fibrillar collagens. Of the fibrillar collagens, type I collagen is the major constituent of bone. Type I and type III collagens are prominent in skin; type II collagen is the predominant form in cartilege. Fibrillar collagens turn over slowly and are generally resistant to proteinase digestion. • Nonfibrillar collagens contain globular domains that prevent fibril formation. They act as transmembrane proteins (type XVII) in the hemidesmosome that attaches epidermal cells to the basement membrane and as fibrillar anchors (type VII) connecting the hemidesmosome and basement membrane to the underlying stroma in the skin. • Network-forming collagens facilitate the formation of flexible “chicken wire”—like networks of basement membrane collagen (type IV). Noncollagenous Matrix Constituents of Stroma Noncollagenous matrix components of stroma include a complex variety of proteins, glycoproteins, elastic fibers, and proteoglycans (Table 3-2): • Elastin is a secreted matrix protein that allows deformable tissues, such as skin, uterus, ligament, lung, elastic cartilage, and

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1. Leukocyte Migration

Monocyte Integrin-ICAM Endothelium

Actin

2. Endothelial Migration- Angiogenesis Capillary Endothelium

Basement membrane

Collagen

Integrin-matrix

Macrophage FGF Collagen-I

VEGF

Fibrin

Fibronectin

Integrin Pericyte

Basement membrane

4. Migrating Fibroblasts

Epidermis 3. Pericyte Migration into Stroma

Migrating pericyte

Capillary Basement membrane

Collagen-I

Fibroblasts

Collagen bundles

Pericytes

5. Reepithelialization- Migrating Epithelium

Epidermis Fibrin clot

Basement membrane Migrating epithelium

Cell migrations during repair. (1) Leukocytes attach to, and migrate between, capillary endothelial cells, penetrate the basement membrane, and enter the matrix. (2) Capillary endothelial cells, released from the basement membrane, migrate through the matrix to form new capillaries. (3) Pericytes detach from endothelial cells and their basement membranes to migrate into the matrix. (4) Fibroblasts become bipolar and migrate through the matrix to the site of injury. (5) Epithelial keratinocytes detach from neighboring cells and basement membranes and migrate between the scab and the wound along the provisional matrix of the dermis. FGF, fibroblast growth factor; VEGF, vascular endothelial growth factor. FIGURE 3-1.

GAG, glycosaminoglycan.

XVII (BP180, BPAG2)

Transmembrane

VIII

Anchoring (epithelium)

X (hypertorphic cartilage)

VIII

IV (basal lamina)

Network-forming

XV & XVIII (also proteoglycans)

XII

IX (cartillage, also a proteoglycan)

B. Nonfibril-forming (Interrupting noncollagen domains)

V, XI

III

II (cartilage)

GAG

XVII

VII

GAG chains

NC1

XII

XVIII

Dimer

Self-association in staggered array

Tetramer

Macromolecular Association

Type I fibril

Type II fibril

III

I, II

Anchoring plague instroma Anchoring fibril in papillary dermis

Collagen VII fibril

Hemidesmosome and basement membrane

Beaded filament

III Fibrils

I & II Fibrils

Aggregate Form

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Type

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Collagen Molecular Composition and Structure

TABLE 3–1

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See Also

Cayenne's therapeutic uses | EBSCO

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TABLE 3–2

Noncollagenous Matrix Constituents of Stroma Stromal Connective Molecular Structure Tissue Components Fibronectin

Molecular Associations

fibrin collagen heparin fibrin heparin cells

Tissue Structures

CELL Integrin receptor

RGD N Dimeric protein

Chains chosen from ~20 splice variants of one gene

Integrin receptors of many cells (RGD-binding site) Plasma fibronectin is soluble Cellular fibronectin can self-associate into fibrils at cell surface Collagen, heparin, decorin, fibrin, certain bacteria (opsonin), LTBP (latent transforming growth factor-β binding proteins)

Collagen or fibrin

Elastin fiber decorated with microfibrils

Elastin Elastin cross-links to form fiber

Monomer with several splice variants, one gene

Self-association to form cross-linked fibers Formed on scaffold of microfibrils

2 members, 2 genes

Other components of microfibrils (LTBP), fibulin, laminin, versican

Fibrillin

Versican (hyaluronan-binding proteoglycans)

Family of 4 related genes Ten−30 chondroitin sulfate and dermatan sulfate GAG chains

Linked to hyaluronan via CD-44 (link protein)

Hyaluronan

Decorin One protein core, one gene Small leucine-rich proteoglycans

Collagen I and II, fibronectin, TGF-β, thrombospondin

Collagen I or II

One chondroitin sulfate or dermatan sulfate GAG chain Biglycan and fibromodulin structurally related, genetically distinct

RGD, arginine-glycine-aspartate; LTBP, latent transforming growth factor binding proteins; GAG, glycosaminoglycan; TGF, transforming growth factor.

aorta, to stretch and bend, and yet recoil. Elastin is deposited as fibrils, which are complexed with several glycoproteins (microfibrils), such as fibrillin, that decorate the perimeter of the elastic fiber (see Table 3-2). • Matrix glycoproteins contribute essential biological functions to basement membranes and stromal connective tissue. They help to (1) organize tissue topography, (2) support cell migration, (3) orient cells, and (4) induce cell behavior. The principal matrix glycoprotein of stromal connective tissue is fibronectin. Specific domains within fibronectin bind bacteria, collagen, heparin, fib-

rin, fibrinogen, and the cell matrix receptor, integrin. The last links matrix molecules to one another or to cells. • Glycosaminoglycans (GAGs), also known as mucopolysaccharides, are long, linear polymers of specific repeating disaccharides (the names of which determine the name of the polymer). Hyaluronin (the only GAG not linked to a protein) binds large amounts of water, creating a viscous gel that produces turgor in the matrix and lubricates the joints and matrix. • Proteoglycans consist of varying numbers of GAGs, heparan, chondroitin sulfate, and keratan sulfate, linked to specific core

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TABLE 3–3

Basement Membrane Constituents and Organization Basement Membrane Components

Molecular Structure

Molecular Associations

Perlecan (heparan sulfate proteoglycan)

GAG chains

Laminin, collagen IV, fibronectin, growth factors (VEGF, FGF), chemokines

Laminin

Basement Membrane Aggregate Form

Integrin and dystroglycan receptors on variety of cells (epithelium, endothelium, muscle, Schwann cells, adipocytes) Forms self-associated noncovalent network assisted by perlecan Laminin, nidogen/entactin, perlecan, agrin, fibulin

Nidogen/Entactin

Collagen IV, laminin, perlecan, fibulin Stabilizes basement membrane through association of laminin and collagen IV networks

Collagen IV

Integrin receptors on many cells Forms covalent selfassociated network Collagen IV, perlecan nidogen/ entactin, SPARC

Minor Collagens VIII, XV, XVIII FGF, fibroblast growth factor; SPARC, secreted protein acidic and rich in cysteine; VEGF, vascular endothelial growth factor.

proteins. They participate in matrix organization, structural integrity, and cell attachment.

Basement Membranes Basement membranes, also called basal lamina, are thin, well-defined layers of specialized extracellular matrix that separate the cells that synthesize it from connective tissue. Epithelium, adipocytes, muscle cells, Schwann cells, and capillary endothelium produce basement membranes (Table 3-3). • Basement membranes are constructed from extracellular matrix molecules. They self-assemble into a sandwich-like structure composed of two interacting networks. • Within different tissues and during development, the expression of unique members of the collagen IV and laminin families imparts diversity to the basement membrane and the many structures and functions it supports. • Basement membranes act as filters, cellular anchors, and a surface for migrating epidermal cells after injury. Basement membranes also determine cell shape and provide a repository for growth factors and chemotactic peptides. • Lamins are a biologically versatile family of basement membrane glycoproteins that contribute to the heterogeneity of tissue morphology and function, in part, by supporting cell attachment. Laminin is key for both normal epidermal function and re-epithelialization of wounds.

Stromal Reorganization is Critical to Repair The matrix metalloproteins (MMPs) are crucial components in wound healing. They enable cells to migrate through the stroma by degrading matrix proteins at the site of injury, thereby allowing re-

organization of the tissue. MMPs are also involved in cell–cell communication and the activation or inactivation of bioactive molecules (e.g., matrix fragments and growth factors), in addition to influencing cell growth and apoptosis. MMPs can disrupt cell–cell adhesions and release, activate, or inactivate bioactive molecules stored in the matrix. In the later stages of the repair process, inflammatory cells diminish in number, and capillary formation is completed. Remodeling of the injury site into a mechanically strong, mature scar indicates that the equilibrium between collagen deposition and degradation has been restored. In this context, MMPs are the main digestive enzymes in remodeling, although neutrophil and serine proteases are also present. Once secreted, MMP activity can be inactivated by binding to specific proteinase inhibitors. In addition to the important plasmaderived proteinase inhibitor, α2-macroglobulin, there is a family of endogenous tissue inhibitors of metalloproteinases.

Cell Proliferation is Evoked by Cytokines and Matrix A prominent early feature in injured tissue is a transient increase in cellularity, which serves to replace damaged cells. Cell proliferation also initiates and perpetuates the formation of granulation tissue, which is a specialized vascular tissue that is formed transiently during repair (discussed below). Cells of granulation tissue accumulate from labile cell populations, including circulating leukocytes and basal epithelial cells, and from stable cells, such as capillary endothelia and resident mesenchymal cells (fibroblasts, myofibroblasts, pericytes, and smooth muscle cells). Local and marrow-derived stem cells or committed progenitor cells may also populate wounds, differentiating into endothelial and fibroblast populations. Cells that are terminally differentiated (e.g., cardiac myocytes, neurons) do not contribute to repair or regeneration.

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Growth factors and small chemotactic peptides (chemokines) provide soluble autocrine and paracrine signals for cell proliferation, differentiation, and migration. Signals from soluble factors and extracellular matrix also work collectively to influence cell behavior.

TABLE 3–4

Repair in Skin EARLY

1. Thrombosis: Formation of a growth factor-rich barrier having significant tensile strength 2. Inflammation: Necrotic debris and microorganisms must be removed by neutrophils; the appearance of macrophages signals and initiates repair 3. Re-epithelialization: Newly formed epithelium establishes a permanent barrier to microorganisms and fluid

MID

4. Granulation tissue formation and function: This specialized organ of repair is the site of extracellular matrix and collagen secretion; it is vascular, edematous, insensitive, and resistant to infection 5. Contraction: Fibroblasts and possibly other cells also transform to actin-containing myofibroblasts, link to each other and collagen, and contract, stimulated by TGF-ß1 or ß2

LATE

6. Accretion of final tensile strength results primarily from the cross-linking of collagen 7. Remodeling: The wound site devascularizes and conforms to stress lines in the skin

Integrated Molecular Signals Mediate Proliferation and Differentiation The behaviors of cells in healing wounds—proliferation, migration, and altered gene expression—are largely initiated by three receptor systems that share integrated signaling pathways. • Protein receptors for peptide growth factors, which contain cytoplasmic tyrosine kinase domains • G protein-coupled receptors for chemokines and other factors • Integrin receptors for extracellular matrix The myriad signaling mechanisms that regulate cell growth, survival, and proliferation are complex and involve the integration of numerous activating and inhibiting molecules and cross-talk between different pathways. A further explanation is beyond the scope of the current discussion.

Repair Outcomes of Injury Include Repair and Regeneration Repair and regeneration develop with the waning of inflammatory responses, as inflammation itself is the primary response to tissue injury (see Chapter 2). Transient acute inflammation may resolve completely, with locally injured parenchymal elements being regenerated without significant scarring. For example, in recovery from moderate sunburn, small numbers of acute inflammatory cells temporarily accompany transient vasodilation beneath the solar-injured epidermis. By contrast, sustained acute inflammation, with emergence of macrophage-predominant inflammation, is a precursor to the sequence of collagen elaboration and repair associated with scar formation and fibrosis.

Wound Healing Exhibits a Defined Sequence Wound healing that results in scar formation remains the predominant mode of repair. Given that wounds in the skin and the extremities are easily accessible, they have been extensively used as models. Although more difficult to study, healing within hollow viscera and body cavities generally parallels the repair sequence in skin (Table 34 and Fig. 3-2).

TGF, transforming growth factor.

liquefies the necrotic tissue. Acute inflammation persists as long as necessary, because repair cannot progress until necrotic structures are liquefied and removed. Plasma-derived fibronectin binds to collagen and cell membranes to facilitate phagocytosis. Fibronectin and cellular debris are chemotactic for macrophages and fibroblasts (see Fig. 3-2 parts 4 and 5). The appearance of macrophages as the predominant cell at the site of injury signals the onset of the repair process. Macrophages ingest proteolytic products of neutrophils and secrete collagenase, thereby promoting further liquefaction. They also provide growth factors that stimulate fibroblast proliferation, collagen secretion, and neovascularization. Fibroblasts are also early responders to injury. These collagen-secreting cells are involved in inflammatory, proliferative, and remodeling phases of wound repair. Fibroblasts are capable of further differentiation to contractile myofibroblasts.

Provisional Matrix Hemostasis A thrombus is formed at the site of injury primarily by the conversion of plasma fibrinogen to fibrin. The thrombus is also rich in fibronectin. Fibrin and fibronectin are soon cross-linked by transglutaminase to provide local tensile strength and maintain closure. The thrombus also contains contracting platelets, an initial source of growth factors. In the skin, a scab or eschar results from the drying of the exposed surface of the thrombus and forms a barrier to invading microorganisms. With time, the thrombus undergoes proteolysis, after which it is penetrated by regenerating epithelium. The scab then detaches.

Provisional matrix is a term that describes the temporary extracellular organization of plasma-derived matrix proteins and tissue-derived components that accumulate at sites of injury. These molecules are associated with the pre-existing stromal matrix and serve to stop blood or fluid loss. They also support the migration of monocytes, endothelial cells, epidermal cells, and fibroblasts to the wound site. Plasma-derived provisional matrix proteins include fibrinogen, fibronectin, and vitronectin. These proteins become insoluble by binding to the stromal matrix and by forming cross-links via the action of tissue- and plasma-derived transglutaminases.

Granulation Tissue Inflammation Repair sites vary in the amount of local tissue destruction. For example, the surgical excision of a minor skin lesion leaves little or no devitalized tissue. Demarcated, localized necrosis accompanies medium-sized myocardial infarcts. By contrast, widespread, irregularly defined necrosis is a feature of a large third-degree burn. Initially, an acute, neutrophil-dominated, inflammatory response

Granulation tissue is the transient, specialized tissue of repair, which replaces the provisional matrix. On gross examination, it is deceptively simple, with a glistening and pebbled appearance (Fig. 3-3). Microscopically, a mixture of fibroblasts and red blood cells first appears, followed by the development of provisional matrix and patent single cell-lined capillaries, which are surrounded by fibroblasts and inflammatory cells.

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6 Summary of the healing process. The initial phase of the repair reaction, which typically begins with hemorrhage into the tissues. (1) A fibrin clot forms and fills the gap created by the wound. Fibronectin in the extravasated plasma is cross-linked to fibrin, collagen, and other extracellular matrix components by the action of transglutaminases. This cross-linking provides a provisional mechanical stabilization of the wound (0 to 4 hours). (2) Macrophages recruited to the wound area process cell remnants and damaged extracellular matrix. The binding of fibronectin to cell membranes, collagens, proteoglycans, DNA, and bacteria (opsonization) facilitates phagocytosis by these macrophages and contributes to the removal of debris (1 to 3 days). (3) Fibronectin, cell debris, and bacterial products are chemoattractants for a variety of cells that are recruited to the wound site (2 to 4 days). The intermediate phase of the repair reaction. (4) As a new extracellular matrix is deposited at the wound site, the initial fibrin clot is lysed by a combination of extracellular proteolytic enzymes and phagocytosis (2 to 4 days). (5) Concurrent with fibrin removal, there is deposition of a temporary matrix formed by proteoglycans, glycoproteins, and type III collagen (2 to 5 days). (6) Final phase of the repair reaction. Eventually, the temporary matrix is removed by a combination of extracellular and intracellular digestion, and the definitive matrix, rich in type I collagen, is deposited (5 days to weeks). FIGURE 3-2.

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Granulation tissue. A. A foot ulcer is covered by granulation tissue. B. Granulation tissue has two major components: cells and proliferating capillaries. The cells are mostly fibroblasts, myofibroblasts, and macrophages. The macrophages are derived from monocytes and macrophages. The fibroblasts and myofibroblasts derive from mesenchymal stem cells, and the capillaries arise from adjacent vessels by division of the lining endothelial cells (detail), in a process termed angiogenesis. Endothelial cells put out cell extensions, called pseudopodia that grow toward the wound site. Cytoplasmic growth enlarges the pseudopodia, and eventually, the cells divide. Vacuoles formed in the daughter cells eventually fuse to create a new lumen. The entire process continues until the sprout encounters another capillary, with which it will connect. At its peak, granulation tissue is the most richly vascularized tissue in the body. C. Once repair has been achieved, most of the newly formed capillaries are obliterated and then reabsorbed, leaving a pale avascular scar. D. A photomicrograph of granulation tissue shows thin-walled vessels embedded in a loose connective tissue matrix containing mesenchymal cells and occasional inflammatory cells. FIGURE 3-3.

A key step in the development of granulation tissue is the recruitment of monocytes to the site of injury by chemokines and fragments of damaged matrix. Later, plasma cells are conspicuous, even predominant. Activated macrophages coordinate the development of granulation tissue through the release of growth factors and cytokines, which (1) direct angiogenesis (see angiogenesis below), (2) activate fibroblasts to form new stroma, and (3) continue the degradation and removal of the provisional matrix. However, recent studies challenge established concepts regarding the central role of the macrophage in wound repair. Granulation tissue is fluid-laden, and its cellular constituents supply antibacterial antibodies and growth factors. It is highly resistant to bacterial infection, allowing the surgeon to create anastomoses at such nonsterile sites as the colon.

Fibroblast Proliferation and Matrix Accumulation The temporary early matrix of granulation tissue contains proteoglycans, glycoproteins, and type III collagen (see Fig. 3-2). The release of cytokines from fixed cells in the damaged tissue causes hemorrhage and attracts inflammatory cells to the site. About 2 to 3 days

after injury, activated fibroblasts and capillary sprouts are detected. The shape of fibroblasts in the wound changes from oval to bipolar, as they begin to form collagen and synthesize other matrix proteins, such as fibronectin. Extracellular cross-linking of newly synthesized collagen progressively increases wound strength.

Growth Factors and Fibroplasia The initial discovery of epidermal growth factor and the subsequent identification of at least 20 other growth factors have provided explanations for many of the rapidly changing events in repair and regeneration. Interactions among growth factors, other cytokines, and MMPs are illustrated in Figures 3-4 and 3-5. Each has a predominant function in repair. Growth factors that are expressed as an early wound response support migration, recruitment, and proliferation of cells involved in fibroplasia, re-epithelialization, and angiogenesis. Growth factors that peak later sustain the maturation phase and remodeling of granulation tissue. Although the roles of growth factors in the initiation and progression of repair are reasonably well understood, the limiting and

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2–4 Days Thrombus Neutrophil Macrophage TGF-α

Epidermis TGF-β TGF-α Platelet plug

Neutrophil Blood vessel

FGF VEGF TGF-β PDGF

Dermis

IGF

PDGF TGF's PDGF

VEGF FGF Macrophage FGF

Fibroblast

TGF

Fat

4–8 Days Thrombus

u-PA MMP's

t-PA MMP's

Epidermis

Fibroblast

Capillary Dermis Collagen

Granulation tissue

Fat

B Cutaneous wound. A. At 2 to 4 days, growth factors controlling migration of cells are illustrated. Extensive redundancy is present, and no growth factor is rate limiting. B. At 4 to 8 days, the blood vessels are proliferating, and the epidermis is penetrating the thrombus, but not at its surface. The upper portion will become an eschar or scab. FGF, fibroblast growth factor; IGF, insulin-like growth factor; TGF, transforming growth factor; PDGF, platelet-derived growth factor; VEGF, vascular endothelial growth factor; MMPs, matrix metalloproteinases; t-PA, tissue plasminogen activator; u-PA, urokinase-type plasminogen activator. FIGURE 3-4.

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FGF and VEGF, and epidermal cells in the wound release VEGF in response to keratinocyte growth factor. Because the chief target of VEGF is the endothelial cell, this molecule is a critical regulator of embryonic vascular development and angiogenesis, regulating endothelial survival, differentiation, and migration. The binding of angiogenic growth factors to heparan sulfate-containing GAG chains is a crucial feature of angiogenesis. The association with heparan sulfate chains affects the availability and action of growth factors and vessel formation by (1) creating a storage reservoir of VEGF and βFGF in capillary basement membranes and (2) using cell surface proteoglycan receptors to regulate VEGF and βFGF receptor congregation, as well as signal delivery and intensity.

Re-Epithelialization

Myofibroblast viewed by electron microscopy. Myofibroblasts have an important role in the repair reaction. These cells, with features intermediate between those of smooth muscle cells and fibroblasts, are characterized by the presence of discrete bundles of myofilaments in the cytoplasm (arrows). FIGURE 3-5.

terminating events are not well defined. Diminishing anoxia as repair progresses may be key to the arrest of the repair process. Repair may also cease because of reduced turnover of extracellular matrix. Finally, increased storage and decreased availability of growth factors may stabilize the matrix, which may then transmit signals that reduce the effects of growth factors. Granulation tissue eventually transitions to scar tissue, as the balance between collagen synthesis and collagen breakdown begins within weeks of injury. Fibroblasts remain active at the wound site, much increasing the density of the scar over several years.

Angiogenesis At its peak, granulation tissue has more capillaries per unit volume than any other tissue. New capillary growth is essential for the delivery of oxygen and nutrients to the cells. New capillaries form by angiogenesis (i.e., sprouting of endothelial cells from preexisting capillary venules) (see Fig. 3-3) and create the granular appearance for which granulation tissue is named. Less often, new blood vessels form de novo from angioblasts. The latter process is known as vasculogenesis and is primarily associated with developmental processes. Angiogenesis in wound repair is tightly regulated. Quiescent capillary endothelial cells are activated by the local release of cytokines and growth factors. The endothelial cells and pericytes are bordered by basement membranes, which must be locally degraded before endothelial cells and pericytes migrate into the provisional matrix. Endothelial passage through the matrix requires the cooperation of plasminogen activators, matrix MMPs, and integrin receptors. The growth of new capillaries is supported by the proliferation and fusion of endothelial cells (see Fig. 3-3), and bone marrow-derived endothelial progenitor cells may also be recruited to support the growing vessel. Migration of cells into the wound site is directed by soluble ligands (chemotaxis) and proceeds along adhesive matrix substrates (haptotaxis). Once capillary endothelial cells are immobilized, cell–cell contacts form, and an organized basement membrane develops on the exterior of the nascent capillary. The association with pericytes and signals from angiopoietin, TGF-β, and PDGF establish a mature vessel phenotype and help form nonleaky capillaries. In vivo angiogenesis is initiated by hypoxia and a redundance of cytokines, growth factors, and various lipids, which stimulate or regulate vascular endothelial growth factor (VEGF). Activated granulation tissue macrophages and endothelial cells produce

Skin provides the best-studied example of epithelial repair. Epidermis constantly renews itself via mitosis of keratinocytes at the basal layer. The squamous cells then cornify or keratinize as they mature, move toward the surface, and are shed. Maturation requires an intact layer of basal cells that are in direct contact with one another and the basement membrane. If cell–cell contact is disrupted, basal epithelial cells re-establish contact with other basal cells through mitosis. Epithelial regeneration is illustrated in Figures 3-5 and 3-6. Once re-established, the epithelial barrier demarcates the scab from the newly covered wound, providing a protective barrier against infection and fluid loss. When epithelial continuity is re-established, the epidermis resumes its normal cycle of maturation and shedding. During the process of re-epithelialization in the skin, the basal layer of epithelial cells contributes important cytokines (interleukin [IL]-1, VEGF, TGF-α, TGF-β, PDGF) for the initiation of healing. To begin migration, keratinocytes must undergo cellular differentiation before forming a new covering over the wound. Normally, these cells are attached to laminin in the underlying basement membrane by hemidesmosome protein complexes containing α6β4 integrin. Collagen fibers are associated with the hemidesmosome, including types XVII and VII, also termed anchoring fibril (see Table 3-1). The anchoring fibril connects the hemidesmosome–basement membrane complex to the dermal connective tissue collagen fibers. Epithelial cells are connected to each other at their lateral edges by tight junctions and by adherens junctions composed of cadherin receptors. Cadherins are calcium-dependent, integral membrane proteins that form extracellular cell–cell connections and anchor intracellular cytoskeletal connections. In the adherens junctions, cadherins bind stable actin bundles to a cytoplasmic complex of α-, β-, and γ-catenins. The layer of actin that encircles the epithelial cytoplasm creates lateral tension and strength and is referred to as the adhesion belt. The shape and the strength of connected epithelial sheets result from tension created by cytoskeletal connections to basement membrane and cell-to-cell connections. Cellular migration is the predominant means by which the wound surface is re-epithelialized. Migrating epidermal cells originate at the margin of the wound and in hair follicles or sweat glands. If the basement membrane is lost, cells come in contact with unfamiliar stromal components, an effect that stimulates cell locomotion and proteinase expression. Activation of epithelial motility is driven by the assembly of actin fibers at focal adhesions organized by integrin receptors, directing the migrating cells along the margin of viable dermis. Movement through cross-linked fibrin apposed to the dermis also requires the activation of plasmin from plasminogen to degrade fibrin. Plasmin also aids in the activation of specific MMPs. Proteolytic cleavage of stromal collagens I and III and laminin at focal adhesion contacts can release adhesion or enable keratinocyte migration. Migrating keratinocytes eventually resume their normal phenotype after reforming a confluent layer and attaching to their newly formed basement membranes.

Wound Contraction As they heal, open wounds contract and deform in a process mediated by a specialized cell of granulation tissue, the myofibroblast. This modified fibroblast cannot be distinguished from the collagen-

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HEALING BY PRIMARY INTENTION (WOUNDS WITH APPOSED EDGES)

HEALING BY SECONDARY INTENTION (WOUNDS WITH SEPARATED EDGES) Top: Healing by primary intention. A. A wound with closely apposed edges and minimal tissue loss. B. Such a wound requires only minimal cell proliferation and neovascularization to heal. C. The result is a small scar. Bottom: Healing by secondary intention. A. A gouged wound, in which the edges are far apart and in which there is substantial tissue loss. B. This wound requires wound contraction, extensive cell proliferation, and neovascularization (granulation tissue) to heal. C. The wound is re-epithelialized from the margins, and collagen fibers are deposited in the granulation tissue. D. Granulation tissue is eventually resorbed and replaced by a large scar that is functionally and esthetically unsatisfactory. FIGURE 3-6.

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secreting fibroblast by conventional light microscopy. Unlike the fibroblast, the myofibroblast expresses α-smooth muscle actin, desmin, and vimentin, and it responds to pharmacological agents that cause smooth muscle to contract or relax. In short, it is a fibroblast that reacts like a smooth muscle cell. The myofib-roblast is the cell responsible for wound contraction, as well as the deforming pathological process termed wound contracture. The appearance of the myofibroblast, usually around the third day of wound healing, is associated with the sudden appearance of contractile forces, which then gradually diminish over the next several weeks. Myofibroblasts persist in hypertrophic scars, particularly burn scars. The myofibroblast may originate from a pericyte, fibroblast, or stem cell.

Wound Strength Skin incisions and surgical anastomoses in hollow viscera ultimately develop 75% of the strength of the unwounded site. Despite a rapid increase in tensile strength at 7 to 14 days, by the end of 2 weeks, the wound has acquired only about 20% of its ultimate strength. Most of the strength of the healed wound results from intermolecular cross-linking of type I collagen. A 2-monthold incision, although healed, is still visibly obvious. The incision line and suture marks are distinct, vascular, and red. By 1 year, the incision is white and avascular but usually still identifiable. As the scar fades further, it is often slowly deformed into an irregular line by stresses in the skin.

Regeneration Regeneration is the renewal of a damaged tissue or a lost appendage that is identical to the original one. Regeneration requires a population of stem or committed progenitor cells with the potential to differentiate and replicate. The adult human body is made up of several hundred types of well-differentiated cells, yet it maintains the remarkable potential to rebuild itself by replenishing dying cells and to heal itself by recruiting or activating cells that repair or regenerate injured tissue. Tissues are adept at healing injury, but their regenerative potential is unfortunately restricted to a limited number of adult tissues. Unique cells within bone marrow, epidermis, intestine, and liver maintain sufficient developmental memory to orchestrate tissuespecific regeneration. The power to regenerate tissue is derived from a small number of unspecialized cells, or stem cells, which are unique in their capacity for self-renewal while also producing clonal progeny that differentiate into more specialized cell types.

Adult Stem Cells are Key to Regeneration Cells able to divide indefinitely, without terminally differentiating, continue to inhabit many adult tissues and have even been identified in tissues not observed to regenerate. These adult stem cells may exist in a specific tissue or be seeded in that tissue from circulating cells of bone marrow origin. Either way, the presence of stem cells within a broader variety of tissues underscores the importance of a permissive and supportive environment for stem cell-driven regeneration. Stem cells may be more generally defined by certain common properties including: • The ability to divide without limit, avoid senescence, and maintain genomic integrity • The ability to undergo division intermittently or to remain quiescent • The ability to propagate by self-renewal and differentiation • The absence of lineage markers Bone marrow contains hematopoietic, mesenchymal, and endothelial stem cells, providing a multifaceted regenerative capacity. Bone marrow stem cells, which are set aside during embryonic development, replenish the hematopoietic population. Endothelial stem cells from bone marrow have been implicated in tissue angiogenesis

and may supplement endothelial hyperplasia during regeneration of blood vessels. Moreover, bone marrow-derived mesenchymal stem cells may populate repairing tissue in other parts of the body. Epithelium of the skin and hair follicles regenerates from stem cells if the wound does not disrupt the epidermal basement membrane or the hair bulbs. Intestinal epithelium turns over rapidly and is replenished by stem cells that reside in the crypts of Lieberkuhn. Liver regeneration is partly a misnomer, because the regeneration of liver following partial hepatectomy is a hyperplastic response by mature differentiated hepatocytes and, for the most part, does not involve stem cells. However, there is evidence for stem cell-driven liver regeneration when hepatocytes are damaged by viral hepatitis or toxins. This regenerative potential is thought to arise from “oval cells,” which have characteristics of both hepatocytes (α-fetoprotein and albumin) and bile duct cells (γ-glutamyl transferase and duct cytokeratins) and may reside in the terminal ductal cells in the canal of Hering.

Cells Can be Classified by their Proliferative Potential The cells of the body divide at different rates. Some mature cells do not divide at all and some divide only under certain permissive conditions, whereas others complete a cycle every 16 to 24 hours. LABILE CELLS: Labile cells are found in tissues that are in a constant state of renewal. Tissues in which more than 1.5% of the cells are in mitosis at any one time are composed of labile cells. However, not all the cells in these tissues are continuously cycling. Rapidly self-renewing (labile) tissues are typically tissues that form physical barriers between the body and the external environment. These include epithelia of the gut, skin, cornea, respiratory tract, reproductive tract, and urinary tract. The hematopoietic cells of the bone marrow and lymphoid organs involved in immune defense also constitute labile tissues. Polymor-phonuclear leukocytes are the best example of a terminally differentiated cell that is rapidly renewed. Under appropriate conditions, tissues composed of labile cells regenerate after injury, provided that enough stem cells remain. STABLE CELLS: Stable cells populate tissues that normally are renewed very slowly but are populated with progenitor cells capable of more rapid renewal after tissue loss. The liver and the proximal renal tubules are examples of stable cell populations. Stable cells populate tissues in which fewer than 1.5% of the cells are in mitosis. Such tissues (e.g., endocrine glands, endothelium, and liver) do not have conspicuous stem cells. Rather, their cells require an appropriate stimulus to divide. It is the potential to replicate and not the actual number of steady state mitoses that determines the ability of an organ to regenerate. For example, the liver, a stable tissue with less than one mitosis for every 15,000 cells, regenerates rapidly after a loss of as much as 75% of its mass. PERMANENT CELLS: Permanent cells are terminally differentiated, have lost all capacity for regeneration, and do not enter the cell cycle. Traditionally, neurons of the central nervous system, cardiac myocytes, and cells of the lens were considered permanent cells, although recent studies are challenging previous dogma. If lost, permanent cells cannot be replaced. Although permanent cells do not divide, most of them do renew their cellular organelles. The extreme example of permanent cells is the lens of the eye. Every lens cell generated during embryonic development and postnatal life is preserved in the adult without turnover of its constituents.

Conditions that Modify Repair Local Factors May Influence Healing Location of the Wound In addition to the size and shape of the wound, its location also affects healing. Sites in which skin covers bone with little interven-

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ing tissue, such as skin over the anterior tibia, are locations where skin cannot contract. Skin lesions in such areas, particularly burns, often require skin grafts because their edges cannot be apposed. Complications or other treatments, such as infection or ionizing radiation, also slow the repair process.

Blood Supply Lower-extremity wounds of diabetics who suffer from diseaserelated vasculopathies often heal poorly or even require amputation. In such cases, advanced atherosclerosis in the legs compromises blood supply and impedes repair. Varicose veins of the legs slow the venous return and can also cause ulceration and nonhealing. Bedsores (decubitus ulcers) result from prolonged, localized, dependent pressure, which diminishes both arterial and venous blood flow. Joint (articular) cartilage is largely avascular and has limited diffusion capacity; often, it cannot mount a vigorous inflammatory response. As a result, articular cartilage repairs poorly, a condition (osteoarthritis) that usually worsens with age.

and surgery and engraftment are necessary to cover or heal the wound site and reduce scarring and contractures.

Liver Acute chemical injury or fulminant viral hepatitis causes widespread necrosis of hepatocytes. However, if liver failure is not quickly fatal, the parenchyma regenerates and normal form and function are restored. In addition to mitosis of hepatocytes, small cells at the canal of Hering, termed oval cells, are thought to be the stem cell responsible for liver regeneration under these conditions. By contrast, chronic injury in viral hepatitis or alcoholism is associated with the development of broad collagenous scars within the hepatic parenchyma, termed cirrhosis of the liver (Fig. 3-7). The hepatocytes form regenerative nodules that lack central veins and expand to obstruct blood vessels and bile flow. Portal hypertension and jaundice ensue despite adequate numbers of regenerated but disconnected hepatocytes.

Kidney Systemic Factors No specific effect of age alone on repair has been found. Although the skin of a 90-year-old person—which exhibits reduced collagen and elastin—may heal slowly, the same person’s cataract extraction or colon resection heals normally because the bowel and the eye are practically unaffected by age. Iatrogenic factors such as therapeutic corticosteroids retard wound repair by inhibiting collagen and protein synthesis as well as by exerting anti-inflammatory effects.

Fibrosis and Scarring Contrasted Successful wound repair that leads to localized scarring is a transient, not chronic, process that leads to resolution of local injury. By contrast, many chronic diseases involve persistent, unresolved inflammation, with progression of the repair response culminating in diffuse fibrosis in affected tissues. For example, inhaled smoke or silica particles induce persistent inflammation in the lung, ultimately leading to pulmonary fibrosis. Continuing insult or inflammation, mediated through the interplay of monocytes and lymphocytes, results in persistent high levels of cytokines, growth factors, and locally destructive enzymes such as collagenases. Whatever the cause, long-standing fibrosis of parenchymal organs such as the lung, kidney, or liver, disrupts the normal architecture and reduces function. Chronic fibrosis is generally irreversible, calling for measures to prevent exposure to the cause, or therapeutic measures to limit the inflammatory process. Fibrosis should be viewed as the pathological end result of persistent injury. Scarring, however, is often beneficial—the scar resulting from a surgical incision in skin, although cosmetically unattractive, holds the skin together.

Although the kidney has limited regenerative capacity, the removal of one kidney (nephrectomy) is followed by compensatory hypertrophy of the remaining kidney. If renal injury is not extensive and the extracellular matrix framework is not destroyed, the tubular epithelium regenerates. In most renal diseases, however, there is some destruction of the framework. Regeneration is then incomplete, and scar formation is the usual outcome. The regenerative capacity of renal tissue is maximal in cortical tubules, less in medullary tubules, and nonexistent in glomeruli. Recent data suggest tubule repair occurs by proliferation of endogenous renal progenitor cells.

Lung The epithelium lining the respiratory tract has an effective regenerative capacity, provided that the underlying extracellular matrix framework is not destroyed. Superficial injuries to tracheal and bronchial epithelia heal by regeneration from the adjacent epithelium. The outcome of alveolar injury ranges from complete regeneration of structure and function to incapacitating fibrosis (Fig. 3-8). Alveolar injury that does not result in damage to the basement membrane is followed by healing by regeneration. Alveolar type II pneumocytes (the alveolar reserve cells) migrate to denuded areas and undergo mitosis to form cells with features intermediate between those of type I and type II pneumocytes. As these cells cover

Specific Sites Exhibit Different Repair Patterns Skin Healing in the skin involves both repair (primarily dermal scarring) and regeneration (principally of the epidermis and vasculature). The salient features of primary and secondary healing are provided in Figure 3-6. Healing by primary intention occurs when the surgeon closely approximates the edges of a wound. The actions of myofibroblasts are minimized, and regeneration of the epidermis is optimal, because epidermal cells need migrate only a minimal distance. Healing by secondary intention proceeds when a large area of hemorrhage and necrosis cannot be completely corrected surgically. In this situation, myofibroblasts contract the wound, and subsequent scarring repairs the defect. The success and method of healing following a burn wound depends on the depth of the burn injury. If the burn is superficial or does not extend beyond the upper dermis, stem cells from the sweat glands and hair follicles will regenerate the epidermis. If the deep dermis is involved, the regenerative elements are destroyed,

Cirrhosis of the liver. The consequences of chronic hepatic injury are the formation of regenerating nodules separated by fibrous bands. A microscopic section shows regenerating nodules (red) surrounded by bands of connective tissue (blue). FIGURE 3-7.

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TISSUE INJURY

NECROSIS

Overview of repair. This figure provides an overview that interrelates the early dynamic events in repair. The time scale in this figure is not linear; initial tensile strength, the first phase, develops almost immediately. Remodeling is ill defined, extending from its early beginning in repair for weeks or months. FIGURE 3-8.

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the alveolar surface, they establish contact with other epithelial cells. Mitosis then stops, and the cells differentiate into type I pneumocytes. If there is extensive disruption to the basement membrane of the alveolus, scarring and fibrosis result. Stimulated by macrophage products, mesenchymal cells from the alveolar septa proliferate and differentiate into fibroblasts and myofibroblasts. These cells migrate into the alveolar space, where they secrete type 1 collagen and proteoglycans, leading to pulmonary fibrosis. The most common chronic pulmonary disease is emphysema, which involves airspace enlargement, the destruction of alveolar walls, and ineffective replacement of elastin. This process results in irreversible loss of tissue resiliency and function.

Heart Cardiac myocytes are permanent, nondividing, terminally differentiated cells. Recent studies, however, have provided evidence for minimal regeneration of cardiac myocytes from previously unrecognized stem or committed progenitor cells. The origin of these cells, whether they reside in the myocardium or migrate there following injury from sites unknown, is not resolved. For practical purposes, myocardial necrosis, from whatever cause, heals by the formation of granulation tissue and eventual scarring (Fig. 3-9). Not only does myocardial scarring result in the loss of contractile elements, but the fibrotic tissue also decreases the effectiveness of contraction in the surviving myocardium.

sists of disorganized axons and proliferating Schwann cells, as well as fibroblasts.

Effects of Scarring Although scarring is essential to the repair of most injuries, scarring in parenchymal organs modifies their complex structure and never improves their function. For example, in the heart, the scar of a myocardial infarction serves to prevent rupture of the weakened wall of the heart but reduces the amount of contractile tissue. If extensive enough, it may be associated with congestive heart failure or the formation of a ventricular aneurysm. Persistent inflammation within the pericardium may result in organization of the inflammatory exudate and conversion of the deposited fibrin into collagen. This is likely to produce fibrous adhesions, which result in constrictive pericarditis and heart failure (Fig. 3-11). Alveolar fibrosis in the lung causes respiratory failure. Infection within the peritoneum or even surgical exploration may lead to adhesions and intestinal obstruction. Immunological injury to the renal glomerulus eventuates in its replacement by a collagenous scar and, if this process is extensive, renal failure. Scarring in the skin following burns or surgical excision of lesions may produce unsatisfactory cosmetic results or worse, deficits in limb function because of wound contractions.

Wound Repair is Often Suboptimal Nervous System Mature neurons have been described as permanent and postmitotic cells, and recent studies suggesting possible regenerative capacity have not altered well-established observations about injury in the nervous system. Following trauma, only regrowth and reorganization of the surviving neuronal cell processes can re-establish neural connections. Although the peripheral nervous system has the capacity for axonal regeneration, the central nervous system lacks this ability. Any damage to the brain or spinal cord is followed by the growth of capillaries and gliosis (i.e., the proliferation of astrocytes and microglia). Gliosis in the central nervous system is the equivalent of scar formation elsewhere; once established, it remains permanently. Neurons in the peripheral nervous system can regenerate their axons, and under ideal circumstances, interruption in the continuity of a peripheral nerve results in complete functional recovery. However, if the cut ends are not in perfect alignment or are prevented from establishing continuity by inflammation or a scar, a traumatic neuroma results (Fig. 3-10). This bulbous lesion con-

Myocardial infarction. A section through a healed FIGURE 3-9. myocardial infarct shows mature fibrosis (*) and disrupted myocardial fibers (arrow).

Abnormalities in any of three healing processes—repair, contraction, and regeneration—result in unsuccessful or prolonged wound healing. The skill of the surgeon is often of critical importance.

Deficient Scar Formation Inadequate formation of granulation tissue or an inability to form a suitable extracellular matrix leads to deficient scar formation and its complications, such as wound dehiscence (splitting upon increased stress) and incisional hernias at prior surgical sites. Systemic factors predisposing to such defects include metabolic deficiency, hypoproteinemia, and the general inanition that often accompanies metastatic cancer.

Ulceration Wounds can ulcerate when there is an inadequate intrinsic blood supply or insufficient vascularization during healing. For example, leg wounds in persons with varicose veins or severe atherosclerosis often ulcerate. Nonhealing wounds also develop in areas

Traumatic neuroma. In this photomicrograph, the original nerve (arrows) enters the neuroma. The nerve is surrounded by dense collagenous tissue, which appears dark blue with this trichrome stain. FIGURE 3-10.

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ture and results in severe deformity of the wound and surrounding tissues. Interestingly, the regions that normally show minimal wound contraction (e.g., the palms, the soles, and the anterior aspect of the thorax) are the ones prone to contractures. Contractures are particularly conspicuous in the healing of serious burns and can be severe enough to compromise the movement of joints. In the alimentary tract, a contracture (stricture) can result in obstruction to the passage of food in the esophagus or a block in the flow of intestinal contents.

Excessive Regeneration and Repair In addition to the many responses to injury described thus far, an additional lesion merits consideration, namely pyogenic granuloma. This lesion is a localized, persistent, exuberant overgrowth of granulation tissue, most commonly seen in gum tissue in pregnant women. It also develops in the squamocolumnar junction of the uterine cervix and at other sites. An injury preceding the development of pyogenic granuloma cannot usually be found. Like injury-induced granulation tissue, it lacks nerves and can be surgically trimmed without anesthesia. Conceptually, pyogenic granuloma is a transitional lesion, resembling granulation tissue but behaving almost as an autonomous benign neoplasm.

FIGURE 3-11.

Organized strands of collagen in constrictive pericarditis (arrows). A

devoid of sensation because of persistent trauma. Such trophic or neuropathic ulcers are commonly seen in diabetic peripheral neuropathy.

Excessive Scar Formation Inordinate deposition of extracellular matrix, mostly excessive collagen, at the wound site results in a hypertrophic scar. A keloid is an exuberant hypertrophic scar that tends to progress beyond the site of initial injury and recurs after excision (Fig. 3-12). Histologically, both of these types of scars exhibit broad and irregular collagen bundles, with more capillaries and fibroblasts than expected for a scar of the same age. More clearly defined in keloids than in hypertrophic scars, the rate of collagen synthesis, the ratio of type III to type I collagen, and the number of reducible crosslinks, remain high. This situation indicates a “maturation arrest,” or block, in the process of wound maturation. Keloids are unsightly, and attempts at surgical repair are always problematic—the outcome likely being a still-larger keloid. Dark-skinned individuals are more frequently affected by keloids than light-skinned ones, and the tendency is sometimes hereditary. By contrast, the occurrence of hypertrophic scars is not associated with skin color or heredity.

Excessive Contraction A decrease in the size of a wound depends on the presence of myofibroblasts, development of cell–cell contacts, and sustained cell contraction. An exaggeration of these processes is termed contrac-

B Keloid. A. A light-skinned black woman developed a keloid as a reaction to having her earlobe pierced. B. Microscopically, the dermis is markedly thickened by the presence of collagen bundles with random orientation and abundant cells. FIGURE 3-12.

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Immunopathology Jeffrey S. Warren Douglas P. Bartlett Roger J. Pomerantz

Biology of the Immune System Cellular Components of the Immune System The Major Histocompatibility Complex (MHC) Immunologically Mediated Tissue Injury IgE-mediated Hypersensitivity Reactions (Type I) Non-IgE Antibody-Mediated Hypersensitivity Reactions (Type II) Cell-mediated Immune Complex Reactions (Type III) Hypersensitivity Reactions (Type IV) Immunodeficiency Diseases Primary Antibody Deficiency Diseases Primary T-Cell Immunodeficiency Diseases Combined Immunodeficiency Diseases

Autoimmunity and Autoimmune Diseases Autoimmune Disease and Tolerance Systemic Lupus Erythematosus (SLE) Sjögren Syndrome Scleroderma (Progressive Systemic Sclerosis) Mixed Connective Tissue Disease Immune Reactions to Transplanted Tissues Hyperacute Rejection Acute Rejection Chronic Rejection Graft-Versus-Host Disease Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) Immunology of AIDS

The immune system protects the host from invasion by foreign and potentially harmful agents. As components of host defense, immune responses are characterized by their ability to (1) distinguish self from nonself, (2) discriminate among potential invaders (specificity), (3) maintain the presence of immune memory (anamnesis), and (4) recall previous exposures and mount an amplified response to them. Immune responses can be elicited by a wide range of agents (termed antigens) including parasites, bacteria, viruses, chemicals, toxins, drugs, and transplanted tissues. Immune responses that show antigen specificity and immune memory are termed adaptive immunity. Innate immunity (discussed in part in Chapter 2) does not demonstrate immune memory and lacks the exacting specificity of adaptive immunity (although patterns and classes of harmful agents such as

bacterial cell wall components are recognized). The host defense systems that constitute the acute inflammatory response, including cell surface-associated and soluble mediator systems (e.g., complement and coagulation systems) and phagocytes (most important being tissue resident macrophages), are integral to innate immunity. The adaptive immune response is critical to host survival, and failure is associated with overwhelming infectious disease. One need only consider the ravages of AIDS. Adaptive immune responses can be appropriate in terms of defense, but nevertheless may lead to host injury (such as the immune rejection of a transplanted organ). The diseases associated with either the lack of appropriate adaptive immunity or injury produced by inappropriate or excessive adaptive immunity constitute the study of immunopathology. 53

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Biology of the Immune System The Cells that Comprise the Immune System Derive from Hematopoietic Stem Cells The antigen-specific or “adaptive” immune system encompasses lymphocytes, plasma cells, antigen-presenting cells (APCs), spe-

cific effector molecules (e.g., immunoglobulins), and a vast array of regulatory mediators. The cellular components of the immune system are derived from pluripotent hematopoietic stem cells (Fig. 4-1). By 8 weeks of gestation, lymphoid stem cells derived from hematopoietic stem cells and fated to become T cells circulate to the thymus, where they differentiate into mature T lymphocytes. Lymphoid stem cells destined to become B cells differentiate first within fetal liver

T Lymphocyte Thymus NK Lymphocyte Lymphoid stem cell

B Lymphocyte CD34+, CD117+ Neutrophil Plasma cell

Pluripotent hematopoietic stem cell CD34+ or CD34LIN-

Monocyte CFU-GM

Macrophage

Dendritic cell Myeloid stem cell CD34+, CD33+ CFU-GEMM HLA-DR CD34+, CD33+

Eosinophil CFU-Eo

Erythrocyte CFU-E

Megakaryocyte CFU-Meg

Basophil CFU-Baso

Mast cell CFU-MC Pluripotent hematopoietic stem cells differentiate into either lymphoid or myeloid stem cells and, in the case of myeloid stem cells, into lineage-specific colony-forming units (CFUs). Under the influence of an appropriate microenvironment, CFUs give rise to definitive cell types. Lymphoid stem cells are precursors of natural killer (NK) cells, T lymphocytes, and B lymphocytes. B lymphocytes give rise to plasma cells. CD, cluster designation; CFU-GEMM, granulocytic, erythroid, monocytic–dendritic, and megakaryocytic colony-forming units; HLA, human leukocyte antigen. FIGURE 4-1.

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(8 weeks) and later within bone marrow (12 weeks). The primary branch point in differentiation is between lymphoid progenitors and myeloid progenitors. The former ultimately give rise to T lymphocytes, B lymphocytes, and natural killer (NK) cells, whereas the latter develop into granulocytic, erythroid, monocytic–dendritic, and megakaryocytic cells. The definition of developing and mature cells of the immune and hematopoietic systems depends in large part on cell surface markers, which are designated by cluster designation (CD) numbers.

Lymphocytes There are three major types of lymphocytes—T cells, B cells, and NK cells—which account for 25% of peripheral blood leukocytes. Some 80% of blood lymphocytes are T cells, 10% B cells, and 10% are NK cells. The relative proportions of lymphocytes in the peripheral blood and central and peripheral lymphoid tissues vary. In contrast to the blood, only 30% to 40% of splenic and bone marrow lymphocytes are T cells. T lymphocytes can be subdivided into subpopulations by virtue of their specialized functions, by surface CD molecules, and in some cases, by morphologic features. Lymphoid progenitor cells destined to become T cells exit the bone marrow and migrate to the thymus, where they undergo a complex multistep maturation process that accomplishes three goals: 1. Recombination of dispersed gene segments that encode the antigen-binding regions of the heterodimeric α/β or γ/δ T-cell receptor (TCR) 2. Formation of functionally distinct helper (CD4+) and cytotoxic/suppressor (CD8+) T-cell populations 3. Positive, followed by negative, thymic selection to produce a Tcell population that recognizes self-peptides plus major histocompatibility antigens, but not with sufficient avidity to result in autoimmunity During this process, the developing T lymphocytes transit from the subcapsular zone of the thymus (containing the least mature T cells) to the medullary region, from which the mature naive T cells are released into the peripheral circulation. During this process, immature T cells interact with thymic epithelial cells (in the cortex) and dendritic cells (in the medulla) and undergo the following maturational events. • Subcapsular zone of thymus: T cells are CD4-, CD8- (double negative). TCR gene arrangements commence. • Cortical zone of thymus: T cells are CD4+, CD8+ (double positive). Positive selection of cells interacting with self-major histocompatibility (MHC) molecules and self-peptides that are displayed by cortical epithelial cells • Cortical zone of thymus: T cells are CD4+ or CD 8+ (single positive), depending on preferential binding to MHC class II or MHC class I molecules, respectively. • Medullary zone of thymus: T cells that react strongly with MHC and self-peptide displayed by medullary dendritic cells are negatively selected and undergo apoptosis to eliminate self-reactivity. • Mature single-positive naive T cells enter the circulation. T lymphocytes exit the thymus and populate peripheral lymphoid tissues. In the thymus, antigen-specific TCRs are formed and are expressed in conjunction with CD3, an essential accessory molecule. Nearly 95% of circulating T lymphocytes express α/β TCRs. In turn, circulating α/β T cells also express either CD4 or CD8. A smaller population (5%) of T cells expresses γ/δ TCRs and CD3, but neither CD4 nor CD8. T lymphocytes recognize specific antigens, usually proteins or haptens bound to proteins. CD4+ and CD8+ T-cell subsets possess a variety of effector and regulatory functions. Effector functions include secretion of proinflammatory cytokines and killing of cells

that express foreign or altered membrane antigens. Regulatory functions comprise augmenting and suppressing immune responses, usually by secreting specific helper or suppressor cytokines. In general, CD4+ T cells promote antibody and inflammatory responses. Such cells recognize antigen in the context of self-MHC class II molecules on APCs. CD4+ T cells can be further distinguished by the types of cytokines produced. Helper type 1, or Th1, cells produce interferon (IFN)-γ and interleukin (IL)-2, whereas helper type 2, or Th2, cells secrete IL-4, IL-5, and IL-10. Th1 lymphocytes have been associated with cell-mediated phenomena and Th2 cells with B-cell activation and allergic responses. By contrast, CD8+ cells, for the most part, exert suppressor and cytotoxic functions. CD8+ cells recognize antigen in the context of self-MHC class I molecules present on many cells. Suppressor cells inhibit the activation phase of immune responses; cytotoxic cells can kill target cells that express specific antigens (see Fig. 4-2). Foreign class I and class II molecules, which are not histocompatible with the host (e.g., transplanted histocompatibility antigens), are themselves potent immunogens and can be recognized by host T cells. This is why human tissue transplantation requires that donor and recipient be HLA-matched. In addition to the binding of foreign peptides presented by MHC molecules to the TCR complex, a number of other receptor–ligand interactions must occur to maximally activate lymphocytes. See Figure 4-2, which summarizes some of the key interactions that occur between CD4+ Thelper cells and APCs. B lymphocytes pass through a series of carefully regulated developmental pathways in a manner analogous to those of T cells. Initially, pro-B cells are produced in the fetal liver and continue to differentiate in the bone marrow after birth. The microenvironment of the bone marrow is critical to B-lymphocyte development; Pro-B cells traverse radially from the marrow nearest to the bone toward the central sinus of the marrow as they mature. They are released to the periphery as immature B cells. Only B lymphocytes that pass through the many ordered stages of DNA recombination necessary to produce surface immunoglobulins survive and exit to the periphery. Immature B cells upregulate the expression of surface immunoglobulins (the B-cell receptor) and undergo a process of negative selection by self-antigens they encounter, resulting in mature B cells. Developing B cells in which surface immunoglobulin binds too avidly to self-antigens are negatively selected and eliminated. B cells express a surface antigen-binding receptor, the membrane-bound immunoglobulin B-cell receptor, which bears the same antigen-binding specificity as the soluble immunoglobulin that will ultimately be secreted by the corresponding terminally differentiated B cell, termed a plasma cell. Mature B lymphocytes exist primarily in a resting state, awaiting activation by foreign antigens. Activation requires (1) crosslinking of membrane immunoglobulin receptors by antigens presented by accessory cells or (2) interactions with membrane molecules of helper T cells via a mechanism called cognate Tcell—B-cell help (see Fig. 4-2). The initial stimulus leads to B-cell proliferation and clonal expansion, a process amplified by cytokines from both accessory cells and T cells. If no additional signal is provided, proliferating B cells return to a resting state and enter the memory cell pool. These events occur largely in lymphoid tissues and can be seen as germinal centers. Within germinal centers, B cells also undergo further somatic gene rearrangements, leading to generation of cells that produce the various immunoglobulin isotypes and subclasses. An isotype is the class of the defining heavy chain of an immunoglobulin molecule. In turn, each immunoglobulin subtype exhibits a different array of biological activities. In the presence of antigen, T cells produce helper cytokines that stimulate isotype switching or induce proliferation of previously committed isotype populations. For example, IL-4 induces switching to the IgE isotype. The final stage of B-cell differentiation into antibody-synthesizing

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T CELL

CD3

CTLL-4

CD4

T Cell Receptor

B7.2 Costimulator

Membrane

CD28

B7 Costimulator

Phagocytosis of Antigen

Membrane

Class II MHC plus Antigen Peptide Complex

Antigen Processing

ANTIGEN PRESENTING CELL

T CELL

CD3 Membrane Antigen on B cell Receptor

CD4

T Cell Receptor

CD40 Ligand

Helper Cytokines CD40 Receptor Membrane Endocytosis Antigen Processing

Class II MHC plus Antigen Peptide Complex

B CELL

A. T-lymphocyte activation (by the T-cell receptor [TCR]) occurs via peptides cleaved from the phagocytized antigen (antigen processing) and presented to the TCR in the context of a histocompatible class II major histocompatibility complex (MHC) molecule. T-cell activation also requires accessory or costimulatory signals from cytotoxic lymphoid line (CTLL)-4 or CD28. B. A similar process applies to B-cell–T-cell interactions. The B-lymphocyte antigen receptor is membrane immunoglobulin. FIGURE 4-2.

plasma cells requires exposure to additional products of T lymphocytes (e.g., IL-5, IL-6), especially in the case of protein antigens. The predominant type of immunoglobulin produced during an immune response changes with age. Newborns tend to produce predominantly IgM. By contrast, older children and adults initially produce IgM following an antigenic challenge, but rapidly shift toward IgG synthesis. NK cells, which are believed to form in both the thymus and bone marrow, recognize target cells via an antigen-independent mechanism. NK cells do not express either a functional TCR or surface immunoglobulin. They bear several types of class I MHC molecule receptors, which when engaged, inhibit the NK cell’s capacity

to secrete cytolytic products. Certain tumor cells and virus-infected cells bear reduced numbers of MHC class I molecules and thus do not inhibit NK cells. NK cells that engage virus-infected or tumor cells secrete complement-like cytolytic proteins (perforin), granzymes A and B, and other lytic factors. NK cells also secrete granulysin, a cationic protein that induces target cell apoptosis.

Mononuclear Phagocytes, Antigen-Presenting Cells, and Dendritic Cells Mononuclear phagocyte is a general term applied to phagocytic cell populations in virtually all organs and connective tissues. Among these cells are macrophages, monocytes, Kupffer cells of

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the liver, and lung alveolar macrophages. Precursor cells (monoblasts and promonocytes) arise in the bone marrow, enter the circulation as monocytes, and then migrate into tissues, where they take up residence as tissue macrophages. In the lung, liver, and spleen, numerous macrophages populate sinuses and pericapillary zones to form an effective filtering system, which removes effete cells and foreign particulate material from blood. Macrophages are important accessory cells by virtue of their expression of class II histocompatibility antigens. They ingest and process antigens for presentation to T cells in conjunction with class II MHC molecules. The subsequent T-cell responses are further amplified by macrophage-derived cytokines. One of the best-characterized cytokines is IL-1, which promotes expression of the IL-2 receptor on T cells, augmenting T-cell proliferation that is driven by IL-2. Among many effects of IL-1 on other tissues is preparation of the body to combat infection. For example, IL-1 induces fever and promotes catabolic metabolism (see Chapter 2). The functional activities of macrophages and the spectrum of molecules that they produce are regulated by external factors, such as T-cell—derived cytokines. Macrophages exposed to such factors become “activated,” after which they produce a variety of reactive oxygen metabolites, cytokines, and soluble mediators of host defense (e.g., IFN-γ, IL-1β, tumor necrosis factor-α, and complement components), and are a critical part of innate, as well as adaptive immunity. Antigen-presenting cells (APCs) acquire the capacity to present antigen to T-helper lymphocytes in the context of histocompatibility, after cytokine-driven upregulation of MHC class II molecules (Fig. 4-2). Monocytes, macrophages, dendritic cells and, under certain conditions, B lymphocytes, endothelial cells and epithelial cells, can act as APCs. In some locations, APCs are highly specialized for this function. For instance, in B-cell-rich follicles of lymph nodes and spleen, antigen presentation by follicular dendritic cells leads to generation of memory B lymphocytes, which are important in anamnesis (immune memory) (Fig. 4-3). Dendritic cells are specialized APCs that are termed “dendritic” by virtue of their spider-like morphologic appearance. They are found in B-lymphocyte-rich lymphoid follicles, in thymic medulla, and in many peripheral sites, including intestinal lamina propria, lung, genitourinary tract, and skin. An example of a peripheral APC is the epidermal Langerhans cell. Upon exposure, the Langerhans cell engulfs antigen, migrates to a regional lymph node through an afferent lymphatic, and differentiates into a more mature dendritic cell. Langerhans cell-derived dendritic cells express high densities of MHC class I and II molecules and present antigen efficiently to T lymphocytes (see Fig. 4-3).

The MHC Coordinates Interactions Among Immune Cells The MHC, in humans termed the HLA complex, orchestrates many of the cell–cell interactions fundamental to the immune response. These antigens are major immunogens and were first recognized as targets in transplant rejection. The MHC includes class I, II, and III antigens. (Class III antigens represent certain complement components and are not histocompatibility antigens per se; Fig. 4-4). Class I MHC molecules are encoded by highly polymorphic genes in the A, B, and C regions of the MHC (see Fig. 4-4). These loci encode similarly structured molecules that are expressed in virtually all tissues. Because the alleles are expressed codominantly, tissues bear class I antigens inherited from each parent. These antigens are recognized by cytotoxic T cells during graft rejection or T-lymphocyte-mediated killing of virus-infected cells.

Class II MHC molecules are encoded by multiple loci in the D region. The D region loci encode structurally similar molecules that are expressed primarily on antigen-presenting cells, including monocytes, macrophages, dendritic cells, and B lymphocytes. Class II antigens have also been referred to as “Ia” (immunity-associated) antigens. As with class I antigens, D region alleles are expressed codominantly, and tissues bear antigens from each parent.

Immunologically Mediated Tissue Injury Immune responses not only protect against invasion by foreign organisms but may also themselves cause tissue damage. Thus, many inflammatory diseases are examples of “friendly fire” in which the immune system attacks the body’s own tissues. An immune response that leads to tissue injury or disease is broadly called a hypersensitivity reaction. Immune, or hypersensitivity-mediated, diseases are common and include such entities as hives (urticaria), asthma, hay fever, hepatitis, glomerulonephritis, and arthritis. Hypersensitivity reactions are classified according to the type of immune mechanism (Table 4-1). Type I, II, and III hypersensitivity reactions all require formation of a specific antibody against an exogenous (foreign) or an endogenous (self) antigen. The antibody class is a critical determinant of the mechanism by which tissue injury occurs. In most type I, or immediate-type hypersensitivity reactions, IgE antibody is formed and binds to high-affinity receptors on mast cells and/or basophils via its Fc domain. Subsequent binding of antigen and cross-linking of IgE trigger rapid (immediate) release of products from these cells, leading to the characteristic symptoms of such diseases as urticaria, asthma, and anaphylaxis. In type II hypersensitivity reactions, IgG or IgM antibody is formed against an antigen, usually a protein on a cell surface. Less commonly, the antigen is an intrinsic structural component of the extracellular matrix (e.g., part of the basement membrane). Such antigen–antibody binding activates complement, which in turn lyses the cell (cytotoxicity) or damages the extracellular matrix. In some type II reactions, other antibody-mediated effects are operative. In type III hypersensitivity reactions, the antibody responsible for tissue injury is also usually IgM or IgG, but the mechanism of tissue injury differs. The antigen circulates in the vascular compartment until it is bound by antibody. The resulting immune complex is deposited in tissues. Complement activation at sites of antigen–antibody deposition leads to leukocyte recruitment, which is responsible for the subsequent tissue injury. In some type III reactions, antigen is bound by antibody in situ. Type IV reactions, also known as cell-mediated, or delayedtype hypersensitivity reactions, do not involve antibodies. Rather, antigen activation of T lymphocytes, usually with the help of macrophages, causes release of products by these cells, thereby leading to tissue injury. Many immunologic diseases are mediated by more than one type of hypersensitivity reaction. Thus, in hypersensitivity pneumonitis, lung injury results from hypersensitivity to inhaled fungal antigens. Types I, III, and IV hypersensitivity reactions all appear to be operative in this disease.

Type I or Immediate Hypersensitivity Reactions are Triggered by IgE Bound to Mast Cells Immediate-type hypersensitivity is manifested by a localized or generalized reaction that occurs within minutes of exposure to an antigen or “allergen” to which the person has previously been sensitized. The clinical manifes-

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Bacterium

Epithelium Site of entry (e.g., skin or mucosa)

Dendritic cellassociated antigen

Free antigen

Naive T and B lymphocytes

Afferent lymphatic vessel

Lymph node

Artery

Efferent lymphatic vessel

Activation of naive lymphocytes and differentation into effector and memory lymphocytes

Memory lymphocyte

Effector T lymphocytes Effector B lymphocytes (plasma cells)

Circulating naive lymphocytes migrate into lymph node via HEVs

Effector lymphocyte Secreted antibodies

Peripheral tissue Effector T cells and antibodies eliminate antigen Peripheral blood vessel

Memory lymphocytes take up residence in tissues in preparation for next infection

In an integrated immune response, antigen is processed and presented by a dendritic cell, which migrates via the afferent lymphatics to a regional lymph node. Within the regional lymph node, antigen is presented to lymphocytes, which in turn are activated and may migrate (via homing mechanism) to specific peripheral sites. HEVs, high endothelial venules. FIGURE 4-3.

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Urine pepsinogen

Short arm of Chromosome 6

MHC Short Arm Gene Regions

Glyoxylase Phosphoglycomytase 3 Centromere

Class II DP

Tap

Class III DO DQ

Class I B

Transcription Processing Translation Glycosylation

α-chain

β-chain

α-chain

β2-microglobulin Cell membrane

Class II FIGURE 4-4.

Class I

The highly polymorphic loci that encode major histocompatibility antigens are located on the short arm of chromosome 6. Class I and class II molecules exhibit different structures, but each participates in fundamentally important T-cell—cell interactions.

tations of a reaction depend on the site of antigen exposure and extent of sensitization. For example, when a reaction involves the skin, the characteristic local reaction is a “wheal and flare,” or urticaria (hives). When the localized manifestations of immediate hypersensitivity involve the upper respiratory tract and conjunctiva, causing sneezing and conjunctivitis, we speak of hay fever (allergic rhinitis). In its generalized and most severe form, immediate hypersensitivity reactions are associated with bronchoconstriction, airway obstruction, and circulatory collapse, as seen in anaphylactic shock. There is a high degree of variability in susceptibility to type I hypersensitivity reactions, which is genetically determined. Type I hypersensitivity reactions usually feature IgE antibodies, which are formed by a CD4+, Th2, T-cell–dependent mechanism and which bind avidly to Fcε receptors on mast cells and basophils. The high avidity of binding of IgE accounts for the term cytophilic antibody. Once exposed to a specific allergen that elicits IgE, a person is sensitized, and subsequent exposures to that allergen induce immediate hypersensitivity reactions. After IgE is elicited, repeat exposure to antigens typically induces additional IgE antibodies, rather than antibodies of other classes, such as IgM or IgG.

IgE can persist for years bound to Fcε receptors on mast cells and basophils, a feature unique to these cells. Upon subsequent reexposure, the soluble antigen or allergen binds the IgE coupled to its surface Fcε receptor and activates the mast cell or basophil. This event releases the potent inflammatory mediators that are responsible for the manifestations of this type I hypersensitivity reaction. As shown in Figure 4-5, the antigen (allergen) binds to the IgE antibody through its Fab sites. Cross-linking of the antigen to more than one IgE antibody molecule is required to activate the cell. Figure 4-5 shows that the complement-derived anaphylatoxic peptides, C3a and C5a, can directly stimulate mast cells by a different receptor-mediated process. These cell-activating events trigger the release of stored granule constituents and rapid synthesis as well as release of other mediators. A number of potent mediators are preformed and released from granules within minutes, after which they exert immediate biological effects (see Fig. 4-5). • Histamine induces (1) constriction of vascular and nonvascular smooth muscle, (2) microvascular dilation, and (3) an increase in venule permeability, mediated largely through H1 receptors.

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TABLE 4–1

Modified Cell and Coombs Classification of Hypersensitivity Reactions Type

Mechanism

Examples

Type I (anaphylactic type): Immediate hypersensitivity

IgE antibody-mediated mast cell activation and degranulation

Hay fever, asthma, hives, anaphylaxis

Non–Ige-mediated

Physical urticarias

Type II (cytotoxic type): Cytotoxic antibodies

Cytotoxic (IgG, IgM) antibodies formed against cell-surface antigens; complement usually involved

Autoimmune hemolytic anemias, Goodpasture disease

Noncytotoxic antibodies against cell surface receptors

Graves disease

Type III (immune complex type): Immune complex disease

Antibodies (IgG, IgM, IgA) formed against exogenous or endogenous antigens; complement and leukocytes (neutrophils, macrophages) often involved

Autoimmune diseases (SLE, rheumatoid arthritis), many types of glomerulonephritis

Type IV (cell-mediated type): Delayed-type hypersensitivity

Mononuclear cells (T lymphocytes, macrophages) with interleukin and lymphokine production

Granulomatous disease (tuberculosis, sarcoidosis)

Ig, immunoglobulin; SLE, systemic lupus erythematosus.

Anaphylactic activation

Activation by complement peptides C3a C5a

Receptor-Ligand Coupling

Antigen IgE antibody

Anaphylatoxin receptors Ca2Arachidonic acid products

Metabolic Responses

Secretory events

Release Of: • Vasoactive amines (histamine) • Eosinophil chemotactic factor • Platelet activating factor • Enzymes • Leukotrienes C, D, E • Prostaglandin PGD2, thromboxane

Effects: • Smooth muscle contraction • Increased vascular permeability • Chemotactic attraction of eosinophils • Platelet activation • Protease effects, kininogenases

In a type I hypersensitivity reaction, allergen binds to cytophilic surface IgE antibody on a mast cell or basophil and triggers cell activation and the release of a cascade of proinflammatory mediators. These mediators are responsible for smooth muscle contraction, edema formation, and the recruitment of eosinophils. Ca2+, calcium ion; Ig, immunoglobulin; PGD2, prostaglandin D2. FIGURE 4-5.

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The biologic effects include urticaria in the skin and bronchospasm, vascular congestion, and edema in the lung. • Chemotactic factors for neutrophils and eosinophils (the later is the hallmark cell of immediate hypersensitivity) Activation of macrophages also results in the synthesis of many other potent inflammatory mediators that are important in the late phase response of immediate hypersensitivity reactions. • Cytokines that are responsible in part for the development of a mixed inflammatory infiltrate • Products of arachidonic acid metabolism, including prostaglandins and leukotrienes (C4, D4, and E4), the “slow-reacting substances of anaphylaxis,” which are responsible for the delayed bronchoconstriction phase of anaphylaxis, and leukotriene B4, a potent chemotactic factor for neutrophils, macrophages, and eosinophils • Platelet-activating factor (PAF), a powerful inducer of platelet activation, neutrophil chemotaxis, and activation of many phagocytic cells Activated T cells, specifically the Th2 type, produce cytokines that have important roles in allergic responses. Activated Th2 Tcell subsets produce IL-4, IL-5, and IL-13, leading to IgE production and increased numbers of mast cells and eosinophils. Allergyprone persons have reduced levels of IFN-γ, which suppresses development of Th2 clones and subsequent production of IgE. The factors responsible for human susceptibility to immediate hypersensitive reactions (allergy) are complex and involve the interaction of environment and multiple genetic loci.

Type II Hypersensitivity Reactions are Mediated by Antibodies Against Fixed Cellular or Extracellular Antigens IgG and IgM typically mediate type II reactions. An important characteristic of these antibodies is their ability to activate complement through the immunoglobulin Fc domain. This occurs when IgM or IgG antibody binds an antigen on the surface of the erythrocyte membrane. At sufficient density, bound immunoglobulin leads to complement fixation via C1q and the classic pathway (see Chapter 2). Once activated, complement can destroy target cells by several methods.

• Insertion of the membrane attack complex into the red cell plasma membrane, thereby inducing lysis. • Opsonization, the coating of target cells with immunoglobulin or C3b and subsequent phagocytosis by cells having receptors for these molecules (including neutrophils and macrophages) (Fig. 4-6). Such complement-dependent mechanisms are responsible for transfusion reactions related to major blood group incompatibilities and some autoimmune hemolytic anemias. There is another type of antibody-mediated cytotoxicity that does not require complement. Antibody-dependent cell-mediated cytotoxicity (ADCC) involves cytolytic leukocytes that attack antibody-coated target cells after binding via Fc receptors. Phagocytic cells and NK cells can function as effector cells in ADCC. The mechanisms by which target cells are destroyed in these reactions are not entirely understood. ADCC may also be involved in the pathogenesis of some autoimmune diseases (e.g., autoimmune thyroiditis). In some type II reactions, antibody binding to a specific target cell receptor does not lead to cell death but rather to a change in function. Autoimmune diseases such as Graves disease and myasthenia gravis feature autoantibodies against cell-surface hormone receptors. In Graves disease, autoantibody directed against the thyroid-stimulating hormone (TSH) receptor on thyrocytes mimics the effect of TSH, stimulating thyroxine production and leading to hyperthyroidism (see Chapter 21). By contrast, in myasthenia gravis, autoantibodies to acetylcholine receptors in neuromuscular endplates either block acetylcholine binding or mediate internalization or destruction of receptors, thereby inhibiting efficient synaptic transmission (see Chapter 27). Patients with myasthenia gravis thus suffer from muscle weakness. Modulatory autoantibodies against receptors for insulin, prolactin, growth hormone, and other messengers are reported. Some type II hypersensitivity reactions result from antibody directed against a structural connective tissue component. A classic example is Goodpasture syndrome, in which antibodies bind the noncollagenous domain of type IV collagen, which is a major structural component of pulmonary and glomerular basement membranes. Local complement activation recruits neutrophils to the site, resulting in tissue injury, pulmonary hemorrhage, and glomerulonephritis. Direct complement-mediated damage to the basement membranes of the glomeruli and the lung alveoli through formation of membrane attack complexes may also be involved.

Phagocytosis and intracellular destruction of red blood cells

Opsonization of red blood cell PMN Fc receptor IgG or IgM RBC

C3b receptor

C3b

In a type II hypersensitivity reaction, opsonization by antibody or complement leads to phagocytosis via either Fc or C3b receptors, respectively. Ig, immunoglobulin; PMN, polymorphonuclear neutrophil; RBC, red blood cell. FIGURE 4-6.

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In Type III Hypersensitivity Reactions, Immune Complex Deposition or Formation In Situ Leads to Complement Fixation and Inflammation IgG, IgM, and occasionally IgA antibody against either a circulating antigen or an antigen that is deposited or “planted” in a tissue can cause a type III response. Physicochemical characteristics of the immune complexes, such as size, charge, and solubility, in addition to immunoglobulin isotype, determine whether an immune complex can deposit in tissue or fix complement. Immune complexes elicit inflammatory responses by activating complement, leading to chemotactic recruitment of neutrophils and monocytes to the site. Activated phagocytes release tissue-damaging mediators, such as proteases and reactive oxygen intermediates. Immune complexes have been implicated in many human diseases (Fig. 4-7). The most compelling cases are those in which the demonstration of immune complexes in injured tissue correlates with the development of injury, because in some diseases immune complexes can be detected in plasma without concomitant evidence of tissue injury. Diseases that seem to be most clearly attributable to immune complex deposition are collagen-vascular autoimmune diseases, such as systemic lupus erythematosus (SLE)

and rheumatoid arthritis, some types of vasculitis, and many varieties of glomerulonephritis. Once immune complexes are deposited in tissues, they may trigger an inflammatory response. Local activation of complement by immune complexes results in the formation of C5a, which is a potent neutrophil chemoattractant. Inflammation proceeds much as described for nonimmune-meditated acute inflammation (see Chapter 2). Once neutrophils arrive, they are activated through contact with, and ingestion of, immune complexes. Activated leukocytes release many inflammatory mediators, including proteases, reactive oxygen intermediates, and arachidonic acid products, which collectively produce tissue injury.

Type IV, or Cell-Mediated, Hypersensitivity Reactions are Cellular Immune Responses that Do Not Involve Antibodies Included among these reactions are delayed-type cellular inflammatory responses and cell-mediated cytotoxic effects. Type IV reactions often occur together with antibody-dependent reactions, which can make it difficult to distinguish these processes. Both clinical obser-

Antigens

Immune complex deposition

Amounts in serum Circulating immune complexes

VASCULITIS

6 Time (days)

GLOMERULONEPHRITIS

COMPLEMENT ACTIVATION Anaphylatoxins C3a, C5a

Blood vessel

Capillary

Epithelial cell

Bronchiole

PMNs PMN

Immune complexes Endothelial cell Immune complexes

Glomerular basement membrane

Smooth muscle contraction Vasopermeability, edema

In type III hypersensitivity, immune complexes are deposited and can lead to complement activation and the recruitment of tissue-damaging inflammatory cells. The ability of immune complexes to mediate tissue injury depends on size, solubility, net charge, and ability to fix complement. PMN, polymorphonuclear neutrophil. FIGURE 4-7.

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vations and experimental studies suggest that the type of tissue response is largely determined by the nature of the inciting agent. Classically, delayed-type hypersensitivity is a tissue reaction, primarily involving lymphocytes and mononuclear phagocytes, which occurs in response to a soluble protein antigen and reaches greatest intensity 24 to 48 hours after initiation. A classic example of a type IV reaction is the contact sensitivity response to poison ivy. Although chemical ligands in poison ivy are not proteins, they bind covalently to cell proteins, after which the compound molecules are recognized by antigen-specific lymphocytes. Figure 4-8 summarizes the stages of a delayed-type hypersensitivity reaction. In the initial phase, foreign protein antigens or chemical ligands interact with accessory cells that express class II human leukocyte antigen (HLA) molecules (Fig. 4-8A). Such accessory cells (macrophages, dendritic cells) secrete IL-12, which along with processed and presented antigen, activates CD4+ T cells. In turn, activated CD4+ T cells secrete IFN-γ and IL-2, which activate more macrophages and trigger T-lymphocyte proliferation, respectively (Fig. 4-8B). The protein antigens are actively processed into short peptides within phagolysosomes of macrophages and then presented on the cell surface in conjunction with class II MHC molecules. Processed and presented antigens are recognized by MHC-restricted, antigenspecific CD4+ T cells, which become activated and synthesize an array of cytokines (Fig. 4-8C). Such activated CD4 cells are referred to as TH1 cells. In turn, the cytokines recruit and activate lymphocytes, monocytes, fibroblasts, and other inflammatory cells. If the antigenic stimulus is eliminated, the reaction spontaneously resolves after about 48 hours. If the stimulus persists (e.g., poorly biodegradable mycobacterial cell wall components), an attempt to sequester the inciting agent may result in a granulomatous reaction. Other mechanisms by which T cells (especially CD8+) mediate tissue damage is direct cytolysis of target cells (Fig. 4-9). These immune mechanisms are important in destroying and eliminating cells infected by viruses and possibly tumor cells that express neoantigens. Cytotoxic T cells also play an important role in transplant graft rejection. Figure 4-9 summarizes the events in T-cell-mediated cytotoxicity. In contrast to delayed-type hypersensitivity reactions, cytotoxic CD8+ T cells specifically recognize target antigens in the context of class I MHC molecules. In the case of virus-infected cells and tumor cells, foreign antigens are actively presented together with self-MHC antigens (Fig. 4-9A,B). In graft rejection, foreign MHC antigens are themselves potent activators of CD8+ T cells. Once activated by antigen, proliferation of cytotoxic cells is promoted by helper cells and mediated by soluble growth factors, such as IL-2 (Fig. 4-9C). An expanded population of antigen-specific cytotoxic cells is thus generated. Actual cell killing involves several mechanisms (Fig. 4-9D). Cytolytic T cells (CTLs) secrete perforins that form pores in target cell membranes, through which they introduce granzymes that activate intracellular caspases, leading to apoptosis. CTLs can also kill targets via engagement of the Fas ligand (by the CTL) and Fas (on the target cell). The Fas ligand-Fas interaction triggers apoptosis of the Fas-bearing cell (see Chapter 2). The chronic inflammation in many autoimmune diseases—including type 1 diabetes, chronic thyroiditis, Sjögren syndrome (SS), and primary biliary cirrhosis—is the result of type IV hypersensitivity.

Immunodeficiency Diseases Immunodeficiency diseases are classified according to two characteristics: (1) whether the defect is congenital (primary) or acquired (secondary) and (2) whether the specific host defense system is defective. The great majority of primary immunodeficiency disorders are genetically determined and uncommon. Disorders of the complement system and primary defects of phagocytes are discussed elsewhere (see Chapters 2 and 20). In contrast to the low prevalence of congenital immunodeficiency disorders, acquired immune deficiencies, like that caused by HIV-1 infection (AIDS), are common. Functional defects in lymphocytes can be localized to particular maturational stages in the ontogeny of the immune system or

Small reactive antigens

Complex protein antigens

HLA class II

Macrophage

IL-1 IL-6 IL-12

T cell (CD4)

Cytokines

Cytokines B

Cytokines

Lymphocyte

Monocyte Fibroblast

C In a type IV (delayed type) hypersensitivity reaction, complex antigens are phagocytized, processed, and presented on macrophage cell membranes in conjunction with class II major histocompatibility complex (MHC) antigens. Antigen-specific, histocompatible, cytotoxic T lymphocytes bind the presented antigens and are activated. Activated cytotoxic T cells secrete cytokines that amplify the response. BV, blood vessel. FIGURE 4-8.

to interruption of discrete immune activation events. The explosive growth of knowledge regarding molecular mechanisms of immunodeficiency disorders has led to improved diagnosis, clinical management, and therapeutic strategies.

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TARGET CELLS

Viral

HLA

Tumor

T-Cytotoxic (CD8)

T-helper (CD4)

RECOGNITION OF ANTIGEN BY T CELLS • T-helper cells recognize antigen plus class II molecules • T-cytotoxic/killer cells recognize antigen plus class I molecules

TARGET ANTIGENS • Virally-coded membrane antigen • Foreign or modified histocompatibility antigen • Tumor-specific membrane antigens

Tk Ca2+ Na+ (CD8) cytotoxic T cells

K+

Tk binding to target cell

Membrane leakage

-2

Perforin

-2

Tk Helper cytokines IL-2

Target lysis

D (CD4) helper T cells

C ACTIVATION AND AMPLIFICATION • T-helper cells activate and proliferate, releasing helper molecules (e.g., IL-2) • T-cytotoxic/killer cells proliferate in response to helper molecules

TARGET CELL KILLING • T-cytotoxic/killer cells bind to target cell • Killing signals perforin release and target cell loses membrane integrity • Target cell undergoes lysis

In T-cell—mediated cytotoxicity, potential target cells include (A) virus-infected host cells, malignant host cells, and foreign (histoincompatible transplanted) cells. B. Cytotoxic T lymphocytes recognize foreign antigens in the context of human leukocyte antigen (HLA) class I molecules. C. Activated T cells secrete lytic compounds (e.g., perforin and other mediators) and cytokines that amplify the response, which is apoptosis (target cell killing). D. Ca2+, calcium ion; IL, interleukin; K+, potassium ion; Na+, sodium ion. FIGURE 4-9.

Primary Antibody Deficiency Diseases Feature Impaired Production of Specific Antibodies

the long arm of the X chromosome (Xq21.22), inactivates the gene that encodes a B-cell tyrosine kinase (Bruton tyrosine kinase), an enzyme critical to B-lymphocyte maturation.

Bruton X-Linked Agammaglobulinemia The congenital disorder, Bruton X-linked agammaglobulinemia, typically presents in male infants at 5 to 8 months old, the period during which maternal antibody levels have declined. The infant suffers from recurrent pyogenic infections and severe hypogammaglobulinemia involving all immunoglobulin isotypes. Occasional patients develop chronic enterovirus infections of the central nervous system (CNS). Immunization with live attenuated poliovirus can lead to paralytic poliomyelitis. Approximately one third of Bruton patients have a poorly understood form of arthritis, believed in some cases to be caused by Mycoplasma. There are no mature B cells in peripheral blood or plasma cells in lymphoid tissues. Pre-B cells, however, can be detected. The genetic defect, on

Selective IgA Deficiency Characterized by low serum and secretory concentrations of IgA, selective IgA deficiency is the most common primary immunodeficiency syndrome. Its incidence is 1:700 among Europeans, but is less frequently seen in Japan (1:18,000). Although patients are often asymptomatic, they occasionally present with respiratory or GI infections of varying severity. They display a strong predilection for allergies and collagen vascular diseases. They are also at high risk of anaphylactic reactions to IgA in transfused blood products. Patients with IgA deficiency have normal numbers of IgA-bearing B cells; their varied defects result in an inability to synthesize and secrete IgA.

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Common Variable Immunodeficiency (CVID) CVID is a heterogenous group of disorders characterized by pronounced hypogammaglobulinemia. A variety of defects in either B-lymphocyte maturation or T- lymphocyte-mediated B-lymphocyte maturation appear to be operative. Many relatives of patients with CVID have selective IgA deficiency. Affected patients present with recurrent severe pyogenic infections, especially pneumonia and diarrhea, the latter often due to infestation with Giardia lamblia. Recurrent attacks of herpes simplex are common; herpes zoster develops in one fifth of patients. The disease appears years to decades after birth, with a mean age at onset of 30 years. The incidence is estimated to be between 1:50,000 and 1:200,000. The inheritance pattern is variable, and the malady features a variety of maturational and regulatory defects of the immune system. A high incidence of malignant disease is seen in CVID, including a 50-fold increase in stomach cancer. Interestingly, lymphoma is 300 times more frequent in women with this immunodeficiency than in affected men. Malabsorption secondary to lymphoid hyperplasia and inflammatory bowel diseases is more frequent than in the general population. CVID patients are also susceptible to other autoimmune disorders, including hemolytic anemia, neutropenia, thrombocytopenia, and pernicious anemia.

Primary T-Cell Immunodeficiency Diseases Typically Result in Recurrent or Protracted Viral and Fungal Infections DiGeorge Syndrome In its complete form, DiGeorge syndrome is one of the most severe T-lymphocyte immunodeficiency disorders. Infants who survive the neonatal period are subject to recurrent or chronic viral, bacterial, fungal, and protozoal infections. The syndrome is caused by defective embryologic development of the third and fourth pharyngeal pouches, which give rise to the thymus and parathyroid glands and influence conotruncal cardiac development, all of which may be abnormal. Most patients have a point deletion in the long arm of chromosome 22. In the absence of a thymus, T-cell maturation is interrupted at the pre—T-cell stage. The disease has been corrected by transplanting thymic tissue. Most patients have partial DiGeorge syndrome, in which a small remnant of thymus is present. With time, these persons recover T-cell function without treatment.

Chronic Mucocutaneous Candidiasis The yeast infection, chronic mucocutaneous candidiasis, is the result of a congenital defect in T-cell function. It is characterized by susceptibility to candidal infections and is associated with an endocrinopathy (hypoparathyroidism, Addison disease, diabetes mellitus). Although most T-cell functions are intact, there is an impaired response to Candida antigens, the precise cause of which is unknown, although it could occur at any of several points during T-cell development. Recent studies suggest that persons with this disorder react to Candida antigens differently than do healthy individuals. In particular, they mount a type 2 (IL-4/IL-6) helper Tcell response, which is ineffective in resisting the organism. By contrast, the normal response features type 1 (IL-2/IFN-γ) T cells, which effectively control candidal infections.

Combined Immunodeficiency Diseases Exhibit Reduced Immunoglobulins and Defects in T-Lymphocyte Function Severe combined immunodeficiencies are conspicuously heterogenous and represent life-threatening disorders.

Severe Combined Immunodeficiency (SCID) SCID is a group of disorders that ultimately affect both T and B lymphocytes. It is characterized by severe, recurrent, viral, bacterial, fungal, and protozoal infections. A virtually complete absence

of T cells is associated with severe hypogammaglobulinemia. Many of these infants have a severely reduced mass of lymphoid tissue and an immature thymus that lacks lymphocytes. In some patients, lymphocytes fail to develop beyond pre-B cells and pre-T cells. Because patients with SCID have profound T- and B-lymphocyte dysfunction, they are susceptible to many pathogens, including cytomegalovirus (CMV), varicella, Pneumocystis, Candida, and many different bacteria. SCID occurs in both X-linked and autosomal recessive forms and typically appears before 6 months of age. In some patients with the autosomal recessive form, B lymphocytes are present but do not function, possibly because of a lack of helper cell activity. In the Xlinked form, the most common defect is due to a mutation of the common γ-chain of the IL-2 receptor, which is also used by receptors for other cytokines, namely IL-4, IL-7, IL-9, IL-11, and IL-15.

Adenosine Deaminase (ADA) Deficiency ADA deficiency is an autosomal recessive form of combined immunodeficiency with mutations in the adenosine deaminase gene. The clinical manifestations range from mild to severe dysfunction of T cells and B cells and include characteristic developmental abnormalities of cartilage.

Wiskott-Aldrich Syndrome (WAS) This rare syndrome is characterized by (1) recurrent infections, (2) hemorrhages secondary to thrombocytopenia, and (3) eczema. It typically manifests in boys within the first few months of life as petechiae and recurrent infections. WAS is caused by numerous distinct mutations in a gene on the X chromosome that encodes a protein called WASP (Wiskott-Aldrich syndrome protein), which is expressed at high levels in lymphocytes and megakaryocytes. Cellular and humoral immunity are both impaired in WAS. Boys with WAS have selective deficiencies in cell-mediated immunity. The numbers of CD4+ and CD8+ T cells are normal, but these children are largely lacking cutaneous delayed hypersensitivity. Virus-specific cytotoxic T-cell immunity is usually absent, although virus-specific antibody responses appear to be normal. Although levels of most immunoglobulins are normal or elevated, however, IgM is only about half of normal. Antibody responses to some antigens are normal, but responses to others may be absent. As many polysaccharide antigens, particularly some bacterial polysaccharides, elicit mainly IgM antibody responses, patients with WAS are susceptible to infection with encapsulated organisms, e.g. Streptococcus pneumoniae, Haemophilus influenzae and such opportunistic pathogens as Pneumocystis jiroveci. They are also prone to viral infections such as CMV, and may die of disseminated herpes simplex or varicella infections and a variety of autoimmune disorders. Thrombo-cytopenia may be severe (200

Inheritance pattern of fragile X syndrome. The number of copies of the trinucleotide repeat (CGG) is shown below selected members in this pedigree. Expansion occurs primarily during meiosis in females. When the number of repeats exceeds ~200, the clinical syndrome is manifested. Individuals shaded pink carry a premutation and are asymptomatic. FIGURE 6-15.

Prader-Willi syndrome when the affected chromosome is inherited from the father and in Angelman syndrome when the mutated chromosome is of maternal origin. The phenotypes of these disorders are remarkably different. Prader-Willi syndrome features hypotonia, obesity, hypogonadism, mental retardation, and a specific facies. By contrast, patients with Angelman syndrome are hyperactive, display inappropriate laughter, and have a facies different from that of Prader-Willi syndrome. UNIPARENTAL INHERITENCE: Uniparental disomy results when both members of a single chromosome pair are inherited from the same parent. Uniparental disomy is rare but has been implicated in unexpected patterns of inheritance of genetic traits. For instance, a child with uniparental disomy may manifest a recessive disease when only one parent carries the trait, as has been observed in a few cases of cystic fibrosis and hemophilia A. About 30% of Prader-Willi disease results from maternal uniparental disomy. Such affected persons have two identical inactivated regions of chromosome 15 and no active paternal contribution.

Multifactorial Inheritance Multifactorial inheritance describes a process by which a disease results from the effects of a number of abnormal genes and environmental factors. Most normal human traits reflect such complexities and are not inherited as simple dominant or as recessive Mendelian attributes. For example, multifactorial inheritance determines height, skin color, and body habitus. Similarly, most of the common chronic disorders of adults—diabetes, atherosclerosis, and many forms of cancer, arthritis, and hypertension—represent multifactorial genetic diseases and are well known to “run in families.” The inheritance of many birth defects is also multifactorial (e.g., cleft lip and palate, pyloric stenosis, and congenital heart disease). The concept of multifactorial inheritance is based on the notion that multiple genes interact with each other and with environmental factors to produce disease in an individual patient. Such inheritance leads to familial aggregation that does not obey simple Mendelian rules.

The Biological Basis of Polygenic Inheritance Resides in Genetic Polymorphism The biological basis of polygenic inheritance rests on the evidence that more than one fourth of all genetic loci in normal humans contain polymor-

• Expression of symptoms is proportional to the number of mutant genes. The probability of expressing the same number of mutant genes is highest in identical twins. • Environmental factors influence expression of the trait. Thus, concordance for the disease may occur in only one third of monozygotic twins. • The risk in first-degree relatives (parents, siblings, children) is the same (5% to 10%). The probability of disease is much lower in second-degree relatives. • The probability of a trait’s expression in later offspring is influenced by its expression in earlier siblings. If one or more children are born with a multifactorial defect, the chance of its recurrence in later offspring is doubled. For simple Mendelian traits, in contrast, the probability is independent of the number of affected siblings. • The more severe a defect, the greater the risk of transmitting it to offspring. Patients with more severe polygenic defects presumably have more mutant genes, and their children thus have a greater chance of inheriting the abnormal genes than do the offspring of less severely affected persons. • Some abnormalities characterized by multifactorial inheritance show a sex predilection. Such differential susceptibility is believed to represent a difference in the threshold for expression of mutant genes in the two sexes.

Cleft Lip and Cleft Palate Exemplify Multifactorial Inheritance At the 35th day of gestation, the frontal prominence fuses with the maxillary process to form the upper lip. This process is under the control of many genes, and disturbances in gene expression (hereditary or environmental) at this time lead to interference with proper fusion and result in cleft lip, with or without cleft palate (Fig. 6-16). The incidence of cleft lip, with or without cleft palate, is 1 in 1,000, and the incidence of cleft palate alone is 1 in 2,500. If one child is born with a cleft lip, the chances are 4% that the second child will exhibit the same defect. If the first two children are affected, the risk of cleft lip increases to 9% for the third child. The more severe the anatomical defect, the greater is the probability of transmitting cleft lip. Whereas 75% of cases of cleft lip occur in boys, the sons of women with cleft lip have a four times higher risk of acquiring the defect than do the sons of affected fathers.

Diseases of Infancy and Childhood Morbidity and mortality rates in the neonatal period differ considerably from those in infancy and childhood. Infants and children are not simply “small adults,” and they may be afflicted by diseases unique to their particular age group.

Prematurity and Intrauterine Growth Retardation Human pregnancy normally lasts 40 ± 2 weeks, and most newborns weigh 3,300 ± 600 g. The World Health Organization defines prematurity as a gestational age of less than 37 weeks (timed from the first day of the last menstrual period). Low-birth-weight

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LUNGS: Pulmonary immaturity is a common and immediate threat to the viability of low-birth-weight infants. The lining cells of the fetal alveoli do not differentiate into type I and type II pneumocytes until late pregnancy. Amniotic fluid fills the fetal alveoli and drains from the lungs at birth. Sometimes immature infants show sluggish respiratory movements that do not fully expel the amniotic fluid from the lungs. Sometimes termed amniotic fluid aspiration syndrome, this actually represents retained amniotic fluid. Air passages contain desquamated squamous cells (squames) and lanugo hair from the fetal skin and protein-rich amniotic fluid. Neonatal respiratory distress syndrome resulting from insufficient pulmonary surfactant in the immature lung is discussed below.

FIGURE 6-16.

Cleft lip and palate in an infant.

infants (1 mL) enter the circulation of an Rh-negative mother at the time of delivery, eliciting maternal antibodies to the D antigen (Fig. 619). Because the quantity of fetal blood necessary to sensitize the mother is introduced into her circulation only at the time of delivery, erythroblastosis fetalis does not ordinarily affect the first baby. However, when a sensitized mother again carries an Rh-positive fetus, much smaller quantities of fetal D antigen elicit an increase in antibody titer. In contrast to IgM, IgG antibodies are small enough to cross the placenta and thus produce hemolysis in the fetus. This cycle is exaggerated in multiparous women, and the severity of erythroblastosis tends to increase progressively with each succeeding pregnancy. Even in those Rh-negative women who are exposed to significant amounts of fetal Rh-positive blood, many do not mount a substantial immune response. In fact, after multiple pregnancies, only 5% of Rh-negative women deliver infants with erythroblastosis fetalis. A second potential source of maternal sensitization is blood transfusions. PATHOLOGY AND CLINICAL FEATURES: The severity of erythroblastosis fetalis varies from mild hemolysis to fatal anemia, and the pathologic findings are determined by the extent of the hemolytic disease. • Death in utero occurs in the most extreme form of the disease, in which case severe maceration is evident on delivery. Numerous erythroblasts are demonstrable in visceral organs that are not extensively autolyzed. • Hydrops fetalis is the most serious form of erythroblastosis fetalis in liveborn infants. It is characterized by severe edema secondary to congestive heart failure caused by severe anemia. Affected infants generally die, unless adequate exchange transfusions with Rh-negative cells correct the anemia and ameliorate the hemolytic disease. • Kernicterus, also termed bilirubin encephalopathy, is defined as a neurologic condition associated with severe jaundice and is characterized by bile staining of the brain, particularly of the basal ganglia, pontine nuclei, and dentate nuclei in the cerebellum. Kernicterus (from the German, kern, nucleus) is essentially confined to newborns with severe unconjugated hyperbilirubinemia, usually related to erythroblastosis. The bilirubin derived from the destruction of erythrocytes and the catabolism of the released heme is not easily conjugated by the immature liver, which is deficient in glucuronyl transferase.

113

• Bilirubin is thought to injure the cells of the brain by interfering with mitochondrial function. Severe kernicterus leads initially to loss of the startle reflex and athetoid movements, which in 75% of newborns progresses to lethargy and death. Most surviving infants have severe choreoathetosis and mental retardation; a minority display varying degrees of intellectual and motor retardation. The incidence of erythroblastosis fetalis secondary to Rh incompatibility has been greatly reduced (to 1 pack/day)

35 30 25 20 15

All smokers 10 Never smoked

FIGURE 8-1.

0 35-44

45-54

55-64

65-74

75-84

Age Death rate from lung cancer among smokers and nonsmokers. Nonsmokers exhibit a small, linear rise in the death rate from lung cancer from the age of 50 onward. By contrast, those who smoke more than one pack per day show an exponential rise in the annual death rate from lung cancer starting at about age 35. By age 70, heavy smokers have about a 20-fold greater death rate from lung cancer than nonsmokers. FIGURE 8-3.

monoxide (CO) inhalation, reduced plasma high-density lipoprotein levels, increased plasma fibrinogen levels, and higher leukocyte counts are all consequences of smoking that may predispose to myocardial infarction and stroke. Buerger disease, a now uncommon peculiar inflammatory and occlusive disease of the lower leg vasculature, occurs almost only in heavy smokers, mainly Eastern European Jews (see Chapter 10).

Cancer of the Lung is Largely a Disease of Cigarette Smokers

extent, the gas phase of cigarette smoke contain thousands of substances that have been identified as carcinogens, tumor promoters, and ciliotoxic agents.

More than 85% of deaths from lung cancer, the single most common cancer death in both men and women in the United States today, are attributed to cigarette smoking (Fig. 8-3). Cigarette smoke is toxic and carcinogenic to the bronchial mucosa. The particulate tars, and to a lesser

• Cancers of the lip, tongue, and buccal mucosa occur principally (>90%) in tobacco users. All forms of tobacco smoke— cigarette, cigar and pipe smoking—expose the oral cavity to toxic compounds.

None

Risk factor combinations

Smoking Hypercholesterolemia or hypertension Hypercholesterolemia and hypertension Smoking and hypercholesterolemia or smoking and hypertension Smoking and hypercholesterolemia and hypertension

100

120

140

160

180

200

Myocardial infaction (rate per 1,000) The risk of myocardial infarction in cigarette smokers. Smoking is an independent risk factor and increases the risk of a myocardial infarction to about the same extent as does hypertension or hypercholesterolemia alone. The effects of smoking are additive to those of these other two risk factors. FIGURE 8-2.

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• Cancer of the larynx is similarly related to cigarette smoking. In some large studies, white male smokers are 6 to 13 times more likely to die from laryngeal cancer as nonsmokers. • Cancer of the esophagus is estimated to result from smoking in 80% of cases in the United States and Great Britain. • Cancer of the bladder is attributable to smoking in 30% to 40% of all cases. • Adenocarcinoma of the kidney is increased 50% to 100% among smokers. A modest increase in cancer of the renal pelvis has also been documented. • Cancer of the pancreas has shown a dramatic increase in incidence, which is, at least in part, related to cigarette smoking. The risk for adenocarcinoma of the pancreas in male smokers is two- to threefold greater than in nonsmokers, and a dose-response relationship exists. • Cancer of the uterine cervix is significantly increased (about 30%) in female smokers.

Smokers are at Higher Risk for Certain Non-Neoplastic Diseases • Chronic bronchitis and emphysema occur primarily in cigarette smokers. The incidence of these diseases is a function of the amount of cigarettes smoked (Fig. 8-4; see Chapter 12). • Peptic ulcer disease is 70% more common in male cigarette smokers than in nonsmokers. • Ocular diseases, particularly macular degeneration and cataracts, are reportedly more frequent in smokers. Of particular concern to women: • Osteoporosis in women is exacerbated by tobacco use. Women who smoke have a diminution of bone density sufficient to increase the risk of bone fractures. • Thyroid diseases are linked to cigarette smoking. The most conspicuous association is with Graves disease, especially when hyperthyroidism is complicated by exophthalmos. • Earlier menopause is experienced by female smokers, possibly because of the effects of tobacco on estrogen metabolism.

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Fetal Tobacco Syndrome Produces Infants Who are Small for Gestational Age Maternal cigarette smoking impairs the development of the fetus. These infants are not born preterm but rather are small for gestational age at every stage of pregnancy. In fact, 20% to 40% of the incidence of low birth weight can be attributed to maternal cigarette smoking. Perinatal mortality is higher among offspring of smokers, reaching almost 40% among children of those who smoke more than one pack per day. Incidences of abruptio placentae, placenta previa, uterine bleeding, and premature rupture of membranes are all increased. These complications of smoking tend to occur at times when the fetus is not viable or is at great risk, (i.e., from 20 to 32 weeks of gestation). Children born of cigarette-smoking mothers have been reported to be more susceptible to several respiratory diseases, including respiratory infections and otitis media. Substantial evidence indicates that maternal cigarette smoking inflicts lasting harm on children, impairing physical, cognitive, and emotional development.

Environmental Tobacco Smoke May Produce a Variety of Diseases in Nonsmokers Environmental tobacco smoke representing involuntary exposure to tobacco smoke in the environment is a risk factor for some diseases in nonsmokers, although the relative risks are not great and deserve further study. For example: • Lung cancer is reported to be increased 20% to 30% in nonsmoking spouses of smokers. • Respiratory illnesses and hospitalizations are increased among infants whose parents smoke. • Coronary artery disease and sudden cardiac death are linked to environmental tobacco smoke. The magnitude of the risk is dose dependent and disproportionately increased for the level of smoke exposure as compared to smokers.

Alcoholism Alcoholism is addiction to ethanol that features dependence and withdrawal symptoms, resulting in acute and chronic toxic effects of alcohol on the body. It is estimated that there are about 15 million alcoholics in the United States (about 5.5% of the population). The proportion has been estimated to be even higher in other countries. Certain ethnic groups, such as Native Americans and Eskimos, have high rates of alcoholism, whereas others, such as Chinese and Jewish individuals, are less afflicted. Although alcoholism is more common in males, the number of female alcoholics has been increasing. Chronic alcoholism has been defined as the regular intake of sufficient alcohol to injure a person socially, psychologically, or physically. Although there are no firm rules, for most people, daily consumption of more than 45 g alcohol should probably be discouraged, and 100 g or more a day may be dangerous (10 g alcohol = 1 oz, or 30 mL, of 86 proof [43%] spirits). Acute alcohol intoxication is hardly a benign condition. Approximately 40% of all fatalities from motor vehicle accidents involve alcohol—more than 16,000 deaths in 2004 in the United States. Alcoholism is also a major contributor to fatal home accidents, deaths in fires, and suicides.

Alcohol Ingestion Affects Organs and Tissues

FIGURE 8-4.

Complications of chronic alcohol abuse.

The pathogenesis of ethanol-induced organ damage remains obscure. Acetaldehyde is the highly toxic product of alcohol metabolism. However, circulating levels of acetaldehyde are extremely low, and it is difficult to attribute all of the changes associated with alcoholism solely to this metabolite (Fig. 8-4).

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Liver Alcoholic liver disease, the most common medical complication of alcoholism, has been known for thousands of years and accounts for a large proportion of cases of cirrhosis of the liver in industrialized countries. The nature of the alcoholic beverage is largely irrelevant; consumed in excess, beer, wine, whiskey, hard cider, and so on all produce cirrhosis. Only the total dose of alcohol itself is relevant (see Chapter 14).

Pancreas Both acute and chronic pancreatitis are complications of alcoholism (see Chapter 15). Chronic calcifying pancreatitis is an unquestioned result of alcoholism and an important cause of incapacitating pain, pancreatic insufficiency, and pancreatic stones.

Heart “Beer-drinker’s heart” is a form of dilated cardiomyopathy, termed alcoholic cardiomyopathy, which leads to low-output congestive heart failure (see Chapter 11). Alcoholics’ hearts seem also to be more susceptible to arrhythmias, and many cases of sudden death in alcoholics are probably caused by sudden, fatal arrhythmias. Ironically, moderate alcohol consumption, or “social drinking” (one to two drinks a day), provides significant protection against coronary artery disease (atherosclerosis) and its consequence, myocardial infarction. Similarly, compared with abstainers, social drinkers have a lower incidence of ischemic stroke.

Skeletal Muscle Muscle weakness, particularly of the proximal muscles, is common in alcoholics. A wide range of changes in skeletal muscle occurs in chronic alcoholics, varying from mild weakness to severe, debilitating chronic myopathy, with degeneration of muscle fibers and diffuse fibrosis. Acute alcoholic rhabdomyolysis (necrosis of muscle fibers and release of myoglobin into the circulation) rarely occurs. This sudden event can be fatal because of renal failure secondary to myoglobinuria.

Endocrine System Feminization of male alcoholics, plus loss of libido and potency, is common. Breasts become enlarged (gynecomastia), body hair is lost, and a female distribution of pubic hair (female escutcheon) develops. Some of these changes can be attributed to impaired estrogen metabolism due to chronic liver disease, but many of the changes—particularly atrophy of the testes—occur even its absence. This may result from lower levels of circulating testosterone because of interference with the pituitary–gonadal axis, possibly complicated by accelerated hepatic metabolism of the hormone. Alcohol also has a direct toxic effect on the testes.

Gastrointestinal Tract Alcohol is directly toxic to the mucosa of the esophagus and stomach. Such injury is potentiated by hypersecretion of gastric hydrochloric acid stimulated by ethanol. Reflux esophagitis may be particularly painful, and peptic ulcers are also more common in alcoholics. Violent retching may lead to tears at the esophageal-gastric junction (Mallory-Weiss syndrome), sometimes severe enough to cause exsanguinating hemorrhage.

Blood Megaloblastic anemia is common in alcoholics and reflects a combination of dietary deficiency of folic acid and the fact that alcohol is a weak folic acid antagonist in humans. Moreover, folate absorption by the small intestine may be decreased in alcoholics. Acute transient thrombocytopenia is common after acute alcohol intoxication and may result in bleeding. Alcohol also interferes with platelet aggregation, thereby contributing to bleeding.

Bone Chronic alcoholics, particularly postmenopausal women, are at increased risk for osteoporosis, although the precise mechanism re-

sponsible for accelerated bone loss is not understood. Interestingly, moderate alcohol intake seems to exert a protective effect against osteoporosis.

Nervous System General cortical atrophy of the brain is common in alcoholics and may reflect a toxic effect of alcohol (see Chapter 28). By contrast, most of the characteristic brain diseases in alcoholics are probably a result of nutritional deficiency. • Wernicke encephalopathy is caused by thiamine deficiency and is characterized by mental confusion, ataxia, abnormal ocular motility, and polyneuropathy, reflecting pathologic changes in the diencephalon and brainstem. • Korsakoff psychosis is characterized by retrograde amnesia and confabulatory symptoms. It was once believed to be pathognomonic of chronic alcoholism, but it has also been seen in several organic mental syndromes and is considered nonspecific. • Alcoholic cerebellar degeneration is differentiated from other acquired or familial cerebellar degeneration by the uniformity of its manifestations. Progressive unsteadiness of gait, ataxia, incoordination, and reduced deep tendon reflex activity are present. • Central pontine myelinolysis is another characteristic change in the brain of alcoholics, apparently caused by electrolyte imbalance. In this complication, a progressive weakness of bulbar muscles terminates in respiratory paralysis. • Polyneuropathy is common in chronic alcoholics. It is usually associated with deficiencies of thiamine and other B vitamins, but a direct neurotoxic effect of ethanol may play a role. The most common complaints include numbness, paresthesias, pain, weakness, and ataxia.

Fetal Alcohol Syndrome Results from Alcohol Abuse in Pregnancy Infants born to mothers who consume excess alcohol during pregnancy may show a cluster of abnormalities that together constitute the fetal alcohol syndrome. This disorder is discussed in detail in Chapter 6.

Drug Abuse Drug abuse has been defined as the use of illegal drugs or the inappropriate use of legal drugs. The repeated illicit use of drugs occurs to produce pleasure, to alleviate stress, or to alter or avoid reality (or all three). Hence, drug abuse generally involves agents that alter mood and perception. The use of illicit drugs is estimated to cause about 17,000 deaths a year in the United States.

Illicit Drugs are Responsible for Many Pathologic Syndromes Heroin Heroin (acetyl morphine) is a common illicit opiate used to induce euphoria and is usually taken subcutaneously or intravenously. In the usual dosage, it is effective for about 5 hours. Overdoses are characterized by hypothermia, bradycardia, and respiratory depression. Other opiates that are subject to abuse include morphine, dilaudid, and oxycodone.

Cocaine Cocaine is a stimulant alkaloid derived from South American coca leaves. The more potent freebase form of cocaine is hard and is “cracked” into smaller pieces that are smoked (“crack”). The halflife of cocaine in the blood is about 1 hour. Cocaine users report extreme euphoria and heightened sensitivity to a variety of stimuli. However, with addiction, paranoid states and conspicuous

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emotional lability occur. Cocaine’s mechanism of action is related to its interference with the reuptake of the neurotransmitter dopamine, thereby increasing the synaptic concentration. Cocaine overdose leads to anxiety and delirium and occasionally to seizures. Cardiac arrhythmias and other effects on the heart may cause sudden death in otherwise apparently healthy individuals. Chronic abuse of cocaine is associated with the occasional development of a characteristic dilated cardiomyopathy, which may be fatal. “Snorted” cocaine produces destructive midline lesions in the nasal passage and septal perforation.

Amphetamines Amphetamines, mainly methamphetamine, are sympathomimetic and resemble cocaine in their effects, although they have a longer duration of action. The most serious complications of amphetamine abuse are seizures, cardiac arrhythmias, and hyperthermia. Amphetamine use has been reported to lead to vasculitis of the brain, and both subarachnoid and intracerebral hemorrhages have been described.

Brain Overdose Withdrawal Pulmonary Narcotic lung Talc granulomas Local Abscesses Cellulitis Ulcers Thrombosed veins

Hallucinogens are a group of chemically unrelated drugs that alter perception and sensory experience. Phencyclidine (PCP) is an anesthetic agent that has psychedelic or hallucinogenic effects. As a recreational drug, it is known as “angel dust” and is taken orally, intranasally, or by smoking. The anesthetic properties of PCP lead to a diminished capacity to perceive pain and, therefore, to self-injury and trauma. Other than the behavioral effects, PCP commonly produces tachycardia and hypertension. High doses result in deep coma, seizures, and even decerebrate posturing. Lysergic acid diethylamide (LSD) is a hallucinogenic drug. Its popularity peaked in the late 1960s, and it is little used today. LSD causes perceptual distortion of the senses, interference with logical thought, alteration of time perception, and a sense of depersonalization. “Bad trips” are characterized by anxiety and panic and objectively by sympathomimetic effects that include tachycardia, hypertension, and hyperthermia. Large overdoses cause coma, convulsions, and respiratory arrest. Marijuana is the most commonly used illicit drug. Its effect is mediated by the active agent delta-9-tetrahydrocannabinol. It binds to brain cannabinoid receptors and produces perceptual changes, loss of coordination, and other psychotropic effects. Chronic use is associated with a variety of pulmonary problems similar to those seen in cigarette users, which are most likely related to smoke-derived tars. Effects on learning and social behavior are also common with prolonged use.

Organic Solvents The recreational inhalation of organic solvents is widespread, particularly among adolescents. Various commercial preparations such as fingernail polish, glues, plastic cements, and lighter fluid are all sniffed. Among the active ingredients are benzene, carbon tetrachloride, acetone, xylene, and toluene. These compounds are all central nervous system (CNS) depressants, although early effects (e.g., with xylene) may be excitatory. Acute intoxication with organic solvents resembles inebriation with alcohol. Large doses produce nausea and vomiting, hallucinations, and eventually coma. Respiratory depression and death may follow. Chronic exposure to, or abuse of, organic solvents may result in damage to the brain, kidneys, liver, lungs, and hematopoietic system.

Intravenous Drug Abuse Has Many Medical Complications Apart from reactions related to pharmacologic or physiological effects of the abused substance, the most common complications (15% of directly drug-related deaths) are caused by introducing infectious organisms by a parenteral route. Most occur at the site of

Infections Bacterial endocarditis Viral hepatitis AIDS

Renal Glomerulopathy

FIGURE 8-5.

Hallucinogens

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Complications of intravenous drug abuse. AIDS, acquired immunodeficiency syndrome.

injection, including cutaneous abscesses, cellulitis, and ulcers (Fig. 8-5). Intravenous introduction of bacteria may lead to septic complications in internal organs, such as bacterial endocarditis. Intravenous drug abusers are at very high risk for AIDS, as well as hepatitis B and C and their many complications.

Oral Contraceptives Orally administered hormonal contraceptives (OCs) are now the most commonly used method of birth control in industrialized countries. Current formulations are combinations of synthetic estrogens and steroids with progesterone-like activity. They act either by inhibiting the gonadotropin surge at midcycle, thereby preventing ovulation, or by preventing implantation by altering the phase of the endometrium. Data available to date include studies focusing on second- and third-generation OCs, which contain lower doses of both estrogens and progestogens than did earlier oral contraceptives. Most complications of oral contraceptives involve either the vasculature or reproductive organs (Fig. 8-6). • Deep vein thrombosis and the potential for thromboembolism has an increased risk of three to four times, even in users of “third-generation” OCs. The risk is much higher in women who also have thrombophilia (see Chapter 20). • Myocardial infarctions and ischemic stroke do not appear to be at increased risk in otherwise normal users of modern formulations of OCs in most studies. It must be emphasized that smoking, hypertension, and other risk factors for arterial thrombosis act synergistically with OC use to elevate the risk (see above). • Tumors of several of the female reproductive organs and possibly colon cancer are reduced in risk in OC users. Benign liver adenomas are rare hepatic neoplasms that are significantly increased in incidence among women who use OCs. • Breast cancer risk with OC use remains controversial. A small increase in relative risk (to 1.24) has been reported, although other studies report no increase in risk. In considering the potential side effects of the use of OCs, it is important to recognize that certain benefits accrue. In addition to a significant reduction in the risk of ovarian and endometrial cancers, the use of these agents decreases the risk of pelvic inflammatory disease, uterine leiomyomas, endometriosis, and fibrocystic disease of the breast, and substantially reduces the severity of acne.

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portance, pneumoconioses and hypersensitivity pneumonitis are discussed in detail in Chapter 12. Chemical carcinogens are ubiquitous in the environment, and their potential for causing disease has elicited widespread concern. In particular, exposure to carcinogens in the workplace has been associated epidemiologically with a number of cancers (Table 8-1), which are reviewed in Chapter 5.

Toxic Effects Differ from Hypersensitivity Responses Many substances elicit disease in a variety of animal species in a dosedependent manner, with a regular time delay and a predictable target organ response. Furthermore, the morphologic changes in injured tissues are constant and reproducible. By contrast, other agents show great variability in their ability to produce disease—irregular lag times before injury are apparent, no dose dependency, and lack of reproducibility. Generally, predictable dose-response reactions reflect direct actions of a compound or its metabolite on a tissue (i.e., a “toxic” effect). The second, unpredictable type of reaction is believed to reflect “hypersensitivity,” probably an immunologic response or idiosyncratic side effect. Scorecard.org (http://www.scorecard.org/ chemical-profiles/index.tcl) provides a helpful summary of uses and toxicity of more than 10,000 industrial chemicals.

Volatile Organic Solvents and Vapors

FIGURE 8-6.

Complications of oral contraceptives.

Postmenopausal Hormone Replacement Therapy Increases the Risk of Some Cancers Hormone replacement preparations containing either estrogen or estrogen plus progestin are given to postmenopausal women in an effort to alleviate menopausal symptoms and decrease the risk of myocardial infarction and osteoporosis. These agents have proved effective in the treatment of postmenopausal symptoms. However, recent studies have cast doubt on their effectiveness in preventing myocardial infarction and osteoporosis. Women who take these preparations have an increased risk for cancers of the breast and endometrium. Hormone replacement regimens involving estrogens with or without added progestins increase the risk of both cancers. However, an increased breast cancer incidence is somewhat greater for hormone replacements that contain both progestin and estrogen, compared to estrogen only but is significant for both types of formulation.

Volatile organic solvents and vapors are widely used in industry in many capacities. With few exceptions, exposures to these compounds are industrial or accidental and represent short-term dangers rather than long-term toxicity. For the most part, exposure to solvents is by inhalation rather than by ingestion, although exceptions occur. • Chloroform (CHCl3) and carbon tetrachloride (CCl4): These solvents exert anesthetic (depressant) effects on the CNS and on the heart and blood vessels but are better known as hepatotoxins. Large doses lead to acute hepatic necrosis, fatty liver, and liver failure. • Trichloroethylene (C2HCl3): A ubiquitous industrial solvent, trichloroethylene in high concentrations depresses the CNS,

TABLE 8–1

Cancers Associated with Exposure to Occupational Carcinogens Agent or Occupation

Site of Cancer

Arsenic

Lung cancer

Asbestos

Mesothelioma (pleura and peritoneum) Lung cancer (in smokers)

Aromatic amines

Bladder cancer

Benzene

Leukemia, multiple myeloma

bis-(chloromethyl)ether

Lung cancer

Environmental Chemicals Humans are surrounded by chemicals that are added to, or appear as contaminants in, foods, water, and air. Several important mechanisms govern the effect of toxic agents, including the toxin’s absorption, distribution, metabolism, and excretion. Among the most important chemical hazards to which humans are exposed are environmental dusts and carcinogens. Inhalation of mineral and organic dusts occurs primarily in occupational settings (e.g., mining, industrial manufacturing, farming) and occasionally as a result of unusual situations (e.g., bird fanciers). Inhaling mineral dusts leads to pulmonary diseases known as pneumoconioses, whereas organic dusts may produce hypersensitivity pneumonitis. Pneumoconioses were formerly common, but control of dust exposure in the workplace by modifying manufacturing techniques, improvements in air handling, and the use of masks has substantially reduced the incidence of these diseases. Because of their im-

Chromium

Lung cancer

Furniture and shoe manufacturing

Nasal carcinoma

Hematite mining

Lung cancer

Nickel

Lung cancer, paranasal sinus cancer

Tars and oils

Cancers of lung, gastrointestinal tract, bladder, and skin

Vinyl chloride

Angiosarcoma of liver

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•

but hepatotoxicity is minimal. It is listed as a possible carcinogen by several groups but more study is needed. Methanol (CH3OH): Because methanol, unlike ethanol, is not taxed, it is used by some impoverished alcoholics as a substitute for ethanol. It produces inebriation similar to that produced by ethanol but is succeeded by gastrointestinal symptoms, visual dysfunction, seizures, coma, and death. The major toxicity of methanol is believed to arise from its metabolism, first to formaldehyde and then to formic acid. Metabolic acidosis is common after methanol ingestion. The most characteristic lesion of methanol toxicity is necrosis of retinal ganglion cells and subsequent degeneration of the optic nerve. Severe poisoning may lead to lesions in the putamen and globus pallidus. Ethylene glycol (HOCH2CH2OH): Because of its low vapor pressure, the toxicity of ethylene glycol chiefly results from ingestion. It is commonly used in antifreeze, and has been drunk by chronic alcoholics as a substitute for ethanol for many years. Accidental ingestion by children and animals occurs because of its sweet taste, although the product is now deliberately made bitter by additives. The toxicity of ethylene glycol is chiefly due to its metabolites, particularly oxalic acid, and occurs within minutes of ingestion. Metabolic acidosis, CNS depression, nausea and vomiting, and hypocalcemia-related cardiotoxicity are seen. Oxalate crystals in the tubules and oxaluria are often noted and may cause renal failure. Gasoline and kerosene: These fuels are mixtures of aliphatic hydrocarbons and branched, unsaturated, and aromatic hydrocarbons. Chronic exposure is by inhalation. Despite prolonged exposure to gasoline by gas station attendants and auto mechanics, there is no evidence that inhalation of gasoline over the long term is particularly injurious. Benzene (C6H6): The prototypic aromatic hydrocarbon is benzene, which must be distinguished from benzine, a mixture of aliphatic hydrocarbons. Benzene is one of the most widely used chemicals in industrial processes, as it is a starting point for innumerable syntheses and a solvent. It is also a constituent of fuels, accounting for as much as 3% of gasoline. Virtually all cases of acute and chronic benzene toxicity have occurred as industrial exposures. Acute benzene poisoning primarily affects the CNS, and death results from respiratory failure. However, with chronic exposure, the bone marrow is the principal target. Patients who develop hematologic abnormalities characteristically exhibit hypoplasia or aplasia of the bone marrow and pancytopenia. With higher exposure, aplastic anemia and subsequent development of acute myeloid leukemia are significant consequences (see Chapter 20). Overall, the risk of leukemia is increased 60fold in workers exposed to the highest atmospheric concentrations of benzene. The closely related compound toluene is occasionally abused as an inhalent. Although it has not been incriminated as a cause of hematologic abnormalities, it is suspected to produce developmental abnormalities.

Agricultural Chemicals Pesticides, fungicides, herbicides, fumigants, and organic fertilizers are central to the success of modern agriculture. However, many of these chemicals persist in soil and water and may pose potential long-term hazards. Acute exposure to industrial concentrations or inadvertently contaminated food can cause severe acute illness. Children are particularly susceptible and may ingest home gardening preparations. Symptoms of acute toxicity are often related to the toxin’s mode of action. For example, organophosphate insecticides are acetylcholinesterase inhibitors that are readily absorbed through the skin. Thus, acute toxicity in humans mainly involves neuromuscular disorders, such as visual disturbances, dyspnea, mucous hypersecretion, and bronchoconstriction. Death may come from respiratory failure. Each year, in the United States, 30 to 40 people die of acute pesticide poisoning. Long-term exposure produces symptoms similar to acute exposure. Organochlorine pesticides,

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such as DDT (dichlorodiphenyltrichloroethane), chlordane, and others, have caused concern because they accumulate in soils and in human tissues, break down very slowly, and have harmful environmental effects. High levels of any such pesticide can be harmful to humans in acute exposures, but the side effects of chronic contact with the materials and their buildup are of greatest interest. Many of these compounds function as weak estrogens, but no harmful effects related to this activity have been documented. There is equivocal evidence suggesting DDT may be a carcinogen. Some compounds, such as aldrin and dieldrin, have been associated with tumor development, but the toxicity of most organochlorine insecticides relates to effects on the CNS. Human exposure to herbicides is not infrequent. Among the best known of these is the highly toxic agent paraquat. Occupational paraquat exposure is usually via the skin, although toxicity from ingestion and inhalation are documented. The compound is very corrosive and causes burns or ulcers on whatever it contacts. It is transported actively to the lung, where it can damage the pulmonary epithelium, causing edema and even respiratory failure. Pulmonary fibrosis may ultimately lead to death. Pulmonary toxicity is likely related to redox cycling and peroxidation.

Aromatic Halogenated Hydrocarbons The halogenated aromatic hydrocarbons that have received considerable attention include (1) the polychlorinated biphenyls (PCBs); (2) chlorophenols (pentachlorophenol, used as a wood preservative); (3) hexachlorophene, used as an antibacterial agent in soaps; and (4) the dioxin TCDD (2,3,7,8-tetrachlorodibenzo-p-dioxin), a byproduct of the synthesis of herbicides and hexachlorophene and, therefore, a potential contaminant of these preparations. Chronic exposure to TCDD does not appear to produce demonstrable toxicity. Serious questions have been raised regarding the danger of long-term exposure to dioxin, particularly its carcinogenic potential. The compound is, however, classified as carcinogenic to humans by the WHO. The problem of the presence of PCBs in the environment resembles that of agricultural chemicals: long-term animal toxicity is well documented, but there are no significant increases in the incidence of cancer or other diseases in workers exposed to PCBs. The same situation pertains to hexachlorophene and pentachlorophenol.

Air Pollutants A precise definition of air pollution is elusive, because the meaning of “pure air” is not established. However, for the purposes of this discussion, the most important pollutants are those generated by the combustion of fossil fuels, industrial and agricultural processes, and so forth. The most important air pollutants that are implicated as factors in human disease are the irritants sulfur dioxide (SO2), oxides of nitrogen, carbon monoxide (CO), and ozone, as well as suspended particulates and acid aerosols. All of the gaseous pollutants are capable of causing toxicity with either acute or high-dose chronic experimental exposure. For example, CO is a colorless, odorless gas that has a very high affinity for hemoglobin. It may be deadly when produced by indoor combustion (see below). The effects of chronic environmental exposure via smog remain unclear. Exposure to atmospheric ozone is reported to lead to deterioration in pulmonary function and may be associated with a slight but significant increase in mortality. Most studies of the effects of air pollution on health have focused on particulates. Many large short-term and long-term epidemiologic studies have shown that particulate air pollution is associated with increased mortality, both overall and from cardiovascular disease and cancer. Shorter-term studies suggested significant increases in acute myocardial infarction as a consequence of exposure to higher levels of fine particulates. It has been proposed that residence within 100 meters of a freeway greatly increases the likelihood of cardiovascular death. Furthermore, experimental studies have demonstrated that particulate exposure may increase atherosclerosis, blood pressure, heart rate, coagulability, and levels of inflammatory mediators. There is experimental evidence to support a suggestion that inflam-

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mation and oxidative stress are responsible for at least part of the harmful effects of pollutants. Thus, the frequency of exacerbations of asthma is related to levels of fine particulates, especially derived from diesel exhaust and ozone in the air.

Carbon Monoxide CO is an odorless and nonirritating gas that results from the incomplete combustion of organic substances. It combines with hemoglobin with an affinity 240 times greater than that of oxygen to form carboxyhemoglobin. CO binding to hemoglobin also increases the affinity of the remaining heme moieties for oxygen, inhibiting its dissociation into tissues. As a consequence, the hypoxia that results from CO poisoning is far greater than can be attributed to loss of oxygen-carrying capacity alone. Atmospheric CO is derived principally from automobile exhaust and does not pose a health problem. Carboxyhemoglobin concentrations under 10% are found in some smokers and may accelerate the onset of exertional angina and cause changes in electrocardiograms in smokers with ischemic heart disease. Indoor combustion, particularly from space heaters, however, can generate much higher concentrations of CO, which can be hazardous. Concentrations up to 30% usually cause only headache and mild exertional dyspnea. Higher levels of carboxyhemoglobin lead to confusion and lethargy. Above 50%, coma and convulsions ensue. Levels greater than 60% are usually fatal. In fatal CO poisoning, a characteristic cherry-red color is imparted to the skin by the carboxyhemoglobin in the superficial capillaries. Recovery from severe CO poisoning may be associated with brain damage, which may be manifested as subtle intellectual deficits, memory loss, or extrapyramidal symptoms (e.g., parkinsonism). Treatment of acute CO poisoning, as in those who attempt suicide or are trapped in fires, consists principally of administering 100% oxygen.

Metals Metals are an important group of environmental chemicals that have caused disease in humans from ancient times to the present. Lead Lead is a ubiquitous heavy metal that is common in the environment of industrialized countries. Before widespread awareness of

FIGURE 8-7.

chronic exposure to lead in the 1950s and 1960s, the classic symptoms of lead poisoning were commonly encountered in children and adults. In the United States, lead poisoning was primarily a pediatric problem related to pica—the habit of chewing on cribs, toys, furniture, and woodwork—and eating painted plaster and fallen paint flakes. To these sources of lead was added a heavy burden of atmospheric lead in the form of dust derived from the combustion of lead-containing gasoline. Children and adults living near point sources of environmental lead contamination, such as smelters, were exposed to even higher levels of lead. In adults, occupational exposure to lead occurred primarily among those engaged in lead smelting and in the production and recycling of automobile batteries. Accidental poisonings occasionally occur from the use of pottery with lead-based glaze, renovation of old residences heavily coated with lead paint, and recently in children who play with inexpensive novelty jewelry and other items manufactured from lead. METABOLISM: Lead is absorbed through the lungs or, less often, the gastrointestinal tract. It crosses the blood-brain barrier readily and concentrations in the brain, liver, kidneys, and bone marrow are directly related to its toxic effects. Lead binds sulfhydryl groups and interferes with the activities of zinc-dependent enzymes and with enzymes involved in synthesis of steroids and cell membranes. TOXICITY: Classic lead overexposure, which is rarely seen in the United States today, affects many organs, but its major toxicity involves dysfunction in (1) the nervous system, (2) the kidneys, and (3) hematopoiesis (Fig. 8-7). The brain is the target of lead toxicity in children; adults usually present with manifestation of peripheral neuropathy. Children with lead encephalopathy (lead levels of 120 mg/mL) are typically irritable and ataxic. They may convulse or display altered states of consciousness, from drowsiness to frank coma. Children with lower blood lead levels exhibit mild CNS symptoms, such as clumsiness, irritability, and hyperactivity. Lead encephalopathy is a condition in which the brain is edematous and displays flattened gyri and compressed ventricles. There may be herniation of the uncus and cerebellar tonsils. Microscopically, congestion, petechial hemorrhages, and foci of

Complications of lead intoxication. RBCs, red blood cells.

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neuronal necrosis are seen. A diffuse astrocytic proliferation in both the gray and white matter may accompany these changes. Vascular lesions in the brain are particularly prominent, with capillary dilation and proliferation.

mercurial nephrotoxicity, and there may be a nephrotic syndrome with more severe intoxication. Pathologically, there is a membranous glomerulonephritis with subepithelial electron-dense deposits, suggesting immune complex deposition.

Peripheral motor neuropathy is the most common manifestation of lead neurotoxicity in the adult, typically affecting the radial and peroneal nerves and resulting in wristdrop and footdrop, respectively. Lead-induced neuropathy is probably also the basis of the paroxysms of gastrointestinal pain known as lead colic.

NEUROTOXICITY: The neurologic effects of mercury are manifested as a constriction of visual fields, paresthesias, ataxia, dysarthria, and hearing loss. Pathologically, there is cerebral and cerebellar atrophy. Microscopically, the cerebellum exhibits atrophy of the granular layer, without loss of Purkinje cells and spongy softening in the visual cortex and other cortical regions.

Anemia is a cardinal sign of lead intoxication. Lead disrupts heme synthesis in bone marrow erythroblasts and is expressed as a microcytic and hypochromic anemia resembling that seen in iron deficiency. The anemia of lead intoxication is also characterized by prominent basophilic stippling of erythrocytes, related to clustering of ribosomes. Erythrocyte life span is decreased; thus, the anemia of lead intoxication is due to both ineffective hematopoiesis and accelerated erythrocyte turnover. Lead nephropathy reflects the toxic effect of the metal on the proximal tubular cells of the kidney. The resulting dysfunction is characterized by aminoaciduria, glycosuria, and hyperphosphaturia (Fanconi syndrome). Lead poisoning is treated with chelating agents such as calcium ethylene diamine tetra-acetic acid (EDTA), either alone or in combination with dimercaprol (BAL). Both the hematologic and renal manifestations of lead intoxication are usually reversible, but alterations in the CNS are generally irreversible. EFFECTS OF CHRONIC EXPOSURE TO LOW LEAD LEVELS: Due to the removal of lead from gasoline, improvements in housing and paint reformulation, ambient levels of lead have fallen significantly: blood levels in the general population of the United States have decreased dramatically, resulting in the near elimination of lead-related childhood fatalities and encephalopathy. However, low lead exposure in children, although not producing recognizable symptoms, may permanently decrease cognitive performance. The regulatory safe threshold for blood levels of lead in children has been progressively reduced and is now thought to be below 10 μg/dL. High blood lead concentrations remain a problem among poor, mainly urban children, and more vigorous campaigns to address this situation are justified. Mercury Inorganic mercury has been used since prehistoric times and has been known to be an occupation-related hazard, at least since the Middle Ages. Although mercury poisoning still occurs in some occupations, there has been increasing concern over the potential health hazards brought about by the contamination of many ecosystems following several well-known outbreaks of methylmercury poisoning. Mercury released into the environment may be bioconcentrated and enter the food chain. Bacteria in bays and oceans can convert inorganic mercury compounds from industrial wastes into highly neurotoxic organomercurials. These compounds are then transferred up the food chain and are eventually concentrated in the large predatory fish (e.g., tuna, pike), which make up a substantial part of the diet in many countries. Although inorganic mercury is not efficiently absorbed in the gastrointestinal tract, organic mercurial compounds are readily absorbed because of their lipid solubility. Both inorganic and organic mercury are preferentially concentrated in the kidney, and methylmercury also distributes to the brain. The kidney is the principal target of the toxicity of inorganic mercury, but the brain is damaged by organic mercurials. NEPHROTOXICITY: At one time, mercuric chloride was widely used as an antiseptic, and acute mercuric chloride poisoning was much more common. Today, most cases are industrial accidents. Under such circumstances, proximal tubular necrosis is accompanied by oliguric renal failure. Proteinuria is common in chronic

Arsenic The toxic properties of arsenic have been known for centuries. Arsenic-containing compounds have been widely used as insecticides, weed killers, wood preservatives, and pigments. Arsenicals may also contaminate soil and leach into ground water as a result of naturally occurring arsenic-rich rock formations or from soil contaminants. As with mercury, there is evidence for the bioaccumulation of arsenic along the food chain. Acute arsenic poisoning is almost always the result of accidental or homicidal ingestion. Death is due to CNS toxicity. Chronic arsenic intoxication affects many organ systems. It is characterized initially by such nonspecific symptoms as malaise and fatigue, followed by gastrointestinal, cardiovascular, and hematologic dysfunction. Both encephalopathy and peripheral neuropathy develop. The latter is characterized by paresthesias, motor palsies, and painful neuritis. On epidemiological grounds, cancers of the skin, respiratory tract, and gastrointestinal tract have been attributed to industrial and agricultural exposure to arsenic. In some parts of the world, notably areas of Bangladesh that use deep tube wells as a water source, chronic exposure of workers in rice paddies to arsenic in the ground water has been associated with keratotic skin disorders and cancer. Nickel Nickel is a widely used metal in electronics, coins, steel alloys, batteries, and food processing. Dermatitis (“nickel itch”), the most frequent effect of exposure to nickel, may occur from direct contact with metals containing nickel, such as coins and costume jewelry. The dermatitis is a sensitization reaction; the body reacts to nickelconjugated proteins formed following the penetration of the epidermis by nickel ions. Exposure to nickel, as to arsenic, increases the risk of development of specific cancer types. Epidemiologic studies have demonstrated that workers who were occupationally exposed to nickel compounds have an increased incidence of lung cancer and cancer of the nasal cavities.

Thermal Regulatory Dysfunction Hypothermia is a Decrease in Body Temperature Below 35°C (95°F) Hypothermia can result in systemic or focal injury. In localized hypothermia, actual tissue freezing does not occur. Frostbite, by contrast, involves the crystallization of tissue water.

Generalized Hypothermia Acute immersion in water at 4°C to 10°C (39.2° to 50°F) reduces central blood flow. Coupled with decreased core body temperature and cooling of the blood perfusing the brain, this results in mental confusion. Tetany makes swimming impossible. Increased vagal discharge leads to premature ventricular contractions, ventricular arrhythmias, and even fibrillation. Within 30 minutes, heat loss exceeds heat production, and core temperature then begins to fall. Below 35°C, respiratory rate, heart rate, and blood pressure decline. If hypothermia is prolonged, decreased body temperature alters cerebrovascular function. When body core temperature reaches

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32°C (89.6°F), the person becomes lethargic, apathetic, and withdrawn. When it falls below 28°C (82.4°F), pulse and breathing weaken and coma supervenes. The most important factor in causing death is a cardiac arrhythmia or sudden cardiac arrest. These observations have been confirmed and extended, largely due to the indication of hypothermia in some patients undergoing open heart surgery. In fact, with careful pharmacologic control, prolonged periods of lower body temperature can be achieved with no residual harm.

Local Hyperthermia: Burns

Focal Hypothermia

• First-degree burns, such as mild sunburn, are recognized by congestion and pain but are not associated with necrosis. Mild endothelial injury produces vasodilation, increased vascular permeability, and slight edema. • Second-degree burns cause epidermal necrosis but spare the dermis. Clinically, these burns are recognized by blisters, in which the epithelium separates from the dermis. • Third-degree burns char both epidermis and dermis. Histologically, tissue is carbonized and cellular structure is lost.

Local reduction in tissue temperature, particularly in the skin, is associated with local vasoconstriction. Tissue water crystallizes if blood circulation is insufficient to counter persistent thermal loss. When freezing occurs slowly, ice crystals form within tissue cells and in the interstitial space. Denaturation of macromolecules and physical disruption of cellular membranes by the ice ensue. The most biologically significant cell injury appears in the endothelial lining of the capillaries and venules, which alters smallvessel permeability. This injury initiates extravasation of plasma, formation of localized edema and blisters, and an inflammatory reaction. Immersion foot (trench foot) is caused by a prolonged reduction in tissue temperature to a point not low enough to freeze tissue. This cooling causes cellular disruption, and endothelial cell damage leads to local thrombosis and changes caused by altered permeability. Vascular occlusion often produces gangrene.

Cutaneous burns are the most common form of localized hyperthermia. Both the degree and rate of temperature elevation determine the tissue response. A temperature of 50°C (120°F) may be sustained for 10 minutes or more without cell death, whereas a temperature of 70°C (158°F) or higher for even several seconds causes necrosis of the entire epidermis. Cutaneous burns have been separated into three categories of severity: first-, second-, and third-degree burns (Fig. 8-8).

Among the most important functions of the skin are fluid retention and protection from infectious agents. Not surprisingly, one of the most serious systemic disturbances caused by extensive cutaneous burns is fluid loss. Many severely burned persons, particularly those with more than 70% of their body surface involved

Hyperthermia Means an Increase in Body Temperature Tissue responses to hyperthermia are similar in some respects to those caused by freezing injuries. In both instances, injury to the vascular endothelium results in altered vascular permeability, edema, and blisters. The degree of injury depends on the extent of temperature elevation and how quickly it is reached. Small increases in body temperature increase the metabolic rate. However, above a certain limit, enzymes denature, other proteins precipitate, and “melting” of lipid bilayers of cell membranes takes place.

Systemic Hyperthermia Fever is an elevation of body core temperature resulting from a change in the thermoregulatory center. It occurs because of (1) increased heat production, (2) decreased elimination of heat from the body (when reflecting an aberrant response of the thermal regulatory center), or (3) a disturbance of the thermal regulatory center itself. In a strict sense, systemic hyperthermia is an elevation of core temperature above the thermal set point, as a result of insufficient dissipation of heat. A body temperature above 42.5°C (108.5°F) leads to profound functional disturbances, including general vasodilation, inefficient cardiac function, altered respiration, and ultimately, death. Few, if any, defined pathologic changes are associated with fever alone. Malignant hyperthermia is a thermal alteration, accompanied by a hypermetabolic state and often by rhabdomyolysis (muscle necrosis), which occurs after gaseous anesthesia in susceptible individuals. This autosomal dominant disorder is associated with mutations in the gene for the sarcoplasmic reticulum ryanodine receptor. Heat stroke is a form of hyperthermia that occurs under conditions of very high ambient temperatures and is not mediated by endogenous pyrogens. It reflects impaired thermal regulatory cooling responses and characteristically occurs in infants, young children, and the very aged. The disorder is often associated with an underlying chronic illness and the use of diuretics, tranquilizers that may affect the hypothalamic thermal regulatory center, or drugs that inhibit perspiration. Another form of heatstroke is seen in healthy men during unusually vigorous exercise. Lactic acidosis, hypocalcemia, and rhabdomyolysis may be severe problems, and almost one third of patients with exertional heatstroke develop myoglobinuric acute renal failure. Heatstroke is not amenable to treatment with standard antipyretics, and only external cooling and fluid and electrolyte replacement are effective therapy.

The pathology of cutaneous burns. A first-degree skin burn exhibits only dilation of the dermal blood vessels. In a second-degree burn, there is necrosis of the epidermis, and subepidermal edema collects under the necrotic epidermis to form a bulla. In a third-degree burn, both the epidermis and dermis are necrotic. FIGURE 8-8.

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with third-degree burns, develop shock as well as acute tubular necrosis of the kidneys, and mortality is very high. Severely burned patients who survive longer are at great risk of lethal surface infections and sepsis. Even normal skin saprophytes may cause infection of charred tissue and pose another difficulty for healing. Healing of cutaneous burns is related to the extent of tissue destruction. First-degree burns, by definition, have little if any cell loss, and healing requires only repair or replacement of injured endothelial cells. Second-degree burns also heal without a scar because epidermal basal cells remain and are a source of regenerating cells for the epithelium. Third-degree burns, in which the entire thickness of the epidermis is destroyed, pose a separate set of problems. If the skin appendages are spared, re-epithelialization can arise from them. Deeper burns that destroy the skin appendages require new epidermis or cultured autologous keratinocytes to be grafted to the débrided area to establish a functional covering. Burned skin that is not replaced by a graft heals with dense scarring. Because this scar tissue lacks the elasticity of normal skin, contractures that limit motion may eventually result. Inhalation burns result from exposure to air and aerosolized flammable materials heated to very high temperatures. Inhalation of these noxious fumes injures or destroys respiratory tract epithelium from the oral cavity to the alveoli. If a patient survives the acute episode, potentially fatal acute respiratory distress syndrome/diffuse alveolar damage may develop (see Chapter 12). Electrical burns are produced by conversion of electrical energy to heat energy when the current encounters the resistance of the tissues. Because electrical energy can potentially disrupt the electrical system within the heart, it frequently causes death through ventricular fibrillation. Electrical burns of the skin reflect the voltage, the area of electrical conductance, and the duration of current flow. Very high-voltage current chars tissue and produces a third-degree burn. Larger areas exposed suffer less injury than small areas exposed under equal conditions.

Physical Injuries The effect of mechanical trauma is related to (1) the force transmitted to the tissue, (2) the rate at which the transfer occurs, (3) the surface area to which the force is transferred, and (4) the area of the body involved. Blows over a hollow viscus can rupture the organ because of compression of the fluid or gas the space contains; organs nestled beneath the skin, such as the liver, can be easily ruptured. An impact directly over the heart can even disturb its electrical systems. The injury may be patterned, giving evidence of the causative agent. Reproducible sets of injuries (injury patterns) may be characteristic of particular injurious circumstances. These findings are of particular interest to the forensic pathologist who must determine both the cause and the manner of death—for example, is the death natural, accidental, suicidal, or homicidal?

A Contusion (Bruise) is a Localized Mechanical Injury with Focal Hemorrhage A force with sufficient energy may disrupt capillaries and venules within an organ by physical means alone. The result may be so limited that the only histologic change is hemorrhage in tissue spaces outside the vascular compartment. A discrete extravascular blood pool within the tissue is called a hematoma or bruise. Initially, the deoxygenated blood renders the area blue to blue-black, as in the classic “black eye.” Macrophages ingest the erythrocytes, convert their hemoglobin to bilirubin and so change the color from blue to yellow. Both mobilization of the pigment by macrophages and further metabolism of bilirubin cause the yellow to fade to yellowish-green and then to disappear.

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An Abrasion (Scrape) is a Skin Defect Caused by the Application of Tangential Force The disruptive force may provide a portal of entry for microorganisms because it leads to damage or loss of the superficial (and sometimes deeper) epithelial layers.

A Laceration is a Split or Tear of the Skin Caused by Crushing or Twisting Force Lacerations are more common over bone prominences and have irregular margins. When they have crushed margins, they are termed abraded lacerations. Lacerations are generally not produced by sharp objects.

Wounds are Mechanical Disruptions of Tissue Integrity An incision is a deliberate opening in the skin by a cutting instrument such as a surgeon’s scalpel. Incisions have sharp edges and, importantly, tissues are cleanly separated through the wound’s extent. Deep penetrating wounds made by high-velocity projectiles, such as bullets, are often deceptive, because the energy of the missile as it passes through the body may be released at sites distant from the entrance itself. Bullets rotate axially and do not tumble, producing a well-defined and usually round entrance wound. Once the projectile enters the flesh, however, it may fragment, tumble, or actually explode, resulting in considerable tissue damage and a large, ragged exit wound (Fig. 8-9).

Radiation Radiation is the transmission of energy by electromagnetic waves and by certain charged particles (alpha and beta particles and neutrons) emitted by radioactive elements. High-energy radiation, in the form of gamma or x-rays, mediates most of the biological effects discussed here. We do not consider the effects of ultraviolet radiation here; they are discussed in Chapters 5 and 24. Radiation is quantitated in a number of ways: • A rad defines the energy, expressed as ergs, absorbed by a tissue. One rad equals 100 ergs per gram of tissue. • A gray (Gy) corresponds to 100 rads (1 joule/kg of tissue), and a centigray (cGy) is equivalent to 1 rad. • A sievert (Sv) is the dose in grays multiplied by an appropriate quality factor Q, so that 1 Sv of radiation is roughly equivalent in biological effectiveness to 1 Gy of gamma rays. Sieverts measure radiation effects in tissue, whereas grays measure absorption in tissue. For example, background radiation averages about 3 milliSv, and 3 Sv will lead to the death of half of exposed people. For the purposes of this discussion of radiation-induced pathology, the rad, gray, and sievert are considered comparable, with 1 Sv being equal to 100 rads. PATHOGENESIS: At the cellular level, radiation essentially has two effects: (1) a somatic effect, associated with acute cell killing and (2) genetic damage. Radiation-induced cell death is believed to be caused by the acute effects of the radiolysis of water and the production of activated oxygen species (see Chapter 1). Genetic damage to the cell (whether caused by direct absorption of energy by DNA or indirectly by a reaction of DNA with oxygen radicals) is expressed either as a mutation or as reproductive failure. Both mutations and reproductive failure may lead to delayed cell death, and mutation is incriminated in the development of radiation-induced neoplasia (see Chapter 5).

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B FIGURE 8-9.

Bullet wounds. A. The entrance wound is sharply punched out. B. The exit wound is irregular with characteristic stellate lacerations.

Different tissues vary in their sensitivity to radiation. The vulnerability of a tissue to radiation-induced damage depends on its proliferative rate, which in turn, correlates with the natural life span of the constituent cells. For example, the intestine and hematopoietic bone marrow are far more vulnerable to radiation than are tissues such as bone and brain. Damage to the DNA of a long-lived, nonproliferating cell does not necessarily impair its function or viability. By contrast, a short-lived, proliferating cell, such as an intestinal crypt cell or a hematopoietic precursor, must be rapidly replaced by division of precursor cells. If radiation-induced DNA damage precludes mitosis of these cells, the mature elements are not replaced, and the tissue can no longer function. Rapid somatic cell death occurs only with extremely high doses of radiation, well in excess of 1,000 cGy. By contrast, irreversible damage to the replicative capacity of cells requires far lower doses, possibly as few as 50 cGy.

Whole-body Irradiation Injures Many Organs Most of our information about whole-body irradiation has been derived from studies of Japanese atom bomb survivors and persons exposed during the Chernobyl nuclear power plant accident (Fig. 8-10). • 300 cGy: At this dose, a syndrome characterized by hematopoietic failure develops within 2 weeks, leading to bleeding, anemia, and infection. The last is often the cause of death, which occurs in about half of the people exposed. • 10 Gy: In the vicinity of this dose, the main cause of death is related to the gastrointestinal system. At this dose, the entire epithelium of the gastrointestinal tract is destroyed within 3 days, which is the time of the normal life span of villous and crypt cells. As a result, fluid homeostasis of the bowel is disrupted, and severe diarrhea and dehydration ensue. Moreover, the epithelial barrier to intestinal bacteria is breached; gut organisms invade and disseminate throughout the body. Septicemia and shock kill the victim. • 20 Gy: With whole-body doses of 20 Gy and above, CNS damage causes death within hours. In most cases, cerebral edema and loss of the integrity of the blood–brain barrier, owing to endothelial injury, predominate. With extreme doses, radiation necrosis of neurons can be expected. Convulsions, coma, and death follow. FETAL EFFECTS: The effects of whole-body irradiation on the human fetus have been documented in studies of Hiroshima nuclear bomb survivors. Pregnant women exposed to 25 cGy or more gave birth to infants with reduced head size, diminished overall growth, and mental retardation. Other effects of irradiation in

utero include hydrocephaly, microphthalmia, chorioretinitis, blindness, spina bifida, cleft palate, clubfeet, and genital abnormalities. Data from experimental and human studies strongly suggest that major congenital malformations are highly unlikely at doses below 20 cGy after day 14 of pregnancy. However, lower doses may produce more subtle effects, such as a decrease in mental capacity. GENETIC EFFECTS: Most data on which predictions of human genetic effects are based are derived from experimental data and analysis of nuclear bomb survivors. After long-term follow-up, even survivors of Hiroshima and Nagasaki have shown no evidence of genetic damage in the form of either congenital abnormalities or heritable diseases in subsequent offspring or their descendants. Consequently, the risk of heritable genetic damage from radiation appears to be small.

Localized Radiation Injury Complicates Radiation Therapy for Tumors During radiation therapy for malignant neoplasms, some normal tissue is inevitably irradiated. Although almost any organ can be damaged by radiation, the skin, lungs, heart, kidney, bladder, and intestine are all susceptible and difficult to shield (Fig. 8-11). Localized damage to the bone marrow is clearly of little functional consequence because of the immense reserve capacity of the hematopoietic system. PATHOLOGY: Persistent damage to radiation-exposed tissue can be attributed to: (1) compromise of the vascular supply and (2) a fibrotic repair reaction to acute necrosis and chronic ischemia. Radiation-induced tissue injury predominantly affects small arteries and arterioles. The endothelial cells are the most sensitive elements in the blood vessels, and in the short term, exhibit swelling and necrosis. With time, vascular walls become thickened by endothelial cell proliferation, and subintimal deposition of collagen and other connective tissue elements occurs. Vacuolization of intimal cells, so called foam cells, is typical. Fragmentation of the internal elastic lamina, loss of smooth muscle cells, scarring in the media, and fibrosis of the adventitia are seen in the small arteries. Bizarre fibroblasts with large hyperchromatic nuclei are common and probably reflect radiation-induced DNA damage. CLINICAL FEATURES: Acute necrosis from radiation is represented by such disorders as radiation pneumonitis, cystitis, dermatitis, and diarrhea from enteritis. Chronic disease is characterized by interstitial fibrosis in the heart and lungs, strictures in the esophagus and small intestine, and constrictive pericarditis. Chronic radiation nephritis, which simulates malignant nephrosclerosis, is

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Acute radiation syndromes. At a dose of approximately 300 rads of whole body radiation, a syndrome characterized by hematopoietic failure develops within 2 weeks. In the vicinity of 1,000 rads, a gastrointestinal syndrome with a latency of only 3 days is seen. With doses of 2,000 rads or more, disease of the central nervous system appears within 1 hour, and death ensues rapidly. FIGURE 8-10.

primarily a vascular disease that leads to severe hypertension and progressive renal insufficiency. Additional sites affected by local radiation include: • Skin: Radiation dermatitis may occur where the therapeutic radiation traverses the skin. Poorly healed or dehisced wounds or persistent ulcers may occur at such sites and often require full-thickness skin grafts. • Gonads: The combination of radiation-induced vascular injury and direct damage to the continuously dividing germ cells leads to progressive atrophy and loss of reproductive function, with persistence of normal hormonal status. • Other sites: Cataracts (lenticular opacities) may be produced if the eye lies in the path of the radiation beam. Transverse myelitis and paraplegia occur with spinal cord irradiation as a result of vascular damage and local ischemia.

estimates of cancer risk at low radiation doses is very low, although they do not demonstrate that the risk is zero. When data from atomic bomb survivors are subjected to a conservative analysis, the lifetime risk from 1 cGy of whole-body x- or gamma irradiation is 1 excess cancer death per 10,000 persons. RADON: The finding that some homes in the United States contain radon formed from the decay of naturally occurring uranium 238 (238U), which is found in some soil and rock formations, has raised concern. Although radon is itself inert, its radioactive decay products are chemically active α ˜ alpha particle emitting isotopes

High Doses of Radiation Cause Cancer The evidence that radiation can lead to cancer is incontrovertible and comes from many sources. The survivors of the nuclear bomb explosions in Japan suffered from a number of cancers. They exhibited more than a 10-fold increase in the incidence of leukemia, which had peaked by 5 years after exposure, then declined over the next 3 decades to near-background rates, although significant excess risk was detectable 30 years after exposure. The frequency of solid tumors, although not as great as that for leukemia, was clearly increased for the breast, lung, thyroid, gastrointestinal tract, and urinary tract. A striking increase in the incidence of thyroid cancer, resulting in at least 1,000 additional cases among children, occurred in geographical areas contaminated by the nuclear catastrophe at Chernobyl in Ukraine in 1986. The increase has been linked to release of radioactive iodine isotopes in that incident. LOW-LEVEL RADIATION AND CANCER: The key question that needs to be answered is whether there is a threshold dose of radiation below which there is no increase in the incidence of cancer or whether any exposure carries a significant risk. Data currently available show that the

FIGURE 8-11.

The nonneoplastic complications of radiation.

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of bismuth, lead, and polonium, which bind to particulates and lung tissues. People who dwell in homes containing high concentrations of radon gas have an increased risk of developing lung cancer, although it may be restricted to smokers and ex-smokers. Ventilation of basement spaces to prevent radon buildup ameliorates the problem.

Nutritional Disorders Protein-Calorie Malnutrition Reflects Starvation or Specific Deficiencies Marasmus is the term used to denote a deficiency of calories from all sources. Kwashiorkor is a form of malnutrition in children caused by a diet deficient in protein alone.

Marasmus Global starvation—that is, a deficiency of all elements of the diet—leads to marasmus. The condition is common throughout the nonindustrialized world, particularly when breast-feeding is unavailable, and a child must subsist on a calorically inadequate diet. Pathologic changes are similar to those in starving adults and include decreased body weight, diminished subcutaneous fat, a protuberant abdomen, muscle wasting, and a wrinkled face. Wasting and increased lipofuscin pigment are seen in most visceral organs, especially the heart and the liver. Pulse, blood pressure, and temperature are low, and diarrhea is common. Because immune responses are impaired, the child suffers from numerous infections. An important consequence of marasmus is growth failure and the inability to reach full potential adult stature. Although still controversial, marasmus also appears to reduce cognitive ability during development.

Vitamins are Organic Catalysts that are Both Required for Normal Metabolism and Available Only from Dietary Sources Vitamins in one species are not necessarily vitamins in another. For example, humans cannot synthesize ascorbic acid (vitamin C) and so require dietary ascorbate to prevent scurvy. By contrast, most lower animals can produce their own vitamin C and do not require it as a vitamin.

Vitamin A Vitamin A is a fat-soluble substance that is important for skeletal maturation, maintenance of specialized epithelial linings, and cell membrane structure. In addition, it is an important constituent of the photosensitive pigments in the retina. Vitamin A occurs naturally as retinoids or as a precursor, β-carotene. The source of the precursor, namely carotene, is in plants, principally leafy, green vegetables. Fish livers are a particularly rich source of vitamin A itself. At times when fat absorption is impaired (e.g., diarrhea), vitamin A absorption decreases. Vitamin A Deficiency Although vitamin A deficiency is uncommon in developed countries, it is a significant health problem in poorer regions of the world, including much of Africa, China, and Southeast Asia. PATHOLOGY: Deficiency of vitamin A results principally in squamous metaplasia, especially in glandular epithelium (Fig. 813). Thus, keratin debris blocks sweat and tear glands (follicular hyperkeratosis). Squamous metaplasia is

Kwashiorkor Kwashiorkor (Fig. 8-12) results from a deficiency of protein in diets relatively high in carbohydrates. It is one of the most common diseases of infancy and childhood in the nonindustrialized world. Like marasmus, it usually occurs after an infant is weaned to a proteinpoor diet, consisting principally of staple carbohydrates. There is generalized growth failure and muscle wasting, as in marasmus, but subcutaneous fat is normal, because caloric intake is adequate. Extreme apathy is notable, in contrast to children with marasmus, who may be alert. Also in contrast to marasmus, there is prominent edema, hepatomegaly, and depigmentation of the skin. Dermatoses consisting of dry, hyperkeratotic “flaky paint” lesions occur on the face, extremities, and perineum. Hair becomes a sandy or reddish color; a characteristic linear depigmentation of the hair (“flag sign”) provides evidence of particularly severe periods of protein deficiency. The abdomen is distended because of flaccid abdominal muscles, hepatomegaly, and ascites due to hypoalbuminemia. Villous atrophy of the intestine may interfere with nutrient absorption. Diarrhea is common. Anemia is the rule, but it is not generally life-threatening. The nonspecific effects on growth, pulse, temperature, and the immune system are similar to those in marasmus. As with marasmus, an effect on intellectual growth is likely, but the subject requires further study. PATHOLOGY: Microscopically, the liver in kwashiorkor is conspicuously fatty. Accumulation of lipid within the cytoplasm of the hepatocyte displaces the nucleus to the periphery of the cell. The adequacy of dietary carbohydrate provides lipid for the hepatocyte, but the inadequate protein stores do not permit synthesis of enough apoprotein carrier to transport the lipid from the liver cell. The changes, with the possible exception of mental retardation, are fully reversible when sufficient protein is made available. In fact, the fatty liver reverts to normal after early childhood, even if the diet remains deficient in protein.

FIGURE 8-12.

Complications of kwashiorkor.

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common in the trachea and bronchi, and bronchopneumonia is a frequent cause of death. With further diminution of vitamin A stores, squamous metaplasia of conjunctival and tear duct epithelial cells occurs, which leads to xerophthalmia (dryness of the cornea and conjunctiva). The cornea becomes softened (keratomalacia) and vulnerable to ulceration and bacterial infection, which may lead to blindness. Excess vitamin A is toxic. Poisoning may be caused by overenthusiastic administration of vitamin supplements to children. Enlargement of the liver and spleen are common; microscopically, these organs show lipid-laden macrophages. Discontinuing the excess vitamin A consumption reverses all or most of the lesions. Both retinoic acid derivatives (used to alleviate severe acne) and a high dietary intake of preformed vitamin A are particularly dangerous in pregnancy because they are potent teratogens. Excessive carotene intake is benign and simply stains the skin yellow, which may be mistaken for jaundice. CLINICAL FEATURES: The earliest sign of vitamin A deficiency is often diminished vision in dim light. Vitamin A is a continuously necessary component in retinal rod pigment and is active in light transduction. Vitamin A deficiency is a leading cause of preventable childhood blindness in the developing world.

Vitamin B Complex Vitamins in the B group of water-soluble vitamins are numbered 1 through 12, but most are not distinct vitamins. The members of the complex currently recognized as true vitamins are vitamins B1 (thiamine), B3 (niacin), B2 (riboflavin), B6 (pyridoxine), and B12 (cyanocobalamin). With the exception of vitamin B12, which is derived only from animal sources, B complex vitamins are found principally in leafy green vegetables, milk, and liver. Thiamine Thiamine was the active ingredient in the original description of vitamin B, which was defined as a water-soluble extract in rice polishings that cured beriberi (clinical thiamine deficiency). This disease was classically seen in Asia, where the staple food was polished rice that had been deprived of its thiamine content by processing. In Western countries, the disease occurs in alcoholics, neglected persons with poor overall nutrition, and food faddists. The cardinal symptoms of thiamine deficiency are polyneuropathy, edema, and cardiac failure. The deficiency syndrome is classically divided into dry beriberi, with symptoms referable to the neuromuscular system, and wet beriberi, in which manifestations of cardiac failure predominate. PATHOGENESIS: Patients with dry beriberi present with paresthesias, depressed reflexes and weakness, and muscle atrophy in the extremities. Wet beriberi is characterized by generalized edema, a reflection of severe congestive failure. The basic lesion is uncontrolled, generalized vasodilation and significant peripheral arteriovenous shunting. This combination leads to compensatory increases in cardiac output, and eventually to a large dilated heart and congestive heart failure. PATHOLOGY: Thiamine deficiency in chronic alcoholics may be manifested by CNS involvement, in the form of Wernicke syndrome, in which progressive dementia, ataxia, and ophthalmoplegia (paralysis of the extraocular muscles) are prominent. A characteristic alteration is myelin sheath degeneration, which often begins in the sciatic nerve and then involves other peripheral nerves and sometimes the spinal cord itself. The most striking lesions in Wernicke encephalopathy comprise atrophy in the mamillary bodies and surrounding areas that abut on the third ventricle. Microscopically, degeneration and loss of ganglion cells, rupture of small blood vessels, and ring hemorrhages are seen in the brain.

FIGURE 8-13.

Complications of vitamin A deficiency.

The changes in the heart are also nonspecific. Grossly, the heart is flabby, dilated, and increased in weight. The process may affect either the right or the left side of the heart, or both. The microscopic changes are nondescript and include edema, inconsistent fiber hypertrophy, and occasional foci of fiber degeneration. Niacin Niacin refers to two chemically distinct compounds: nicotinic acid and nicotinamide. These components are derived from dietary niacin or are biosynthesized from tryptophan. Niacin plays a major role in formation of nicotinamide adenine dinucleotide (NAD) and its phosphate (NADP). Animal protein, as found in meat, eggs, and milk, is high in tryptophan and is, therefore, a good source of endogenously synthesized niacin. Niacin itself is available in many types of grain. Pellagra is the term for clinical niacin deficiency. It is uncommon today and is seen principally in patients who have been weakened by other diseases and also in malnourished alcoholics. PATHOLOGY: Pellagra is particularly prevalent in areas where corn (maize) is the staple food, because the niacin in corn is chemically bound and is thus poorly available. Corn is also a poor source of tryptophan. The disease is characterized by the three “Ds” of niacin deficiency: dermatitis, diarrhea, and dementia. Areas exposed to light, such as the face and the hands, and those subjected to pressure, such as the knees and the elbows, exhibit a rough, scaly dermatitis. The involvement of the hands leads to so-called glove dermatitis. Microscopically, hyperkeratosis, vascularization, and chronic inflammation of the skin are characteristic. Subcutaneous fibrosis and scarring may be seen in late stages. Similar lesions are found in the mucous membranes of the mouth and vagina. In the mouth, chronic inflammation and edema lead to a large, red fissured tongue. Chronic, watery diarrhea is typical for the disease, presumably due to mucosal atrophy and ulceration in the entire gastrointestinal tract, particularly in the colon. The dementia, characterized by aberrant ideation bordering on psychosis, is represented in the brain by degeneration of ganglion cells in the cortex. Myelin degeneration of tracts in the spinal cord resembles the subacute combined degeneration of vitamin B12 deficiency (see below).

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Riboflavin PATHOGENESIS: Riboflavin, a vitamin derived from many plant and animal sources, is important for the synthesis of flavin nucleotides, which are important in electron transport and other reactions in which energy transfer is crucial. Clinical symptoms of riboflavin deficiency are uncommon; they are usually seen only in debilitated patients with a variety of diseases and in poorly nourished alcoholics. PATHOLOGY: Riboflavin deficiency is manifested principally by lesions of the facial skin and corneal epithelium. Cheilosis, a term used for fissures in the skin at the angles of the mouth, is a characteristic feature. Seborrheic dermatitis, an inflammation of the skin that exhibits a greasy, scaling appearance, typically involves the cheeks and the areas behind the ears. Microscopically, hyperkeratosis and a mild mononuclear infiltrate of the skin are noted. The tongue is smooth and purplish (magenta), owing to mucosal atrophy. The most troubling lesion may be corneal interstitial keratitis, which is followed by opacification of the cornea and eventual ulceration. The localization of the lesions in riboflavin deficiency is not explained biochemically. Pyridoxine Vitamin B6 activity is found in three related, naturally occurring compounds: pyridoxine, pyridoxal, and pyridoxamine. For convenience, they are grouped under the heading pyridoxine. These compounds are widely distributed in vegetable and animal foods. PATHOGENESIS: Pyridoxine is converted to pyridoxal phosphate, a coenzyme for many enzymes, including transaminases and carboxylases. Pyridoxine deficiency is rarely caused by an inadequate diet. Of particular concern is the deficiency of pyridoxine that follows prolonged medication with a number of drugs, particularly isoniazid, cycloserine, and penicillamine. A deficiency state is also occasionally reported in alcoholics. CLINICAL FEATURES: There are no clinical manifestations of pyridoxine deficiency that can be considered characteristic or pathognomonic. The usual dermatologic complications of other B vitamin deficiencies occur with pyridoxine deficiency. The primary expression of the disease is in the CNS, a feature consistent with the role of this vitamin in the formation of pyridoxal-dependent decarboxylase of the neurotransmitter GABA. In infants and children, diarrhea, anemia, and seizures have occurred. Pyridoxine-responsive anemia is hypochromic and microcytic and therefore can be confused with iron-deficiency anemia. By definition, the anemia responds well to massive doses of pyridoxine. Vitamin B12 and Folic Acid Deficiencies Comprehensive discussions of vitamin B12 and folic acid deficiencies are found in Chapters 20 and 28. In pregnant women, deficiency of folate may lead to spina bifida and other dysraphic anomalies in the fetus, which are in turn prevented by folate supplementation (see Chapter 6).

Vitamin C (Ascorbic Acid) PATHOGENESIS: Ascorbic acid is a powerful biological reducing agent involved in many oxidation–reduction reactions and in proton transfer. This vitamin is important for chondroitin sulfate synthesis and for proline hydroxylation to form the hydrox-

yproline of collagen. Wound healing and immune functions also involve ascorbic acid. The best dietary sources of vitamin C are citrus fruits, green vegetables, and tomatoes. Scurvy is the clinical vitamin C deficiency state. Scurvy is now a disease of persons afflicted with chronic diseases who do not eat well, the neglected aged, and malnourished alcoholics. The stress of cold, heat, fever, or trauma (accidental or surgical) leads to an increased requirement for vitamin C. Children who are fed only milk for the first year of life tend to develop scurvy. PATHOLOGY: Most of the events associated with vitamin C deficiency are caused by the formation of abnormal collagen that lacks tensile strength (Fig. 8-14). Within 1 to 3 months, subperiosteal hemorrhages produce pain in the bones and joints. Petechial hemorrhages, ecchymoses, and purpura are common, particularly after mild trauma or at pressure points. Perifollicular hemorrhages in the skin are particularly typical of scurvy. In advanced cases, swollen, bleeding gums are a classic finding. Alveolar bone resorption results in loss of teeth. Wound healing is poor, and dehiscence of previously healed wounds occurs. Anemia may result from prolonged bleeding, impaired iron absorption, or associated folic acid deficiency. In children, vitamin C deficiency leads to growth failure, and collagen-rich structures, such as teeth, bones, and blood vessels, develop abnormally. Although the claims that ascorbic acid may help to prevent upper respiratory infections lack substantiation, ingestion of large amounts of vitamin C is not known to be harmful.

Vitamin D Vitamin D is a fat-soluble steroid hormone found in two forms: vitamin D3 (cholecalciferol) and vitamin D2 (ergocalciferol), both of which have equal biological potency in humans. Vitamin D3 is produced in the skin, and D2 is derived from plant ergosterol. The vitamin is absorbed in the jejunum along with fats and is transported in the blood bound to an α-globulin (vitamin D-binding protein). To achieve biological potency, vitamin D must be hydroxylated to active metabolites in the liver and kidney. The active form of the vitamin promotes calcium and phosphate absorption from the small intestine and may directly influence mineralization of bone. Vitamin D Deficiency PATHOGENESIS: In children, vitamin D deficiency causes rickets; in adults, osteomalacia occurs. Vitamin D deficiency results from (1) insufficient dietary vitamin D, (2) insufficient production of vitamin D in the skin because of limited sunlight exposure, (3) inadequate absorption of vitamin D from the diet (as in the fat malabsorption syndromes), or (4) abnormal conversion of vitamin D to its bioactive metabolites. The last occurs in liver disease and chronic renal failure. CLINICAL FEATURES: The bone lesions of vitamin D deficiency in children (rickets) have been recognized for centuries and were common in the Western industrialized world until recently. Addition of vitamin D to milk and many processed foods, administration of vitamin preparations to young children, and generally improved levels of nutrition have made rickets a curiosity in industrialized countries (See Chapter 26). Excess vitamin D may be harmful and result in hypercalcemia, which leads to nonspecific symptoms such as weakness and headaches and ultimately to nephrolithiasis or nephrocalcinosis. Ectopic calcification in other organs may be seen. Infants are particularly susceptible to excess vitamin D and may develop premature arteriosclerosis, supravalvular aortic stenosis, and renal acidosis.

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FIGURE 8-14.

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Complications of vitamin C deficiency (scurvy).

Vitamin E Vitamin E is an antioxidant that (experimentally at least) protects membrane phospholipids against lipid peroxidation by free radicals formed by cellular metabolism. The activity of this fat-soluble vitamin is found in a number of dietary constituents, principally in α-tocopherol. Corn and soy beans are particularly rich in vitamin E. Dietary deficiency of vitamin E is rare, and no clearly definable syndrome is associated with it. In premature infants, hemolytic anemia, thrombocytosis, and edema have been reported with vitamin E deficiency. Claims for a variety of beneficial effects of vitamin E abound, but the evidence for efficacy is unsubstantiated.

Vitamin K Vitamin K, a fat-soluble material, occurs in two forms: vitamin K1, from plants and vitamin K2, which is principally synthesized by the normal intestinal bacteria. Green leafy vegetables are rich in vitamin K, and liver and dairy products contain smaller amounts. Dietary deficiency is very uncommon in the United

States; most cases are associated with other disorders. However, newborn infants may exhibit vitamin K deficiency because the vitamin is not transported well across the placenta, and the sterile gut of the newborn does not have bacteria to produce it. Vitamin K confers calcium-binding properties to certain proteins and is important for the activity of several clotting factors. For this reason, a deficiency of this vitamin can lead to catastrophic bleeding (see Chapter 20). Parenteral vitamin K therapy is rapidly effective.

Essential Trace Minerals are Mostly Components of Enzymes and Cofactors Essential trace minerals include iron, copper, iodine, zinc, cobalt, selenium, manganese, nickel, chromium, tin, molybdenum, vanadium, silicon, and fluorine. Dietary deficiencies of these minerals are clinically important in the case of iron and iodine. These are discussed in Chapters 20 and 21, which deal with blood and endocrine diseases, respectively.

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Infectious and Parasitic Diseases David A. Schwartz Robert M. Genta Douglas P. Bennett Roger J. Pomerantz

Infectivity and Virulence Host Defense Mechanisms Heritable Differences Age Behavior Compromised Host Defense

VIRAL INFECTIONS: INTRODUCTION VIRAL INFECTIONS: RNA VIRUSES Respiratory Viruses The Common Cold Influenza Virus Respiratory Syncytial Virus (RSV) Viral Exanthems Measles (Rubeola) Rubella Mumps Intestinal Virus Infections: Rotavirus Viral Hemorrhagic Fevers Yellow Fever Ebola and Marburg Hemorrhagic Fevers Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) Transmission of HIV Pathology and Clinical Features of AIDS Opportunistic Infections Common in Patients with AIDS

VIRUS INFECTIONS: DNA VIRUSES Herpes Viruses Varicella-Zoster Virus Herpes Simplex Virus Epstein-Barr Virus Cytomegalovirus Human Papillomavirus

PRIONS: A NEW DISEASE PARADIGM BACTERIAL INFECTIONS Pyogenic Gram-Positive Cocci Staphylococcus aureus 148

S. aureus Antibiotic Resistance Streptococcus pyogenes Streptococcus pneumoniae Bacterial Infections of Childhood Diphtheria Pertussis Haemophilus influenzae Neisseria meningitides Sexually Transmitted Bacterial Diseases Gonorrhea Syphilis (lues) Enteropathogenic Bacterial Infections Escherichia coli Salmonella Enterocolitis and Typhoid Fever Shigellosis Cholera Campylobacter jejuni Pulmonary Infections with Gram-Negative Bacteria Clostridial Diseases Clostridial Food Poisoning Gas Gangrene Tetanus Botulism Clostridium difficile Colitis Bacterial Infections with Animal Reservoirs or Insect Vectors Brucellosis Yersinia pestis Tularemia Anthrax Listeriosis Infections Caused by Branching Filamentous Organisms Actinomycosis Nocardiosis

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SPIROCHETAL INFECTIONS

PROTOZOAL INFECTIONS

Syphilis Primary Syphilis Secondary Syphilis Tertiary Syphilis Congenital Syphilis Lyme Disease

Malaria Toxoplasmosis Congenital Toxoplasma Infections Toxoplasmosis in Immunocompromised Hosts Amebiasis Cryptosporidiosis Giardiasis Leishmaniasis Localized and Diffuse Cutaneous Leishmaniasis Mucocutaneous Leishmaniasis Viscaral Leishmaniasis (Kala Azar) Chagas Disease (American Trypanosomiasis) African Trypanosomiasis

CHLAMYDIAL INFECTIONS Chlamydia Trachomatis Infection Psittacosis (Ornithosis)

RICKETTSIAL INFECTIONS Rocky Mountain Spotted Fever Epidemic (Louse-Borne) Typhus

MYCOPLASMAL INFECTIONS: MYCOPLASMA PNEUMONIA MYCOBACTERIAL INFECTIONS Tuberculosis Primary Tuberculosis Secondary (Cavitary) Tuberculosis Leprosy

FUNGAL INFECTIONS Pneumocystis Jiroveci Pneumonia Candida Aspergillosis Cryptococcosis Histoplasmosis Coccidioidomycosis Blastomycosis Dermatophyte Infections

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HELMINTHIC INFECTION Filarial Nematodes Lymphatic Filariasis Onchocerciasis Intestinal Nematodes Ascariasis Trichuriasis Hookworms Strongyloidiasis Tissue Nematodes: Trichinellosis Trematodes (Flukes) Schistosomiasis Clonorchiasis Cestodes: Intestinal Tapeworms Echinococcosis

Bacterial and viral diarrheas and pneumonias, tuberculosis, measles, malaria, hepatitis B, pertussis, as well as tetanus kill more people each year than do all cancers and cardiovascular diseases. The impact of infectious diseases is greatest in less-developed countries, where millions of people, mostly children younger than 5 years of age, die of treatable or preventable infectious diseases. Even in the industrialized countries of Europe and North America, the mortality, morbidity, and loss of economic productivity from infectious diseases is enormous. In the United States each year, infectious diseases cause more than 200,000 deaths and more than 50 million days of hospitalization.

parasitize human resources. Virulence reflects both the structures inherent to the offending microbe and the interplay of those factors with host defense mechanisms.

Infectivity and Virulence

Heritable Differences in the Host Influence Organism Virulence

Infectious organisms cause diseases in which tissue dysfunction results from an invading transmissible agent. Virulence refers to the complex of properties that allows that agent to achieve infection and cause diseases of different degrees of severity. The organism must (1) gain access to the body, (2) avoid multiple host defenses, (3) accommodate to growth in the human milieu, and (4)

Host Defense Mechanisms The means by which the body prevents or contains infections are known as host defense mechanisms. There are major anatomical barriers to infection—mainly the skin and the aerodynamic filtration system of the upper airway—that prevent most organisms from ever penetrating the body. The mucociliary blanket of the airways is also an essential defense, providing a means of expelling organisms that gain access to the respiratory system. The microbial flora normally resident in the gastrointestinal tract and in various body orifices compete with outside organisms, preventing them from gaining sufficient nutrients or binding sites in the host. The body’s orifices are also protected by secretions that possess antimicrobial properties, both nonspecific (e.g., lysozyme and interferon) and specific (IgA). In addition, gastric acid and bile chemically destroy many ingested organisms.

The first step in infection is often a specific interaction of a binding molecule on the infecting organism with a receptor molecule on the host. If the host lacks a suitable receptor, the organism cannot attach to the target. An example is Plasmodium vivax, one of the parasites that causes malaria. It infects human erythrocytes by us-

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ing Duffy blood group determinants on the cell surface as receptors. Many individuals, particularly blacks, lack these determinants and are not susceptible to infection with P. vivax. As a result, P. vivax malaria is absent from much of Africa.

Age Influences the Outcome of Infection The effect of age on the outcome of exposure to many infectious agents is illustrated by fetal infections. Some organisms produce more severe disease in utero than in children or adults. Infections of the fetus with cytomegalovirus (CMV), rubellavirus, parvovirus B19, and Toxoplasma gondii interfere with fetal development. Fetal protection is dependent on the presence of maternal IgG antibodies, which cross the placenta. An acute infection in a nonimmune pregnant woman may allow the organism to infect the fetus. These infections are usually subclinical or produce minimal disease in the mother but may lead to major congenital abnormalities or death in the fetus. Age also affects the course of common illnesses, such as the diverse viral and bacterial diarrheas. In older children and adults, these infections cause discomfort and inconvenience, but rarely severe disease. The outcome can be different in children under 3 years, who cannot compensate for the rapid volume loss that results from profuse diarrhea. In 2000, the World Health Organization estimated that acute diarrheal diseases kill 2.2 million children yearly. The elderly fare more poorly with almost all infections than younger persons. Common respiratory illnesses such as influenza and pneumococcal pneumonia are more often fatal in those older than 65 years of age.

Human Behavior Plays a Large Role in Exposure to Infectious Agents The link between behavior and infection is probably most obvious for sexually transmitted diseases, in which the type and number of sexual encounters profoundly influence the risk of acquiring disease. Other aspects of behavior also influence the risk of acquiring infections. Humans contract brucellosis and Q fever, which are primarily bacterial diseases transmitted by close contact with domesticated farm animals or their secretions. These infections occur in farmers, herders, meat processors, and, in the case of brucellosis, in persons who drink unpasteurized milk. Transmission of a number of parasitic diseases is strongly affected by behavior. Schistosomiasis, acquired when water-borne parasite larvae penetrate the skin of a susceptible host, is primarily a disease of farmers who work in fields irrigated by infected water. The larvae of hookworm and Strongyloides stercoralis live in humid soil and make their way through the skin of the lower extremities in people who walk barefoot. The introduction of shoes has probably been the single most important factor in reducing the prevalence of infection with soil-transmitted nematodes. Botulism is contracted by (1) ingestion of improperly canned food that contains the toxin; (2) ingestion of clostridia spores, often via honey, by infants; or (3) from inoculation of wounds by spores, which then germinate in devitalized tissue.

People with Compromised Defenses are More Likely to Contract Infections and to Have More Severe Infections Disruption or absence of any host defense mechanism results in increased numbers and severity of infections. Disruption of epithelial surfaces by trauma or burns frequently leads to invasive bacterial or fungal infections. Injury to the mucociliary apparatus of the airways, as in smoking or influenza, impairs clearance of inhaled microorganisms and leads to an increased incidence of bacterial pneumonia. Congenital absence of complement components C5, C6, C7, and C8 prevents formation of a fully functional membrane attack complex and permits disseminated, and often recurrent, Neisseria infections (see Chapter 2). Diseases such as diabetes mellitus and chemotherapeutic drugs that interfere with the production

or function of neutrophils increase the likelihood of bacterial infections or invasive fungal infections (see Chapter 20). Organisms that cause disease mainly in hosts with impaired immunity are termed opportunistic pathogens. These organisms, many of which are part of the normal endogenous human or environmental microbial flora, take advantage of a host’s inadequate defenses to stage a more violent and sustained attack.

VIRAL INFECTIONS Viruses range from 20 to 300 nm and consist of RNA or DNA contained in a protein shell. Some are also enveloped in lipid membranes. Viruses do not engage in metabolism or reproduction independently, and thus are obligate intracellular parasites that require living cells in order to replicate. After invading cells, they divert the cells’ biosynthetic and metabolic capacities toward the synthesis of virus-encoded nucleic acids and proteins. Viruses often cause disease by killing infected cells, but many do not. For example, rotavirus, a common cause of diarrhea, interferes with the function of infected enterocytes without immediately killing them. It prevents enterocytes from synthesizing proteins that transport molecules from the intestinal lumen and thereby causes diarrhea. Viruses may also promote the release of chemical mediators that elicit inflammatory or immunologic responses. The symptoms of the common cold are due to the release of bradykinin from infected cells. Other viruses cause cells to proliferate and form tumors. Human papillomaviruses (HPVs), for instance, cause squamous cell proliferative lesions, which range from common warts to cervical cancer. Some viruses infect and persist in cells without interfering with cellular functions, a process known as latency. Latent viruses can emerge to produce disease years after the primary infection. Opportunistic infections are frequently caused by viruses that have established latent infections. CMV and herpes simplex viruses are among the most frequent opportunistic pathogens because they are commonly present as latent agents and emerge in persons with impaired cell-mediated immunity. Finally, some viruses may reside within cells, either by integrating into their genomes or by remaining episomal, and cause those cells to generate tumors. Examples of this are Epstein-Barr virus (EBV), which causes endemic Burkitt lymphoma in Africa, and other tumors in different settings, and human T-cell leukemia virus-1 (see Chapter 5), which causes a form of T-cell lymphoma. In the following section, viruses with highly organ-specific tropisms are not described in detail, but are addressed in those chapters that deal with the organs that are principally affected (e.g., hepatitis B and C) (see Chapter 14).

RNA VIRUSES A number of important pathogenic RNA viruses (e.g., human immunodeficiency virus [HIV]-1, hepatitis C virus) differ from many DNA viruses in that the RNA viral polymerases do not proofread the RNA strand being synthesized. This has two important consequences. First, the mutation rate—and therefore the plasticity of these viruses in circumventing therapies—is very high. Second, a greater percentage of daughter virions are inactive.

Respiratory Viruses The Common Cold is the Most Common Viral Disease The common cold (coryza) is an acute, self-limited upper respiratory tract disorder caused by infection with a variety of RNA viruses, including

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more than 100 distinct rhinoviruses and several coronaviruses. Colds are frequent and worldwide in distribution, spreading from person to person by contact with infected secretions. Infection is more likely during the winter months in temperate areas and during the rainy seasons in the tropics, when spread is facilitated by indoor crowding. In the United States, children usually suffer six to eight colds per year and adults two to three. PATHOGENESIS: The viruses infect the nasal respiratory epithelial cells, causing increased mucus production and edema. Rhinoviruses and coronaviruses have a tropism for respiratory epithelium and optimally reproduce at temperatures well below 37°C (98.6°F). Thus, infection remains confined to the cooler passages of the upper airway. Infected cells release chemical mediators, such as bradykinin, which produce most of the symptoms associated with the common cold, namely increased mucus production, nasal congestion, and eustachian tube obstruction. The resulting stasis of secretions may predispose to secondary bacterial infection and lead to bacterial sinusitis and otitis media. Rhinoviruses and coronaviruses do not destroy the respiratory epithelium and produce no visible alterations. Clinically, the common cold is characterized by rhinorrhea, pharyngitis, cough, low-grade fever. and malaise.

Influenza Virus is a Highly Contagious Epidemic Disease Influenza is an acute, usually self-limited, infection of upper and lower airways caused by influenza virus. These viruses are enveloped and contain single-stranded RNA. PATHOGENESIS AND PATHOLOGY: Influenza spreads from person to person by virus-containing respiratory droplets and secretions. Upon reaching the respiratory epithelial cell surface, the virus binds and enters the cell by fusion with the cell membrane, a process mediated by a viral glycoprotein (hemagglutinin) that binds to sialic acid residues on human respiratory epithelium. Once inside, the virus directs the cell to produce progeny viruses and causes cell death. The infection usually involves both the upper and lower airways. Influenza virus causes necrosis and desquamation of the ciliated respiratory tract epithelium and is associated with a predominantly lymphocytic inflammatory infiltrate. Extension of the infection to the lungs leads to necrosis and sloughing of alveolar lining cells and the histologic appearance of viral pneumonitis. Destruction of the ciliated epithelium cripples the mucociliary blanket, predisposing to bacterial pneumonia, especially with Staphylococcus aureus and Streptococcus pneumoniae. CLINICAL FEATURES: Influenza manifests with a rapid onset of fever, chills, myalgia, headaches, weakness, and nonproductive cough. Symptoms may be primarily those of an upper respiratory infection or those of tracheitis, bronchitis, and pneumonia. Epidemics are accompanied by deaths from both the disease and its complications, particularly in the elderly and in persons with underlying cardiopulmonary disease. Killed viral vaccines specific to epidemic strains are 75% effective in preventing influenza.

Respiratory Syncytial Virus (RSV) Causes Bronchiolitis in Infants RSV is a major cause of bronchiolitis and pneumonia in children under 1 year of age with most children having been infected by school age. It is spread by respiratory aerosols and secretions, often in the setting of hospitals or daycare centers.

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PATHOGENESIS AND PATHOLOGY: Viral surface proteins bind to specific receptors on host respiratory epithelium and then fuse with the cell membrane. RSV produces necrosis and sloughing of bronchial, bronchiolar, and alveolar epithelium, which are associated with a predominantly lymphocytic inflammatory infiltrate. Multinucleated syncytial cells are sometimes seen in infected tissues. CLINICAL FEATURES: Infants and young children with RSV bronchiolitis or pneumonitis present with wheezing, cough, and respiratory distress, sometimes accompanied by fever. The illness is usually self-limited, resolving in 1 to 2 weeks. In older children and adults, RSV produces much milder disease. Among otherwise healthy young children, the mortality rate from RSV infection is very low, but it rises dramatically to 20% to 40% among children with congenital heart disease or immunosuppression.

Viral Exanthems Measles (Rubeola) is a Highly Contagious Virus that May Cause Fatal Infection Measles virus is an enveloped, single-stranded RNA virus that causes an acute illness, characterized by upper respiratory tract symptoms, fever, and rash. The virus is transmitted in respiratory aerosols and secretions. In nonimmunized populations, measles is primarily a disease of children. PATHOGENESIS AND PATHOLOGY: The initial site of infection is the mucous membranes of the nasopharynx and bronchi, where the virus produces necrosis of respiratory epithelium and is associated with a predominantly lymphocytic inflammatory infiltrate. The virus extends to the regional lymph nodes and then to the bloodstream, leading to widespread dissemination and prominent involvement of the skin and lymphoid tissues. Lymphoid hyperplasia is often prominent in the cervical and mesenteric lymph nodes, spleen, and appendix. In lymphoid tissues, the virus sometimes causes fusion of infected cells, producing multinucleated giant cells containing up to 100 nuclei, with both intracytoplasmic and intranuclear inclusions. These cells, named Warthin-Finkeldey giant cells, are pathognomonic for measles. The virus produces a T-cell-mediated vasculitis of small blood vessels in the skin and a resultant rash. CLINICAL FEATURES: Measles first manifests with fever, rhinorrhea, cough, and conjunctivitis and progresses to the characteristic mucosal and skin lesions. The mucosal lesions, known as “Koplik spots,” appear on the posterior buccal mucosa and consist of minute gray-white dots on a red base. The skin lesions begin on the face as an erythematous maculopapular rash, which usually spreads to involve the trunk and extremities. The rash fades in 3 to 5 days, and the symptoms gradually resolve. Measles often leads to secondary bacterial infections, especially otitis media and pneumonia. Measles is a particularly severe disease in the very young, the sick, or the malnourished. In impoverished countries, the disease has a high mortality rate (10% to 25%). Uncommonly, patients can develop subacute sclerosing panencephalitis (SSPE), a slow, chronic neurodegenerative disorder that occurs years after a measles infection. The exact pathophysiology of SSPE is unclear. Live attenuated vaccines are highly effective in preventing measles and in eliminating the spread of the virus and have also greatly reduced the incidence of SSPE.

Rubella Infection in Utero is Associated with Congenital Anomalies Rubellavirus is an enveloped, single-stranded RNA virus that causes a mild, self-limited systemic disease, usually associated with a rash, which is

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spread primarily by the respiratory route. Many infections are so mild that they go unnoticed. However, in pregnant women, rubella (part of the TORCH complex) is a destructive fetal pathogen (see Chapter 5). Infection early in gestation can produce fetal death, premature delivery, and congenital anomalies, including deafness, cataracts, glaucoma, heart defects, and mental retardation. The live attenuated vaccine currently available prevents rubella and has largely eliminated the disease from developed countries. PATHOGENESIS: Rubella infects respiratory epithelium and then disseminates to various organs through the bloodstream and lymphatics. The rubella rash is believed to result from an immunologic response to the disseminated virus. Fetal infection occurs through the placenta during the viremic phase of maternal illness. A congenitally infected fetus remains persistently infected and sheds large amounts of virus in body fluids, even after birth. Maternal infection after 20 weeks’ gestation usually does not cause significant fetal disease.

Mumps Mumps virus is an enveloped, single-stranded highly contagious RNA virus that causes an acute, self-limited systemic illness, characterized by parotid gland swelling and meningoencephalitis. PATHOGENESIS AND PATHOLOGY: Mumps begins with viral infection of respiratory tract epithelium. The patient experiences fever and malaise, followed by painful swelling of the salivary glands, usually one or both parotids. The virus then disseminates through the blood and lymphatic systems to infect other sites, most commonly the salivary glands, CNS, pancreas, and testes. The virus causes necrosis of infected cells and a predominantly lymphocytic inflammatory infiltrate. The affected salivary glands are swollen, the ducts lined by necrotic epithelium, and the interstitium infiltrated with lymphocytes. The CNS is involved in more than half of cases, producing symptomatic disease in 10%. Epididymoorchitis occurs in 30% of males infected after puberty. The swelling of testicular parenchyma, confined within the tunica albuginea, produces focal infarcts. Mumps orchitis is usually unilateral and, thus, rarely causes sterility. A live attenuated vaccine prevents mumps, and the disease has been largely eliminated from most developed countries.

Intestinal Virus Infections: Rotavirus Rotavirus infection is the most common cause of severe diarrhea worldwide. The organism produces profuse watery diarrhea that can lead to dehydration and death if untreated. This double-stranded RNA virus usually infects young children. Rotavirus infection spreads from person to person by the oral–fecal route. PATHOGENESIS AND PATHOLOGY: Rotavirus infects the enterocytes of the upper small intestine, disrupting the absorption of sugars, fats, and various ions. The resulting osmotic load causes a net loss of fluid into the bowel lumen, producing profuse watery diarrhea and dehydration. Infected cells are shed from intestinal villi, and the regenerating epithelium initially lacks full absorptive capabilities. Pathologic changes in rotavirus infection are largely confined to the duodenum and jejunum, where there is shortening of the intestinal villi, associated with a mild infiltrate of neutrophils and lymphocytes.

Viral Hemorrhagic Fevers Viral hemorrhagic fevers are a group of at least 20 distinct viral infections that cause varying degrees of hemorrhage and shock and often death. There are many similar viral hemorrhagic fevers in different parts of the world, for the most part named for the area where they were first described. The viral hemorrhagic fevers encompass members of four virus families—the Bunyaviridae, Flaviviridae, Arenaviridae, and Filoviridae. On the basis of differences in routes of transmission, vectors, and other epidemiologic characteristics, the viral hemorrhagic fevers have been divided into four groups (Table 9-1): mosquito-borne; tick-borne; zoonotic; and the filoviruses, Marburg and Ebola virus, in which the route of transmission is unknown.

Yellow Fever May Lead to Fulminant Hepatic Failure Yellow fever is an acute hemorrhagic fever, sometimes associated with extensive hepatic necrosis and jaundice. The illness is caused by an insectborne flavivirus, an enveloped, single-stranded RNA virus. The usual reservoir for the virus is tree-dwelling monkeys, and the agent is passed among them in the forest canopy by mosquitoes. These monkeys serve as a reservoir because the virus does not makes them ill. Humans acquire jungle yellow fever by entering the forest and being bitten by infected Aedes mosquitoes. On returning to the village or city, the human victim becomes the reservoir for epidemic yellow fever in the urban setting in Africa or South America, where Aedes aegypti is the vector. PATHOGENESIS AND PATHOLOGY: On inoculation by the mosquito, the virus multiplies within tissue and vascular endothelium and then disseminates through the bloodstream. The virus has a tropism for liver cells, where it causes coagulative necrosis of hepatocytes, which begins among cells in the middle of hepatic lobules and spreads toward the central veins and portal tracts. In the most severe cases, the entire lobule may be necrotic. Some necrotic hepatocytes lose their nuclei and become intensely eosinophilic Councilman bodies (recognized today as apoptotic bodies). The jaundice in yellow fever results from the hepatic damage. Extensive damage to the endothelium of small blood vessels may lead to a loss of vascular integrity, hemorrhages, and shock, hallmarks of the hemorrhagic fevers.

Ebola and Marburg Hemorrhagic Fevers are Fatal African Diseases Ebola and Marburg hemorrhagic fevers are severe viral diseases caused by the Ebola and Marburg RNA filoviruses. Both diseases continue to cause sporadic outbreaks in sub-Saharan Africa. Infections with Ebola (Zaire strain) and Marburg viruses have case fatality rates of 80% to 90% in major occurrences. Ebola (Sudan strain) has a somewhat lower fatality rate of about 50%. In the wild, the Ebola virus infects humans, gorillas, chimpanzees, and monkeys. Recent field evidence has implicated several species of fruit bats as the natural reservoir of the Ebola virus. The natural reservoir for Marburg virus remains unknown. Healthcare workers and family members have become infected while treating patients with Ebola and Marburg hemorrhagic fever or during funerary preparation of the bodies of deceased victims. The virus can be transmitted via bodily secretions, blood, and used needles. PATHOGENESIS AND PATHOLOGY: Ebola and Marburg viruses result in the most widespread destructive tissue lesions of all viral hemorrhagic fever agents. The viruses undergo massive replication in endothelial cells, mononuclear phagocytes, and hepatocytes. Necrosis is most severe in the liver, kidneys, gonads, spleen, and lymph nodes. Characteristic findings in the liver include hepatocellular necrosis, Kupffer cell hyperplasia, Councilman

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Viral Hemorrhagic Fevers Vector

Viral Fever

Mosquitoes

Yellow fever Rift Valley fever Dengue hemorrhagic fever Chikungunya hemorrhagic fever Omsk hemorrhagic fever Crimean hemorrhagic fever Kyasanur forest disease Lassa fever Bolivian hemorrhagic fever Argentine hemorrhagic fever Korean hemorrhagic fever Ebola virus disease Marburg virus disease

Ticks

Rodents

Undefined

(acidophilic, apoptotic) bodies, and microsteatosis. The lungs are usually hemorrhagic, and petechial hemorrhages are present in the skin, mucous membranes, and internal organs. Injury to the microvasculature and increased endothelial permeability are important causes of shock. Multiorgan dysfunction syndrome is common and results in death (see Chapter 7).

Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) AIDS is a widespread disease caused principally by the enveloped RNA retrovirus HIV-1, a member of the lentivirus subfamily. A small minority of patients, primarily in western Africa, are infected with HIV-2, a very similar virus. Persons infected with HIV-1 exhibit a variety of immunologic defects, the most devastating of which is a progressive loss of cellular immunity. Immunosuppression is progressive and may become complete if not treated with appropriate drugs (see Chapter 4 for details on immune aspects and pathology of infection). As a result, rather than dying of HIV infection itself, patients with AIDS usually die of opportunistic infections. There is also a high incidence of malignant tumors, principally B-cell lymphomas and Kaposi sarcoma (KS). Finally, infection of the CNS with HIV often leads to an array of syndromes, ranging from minor cognitive or motor neuron disorders to frank dementia.

HIV is Transmitted by Contact with Blood and Certain Body Fluids With the exception of intravenous drug users and transfusion recipients, AIDS is transmitted principally as a venereal disease, in both homosexuals and heterosexuals. Transmission to newborns via breast milk is a concern in the developing world. Significant amounts of HIV have been isolated from blood, semen, vaginal secretions, breast milk, and cerebrospinal fluid. Except for the last, HIV in these fluids is both present in lymphocytes and as free virus. The receptive partner in unprotected anal intercourse is at particularly high risk of becoming infected with HIV. The virus is transmitted via semen through tears in the rectal mucosa, where it can directly infect epithelial cells. In heterosexual contact, transmission from male to female is more likely than the reverse, perhaps reflecting the greater concentration of HIV in semen than in vaginal fluids. Genital lesions, usually caused by other sexually transmitted diseases such as syphilis and HPV, facilitate entry of the virus and lead to a particularly high risk of contracting AIDS. AIDS is not transmissible by nonsexual, casual exposure to infected persons. In prospective studies of hundreds of health care workers who sustained “needle sticks” or other accidental exposures to

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blood from patients with AIDS, fewer than 1% actually seroconverted and became infected with HIV-1. Immediate postexposure prophylaxis with antiretroviral therapy is indicated in such accidental exposures, with the goal of preventing HIV-1 infection. (Specific recommendations are available online at the Centers for Disease Control and Prevention [CDC]. See www.cdc.gov/mmwr/ preview/ mmwrhtml/rr5409a1.htm.) PATHOGENESIS: Specific target cells for HIV-1 are CD4+ helper T lymphocytes and mononuclear phagocytes, although infection of other cells can occur, such as in B lymphocytes, glial cells, and intestinal epithelial cells. Free HIV or an infected lymphocyte can transmit the virus to an uninfected cell. The HIV envelope glycoprotein, gp120, either on the free virus or on the surface of an infected cell, binds the CD4 molecule on the surface of helper T lymphocytes and other cells, as well as one of a family of β–chemokine receptors. The most important of these chemokine receptors are CXCR4 (on T lymphocytes) and CCR-5 (on many phagocytic cells). Binding of both receptors is necessary for HIV entry. Virus cDNA integrates into the host genome using a viral integrase protein, generating the latent proviral form of HIV-1. Viral genes are replicated along with host DNA and therefore persist for the life of the cell. As memory T cells have long life spans, some experts estimate that even if total suppression of HIV-1 replication were achieved, more than 60 years would be needed for infected T cells to die off. To complete its cycle, nascent virus is assembled in the cytoplasm just beneath the cell membrane and disseminated to other target cells. This is accomplished either by fusion of an infected cell with an uninfected one or by the budding of virions from the plasma membrane of the infected cell (see Fig. 9-1 for details). The long interval between HIV-1 infection and the appearance of clinical symptoms of AIDS is related to the small number of infected T lymphocytes and viral latency. Only 10–5 to 10–4 circulating mononuclear cells display detectable viral messenger RNA, but about 1% of circulating T cells contain proviral DNA. Initiation of viral replication in latent HIV-1 infection depends on the induction of host proteins during T-cell activation. Viral transcription may be activated by many T-cell mitogens and cytokines produced by monocyte/macrophages including tumor necrosis factor (TNF)-α and IL-1, and in addition, by proteins produced by other viruses that infect patients with AIDS, such as herpes virus, EBV, adenovirus, and CMV. Thus, immune system activation by a variety of infectious agents may promote HIV replication. Active HIV replication and increasing viral loads render such individuals more likely to transmit disease. PATHOLOGY AND CLINICAL FEATURES: Patients recently infected with HIV-1 may have an acute, usually self-limited, infectious mononucleosis-like illness called the acute retroviral syndrome, which is associated with intense viremia and a drop in CD4+ T cells. This occurs 2 to 3 weeks after exposure to HIV, before the appearance of antibodies against the virus. Fever, myalgia, lymphadenopathy, sore throat, and a macular rash are common. Most of these symptoms usually resolve within 2 to 3 weeks. Seroconversion occurs 1 to 10 weeks after the onset of this acute illness. Thus, the standard HIV-1 enzyme immunoassay and Western blot testing, which depend on the presence of anti—HIV-1 antibodies, are negative during the initial stage of the infection. As a patient’s immune system begins to recognize the new infection, the viral load drops, and the CD4+ T-cell count begins to climb as a result of a vigorous cytotoxic T-cell response, although a small percentage of persons progress to frank AIDS. After the initial acute syndrome, most newly infected individuals enter a period of latency and slow immune system decline, which averages approximately 10 years before they reach a state of serious immune compromise.

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FIGURE 9-1.

Human immunodeficiency virus-1 (HIV-1) virions can be seen budding from infected cells (arrows).

During this period, viral replication continues but is constrained by the immune response. However, viral replication virtually always begins to increase, with a concomitant decrease in CD4+ T cells. Nonspecific constitutional symptoms and opportunistic infections begin to appear when CD4+ lymphocyte counts fall below 500/μL. If unrecognized or untreated, the outcome is fulminant immunodeficiency and its fatal complications (Fig. 9-2). As CD4+ T cells fall below 350/μL, patients become much more susceptible to primary or reactivation Mycobacterium tuberculosis, which may progress rapidly to severe disease or death. Once CD4+ levels are under 150/μL and CD4:CD8 ratios are less than 0.8, the disease progresses rapidly. A variety of bacteria, viruses, fungi, and protozoa attack the immunocompromised patient. Kaposi sarcoma (KS) and lymphoproliferative disorders may appear, and neurologic disease is common. Discussion of the diversity of infectious agents that ravage patients with AIDS is beyond the scope of this discussion, and only a few representative examples are mentioned (see Fig. 9-2). It is important to recognize that although most persons with normal immune function will suffer only one infection at a time, HIV-1-infected patients can develop multiple severe infections simultaneously.

Opportunistic Infections, Particularly Polymicrobial Infections, are Common in Patients with AIDS The majority of patients with HIV-1/AIDS suffer from opportunistic pulmonary infections, although this complication has been greatly reduced through the use of prophylactic antibiotics. Pneumocystis jiroveci pneumonia may occur in patients with advanced HIV-1 disease. Lung infection with CMV, Mycobacterium avium-intracellulare, and Legionella are less common. Diarrhea occurs in more than 75% of AIDS patients, often representing simultaneous infections with more than one organism. The most frequent pathogens are protozoans, including Cryptosporidium, Isospora belli, and Giardia lamblia. M. avium-intracellulare and Salmonella species are the most common bacterial cause. CMV infection of the gastrointestinal tract can manifest as a colitis associated with watery diarrhea in patients whose CD4 counts are under 50 cells/μL. Cryptococcal meningitis is a devastating complication and represents 5% to 8% of all opportunistic infections in patients with AIDS. CNS complications include cerebral toxoplasmosis; primary CNS lymphoma; encephalitis caused by herpes simplex, varicella, or CMV; and progressive multifocal leukoencephalopathy, which is produced by the JC virus. Virtually all patients with AIDS develop some form of skin disease, infections being the most prominent. Staphylococcus aureus is the most common, causing bullous impetigo, deeper purulent le-

sions (ecthyma), and folliculitis. Chronic mucocutaneous herpes simplex infection is so characteristic of AIDS that it is considered an index infection in establishing the diagnosis. Among the most common causes of death in patients with HIV/AIDS is hepatitis C (see Chapter 14). Patients with AIDS, especially homosexual men, are at very high risk for Kaposi sarcoma (KS) (see Chapter 24). In fact, the occurrence of KS in an otherwise healthy person under 60 years is strong evidence of AIDS. KS in AIDS is usually aggressive, often involving viscera such as the gastrointestinal tract or lungs. Lung involvement frequently leads to death. A strain of herpesvirus, namely human herpesvirus 8 (HHV8), is implicated in all forms of KS, including that associated with AIDS.

DNA VIRUSES Herpes Viruses The virus family Herpesviridae includes a large number of enveloped, DNA viruses, many of which infect humans. Almost all herpes viruses express some common antigenic determinants, and many produce type A nuclear inclusions (acidophilic bodies surrounded by a halo). The most important human pathogens among the herpes viruses are varicella-zoster, herpes simplex, EBV, human herpesvirus 6 (HHV6, the cause of roseola), and CMV. Recently, HHV8 was implicated in the pathogenesis of KS in HIV-infected patients. These viruses are also distinguished by their capacity to remain latent for long periods of time.

Varicella-Zoster Infection Causes Chickenpox and Herpes Zoster The first exposure to varicella-zoster virus (VZV) produces chickenpox, an acute systemic illness, which has a dominant feature of generalized vesicular skin eruption (Fig. 9-3). The virus then becomes latent, and its reactivation in ganglion cells later in life causes herpes zoster (“shingles”). The virus travels down the sensory nerve for a single dermatome. It then infects the corresponding epidermis, producing a localized, painful vesicular eruption. VZV is restricted to human hosts and spreads from person to person primarily by the respiratory route. It can also be spread by contact with secretions from skin lesions. The virus is present worldwide and is highly contagious. Most children in the United States are infected by early school age, but an effective vaccine has reduced this incidence. An adult VZV vaccine has recently proved effective in reducing the incidence of herpes zoster.

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OPPORTUNISTIC INFECTIONS CNS Cryptococcal meningitis Toxoplasmosis Papovavirus (Progressive multifocal leukoencephalopathy) MUCOCUTANEOUS Herpes simplex Candidiasis

AIDS dementia LYMPHOPROLIFERATIVE DISEASE CNS lymphoma Persistent generalized lymphadenopathy B cell lymphoma

PNEUMONIA Pneumcystis carinii Mycobaterium avium intracellulare Cytomegalovirus SKIN Staphylococcus Scabies HPV Molluscum contagiosum DIARRHEA Protozoa: Cryptosporidium Isospora belli Giardia lamblia Bacteria: Mycobacterium avium intracellulare Viruses: Cytomegalovirus FIGURE 9-2.

AIDS nephropathy

Kaposi sarcoma

Human immunodeficiency virus-1 (HIV-1)–mediated destruction of the cellular immune system results in acquired immunodeficiency syndrome (AIDS). The infectious and neoplastic complications of AIDS can affect practically every organ system. CNS, central nervous system; HPV, human papilloma virus.

PATHOGENESIS AND PATHOLOGY: VZV initially infects cells of the respiratory tract or conjunctival epithelium. There it reproduces and spreads through the blood and lymphatic systems. Many organs are infected during this viremic stage, but skin involvement usually dominates the clinical picture. Skin lesions begin as maculopapules that rapidly evolve into vesicles and then pustules that soon ulcerate and crust. The virus spreads from the capillary endothelium to the epidermis, where its replication destroys the basal cells. As a result, the upper layers of the epidermis separate from the basal layer to form vesicles that fill with neutrophils and soon erode to become shallow ulcers. In infected cells, VZV produces a characteristic cytopathic effect, consisting of nuclear homogenization and intranuclear inclusions (Cowdry type A). The inclusion is large and eosinophilic and is separated from the nuclear membrane by a clear zone (halo). Multinucleated cells are common (Fig. 9-4). During primary infection, VZV establishes latent infection in perineuronal satellite cells of the dorsal nerve root ganglia. Transcription of viral genes continues during latency, and viral DNA can be demonstrated years after the initial infection. The skin lesions of chickenpox and shingles are identical and are also similar to the lesions of herpes simplex virus (HSV) (see below).

Herpesvirus (HSV) Produces Necrotizing Infections at Diverse Body Sites HSVs are common human viral pathogens, which most frequently produce recurrent painful vesicular eruptions of the skin and mucous

membranes (Table 9-2). HSV spreads from person to person, primarily through direct contact with infected secretions or open lesions. Two antigenically and epidemiologically distinct HSVs cause human disease (Fig. 9-5). Clusters of painful, ulcerating, vesicular lesions on the skin or mucous membranes are the most frequent manifestation of HSV infection. These lesions persist for 1 to 2 weeks and then resolve. • HSV-1 is transmitted in oral secretions and typically causes disease “above the waist,” including oral, facial, and ocular lesions. • HSV-2 is transmitted in genital secretions and typically produces disease “below the waist,” including genital ulcers and neonatal herpes infection acquired by passage through the infected birth canal. PATHOGENESIS AND PATHOLOGY: Primary HSV disease occurs at a site of initial viral inoculation, such as the oropharynx, genital mucosa, or skin. The virus infects epithelial cells, producing progeny viruses and destroying basal cells in the squamous epithelium, with resulting formation of vesicles. Cell necrosis also elicits an inflammatory response, initially dominated by neutrophils and then followed by lymphocytes. The cellular alterations are similar to those produced by VZV (see Fig. 9-4). Primary infection resolves with the development of humoral- and cell-mediated immunity to the virus. Latent infection is established in a manner analogous to that of VZV. Upon reactivation, HSV travels back down the nerve to the epithelial site served by the ganglion, where it again infects epithelial cells. Sometimes, this

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Varicella. Photomicrograph of the skin from a patient with chickenpox shows an intraepidermal vesicle. Multinucleated giant cells (straight arrows) and nuclear inclusions (curved arrow) are present. FIGURE 9-4.

Neonatal herpes is a serious complication of maternal genital herpes. The virus is transmitted to the fetus from the infected birth canal, often the uterine cervix, and readily disseminates in the unprotected newborn child. The disease begins 5 to 7 days after delivery, with irritability, lethargy, and a mucocutaneous vesicular eruption. The infection rapidly spreads to involve multiple organs, including the brain. The infected newborn develops jaundice, bleeding problems, respiratory distress, seizures, and coma. Treatment of severe HSV infections with acyclovir is often effective, but neonatal herpes still carries a high mortality rate.

Epstein-Barr Virus (EBV) is the Cause of Infectious Mononucleosis

Varicella (chickenpox) and herpes zoster (shingles). Varicella-zoster virus (VZV) in droplets is inhaled by a nonimmune person (usually a child) and initially causes a “silent” infection of the nasopharynx. This progresses to viremia, seeding of fixed macrophages and dissemination of VZV to skin (chickenpox) and viscera. VZV resides in a dorsal spinal ganglion, where it remains dormant for many years. Latent VZV is reactivated and spreads from ganglia along the sensory nerves to the peripheral nerves of sensory dermatomes, causing shingles. FIGURE 9-3.

Infectious mononucleosis is a viral disease characterized by fever, pharyngitis, lymphadenopathy, and increased circulating lymphocytes. By adulthood, most persons have been infected with EBV. Infection in early childhood is usually asymptomatic, but two thirds of individuals with primary infections occurring in adolescence or early adulthood develop infectious mononucleosis. EBV has also been associated with several cancers, including African Burkitt lymphoma, B-cell lymphoma in immunosuppressed persons, and nasopharyngeal carcinoma. These neoplastic complications are discussed in Chapters 5, 20, and 25. EBV spreads from person to person primarily through contact with infected oral secretions. Once it enters the body, EBV remains for life, analogous to latent infections with other herpesviruses. A few people (10% to 20%) intermittently shed the virus. Transmission requires close contact with infected persons. Thus, EBV spreads readily among young children in crowded conditions, where there is considerable “sharing” of oral secretions.

TABLE 9–2

secondary infection produces ulcerating vesicular lesions. At other times, the secondary infection does not cause visible tissue destruction, but contagious progeny viruses are shed from the site of infection. Both HSV-1 and HSV-2 can cause severe protracted and disseminated disease in immunocompromised persons. Herpes encephalitis is a rare (1 in 100,000 HSV infections), but devastating manifestation of HSV-1 infection. In some instances, it occurs when a virus that is latent in the trigeminal ganglion is reactivated and travels retrograde to the brain. However, herpes encephalitis also occurs in people who have no history of “cold sores” (see Chapter 28). Equally rare is herpes hepatitis, which may occur in immunocompromised patients but has also been reported in young, previously healthy, pregnant women.

Herpes Simplex Viral Diseases

Viral Type

Common Presentations

HSV-1

Oral-labial herpes

HSV-2

Genital herpes

Infrequent Presentations Conjunctivitis, keratitis Encephalitis Herpetic whitlow Esophagitis* Pneumonia* Disseminated infection* Perinatal infection Disseminated infection*

These conditions usually occur in immunocompromised hosts.

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mised persons are particularly vulnerable to the destructive effects of the virus. CMV (a member of the TORCH complex) crosses the placenta, infects 0.5% to 2.0% of all fetuses, and injures 10% to 20% of those infected, making it the most common congenital pathogen. The brain, inner ears, eyes, liver, and bone marrow are the most common fetal organ systems affected (see Chapter 6). PATHOGENESIS AND PATHOLOGY: CMV infects various human cells, including epithelial cells, lymphocytes, and monocytes, and establishes latency in white blood cells. The normal immune response rapidly controls CMV infection; infected persons rarely show ill effects, although they shed the virus periodically in body secretions. Like other herpes viruses, CMV may remain latent for life. Microscopically, the lesions of fetal CMV disease show cellular necrosis and a characteristic cytopathic effect, consisting of marked cellular and nuclear enlargement, with nuclear and cytoplasmic inclusions. The giant nucleus, which is usually solitary, contains a large central inclusion surrounded by a clear zone (Fig. 9-6). The cytoplasmic inclusions are less prominent. CLINICAL FEATURES: When an infected pregnant woman passes CMV to her fetus, the fetus is not protected by maternally derived antibodies, and the virus invades fetal cells with little initial immunologic response, causing widespread necrosis and inflammation. CMV disease in immunosuppressed patients has diverse clinical manifestations. It can manifest as decreased visual acuity (chorioretinitis), diarrhea or gastrointestinal hemorrhage (colonic ulcerations), change in mental status (encephalitis), shortness of breath (pneumonitis), or a wide range of other symptoms.

Human Papillomavirus (HPV) Herpesvirus infections. HSV-1 infects a nonimmune adult, causing gingivostomatitis (“fever blister” or “cold sore”), keratoconjunctivitis, meningoencephalitis, and aseptic spinal meningitis. HSV-2 infects the genitalia of a nonimmune adult, involving the cervix, vagina, and vulva. HSV-2 infects the fetus as it passes through the birth canal of an infected mother. The infant’s lack of a mature immune system results in disseminated infection with HSV-1. The infection is often fatal, involving the lung, liver, adrenal glands, and central nervous system. FIGURE 9-5.

PATHOGENESIS AND PATHOLOGY: The virus first binds to and infects nasopharyngeal cells and then B lymphocytes, which carry the virus throughout the body, producing a generalized infection of lymphoid tissues and spleen. The resultant asymmetric lymphadenopathy is most striking in the neck. Microscopically, the general nodal architecture is preserved. The germinal centers are enlarged and have indistinct margins because of a proliferation of immunoblasts. The nodes contain occasional large hyperchromatic cells with polylobular nuclei that resemble Reed-Sternberg cells. In fact, the appearance of the lymph nodes histology may be difficult to distinguish from that of Hodgkin disease or other lymphomas (see Chapter 20). The liver is almost always involved, and the sinusoids and portal tracts contain atypical lymphocytes.

HPVs cause proliferative lesions of squamous epithelium, including common warts, flat warts, plantar warts, anogenital warts (condyloma acuminatum), and laryngeal papillomatosis. Some HPV serotypes cause squamous cell dysplasia and squamous cell carcinomas of the female genital tract (see Chapter 18). HPVs are nonenveloped, double-stranded DNA viruses. More than 100 types of HPV are known, and different types are associated with different lesions. Thus, HPV types 1, 2, and 4 produce common warts and plantar warts. Types 6, 10, 11, and 40 through 45 cause anogenital warts. Types 16, 18, and 31 are associated with

A distinguishing feature of infectious mononucleosis is a lymphocytosis with atypical lymphocytes. The atypical cells (characterized by lobulated, eccentric nuclei and vacuolated cytoplasm) are activated T cells, which are involved in the suppression and killing of polyclonally stimulated EBV-infected B lymphocytes.

Cytomegalovirus (CMV) Infects Many Persons but Rarely Produces Disease CMV is a congenital and opportunistic pathogen that usually produces an asymptomatic infection. However, the fetus and immunocompro-

Cytomegalovirus pneumonitis. Type II pneumocytes display enlarged nuclei containing solitary inclusions surrounded by a clear zone. FIGURE 9-6.

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squamous carcinoma of the female genital tract. HPV infection is widespread and is transmitted from person to person by direct contact. The viruses that cause genital lesions are transmitted sexually. PATHOGENESIS AND PATHOLOGY: HPV infection begins with viral inoculation into a stratified squamous epithelium where the virus enters the nuclei of basal cells. Some infected cells display a characteristic cytopathic effect, termed koilocytosis, which features large squamous cells with shrunken nuclei enveloped in large cytoplasmic vacuoles (koilocytes). Infection stimulates replication of the squamous epithelium, producing the various HPV-associated proliferative lesions. The rapidly growing squamous epithelium replicates innumerable progeny viruses, which are shed in the degenerating superficial cells. Many HPV lesions resolve spontaneously, although depressed cell-mediated immunity is associated with the persistence and spread of HPV lesions. The mechanism by which HPV infections participate in malignant change is discussed in Chapter 5. Common warts (verruca vulgaris) are firm, circumscribed, raised, rough-surfaced lesions, which usually appear on surfaces subject to trauma, especially the hands. Plantar warts are similar squamous proliferative lesions on the soles of the feet but are compressed inward by standing and walking. Anogenital warts (condyloma acuminatum) are soft, raised, fleshy lesions found on the penis, vulva, vaginal wall, cervix, or perianal region. When caused by certain HPV types, flat warts can develop into malignant squamous cell proliferations. The relationship between HPV, cervical intraepithelial neoplasia, and invasive squamous carcinoma of the cervix is discussed in Chapter 18.

PRIONS: A NEW DISEASE PARADIGM In the last several decades, it has become clear that infection can be transmitted and propagated solely by proteins without the participation of nucleic acids. These protein aggregates, termed prions, are only known to cause CNS disease, the prototype being Kuru, a now-extinct disease of the Fore people of New Guinea transmitted by cannibalism. Prions are essentially misfolded proteins that aggregate in the CNS and cause progressive neurodegeneration that leads to death. The prion protein (PrP) exists in a normal isoform and in a pathogenic form that can transmit the disease. These pathogenic isoforms aggregate into prion rods, which are a diagnostic characteristic of these rare disorders. Of particular importance is the uncommon persistence of these infectious agents, which are highly resistant to the normal methods of sterilization and which may be transmitted via surgical instruments or electrodes that are implanted in nervous tissue (unless special sterilization protocols are followed). Two of the better known prion diseases are: • Sporadic, Familial, and Iatrogenic Creutzfeldt-Jakob Disease (sCJD, fCJD, and iCJD): CJD is a rapidly progressive neurodegenerative disorder characterized by myoclonus, behavior changes, and dementia (see Chapter 28). With a frequency of 1/1,000,000, sCJD is probably the most common human prion disease. Rarely, iCJD has resulted from transmission through transplanting such tissues as cornea and dura mater. fCJD is associated with a variety of mutations in the PRNP gene coding for the prion protein. • New Variant Creutzfeldt-Jakob Disease (vCJD): One of the more infamous emerging infectious diseases of the last few decades, both vCJD and the associated bovine spongiform encephalopathy, also known as “mad cow” disease, underscore the interrelatedness of animal and human infectious agents. The use of certain animal products in feeds for domestic ungulates led to a prion disease epidemic, initially in cattle herds in the United Kingdom and subsequently found in many other countries. Nearly 150 persons have been infected with this relentless termi-

nal disease, presumably contracted by eating the meat of infected animals. To date, all patients have been homozygous for methionine at codon 129 of the PRNP gene that encodes the prion protein, a condition found in about 40% of Europeans. The same homozygous residue is also found in most (but not all) cases of sCJD. Although the mean onset of sCJD has been 65 years of age, vCJD has mainly occurred in young adults, with a mean age of 26 years. Psychiatric signs and symptoms have also been predominant in vCJD. Pathologic changes in vCJD are strikingly similar to those seen in bovine spongiform encephalopathy, although they differ somewhat from changes seen in the sporadic form.

BACTERIAL INFECTIONS Bacteria, at 0.1 to 10 μm, are the smallest living cells. They are classified according to the structural features of their envelope. The simplest envelope found in mycoplasmas is only a phospholipid–protein bilayer membrane. Most bacteria, however, have a rigid cell wall that surrounds the cell membrane. Two types of bacterial cell walls are identified by their Gram-stain properties. Gram-positive bacteria stain dark blue and have cell walls containing teichoic acids and a thick peptidoglycan layer. Gram-negative bacteria stain red and have an outer membrane containing a lipopolysaccharide component known as endotoxin, a potent mediator of shock (see Chapter 7). Both classes of bacteria may be surrounded by an additional layer of polysaccharide or protein gel (a capsule), which contributes to the virulence of the organism; hence, bacteria may also be classified as encapsulated or unencapsulated. The cell wall confers rigidity to bacteria and allows them to be distinguished on the basis of shape and pattern of growth in cultures. Round or oval bacteria are cocci. Those that grow in clusters are called staphylococci, whereas those that grow in chains are called streptococci. Elongate bacteria are rods or bacilli, and curved ones are vibrios. Some spiral-shaped bacteria are called spirochetes.

Pyogenic Gram-Positive Cocci Staphylococcus aureus Produces Suppurative Infections S. aureus is a gram-positive coccus that typically grows in clusters and is one of the most common bacterial pathogens. It normally resides on the skin, is spread by direct contact, and is readily inoculated into deeper tissues. It is the most common cause of suppurative infections of the skin, joints, and bones, and is a leading cause of infective endocarditis. S. aureus is commonly distinguished from other, less virulent staphylococci by the coagulase test. S. aureus is coagulase-positive; the other staphylococci are coagulase-negative. PATHOGENESIS: Many S. aureus infections begin as localized infections of the skin and skin appendages, producing cellulitis and abscesses filled with pus and bacteria. The organism, equipped with destructive enzymes and toxins, sometimes invades beyond the initial site, spreading by the blood or lymphatics to almost any location in the body. The bones, joints, and heart valves are the most common sites of metastatic S. aureus infections. The organism also causes several distinct diseases by elaborating toxins that are carried to distant sites. CLINICAL FEATURES: The clinical manifestations of S. aureus disease vary according to the sites and types of infection. • Furuncles (boils) and carbuncles: Deep-seated S. aureus infections occur in and around hair follicles, often in a nasal carrier.

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•

• • •

•

The boil begins as a nodule at the base of a hair follicle, followed by a pimple that remains painful and red for a few days. A yellow apex forms, and the central core becomes pus-filled, soft, and necrotic. Rupture or incision of the boil relieves the pain. Carbuncles result from coalescent furuncles and produce draining sinuses. Scalded skin syndrome: This disease affects infants and children under 3 years of age, who present with a sunburn-like rash that begins on the face and spreads over the body. Bullae begin to form, and even gentle rubbing causes the skin to desquamate. The disease begins to resolve in 1 to 2 weeks, as the skin regenerates. Desquamation is due to systemic effects of a specific exotoxin, often from an unknown site of infection. Osteomyelitis: Acute staphylococcal osteomyelitis, usually in the bones of the legs, most commonly afflicts boys between 3 and 10 years old, most of whom have a history of infection or trauma. Osteomyelitis may become chronic if not properly treated. Adults older than 50 are more frequently afflicted with vertebral osteomyelitis, which may follow staphylococcal infections of the skin or urinary tract, prostatic surgery, or pinning of a fracture. Respiratory tract infections: Staphylococcal respiratory tract infections are most common in infants under 2 years of age and especially under 2 months. The infection is characterized by ulcers of the upper airway, scattered foci of pneumonia, pleural effusions, empyema, and pneumothorax. In adults, staphylococcal pneumonia may follow viral influenza, which destroys the ciliated surface epithelium and leaves the bronchial surface vulnerable to secondary infection. Bacterial arthritis: S. aureus is the causative organism in half of all cases of septic arthritis, mostly in patients 50 to 70 years old. Rheumatoid arthritis and corticosteroid therapy are common predisposing conditions. Septicemia: Septicemia with S. aureus afflicts patients with lowered resistance who are in the hospital for other diseases. Miliary abscesses and endocarditis are serious complications. Bacterial endocarditis: Bacterial endocarditis is a common serious complication of S. aureus septicemia (see Chapter 11). Toxic shock syndrome: This disorder most commonly afflicts menstruating women who present with high fever, nausea, vomiting, diarrhea, and myalgias. Subsequently, they develop shock and within several days, a sunburn-like rash. The disease is associated with use of tampons, which provide a site for replication and toxin elaboration by S. aureus but can occur in nontampon users. Toxic shock syndrome occurs rarely in children and men and when it does, it is usually associated with an occult S. aureus infection. Staphylococcal food poisoning: Staphylococcal food poisoning typically begins less than 6 hours after a meal. Nausea and vomiting begin abruptly and usually resolve within 12 hours. This disease is caused by preformed toxin, rather than by secretion of toxin by ingested bacteria.

Antibiotic-Resistant S. aureus Presents an Increasing Clinical Challenge One of the most important clinical issues concerning S. aureus is the relentless increase in antibiotic resistance that has occurred over the last 6 decades. Today, methicillin-resistant S. aureus (MRSA) infections represent one of the most dreaded of nosocomial infections. According to the CDC, between 1995 and 2004, the percentage of MRSA infections in patients in intensive care units almost doubled, from slightly over one-third to almost two-thirds. The recent increase in community-acquired MRSA raises concerns of dissemination of antibiotic resistance among Staphylococcus and other bacteria.

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of diverse organ systems, from acute self-limited pharyngitis to major illnesses such as rheumatic fever (Fig. 9-7). S. pyogenes is a gram-positive coccus that is frequently part of the endogenous flora of the skin and oropharynx. Diseases caused by S. pyogenes fall into two categories, namely suppurative and nonsuppurative. Suppurative diseases occur at sites where the bacteria invade and cause tissue necrosis, usually inducing an acute inflammatory response. Suppurative S. pyogenes infections include pharyngitis, impetigo, cellulitis, myositis, pneumonia, and puerperal sepsis. By contrast, nonsuppurative diseases occur at locations remote from the site of bacterial invasion. S. pyogenes causes two major nonsuppurative complications: rheumatic fever and acute poststreptococcal glomerulonephritis. Rheumatic fever is discussed in Chapter 11 and poststreptococcal glomerulonephritis in Chapter 16.

Streptococcal Pharyngitis (“Strep Throat”) S. pyogenes is the common bacterial cause of pharyngitis with associated fever, malaise, headache, and elevated leukocyte count. It spreads from person to person by direct contact with oral or respiratory secretions. “Strep throat” occurs worldwide, predominantly affecting children and adolescents. Streptococcal pharyngitis may lead to rheumatic fever or acute poststreptococcal glomerulonephritis if not promptly treated with penicillin. PATHOGENESIS: S. pyogenes attaches to epithelial cells by binding to fibronectin on their surface. The bacterium produces hemolysins, DNAase, hyaluronidase, and streptokinase, which allow it to damage and invade human tissues. A bacterial cell wall component, designated M protein, is associated with virulence and prevents complement deposition, thereby protecting bacteria from phagocytosis. The invading organism elicits an acute inflammatory response, often producing an exudate of neutrophils in the tonsillar fossae.

Scarlet Fever Scarlet fever describes a punctate red rash on skin and mucous membranes seen in some cases of Streptococcal pharyngitis and occasionally other S. pyogenes infections. The rash is associated with production of a bacterial erythrogenic toxin.

Erysipelas Erysipelas is an erythematous swelling of the skin caused chiefly by S. pyogenes. The rash usually begins on the face and spreads rapidly. A diffuse, edematous, acute inflammatory reaction in the epidermis and dermis extends into subcutaneous tissues. The inflammatory infiltrate is principally composed of neutrophils and is most intense around vessels and adnexa of the skin. Cutaneous microabscesses and small foci of necrosis are common.

Impetigo Impetigo (pyoderma) is a localized, intraepidermal infection of the skin that is caused by S. pyogenes or S. aureus and most commonly seen in children. The strains of S. pyogenes that cause impetigo are antigenically and epidemiologically distinct from those that cause pharyngitis. Minor trauma or an insect bite inoculates the bacteria into the skin, where they form an intraepidermal pustule, which ruptures and leaks a purulent exudate.

Streptococcal Cellulitis

Streptococcus pyogenes Causes Suppurative, Toxin-Related, and Immunologic Reactions S. pyogenes, also known as group A streptococcus, is one of the most common human bacterial pathogens, causing many diseases

S. pyogenes causes an acute spreading infection of the loose connective tissue of the deeper layers of the dermis. This suppurative infection results from traumatic inoculation of microorganisms into the skin and frequently occurs on the extremities in the context of impaired lymphatic drainage.

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FIGURE 9-7.

Streptococcal diseases.

Streptococcus pneumoniae Infection is a Major Cause of Lobar Pneumonia Streptococcus pneumoniae is an aerobic, gram-positive diplococcus, often simply called pneumococcus, which causes pyogenic infections, primarily involving the lungs (pneumonia), middle ear (otitis media), sinuses (sinusitis), and meninges (meningitis). It is one of the most common bacterial pathogens of humans, and by age 5, most children in the world have suffered from at least one episode of pneumococcal disease (usually otitis media). S. pneumoniae is a commensal organism in the oropharynx, and virtually all persons are colonized at some time. PATHOGENESIS: Pneumococcal pneumonia commonly arises in the wake of viral, smoking, or alcoholrelated injury to the mucociliary blanket and cough response that allows S. pneumoniae access to the lower airway. Once in the alveoli, the organisms proliferate and elicit

an acute inflammatory response. Unlike pneumonia caused by Staphylococcus aureus, which can cause permanent lung damage, pneumonia caused by S. pneumoniae often resolves completely. Invasive disease generally occurs in the setting of an illness that compromises the host’s ability to opsonize the bacteria. Splenectomized patients have a high risk of fulminant disease and septic shock. The pathogenesis and clinical features of pneumococcal infections are discussed further in Chapter 12.

Bacterial Infections of Childhood Diphtheria is a Necrotizing Upper Respiratory Tract Infection Infection with Corynebacterium diphtheriae, an aerobic, pleomorphic, gram-positive rod may lead to cardiac and neurologic disturbances via toxin production. Humans are the only known reservoir

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for C. diphtheria, which spreads from person to person in respiratory droplets or oral secretions. Immunization has largely eliminated the disease in developed countries, but it persists in areas lacking aggressive vaccination programs. PATHOGENESIS AND PATHOLOGY: C. diphtheriae enters the pharynx and proliferates, often on the tonsils, producing a characteristic pseudomembrane. This lesion is composed of sloughed epithelium, necrotic debris, neutrophils, fibrin, and bacteria that line affected respiratory passages. The inflammatory process in the mucosal epithelium below the membrane often produces swelling in the surrounding soft tissues, which can be severe enough to cause respiratory compromise. Diphtheria toxin produced by some bacterial strains is absorbed systemically and acts on tissues throughout the body; the heart, nerves, and kidneys are most susceptible to damage. When the heart is affected, the myocardium displays fat droplets in the myocytes and focal necrosis. In the case of neural involvement, the affected peripheral nerves exhibit demyelination.

Pertussis is Characterized by Debilitating Paroxysmal Coughing Pertussis infection, commonly called whooping cough, is a prolonged upper respiratory tract illness, which lasts 4 to 5 weeks. It is characterized by paroxysmal coughing, followed by a long, highpitched inspiration, the “whoop,” which gives the disease its common name. The causative organism is Bordetella pertussis, a small, gram-negative coccobacillus, which is highly contagious and spreads from person to person, primarily by infected respiratory aerosols. Pertussis is primarily a disease of children younger than the age of 5 years, although the incidence is increasing among adults. PATHOGENESIS: B. pertussis initiates infection by attaching to the cilia of respiratory epithelial cells. The organism then elaborates a cytotoxin that results in necrosis of the ciliated respiratory epithelium and an acute inflammatory response, thereby producing an extensive tracheobronchitis. Vaccination protects against B. pertussis, but worldwide, there are approximately 50 million cases of pertussis each year, resulting in almost 1 million deaths, particularly in infants, who often die from secondary pneumonia.

Haemophilus influenzae Causes Pyogenic Infections in Young Children Haemophilus influenzae infections involve the middle ear, sinuses, facial skin, epiglottis, meninges, lungs, and joints and are the most common cause of meningitis in children younger than 2 years of age. The organism is a major pediatric bacterial pathogen with the incidence of serious disease peaking at 6 to 18 months of age. The bacteria is an aerobic, pleomorphic, gram-negative coccobacillus, which spreads from person to person in respiratory droplets and secretions. Nonencapsulated strains (type a) usually produce localized infections; encapsulated strains, designated type b, are more virulent and cause more than 95% of the invasive bacteremic infections. Inoculating infants with a specific vaccine has greatly reduced H. influenzae type b disease, particularly meningitis, in children. PATHOGENESIS: H. influenzae type b is capable of invading tissue and eliciting a strong acute inflammatory response. The capsular polysaccharide of type b organisms allows them to evade phagocytosis, and bacteremic infections are common. Epiglottitis, facial cellulitis, septic arthritis, and meningitis result from invasive bacteremic infections. H. influenzae type b also elaborates an IgA protease, which facilitates local survival of the organism in the respiratory tract.

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CLINICAL FEATURES • H. influenzae meningitis is characterized by predominantly acute, inflammatory, leptomeningeal infiltrates, sometimes involving the subarachnoid space. • H. influenzae pneumonia usually complicates chronic lung disease. In half of patients, it follows a viral infection of the respiratory tract. The alveoli are filled with neutrophils, macrophages containing bacilli, and fibrin. The bronchiolar epithelium is necrotic and infiltrated by macrophages. • H. influenzae epiglottitis is characterized by swelling and acute inflammation of the epiglottis, aryepiglottic folds, and pyriform sinuses. It may sometimes completely obstruct the upper airway.

Neisseria meningitidis Causes Pyogenic Meningitis and Overwhelming Shock Neisseria meningitidis, commonly termed meningococcus, produces disseminated blood-borne infections, often accompanied by shock and profound disturbances in coagulation. The organism is aerobic, appears as paired, bean-shaped, gram-negative cocci and is spread from person to person, primarily by respiratory droplets. Meningococcal diseases appear as sporadic cases, clusters of cases, and epidemics (the last seen most frequently in crowded quarters). Most infections in industrialized countries are sporadic and afflict children under the age of 5. PATHOGENESIS AND PATHOLOGY: On colonizing the upper respiratory tract, N. meningitidis attaches to nonciliated respiratory epithelium by means of its pili. If the organism spreads to the bloodstream before the development of protective immunity, it can proliferate rapidly in unprotected human tissue, resulting in fulminant meningococcal disease. Meningococcal disease can be confined to the CNS, with the leptomeninges and subarachnoid space infiltrated with neutrophils and the underlying brain parenchyma swollen and congested. The organism may also be disseminated throughout the body (septicemia), resulting in diffuse damage to the endothelium of small blood vessels, with widespread petechiae and purpura in the skin and viscera. Many of the systemic effects of meningococcal disease are due to the endotoxin of the outer membrane lipopolysaccharide, which promotes an increase in production of TNF by macrophages and the simultaneous activation of the complement and coagulation cascades. Disseminated intravascular coagulation, fibrinolysis, and shock follow abruptly. Vasculitis and thrombosis rarely (3% to 4% of all cases) produce hemorrhagic necrosis of both adrenals, called the Waterhouse-Friderichsen syndrome. Meningococcal disease was once almost invariably fatal, but antibiotic treatment has reduced the mortality rate to less than 15%.

Sexually Transmitted Bacterial Diseases Gonorrhea Remains a Common Infection that Causes Sterility Neisseria gonorrhoeae, also termed gonococcus, causes gonorrhea, an acute suppurative genital tract infection, which is reflected in urethritis in men and endocervicitis in women. It may ascend the female genital tract to produce endometritis, salpingitis, and pelvic inflammatory disease. N. gonorrhoeae is an aerobic, bean-shaped, gram-negative diplococcus. Neonatal infections derived from the birth canal of a mother with gonorrhea usually manifest as conjunctivitis, although disseminated infections are occasionally seen. Except for perinatal transmission, spread is almost always by sexual intercourse.

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PATHOGENESIS AND PATHOLOGY: Gonorrhea is a suppurative infection, which begins in the mucous membranes of the urogenital tract (Fig. 9-8). Bacteria attach to surface cells using hair-like extensions, termed “pili,” which project from the gonococcal cell wall. The pili contain a protease that digests IgA on the mucous membrane, thereby facilitating the attachment of the bacterium to the columnar and transitional epithelium of the urogenital tract. After attachment, the bacteria invade superficially, provoking acute inflammation and the formation of copious pus and often-submucosal abscesses. Men present with purulent urethral discharge and dysuria, which, if left untreated, may lead to stricture and extension of the infection in the genitourinary tract. In about one half of infected women, gonorrhea remains asymptomatic. Symptomatic women initially exhibit endocervicitis, with a vaginal discharge or bleeding and dysuria. Infection often extends to produce acute and chronic salpingitis and eventually pelvic inflammatory disease. The fallopian tubes swell with pus, causing acute abdominal pain. Infertility occurs when inflammatory adhesions block the tubes.

times covered by an inflammatory pseudomembrane. Patients exhibit abdominal pain, fever, tenesmus, and bloody diarrhea.

E. coli Urinary Tract Infection Urinary tract infections with E. coli are most common in sexually active women and in persons of both sexes who have structural or functional abnormalities of the urinary tract. Such infections are extremely common, afflicting more than 10% of the human population, often repeatedly. PATHOGENESIS: E. coli gains access to the sterile proximal urinary tract by ascending from the distal urethra. Because the shorter female urethra provides a less effective mechanical barrier to infection, women are much more prone to urinary tract infections. Uropathogenic E. coli have specialized adherence factors on the pili, which enable them to bind the uroepithelium. Urinary tract infections initially produce an acute inflammatory infiltrate at the site of infection, usually the bladder mucosa, which may ascend to the kidney to produce pyelonephritis (see Chapter 16).

Syphilis (lues) Syphilis (lues) is a chronic, sexually transmitted, systemic infection caused by Treponema pallidum. The disease is discussed below under Diseases Caused by Spirochetes.

Enteropathogenic Bacterial Infections Escherichia coli is a Common Cause of Diarrhea and Urinary Tract Infections E. coli is among the most common and important human bacterial pathogens, causing more than 90% of all urinary tract infections and many cases of diarrheal illness worldwide. It is also a major opportunistic pathogen and frequently causes pneumonia and sepsis in immunocompromised hosts and meningitis and sepsis in newborns. E. coli comprises a group of diverse, aerobic (facultatively anaerobic), gram-negative bacteria. Most strains are intestinal commensals, well adapted to grow in the human colon without harming the host. However, E. coli can be aggressive when it gains access to usually sterile body sites, such as the urinary tract, meninges, or peritoneum. Strains of E. coli that produce diarrhea possess specialized virulence properties, usually plasmid-borne, which confer the capacity to cause intestinal disease.

E. coli Diarrhea Of the four distinct strains of E. coli that cause diarrhea, two are associated with serious illness in developed countries. • ENTEROHEMORRHAGIC E. coli: Enterohemorrhagic E. coli (serotype 0157:H7) causes a bloody diarrhea, which occasionally is followed by the hemolytic–uremic syndrome (see Chapter 16). The source of infection is usually the ingestion of contaminated meat, milk, vegetables or other food products contaminated with bovine feces, a common source for the serotype. Enterohemorrhagic E. coli adheres to the colonic mucosa and elaborates an enterotoxin, virtually identical to Shigatoxin (see below), which destroys the epithelial cells. Patients infected with E. coli 0157:H7 present with cramping abdominal pain, low-grade fever, and sometimes bloody diarrhea. Occasional fatalities occur in the very young and elderly, often associated with hemolytic–uremic syndrome. • ENTEROINVASIVE E. coli causes food-borne dysentery that is clinically and pathologically indistinguishable from that caused by Shigella. It invades and destroys mucosal cells of the distal ileum and colon. As in shigellosis, the mucosa of the distal ileum and colon are acutely inflamed and focally eroded and are some-

E. coli Sepsis (Gram-Negative Sepsis) E. coli is the most common cause of enteric gram-negative sepsis, but other gram-negative rods, including Pseudomonas, Klebsiella, and Enterobacter species, produce identical disease. This discussion relates to gram-negative sepsis in general. PATHOGENESIS: E. coli sepsis is usually an opportunistic infection, occurring in persons with predisposing conditions, such as neutropenia, pyelonephritis, or cirrhosis, and in hospitalized patients. The microbe occasionally seeds the bloodstream. Patients with neutropenia or cirrhosis develop E. coli sepsis because of an impaired capacity to eliminate even low-level bacteremias. Persons with ruptured abdominal organs or acute pyelonephritis suffer gram-negative sepsis because the large numbers of organisms that gain access to the circulation overwhelm the normal defenses. The presence of E. coli in the bloodstream causes septic shock through the effects of TNF, whose release from macrophages is stimulated by bacterial endotoxin. Septic shock is discussed in Chapters 7 and 20.

Salmonella Enterocolitis and Typhoid Fever are Both Intestinal Infections The bacterial genus Salmonella comprises more than 1,500 antigenically distinct but biochemically and genetically related gramnegative rods, which cause two important human diseases: Salmonella enterocolitis and typhoid fever. SALMONELLA ENTEROCOLITIS: Salmonella enterocolitis is an acute, self-limited (1 to 3 days), gastrointestinal illness that manifests as nausea, vomiting, diarrhea, and fever. Infection is typically acquired by eating food contaminated with nontyphoidal Salmonella strains and is commonly called Salmonella food poisoning. The organisms proliferate in the small intestine and invade enterocytes in the distal small bowel and colon. The nontyphoidal Salmonella species elaborate several toxins that contribute to the dysfunction of intestinal cells. The mucosa of the ileum and colon is acutely inflamed and sometimes superficially ulcerated. TYPHOID FEVER: Typhoid fever is an acute systemic illness caused by infection with Salmonella typhi. The disease is acquired from infected patients or chronic carriers and is spread primarily by ingestion of contaminated water and food. S. typhi attaches to and invades the ileum in areas overlying Peyer patches, which become hypertrophic. In some cases, concomitant capillary thrombosis causes necrosis of overlying mucosa and characteristic ulcers ori-

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Pathogenesis of gonococcal infections. Neisseria gonorrhoeae is a gram-negative diplococcus with surface pili that form a barrier against phagocytosis by neutrophils. The pili contain an IgA protease that digests IgA on the luminal surface of the mucous membranes of the urethra, endocervix, and fallopian tube, thereby facilitating attachment of gonococci. Gonococci cause endocervicitis, vaginitis, and salpingitis. In men, gonococci attached to the mucous membrane of the urethra cause urethritis and, sometimes, urethral stricture. Gonococci may also attach to sperm heads and be carried into the fallopian tube. Penetration of the mucous membrane by gonococci leads to stricture of the fallopian tube, pelvic inflammatory disease (PID), or tuboovarian abscess. IgA, immunoglobulin A; PMN, polymorphonuclear neutrophil. FIGURE 9-8.

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ented along the long axis of the bowel. These ulcers frequently bleed and occasionally perforate, producing infectious peritonitis. The organisms block the respiratory burst of macrophages and multiply within these cells, spreading throughout the body via the lymphatics and bloodstream. IL-1 and TNF production cause the prolonged fever, malaise, and wasting characteristic of typhoid fever. The treatment of typhoid fever entails antibiotics and supportive care. Ten percent to 20% of untreated patients die, usually of secondary complications, such as pneumonia. However, treatment within 3 days of the onset of fever is generally curative.

Shigellosis is an Acute Bacterial Dysentery Shigellosis is characterized by a necrotizing infection of the distal small bowel and colon. It is caused by any of four species of aerobic, gramnegative rods. Of these species, S. dysenteriae is the most virulent. Shigellosis is a self-limited disease that typically presents with abdominal pain and bloody, mucoid stools. The agent proliferates rapidly in the small bowel and attaches to enterocytes, where it replicates within the cytoplasm. Replicating shigellae kill infected cells and then spread to adjacent cells and into the lamina propria, producing a patchy inflammatory pseudomembrane, composed of neutrophils, fibrin, and necrotic epithelium. Shigellae also produce a potent exotoxin, known as Shiga toxin, which causes watery diarrhea, by interfering with fluid absorption in the colon. Regeneration of colonic epithelium occurs rapidly, usually within 10 to 14 days.

Cholera is an Epidemic Enteritis Usually Acquired from Contaminated Water Cholera is a severe diarrheal illness caused by the enterotoxin of Vibrio cholerae, an aerobic, curved gram-negative rod. The organism proliferates in the lumen of the small intestine and causes profuse watery diarrhea, rapid dehydration, and if not treated, shock and death within 24 hours of symptom onset. The disease is acquired by ingesting V. cholerae, primarily from fecally contaminated food or water. Cholera is common in most parts of the world, and major epidemics affecting tens of thousands have occurred in South America and currently in central sub-Saharan Africa. PATHOGENESIS: Bacteria that survive passage through the stomach thrive and multiply in the mucous layer of the small bowel. They do not themselves invade the mucosa but cause diarrhea by elaborating a potent exotoxin, cholera toxin, which activates adenylyl cyclase of the enterocyte. The consequent rise in cyclic adenosine monophosphate (cAMP content results in massive secretion of sodium and water by the enterocyte into the intestinal lumen (Fig. 9-9). V. cholerae causes little visible alteration in the affected intestine, which appears grossly normal or only slightly hyperemic. Untreated cholera has a 50% mortality rate. Replacing lost salts and water is a simple, effective treatment, which can often be accomplished by oral rehydration with preparations of salt, glucose, and water.

Campylobacter jejuni is the Most Common Cause of Bacterial Diarrhea in the Developed World C. jejuni causes an acute, self-limited inflammatory diarrheal illness. The bacterium is a microaerophilic, curved gram-negative rod, morphologically similar to the vibrios. C. jejuni infection is acquired through food or water contaminated by animal waste. Raw milk and inadequately cooked poultry and meat are frequent sources of disease. C. jejuni can also spread from person to person by fecal–oral contact. Ingested C. jejuni multiply in the alkaline environment of the upper small intestine. The organisms produce a superficial enterocolitis of the terminal ileum and colon and secrete several toxic proteins.

Pulmonary Infections with Gram-Negative Bacteria Pulmonary infection with Klebsiella and Legionellosis are discussed in Chapter 12.

Clostridial Diseases Clostridia are gram-positive, spore-forming, obligate anaerobic bacilli. The vegetative bacilli are found in the gastrointestinal tract of herbivorous animals and humans. Anaerobic conditions promote vegetative division, whereas aerobic ones lead to sporulation. Spores pass in animal feces and contaminate soil and plants, where they can survive unfavorable environmental circumstances. Under anaerobic conditions, the spores revert to vegetative cells, thereby completing the cycle. During sporulation, vegetative cells degenerate, and their plasmids produce a variety of specific toxins that cause widely differing diseases, depending on the species (Fig. 9-10).

Clostridial Food Poisoning is Common and Self-Limited C. perfringens is one of the most common causes of bacterial food poisoning in the world, characterized by an acute, generally benign, diarrheal disease, usually lasting less than 24 hours. The bacteria are omnipresent in the environment, contaminating soil, water, air samples, clothing, dust, and meat. Spores survive cooking temperatures and germinate to yield vegetative forms, which proliferate when food is allowed to stand without refrigeration. The vegetative clostridia sporulate and elaborate a variety of exotoxins, which are cytotoxic to enterocytes and cause the loss of intracellular ions and fluid into the gut.

Gas Gangrene May Complicate Penetrating Wounds Gas gangrene (clostridial myonecrosis) is a necrotizing, gas-forming infection that begins in contaminated wounds and spreads rapidly to adjacent tissues. The disease can be fatal within hours of onset. C. perfringens is the most common cause of gas gangrene, but other clostridial species occasionally produce the disease. PATHOGENESIS AND PATHOLOGY: Gas gangrene follows anaerobic deposition of C. perfringens into tissue. Clostridial growth requires extensive devitalized tissue, as in severe penetrating trauma, wartime injuries, and septic abortions. Necrosis of previously healthy muscle is caused by myotoxins, which are phospholipases that destroy the membranes of muscle cells, leukocytes, and erythrocytes. Affected tissues rapidly become mottled and then frankly necrotic. Tissues such as muscle may even liquefy. The overlying skin becomes tense, as edema and gas expand underlying soft tissues. Microscopic examination shows extensive tissue necrosis with dissolution of the cells. A striking feature is the paucity of neutrophils, which are apparently destroyed by the myotoxin. The lesion develops a thick, serosanguineous discharge, which has a fragrant odor and may contain gas bubbles. Hemolytic anemia, hypotension, and renal failure may develop, and in the terminal stages, coma, jaundice, and shock supervene.

Tetanus is a Disease Characterized by Spastic Skeletal Muscle Contractions Caused by C. tetani Neurotoxin Tetanus occurs when C. tetani contaminates wounds and proliferates in tissue, releasing its exotoxin. Immunization programs using inactivated tetanus toxin have largely eliminated the disease

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Cholera. Infection comes from water contaminated with Vibrio cholerae or food prepared with contaminated water. Vibrios traverse the stomach, enter the small intestine, and propagate. Although they do not invade the intestinal mucosa, vibrios elaborate a potent toxin that induces a massive outpouring of water and electrolytes. Severe diarrhea (“ricewater stool”) leads to dehydration and hypovolemic shock. FIGURE 9-9.

from developed countries. Nonetheless, tetanus remains a frequent and lethal disease in developing countries. PATHOGENESIS: Necrotic tissue and suppuration create a fertile anaerobic environment for the spores to revert to vegetative bacteria, which release toxins when they autolyse. The potent neurotoxin (tetanospasmin) undergoes retrograde transport through the ventral roots of peripheral nerves to the anterior horn cells of the spinal cord, where it binds to receptors on inhibitory motor neurons in the ventral horns. The release of inhibitory neurotransmitters is blocked, permitting unopposed neural stimulation and sustained contraction of skeletal muscles (tetany). Spastic rigidity often begins in the muscles of the face, giving rise to “lockjaw,” which extends to several facial muscles, causing a fixed grin (risus sardonicus). Rigidity of the muscles of the back produces a backward arching (opisthotonos). Prolonged spasm of respiratory and laryngeal musculature may lead to death.

Botulism is a Paralyzing Disease due to C. botulinum Neurotoxin C. botulinum spores are widely distributed and are especially resistant to drying and boiling. In the United States, the toxin is most often present in foods that have been improperly home canned and stored without refrigeration. These circumstances provide suitable anaerobic conditions for growth of the vegetative cells that elaborate the neurotoxin. Botulism can also be contracted from home-cured ham, other meats, and nonacidic vegetable products, such as carrot juice that has been left unrefrigerated for several days. PATHOGENESIS: Ingested botulinum neurotoxin is readily absorbed into the blood from the proximal small intestine. When it reaches cholinergic nerve endings at the myoneural junction, it inhibits acetylcholine (ACh) release. Ultimately, untreated botulism can progress to respiratory weakness, respiratory arrest, and death. Treatment with antitoxin reduces the mortality rate to 25%.

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Clostridial diseases. Clostridia in the vegetative form (bacilli) inhabit the gastrointestinal tract of humans and animals. Spores pass in the feces, contaminate soil and plant materials, and are ingested or enter sites of penetrating wounds. Under anaerobic conditions, they revert to vegetative forms. Plasmids in the vegetative forms elaborate toxins that cause several clostridial diseases. Food poisoning and necrotizing enteritis. Meat dishes left to cool at room temperature grow large numbers of clostridia (>106 organisms per gram). When contaminated meat is ingested, Clostridium perfringens types A and C produce α enterotoxin in the small intestine during sporulation, causing abdominal pain and diarrhea. Type C also produces ß enterotoxin. Gas gangrene. Clostridia are widespread and may contaminate a traumatic wound or surgical operation. C. perfringens type A elaborates a myotoxin (α toxin), a lecithinase that destroys cell membranes, alters capillary permeability, and causes severe hemolysis following intravenous injection. The toxin causes necrosis of previously healthy skeletal muscle. Tetanus. Spores of Clostridium tetani are in soil and enter the site of an accidental wound. Necrotic tissue at the wound site causes spores to revert to the vegetative form (bacilli). Autolysis of vegetative forms releases tetanus toxin. The toxin is transported in peripheral nerves and (retrograde) through axons to the anterior horn cells of the spinal cord. The toxin blocks synaptic inhibition, and the accumulation of ACh in damaged synapses leads to rigidity and spasms of the skeletal musculature (tetany). Botulism. Improperly canned food is contaminated by the vegetative form of Clostridium botulinum, which proliferates under aerobic conditions and elaborates a neurotoxin. After the food is ingested, the neurotoxin is absorbed from the small intestine and eventually reaches the myoneural junction, where it inhibits the release of ACh. The result is a symmetric descending paralysis of cranial nerves, trunk and limbs, with eventual respiratory paralysis and death. FIGURE 9-10.

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Clostridium difficile Colitis Follows Antibiotic Treatment C. difficile colitis is an acute necrotizing infection of the terminal small bowel and colon. It is responsible for a large fraction (25% to 50%) of antibiotic-associated diarrheas and is potentially lethal. C. difficile colitis is often called pseudomembranous colitis, although that condition may have many etiologies (see Chapter 13).

Bacterial Infections with Animal Reservoirs or Insect Vectors Brucellosis is a Chronic Febrile Disease Acquired from Domestic Animals Brucellosis is a zoonotic disease caused by one of four Brucella species. Human brucellosis may manifest as an acute systemic disease or as a chronic infection and is characterized by waxing and waning febrile episodes, weight loss, and fatigue. Brucella species are small, aerobic, gram-negative rods that in humans primarily infect monocytes/macrophages. Each species of Brucella has its own animal reservoir: • • • •

Brucella melitensis: sheep and goats Brucella abortus: cattle Brucella suis: swine Brucella canis: dogs (human infections are very uncommon)

Humans acquire the bacteria by several mechanisms including (1) contact with infected blood or tissue, (2) ingestion of contaminated meat or milk, or (3) inhalation of contaminated aerosols. Brucellosis is an occupational hazard among ranchers, herders, veterinarians, and slaughterhouse workers. Elimination of infected animals and vaccination of herds have reduced the incidence of brucellosis in many countries, including the United States, where only about 100 cases are reported annually. However, the disease remains common in many parts of the world. PATHOGENESIS AND PATHOLOGY: Brucellosis is a systemic infection that can involve any organ or organ system of the body. Bacteria enter the circulation through skin abrasions, the conjunctiva, oropharynx, or lungs. They then spread in the bloodstream to the liver, spleen, lymph nodes, and bone marrow, where they multiply in macrophages. Generalized hyperplasia of these cells may ensue. CLINICAL FEATURES: Patients infected with B.abortus develop conspicuous noncaseating granulomas in the liver, spleen, lymph nodes, and bone marrow. Periodic release of organisms from infected phagocytic cells may be responsible for the febrile episodes of the illness, which wax and wane (hence the term undulant fever). The most common complications of brucellosis involve the bones and joints and include spondylitis of the lumbar spine and suppuration in large joints. Endocarditis, although uncommon, can be lethal. Treatment with doxycycline and rifampin is usually effective.

Yersinia pestis Causes Bubonic Plague, the Medieval “Black Death” Plague is a bacteremic, often fatal, infection that is usually accompanied by enlarged, painful regional lymph nodes (buboes). Historically, plague caused massive epidemics that killed a substantial portion of the population affected. Y. pestis is a short gram-negative rod that stains more heavily at the ends (i.e., bipolar staining). Y. pestis infection is an endemic zoonosis in many parts of the world, including the Americas, Africa, and Asia. The organisms are found in wild rodents, such as rats, squirrels, and prairie dogs. Fleas transmit it from animal to animal,

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and most human infections result from bites of infected fleas. Some infected humans develop plague pneumonia and shed large numbers of organisms in aerosolized respiratory secretions, which allow disease transmission from person to person. In the United States, 30 to 40 cases of plague occur annually, mostly in the four corners region of the Southwest and South-Central California. PATHOGENESIS: After inoculation into the skin, Y. pestis is phagocytosed by neutrophils and macrophages. Organisms ingested by neutrophils are killed, but those engulfed by macrophages survive and replicate intracellularly. The bacteria are carried to regional lymph nodes, where they continue to multiply, producing extensive hemorrhagic necrosis. Affected lymph nodes, known as “buboes,” are enlarged and fluctuant. From the regional lymph nodes, the bacteria disseminate through the bloodstream and lymphatics, producing septic shock and death (bubonic plague). In the lungs, Y. pestis produces a necrotizing pneumonitis that releases organisms into the alveoli and airways. These are expelled by coughing, enabling pneumonic spread of the disease (pneumonic plague). Septicemic plague occurs when bacteria are inoculated directly into the blood and do not produce buboes. All types of plague carry a high mortality rate (50% to 75%) if untreated. Streptomycin or gentamicin is the recommended therapy.

Tularemia is an Acute Febrile Disease Usually Acquired from Rabbits Tularemia is caused by Francisella tularensis, a small, gram-negative coccobacillus. The most important reservoirs of this zoonosis are rabbits and rodents. Human infection results from contact with infected animals (generally rabbits) or from the bites of infected insects, most commonly ticks. The incidence of the infection has fallen to about 200 cases annually, presumably related to a decline in hunting and trapping, formerly major sources of infection. There is renewed awareness of the organism because of its potential as a bioterrorism agent. PATHOGENESIS: F. tularensis multiplies at the site of inoculation, where it initially produces an exudative pyogenic ulcer. The bacteria then spread to regional lymph nodes. Dissemination in the bloodstream leads to metastatic infections that involve the monocyte/macrophage system and sometimes the lungs, heart, and kidneys. F. tularensis survives within macrophages until these cells are activated by a cell-mediated immune response to the infection. Disseminated lesions undergo central necrosis and are surrounded by a perimeter of granulomatous reaction resembling the lesions of tuberculosis. The most serious infections are complicated by secondary pneumonia and endotoxic shock, in which case the prognosis is grave.

Anthrax is Rapidly Fatal When it Disseminates Anthrax is a necrotizing disease caused by Bacillus anthracis, a large sporeforming, gram-positive rod. Anthrax is a zoonosis with major reservoirs in goats, sheep, cattle, horses, pigs, and dogs. Spores form in the soil and dead animals, resisting heat, desiccation, and chemical disinfection for years. Humans are infected when spores enter the body through breaks in the skin, by inhalation, or by ingestion. Human disease may also result from exposure to contaminated animal byproducts, such as hides, wool, brushes, or bone meal. In North America, human infection is extremely rare (one case per year for the past few years) and usually results from exposure to imported animal products. However, increased vigilance for anthrax has emerged following a recent act of bioterrorism that used spores delivered in mail and resulted in 11 cases of pulmonary disease.

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PATHOGENESIS: The spores of B. anthracis germinate in the human body to yield vegetative bacteria that multiply and release a potent necrotizing toxin. In 80% of cutaneous anthrax cases, the infection remains localized, and the host immunologic response eventually eliminates the organism. Cutaneous lesions are ulcerated, contain numerous organisms, and are covered by a black scab. Extensive tissue necrosis occurs at the sites of infection and is associated with only a mild infiltrate of neutrophils. Pulmonary infection produces a necrotizing, hemorrhagic pneumonia, associated with hemorrhagic necrosis of mediastinal lymph nodes and widespread dissemination of the organism.

Listeriosis is a Systemic Multiorgan Infection that Carries a High Mortality Rate Listeriosis is caused by Listeria monocytogenes, a small, motile, gram-positive coccobacillus with a widespread distribution in the environment. L. monocytogenes grows at refrigerator temperatures, and outbreaks have been traced to unpasteurized milk, cheese, and dairy products. PATHOGENESIS: L. monocytogenes has an unusual life cycle, which accounts for its ability to evade intracellular and extracellular antibacterial defense mechanisms. After phagocytosis by host cells, the organism enters a phagolysosome, where the acidic pH activates listeriolysin O, an exotoxin that disrupts the vesicular membrane and permits the bacterium to escape into the cytoplasm. After replicating, bacteria usurp the contractile elements of the host cytoskeleton to form elongated protrusions that are engulfed by adjacent cells. Thus, Listeria spread from one cell to another without exposure to the extracellular environment. PATHOLOGY AND CLINICAL FEATURES: Listeriosis of pregnancy includes prenatal and postnatal infections. Maternal infection early in pregnancy may lead to abortion or premature delivery. Infected infants rapidly develop respiratory distress, hepatosplenomegaly, cutaneous and mucosal papules, leukopenia, and thrombocytopenia. Intrauterine infections involve many organs and tissues, including amniotic fluid, placenta, and the umbilical cord. Abscesses are found in many organs. Microscopically, foci of necrosis and suppuration contain many bacteria. Older lesions tend to be granulomatous. Neurologic sequelae are common, and the mortality rate of neonatal listeriosis is high even with prompt antibiotic therapy. Chronic alcoholics, patients with cancer, those receiving immunosuppressive therapy, and patients with AIDS are far more susceptible to infection than is the general population. Meningitis is the most common form of the disease in adults. Septicemic listeriosis is a severe febrile illness most common in immunodeficient patients. It may lead to shock and disseminated intravascular coagulation, a situation that may be misdiagnosed as gram-negative sepsis. The mortality rate from systemic listeriosis remains at 25%.

Infections Caused by Branching Filamentous Organisms Actinomycosis is Characterized by Abscesses and Sinus Tracts Actinomycosis is a slowly progressive, suppurative, fibrosing infection involving the jaw, thorax, or abdomen. The disease is caused by a number of anaerobic and microaerophilic bacteria termed Actinomyces,

and the most common is Actinomyces israelii. These organisms are branching, filamentous, gram-positive rods that normally reside as saprophytes in the oropharynx, gastrointestinal tract, and vagina without producing disease. PATHOGENESIS AND PATHOLOGY: Actino-myces can cause disease only if inoculated into anaerobic deep tissues. Trauma can produce tissue necrosis, providing an excellent anaerobic medium for growth of Actinomyces and can inoculate the organism into normally sterile tissue. Actinomycosis occurs at four distinct sites: • Cervicofacial actinomycosis results from jaw injury, dental extraction, or dental manipulation. • Thoracic actinomycosis is caused by the aspiration of organisms contaminating dental debris. • Abdominal actinomycosis follows traumatic or surgical disruption of the bowel, especially the appendix. • Pelvic actinomycosis is associated with the prolonged use of intrauterine devices. Actinomycosis begins as a nidus of proliferating organisms that attract an acute inflammatory infiltrate. The small abscess grows slowly, becoming a series of abscesses connected by sinus tracts that burrow across normal tissue boundaries and into adjacent organs. Eventually, a tract may penetrate onto an external surface or mucosal membrane, producing a draining sinus. Within the abscesses and sinuses are pus and colonies of organisms that appear as hard, yellow grains, known as sulfur granules, because of their resemblance to elemental sulfur. Histologically, the colonies appear as rounded, basophilic grains with scalloped eosinophilic borders (Fig. 9-11A,B).

Nocardiosis is a Suppurative Respiratory Infection in Immunocompromised Hosts Nocardia are aerobic, gram-positive filamentous, branching bacteria that are widely distributed in soil. Human disease is caused by inhaling or inoculating soil-borne organisms. From the lung, the infection often spreads to the brain and skin. Nocardiosis is most common in persons with impaired immunity, particularly cell-mediated immunity. Organ transplantation, long-term corticosteroid therapy, lymphomas, leukemias, and other debilitating diseases predispose to Nocardia infections. PATHOGENESIS: The respiratory tract is the usual portal of entry for Nocardia. The organism elicits a brisk infiltrate of neutrophils, and disease begins as a slowly progressive, pyogenic pneumonia. In immunocompromised persons, Nocardia produces pulmonary abscesses, which are frequently multiple and confluent. Direct extension to the pleura, trachea, and heart, and metastases to the brain or skin through the circulation, carry a grave prognosis. Untreated nocardiosis is usually fatal. Sulfonamides or related antibiotics for several months are often effective therapy.

SPIROCHETAL INFECTIONS Spirochetes are long, slender, helical bacteria with specialized cell envelopes that permit them to move by flexion and rotation. Although spirochetes have the basic cell wall structure of gramnegative bacteria, they stain poorly with the Gram stain. Three genera of spirochetes, Treponema, Borrelia, and Leptospira cause human disease (Table 9-3). They are adept at evading host inflammatory and immunological defenses, and diseases caused by these organisms are all chronic or relapsing.

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A FIGURE 9-11.

Actinomycosis. A. A typical sulfur granule lies within an abscess. B. The individual filaments of Actinomyces israeli are readily visible with the silver impregnation technique.

Syphilis

Primary Syphilis is Characterized by the Chancre

Syphilis (lues) is a chronic systemic infection that is transmitted almost exclusively by sexual contact or from an infected mother to her fetus (congenital syphilis). Infection is caused by Treponema pallidum, a thin, long spirochete (Fig. 9-12). PATHOGENESIS AND PATHOLOGY: Person-toperson transmission requires direct contact between a rich source of spirochetes (e.g., an open lesion) and mucous membranes or abraded skin of the genital organs, rectum, mouth, fingers, or nipples. The organisms reproduce at the site of inoculation, pass to regional lymph nodes, gain access to systemic circulation, and disseminate throughout the body. Although T. pallidum induces an inflammatory response and is taken up by phagocytic cells, it persists and proliferates. Chronic infection and inflammation cause tissue destruction, sometimes for decades. The course of syphilis is classically divided into three stages (Fig. 9-13).

The classic lesion of primary syphilis is the chancre (Fig. 9-14), a characteristic ulcer at the site of T. pallidum entry. It appears 1 week to 3 months after exposure and tends to be solitary. Spirochetes tend to concentrate in vessel walls and in the epidermis around the ulcer. The vessels display a characteristic “luetic vasculitis,” in which endothelial cells proliferate and swell, and vessel walls become thickened by lymphocytes and fibrous tissue. Chancres are painless and heal without scarring.

Secondary Syphilis Features the Systemic Spread of the Organism In secondary syphilis, T. pallidum spreads systemically and proliferates to cause lesions in the skin, mucous membranes, lymph nodes, meninges, stomach, and liver. Lesions show perivascular lymphocytic infiltration and endarteritis obliterans. The most common presentation of secondary syphilis is an erythematous

TABLE 9–3

Spirochete Infections Disease

Organism

Syphilis

Treponemes Treponema pallidum

Clinical Manifestation

Distribution

Mode of Transmission

See text

Common worldwide

Sexual contact, congenital

Bejel

Treponema endenicum (Treponema pallidum, subspecies endenicum)

Mucosal, skin, and bone lesions

Middle East

Mouth-to-mouth contact

Yaws

Treponema pertenue (Treponema pallidum subspecies pertenue)

Skin and bone

Tropics

Skin-to-skin contact

Pinta

Treponem acarateum

Skin lesions

Latin America

Skin-to-skin contact

Borrelia Lyme disease

Borrelia burgdorferi

See text

North America, Europe, Russia, Asia, Africa, Australia

Tick bite

Relapsing fever

Borrelia recurrentis and related species

Relapsing flu-like illness

Worldwide

Tick bite, louse bite

Flu-like illness, meningitis

Worldwide

Contact with animal urine

Leptospirosis

Leptospira Leptospira interrogans

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FIGURE 9-12.

Syphilis. Spirochetes of Treponema pallidum, visualized by silver impregnation, in the eye of a child with

congenital syphilis.

and maculopapular rash, involving the trunk and extremities and often includes the palms and soles. The rash appears 2 weeks to 3 months after the chancre heals. Lesions on mucosal surfaces of the mouth and genital organs, called mucous patches, teem with organisms and are highly infectious.

The Gumma is the Hallmark Lesion of Tertiary Syphilis Following secondary syphilis, an asymptomatic period lasts for years. However, spirochetes continue to multiply, and the deep-

FIGURE 9-13.

Essentials of Rubin’s Pathology

seated lesions of tertiary syphilis gradually develop in one third of untreated patients. The appearance of a gumma in any organ or tissue is the hallmark of tertiary syphilis. Gummas are most commonly found in the skin, bone, and joints, although they can occur anywhere. These granulomatous lesions are composed of a central area of coagulative necrosis, epithelioid macrophages, occasional giant cells, and peripheral fibrous tissue. Gummas are usually localized lesions and generally do not contribute to the disease process. Rather, the underlying mechanism for much of the damage associated with tertiary syphilis is focal ischemic necrosis secondary to obliterative endarteritis. T. pallidum induces a mononuclear inflammatory infiltrate composed predominantly of lymphocytes and plasma cells. These cells infiltrate small arteries and arterioles, producing a characteristic obstructive vascular lesion (endarteritis obliterans). The small arteries are inflamed, and their endothelial cells are swollen. They are surrounded by concentric layers of proliferating fibroblasts, which confer an “onion skin” appearance to the vascular lesions. Syphilitic aortitis results from destruction of the vasa vasorum, eventually leading to necrosis of the aortic media, gradual weakening and stretching of the aortic wall, aortic aneurysm, and ultimately rupture, causing sudden death. Syphilitic aneurysms are saccular and involve the ascending aorta. On gross examination, the aortic intima is rough and pitted (tree-bark appearance). Damage to, and scarring of, the ascending aorta also commonly lead to dilation of the aortic ring, separation of the valve cusps, and regurgitation of blood through the aortic valve (aortic insufficiency) (see Chapter 10). Neurosyphilis results from the slowly progressive infection and damages the meninges, cerebral cortex, spinal cord, cranial nerves, or eyes.

Congenital Syphilis Affects the Fetus In this setting, the organism disseminates in fetal tissues, which are injured by the proliferating organisms and accompanying inflammatory response. Fetal infection produces stillbirth, neonatal illness or death, or progressive postnatal disease. Histopathologically, the lesions of congenital syphilis are identical to those of adult disease.

Clinical characteristics of the various stages of syphilis.

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clude severe arthritis of the large joints, especially the knee. The histopathology of affected joints is virtually indistinguishable from that of rheumatoid arthritis, with villous hypertrophy and a conspicuous mononuclear infiltrate in the subsynovial lining area. Treatment with tetracycline or erythromycin is effective in eliminating early Lyme disease. In later stages, high doses of intravenous penicillin G and other combinations of antibiotic regimens for long periods are necessary.

CHLAMYDIAL INFECTIONS

FIGURE 9-14.

Syphilitic chancre. A patient with primary syphilis displays a raised, erythematous penile lesion.

Lyme Disease Lyme disease is a chronic systemic infection, which begins with a characteristic skin lesion and later manifests as cardiac, neurologic, or joint disturbances. The causative agent is Borrelia burgdorferi, a large, microaerophilic spirochete transmitted from its animal reservoir to humans by the bite of the minute Ixodes tick, which usually feeds on mice and deer. Lyme disease has become the most common tick-borne illness in the United States, causing an estimated 20,000 to 25,000 cases annually. PATHOGENESIS, PATHOLOGY, AND CLINICAL FEATURES: B. burgdorferi reproduces locally at the site of inoculation, spreads to regional lymph nodes, and is disseminated throughout the body in the bloodstream. Like other spirochetal diseases, Lyme disease is chronic, occurring in stages, with remissions and exacerbations. B. burgdorferi elicits a chronic inflammatory infiltrate composed of lymphocytes and plasma cells. Three clinical stages are recognized in Lyme disease: • Stage 1: The characteristic skin lesion, erythema chronicum migrans, appears at the site of the tick bite. It begins as an erythematous macule or papule, which grows into an erythematous patch. The last often is intensely red at its periphery and pale in the center, imparting an annular appearance. Secondary annular skin lesions develop in about half of patients and may persist for long periods. During this phase, patients experience constant malaise, fatigue, headache, and fever. Intermittent manifestations may also include meningeal irritation, migratory myalgia, cough, generalized lymphadenopathy, and testicular swelling. • Stage 2: The second stage begins within several weeks to months of the skin lesion and is characterized by exacerbation of migratory musculoskeletal pains as well as cardiac and neurologic abnormalities. In 10% of cases, conduction abnormalities, particularly atrioventricular block, result from myocarditis. Neurologic abnormalities, most commonly meningitis and facial nerve palsies, occur in 15% of patients. • Stage 3: The third stage of Lyme disease begins months to years after the initial infection and is manifested by joint, skin, and neurologic abnormalities, which range from tingling paresthesias to slowly progressive encephalomyelitis, transverse myelitis, organic brain syndromes, and dementia. Joint abnormalities develop in over half of infected persons and in-

Chlamydiae are obligate intracellular parasites that are smaller than most other bacteria. They lack the enzymatic capacity to generate adenosine triphosphate (ATP) and must parasitize the metabolic machinery of a host cell to reproduce. The chlamydial life cycle involves two distinct morphologic forms, the reticulate and elementary bodies. The former is metabolically active and commandeers host cell metabolism to fuel chlamydial replication. The reticulate body divides repeatedly, forming daughter elementary bodies and destroying the host cell. Necrotic debris elicits inflammatory and immunologic responses that further damage infected tissue. Chlamydial infections are widespread among birds and mammals, and as many as 20% of humans are infected. Three species of chlamydiae (Chlamydia trachomatis, Chlamydia psittaci, and Chlamydia pneumoniae) cause human infection.

Chlamydia Trachomatis Infection The species C. trachomatis contains a variety of strains, which cause three distinct types of disease: (1) genital and neonatal disease; (2) lymphogranuloma venereum; and (3) trachoma. • Genital disease: C. trachomatis causes a genital epithelial infection that is now the most common venereal disease in North America. Chlamydial infection elicits an infiltrate of neutrophils and lymphocytes. Lymphoid aggregates, with or without germinal centers, may appear at the site of infection. In men, C. trachomatis infection produces urethritis and sometimes epididymitis or proctitis. In women, it usually begins with cervicitis, which can progress to endometritis, salpingitis, and generalized infection of the pelvic adnexal organs (pelvic inflammatory disease). • Neonatal Disease: Perinatal transmission of C. trachomatis by passage through an infected birth canal causes neonatal conjunctivitis in about two thirds of exposed neonates. Infected conjunctival epithelium often contains characteristic vacuolar cytoplasmic inclusions, and the disease is frequently called inclusion conjunctivitis. Chlamydial pneumonia manifests in the second or third month with tachypnea and paroxysmal cough, usually without fever. • Lymphogranuloma venereum is a sexually transmitted disease that begins as a genital ulcer, spreads to lymph nodes and may cause local scarring. The disease is uncommon in developed countries, but is endemic in the tropics and subtropics. The organism is introduced through a break in the skin. After an incubation period of 4 to 21 days, an ulcer appears, usually on the penis, vagina, or cervix. The organisms are transported by lymphatics to regional lymph nodes, where a necrotizing lymphadenitis and abscess formation occurs. The abscesses have a granulomatous appearance, containing neutrophils and necrotic debris in the center, surrounded by palisading epithelioid cells, macrophages, and occasional giant cells. Abscesses are rimmed by lymphocytes, plasma cells, and fibrous tissue. The nodal architecture is eventually effaced by fibrosis. The intense inflammatory process can result in severe scarring, which may produce chronic lymphatic obstruction, ischemic necrosis of overlying structures, or strictures and adhesions.

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• Trachoma: This chronic infection causes progressive scars of the conjunctiva and cornea. Trachoma is worldwide, associated with poverty, and most prevalent in dry or sandy regions of Africa, Asia, and the Middle East. In endemic areas, infection is acquired early in childhood, becomes chronic, and eventually progresses to blindness. The agent reproduces in the conjunctival epithelium, inciting a mixed acute and chronic inflammatory infiltrate. Progressive scarring distorts the eyelids thereby leading to corneal abrasions and secondary bacterial infections. Ultimately, the combination of chronic inflammation, infection, scarring, and abrasion produces blindness.

Rickettsia. The organisms reside in animals and insects and do not require humans for perpetuation. Human rickettsial infection results from insect bites. Many species of Rickettsia cause different human diseases often localized to a geographic region (Table 9-4), although rickettsial infections have many features in common. The human target cell for all rickettsiae is the endothelial cell of capillaries and other small blood vessels. The organisms reproduce within these cells, killing them in the process and produce a necrotizing vasculitis. Human rickettsial infections are traditionally divided into the “spotted fever group” and the “typhus group.”

Rocky Mountain Spotted Fever

Psittacosis (Ornithosis) Psittacosis is a self-limited pneumonia transmitted to humans from birds. The causative agent, Chlamydia psittaci, is spread to humans by the excreta, dust, and feathers of infected birds. Treatment and quarantine of imported tropical birds has limited the spread of disease, and fewer than 50 cases of psittacosis are reported annually in the United States. PATHOLOGY: C. psittaci first infects pulmonary macrophages, which carry the organism to the phagocytic cells of the liver and spleen, where it reproduces. The organism is then distributed by the bloodstream, producing systemic infection, particularly diffuse involvement of the lungs. The pneumonia is predominantly interstitial, with a lymphocytic inflammatory infiltrate and hyperplasia of type II pneumocytes, which may show characteristic chlamydial cytoplasmic inclusions. Dissemination of the infection is characterized by foci of necrosis in the liver and spleen as well as diffuse mononuclear cell infiltrates in the heart, kidneys, and brain.

RICKETTSIAL INFECTIONS The rickettsiae are small, gram-negative, coccobacillary bacteria that are obligate intracellular pathogens and cannot replicate outside a host. Humans are accidental hosts for most species of

Rocky Mountain spotted fever is an acute, potentially fatal, systemic vasculitis, usually manifested by headache, fever, and rash. The causative organism, Rickettsia rickettsii, is transmitted to humans by tick bites. About 1,500 cases are reported annually in the United States, mostly from the eastern seaboard (Georgia to New York) westward to Texas, Oklahoma, and Kansas. Although the disease is uncommon in the Rocky Mountain region, it was discovered in Idaho. PATHOGENESIS AND PATHOLOGY: R. rickettsii in salivary glands of ticks is introduced into the skin while the ticks feed. The organisms spread via lymphatics and small blood vessels to the systemic and pulmonary circulation, where the agent attaches to and is engulfed by endothelial cells. The organisms reproduce and are shed into the vascular and lymphatic systems. Destruction of vascular endothelium causes a systemic vasculitis. Vessel walls are infiltrated, initially with neutrophils and macrophages, and later with lymphocytes and plasma cells. Microscopic infarctions and extravasation of blood into surrounding tissues are common. The rash is the most visible manifestation of the generalized phenomenon of vascular injury, which may eventuate in disseminated intravascular coagulation and shock. Damage to pulmonary capillaries can produce pulmonary edema and acute alveolar injury. The disease manifests with fever, headache, and myalgias, followed by a rash. Skin lesions begin as a maculopapular eruption but rapidly become petechial, spreading centripetally from the distal extremities to the trunk. If untreated, more than 20% to 50% of infected

TABLE 9–4

Rickettsial Infections Disease

Organism

Distribution

Transmission

Spotted-Fever Group (genus Rickettsia) Rocky Mountain spotted fever

R. rickettsii

Americas

Ticks

Queensland tick fever

R. australis

Australia

Ticks

Boutonneuse fever, Kenya tick fever

R. conorii

Mediterranean, Africa, India

Ticks

Siberian tick fever

R. sibirica

Siberia, Mongolia

Ticks

Rickettsialpox

R. akari

United States, Russia, Central Asia, Korea, Africa

Mites

Typhus Group Louse-borne typhus (epidemic typhus)

R. prowazekii

Latin America, Africa, Asia

Lice

Murine typhus (endemic typhus)

R. typhi

Worldwide

Fleas

Scrub typhus

R. tsutsugamushi

South Pacific, Asia

Mites

Q fever

Coxiella burnetii

Worldwide

Inhalation

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persons die within 8 to 15 days. Prompt diagnosis and antibiotic treatment (usually with doxycycline) is life saving, and the mortality rate in the United States is less than 5%.

Epidemic (Louse-Borne) Typhus Epidemic typhus is a severe systemic vasculitis transmitted by the bite of infected lice. The disease is caused by Rickettsia prowazekii, an organism that has a human-louse-human life cycle (Fig. 9-15). The bacteria are transmitted from one infected person to another by the bite of an infected body louse. Devastating epidemics of typhus were as-

sociated with conditions of social stress, such as war or famine, which led to louse infestation of human populations. Currently, the disease is limited to mountainous areas of Africa, the Andes in South America, and is very uncommon in the US. PATHOGENESIS AND PATHOLOGY: A person becomes infected when the contaminated louse feces penetrate an abrasion or scratch or when the person inhales airborne rickettsiae. The disease begins with localized infection of capillary endothelium and progresses to a systemic vasculitis with many similarities to Rocky Mountain spotted fever. Focal necrosis is associated with an infiltrate of mast cells, lympho-

Epidemic typhus (louse-borne typhus). Rickettsia prowazekii has a man-louse-man life cycle. The organism multiplies in endothelial cells, which detach, rupture, and release organisms into the circulation (rickettsemia). A louse taking a blood meal becomes infected with rickettsiae, which enter the epithelial cells of its midgut, multiply, and rupture the cells, thereby releasing rickettsiae into the lumen of the louse intestine. Contaminated feces are deposited on the skin or clothing of a second host, penetrate an abrasion, or are inhaled. The rickettsiae then enter endothelial cells, multiply and rupture the cells, thus completing the cycle. FIGURE 9-15.

173

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cytes, plasma cells, and macrophages, frequently arranged as typhus nodules around arterioles and capillaries.

MYCOPLASMAL INFECTIONS: MYCOPLASMA PNEUMONIA At less than 0.3 μm in greatest dimension, mycoplasmas are the smallest free-living prokaryotes, and they lack the rigid cell walls of more complex bacteria. M. pneumoniae produces acute, self-limited lower respiratory tract infections, affecting mostly children and young adults. The organism is spread by aerosol transmission, mostly in small groups of persons who have frequent close contact. M. pneumoniae infection occurs worldwide, and in developed countries, the organism causes 15% to 20% of all pneumonias. PATHOGENESIS AND PATHOLOGY: M. pneumoniae initiates infection by attaching to a glyco-lipid on the surface of the respiratory epithelium. The organism remains outside the cells, where it reproduces and causes progressive dysfunction and eventual death of the host cells. Pneumonia caused by M. pneumoniae usually shows patchy consolidation of a single segment of a lower lung lobe. The alveoli show a largely interstitial process, with reactive alveolar lining cells and mononuclear infiltration. Pulmonary changes are often complicated by bacterial superinfection. Mycoplasma pneumonia tends to be milder than other bacterial pneumonias and is sometimes called “walking pneumonia.”

berculosis is most common in the elderly, with a case rate of 8 per 100,000 in the population over the age of 65, accounting for about 20% of the patients with the disease. This may reflect reactivation of infections acquired early in life before the decline in the prevalence of the disease. M. tuberculosis is transmitted from person to person by aerosolized droplets. Coughing, sneezing, and talking all create aerosolized respiratory droplets; usually, droplets evaporate, leaving an organism (droplet nucleus) that is readily carried in the air. PATHOGENESIS: The course of tuberculosis depends on age and immune competence, as well as the total burden of organisms (Fig. 9-16). Some patients have only an indolent, asymptomatic infection, whereas in others, tuberculosis is a destructive, disseminated disease. Many more persons are infected with M. tuberculosis than develop clinical symptoms. Thus, one must distinguish between infection and active tuberculosis. Tuberculous infection refers to growth of the organism in a person, whether there is symptomatic disease or not. Active tuberculosis denotes the subset of tuberculous infections manifested by destructive and symptomatic disease. Primary tuberculosis occurs on first exposure to the organism and can pursue either an indolent or aggressive course (Fig. 916). Secondary tuberculosis develops long after a primary infection, mostly as a result of reactivation of a primary infection. Secondary tuberculosis can also be produced by exposure to exogenous organisms and is always an active disease.

MYCOBACTERIAL INFECTIONS Mycobacteria are distinctive organisms, 2 to 10 μm in length, which share the cell wall architecture of gram-positive bacteria but also contain large amounts of lipid. Mycobacteria are structurally gram-positive; however, this property is difficult to demonstrate by routine staining. The waxy lipids of the cell wall make the mycobacteria “acid fast” (i.e., they retain carbolfuchsin after rinsing with acid alcohol). The mycobacteria grow more slowly than other pathogenic bacteria and cause chronic, slowly progressive illnesses. Most mycobacterial pathogens replicate within cells of the monocyte/ macrophage lineage and elicit granulomatous inflammation. The outcome of mycobacterial infection is largely determined by the host’s capacity to contain the organism through delayed-type hypersensitivity mechanisms and cell-mediated immune responses. The two main mycobacterial pathogens, Mycobacterium tuberculosis and Mycobacterium leprae, infect only humans and have no environmental reservoir.

Tuberculosis Tuberculosis is a chronic, communicable disease in which the lungs are the prime target, although any organ may be infected. The disease is mainly caused by M. tuberculosis hominis (Koch bacillus) but also occasionally by M. tuberculosis bovis. The characteristic lesion is a spherical granuloma with central caseous necrosis. M. tuberculosis is an obligate aerobe, a slender, beaded, nonmotile, acid-fast bacillus. Tuberculosis is one of the most important human bacterial diseases. The World Health Organization estimates a worldwide annual incidence of 140 tuberculosis cases and 27 deaths per 100,000. By comparison, the US annual incidence is currently 5 tuberculosis cases and 0.2 deaths per 100,000, with more than half of the cases occurring in foreign-born individuals. This represents a greater than 10-fold reduction in incidence in the last 50 years. The HIV-infected, homeless, and malnourished persons in impoverished areas are highly susceptible, as are immigrants from areas where the disease is endemic. In the United States, tu-

Primary Tuberculosis is a First Exposure to the Tubercle Bacillus PATHOGENESIS AND PATHOLOGY: Inhaled M. tuberculosis is deposited in alveoli. The organisms are phagocytosed by alveolar macrophages but resist killing; cell wall lipids of M. tuberculosis apparently block fusion of phagosomes and lysosomes, allowing the bacilli to proliferate within macrophages. Development of activated lymphocytes responsive to M. tuberculosis antigen produces a type IV hypersensitivity response to the organism, which results in the emergence of activated macrophages that can ingest and destroy the bacilli. The process requires 3 to 6 weeks to come into play. If an infected person is immunologically competent, a vigorous granulomatous reaction is produced. Microscopically, the classic lesion of tuberculosis is a caseous granuloma (Fig. 9-17), a lesion that has a soft, semisolid core surrounded by epithelioid macrophages, Langhans giant cells, lymphocytes, and peripheral fibrous tissue. Although not invariably caused by M. tuberculosis, caseous necrosis is so strongly associated with tuberculosis, that its discovery in tissue must raise a suspicion of this disease. The lung lesion of primary tuberculosis is known as a Ghon focus. It is found in the subpleural area of the upper segments of the lower lobes or in the lower segments of the upper lobes. Initially, it is a small, ill-defined area of inflammatory consolidation, which then drains to hilar lymph nodes. The combination of a peripheral Ghon focus and involved mediastinal or hilar lymph nodes is called the Ghon complex. In more than 90% of normal adults, tuberculous infection is self-limited. In both lungs and lymph nodes, the Ghon complex heals, undergoing shrinkage, fibrous scarring, and calcification, the latter visible radiographically. Small numbers of organisms may remain viable for years. Later, if immune mechanisms wane or fail, resting bacilli may proliferate and break out, causing serious secondary tuberculosis. In immunologically immature subjects (a young child or immunosuppressed patient), granulomas are poorly formed or not formed at all, and infection progresses at the primary site in the lung, in the regional lymph nodes, or in multiple sites of dissemi-

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90%) present with symptoms referable to the respiratory tract, particularly pneumonitis and sinusitis. Glomerular disease can progress to renal failure. In untreated Wegener granulomatosis, most individuals (80%) die within a year of onset, with a mean survival of 5 to 6 months. Treatment with cyclophosphamide produces both complete remissions and substantial disease-free intervals in most patients.

Aneurysms Arterial aneurysms are localized dilations of blood vessels caused by a congenital or acquired weakness of the media. They are not rare, and their incidence tends to rise with age. Aneurysms of the aorta and other arteries are found in as many as 10% of autopsies. The wall of an aneurysm is formed by the stretched remnants of the arterial wall. Aneurysms are classified by location, configuration, and etiology (Fig. 10-18). The location refers to the type of vessel involved— artery or vein—and the specific vessel affected, such as the aorta or popliteal artery. The gross morphology of aneurysms reveals several different pathologic features. • Fusiform aneurysm is an ovoid swelling parallel to the long axis of the vessel. • Saccular aneurysm is a bubble-like arterial wall outpouching at a site of weakened media. • Dissecting aneurysm is actually a dissecting hematoma, in which hemorrhage into the media separates the layers of the vascular wall. • Arteriovenous aneurysm is a direct communication between an artery and a vein.

Abdominal Aortic Aneurysms are Complications of Atherosclerosis Abdominal aortic aneurysms are dilations that increase vessel wall diameter by at least 50%. They are the most frequent aneurysms, usually developing after the age of 50 and are associated with severe atherosclerosis of the artery. Aortic aneurysms occur much more often in men than in women, and half of the patients are hypertensive. Occasionally, aneurysms are found in ascending, arch, and descending parts of the thoracic aorta and in iliac and popliteal arteries. Although abdominal aortic aneurysms occur in the context of atherosclerosis, it is thought that the disease is actually multifactorial, as familial clustering suggests a genetic predisposition. Changes in the extracellular matrix of the aortic wall, inflammation or alterations in cell-mediated immune responses, and hemodynamic factors, especially hypertension, have all been implicated in the pathogenesis of abdominal aortic aneurysms. PATHOLOGY: Most abdominal aortic aneurysms are distal to the renal arteries and proximal to the bifurcation (Fig. 10-19). They are usually fusiform, although saccular varieties are occasionally encountered. Symptomatic aneurysms are generally more than 5 to 6 cm in diameter. Aneurysms that extend above the renal arteries may occlude the origin of the superior mesenteric artery and the celiac axis. Most abdominal aortic aneurysms are lined by raised, ulcerated, and calcified (complicated) atherosclerotic lesions. They tend to contain mural thrombi of varying degrees of organization, portions of which may embolize to peripheral arteries. Infrequently, the thrombus itself may enlarge enough to compromise the lumen of the aorta. Microscopically, complicated atherosclerotic lesions show destruction of the normal arterial wall and its replacement by fibrous tissue. Remnants of normal media

FIGURE 10-18. The locations of aneurysms. Syphilitic aneurysms are the common variety in the ascending aorta, which is usually spared by the atherosclerotic process. Atherosclerotic aneurysms can occur in the abdominal aorta or muscular arteries, including the coronary and popliteal arteries and other vessels. Berry aneurysms are seen in the circle of Willis, mainly at branch points; their rupture leads to subarachnoid hemorrhage. Mycotic aneurysms occur almost anywhere that bacteria can deposit on vessel walls.

are seen focally, and atheromatous lesions extend to variable depths. The adventitia is thickened and focally inflamed as a response to severe atherosclerosis. CLINICAL FEATURES: Many abdominal aortic aneurysms are asymptomatic and are discovered only by palpation of a mass in the abdomen or on nonrelated radiologic examination. In some cases, the condition is brought to medical attention by the onset of abdominal pain, which reflects aneurysmal expansion. Abrupt occlusion of a peripheral artery by an embolus from the mural thrombus presents as sudden ischemia of a lower limb. The most dreaded complication is rupture and exsanguinating retroperitoneal (or thoracic) hemorrhage, in which case the patient presents with pain, shock, and a pulsatile mass in the abdomen. Such a situation is an acute

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emergency, and even with prompt surgical intervention, half of the patients die. Therefore, large aneurysms, even if entirely asymptomatic, are often replaced by or bypassed with prosthetic grafts. The risk of rupture of an abdominal aortic aneurysm is a function of its size. Aneurysms under 4 cm in diameter rarely rupture (2%), whereas about one third of those larger than 5 cm rupture within 5 years of their discovery.

Aneurysms of Cerebral Arteries Lead to Subarachnoid Hemorrhage The most common type of cerebral aneurysm is saccular and is called a berry aneurysm (see Chapter 28).

Dissecting Aneurysm is a Hematoma of the Aortic Wall Hemorrhage into the arterial wall separates the layers of the wall as it dissects a path along the length of the vessel (Fig. 10-20). The dissection is essentially a false lumen within the wall of the artery. Although this lesion is conventionally termed an aneurysm, it is actually a form of hematoma. Dissecting aneurysms most often affect the aorta and its major branches. Their frequency has been estimated to be as high as 1 in 400 autopsies, with men affected three times as frequently as women. They may occur at almost any age but are most common in the sixth and seventh decades. Most patients have histories of hypertension. PATHOGENESIS: The basis of dissecting aneurysms is usually weakening of the aortic media. The changes were originally described as cystic medial necrosis (of Erdheim) because focal loss of elastic and muscle fibers in the media leads to “cystic” spaces filled with a metachromatic myxoid material. These spaces are not true cysts but are rather pools of matrix collected between the cells and tissues of the media. The cause of medial degeneration is not known. Some cases are complications of Marfan syndrome, (see Chapter 6). Aging also results in mild degenerative changes in the aorta, characterized by focal elastin loss and medial fibrosis. Taken together, these data suggest that the common factor in these several situations is a defect that leads to weakness of aortic connective tissue. More than 95% of cases have a transverse tear in the intima and internal media, and it is widely held that spontaneous laceration of the intima allows blood from the lumen to enter and dissect the media. PATHOLOGY: Most intimal tears are in the ascending aorta, 1 or 2 cm above the aortic ring. Dissection in the media occurs within seconds and separates the inner two thirds of the aorta from the outer third. It can also involve coronary arteries, great vessels of the neck, and renal, mesenteric, or iliac arteries. Because the outer wall of the false channel of the dissecting aneurysm is thin, hemorrhage into the extravascular space, including the pericardium, mediastinum, pleural space, and retroperitoneum, frequently causes death. CLINICAL FEATURES: The typical patient with an aortic dissection presents with the acute onset of severe, “tearing” pain in the anterior chest, which is sometimes misdiagnosed as MI. Loss of one or more arterial pulses is common, and a murmur of aortic regurgitation is often present. Whereas many patients suffer from hypertension, hypotension is an ominous sign, suggesting aortic rupture. Cardiac tamponade or congestive heart failure may occur. Surgical intervention and control of hypertension have reduced overall mortality to less than 20%.

FIGURE 10-19. Atherosclerotic aneurysm of the abdominal aorta. The aneurysm has been opened longitudinally to reveal a large mural thrombus in the lumen. The aorta and common iliac arteries display complicated lesions of atherosclerosis.

Syphilitic Aneurysms are due to Inflammation of Aortic Vasa Vasorum Syphilis was once the most common cause of aortic aneu-rysms, but as this infection has become less common, so has syphilitic vascular disease, including aortitis and aneurysms. Syphilitic aneurysms mainly affect the ascending aorta, where microscopic examination shows endarteritis and periarteritis of the vasa vasorum (see Chapter 9 for additional details).

Veins Varicose Veins of the Legs Involve the Superficial Saphenous System A varicose vein is an enlarged and tortuous vein. Superficial varicosities of leg veins are usually in the saphenous system and are very common. They vary from a trivial knot of dilated veins to disabling distention of the whole venous system of the leg. It is estimated that as much as 10% to 20% of the population has some varicosities in the leg veins, but only a fraction of these individuals develop symptoms. PATHOGENESIS: There are a number of risk factors for varicose veins: • Age: Varicose veins increase in frequency with age and may reach 50% in persons over 50.

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FIGURE 10-20. Dissecting aneurysm of the aorta. A. A transverse tear is present in the aortic arch. The orifices of the great vessels are on the left. B. The thoracic aorta has been open longitudinally and reveals clotted blood dissecting the media of the vessel. The luminal surface shows extensive complicated lesions of atherosclerosis. C. A section of the aortic wall stained with aldehyde fuchsin shows pools of metachromatic material characteristic of the degenerative process known as cystic medial necrosis.

• Gender: Among 30- to 50-year-olds, women are more often affected by varicose veins than men, particularly those who have experienced pregnancy. • Heredity: There is a strong familial predisposition to varicose veins, possibly due to inherited configurations or structural weakness of the walls or valves of the veins. • Posture: Leg vein pressure is 5 to 10 times higher when a person is erect, rather than recumbent. As a result, the incidence of varicose veins and its complications are greater in people whose occupations require them to stand in one place for long periods. • Obesity: Excessive body weight increases the incidence of varicose veins, possibly because of increased intra-abdominal pressure or poor support provided by the subcutaneous fat to vessel walls. Other factors that raise venous pressure in the legs can cause varicose veins, including pelvic tumors, congestive heart failure, and thrombotic obstruction of the main venous trunks of the thigh or pelvis. In the pathogenesis of varicose veins, it is not clear whether incompetence of the valves or dilation of the vessels comes first. Whatever the case, the two reinforce each other. The vein increases in length and diameter, so that tortuousities develop. Once the process begins, the varicosity extends progressively throughout the length of the affected vein.

PATHOLOGY: Microscopically, varicose veins show variations in wall thickness. Thinning due to dilation is present in some areas, whereas others are thickened by smooth muscle hypertrophy, subintimal fibrosis, and incorporation of mural thrombi into the wall. Patchy calcification is frequently seen. Valvular deformities consist of thickening, shortening, and rolling of the cusps. CLINICAL FEATURES: Most varicose veins are without clinical effects and are mainly cosmetic problems. The principal symptoms are aching in the legs, aggravated by standing and relieved by elevation. Severe varicosities may lead to alterations in the skin drained by the affected veins, termed stasis dermatitis. Surgical intervention is mandated if the overlying skin has ulcerated or if the patient has spontaneous bleeding or extensive thrombosis (which may lead to pulmonary embolism).

Varicose Veins also Occur at Other Sites HEMORRHOIDS: These are dilations of the veins of the rectum and anal canal, which may occur inside or outside the anal sphincter (see Chapter 13). ESOPHAGEAL VARICES: This complication of portal hypertension is caused mainly by cirrhosis of the liver (see Chapter 14). Hemorrhage from esophageal varices is one of the most common causes of death in cirrhosis.

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VARICOCELE: This palpable mass in the scrotum represents varicosities of the pampiniform plexus (see Chapter 17).

Deep Venous Thrombosis Principally Affects Leg Veins • Thrombophlebitis is inflammation and secondary thrombosis of small veins and sometimes larger ones, commonly as part of a local reaction to bacterial infection. • Phlebothrombosis is the term for venous thrombosis that occurs without an initiating infection or inflammation. • Deep venous thrombosis now refers to both phlebothrombosis and thrombophlebitis. Because most cases of venous thrombosis are not associated with inflammation or infection, the condition is most commonly associated with prolonged bed rest, reduced cardiac output, or other prothrombotic states such as protein C or antithrombin III deficiency. It is most frequent in deep leg veins and can be a major threat to life because of pulmonary embolization (witness the well-known phenomenon of sudden death with ambulation after surgery). Deep venous thrombosis is discussed more fully in Chapter 7.

Lymphatic Vessels Lymphangitis Refers to Infection and Inflammation in Lymphatic Vessels Transport of infectious material to regional lymph nodes leads to intranodal inflammation termed lymphadenitis. The periphery of a focus of inflammation reveals dilated lymphatics filled with fluid exudate, cells, cellular debris, and bacteria. Almost any virulent pathogen can cause acute lymphangitis, but ␤-hemolytic streptococci (S. pyogenes) are common offenders. Draining lymph nodes are regularly enlarged and inflamed. Painful subcutaneous red streaks, often accompanied by tender regional lymph nodes, characterize acute lymphangitis.

Lymphatic Obstruction Causes Lymphedema Lymphatics may be obstructed by scar tissue, intraluminal tumor cells, pressure from surrounding tumor tissue, or plugging with parasites. As collateral lymphatic routes are abundant, lymphedema (distention of tissue by lymph) usually occurs only when major trunks, most commonly in the axilla or groin, are obstructed. For example, when radical mastectomy for breast cancer was routine, axillary lymph node dissection frequently disrupted lymphatic channels and led to lymphedema of the arm. Prolonged lymphatic obstruction causes progressive dilation of lymphatic vessels, termed lymphangiectasia, and overgrowth of fibrous tissue. The term elephantiasis describes a lymphedematous limb that has become grossly enlarged. An important cause of elephantiasis in the tropics is filariasis, in which a parasitic worm invades the lymphatics (see Chapter 9). Milroy disease is an inherited type of lymphangiectasia that is present at birth. It usually affects only one limb, but it may be more extensive and involve the eyelids and lips. Affected tissues show hugely dilated lymphatic channels, and the entire area appears honeycombed or spongy.

Benign Tumors of Blood Vessels Hemangiomas are Common Benign Tumors of Vascular Channels Hemangiomas usually occur in the skin but may also be found in internal organs.

PATHOGENESIS: Although hemangiomas are clearly benign, their origin is uncertain; they represent either true neoplasms or hamartomas. The evidence favoring hamartoma (i.e., a malformation) includes (1) the lesion is present at birth, (2) it grows only as the rest of the body grows and remains limited in size, and (3) after growth ceases, it usually remains unchanged indefinitely in the absence of trauma, thrombosis, or hemorrhage. At present, hemangiomas are classified by histologic type and location. PATHOLOGY: CAPILLARY HEMANGIOMA: This lesion is composed of vascular channels with the size and structure of normal capillaries. Capillary hemangiomas may be located in any tissue. The most common sites are skin, subcutaneous tissues, mucous membranes of lips and the mouth, and internal viscera, including spleen, kidneys, and liver. Capillary hemangiomas vary from a few millimeters to several centimeters in diameter. They are bright red to blue, depending on the degree of oxygenation of the blood. In the skin, capillary hemangiomas are known as birthmarks or ruby spots. The only disability is cosmetic. JUVENILE HEMANGIOMA: Also called strawberry hemangiomas, these benign lesions are found on the skin of newborns. They grow rapidly in the first months of life, begin to fade at 1 to 3 years of age, and completely regress in most (80%) cases by 5 years of age. Juvenile hemangiomas contain packed masses of capillaries separated by connective tissue stroma. The endotheliumlined channels are usually filled with blood. CAVERNOUS HEMANGIOMA: This designation is reserved for lesions consisting of large vascular channels, frequently interspersed with small, capillary-type vessels. Cavernous hemangiomas occur in the skin, where they are termed port wine stains. They also appear on mucosal surfaces and visceral organs, including the spleen, liver, and pancreas. Occasionally, they are encountered in the brain, where they may slowly enlarge and cause neurologic symptoms. A cavernous hemangioma is a red-blue, soft, spongy mass, with a diameter of up to several centimeters. Unlike the capillary hemangioma, a cavernous hemangioma does not regress spontaneously. Although the lesion is demarcated by a sharp border, it is not encapsulated. Large endothelial-lined, blood-containing spaces are separated by sparse connective tissue. MULTIPLE HEMANGIOMATOUS SYNDROMES: More than one hemangioma may occur in a single tissue. Two or more tissues may be involved, such as skin and nervous system or spleen and liver. von Hippel-Lindau syndrome is a rare entity in which cavernous hemangiomas occur in the cerebellum or brainstem and the retina. Sturge-Weber syndrome involves a developmental disturbance of blood vessels in the brain and skin.

Glomus Tumor (Glomangioma) is a Painful Arteriolar–Venous Anastomosis A glomus tumor is a benign neoplasm of the glomus body. Glomus bodies are normal neuromyoarterial receptors that are sensitive to temperature and regulate arteriolar flow. They are widely distributed in the skin, mostly in the distal regions of fingers and toes. This pattern is reflected in the location of glomus tumors at these sites, typically in a subungual location. PATHOLOGY: The lesions are small, usually under 1 cm in diameter; many are smaller than a few millimeters. In the skin, they are slightly elevated, rounded, redblue, and firm (Fig. 10-21). The two main histologic components are branching vascular channels in a connective tissue stroma and aggregates or nests of the specialized glomus cells.

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A FIGURE 10-21. Glomus tumor. A. The dorsal surface of the hand displays a prominent tumor nodule on the proximal third finger. B. A photomicrograph of (A) reveals nests of glomus tumor cells embedded in a fibrovascular stroma.

The latter are regular, round-to-cuboidal cells that reveal typical smooth muscle cell features by electron microscopy.

Hemangioendothelioma Has Some Malignant Characteristics Hemangioendothelioma is a vascular tumor of endothelial cells that is intermediate between benign hemangiomas and frankly malignant angiosarcomas. The epithelioid or histiocytoid variant displays endothelial cells with considerable eosinophilic, often vacuolated, cytoplasm. Vascular lumina are evident, and there are few mitoses. These tumors occur in almost all locations. Surgical removal is generally curative, but about one fifth of patients develop metastases. Spindle cell hemangioendothelioma occurs principally in males of any age, usually in the dermis and subcutaneous tissue of the distal extremities. It features vascular, endothelial-lined spaces into which papillary projections extend. Although the lesion may recur locally after excision, it rarely metastasizes.

Malignant Tumors of Blood Vessels Malignant vascular neoplasms are rare and may sometimes arise in pre-existing benign tumors.

Angiosarcoma is a Rare, Highly Malignant Tumor of Endothelial Cells The lesions occur in either gender and at any age and begin as small, painless, sharply demarcated, red nodules. The most common locations are skin, soft tissue, breast, bone, liver, and spleen. Eventually, most lesions enlarge to become pale gray, fleshy masses without a capsule. Often, these tumors undergo central necrosis, with softening and hemorrhage. PATHOLOGY: Angiosarcomas exhibit varying degrees of differentiation, ranging from those composed mainly of distinct vascular elements to undifferentiated tumors with few recognizable blood channels. The latter display frequent mitoses, pleomorphism, giant cells, and tend

to be more aggressive. Almost half of patients with angiosarcoma die of the disease. Angiosarcoma of the liver is of special interest because of its association with environmental carcinogens, particularly arsenic (a component of pesticides) and vinyl chloride (used in the production of plastics). Hepatic angiosarcoma was associated with the administration of thorium dioxide, a radioactive contrast medium (Thorotrast) used by radiologists prior to 1950. The earliest detectable changes are atypism and diffuse hyperplasia of the cells lining the hepatic sinusoids. The tumors are frequently multicentric and may arise in the spleen as well. Hepatic angiosarcomas are highly malignant and show both local invasion and metastatic spread.

Kaposi Sarcoma is a Complication of Acquired Immunodeficiency Syndrome (AIDS) Kaposi sarcoma is a malignant angioproliferative tumor derived from endothelial cells. EPIDEMIOLOGY: Originally described as uncommon, Kaposi sarcoma now appears in epidemic form in association with AIDS and in immunosuppressed patients. Human herpesvirus 8, also termed Kaposi sarcoma-associated herpes virus, is thought to be responsible for this tumor. Only a small faction of individuals infected with Kaposi sarcoma-associated herpes virus develop Kaposi sarcoma. PATHOLOGY: Kaposi sarcoma begins as painful purple or brown cutaneous nodules, 1 mm to 1 cm in diameter. They appear most often on the hands or feet but may occur anywhere. The histologic appearance is highly variable. One form resembles a simple hemangioma with tightly packed clusters of capillaries and scattered hemosiderinladen macrophages. Other forms are highly cellular, and the vascular spaces are less prominent. These lesions may be difficult to distinguish from fibrosarcomas, but the characteristic features of endothelial cells can be demonstrated immunochemically and by electron microscopy. Although Kaposi sarcoma is considered a malignant lesion and may be widely disseminated in the body, it is only exceptionally a cause of death.

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The Heart Jeffrey E. Saffitz

Coronary Arteries Myocardial Hypertrophy and Heart Failure Congenital Heart Disease (CHD) Early Left-to-Right Shunt Tetralogy of Fallot (Dominant Right-to-Left Shunt) Congenital Heart Diseases Without Shunts Ischemic Heart Disease Many Conditions Limit the Supply of Blood to the Heart Myocardial Infarcts Reperfusion of Ischemic Myocardium Clinical Diagnosis of Acute Myocardial Infarction Complications of Myocardial Infarction Therapeutic Interventions Chronic Congestive Heart Failure Hypertensive Heart Disease Effects of Hypertension on the Heart Cause of Death in Patients with Hypertension Cor Pulmonale Acquired Valvular and Endocardial Diseases Rheumatic Heart Disease Collagen Vascular Diseases Bacterial Endocarditis Nonbacterial Thrombotic Endocarditis (Marantic Endocarditis)

Calcific Aortic Stenosis Mitral Valve Prolapse (MVP) Carcinoid Heart Disease Myocarditis Viral Myocarditis Metabolic Diseases of the Heart Hyperthyroidism Thiamine Deficiency (Beriberi) Hypothyroid Heart Disease Cardiomyopathy Idiopathic Dilated Cardiomyopathy Secondary Dilated Cardiomyopathy Hypertrophic Cardiomyopathy Restrictive Cardiomyopathy Cardiac Tumors Cardiac Myxoma Rhabdomyoma Metastatic Tumors Diseases of the Pericardium Pericardial Effusions Acute Pericarditis Constrictive Pericarditis

The heart is a fist-sized muscular pump that has a remarkable capacity to work unceasingly for the 80 or more years of a human lifetime. As demand requires, it can increase its output manyfold, in part because the coronary circulation can augment its blood flow to more than 10 times normal. The ventricles also respond to short-term increases in workload by dilating, in accordance with Starling law of the heart. When an increased workload is imposed for a longer period (e.g., in

cases of essential hypertension), the left ventricle hypertrophies, an adaptation that increases its work capacity. However, when this compensatory mechanism reaches its limits, the heart no longer provides an adequate supply of blood to peripheral tissues, and the result is congestive heart failure. Damage to the myocardium, caused mostly by ischemic heart disease, also limits the capacity of the left ventricle to pump blood and similarly results in heart failure.

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Coronary Arteries Supply Blood to the Heart The right and left main coronary arteries originate in, or immediately above, the sinuses of Valsalva of the aortic valve. The left main coronary artery bifurcates within 1 cm of its origin into the left anterior descending (LAD) and left circumflex coronary ar-

teries. The left circumflex coronary artery rests in the left atrioventricular groove and supplies the lateral wall of the left ventricle (Fig. 11-1). The LAD coronary artery lies in the anterior interventricular groove and provides blood to the (1) anterior left ventricle, (2) adjacent anterior right ventricle, and (3) anterior half to two thirds of the interventricular septum. In the apical region, the LAD artery supplies the ventricles circumferentially (see Fig. 11-1).

A Posterior Infarct

= Zone of infarction

= Coronary artery occlusion

B Posterior

Left circunflex artery

Anterior Right coronary artery Left coronary artery (LAD)

Infarct

C Posterior

Infarct

Position of left ventricular infarcts resulting from occlusion of each of the three main coronary arteries. A. Posterolateral infarct, which follows occlusion of the left circumflex artery and is present in the posterolateral wall. B. Anterior infarct, which follows occlusion of the anterior descending branch (left anterior descending, LAD) of the left coronary artery. The infarct is located in the anterior wall and adjacent two thirds of the septum. It involves the entire circumference of the wall near the apex. C. A posterior (“inferior” or “diaphragmatic”) infarct results from occlusion of the right coronary artery and involves the posterior wall, including the posterior third of the interventricular septum and the posterior papillary muscle in the basal half of the ventricle. FIGURE 11-1.

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The right coronary artery travels along the right atrioventricular groove and nourishes the bulk of the right ventricle and posteroseptal left ventricle (see Fig. 11-1), including the posterior third to half of the interventricular septum at the base of the heart (also referred to as the “inferior” or “diaphragmatic” wall). From these distributions, one can predict the location of infarcts that result from occlusion of any of the three major epicardial coronary arteries. The epicardial coronary arteries are usually arranged in a so-called right coronary-dominant distribution. The pattern of dominance is determined by the coronary artery that contributes most of the blood to the posterior descending coronary artery. Ten percent of human hearts display a left-dominant pattern with the left circumflex coronary artery supplying the posterior descending coronary artery. Blood flow in the myocardium occurs inward from epicardium to endocardium. Thus, as a general rule, the endocardium is most vulnerable to ischemia when flow through a major epicardial coronary artery is compromised. The epicardial portion of each coronary artery fills and expands during systole and empties and narrows during diastole. The intramyocardial arteries have the opposite action and are narrowed by the systolic muscular pressure. As a result, blood flow within myocardium, especially in the subendocardial ventricular regions, is decreased or absent during systole.

Myocardial Hypertrophy and Heart Failure During systole, ventricles contract vigorously and eject about 60% of the blood present in the ventricle at the end of diastole (ejection fraction). When a heart is injured, the clinical consequences are similar, regardless of the cause of cardiac dysfunction. If the initial impairment is severe, cardiac output is not maintained despite compensatory changes, and the result is acute, life-threatening, cardiogenic shock. When the functional impairment is less, compensatory mechanisms (see below) maintain cardiac output by increasing diastolic ventricular filling pressure and end-diastolic volume. This situation results in the characteristic signs and symptoms of congestive heart failure. Because of the heart’s capacity to compensate, congestive heart failure is often tolerated for years. The heart’s ability to adapt to injury is based on the same mechanisms that allow cardiac output to increase in response to stress. The fundamental compensatory mechanism is the Frank-Starling mechanism: the cardiac stroke volume is a function of diastolic fiber length and, within certain limits, a normal heart will pump whatever volume is brought to it by the venous circulation. Stroke volume, a measure of ventricular function, is enhanced by increasing ventricular end-diastolic volume secondary to an increase in atrial filling pressure. The most prominent feature of heart failure is the abnormally high atrial filling pressure relative to stroke volume. However, the absolute values of stroke volume and cardiac output are generally well maintained in the failing heart. PATHOGENESIS: Myocardial hypertrophy is an adaptive response that augments myocyte contractile strength. It develops as a compensatory response to hemodynamic overload, which occurs in association with chronic hypertension or valvular stenosis (pressure overload), myocardial injury, valvular insufficiency (volume overload), and other stresses that increase heart workload. A distinction must be made between physiologic hypertrophy of a heart that develops in highly trained athletes and pathologic hypertrophy that occurs in response to injury or overload. Hypertrophic responses feature enlargement of cardiac myocytes and accumulation of sarcomeric proteins without an increase in the number of cardiac myocytes. Hypertrophy initially reflects a compensatory and potentially reversible mechanism, but faced with persistent stress, the myocardium becomes irreversibly enlarged and dilated (Fig. 11-2).

Receptor-mediated myocardial events that are triggered by a stimulus promote the hypertrophic response by autocrine and paracrine mechanisms. Contractile cells respond to mechanical stimuli, such as stretching, by activating receptor-mediated signaling pathways that produce hypertrophy. Among the most important ligands that activate these pathways are (1) angiotensin II, (2) endothelin1, and (3) various growth factors, including insulin-like growth factor-1 and transforming growth factor-␤. Some of these mediators may also act on interstitial fibroblasts in the heart to promote synthesis and deposition of extracellular matrix. The heart has traditionally been thought of as incapable of growing new myocytes to regenerate or repair damage due to a lack of cardiac stem cells. In this view, cardiac myocytes can respond to injury only by hypertrophy or death. Many controversies remain, but there is now compelling evidence that cardiac stem cells exist in adults. For example, male transplant recipients who have received female hearts exhibit fully differentiated cardiac myocytes bearing the Y chromosome, which must have been derived from the circulation. Moreover, embryonic stem cells and adult bone marrow-derived cells can experimentally repopulate areas of myocardial injury and differentiate into cardiac myocytes. In addition, resident cardiac progenitor cells have been identified in interstitial “niches” in the heart. Thus, the failing heart is a candidate for potential stem cell therapy (see Chapter 3). PATHOLOGY: Anything that increases cardiac workload for a prolonged period or produces structural damage may eventuate in myocardial failure. Ischemic heart disease is by far the most common condition responsible for cardiac failure, accounting for more than 80% of deaths from heart disease. Most of the remaining deaths are caused by nonischemic forms of heart muscle disease (cardiomyopathies) and congenital heart disease (CHD). Other than changes characteristic of specific disease entities (e.g., ischemic heart disease or cardiac amyloidosis), the morphology of the failing heart is nonspecific. Ventricular hypertrophy is observed in virtually all conditions associated with chronic heart failure. Initially, only the left ventricle may be hypertrophied, as occurs in compensated hypertensive heart disease. But when the left ventricle fails, some right ventricular hypertrophy usually follows because of the increased workload imposed on the right ventricle by the failing left ventricle. In most cases of clinically apparent heart failure, the ventricles are conspicuously dilated. The distribution of end-organ involvement depends on whether the heart failure is predominantly left-sided or right-sided. Left-sided heart failure is more common, because the most frequent causes of cardiac injury (e.g., ischemic heart disease and hypertension) primarily affect the left ventricle. To compensate for left ventricular failure, left atrial and pulmonary venous pressures increase, resulting in passive pulmonary congestion. The capillaries in the alveolar septa fill with blood, and small ruptures allow erythrocytes to escape. As a result, alveoli contain many hemosiderin-laden macrophages (so-called heart failure cells). Moreover, if capillary hydrostatic pressure exceeds plasma osmotic pressure, fluid leaks from capillaries into alveoli. The resultant pulmonary edema may be massive, with alveoli being “drowned” in a transudate. Interstitial pulmonary fibrosis results when congestion is present over an extended period (see Chapters 7 and 12). Right-sided heart failure commonly complicates left-sided failure, or it can develop independently secondary to intrinsic pulmonary disease or pulmonary hypertension, which create resistance to blood flow through the lungs. As a consequence, right atrial pressure and systemic venous pressure both increase, resulting in jugular venous distention, lower-extremity edema, and congestion of the liver and spleen. Hepatic congestion in heart failure is discussed in Chapter 14. Diastolic heart failure is seen in up to one third of elderly patients with obvious heart failure. As the heart ages, the ventricles become progressively stiffer and require greater filling (diastolic) pressures. Some patients exhibit signs and symptoms of

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NORMAL MYOCARDIAL CELL

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HYPERTROPHIC CARDIAC MYOCYTE ↑Extracellular matrix

Extracellular matrix β-adrenergic receptors

↓Norepinephrine stores Nucleus

TGF-β

c-myc c-fos HSP-70

Cardiac growth factors

Sarcoplasmic reticulum (SR)

Ang II Endothelin IGF-I Cardiotrophic cytokines

↓β-adrenergic receptors

Norepinephrine Ca2+

↓Ca2+ uptake by SR Ca2+

Adult isoforms of myofibrillar proteins

↓Ca2+ efflux from SR

Fetal isoforms of myofibrillar proteins

Ca2+

ANF Ca2+ channels

Ca2+

↑Ca2+ channels (?)

↑Ca2+ influx (?)

Biochemical characteristics of myocardial hypertrophy and congestive heart failure. ANF, atrial natriuretic factor; ANG II, angiotensin II; HSP-70, heat shock protein 70; IGF, insulin-like growth factor; TGF, transforming growth factor. FIGURE 11-2.

heart failure although their hearts are normal in size, do not show left ventricular hypertrophy, and have normal systolic contractile function. These patients do not easily tolerate increases in blood volume and are susceptible to developing pulmonary edema in response to a fluid challenge. Microscopically, these hearts typically exhibit interstitial fibrosis, which may contribute to the decreased compliance of ventricular myocardium. CLINICAL FEATURES: Symptoms of left-sided failure include dyspnea on exertion, orthopnea (dyspnea when lying down), and paroxysmal nocturnal dyspnea. Dyspnea on exertion reflects the increasing pulmonary congestion that accompanies a higher end-diastolic pressure in the left atrium and ventricle. Orthopnea and paroxysmal nocturnal dyspnea result when thoracic blood volume increases, on account of reduced blood volume in the lower extremities during recumbency. Although much of the clinical presentation of heart failure can be explained by venous congestion (backward failure), certain aspects of congestive failure involve inadequate arterial perfusion of vital organs (forward failure). Most patients with left-sided heart failure retain sodium and water (edema), owing to decreased renal perfusion, decreased glomerular filtration rate, and activation of the renin–angiotensin–aldosterone system (see Chapters 7 and 10). Inadequate cerebral perfusion can lead to confusion, memory loss, and disorientation. Reduced perfusion of skeletal muscle is associated with fatigue and weakness.

Congenital Heart Disease (CHD) CHD is a consequence of faulty embryonic development, expressed either as misplaced structures (e.g., transposition of the great vessels) or as an arrest in the progression of a normal structure from an early stage to one that is more mature (e.g., atrial septal defect). Significant CHD occurs in almost 1% of all live births. This does not include certain common defects that are not functionally important, such as an anatomically patent foramen ovale that is functionally closed by the left atrial flap that covers it. In this circumstance, the foramen ovale remains closed as long as left atrial pressure exceeds that in the right atrium. A bicuspid aortic valve is also common and is usually asymptomatic until adulthood, when it is often associated with calcific aortic stenosis. Estimates of the incidence of particular cardiovascular anomalies vary, depending on many factors. A range derived from several sources is shown in Table 11-1. PATHOGENESIS: The causes of CHD are usually not ascertained. Most congenital heart defects reflect both multifactorial genetic and environmental influences. As in other diseases with multifactorial inheritance (see Chapter 6), the risk of recurrence is increased among siblings of an affected child. Moreover, an infant born to a mother with CHD also has an increased risk of cardiac defects.

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TABLE 11–1

Relative Incidence of Specific Anomalies in Patients With Congenital Heart Disease Ventricular septal defects—25% to 30% Atrial septal defects—10% to 15% Patent ductus arteriosus—10% to 20% Tetralogy of Fallot—4% to 9% Pulmonary stenosis—5% to 7% Coarctation of the aorta—5% to 7% Aortic stenosis—4% to 6% Complete transposition of the great arteries—4% to 10% Truncus arteriosus—2% Tricuspid atresia—1%

shunt. Left ventricular dilation and congestive heart failure are common complications of such shunts. If a defect is small enough to permit prolonged survival, augmented pulmonary blood flow caused by shunting of blood into the right ventricle eventually leads to thickening of pulmonary arteries and increased pulmonary vascular resistance. This increased vascular resistance may be so great that the direction of the shunt is reversed and goes from right to left (Eisenmenger syndrome). A patient with this condition displays late onset of cyanosis (i.e., tardive cyanosis), right ventricular hypertrophy, and right-sided heart failure. Additional complications of ventricular septal defects include (1) infective endocarditis at the site of the defect, (2) paradoxical emboli (moving right to left through a patent foramen ovale), and (3) prolapse of an aortic valve cusp (with resulting aortic valve insufficiency). Large ventricular septal defects are repaired surgically, usually in infancy.

Atrial Septal Defects Single-gene syndromes are rare causes of CHD. Mutations in Csx/Mkx2-5 in humans have been associated with a spectrum of congenital cardiac malformations. Chromosomal abnormalities associated with an increased incidence of congenital heart anomalies include Down syndrome (trisomy 21), other trisomies, Turner syndrome, and DiGeorge syndrome. Together, these account for no more than 5% of all cases of CHD. The best evidence for intrauterine influence in the occurrence of congenital cardiac defects relates to maternal rubella infection during the first trimester, especially during the first 4 weeks of gestation. Maternal use of certain drugs, including alcohol, phenytoin, amphetamines, lithium, estrogenic steroids and, historically, thalidomide have been associated with an increased risk of CHD, as is maternal diabetes. A contemporary classification divides the cases into the groups shown in Table 112 and is based on the pattern of blood shunting.

Early Left-to-Right Shunt Reflects Higher Pressure on the Left Side of the Heart Ventricular Septal Defect Ventricular septal defects are the most common congenital heart lesions (see Table 11-1). They occur as isolated defects or in combination with other malformations. PATHOGENESIS: The fetal heart consists of a single chamber until the fifth week of gestation, after which it is divided by the development of interatrial and interventricular septa and by the formation of atrioventricular valves from endocardial cushions. A muscular interventricular septum grows upward from the apex toward the base of the heart (Fig. 11-3). It is joined by the down-growing membranous septum, separating right and left ventricles. The most common ventricular septal defect is related to failure of the membranous portion of the septum to form in whole or in part. PATHOLOGY: Ventricular septal defects occur as (1) a small hole in the membranous septum, (2) a large defect involving more than the membranous region (perimembranous defects), (3) defects in the muscular portion, which are more common anteriorly but can occur anywhere in the muscular septum, or (4) complete absence of the muscular septum (leaving a single ventricle). CLINICAL FEATURES: A small septal defect may have little functional significance and may actually close spontaneously as the child matures. Closure is accomplished by either hypertrophy of adjacent muscle or adherence of tricuspid valve leaflets to the margins of the defect. In infants with large septal defects, higher left ventricular pressure initially creates a left-to-right

Atrial septal defects range in severity from clinically insignificant and asymptomatic anomalies to chronic, life-threatening conditions. PATHOGENESIS: The embryologic development of the atrial septum occurs in a sequence that permits the continued passage of oxygenated placental blood from the right to the left atrium through the patent foramen until birth. Beginning at the fifth week of intrauterine life, the septum primum extends downward from the roof of the atrium to join with the endocardial cushions, thereby closing the incomplete segment, or “ostium primum” (see Fig. 11-3). Before this closure is complete, the midportion of the septum primum develops a defect, or “ostium secundum,” so that right-to-left flow continues. During the sixth week, a second septum (septum secundum) develops to the right of the septum primum, passing from the roof of the atrium toward the endocardial cushions. This process leaves a patent foramen at about the midpoint of the septum, known as the foramen ovale. The defect persists after birth until it is sealed off by fusion of the septum primum and septum secundum, after which it is termed the fossa ovalis.

TABLE 11–2

Classification of Congenital Heart Disease Initial left-to-right shunt Ventricular septal defect Atrial septal defect Patent ductus arteriosus Persistent truncus arteriosus Anomalous pulmonary venous drainage Hypoplastic left heart syndrome Right-to-left shunt Tetralogy of Fallot Tricuspid atresia No shunt Complete transposition of the great vessels Coarctation of the aorta Pulmonary stenosis Aortic stenosis Coronary artery origin from pulmonary artery Ebstein malformation Complete heart block Endocardial fibroelastosis

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PATHOLOGY: The atrial septum may be defective at a number of sites (see Fig. 11-3). • Patent foramen ovale: Tissue derived from the septum primum situated on the left side of the foramen ovale functions as a flap valve that normally fuses with the margins of the foramen ovale, thereby sealing the opening. An incomplete seal of the foramen ovale is found in 25% of healthy adults and is not usually functional. If circumstances increase right atrial pressure, as can occur with recurrent pulmonary thromboemboli, a right-to-left shunt will be produced, and thromboemboli from the right-sided circulation will pass directly into the systemic circulation. These paradoxical emboli can produce infarcts in many parts of the arterial circulation, most commonly in the brain, heart, spleen, intestines, kidneys, and lower extremities. • Atrial septal defect, ostium secundum type: This is by far the most common atrial septal defect, accounting for 90% of all cases. It is a true deficiency of the atrial septum and should not be confused with a patent foramen ovale. An ostium secundum defect occurs in the middle portion of the septum and varies from a trivial opening to a large defect of the entire fossa ovalis region. A small defect is usually not functional, but a larger one may allow shunting of sufficient blood from left to right to cause dilation and hypertrophy of the right atrium and ventricle. In this setting, the diameter of the pulmonary artery may exceed that of the aorta. • Lutembacher syndrome, a variant of the ostium secundum type of atrial septal defect, is the combination of either congenital or rheumatic mitral stenosis and an ostium secundum atrial septal defect. • Sinus venosus defect: This anomaly occurs in the upper portion of the atrial septum, above the fossa ovalis, near the entry of the superior vena cava. It is usually accompanied by drainage of the right pulmonary veins into the right atrium or superior vena cava. This defect represents 5% of atrial septal defects. • Atrial septal defect, ostium primum type: This condition involves the region adjacent to the endocardial cushion and comprises 7% of all atrial septal defects. There are usually clefts in the anterior leaflet of the mitral valve and the septal leaflet of the tricuspid valve, which may be accompanied by an associated defect in the adjacent interventricular septum. • Persistent common atrioventricular canal: This anomaly represents fully developed combined atrial and ventricular septal defects. Although ordinarily uncommon, this defect is frequently encountered in patients with Down syndrome. Incomplete defects are also observed. CLINICAL FEATURES: Young children with atrial septal defects are ordinarily asymptomatic, although they may complain of easy fatigability and dyspnea on exertion. Later in life, usually in adulthood, changes in the pulmonary vasculature may reverse the flow of blood through the defect and create a right-to-left shunt. In such cases, cyanosis and clubbing of the fingers ensue. Complications of atrial septal defects include atrial arrhythmias, pulmonary hypertension, right ventricular hypertrophy, heart failure, paradoxical emboli, and bacterial endocarditis. Symptomatic cases are treated surgically or with closure devices, which can be delivered and placed percutaneously.

Patent Ductus Arteriosus (PDA) The ductus arteriosus in the fetus connects the descending aortic arch with the pulmonary artery and conveys most of the pulmonary outflow into the aorta. After birth, the ductus constricts in response to the increased arterial oxygen content and becomes occluded by fibrosis (ligamentum arteriosus).

221

PATHOGENESIS: Persistent PDA is one of the most common congenital cardiac defects and is seen frequently in infants whose mothers were infected with the rubella virus early in pregnancy. In full-term infants with PDA, the ductus has an abnormal endothelium and media and only rarely closes spontaneously. CLINICAL FEATURES: The luminal diameter of a PDA varies greatly. A small shunt has little effect on the heart, whereas a large shunt leads to considerable diversion of blood from the aorta to the low-pressure pulmonary artery. In severe cases, left ventricular hypertrophy and heart failure ensue because of increased demand for cardiac output. The increased volume and pressure of blood in the pulmonary circulation eventually produce pulmonary hypertension and its cardiac complications. Infective endarteritis is a frequent complication of untreated PDA. PDA can be corrected surgically or by cardiac catheterization. It can be caused to contract and then close by the instillation of prostaglandin synthesis inhibitors (e.g., indomethacin).

Truncus Arteriosus Persistent truncus arteriosus refers to a common trunk for the origin of the aorta, pulmonary arteries, and coronary arteries. It results from absent or incomplete partitioning of the truncus arteriosus by the spiral septum. Truncus arteriosus always overrides a ventricular septal defect and receives blood from both ventricles. Several structural variants have been described. The most common (type 1) consists of a single trunk that gives rise to a common pulmonary artery and ascending aorta. CLINICAL FEATURES: Most infants with truncus arteriosus have torrential pulmonary blood flow, causing heart failure, recurrent respiratory tract infections, and often, early death. Pulmonary vascular disease develops in children with prolonged survival, in which case cyanosis, polycythemia, and clubbing of the fingers appear. Open-heart surgery prior to the development of significant pulmonary vascular changes is an effective treatment.

Tetralogy of Fallot (Dominant Right-to-Left Shunt) is the Most Common Cyanotic CHD Tetralogy of Fallot represents 10% of all cases of CHD and is the most common cyanotic heart disease in older children and adults. PATHOLOGY: The four anatomical changes that define the tetralogy of Fallot are (Fig. 11-4): • Pulmonary stenosis • Ventricular septal defect • Dextroposition of the aorta so that it overrides the ventricular septal defect • Right ventricular hypertrophy The heart is hypertrophied so as to give it a boot shape. Almost half of patients with tetralogy of Fallot have other cardiac anomalies, including ostium secundum atrial septal defects, PDA, left superior vena cava, and endocardial cushion defects. The aortic arch is on the right side in about 25% of cases of tetralogy of Fallot. Patency of the ductus arteriosus is actually protective, because it provides a source of blood to the otherwise deprived pulmonary vascular bed. CLINICAL FEATURES: In the face of severe pulmonary stenosis, right ventricular blood is shunted through the ventricular septal defect into the aorta, resulting in arterial desaturation and cyanosis. Surgical correction is typ-

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Right pulmonary veins SVC

Septum secundum Ostium secundum

Septum primum RA

Left pulmonary veins

LA Septum primum

Ostium primum IVC

Membranous interventricular septum

Endocardial cushions Interventricular septum RV

Pulmonary veins

Septum venosus defect

Ostium primum LA

LA RA

D Pathogenesis of ventricular and atrial septal defects. A. The common atrial chamber is being separated into the right and left atria (RA and LA) by the septum primum. Because the septum primum has not yet joined the endocardial cushions, there is an open ostium primum. The ventricular cavity is being divided by a muscular interventricular septum into right and left chambers (right and left ventricles, RV and LV). SVC, superior vena cava; IVC, inferior vena cava. B. The septum primum has joined the endocardial cushions but at the same time, has developed an opening in its midportion (the ostium secundum). This opening is partly overlaid by the septum secundum, which has grown down to cover, in part, the foramen ovale. Simultaneously, the membranous septum joins the muscular interventricular septum to the base of the heart, completely separating the ventricles. C. The sinus venosus type of atrial septal defect is located in the most cephalad region and is adjacent to the inflow of the right pulmonary veins, which thus tend to open into the RA. D. The ostium primum defect occurs just above the atrioventricular (AV) valve ring, sometimes in the presence of an intact valve ring. It may also, in conjunction with a defect of the valve ring and ventricular septum, form an AV canal, as shown in (E). This common opening allows free communication between the atria and the ventricles. FIGURE 11-3.

Ostium primum Single AV valve Ventricular septal defect

LV Muscular interventricular septum

AV canal

Muscular interventricular septum

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Aorta Ductus arteriosus Infundibular stenosis

Pulmonary artery LA

Pulmonary valvular stenosis

Ventricular septal defect (Note the overriding transposed aorta)

Tetralogy of Fallot. Note the pulmonary stenosis, which is due to infundibular hypertrophy as well as pulmonary valvular stenosis. The ventricular septal defect involves the membranous septum region. Dextroposition of the aorta and right ventricular hypertrophy are shown. Because of the pulmonary obstruction, the shunt is from right to left, and the patient is cyanotic. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle. FIGURE 11-4.

ically performed in the first 2 years of life. In children who are unrepaired, dyspnea on exertion is particularly noticeable, and the affected child often assumes a squatting position to relieve the shortness of breath. Physical development is characteristically retarded. Cerebral thromboses may complicate the disease due to marked polycythemia. Patients are also at risk for bacterial endocarditis and brain abscesses. Without surgical intervention, tetralogy of Fallot has a dismal prognosis. However, total correction is now possible with open-heart surgery, which carries a mortality rate that is less than 10%. After successful surgery, patients are asymptomatic and have an excellent long-term prognosis.

CHDs Without Shunts Involve Various Cardiovascular Sites

CLINICAL FEATURES: Before cardiac surgery, the outlook for infants with TGA was hopeless; 90% died in their first year. It is now possible to correct the malformation within the first 2 weeks of life using an arterialswitch operation, with overall survival rate of 90%. Patients in whom corrected TGA is the only malformation are clinically entirely normal. Unfortunately, many cases are complicated by other cardiac anomalies, which require their own specific interventions.

Coarctation of the Aorta Coarctation of the aorta is a local constriction that almost always occurs immediately below the origin of the left subclavian artery at the site of the ductus arteriosus (Fig. 11-6). Rare coarctations can occur at any point from the aortic arch to the abdominal bifurcation. The condition is two to five times more frequent in males than females and is associated with a bicuspid aortic valve in two thirds of cases. Mitral valve malformations, ventricular septal defects, and subaortic stenosis may also accompany coarctation of the aorta. There is a particular association of coarctation with Turner syndrome, and berry aneurysms in the brain are also more common. CLINICAL FEATURES: The clinical hallmark of coarctation of the aorta is a discrepancy in blood pressure between the upper and lower extremities. The pressure gradient produced by the coarctation causes hypertension proximal to the narrowed segment and, occasionally, dilation of that portion of the aorta. Hypertension in the upper part of the body results in left ventricular hypertrophy and may produce dizziness, headaches, and nosebleeds. Hypotension below the coarctation leads to weakness, pallor, and coldness of lower extremities. Radiologic examination of the chest shows notching of the inner surfaces of the ribs, produced by increased pressure in markedly dilated intercostal arteries. Most patients with coarctation of the aorta die by age 40 unless they are treated. Complications include (1) heart failure, (2) rupture of a dissecting aneurysm (secondary to cystic medial necrosis of the aorta), (3) infective endarteritis at the point of narrowing or at the

Aorta Ligamentum arteriosum RA LA

Transposition of the Great Arteries (TGA)

Pulmonary artery

In transposition of the great arteries (TGA), the aorta arises from the right ventricle and the pulmonary artery from the left ventricle. In TGA, the aorta is anterior to the pulmonary artery and to its right (“D” or dextrotransposition) all the way from its origin. The condition shows a male predominance and is more common in offspring of mothers with diabetes. TGA is responsible for more than half of deaths in infants with cyanotic heart disease who are younger than 1 year of age. PATHOGENESIS: Because the venous blood from the right side of the heart flows to the aorta, and the oxygenated blood from the lungs returns to the pulmonary artery, there are, in effect, two independent and parallel blood circuits for the systemic and pulmonary circulations (Fig. 11-5). Survival is possible only if there is a communication between the circuits. Virtually all infants with TGA have an atrial septal defect. One half of patients exhibit a ventricular septal defect and two thirds have a PDA.

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Complete transposition of great arteries, regular type. The aorta is anterior to, and to the right of, the pulmonary artery (“D-transposition”) and arises from the right ventricle. In the absence of interatrial or interventricular connections or patent ductus arteriosus, this anomaly is incompatible with life. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle. FIGURE 11-5.

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Aortic isthmus FETAL Posterior shelf

Ductus arteriosus Persistence of narrowed aortic isthmus

Dilated aortic isthmus Posterior shelf

Posterior shelf

INFANTILE

LATE GESTATION Patent ductus arteriosus Pathogenesis of coarctation of the aorta. In the fetus, ductal blood is diverted into cephalad and descending streams by the posterior aortic shelf. In late fetal life, the isthmus dilates, and the increased descending blood flow is accommodated by the ductal orifice. After birth, if the shelf does not undergo the normal involution, obliteration of the ductal orifice does not permit free flow around the persistent posterior shelf, thereby creating a juxtaductal obstruction of blood flow to the distal aorta. If the aortic isthmus does not dilate during late fetal life, it remains narrow, resulting in an infantile or preductal coarctation. In this circumstance, the ductus arteriosus usually remains patent. FIGURE 11-6.

Persistent posterior shelf

NEWBORN Ligamentum arteriosus

site of jet stream impingement on the wall immediately distal to the coarctation, (4) cerebral hemorrhage, and (5) stenosis or infective endocarditis of a bicuspid aortic valve. Coarctation of the aorta is successfully treated by surgical excision of the narrowed segment, preferably between 1 and 2 years of age for asymptomatic patients.

Congenital Aortic Stenosis Three types of congenital aortic stenosis are recognized: valvular, subvalvular, and supravalvular. VALVULAR AORTIC STENOSIS: The most common congenital aortic stenosis is a bicuspid valve, which arises through the abnormal development of the endocardial cushions. A congenitally bicuspid aortic valve is considerably more frequent (4:1) in males than in females and is associated with other cardiac anomalies (e.g., coarctation of the aorta) in 20% of cases. A bicuspid valve typically features fusion of two of the three semilunar cusps (the right coronary cusp with one of the adjacent two cusps). CLINICAL FEATURES: Many children with bicuspid aortic stenosis are asymptomatic. Over the years, the resulting bicuspid valve tends to become thickened and calcified, generally leading to symptoms in adulthood. More severe forms of congenital aortic stenosis involving unicommissural or valves without commissures cause symptoms in early life. Exertional dyspnea and angina pectoris may be prominent. Sudden death, principally due to ventricular arrhythmias, is a distinct threat for patients with severe obstruction. Bacterial endo-

carditis sometimes complicates the disease. In symptomatic cases, aortic valvulotomy has had a high degree of success, although valve replacement is occasionally indicated. SUBVALVULAR AORTIC STENOSIS: This defect accounts for 10% of all cases of congenital aortic stenosis. Stenosis results from a membranous diaphragm or fibrous ring that surrounds the left ventricular outflow tract immediately below the aortic valve. It is twice as common in males as in females. In many persons with subvalvular aortic stenosis, thickening and immobility of the aortic cusps develops, with mild aortic regurgitation. Bacterial endocarditis may occur and also aggravate the regurgitation. Surgical treatment of subvalvular aortic stenosis involves excising the membrane or fibrous ridge. SUPRAVALVULAR AORTIC STENOSIS: This type of stenosis is much less common than the other two and is often associated with defects in the elastin gene, such as are found in Williams syndrome, a congenital disease associated with a deletion of an area of chromosome 7. The syndrome is characterized by idiopathic infantile hypercalcemia, mental retardation, and multiple system disorders.

Ebstein Malformation Ebstein malformation results from downward displacement of an abnormal tricuspid valve into an underdeveloped right ventricle. One or more tricuspid valve leaflets are plastered to the right ventricular wall for a variable distance below the right atrioventricular annulus.

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PATHOLOGY: Septal and posterior tricuspid valve leaflets are usually affected. They are irregularly elongated and adherent to the right ventricular wall, so that the upper part of the right ventricular cavity (inflow region) functions separately from the distal chamber. Thus, the effective tricuspid valve orifice is displaced downward into the ventricle, thereby dividing it into two separate parts: the “atrialized” ventricle (proximal ventricle) and the functional right ventricle (distal ventricle). In two thirds of cases, conspicuous dilation of the functional ventricle hinders its ability to pump blood efficiently through the pulmonary arteries. The degree of insufficiency of the tricuspid valve depends on the severity and configuration of the defect in the leaflets. CLINICAL FEATURES: Ebstein malformation leads to heart failure, massive right atrial dilation, arrhythmias with palpitations and tachycardia, and sudden death. Surgical treatment has met with variable success.

Congenital Heart Block PATHOGENESIS: Congenital complete heart block is usually associated with other cardiac anomalies. In such cases, disruption in the continuity of the conduction system is probably caused by the accompanying cardiac abnormality. Congenital heart block in the absence of structural heart disease has been linked to maternal connective tissue disease, especially systemic lupus erythematosus (SLE). If maternal SS-A/Ro or SS-B/La autoantibodies are transplacentally transmitted to the fetus, the incidence of congenital complete heart block approaches 100%. PATHOLOGY AND CLINICAL FEATURES: The hearts of patients with congenital heart block tend to show a lack of continuity between the atrial myocardium and the atrioventricular node. Alternatively, the defect may consist of a fibrous separation of the atrioventricular node from the ventricular conducting tissue. Although the heart rate is abnormally slow, patients with isolated heart block often have little functional difficulty. Later in life, cardiac hypertrophy, attacks of Stokes-Adams syncope (dizziness and unexpected fainting), arrhythmias, and heart failure may develop.

Endocardial Fibroelastosis Endocardial fibroelastosis (EFE) is characterized by thickening of the endocardium of the left ventricle, which may also affect the valves. The disorder is classified as primary or secondary, the latter being far more common. SECONDARY ENDOCARDIAL FIBROELASTOSIS: This disorder occurs in association with underlying cardiovascular anomalies that lead to left ventricular hypertrophy in the face of an inability to meet the increased myocardial oxygen demands. Thus, secondary EFE is a frequent complication of congenital aortic stenosis (including hypoplastic left ventricle syndrome) and coarctation of the aorta. Presumably, some type of endocardial injury is involved in its pathogenesis. PATHOLOGY: On gross examination, the left ventricle endocardium displays irregular, opaque, grey-white patches, which also may be present on the cardiac valves. Microscopically, these plaques are areas of endocardial fibroelastotic thickening, frequently accompanied by degeneration of adjacent subendocardial myocytes. The valves may show collagenous thickening. PRIMARY ENDOCARDIAL FIBROELASTOSIS: De-fined as fibroelastosis in the absence of any associated lesion, this disorder

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is now quite rare. It afflicts infants, usually 4 to 10 months of age. Although it has occurred in siblings, no specific mode of inheritance has been established. Recent evidence links primary EFE to mumps infection, which may explain why this condition is now so rarely encountered. PATHOLOGY: The left ventricle is usually conspicuously dilated but occasionally contracted and hypertrophic. Diffuse endocardial thickening involves most of the left ventricle as well as the aortic and mitral valve leaflets. The thickened endocardium tends to obscure the trabecular pattern of the underlying myocardium, and papillary muscles and chordae tendineae are thick and short. Mural thrombi may complicate the condition. Infants with primary EFE develop progressive heart failure. The prognosis is dismal, and cardiac transplantation offers the only hope for a cure.

Dextrocardia Dextrocardia is rightward orientation of the base–apex axis of the heart. It is often associated with a mirror image of the normal left-sided location and configuration. The position of the ventricles is determined by the direction of the embryonic cardiac loop. If the loop protrudes to the right, the future right ventricle develops on the right, and the left ventricle comes to occupy its proper position. If the loop protrudes to the left, the opposite occurs. PATHOLOGY: When dextrocardia occurs without abnormal positioning of the visceral organs (situs inversus), the condition is invariably associated with severe cardiovascular anomalies. These include transposition of the great arteries, a variety of atrial and ventricular septal defects, anomalous pulmonary venous drainage, and many others. In dextrocardia that occurs with situs inversus, the heart is functionally normal, although minor anomalies are not uncommon.

Ischemic Heart Disease Ischemic heart disease is, in most cases, a consequence of coronary artery atherosclerosis. It develops when blood flow is inadequate to meet the oxygen demands of the heart. Ischemic heart disease is responsible for at least 80% of all deaths attributable to heart disease in the United States and other industrialized nations, where it remains the leading cause of death. By contrast, atherosclerotic heart disease is far less frequent in developing countries. The principal effects of ischemic heart disease are angina pectoris, myocardial infarction, chronic congestive heart failure, and sudden death. ANGINA PECTORIS: This term refers to the pain resulting from myocardial ischemia. It typically occurs in the substernal portion of the chest and may radiate to the left arm, jaw, and epigastrium. It is the most common symptom of ischemic heart disease. Coronary atherosclerosis usually becomes symptomatic only when the luminal cross-sectional area of the affected vessel is reduced by more than 75%. A patient with typical angina pectoris exhibits recurrent episodes of chest pain, usually brought on by increased physical activity or emotional excitement. The pain is of limited duration (1 to 15 minutes) and is relieved by reducing physical activity or by treatment with sublingual nitroglycerin (a potent vasodilator). Although the most common cause of angina pectoris is severe coronary atherosclerosis, decreased coronary blood flow can result from other conditions, including coronary vasospasm, aortic stenosis, or aortic insufficiency. Angina pectoris is not associated with anatomic changes in the myocardium as long as the duration and severity of ischemic episodes are insufficient to cause myocardial cell necrosis. PRINZMETAL ANGINA (VARIANT ANGINA) is an atypical form of angina that occurs at rest and is caused by coronary artery spasm. The responsible mechanisms are not fully understood. Whereas coronary artery spasm may contribute to the pathogenesis of an

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acute myocardial infarction or to the size of the infarct, it is generally not the principal cause of infarction. UNSTABLE ANGINA, a variety of chest pain that has a less predictable relationship to exercise than does stable angina and may occur during rest or sleep, is associated with development of nonocclusive thrombi over atherosclerotic plaques. In some cases of unstable angina, episodes of chest pain become progressively more frequent and longer in duration over a 3- to 4-day period. Electrocardiographic changes are not characteristic of infarction, and serum levels of cardiac-specific intracellular proteins, such as MB isoform of CK (MB-CK) or cardiac troponin T or I (evidence of myocardial necrosis), remain normal. Unstable angina is also termed preinfarction angina, accelerated angina, or “crescendo” angina. Without pharmacologic or mechanical intervention to “open up” the coronary narrowing, many patients with unstable angina progress to myocardial infarction. MYOCARDIAL INFARCT: A myocardial infarct is a discrete focus of ischemic muscle necrosis in the heart. This definition excludes patchy foci of necrosis caused by drugs, toxins, or viruses. The development of an infarct is related to the duration of ischemia and the metabolic rate of the ischemic tissue. In experimental coronary artery ligation, foci of necrosis form after 20 minutes of ischemia and become more extensive as the period of ischemia lengthens. CHRONIC CONGESTIVE HEART FAILURE: Contractile impairment in these patients is due to irreversible loss of myocardium from previous infarcts and hypoperfusion of surviving muscle, which leads to chronic ventricular dysfunction. Many patients will develop progressive pump failure and die of multiorgan failure. SUDDEN DEATH: In some patients, the first and only clinical manifestation of ischemic heart disease is sudden death occurring within 1 hour of symptom onset due to spontaneous ventricular fibrillation. Coronary atherosclerosis underlies most of such cases. In many cases, lethal arrhythmia is likely triggered by acute ischemia without overt myocardial infarction. However, the presence of a healed infarct or ventricular hypertrophy increases the risk that an episode of acute ischemia will initiate a life-threatening ventricular arrhythmia. EPIDEMIOLOGY: The major risk factors that predispose to coronary artery disease are (1) systemic hypertension, (2) cigarette smoking, (3) diabetes mellitus, and (4) elevated blood cholesterol level. Any one of these factors significantly increases the risk of myocardial infarction, but a combination of multiple factors augments the risk more than sevenfold (see Chapter 8). In 1950, the age-adjusted death rate from myocardial infarction was 226 per 100,000 cases; 50 years later, it was 150. This shift reflects many factors, including reduced smoking, lower dietary saturated fat, and new drugs that control hypertension, reduce cholesterol, and lyse coronary thrombi. Multiple studies established that elevated serum LDLs increase the risk of myocardial infarction, whereas elevated levels of high-density lipoproteins (HDLs) decrease the risk. The total cholesterol/HDL cholesterol ratio appears to be a better predictor of coronary artery disease than serum cholesterol level alone. Factors other than blood lipid profile have powerful independent effects. A person with a blood pressure of 160/95 mm Hg has twice the risk of ischemic heart disease as one whose blood pressure is 140/75 mm Hg or less. The risk of ischemic heart disease increases in proportion to the number of cigarettes smoked. Increased levels of plasma factors involved in thrombosis or the inhibition of thrombolysis, such as fibrinogen, plasminogen activator inhibitor-1, homocysteine, and decreased fibrinolytic activity, contribute to the risk of myocardial infarction. Levels of selected serum markers of inflammation, such as C-reactive protein, are also predictors of ischemic heart disease. During the past several years, there has been a remarkable increase in the incidence of type II diabetes in the United States, which mirrors a similar increase in obesity (see Chapter 22). Ischemic heart disease is a consequence of both type 1 and type 2 diabetes, and the risk is two- to threefold greater than in nondiabetic individuals. Conversely, atherosclerotic cardiovascular dis-

ease (myocardial infarction, stroke, peripheral vascular disease) accounts for 80% of all deaths in patients with diabetes. Other risk factors for ischemic heart disease include: • Obesity: In a major, longitudinal study of one population (Framingham Heart Study), obesity was an independent risk factor for cardiovascular disease, with an increased risk for obese persons over those who are lean of 2 to 2.5. • Age: The risk of infarction is greater with increasing age, up to age 80 years. • Gender: Men have an increased risk of ischemic heart disease; 60% of coronary events occur in men. Angina pectoris is considerably more frequent in men than in women; the male: female ratio at ages younger than 50 years is 4:1 and that at age 60 years is 2:1. • Family history: In one study that controlled for other risk factors, relatives of patients with ischemic heart disease had a twoto fourfold increased risk for coronary artery disease. The genetic basis for this familial risk may interact with the other risk factors. • Use of oral contraceptives: Women over 35 years who smoke cigarettes and use oral contraceptives have a modestly increased incidence of myocardial infarction. • Sedentary life habits: Regular exercise reduces the risk of myocardial infarction, perhaps by increasing HDL levels. In one study, the least-fit quartile of persons subjected to exercise testing had six times the risk of myocardial infarction than did those in the fittest quartile. • Personality features: The relationship between coronary artery disease and “type A personality” is controversial, and recent studies have failed to show the strong association previously reported.

Many Conditions Limit the Supply of Blood to the Heart The heart is an aerobic organ, requiring oxidative phosphorylation to provide energy for contraction. The anaerobic glycolysis used by skeletal muscle under conditions of extreme physical exertion is insufficient to sustain cardiac contraction. Ischemic heart disease is caused by an imbalance between the oxygen demands of the myocardium and the supply of oxygenated blood. Any increase in cardiac workload increases the heart’s need for oxygen. Conditions that raise blood pressure or cardiac output, such as exercise or pregnancy, augment oxygen demand by the myocardium, which may lead to angina pectoris or myocardial infarction in the compromised organ. Disorders in this category include valvular disease (mitral or aortic insufficiency, aortic stenosis), infection, and conditions such as hypertension, coarctation of the aorta, and hypertrophic cardiomyopathy (HCM). The increased metabolic rate and tachycardia in patients with hyperthyroidism are also accompanied by increased oxygen demand as well as an increase in the workload of the heart (Table 11-3).

Atherosclerosis and Thrombosis The pathogenesis of atherosclerosis is detailed in Chapter 10. Here, the features of special importance to ischemic heart disease are briefly discussed. Maximal blood flow to the myocardium is not impaired until about 75% of the cross-sectional area of a coronary artery (⬃50% of the diameter as assessed during coronary angiography) is compromised by atherosclerosis. However, resting blood flow is not reduced until more than 90% of the lumen is occluded. In patients with long-standing angina pectoris, the extent and distribution of collateral circulation exerts an important influence on the risk of acute myocardial infarction. Although myocardial infarction often occurs during physically demanding activities, such as running or shoveling snow, many infarcts occur at rest or even during sleep. Thus, for most people, conversion of the clinically silent disease of coronary atherosclerosis to the catastrophic event of my-

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TABLE 11–3

Causes of Ischemic Heart Disease Decreased supply of oxygen Conditions that influence the supply of blood Atherosclerosis and thrombosis Thromboemboli Coronary artery spasm Collateral blood vessels Blood pressure, cardiac output, and heart rate Miscellaneous: arteritis (e.g., periarteritis nodosa), dissecting aneurysm, luetic aortitis, anomalous origin of coronary artery, muscular bridging of coronary artery Conditions that influence the availability of oxygen in the blood Anemia Shift in the hemoglobin-oxygen dissociation curve Carbon monoxide Cyanide Increased oxygen demand (i.e., increased cardiac work) Hypertension

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the left ventricle and the posterior third to half of the interventricular septum (“inferior” infarct). • LAD coronary artery: Blockage of this artery produces an infarct of the apical, anterior, and anteroseptal walls of the left ventricle. • Left circumflex coronary artery: Obstruction of this vessel is the least common cause of myocardial infarction and leads to an infarct of the lateral wall of the left ventricle. Myocardial infarction does not occur instantaneously. Rather, it first develops in the subendocardium and progresses as a wavefront of necrosis from subendocardium to subepicardium over the course of several hours. Transient coronary occlusion may cause only subendocardial necrosis, whereas persistent occlusion eventually leads to transmural necrosis. The goal of acute coronary interventions (pharmacologic or mechanical thrombolysis) is to interrupt this wavefront and limit myocardial necrosis. Infarcts involve the left ventricle much more commonly and extensively than they do the right ventricle. This difference may be partly explained by the greater workload imposed on the left ventricle by systemic vascular resistance and the greater thickness of the left ventricular wall. Right ventricular hypertrophy (e.g., in pulmonary hypertension) increases the incidence of right ventricular infarction, although infarcts limited to the right ventricle are rare.

Valvular stenosis or insufficiency

Macroscopic Characteristics of Myocardial Infarcts

Hyperthyroidism

Total ischemia for up to 20 to 30 minutes results in reversible cyanosis and bulging during systole. On gross examination, an acute myocardial infarct is not identifiable within the first 12 hours.

Fever Thiamine deficiency Catecholamines

ocardial infarction involves a sudden, marked decrease in myocardial blood flow, with or without an increase in myocardial oxygen demand. It is now well established that coronary artery thrombosis is the event that usually precipitates an acute myocardial infarction. Thrombosis typically results from spontaneous rupture of an atherosclerotic plaque, usually in a region that contains numerous inflammatory cells and a thin fibrous cap. The initiating event may be hemorrhage into or beneath the plaque.

• By 24 hours, the infarct can be recognized on the cut surface of the involved ventricle by its pallor. • After 3 to 5 days, the infarcted area becomes mottled and more sharply outlined, with a central pale, yellowish, necrotic region bordered by a hyperemic zone (Fig. 11-7). • Within 2 to 3 weeks, the infarcted region is depressed and soft, with a refractile, gelatinous appearance. • After several months, healed infarcts are firm and contracted and have the pale-gray appearance of scar tissue (Fig. 11-8).

Microscopic Characteristics of Myocardial Infarcts

Myocardial Infarcts May be Mainly Subendocardial or Transmural PATHOLOGY

Location of Infarcts There are important differences between these two types of infarction. A subendocardial infarct affects the inner one third to one half of the left ventricle. It may arise within the territory of one of the major epicardial coronary arteries or it may be circumferential, involving subendocardial territories of multiple coronary arteries. Subendocardial infarction generally occurs as a consequence of hypoperfusion of the heart. It may result from atherosclerosis in a specific coronary artery or develop in disorders that limit myocardial blood flow globally, such as aortic stenosis, hemorrhagic shock, or hypoperfusion during cardiopulmonary bypass. Most subendocardial infarcts do not involve occlusive coronary thrombi. In the case of circumferential subendocardial infarction caused by global hypoperfusion of the myocardium, coronary artery stenosis need not be present. Because necrosis is limited to the inner layers of the heart, complications arising in transmural infarcts (e.g., pericarditis and ventricular rupture) are generally not seen in subendocardial infarcts. A transmural infarct involves the full left ventricular wall thickness and usually follows occlusion of a coronary artery. As a result, transmural infarcts typically conform to the distribution of one of the three major coronary arteries (see Fig. 11-1). • Right coronary artery: Occlusion of the proximal portion of this vessel results in an infarct of the posterior basal region of

THE FIRST 24 HOURS: Electron microscopy is required to discern the earliest morphologic features of ischemic injury. After 30 to 60 minutes of ischemia, when myocyte injury has become irreversible, mitochondria are greatly swollen, with disorganized cristae and amorphous matrix densities. The nucleus shows clump-

Acute myocardial infarct. A transverse section of the heart of a patient who died a few days after the onset of severe chest pain shows a transmural infarct in the anteroseptal region of the left ventricle (left anterior descending [LAD] coronary artery territory). The necrotic myocardium is soft, yellowish, and sharply demarcated. FIGURE 11-7.

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gen is deposited. Lymphocytes and pigment-laden macrophages are prominent. The process of replacing necrotic muscle with scar tissue is initiated at about 5 days, beginning at the periphery of the infarct and gradually extending toward the center. ONE TO 3 WEEKS: Collagen deposition proceeds, the inflammatory infiltrate gradually recedes, and the newly sprouted capillaries are progressively obliterated.

Healed myocardial infarct. A cross-section of the heart from a man who died after a long history of angina pectoris and several myocardial infarctions shows circumferential scarring of the left ventricle. FIGURE 11-8.

ing and margination of chromatin, and the sarcolemma is focally disrupted. Loss of sarcolemmal integrity leads to release of intracellular proteins, such as myoglobin, LDH, CK, and troponins I and T. The noncontractile ischemic myocytes are stretched with each systole and by light microscopy become “wavy fibers.” After 24 hours, myocytes are deeply eosinophilic (Fig. 11-9) and show the characteristic changes of coagulation necrosis (see Chapter 1). However, it takes several days for the myocyte nucleus to disappear totally. TWO TO 3 DAYS: Polymorphonuclear leukocytes (PMNs) are attracted to necrotic myocytes. The PMNs accumulate at infarct borders where blood flow is maintained and reach maximal concentration after 2 to 3 days (see Figs. 11-9 and 11-10). Interstitial edema and microscopic areas of hemorrhage may also appear. Muscle cells are more clearly necrotic, nuclei disappear, and striations become less prominent. Some of the PMNs that were attracted to the area begin to undergo karyorrhexis. FIVE TO 7 DAYS: By this time, few, if any, PMNs remain. The periphery of the infarcted region shows phagocytosis of dead muscle by macrophages. Fibroblasts begin to proliferate, and new colla-

Normal

MORE THAN 4 WEEKS: Considerable dense fibrous tissue is present. The debris is progressively removed, and the scar becomes more solid and less cellular as it matures (Fig. 11-11). In estimating the age of a large infarct, it is more accurate to base the interpretation on the outer border where repair begins, rather than on changes in the central region. In fact, in some large infarcts, rather than being removed, dead myocytes remain indefinitely “mummified.”

Reperfusion of Ischemic Myocardium Blood flow may be restored to regions of evolving infarcts either because of spontaneous thrombolysis or in response to pharmacologic or mechanical means of opening up occluded coronary arteries. When that happens, the infarct’s gross and microscopic appearances change. Reperfused infarcts are typically hemorrhagic, the result of blood flow through a damaged microvasculature. One of the most characteristic features of reperfused infarcts is contraction band necrosis. Contraction bands are thick, irregular, transverse eosinophilic bands in necrotic myocytes. By electron microscopy, these bands are small groups of hypercontracted and disorganized sarcomeres with thickened Z lines. The bands form as a result of massive infusion of Ca2⫹ into the myocytes as a result of sarcolemmal damage mediated by reactive oxygen species. CLINICAL FEATURES:

Clinical Diagnosis of Acute Myocardial Infarction May be Complicated by “Silent Disease” The onset of acute myocardial infarction is often sudden and associated with severe, crushing substernal or precordial pain. These symptoms may be accompanied by sweating, nausea, vomiting, and shortness of breath. In some cases, an acute myocardial infarc-

12-18 hours

1 day

Development of a myocardial infarct. A. Normal myocardium. B. After about 12 to 18 hours, the infarcted myocardium shows eosinophilia (red staining) in sections of the heart stained with hematoxylin and eosin. C. About 24 hours after the onset of infarction, polymorphonuclear neutrophils infiltrate necrotic myocytes at the periphery of the infarct. FIGURE 11-9.

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Continued. Development of a myocardial infarct. D. After about 3 weeks, peripheral portions of the infarct are composed of granulation tissue with prominent capillaries, fibroblasts, lymphoid cells, and macrophages. The necrotic debris has been largely removed from this area, and a small amount of collagen has been laid down. E. After 3 months or more, the infarcted region has been replaced by scar tissue. FIGURE 11-9.

tion is preceded by unstable angina of several days’ duration. One fourth to one half of all nonfatal myocardial infarctions occur without any symptoms, and infarcts are identified only later by electrocardiographic changes or at autopsy. These “clinically silent” infarcts are par-

ticularly common among diabetic patients with autonomic dysfunction and also in cardiac transplant patients whose hearts are denervated.

Complications of Myocardial Infarction Influence the Clinical Course Early mortality in acute myocardial infarction (within 30 days) has dropped from 30% in the 1950s to less than 5% today. Nevertheless,

the clinical course after acute infarction may be dominated by functional or mechanical complications of the infarct. ARRHYTHMIAS: Virtually all patients who have a myocardial infarct have an abnormal cardiac rhythm at some time during their illness. Arrhythmias still account for half of all deaths caused by ischemic heart disease, although the advent of coronary care units and defibrillators has greatly reduced early mortality. LEFT VENTRICULAR FAILURE AND CARDIOGENIC SHOCK: The development of left ventricular failure soon after myocardial infarction is an ominous sign that generally indicates massive loss of muscle. Fortunately, cardiogenic shock occurs in less than 5% of cases, owing to the development of techniques that limit the extent of infarction (thrombolytic therapy, angioplasty) or assist damaged myocardium (intra-aortic balloon pump). Cardiogenic shock tends to develop early after infarction, when 40% or more of the left ventricle has been lost; the mortality rate is as high as 90%. EXTENSION OF THE INFARCT: Clinically recognizable extension of an acute myocardial infarct occurs in the first 1 to 2 weeks in up to 10% of patients. Such a situation is associated with a doubling of mortality.

FIGURE 11-10. Acute myocardial infarct. The necrotic myocardial fibers, which are eosinophilic and devoid of crossstriations and nuclei, are immersed in a sea of acute inflammatory cells.

FIGURE 11-11. Healed myocardial infarct. A section at the edge of a healed infarct stained for collagen shows dense, acellular regions of collagenous matrix sharply demarcated from the adjacent viable myocardium.

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RUPTURE OF THE FREE WALL OF THE MYOCARDIUM: Myocardial rupture may occur at almost any time during the 3 weeks after acute myocardial infarction but is most common between the first and fourth days, when the infarcted wall is weakest. During this vulnerable period, the infarct is composed of soft, necrotic tissue in which the extracellular matrix has been degraded by proteases released by inflammatory cells but new matrix deposition has not yet occurred. Once scar tissue begins to form, rupture is less likely. Rupture of the free wall is a complication of transmural infarcts. The remaining viable, contractile myocardium adjacent to the infarct produces mechanical forces that can initiate and propagate tearing along the lateral border of the infarct where neutrophils accumulate. Rupture of the left ventricle’s free wall most often leads to hemopericardium and death from cardiac tamponade. Myocardial rupture accounts for 10% of deaths after acute myocardial infarction in hospitalized patients. OTHER FORMS OF MYOCARDIAL RUPTURE: A few patients in whom a myocardial infarct involves the interventricular septum develop septal perforation, varying in length from 1 cm or more. The magnitude of the resulting left-to-right shunt and, therefore, the prognosis varies with the size of the rupture. Rupture of a portion of a papillary muscle results in mitral regurgitation. In some cases, an entire papillary muscle is transected, in which case, massive mitral valve incompetence may be fatal. ANEURYSMS: Left ventricular aneurysms complicate 10% to 15% of transmural myocardial infarcts. After acute transmural infarction, the affected ventricular wall tends to bulge outward during systole in one third of patients. Localized thinning and stretching of the ventricular wall in the region of a healing myocardial infarct has been termed “infarct expansion” but is actually an early aneurysm (Fig. 11-12). Such an aneurysm is composed of a thin layer of necrotic myocardium and collagenous tissue, which expands with each contraction of the heart. As the evolving aneurysm becomes more fibrotic, its tensile strength increases. However, the aneurysm continues to dilate with each beat, thereby “stealing” some of the left ventricular output and increasing the workload of the heart. Mural thrombi often develop within aneurysms and are a source of systemic emboli. A distinction should be made between “true” aneurysms (as above) and “false.” False aneurysms result from rupture of a portion of the left ventricle that has been walled off by pericardial scar tissue. Thus, the wall of a false aneurysm is composed of pericardium and scar tissue but not left ventricular myocardium. MURAL THROMBOSIS AND EMBOLISM: Half of all patients who die after myocardial infarction have mural thrombi overlying the infarct at autopsy. This occurs particularly often when the infarct involves the apex of the heart. In turn, half of these patients have some evidence of systemic embolization. PERICARDITIS: A transmural myocardial infarct involves the epicardium and leads to inflammation of the pericardium in 10% to 20% of patients. Pericarditis is manifested clinically as chest pain and may produce a pericardial friction rub. One fourth of patients with acute myocardial infarction, particularly those with larger infarcts and congestive heart failure, develop a pericardial effusion, with or without pericarditis. Postmyocardial infarction syndrome (Dressler syndrome) refers to a delayed form of pericarditis that develops 2 to 10 weeks after infarction. A similar disorder may occur after cardiac surgery. Antibodies to heart muscle appear in these patients, and the condition improves with corticosteroid therapy, suggesting that Dressler syndrome may have an immunologic basis.

Therapeutic Interventions Limit Infarct Size Because the amount of myocardium that undergoes necrosis is an important predictor of morbidity and mortality, any therapy that limits infarct size should be beneficial. Restoration of arterial

FIGURE 11-12. Ventricular aneurysm. The heart of a patient with a history of an anteroapical myocardial infarct who developed a massive ventricular aneurysm. The apex of the heart shows marked thinning and aneurysmal dilation.

blood flow remains the only way to salvage ischemic myocytes permanently, although a number of interventions can delay ischemic injury. Several methods have been developed to restore blood flow to the area of myocardium supplied by an obstructed coronary artery. • Thrombolytic enzymes such as tissue plasminogen activator or streptokinase can be infused intravenously to dissolve the clot causing the obstruction. • Percutaneous transluminal coronary angioplasty is dilation of a narrowed coronary artery by inflation with a balloon catheter. It also allows stent placement in the coronary artery to maintain its patency. • Coronary artery bypass grafting can restore blood flow to the distal segment of a coronary artery with a proximal occlusion. Procedures that restore blood flow must be performed as quickly as possible, preferably in the first few hours after the onset of symptoms. Beyond 6 hours, it is unlikely that much salvageable ischemic myocardium remains.

Chronic Congestive Heart Failure is Most Commonly Related to Ongoing Coronary Artery Disease Because the rate of early mortality associated with acute myocardial infarction has fallen to less than 5%, many patients with ischemic heart disease survive longer and eventually develop chronic congestive heart failure. In more than 75% of all patients with heart failure, coronary artery disease is the major cause of their condition. Contractile impairment in these patients is due to irreversible loss of myocardium (previous infarcts) and hypoperfusion of surviving muscle. Because coronary artery disease is often so extensive in these patients, and many have already undergone coronary artery bypass surgery, the only treatments available are cardiac transplantation or the use of artificial pumps (ventricular assist devices). In a minority of pa-

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tients with severe coronary atherosclerosis, myocardial contractility is impaired globally without discrete infarcts. This situation usually reflects a combination of ischemic myocardial dysfunction, diffuse fibrosis, and multiple small healed infarcts. However, there is a group of patients with left ventricular failure in whom cardiac dysfunction occurs without obvious infarction. These patients are said to have ischemic cardiomyopathy, which is a condition that results from repetitive episodes of ischemic injury, leading to myocyte degeneration.

Hypertensive Heart Disease Effects of Hypertension on the Heart Hypertension has been defined by the World Health Organization as a persistent increase of systemic blood pressure above 140 mm Hg systolic or 90 mm Hg diastolic, or both (see Chapter 10). Systemic hypertension is one of the most prevalent and serious causes of coronary artery and myocardial disease in the United States. Chronic hypertension leads to pressure overload and results first in compensatory left ventricular hypertrophy and, eventually, cardiac failure. The term hypertensive heart disease is used when the heart is enlarged in the absence of a cause other than hypertension. PATHOLOGY: Hypertension causes compensatory left ventricular hypertrophy as a result of the increased cardiac workload. The left ventricular free walls and interventricular septum become thickened uniformly and concentrically (Fig. 11-13), and heart weight increases, exceeding 375 g in men and 350 g in women. Microscopically, hypertrophic myocardial cells have an increased diameter with enlarged, hyperchromatic, and rectangular (“boxcar”) nuclei (Fig. 11-14). CLINICAL FEATURES: Myocardial hypertrophy clearly adds to the ability of the heart to handle an increased workload. However, there is a limit beyond which additional hypertrophy no longer compensates. This upper limit to useful hypertrophy may reflect increasing diffusion distance between the interstitium and the center of each myofiber; if the distance becomes too great, the oxygen supply to the myofiber will be deficient. Diastolic dysfunction is the most common functional abnormality caused by hypertension and by itself can lead to congestive heart failure. Some interstitial fibrosis typically develops as part of hypertrophy, which further contributes to left ventricular stiffness. Hypertension is also associated with increased severity of coronary artery

FIGURE 11-14. Hypertensive heart disease with myocardial hypertrophy. (Left) Normal myocardium. (Right) Hypertrophic myocardium shows thicker fibers and enlarged, hyperchromatic, rectangular nuclei.

atherosclerosis. The combination of increased cardiac workload (systolic dysfunction), diastolic dysfunction, and narrowed coronary arteries leads to a greater risk for myocardial ischemia, infarction, and heart failure.

Cause of Death in Patients with Hypertension Congestive heart failure is the most common cause of death in untreated hypertensive patients. Fatal intracerebral hemorrhage is also common. Death may also result from coronary atherosclerosis and myocardial infarction, dissecting aneurysm of the aorta, or ruptured berry aneurysm of the cerebral circulation. Renal failure may supervene when nephrosclerosis induced by hypertension becomes severe.

Cor Pulmonale Cor pulmonale is right ventricular hypertrophy and dilation due to pulmonary hypertension. Increased pressure in the pulmonary circulation may reflect a disorder of the lung parenchyma or, more rarely, a primary disease of the vasculature (e.g., primary pulmonary hypertension, recurrent small pulmonary emboli). Acute cor pulmonale is the sudden occurrence of pulmonary hypertension, most commonly as a result of sudden, massive pulmonary embolization. This condition causes acute right-sided heart failure and is a medical emergency. At autopsy, the only cardiac findings are severe dilation of the right ventricle and sometimes the right atrium. Chronic cor pulmonale is a common heart disease, accounting for 10% to 30% of all cases of heart failure. This frequency reflects the prevalence of chronic obstructive pulmonary disease, especially chronic bronchitis and emphysema.

FIGURE 11-13. Hypertensive heart disease. A transverse section of the heart shows marked hypertrophy of the left ventricular myocardium without dilation of the chamber. The right ventricle is of normal dimensions.

PATHOGENESIS: Chronic cor pulmonale may be caused by any pulmonary disease that interferes with ventilatory mechanics or gas exchange or obstructs the pulmonary vasculature. The most common causes of chronic cor pulmonale are chronic obstructive pulmonary disease and pulmonary fibrosis. In addition to the obliteration of blood vessels in the lung, these disorders also lead to pulmonary arteriolar vasoconstriction, which reduces the effective cross-sectional area of the pulmonary vascular bed without destroying the vessels. Hypoxia, acidosis, and hypercapnia directly cause pulmonary vasoconstriction.

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Rheumatic Heart Disease Encompasses Acute Myocarditis and Residual Valvular Deformities Acute Rheumatic Fever Rheumatic fever (RF) is a multisystem childhood disease that follows a streptococcal infection and is characterized by an inflammatory reaction involving the heart, joints, and central nervous system. EPIDEMIOLOGY: RF is a complication of an acute streptococcal infection, almost always pharyngitis (i.e., “strep” throat) (see Chapter 9). The offending agent is Streptococcus pyogenes, also known as group A ␤-hemolytic Streptococcus. In some epidemics of streptococcal pharyngitis, the incidence of RF has been as high as 3%. RF is principally a disease of childhood, and the median age is 9 to 11 years, although it can occur in adults. Despite its declining importance in industrialized countries, RF is a leading cause of death of heart disease in persons 5 to 25 years old in less-developed regions. FIGURE 11-15. Cor pulmonale. A transverse section of the heart from a patient with primary (idiopathic) pulmonary hypertension shows a markedly hypertrophied right ventricle (left). The right ventricular free wall has a thickness equal to the left ventricular wall. The right ventricle is dilated. The straightened interventricular septum has lost its normal curvature toward the left ventricle as part of the remodeling process in cor pulmonale.

PATHOLOGY: Chronic cor pulmonale is characterized by conspicuous right ventricular hypertrophy (Fig. 1115) to the extent of exceeding 1.0 cm in thickness (normal range, 0.3 to 0.5 cm). Dilation of the right ventricle and right atrium are often present.

Acquired Valvular and Endocardial Diseases A variety of inflammatory, infectious, and degenerative diseases damage cardiac valves and impair their function. The valves normally consist of thin flexible membranes, which close tightly to prevent backward blood flow. When they become damaged, leaflets or cusps may be thickened and fused enough to narrow the aperture and obstruct blood flow, a condition labeled valvular stenosis. Diseases that destroy valve tissue may also allow retrograde blood flow, termed valvular regurgitation or insufficiency. In many cases, diseases of the cardiac valves produce both stenosis and insufficiency, but generally one or the other predominates. Stenosis of a cardiac valve results in hypertrophy of the myocardium proximal (in terms of blood flow) to the obstruction. Once compensatory mechanisms are exhausted, pressure overload eventually causes myocardial dilation and failure of the chamber proximal to the valve. Thus, mitral stenosis leads to left atrial hypertrophy and dilation. As the left atrium decompensates and can no longer force the venous return through the stenotic mitral valve, signs of pulmonary congestion develop, followed by right ventricular hypertrophy and even cor pulmonale. Similarly, aortic stenosis causes left ventricular hypertrophy and eventually left heart failure. Valvular regurgitation or insufficiency also results in hypertrophy and dilation of the chamber proximal to the valve, owing to volume overload. In aortic insufficiency, the left ventricle first hypertrophies and then dilates when it can no longer accommodate the regurgitant volume and provide adequate cardiac output. On the other hand, an incompetent mitral valve leads to hypertrophy and dilation of both the left atrium and left ventricle, because both are subjected to volume overload.

PATHOGENESIS: The pathogenesis of RF remains unclear, and with the exception of the link to streptococcal infection, no theory has been proven unequivocally. Most hypotheses relate rheumatic carditis to antibodies against streptococcal antigens that cross-react with heart antigens, an observation that raises the possibility of an autoimmune etiology related to so-called molecular mimicry (Fig. 11-16). However, it has not been proved that such antibodies are cytotoxic or that they are directly involved in the pathogenesis of the disease. A direct toxic effect of some streptococcal product on the myocardium has not yet been excluded. PATHOLOGY: Acute rheumatic heart disease is a pancarditis, involving all three layers of the heart (endocardium, myocardium, and pericardium). MYOCARDITIS: At the most early stage, the heart tends to be dilated and exhibits a nonspecific myocarditis, in which lymphocytes and macrophages predominate, although a few neutrophils and eosinophils may be evident. Fibrinoid degeneration of collagen, in which fibers become swollen, fragmented, and eosinophilic, is characteristic of this early phase. In severe cases, a few patients may die acutely. The Aschoff body is the characteristic granulomatous lesion of rheumatic myocarditis (Fig. 11-17), developing several weeks after symptoms begin. This structure initially consists of a perivascular focus of swollen eosinophilic collagen surrounded by lymphocytes, plasma cells, and macrophages. With time, the Aschoff body assumes a granulomatous appearance, with a central fibrinoid focus associated with a perimeter of lymphocytes, plasma cells, macrophages, and giant cells. Eventually, the Aschoff body is replaced by a nodule of scar tissue. Anitschkow cells are unusual cells within the Aschoff body, with nuclei that contain a central band of chromatin (see Fig. 11-17). These cells are macrophages that are normally present in small numbers but accumulate and become prominent in certain types of inflammatory diseases of the heart. Anitschkow cells may become multinucleated, in which case they are termed Aschoff giant cells. PERICARDITIS: Tenacious irregular fibrin deposits are found on both visceral and parietal surfaces of the pericardium during the acute inflammatory phase of RF. These deposits resemble the shaggy surfaces of two slices of buttered bread that have been pulled apart (“bread-and-butter pericarditis”). The pericarditis may be recognized clinically by hearing a friction rub, but it has little functional effect and ordinarily does not lead to constrictive pericarditis.

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Streptococcal pharyngitis Group A streptococci

T cells activated by streptococcal antigens

B cells produce antistreptococcal antibodies

Antibodies and T cells cross-react with antigens of cardiac sarcolemma and valvular glycopeptides

Myocardial cell

Valvular glycopeptides

MYOCARDITIS; VALVULITIS Repeated antigenic exposure ? CHRONIC RHEUMATIC HEART DISEASE

Aortic valve Tricuspid valve BACTERIAL ENDOCARDITIS • Mitral valve • Aortic valve • Tricuspid valve

Mitral valve

CHRONIC VALVULITIS with STENOSIS and/or INSUFFICIENCY • Mitral valve • Aortic valve • Tricuspid valve

PERICARDITIS

FIGURE 11-16. Biological factors in rheumatic heart disease. The upper portion illustrates the initiating ␤-hemolytic streptococcal infection of the throat, which introduces the streptococcal antigens into the body and may also activate cytotoxic T cells. These antigens lead to the production of antibodies against various antigenic components of the streptococcus, which can cross-react with certain cardiac antigens, including those from the myocyte sarcolemma and glycoproteins of the valves. This may be the mechanism of inflammation of the heart in acute rheumatic fever, which involves all cardiac layers (endocarditis, myocarditis, and pericarditis). This inflammation becomes apparent after a latent period of 2 to 3 weeks. Active inflammation of the valves may eventually lead to chronic valvular stenosis or insufficiency. These lesions involve the mitral, aortic, tricuspid, and pulmonary valves, in that order of frequency.

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alterations. Severe valvular scarring may develop months or years after a single bout of acute RF. On the other hand, recurrent episodes of acute RF are common and result in repeated and progressively increasing damage to the heart valves. The mitral valve is the most commonly and severely affected valve in chronic rheumatic disease. Chronic mitral valvulitis is characterized by conspicuous, irregular thickening and calcification of the leaflets, often with fusion of the commissures and chordae tendineae (Fig. 11-18). In severe disease, the valve orifice becomes reduced to a fixed narrow opening that has the appearance of a “fish mouth” when viewed from the ventricular aspect (Fig. 11-19). Mitral stenosis is the predominant functional lesion, but such a valve is also regurgitant. Chronic regurgitation produces a “jet” of blood directed at the posterior aspect of the left atrium, which damages the atrial endocardium. The aortic valve is the second most commonly involved valve in rheumatic heart disease. Diffuse fibrous thickening of the cusps and fusion of the commissures cause aortic stenosis, which progresses because of the chronic effects of turbulent blood flow across the valve. Often, cusps become rigidly calcified as the patient ages, resulting in stenosis and insufficiency, although either lesion may predominate. In cases of recurrent RF, the tricuspid valve may become deformed, virtually always in association with mitral and aortic lesions. The pulmonic valve is rarely affected.

Complications of Chronic Rheumatic Heart Disease FIGURE 11-17. Acute rheumatic heart disease. An Aschoff body is located interstitially in the myocardium. Note collagen degeneration, lymphocytes, and a multinucleated Aschoff giant cell. (Inset) Nuclei of Anitschkow myocytes, showing “owl-eye” appearance in cross-section and “caterpillar” shape longitudinally.

ENDOCARDITIS: During the acute stage of rheumatic carditis, valve leaflets become inflamed and edematous. All four valves are affected, but left-sided valves are most injured. The result is damage and focal loss of endothelium along the lines of closure of the valve leaflets. This leads to deposition of tiny nodules of fibrin, which can be recognized grossly as “verrucae” along the leaflets (so-called verrucous endocarditis of acute RF). CLINICAL FEATURES: There is no specific test for RF. The clinical diagnosis is made when either two major or one major and two minor criteria (the Jones criteria) are met. The major criteria of acute RF include carditis (murmurs, cardiomegaly, pericarditis, and congestive heart failure), polyarthritis, chorea, erythema marginatum, and subcutaneous nodules. The minor criteria are previous history of RF, arthralgia, fever, certain laboratory tests indicating an inflammatory process, and electrocardiographic changes. The acute symptoms of RF usually subside within 3 months, but with severe carditis, clinical activity may continue for 6 months or more. The mortality rate from acute rheumatic carditis is low. The main cause of death is heart failure due to myocarditis, although valvular dysfunction may also play a role. Recurrent attacks of RF are associated with types of group A ␤-hemolytic streptococci to which the patient has not been previously exposed. In patients with a history of a recent attack of RF, the recurrence rate is as high as 65%, whereas after 10 years, a streptococcal infection is followed by an acute relapse in only 5% of cases. Prompt treatment of streptococcal pharyngitis with antibiotics prevents an initial attack of RF and, less often, a recurrence of the disease. There is no specific treatment for acute RF, but corticosteroids and salicylates are helpful in managing the symptoms.

• Bacterial endocarditis follows episodes of bacteremia (e.g., during dental procedures). The scarred valves of rheumatic heart disease provide an attractive environment for bacteria that would bypass a normal valve. • Mural thrombi form in atrial or ventricular chambers in 40% of patients with rheumatic valvular disease. They give rise to thromboemboli, which can produce infarcts in various organs. • Congestive heart failure is associated with rheumatic disease of both mitral and aortic valves.

Collagen Vascular Diseases Affect Both Cardiac Valves and Myocardium Systemic Lupus Erythematosus (SLE) The heart is often involved in SLE, but cardiac symptoms are usually less prominent than are other manifestations of the disease. PATHOLOGY: The most common cardiac lesion is fibrinous pericarditis, usually with an effusion. Myocarditis in SLE, in the form of subclinical left ventricular dysfunction, is also common and reflects the

Chronic Rheumatic Heart Disease PATHOLOGY: The myocardial and pericardial components of rheumatic pancarditis typically resolve without permanent sequelae. By contrast, the acute valvulitis of RF often results in long-term structural and functional

FIGURE 11-18. Chronic rheumatic valvulitis. The mitral valve leaflets are thickened and focally calcified (arrow), and the commissures are partially fused. The chordae tendineae are also short, thick, and fused.

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A Chronic rheumatic valvulitis. A view of a surgically excised rheumatic mitral valve from the left atrium (A) and left ventricle (B) shows rigid, thickened, and fused leaflets with a narrow orifice, creating the characteristic “fish mouth” appearance of rheumatic mitral stenosis. Note that the tips of the papillary muscles (shown in B) are directly attached to the underside of the valve leaflets, reflecting marked shortening and fusion of the chordae tendineae. FIGURE 11-19

severity of the disease in other organs. Microscopically, fibrinoid necrosis of small vessels and focal degeneration of interstitial tissue are seen. Endocarditis is the most striking cardiac lesion of SLE. Verrucous vegetations up to 4 mm across occur on endocardial surfaces and are termed Libman-Sacks endocarditis. They are most common on the mitral valve. Ordinarily, Libman-Sacks endocarditis heals without scarring and does not produce a functional deficit.

Scleroderma (Progressive Systemic Sclerosis) Cardiac involvement is second only to renal disease as a cause of death in scleroderma. The myocardium exhibits intimal sclerosis of small arteries, which leads to small infarcts and patchy fibrosis. As a result, congestive heart failure and arrhythmias are common. Cor pulmonale secondary to interstitial fibrosis of the lungs and hypertensive heart disease (caused by renal involvement) are also seen.

Polyarteritis Nodosa The heart is involved in up to 75% of cases of polyarteritis nodosa. Necrotizing lesions in branches of the coronary arteries result in myocardial infarction, arrhythmias, or heart block. Cardiac hypertrophy and failure secondary to renal vascular hypertension are common.

Bacterial Endocarditis Refers to Infection of the Cardiac Valves Before the antibiotic era, bacterial endocarditis was untreatable and almost invariably fatal. The infection is classified according to its clinical course as either acute or subacute endocarditis. Acute bacterial endocarditis is an infection of a normal cardiac valve by highly virulent suppurative organisms, typically Staphylococcus aureus and S. pyogenes. The affected valve is rapidly destroyed, and prior to modern therapy, the patient died within 6 weeks in acute heart failure or of overwhelming sepsis. Subacute bacterial endocarditis is a less fulminant disease in which less-virulent organisms (e.g., Streptococcus viridans or Staphylococcus epidermidis) infect a structurally abnormal valve, which typically had been deformed by rheumatic heart disease. In these cases, patients typically survived for 6 months or more, and infectious complications were uncommon. Antimicrobial therapy changed the clinical patterns of bacterial endocarditis, and classical presentations described above are

now unusual. The disease is currently classified according to the anatomical location and the etiologic agent. EPIDEMIOLOGY: The most common predisposing condition for bacterial endocarditis in children now is CHD. Under 10% of cases of bacterial endocarditis in children today are attributable to rheumatic heart disease. The epidemiology of bacterial endocarditis has also changed in adults. Mitral valve prolapse (MVP) and CHD are today the most frequent bases for bacterial endocarditis in adults, and rheumatic heart disease accounts for few cases. More than half of adults with bacterial endocarditis have no predisposing cardiac lesion. Other predisposing conditions include: • Intravenous drug abuse related to the injection of pathogenic organisms along with illicit drugs. The most common source of bacteria in intravenous drug abusers is the skin, with S. aureus causing more than half of the infections. • Prosthetic valves are sites of infection in 15% of all cases of endocarditis in adults, and 4% of patients with prosthetic valves have this complication. Staphylococci are again responsible for half of these infections, and most of the rest are caused by gram-negative aerobic organisms. • Transient bacteremia from any procedure may lead to infective endocarditis. Examples include dental procedures, urinary catheterization, gastrointestinal endoscopy, and obstetric procedures. Antibiotic prophylaxis is recommended during such maneuvers for patients at increased risk for bacterial endocarditis (e.g., those with a history of RF or a cardiac murmur). • The elderly also have an increasing tendency to develop endocarditis. A number of degenerative changes in heart valves, including calcific aortic stenosis and calcification of the mitral annulus, predispose to endocarditis. PATHOGENESIS: Virulent organisms, such as S. aureus, can infect apparently normal valves, but the mechanism of such bacterial colonization is poorly understood. The pathogenesis of the infection of a damaged valve by less virulent organisms is initiated by damage to the affected valve’s endothelium by turbulent blood flow. The damage leads to focal deposition of platelets and fibrin, creating small sterile vegetations that are hospitable sites for bacterial colonization and growth (Fig. 11-20). Microorganisms that gain access to the circulation can be de-

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tion with cancer or some other wasting disease. NBTE affects mitral and aortic valves with equal frequency. Its gross appearance is similar to that of infective endocarditis, but it does not destroy the affected valve, and on microscopic examination, neither inflammation nor microorganisms can be demonstrated. The cause of NBTE is poorly understood. It is seen commonly in complicating adenocarcinomas (particularly of pancreas and lung) and hematologic malignancies.

Calcific Aortic Stenosis Reflects Chronic Damage to the Valve Calcific aortic stenosis refers to a narrowing of the aortic valve orifice as a result of calcium deposition in the cusps and valve ring. PATHOGENESIS AND PATHOLOGY: Calcific aortic stenosis has three main causes. Bacterial endocarditis. The mitral valve shows destructive vegetations, which have eroded through the free margins of the valve leaflets. FIGURE 11-20

posited within the vegetations. In this protected environment, colony counts upon culture may reach 1010 organisms per gram of tissue. PATHOLOGY: Bacterial endocarditis most commonly involves the mitral valve, the aortic valve, or both. The most common congenital heart lesions that underlie bacterial endocarditis are patent ductus arteriosus, tetralogy of Fallot, ventricular septal defect, and bicuspid aortic valve; the last is an increasingly recognized risk factor, especially in men over 60 years of age. Vegetations are composed of platelets, fibrin, cell debris, and masses of organisms. The underlying valve tissue is edematous and inflamed and may eventually become so damaged that a leaflet perforates, causing regurgitation. Lesions vary in size from a small, superficial deposit to bulky, exuberant vegetations. The infective process may spread locally to involve the valve ring or adjacent mural endocardium and chordae tendineae. Infected thromboemboli travel to multiple systemic sites, causing infarcts or abscesses in many organs, including the brain, kidneys, intestine, and spleen.

• Rheumatic aortic valve disease, in which it is characterized by diffuse fibrous thickening and scarring of the cusps, commissural fusion, and deposition of calcium, all of which reduce the valve orifice and limit valve mobility. The disorder is now uncommon due to surgical intervention. • Degenerative (senile) calcific stenosis develops in elderly patients as a degenerative process that involves a normal symmetric tricuspid aortic valve. Valve cusps become rigidly calcified, but unlike the case in the rheumatic valve, there is no commissural fusion. • Congenital bicuspid aortic stenosis often develops with age and, as above, shows no commissural fusion (Fig. 11-21). Calcific aortic stenosis in both congenitally malformed valves as well as normal valves is probably related to the cumulative effect of years of trauma, owing to turbulent blood flow around the valve. In any of the forms of calcific aortic stenosis, calcification produces nodules restricted to the base and lower half of the cusps, rarely involving free margins.

CLINICAL FEATURES: Many patients show early symptoms of bacterial endocarditis within a week of the bacteremic episode, and almost all are symptomatic within 2 weeks. Heart murmurs develop almost invariably, often with a changing pattern during the course of the disease. In cases of more than 6 weeks duration, splenomegaly, petechiae, and clubbing of the fingers are frequent. In one third of patients, systemic emboli are recognized at some time during the illness. One third of the victims of bacterial endocarditis manifest some evidence of neurologic dysfunction, owing to the frequency of embolization to the brain. Antibacterial therapy is effective in limiting the morbidity and mortality of bacterial endocarditis. Most patients defervesce within a week of instituting such therapy. However, the prognosis depends on the offending organism and the stage at which the infection is treated. One third of cases of S. aureus endocarditis are still fatal. The most common serious complication of bacterial endocarditis is congestive heart failure, usually due to destruction of a valve. Surgical replacement of a valve destroyed by endocarditis is risky and carries a high surgical mortality.

Nonbacterial Thrombotic Endocarditis (Marantic Endocarditis) is a Complication of Wasting Diseases Nonbacterial thrombotic endocarditis (NBTE), also known as marantic endocarditis (from the Greek, marantikos, “wasting away”), refers to sterile vegetations on apparently normal cardiac valves, almost always in associa-

FIGURE 11-21. Calcific aortic stenosis of a congenitally bicuspid aortic valve. The two leaflets are heavily calcified, but there is no commissural fusion.

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CLINICAL FEATURES: Severe aortic stenosis results in striking concentric left ventricular hypertrophy. Eventually, the heart dilates and fails. The disease is treated with great success (5-year survival rate of 85%) with surgical valve replacement, provided the operation is performed before ventricular dysfunction becomes irreversible. The hypertrophic left ventricle is then restored to its normal size.

Mitral Valve Prolapse (MVP) is the Most Common Indication for Valve Replacement MVP is a condition in which mitral valve leaflets become enlarged and redundant, and chordae tendineae become thinned and elongated, such that the billowed leaflets prolapse (protrude) into the left atrium during systole (Fig. 1122A). Also referred to as “floppy mitral valve syndrome,” MVP is the most frequent cause of mitral regurgitation that requires surgical valve replacement. As much as 5% of the adult population may show echocardiographic evidence of MVP, although most will not have regurgitation severe enough to warrant surgical intervention.

PATHOGENESIS: MVP has an important hereditary component and many cases appear to be transmitted as an autosomal dominant trait. Patients with primary MVP exhibit a striking accumulation of myxomatous connective tissue in the center of the valve leaflet (see Fig. 11-22B). Presumably, the extracellular matrix defect allows the leaflets and chordae to enlarge and stretch under the high-pressure conditions they experience during the cardiac cycle. PATHOLOGY: On gross examination, mitral valve leaflets are redundant and deformed (see Fig. 11-22A). On cross-section, they have a gelatinous appearance and B slippery texture, owing to the accumulation of acid muFIGURE 11-22. Mitral valve prolapse. A. A view of the mitral valve copolysaccharides (proteoglycans; Fig. 11-22B). The myxomatous (left) from the left atrium shows redundant and dedegenerative process also affects the annulus and chordae formed leaflets, which billow into the left atrial cavity. B. A microscopic tendineae, which increases the degree of prolapse and regurgitation. section of one of the mitral valve leaflets reveals conspicuous myxomatous connective tissue in the center of the leaflet. Although the mitral valve is usually the only valve affected, myxomatous degeneration can develop in the other cardiac valves, especially in patients with Marfan syndrome, 90% of whom have some clinical evidence of MVP. CLINICAL FEATURES: Most patients with MVP are asymptomatic. Endocarditis, both infective and nonbacterial, is sometimes a serious complication, and cerebral emboli are common. Significant mitral regurgitation develops in 15% of patients after 10 to 15 years of MVP, after which mitral valve replacement is indicated.

Carcinoid Heart Disease Affects Right-Sided Valves Carcinoid heart disease is an unusual condition that uniquely affects the right side of the heart and produces tricuspid regurgitation and pulmonary stenosis. It arises in patients with carcinoid tumors, usually of the small intestine, that have metastasized to the liver. PATHOGENESIS: The pathogenesis of carcinoid heart disease is not fully understood. The valvular and endocardial lesions are thought to be caused by high concentrations of serotonin or other vasoactive amines and peptides produced by the tumor in the liver. Because these moieties are metabolized in the lung, carcinoid heart disease affects the right side of the heart almost exclusively. Use of anorexigenic drugs (such as “fen-phen”) and ergot alkaloids, such as methysergide and ergotamine (used to treat migraine headaches), are also associated with cardiac disease strikingly similar to those seen in carcinoid syndrome,

except that lesions develop on the left-sided valves. Because these drugs interfere with serotonin metabolism and signaling, it has been suggested that the pathogenesis of drug-related and carcinoid valvular disease is similar. PATHOLOGY: The cardiac lesions are plaque-like deposits of dense, pearly gray, fibrous tissue on the tricuspid and pulmonary valves and on the endocardial surface of the right ventricle. Microscopically, these patches appear “tacked on” to valve leaflets and are not associated with inflammation or apparent damage to underlying valve structures. However, leaflets become deformed, and their surface area is reduced. As a result, the tricuspid leaflets become “stuck down” onto adjacent right ventricular mural endocardium, resulting in tricuspid insufficiency or stenosis. Shrinkage of the pulmonary valve and its annulus leads to pulmonary stenosis.

Myocarditis Myocarditis is inflammation of the myocardium associated with myocyte necrosis and degeneration. This definition specifically excludes ischemic heart disease. Myocarditis can occur at any age but is most common in children between the ages of 1 and 10. It is one of the few heart diseases that can produce acute heart failure in

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TABLE 11–4

Causes of Myocarditis Idiopathic Infectious • Viral: Coxsackievirus, adenovirus, echovirus, influenza virus, human immunodeficiency virus, and many others • Rickettsial: Typhus, Rocky Mountain spotted fever • Bacterial: Diphtheria, staphylococcal, streptococcal, meningococcal, Borrelia (Lyme disease), and leptospiral infection • Fungi and protozoan parasites: Chagas’ disease, toxoplasmosis, aspergillosis, cryptococcal, and candidal infection • Metazoan parasites: Echinococcus, Trichina Noninfectious • Hypersensitivity and immunologically related diseases: Rheumatic fever, systemic lupus erythematosus, scleroderma, drug reaction (e.g., to penicillin or sulfonamide), and rheumatoid arthritis • Radiation • Miscellaneous: Sarcoidosis, uremia

previously healthy children, adolescents, or young adults. Severe myocarditis can cause arrhythmias and even sudden cardiac death.

Viral Myocarditis May be Difficult to Demonstrate Most cases of myocarditis in North America occur without an easily demonstrable cause but are believed to be viral, although the evidence is usually circumstantial. The most common viruses that cause myocarditis are listed in Table 11-4. PATHOGENESIS: The pathogenesis of viral myocarditis is thought to involve direct viral cytotoxicity or cell-mediated immune reactions directed against infected myocytes. There is substantial evidence for both mechanisms. The stimulus for the immune attack on myocytes is not established but appears to involve major histocompatibility antigens. PATHOLOGY: The hearts of patients with myocarditis who develop clinical heart failure during the active inflammatory phase show biventricular dilation and generalized myocardial hypokinesis. At autopsy, these hearts are flabby and dilated. The histologic changes of viral myocarditis vary with the clinical severity of the disease. Most cases show a patchy or diffuse interstitial, predominantly mononuclear, inflammatory infiltrate composed principally of T lymphocytes and macrophages (Fig. 11-23). Multinucleated giant cells may also be present. The inflammatory cells often surround individual myocytes, and focal myocyte necrosis is seen. During the resolving phase, fibroblast proliferation and interstitial collagen deposition predominate. CLINICAL FEATURES: Many persons who develop viral myocarditis may be asymptomatic. When symptoms do occur, they usually begin a few weeks after infection. Most patients recover from acute myocarditis, although a few die of congestive heart failure or arrhythmias. The disease may be unusually severe in infants and pregnant women. Despite resolution of the active inflammatory phase of viral myocarditis, subtle functional impairment may persist for years, and progression to overt cardiomyopathy is well documented. There is no specific treatment for viral myocarditis, and supportive measures usually suffice. In addition to viruses, other microorganisms and

FIGURE 11-23. Viral myocarditis. The myocardial fibers are disrupted by a prominent interstitial infiltrate of lymphocytes and macrophages.

parasites that gain access to the bloodstream can infect the heart. Myocarditis may also result from noninfectious etiologies (see Table 11-4).

Metabolic Diseases of the Heart Hyperthyroidism Causes High-Output Failure Hyperthyroidism causes conspicuous tachycardia and an increased cardiac workload, owing to decreased peripheral resistance and increased cardiac output. It may eventually lead to angina pectoris and high-output failure.

Thiamine Deficiency (Beriberi) Heart Disease is Similar to Hyperthyroidism In the United States, thiamine deficiency (beriberi) is occasionally seen in alcoholics or neglected individuals who consume an inadequate amount of thiamine (see Chapter 8). Beriberi heart disease results in decreased peripheral vascular resistance and increased cardiac output, a combination similar to that produced by hyperthyroidism. At autopsy, the heart is dilated and shows only nonspecific microscopic changes.

Hypothyroid Heart Disease Diminishes Cardiac Output Patients with severe hypothyroidism (myxedema) have decreased cardiac output, reduced heart rate, and impaired myocardial contractility—changes that are the reverse of those seen in hyperthyroidism. The hearts of patients with myxedema are flabby and dilated, and the myocardium exhibits myofiber swelling. Basophilic (mucinous) degeneration is common. Interstitial fibrosis may also be present. Despite these changes, myxedema does not produce congestive heart failure in the absence of other cardiac disorders.

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Cardiomyopathy Cardiomyopathy refers to a primary disease of the myocardium and excludes damage caused by extrinsic factors. Dilated cardiomyopathy (DCM) is the most common type of cardiomyopathy and is characterized by biventricular dilation, impaired contractility, and eventually congestive heart failure. DCM can develop in response to a large number of known insults that directly injure cardiac myocytes (“secondary DCM”), or it may be idiopathic (primary).

Idiopathic Dilated Cardiomyopathy is Characterized by Impaired Contractility PATHOGENESIS: Numerous etiologies have been implicated in idiopathic DCM, but the pathogenesis is unresolved. Genetic factors now appear to be more important than previously believed. Among patients with idiopathic DCM, at least onethird have a familial disease. Most familial cases seem to be transmitted as an autosomal dominant trait, but autosomal recessive, X-linked recessive, and mitochondrial inheritance patterns have all been described. Mutations in several known genes including those encoding dystrophin, ␦-sarcoglycan, troponin T, ␤-myosin heavy chain, actin, lamin A/C, and desmin have been identified as causing a dilated cardiomyopathic phenotype. A current hypothesis holds that defects in force transmission lead to development of a dilated, poorly contracting heart. Interestingly, mutations in proteins such as actin, troponin T, and ␤-myosin heavy chain may produce either dilated or hypertrophic cardiomyopathy (HCM) phenotypes, perhaps depending on whether they produce a defect in force generation (HCM) or force transmission (dilated cardiomyopathy). Viral myocarditis may eventually lead to DCM, but how this would develop has not been clear. Interestingly, a protease expressed by cardiotropic enteroviruses has been shown to cleave dystrophin, thereby providing a potential mechanistic link between viral infection and the development of a dilated cardiomyopathy phenotype. Immunologic abnormalities involving both cellular and humoral effects have been recognized in both myocarditis and idiopathic DCM. Autoantibodies to cardiac antigens that have been identified include those directed against a variety of mitochondrial antigens, cardiac myosin, and ␤-adrenergic receptors. However, a pathogenic role for immune mechanisms remains to be proved. PATHOLOGY: The pathologic changes in patients with DCM are generally nonspecific and are similar whether the disorder is idiopathic or secondary to a known injurious agent. At autopsy, the heart is invariably enlarged, reflecting conspicuous left and right ventricular hypertrophy. The weight of the heart may be as much as tripled (⬎900 g). As a rule, all chambers of the heart are dilated, although the ventricles are more severely affected than are the atria (Fig. 1124). The myocardium is flabby and pale, and small subendocardial scars are occasionally evident. The left ventricular endocardium, especially at the apex (not shown), tends to be thickened. Adherent mural thrombi are often present in this area. Microscopically, DCM is characterized by atrophic and hypertrophic myocardial fibers. Cardiac myocytes, especially in the subendocardium, often show advanced degenerative changes characterized by myofibrillar loss, an effect that gives cells a vacant, vacuolated appearance. Interstitial and perivascular fibrosis of myocardium is evident, also most prominently in the subendocardial zone. CLINICAL FEATURES: The clinical courses of idiopathic and secondary DCM are comparable. The disease begins insidiously with compensatory ventricular hypertrophy and asymptomatic left ventricular dilation.

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Commonly, exercise intolerance progresses relentlessly to frank congestive heart failure, and 75% of patients die within 5 years of symptom onset. Although supportive treatment is useful, cardiac transplantation or a ventricular assist device eventually becomes the only option.

Secondary Dilated Cardiomyopathy Has Many Causes Almost 100 distinct myocardial diseases can result in the clinical features of DCM. Thus, secondary DCM is best viewed as a final common pathway for the effects of virtually any toxic, metabolic, or infectious disorder that directly injures cardiac myocytes. In this context, alcohol abuse, hypertension, pregnancy, and viral myocarditis predispose to secondary DCM. Diabetes mellitus and cigarette smoking are also associated with increased incidence of this disorder.

Toxic Cardiomyopathy Numerous chemicals and drugs cause myocardial injury. Several of the more important substances are discussed here. ETHANOL: Alcoholic cardiomyopathy is the single most common identifiable cause of DCM in the United States and Europe. Ethanol abuse can lead to chronic, progressive cardiac dysfunction, which may be fatal. The typical patient is between 30 and 55 years of age and has been drinking heavily for at least 10 years. Although the shortterm action of alcohol on cardiac myocytes is reversible, the cumulative injury eventually becomes irreversible. CATECHOLAMINES: In high concentrations, catecholamines can cause focal myocyte necrosis. Toxic myocarditis may occur in patients with pheochromocytomas, those who require high doses of inotropic drugs to maintain blood pressure, and in accident victims who sustain massive head trauma. ANTHRACYCLINES: Doxorubicin (Adriamycin) and other anthracycline drugs are potent chemotherapeutic agents, and their usefulness is limited by cumulative, dose-dependent, cardiac toxicity. The clinical major effect is poor myocyte contractility secondary to chronic, irreversible degeneration of cardiac myocytes. The histopathology of this disorder includes vacuolization and loss of myofibrils. Once severe degeneration occurs, intractable congestive heart failure develops. COCAINE: Cocaine use is frequently associated with chest pain and palpitations. True DCM is an unusual complication of cocaine abuse, but myocarditis, focal necrosis, and thickening of intramyocardial coronary arteries have been reported. Sudden death

FIGURE 11-24. Idiopathic dilated cardiomyopathy. A transverse section of the enlarged heart reveals conspicuous dilation of both ventricles. Although the ventricular wall appears thinned, the increased mass of the heart indicates considerable hypertrophy.

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due to spontaneous ventricular tachyarrhythmias is well documented. Mechanisms underlying the arrhythmogenic effects of cocaine include vasoconstriction, sympathomimetic activity, hypersensitivity responses, and direct toxicity.

Cardiomyopathy of Pregnancy A unique form of DCM develops in the last trimester of pregnancy or the first 6 months after delivery. The disorder is relatively uncommon in the United States, but in some regions of Africa, it is encountered in as many as 1% of pregnant women. The risk of cardiomyopathy of pregnancy is greatest in black, multiparous women, older than 30 years of age. The cause of this form of DCM is unknown. Some patients exhibit inflammatory cells in heart biopsies taken during the symptomatic phase of the illness, consistent with the hypothesis that disordered immunity may underlie the development of DCM in this setting.

In Hypertrophic Cardiomypathy (HCM), Cardiac Hypertrophy is Out of Proportion to the Hemodynamic Load HCM that develops for no apparent physiologic reason is probably genetically determined in most patients and is identified as an autosomal dominant trait in half of patients. HCM is now known to be far more common than previously appreciated: its prevalence in the United States is about 1 in 500. PATHOGENESIS: The clinical picture of HCM is caused by more than 100 mutations in at least nine genes encoding proteins of the sarcomere. The mutated genes most commonly involved encode (1) ␤myosin heavy chain (35%), (2) myosin-binding protein C (20%), and (3) troponin T (15%). This proposed mechanism has led to the hypothesis that HCM is related to defects in force generation owing to altered sarcomeric function.

PATHOLOGY: The heart in HCM is always enlarged, but the degree of hypertrophy varies in different genetic forms. The left ventricular wall is thick, and its cavity is small, sometimes reduced to a slit. Papillary muscles and trabeculae carneae are prominent and encroach on the ventricular lumen. More than half of cases exhibit asymmetric hypertrophy of the interventricular septum, with a ratio of the septum thickness to that of the left ventricular free wall greater than 1.5 (Fig. 11-25A). The most notable histologic feature of HCM is myofiber disarray, which is most extensive in the interventricular septum. Instead of the usual parallel arrangement of myocytes into muscle bundles, myofiber disarray is characterized by an oblique and often perpendicular orientation of adjacent hypertrophic myocytes (see Fig. 11-25B). CLINICAL FEATURES: Most patients with HCM have few if any symptoms, and the diagnosis is commonly made during screening of the family with an affected member. Despite a lack of symptoms, such persons may be at risk for sudden death, particularly during severe exertion. In fact, unsuspected HCM is commonly found at autopsy in young competitive athletes who die suddenly. Clinical recognition of HCM can occur at any age, often in the third, fourth, or fifth decade of life, but the disorder is also encountered in the elderly. Some patients with HCM become incapacitated by cardiac symptoms, of which dyspnea, angina pectoris, and syncope are most common. The clinical course tends to remain stable for many years, although eventually, the disease can progress to congestive heart failure.

Restrictive Cardiomyopathy Impairs Diastolic Function Restrictive cardiomyopathy describes a group of diseases in which myocardial or endocardial abnormalities limit diastolic filling, while contractile function remains normal. It is the least common category of cardiomyopathy in Western countries, although in some less-devel-

B,C FIGURE 11-25. Hypertrophic cardiomyopathy (HCM). A. The heart has been opened to show striking asymmetric left ventricular hypertrophy. The interventricular septum is thicker than the free wall of the left ventricle and impinges on the outflow tract such that it contacts the underside of the anterior mitral valve leaflet. B. A section of the myocardium shows the characteristic myofiber disarray and hyperplasia of interstitial cells. C. A small intramural coronary artery shows thickened, hypercellular media. This type of remodeling of coronary vessels could contribute to development of angina-like symptoms in some patients with HCM.

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oped regions (e.g., parts of equatorial Africa, South America, and Asia), endomyocardial disease related to parasitic infections leads to many cases of restrictive cardiomyopathy. PATHOGENESIS AND PATHOLOGY: Restrictive cardiomyopathy is caused by (1) interstitial infiltration of amyloid, metastatic carcinoma, or sarcoid granulomas; (2) endomyocardial disease characterized by marked fibrotic thickening of the endocardium; (3) storage diseases, including hemochromatosis; and (4) markedly increased interstitial fibrous tissue. Many cases of restrictive cardiomyopathy are classified as idiopathic, with interstitial fibrosis as the only histologic abnormality. The disease almost invariably progresses to congestive heart failure, and only 10% of the patients survive for 10 years.

Amyloidosis The heart is affected in most forms of generalized amyloidosis (see Chapter 23). In fact, restrictive cardiomyopathy is the most common cause of death in AL amyloidosis of plasma cell dyscrasias. PATHOLOGY: Amyloid infiltration of the heart results in cardiac enlargement without ventricular dilation, and the gross appearance of the heart may resemble that of HCM. Ventricular walls are typically thickened, firm, and rubbery. Microscopically, amyloid accumulation is most prominent in interstitial, perivascular, and endocardial regions. Endocardial involvement is common in the atria, where nodular endocardial deposits often impart a granular appearance and gritty texture to the endocardial surface. Amyloid deposits can also cause thickening of cardiac valves. CLINICAL FEATURES: Cardiac amyloidosis is most often a restrictive cardiomyopathy, with symptoms mainly referable to right-sided heart failure. Infiltration of the conduction system can result in arrhythmias, and sudden cardiac death is not unusual. Cardiomegaly is characteristically prominent. The prognosis is grim; most patients survive less than 1 year once the disease becomes symptomatic. SENILE CARDIAC AMYLOIDOSIS: Senile cardiac amyloidosis refers to the deposition of a protein closely related to prealbumin (transthyretin) in the hearts of elderly persons (see Chapter 23). The disorder may be present to some extent in up to 25% of patients who are 80 years old or older. The functional significance of senile cardiac amyloidosis is often minimal, and it is usually an incidental finding at autopsy.

Endomyocardial Disease Endomyocardial disease comprises two geographically separate disorders. ENDOMYOCARDIAL FIBROSIS: This condition is particularly common in equatorial Africa, where it accounts for 10% to 20% of all deaths from heart disease. The malady is also occasionally seen in other tropical and subtropical regions of the world. It is most common in children and young adults but has been reported to occur in persons up to 70 years of age. Endomyocardial fibrosis leads to progressive myocardial failure and has a poor prognosis, although survival for as long as 12 years has been reported. EOSINOPHILIC ENDOMYOCARDIAL DISEASE (LÖFFLER ENDOCARDITIS): This is a cardiac disorder of temperate regions characterized by hypereosinophilia (as high as 50,000/␮L). It is usually encountered in men in the fifth decade and is often accompanied by a rash. Löffler endocarditis typically progresses to congestive heart failure and death, although corticosteroids may improve survival.

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PATHOGENESIS: Endomyocardial fibrosis and Löffler endocarditis were once considered distinct entities, but there is a growing consensus that they represent variants of the same underlying disease. Endomyocardial disease is suspected to result from myocardial injury produced by eosinophils, possibly mediated by cardiotoxic granule components. In the tropics, transient high blood eosinophil counts often result from parasitic infestations; in temperate climates, idiopathic hypereosinophilia is usually persistent. PATHOLOGY: At autopsy, a grayish-white layer of thickened endocardium extends from the apex of the left ventricle over the posterior papillary muscle to the posterior leaflet of the mitral valve and for a short distance into the left outflow tract. On cut section of the ventricle, endocardial fibrosis spreads into the inner one-third to one-half of the wall. Mural thrombi in various stages of organization may be present. When the right ventricle is involved, the entire cavity may exhibit endocardial thickening, which may penetrate as far as the epicardium. Microscopically, the fibrotic endocardium contains only a few elastic fibers. Myofibers trapped within the collagenous tissue display nonspecific degenerative changes.

Storage Diseases The various lysosomal storage diseases are discussed in detail in Chapter 6. Only the cardiac manifestations are reviewed here. GLYCOGEN STORAGE DISEASES: Of the various forms of glycogen storage disease, types II (Pompe disease), III (Cori disease), and IV (Andersen disease) affect the heart. The most common and severe involvement is with Pompe disease. In infants with this condition, the heart is markedly enlarged (up to seven times normal), and endocardial fibroelastosis is seen in 20% of patients. The myocytes are vacuolated as a result of the large amounts of stored glycogen. The functional changes are those of a restrictive type of cardiomyopathy, and the usual cause of death is cardiac failure. MUCOPOLYSACCHARIDOSES: Several of the mucopolysaccharidoses involve the heart. Cardiac disease results from lysosomal accumulation of mucopolysaccharides (glycosaminoglycans) in various cells. In general, pseudohypertrophy of the ventricles develops, and contractility gradually diminishes. The coronary arteries may be narrowed by thickening of the intima and media, and in Hurler and Hunter syndromes, myocardial infarction is common. SPHINGOLIPIDOSES: Fabry disease may result in the accumulation of glycosphingolipids in the heart, with functional and pathologic changes similar to those that complicate the mucopolysaccharidoses. HEMOCHROMATOSIS: This multiorgan disease is associated with excessive iron deposition in many tissues (see Chapter 14). The degree of iron deposition in the heart varies and only roughly correlates with that in other organs. Cardiac involvement has features of both dilated and restrictive cardiomyopathy, with systolic and diastolic impairment. Congestive heart failure occurs in as many as one third of patients with hemochromatosis. At autopsy, the heart is dilated, and ventricular walls are thickened. The brown color seen on gross examination correlates with iron deposition in cardiac myocytes. The severity of myocardial dysfunction seems to be proportional to the quantity of iron deposited.

Cardiac Tumors Primary cardiac tumors are rare but can result in serious problems when they occur.

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Cardiac Myxoma is the Most Common Primary Tumor of the Heart Cardiac myxoma accounts for about 50% of all primary cardiac tumors. It is usually sporadic, but it is occasionally associated with familial autosomal dominant syndromes. PATHOLOGY: Most myxomas (75%) arise in the left atrium, although they can occur in any cardiac chamber or on a valve. The tumor appears as a glistening, gelatinous, polypoid mass, usually 5 to 6 cm in diameter, with a short stalk (Fig. 11-26). It may be sufficiently mobile to obstruct the mitral valve orifice. Microscopically, cardiac myxoma has a loose myxoid stroma containing abundant proteoglycans. Polygonal stellate cells are found within the matrix, occurring singly or in small clusters. CLINICAL FEATURES: More than half of patients with left atrial myxoma have clinical evidence of mitral valve dysfunction. Although the tumor does not metastasize in the usual sense, it often embolizes. One third of patients with myxomas of the left atrium or left ventricle die from tumor embolization to the brain. Surgical removal of the tumor is successful in most cases.

Rhabdomyoma is a Childhood Tumor Rhabdomyoma is the most common primary cardiac tumor in infants and children and forms nodular masses in the myocardium. It may actually be a hamartoma rather than a true neoplasm, although the issue is still debated. Almost all are multiple and involve both ventricles and, in one third of cases, the atria as well. In half of cases, the tumor projects into a cardiac chamber and obstructs the lumen or valve orifices. PATHOLOGY: On gross examination, cardiac rhabdomyomas are pale masses, from 1 mm to several centimeters in diameter. Microscopically, tumor cells show small central nuclei and abundant glycogen-rich clear cytoplasm, in which fibrillar processes containing sarcomeres radiate

to the margin of the cell (“spider cell”). Rhabdomyomas often occur in association with tuberous sclerosis (one third to one half of cases). A few cardiac rhabdomyomas have been successfully excised.

Metastatic Tumors to the Heart May Manifest as Restrictive Cardiomyopathy Metastatic tumors to the heart are seen most frequently in patients with the most prevalent forms of carcinomas—those of the lung, breast, and gastrointestinal tract. Still, only a minority of patients with these tumors will show cardiac metastases. Lymphomas and leukemia may also involve the heart. Of all tumors, the one most likely to metastasize to the heart is malignant melanoma. Metastatic cancer of the myocardium can result in clinical manifestations of restrictive cardiomyopathy, particularly if the cardiac tumors are associated with extensive fibrosis.

Diseases of the Pericardium Pericardial Effusion Can Cause Cardiac Tamponade Pericardial effusion is the accumulation of excess fluid within the pericardial cavity, either as a transudate or an exudate. The pericardial sac normally contains no more than 50 mL of lubricating fluid. If the pericardium is slowly distended, it can accommodate up to 2 L of fluid without notable hemodynamic consequences. However, rapid accumulation of as little as 150 to 200 mL of pericardial fluid or blood may significantly increase intrapericardial pressure and restrict diastolic filling, especially of the right ventricle. Cardiac tamponade is the syndrome produced by the rapid accumulation of pericardial fluid, which restricts the filling of the heart. • Serous pericardial effusion is often a complication of an increase in extracellular fluid volume, as occurs in congestive heart failure or the nephrotic syndrome. The fluid has a low protein content and few cellular elements. • Chylous effusion (fluid containing chylomicrons) results from a communication of the thoracic duct with the pericardial space secondary to lymphatic obstruction by tumor or infection. • Hemopericardium is bleeding directly into the pericardial cavity. The most common cause is ventricular free wall rupture at a myocardial infarct. Less frequent causes are penetrating cardiac trauma, rupture of a dissecting aneurysm of the aorta, infiltration of a vessel by tumor, or a bleeding diathesis. The hemodynamic consequences range from a minimally symptomatic condition to abrupt cardiovascular collapse and death. As the pericardial pressure increases, it reaches and then exceeds central venous pressure, thereby limiting return of blood to the heart. Acute cardiac tamponade is almost invariably fatal unless the pressure is relieved by removing pericardial fluid, by either needle pericardiocentesis or surgical procedures.

Acute Pericarditis May Follow Viral Infections Pericarditis refers to inflammation of the visceral or parietal pericardium.

FIGURE 11-26. Cardiac myxoma. The left atrium contains a large, polypoid tumor that protrudes into the mitral valve orifice.

PATHOGENESIS: The causes of pericarditis are similar to those for myocarditis (see Table 11-4). In most cases, the cause of acute pericarditis is obscure and (as in myocarditis) is attributed to an undiagnosed viral infection. Bacterial pericarditis is distinctly unusual in the antibiotic era. Metastatic tumors, most commonly breast and lung carcinomas, may involve the pericardium and cause a malignant pericardial effusion. Pericarditis associated with myocardial infarction and rheumatic fever is discussed above.

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FIGURE 11-27. Fibrinous pericarditis. The heart of a patient who died in uremia displays a shaggy, fibrinous exudate covering the visceral pericardium.

FIGURE 11-28. Constrictive pericarditis. The pericardial space has been obliterated, and the heart is encased in a fibrotic, thickened pericardium.

PATHOLOGY: Acute pericarditis can be classified as fibrinous, purulent, or hemorrhagic, depending on the gross and microscopic characteristics of the pericardial surfaces and fluid. The most common form is fibrinous pericarditis, in which the normal smooth, glistening appearance of the pericardial surfaces becomes replaced by a dull, granular fibrin-rich exudate (Fig. 11-27). The rough texture of the inflamed pericardial surfaces produces the characteristic friction rub heard by auscultation. The effusion fluid in fibrinous pericarditis is usually rich in protein, and the pericardium contains primarily mononuclear inflammatory cells.

PATHOGENESIS AND PATHOLOGY: Constrictive pericarditis results from an exuberant healing response after acute pericardial injury, in which the pericardial space becomes obliterated and visceral, and parietal layers become fused in a dense, rigid mass of fibrous tissue. The scarred pericardium may be so thick (up to 3 cm) that it narrows the orifices of the venae cavae (Fig. 11-28). The fibrous envelope may contain calcium deposits. The condition is infrequent today and, in developed countries, is predominantly idiopathic. Constrictive pericarditis may follow tuberculous infection and is still the major cause in underdeveloped regions.

CLINICAL FEATURES: The initial manifestation of acute pericarditis is sudden, severe, substernal chest pain, sometimes referred to the back, shoulder, or neck. A characteristic pericardial friction rub is easily heard. Idiopathic or viral pericarditis is a self-limited disorder, although it may infrequently lead to constrictive pericarditis. Corticosteroids are the treatment of choice. The therapy for other specific forms of acute pericarditis varies with the cause.

Constrictive Pericarditis May Mimic Right Heart Failure Constrictive pericarditis is a chronic fibrosing disease of the pericardium that compresses the heart and restricts inflow.

CLINICAL FEATURES: Patients with constrictive pericarditis have a small, quiet heart in which venous inflow is restricted, and the rigid pericardium determines the diastolic volume of the heart. These patients have high venous pressure, low cardiac output, small pulse pressure, and fluid retention with ascites and peripheral edema. Total pericardiectomy is the treatment of choice.

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The Respiratory System Mary Beth Beasley William D. Travis Emanuel Rubin

THE LUNGS Congenital Anomalies Diseases of the Bronchi and Bronchioles Airway Infections Bronchocentric Granulomatosis Constrictive Bronchiolitis Bronchial Obstruction Bronchiectasis Bacterial Infections Bacterial Pneumonia Mycoplasma Pneumoniae Tuberculosis Fungal Infections Viral Infections Lung Abscess Diffuse Alveolar Damage (Acute Respiratory Distress Syndrome) Causes of Diffuse Alveolar Damage Respiratory Distress Syndrome of the Newborn Diffuse Pulmonary Hemorrhage Obstructive Pulmonary Diseases Chronic Bronchitis Emphysema Asthma

Diseases of the lung are not only important problems for the individual but are major public health concerns. Cancer of the lung, mostly related to smoking, remains the most common cause of cancer-related death in the US, killing more than 160,000 persons per year. Chronic obstructive pulmonary disease, also frequent in smokers, is responsible for at least 120,000 deaths per year in the US. Acute respiratory distress syndrome 244

Pneumoconioses Silicosis Coal Workers’ Pneumoconiosis (CWP) Asbestos-Related Diseases Berylliosis Interstitial Lung Disease Hypersensitivity Pneumonitis (Extrinsic Allergic Alveolitis) Sarcoidosis Usual Interstitial Pneumonia (UIP) Organizing Pneumonia Pattern Vasculitis and Granulomatosis Pulmonary Hypertension Origin of Pulmonary Hypertension Carcinoma of the Lung Common Clinical Features Pulmonary Metastases

THE PLEURA Pneumothorax Pleural Effusion Tumors of the Pleura: Malignant Mesothelioma

(ARDS) affects about 150,000 persons a year and even humble respiratory tract infections, mostly benign and self-limited are the most common cause of days lost from work. The growing number of respiratory infections of public concern, including drug-resistant tuberculosis, the potential for the recurrence of SARS, and the threat of pandemic avian influenza, highlight the importance of respiratory disease worldwide.

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THE LUNGS Congenital Anomalies PULMONARY HYPOPLASIA: This condition reflects incomplete or defective development of the lung. The lung is smaller than normal, owing to the presence of fewer acini or a decrease in their size. Pulmonary hypoplasia, the most common congenital lesion of the lung, is found in 10% of neonatal autopsies. In most cases (90%), it occurs in association with other congenital anomalies, most of which impinge on the thorax. The lesion may be accompanied by hypoplasia of the bronchi and pulmonary vessels if the insult occurs early in gestation, as in congenital diaphragmatic hernia. PATHOGENESIS: Three major factors have been implicated as causes of pulmonary hypoplasia: (1) Compression of the lung is usually caused by a congenital diaphragmatic hernia, typically on the left side, owing to failure of the pleuroperitoneal canal to close; (2) Oligohydramnios (inadequate volume of amniotic fluid) is usually due to genitourinary anomalies and is an important cause of pulmonary hypoplasia; (3) Decreased respiration has been shown experimentally to produce hypoplastic lungs, which may be caused by a lack of repetitive stretching of the lung. CONGENITAL CYSTIC ADENOMATOID MALFORMATION: This common anomaly consists of abnormal bronchiolar structures of varying sizes or distribution. Most cases are seen in the first 2 years of life. The lesion usually affects one lobe of the lung and consists of multiple cyst-like spaces, which are lined by bronchiolar epithelium and separated by loose fibrous tissue (Fig. 12-1). Some patients with congenital cystic adenomatoid malformation have other congenital anomalies. The most common presenting symptom is respiratory distress and cyanosis. Surgical resection is the treatment of choice. BRONCHOGENIC CYST: This lesion is a discrete, extrapulmonary, fluid-filled mass lined by respiratory epithelium and limited by walls that contain muscle and cartilage. It is most commonly found in the middle mediastinum. In the newborn, a bronchogenic cyst may compress a major airway and cause respiratory distress. Secondary infection of the cyst in older patients may lead to hemorrhage and perforation. Many bronchogenic cysts are asymptomatic and are found on routine chest radiographs. EXTRALOBAR SEQUESTRATION: Extralobar sequestration is a mass of lung tissue that is not connected to the bronchial tree and is located outside the visceral pleura. An abnormal artery, usually arising from the aorta, supplies the sequestered tissue. PATHOGENESIS: This lesion is thought to originate from an outpouching of the foregut that later loses its connection to the original foregut. It is three to four times as common in males as in females and is associated with other anomalies in two thirds of patients. PATHOLOGY: On gross examination, extralobar sequestration is a pyramidal or round mass covered by pleura, from 1 to 15 cm in greatest dimension. Microscopically, dilated bronchioles, alveolar ducts, and alveoli are noted. Infection or infarction may alter the histologic appearance. CLINICAL FEATURES: In the neonatal period, often during the first day of life, the disorder may manifest as dyspnea and cyanosis. In older children, it may come to medical attention because of recurrent bronchopulmonary infections. Surgical excision is curative.

FIGURE 12-1.

Congenital cystic adenomatoid malformation. Multiple gland-like spaces are lined by bronchiolar

epithelium.

INTRALOBAR SEQUESTRATION: Intralobar sequestration is a mass of lung tissue within the visceral pleura, isolated from the tracheobronchial tree and supplied by a systemic artery. For many years, it was considered a congenital malformation, but it is now thought to be acquired. PATHOLOGY: Intralobar sequestration is found in a lower lobe in almost all cases. Bilateral involvement is distinctly unusual. On gross examination, the sequestered pulmonary tissue shows the result of chronic recurrent pneumonia, with end-stage fibrosis and honeycomb cystic changes. The cysts range up to 5 cm in diameter and lie in a dense fibrous stroma. Microscopically, the cystic spaces are mostly lined by cuboidal or columnar epithelium, and the lumen contains foamy macrophages and eosinophilic material. Interstitial chronic inflammation and hyperplasia of lymphoid follicles is often prominent. Acute and organizing pneumonia may be seen. CLINICAL FEATURES: Cough, sputum production, and recurrent pneumonia are noted in almost all patients. Most cases are discovered in adolescents or young adults. Surgical resection is often indicated.

Diseases of the Bronchi and Bronchioles Most bronchial and bronchiolar diseases deal with acute conditions and their sequelae. Chronic bronchitis will be discussed with chronic obstructive pulmonary disease (COPD).

Airway Infections are Caused by Diverse Organisms The agents causing pulmonary infections are discussed in detail in Chapter 9. Many infectious agents that involve the intrapulmonary airways tend to affect the more peripheral airways (bronchiolitis). The classic examples are adenovirus, respiratory syncytial virus (RSV), and measles. All are more serious in malnourished children and populations not ordinarily exposed to these agents. Severe symptomatic illnesses with these agents are more commonly encountered in infants and children, and recovery is the rule. Symptoms include cough, a feeling of tightness in the chest, and, in extreme cases, shortness of breath and even cyanosis. INFLUENZA: This is a characteristic example of tracheobronchitis, and in the occasional patient who dies with this infection,

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the appearance of the bronchi is dramatic. The surface of the airway is fiery red, reflecting acute inflammation and congestion of the mucosa. ADENOVIRUS: Infection with adenovirus produces the most serious sequelae, including extensive inflammation of bronchioles (Fig. 12-2) and subsequent healing by fibrosis. Bronchioles may become obliterated or occluded by loose fibrous tissue (obliterative bronchiolitis). RSV: RSV infection tends to occur in epidemics in nurseries. It is usually self-limited, but rare fatal cases occur. It can cause nosocomial infection in children and (rarely) in adults. Histologically, one encounters peribronchiolar inflammation and disorganization of the epithelium. Severe overdistention may be found without obvious bronchiolar obstruction, possibly due to displacement of surfactant from the bronchiolar surface. MEASLES: At one time, a major cause of bronchiolitis, measles is rarely a problem in developed countries since the advent of the measles vaccine. Similar to adenovirus, it may result in bronchiolar obliteration and bronchiectasis. BORDETELLA PERTUSIS: This bacterium commonly infects the airways and is the cause of whooping cough. With the advent of a pertussis vaccine, the disease has become rare in the United States, but the disease is still a problem in nonvaccinated populations. Clinically, whooping cough is typified by fever and severe prolonged bouts of coughing, followed by a characteristic deep whooping inspiration. Severe bronchial and bronchiolar inflammation has been found in fatal cases. Whooping cough occasionally leads to the development of bronchiectasis.

Bronchocentric Granulomatosis Usually Reflects Allergic Responses to Infection Bronchocentric granulomatosis refers to nonspecific granulomatous inflammation centered on bronchi or bronchioles. The histologic pattern can be seen in a number of clinical settings and is not a distinct clinical entity. Bronchocentric granulomatosis can be the predominant pulmonary pathologic finding in two groups of patients, namely asthmatics and nonasthmatic patients with tuberculosis or fungi such as Histoplasma capsulatum. Bronchocentric granulomatosis can also be a manifestation of rheumatoid arthritis, ankylosing spondylitis, and Wegener granulomatosis. Patients with bronchocentric granulomatosis of either the allergic or nonallergic type generally respond well to corticosteroid therapy.

Constrictive Bronchiolitis May Obliterate the Airway Constrictive (obliterative) bronchiolitis is an uncommon disorder in which an initial inflammatory bronchiolitis is followed by bronchiolar scarring and fibrosis, resulting in constrictive narrowing and eventually complete obliteration of the airway lumen. PATHOLOGY: Bronchioles show chronic mural inflammation and varying amounts of submucosal fibrosis. These lesions are often focal and may be difficult to identify. Elastic stains may assist in recognizing the scarred bronchioles. Bronchiolectasis and mucus plugs may be seen in adjacent airways. The surrounding lung is usually normal. CLINICAL FEATURES: Patients may have dyspnea and wheezing due to severe obstruction of pulmonary function. This pattern of fibrosis is seen in a number of situations, including (1) bone marrow transplantation (graft-versus-host disease), (2) lung transplantation (chronic rejection), (3) collagen vascular diseases (especially rheumatoid arthritis), (4) postinfectious disorders (especially viral infections), (5) after inhalation of toxins (SO2, ammonia, phosgene), and (6) intake of certain drugs (penicillamine). It may also occur as an idiopathic entity. Most patients have a relentless progressive clinical course. Many are treated with steroids, but no therapy is effective for this disease.

Bronchial Obstruction Leads to Atelectasis Bronchial obstruction in adults is most often the consequence of the endobronchial extension of primary lung tumors, although mucus plugs from aspirated gastric contents or foreign bodies may be responsible, especially in children. In the case of partial obstruction, the trapped air may lead to overdistention of the distal affected segment; complete obstruction results in atelectasis. Areas distal to the obstruction are also susceptible to pneumonia, pulmonary abscess, and bronchiectasis (see below). Atelectasis refers to the collapse of expanded lung tissue (Fig. 12-3). If the air supply is obstructed, the loss of gas from the alveoli to the blood causes collapse of the affected region. Atelectasis is an important postoperative complication of abdominal surgery, occurring because of (1) mucus obstruction of a bronchus and (2) diminished respiratory movement resulting from postoperative pain. It is often asymptomatic, but when severe, it results in hypoxemia and a shift of the mediastinum toward the affected side. Atelectasis is usually caused by bronchial obstruction but may also result from direct compression of the lung (e.g., hydrothorax or pneumothorax). Such pressure may seriously compromise the function of the affected lung and cause a mediastinal shift away from the affected side. In long-standing atelectasis, the collapsed lung becomes fibrotic and bronchi dilate, in part, because of infection distal to the obstruction. Permanent bronchial dilation (bronchiectasis) results.

Bronchiectasis is Irreversible Dilation of Bronchi Caused by Destruction of Bronchial Wall Muscle and Elastic Elements

Bronchiolitis due to adenovirus. The wall of this bronchiole shows an intense chronic inflammatory infiltrate with local extension into the surrounding peribronchial tissue. FIGURE 12-2.

PATHOGENESIS: Bronchiectasis may be obstructive or nonobstructive. Obstructive bronchiectasis is localized to a segment of the lung distal to a mechanical obstruction of a central bronchus by a variety of lesions, including tumors, inhaled foreign bodies, mucus plugs (in asthma), and compressive lymphadenopathy. Nonobstructive bronchiectasis is usually a complication of respiratory infections or defects in the defense mechanisms that protect the airways from infection. It may be localized or generalized.

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FIGURE 12-3.

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Atelectasis. The right lung of an infant is pale and expanded by air; the left lung is collapsed.

Localized nonobstructive bronchiectasis was once common, usually resulting from childhood bronchopulmonary infections. Although reduced in frequency by antibiotics and childhood immunizations, one half to two thirds of all cases still follow a bronchopulmonary infection. At present, adenovirus and RSV infections are frequent causes of bronchiectasis in children. Generalized bronchiectasis is, for the most part, secondary to inherited impairment in host defense mechanisms or acquired conditions that permit introduction of infectious organisms into the airways. The acquired disorders that predispose to bronchiectasis include (1) neurologic diseases that impair consciousness, swallowing, respiratory excursions and the cough reflex; (2) incompetence of the lower esophageal sphincter, which promotes gastric reflux; (3) nasogastric intubation; and (4) chronic bronchitis. The principal inherited conditions associated with generalized bronchiectasis are cystic fibrosis, the dyskinetic ciliary syndromes, hypogammaglobulinemias, and deficiencies of specific immunoglobulin (Ig)G subclasses. Kartagener syndrome is one of the immotile cilia (ciliary dyskinesia) syndromes and comprises the triad of dextrocardia (with or without situs inversus), bronchiectasis, and sinusitis. It is caused by absence of inner or outer dynein arms of cilia. In the respiratory tract, ciliary defects lead to repeated upper and lower respiratory tract infections in the lung and, thus, to bronchiectasis. PATHOLOGY: Generalized bronchiectasis is usually bilateral and is most common in the lower lobes, the left more commonly involved than the right. Localized bronchiectasis may occur wherever there is obstruction or infection. Bronchi are dilated and have white or yellow thickened walls, and lumina frequently contain thick, mucopurulent secretions (Fig. 12-4). Microscopically, severe inflammation of bronchi and bronchioles results in destruction of all components of the bronchial wall. With the consequent collapse of distal lung parenchyma, the damaged bronchi dilate. The distal bronchi and bronchioles are scarred and often obliterated.

Bronchiectasis. The resected upper lobe shows widely dilated bronchi, with thickening of the bronchial walls and collapse and fibrosis of the pulmonary parenchyma. FIGURE 12-4.

CLINICAL FEATURES: Patients with bronchiectasis have a chronic productive cough, often with several hundred milliliters of mucopurulent sputum a day. Hemoptysis is common, as bronchial inflammation

Lobar pneumonia. The entire left lower lobe is consolidated and in the stage of red hepatization. The upper lobe is normally expanded. FIGURE 12-5.

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erodes through the walls of adjacent bronchial arteries. Dyspnea and wheezing are variable, depending on the extent of the disease. Pneumonia is a common complication, and patients with longstanding cases are at risk of chronic hypoxia and pulmonary hypertension. Acute, reversible dilation of bronchi may occur as a consequence of bacterial or viral bronchopulmonary infection, and it may take months before the bronchi return to normal size. Surgical resection of localized bronchiectasis may be necessary, but in generalized disease, surgical treatment is more palliative than curative.

Bacterial Infections Pulmonary infections are discussed in detail in Chapter 9. The major pulmonary entities are described below, with particular emphasis on pathologic features.

Bacterial Pneumonia is Inflammation and Consolidation of the Lung Parenchyma Older terminology refers to lobar pneumonia or bronchopneumonia, but these terms have little clinical relevance today. In general, lobar pneumonia denotes consolidation of an entire lobe (Fig. 125), whereas bronchopneumonia is characterized by scattered solid foci in the same or several lobes (Fig. 12-6). Streptococcus pneumoniae was the classic cause of lobar pneumonia, but today, largely due to antibiotic therapy, the involvement of a lobe tends to be incomplete, and more than one lobe is usually affected. By contrast, bronchopneumonia is still a common cause of death. It typically develops in terminally ill patients, usually in the dependent and posterior portions of the lung. Scattered irregular foci of pneumonia are centered on terminal bronchioles and respiratory bronchioles. Bronchiolitis is present, with exudation of polymorphonuclear leukocytes into the adjacent alveoli.

PATHOGENESIS: Most bacteria that cause pneumonia are normal inhabitants of the oropharynx and nasopharynx and reach the alveoli by aspiration of secretions. Other routes of infection include inhalation from the environment, hematogenous dissemination from an infectious focus elsewhere, and (rarely) spread of bacteria from an adjacent site. A change in oropharyngeal flora from the normal commensals to a virulent organism may proceed to pneumonia in debilitated or immunosuppressed patients in the hospital, in whom nosocomial pneumonia can occur in as many as 25% of cases. A number of conditions predispose to infection by depressing the host’s defenses, including cigarette smoking, chronic bronchitis, alcoholism, severe malnutrition, wasting diseases, and poorly controlled diabetes.

Pneumococcal Pneumonia Despite the impact of antibiotic therapy, pneumonia caused by Streptococcus pneumoniae (pneumococcus) remains a significant problem. It is principally a disease of young to middle-aged adults. The disease is rare in infants, less common in the elderly, and considerably more frequent in men than in women. PATHOGENESIS: Pneumococcal pneumonia is mostly a consequence of altered defense barriers in the respiratory tract. Frequently, it follows a viral infection of the upper respiratory tract (e.g., influenza). The bronchial secretions stimulated by a viral infection provide a hospitable environment for proliferation of S. pneumoniae, which are normal flora of the nasopharynx. The aspiration of pneumococci is also promoted by factors that impair the epiglottic reflex, including exposure to cold, anesthesia, and alcohol intoxication. Lung injury caused by factors such as congestive heart failure and irritant gases also renders the lung more susceptible to pneumococcal pneumonia. PATHOLOGY: In the earliest stage of pneumococcal pneumonia, protein-rich edema fluid containing numerous organisms fills the alveoli. Marked capillary congestion leads to massive outpouring of polymorphonuclear leukocytes and intra-alveolar hemorrhage (Fig. 127). Because the firm consistency of the affected lung is reminiscent of the liver, this stage has been aptly named “red hepatization” (Fig. 12-8). The next phase, occurring after 2 or more days, depending on the success of treatment, involves lysis of polymorphonuclear leukocytes and appearance of macrophages, which phagocytose the fragmented neutrophils and other inflammatory debris. At this stage, the congestion has diminished, but the lung is still firm (“grey hepatization”) (see Fig. 12-8). The alveolar exudate is then removed, and the lung gradually returns to normal. A number of complications may follow pneumococcal pneumonia:

FIGURE 12-6.

Bronchopneumonia. Scattered foci of consolidation are centered on bronchi and bronchioles.

• Pleuritis, often painful, is common, because the pneumonia readily extends to the pleura. • Pleural effusion occurs frequently but usually resolves. • Pyothorax results from an infection of a pleural effusion and may heal with extensive fibrosis. • Empyema (a loculated collection of pus with fibrous walls) results from the persistence of pyothorax. • Bacteremia is present in more than 25% of patients in the early stages of pneumococcal pneumonia and may lead to endocarditis or meningitis. Patients whose spleens have been removed often die of this bacteremia.

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Pneumococcal pneumonia. The alveoli are packed with an exudate composed of polymorphonuclear leukocytes and occasional macrophages. FIGURE 12-7.

CLINICAL FEATURES: The onset of pneumococcal pneumonia is acute, with fever and chills. Chest pain secondary to pleural involvement is common. Hemoptysis is frequent and is characteristically “rusty,” because it is derived from altered blood in alveolar spaces. Pneumococcal pneumonia is treated effectively with antibiotics. Although symptoms of pneumonia respond rapidly to antibiotics, the lesion still takes several days to resolve radiologically.

Klebsiella Pneumonia Other than S. pneumoniae, Klebsiella pneumoniae is the only organism that causes lobar pneumonia with any frequency. However, it accounts for no more than 1% of all cases of community-acquired pneumonia. The disease is commonly associated with alcoholism and is seen most frequently in middle-aged men, although persons with diabetes and chronic pulmonary disease are also at increased risk. PATHOLOGY: K. pneumoniae has a thick, gelatinous capsule, which is responsible for the characteristic mucoid appearance of the cut surface of the lung. Another distinctive characteristic of Klebsiella pneumonia is that the affected lobe increases in size, so that the fissure “bulges” toward the unaffected region. There is a tendency toward tissue necrosis and abscess formation. A serious complication is bronchopleural fistula, (i.e., a communication between the bronchial airway and the pleural space). The onset of Klebsiella pneumonia is less dramatic than that of pneumococcal pneumonia, but the disease may be more dangerous. Before the antibiotic era, mortality rates in Klebsiella pneumonia ranged from 50% to 80%. Even with prompt antibiotic treatment, the mortality is still considerable.

Staphylococcal Pneumonia Community-acquired staphylococcal pneumonia is uncommon, accounting for only 1% of the bacterial pneumonias. However, pulmonary infection with Staphylococcus aureus is a common superinfection after influenza and other viral respiratory tract infec-

Pathogenesis of pneumococcal lobar pneumonia. Pneumococci, characteristically in pairs (diplococci), multiply rapidly in the alveolar spaces and produce extensive edema. They incite an acute inflammatory response in which polymorphonuclear leukocytes and congestion are prominent (red hepatization). As the inflammatory process progresses, macrophages replace the polymorphonuclear leukocytes and ingest debris (grey hepatization). The process usually resolves, but complications may ensue. PMN, polymorphonuclear neutrophil; RBC, red blood cell. FIGURE 12-8.

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tions. Repeated episodes of staphylococcal pneumonia are seen in patients with cystic fibrosis. Nosocomial staphylococcal pneumonia typically occurs in weakened, chronically ill patients, who are prone to aspiration and in intubated persons. PATHOLOGY: Like staphylococcal infection elsewhere, staphylococcal pneumonia is characterized by the production of many small abscesses. In infants and, to a lesser extent, in adults, these may lead to pneumatoceles (thin-walled cystic spaces lined primarily by respiratory tissue), which develops when an abscess breaks into an airway. Cavitation and pleural effusions are common complications of staphylococcal pneumonia, but empyema is infrequent. Staphylococcal pneumonia requires aggressive therapy, particularly because S. aureus is often antibiotic resistant.

Legionella Pneumonia In 1976, a mysterious respiratory ailment that carried a high mortality broke out at an American Legion convention in Philadelphia. The responsible organism, Legionella pneumophila, was soon identified as a fastidious bacterium, with special requirements for growth in culture. Legionella organisms thrive in aquatic environments, and outbreaks of pneumonia have been traced to contaminated water in air-conditioning cooling towers, evaporative condensers, and construction sites. Person-to-person spread does not occur, and there is no animal or human reservoir. PATHOLOGY: In fatal cases of Legionella pneumonia, multiple lobes exhibit a bronchopneumonia, with large confluent areas. Microscopically, alveoli contain fibrin and inflammatory cells, with either neutrophils or macrophages predominating. Necrosis of inflammatory cells (leukocytoclasis) may be extensive. One third of cases have been complicated by empyema. Legionella organisms are usually abundant within and outside the phagocytic cells but require special stains for visualization. CLINICAL FEATURES: The onset of Legionella pneumonia tends to be abrupt, with malaise, fever, muscle aches and pains and, curiously, abdominal pain. A productive cough is usual, and chest pain due to pleuritis occasionally occurs. Mortality rates have been high (10% to 20%), especially in immunocompromised patients. Erythromycin is the antibiotic of choice.

Opportunistic Pneumonia Caused by GramNegative Bacteria Pneumonias caused by gram-negative organisms have become more common with the advent of immunosuppressive and cytotoxic therapies, treatment with broad-spectrum antibiotics, and AIDS. The most common bacteria are Escherichia coli and Pseudomonas aeruginosa; the latter is also a common pathogen in patients with cystic fibrosis.

the organisms are inhaled directly without transmission by an arthropod vector, and the disease may be spread from person to person or animal (such as a cat) to person. The lungs typically show extensive hemorrhagic bronchopneumonia, pleuritis, and enlargement of mediastinal lymph nodes. The untreated disease progresses rapidly and is often fatal.

Mycoplasma Pneumoniae Causes Atypical Pneumonia In contrast to lobar pneumonia, the onset of atypical pneumonia is insidious, leukocytosis is absent or slight, and the course is prolonged. Respiratory symptoms may range from minimal to severe. The infection characteristically causes a bronchiolitis with a neutrophilic intraluminal exudate and an intense lymphoplasmacytic infiltrate in the bronchiolar wall (Fig. 12-9). Erythromycin is effective, and the infection is only rarely fatal.

Tuberculosis is the Classic Granulomatous Infection Tuberculosis represents infection with Mycobacterium tuberculosis, although atypical mycobacterial infections may mimic tuberculosis. The disease is divided into primary and secondary (or reactivation) tuberculosis. The infection is discussed in detail in Chapter 9.

Fungal Infections May be Geographic or Opportunistic Fungal infections of the lung, including Histoplasmosis, Coccidioidomycosis, Cryptococcosis, North American blastomycosis, Aspergillosis, and Pneumocystis, all cause pulmonary infections, which are discussed in detail in Chapter 9.

Viral Infections of the Lung Produce Diffuse Alveolar Damage or Interstitial Pneumonia PATHOLOGY: Viral infections initially affect the alveolar epithelium and result in a mononuclear infiltrate in the interstitium of the lung (Fig. 12-10). Necrosis of type I epithelial cells and the formation of hyaline membranes result in an appearance that is indistinguishable from diffuse alveolar damage from other causes (see below). In some instances, alveolar damage may be indolent, and the disease is characterized by hyperplasia of type II pneumocytes and interstitial inflammation. This appearance contrasts with that of most

Anthrax Pneumonia and Pneumonic Plague Recent world events have refocused attention on infectious agents that may be used as potential weapons of bioterrorism. Chief among these are Bacillus anthracis and Yersinia pestis. B. anthracis, the causative agent of anthrax, is a gram-positive, spore-forming bacillus. Anthrax occurs in many species of domestic animals, and infection of humans is seen infrequently, most often as a nonfatal cutaneous infection in agricultural workers. Anthrax spores are highly resistant to heat and drying, and when inhaled, they are transported to mediastinal lymph nodes. From there, bacilli emerge and rapidly disseminate. In the lungs, the disease is manifested by hemorrhagic bronchitis and confluent areas of hemorrhagic pneumonia. Anthrax is susceptible to antibiotic therapy. Yersinia pestis, the causative agent of plague, produces three forms of infection, namely a bubonic form, a pneumonic form, and a rarely encountered septicemic form. In pneumonic plague,

FIGURE 12-9.

Mycoplasma pneumonia. Chronic bronchiolitis with a neutrophilic luminal exudate.

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INFECTIOUS AGENT • Viruses • Rickettsia • Chlamydia • Myoplasma Inhalation Type II pneumocyte Alveolus Entry of organisms into alveolus

Capillary

Infectious agent

Type I pneumocyte

Infection of type I pneumocytes

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eosinophilic cytoplasmic inclusions. Although interstitial pneumonia is a well-characterized complication of measles, it is rarely fatal, except in immunocompromised, previously unexposed persons. Varicella infection (both chickenpox and herpes zoster) produces disseminated, focally necrotic lesions in the lung as well as interstitial pneumonia. Pulmonary involvement is usually asymptomatic; however, in immunocompromised persons, it may be fatal. The viral inclusions are nuclear, eosinophilic, refractile and are surrounded by a clear halo. Multinucleation can occur. Herpes simplex can cause necrotizing tracheobronchitis as well as diffuse alveolar damage. The viral inclusions are identical to those seen in varicella infection. Adenovirus pneumonia results in a necrotizing bronchiolitis and bronchopneumonia. It can cause two types of nuclear inclusions: eosinophilic nuclear inclusions surrounded by a clear halo and “smudge cells,” with indistinct, basophilic, nuclear inclusions that fill the entire nucleus and are surrounded by only a thin rim of chromatin.

Lung Abscess Lung abscess is a localized accumulation of pus accompanied by the destruction of pulmonary parenchyma, including alveoli, airways, and blood vessels, which is most often caused by aspiration of anaerobic bacteria from the oropharynx. Infections are typically polymicrobial, with fusiform bacteria and Bacteroides species often isolated.

Hyaline membrane Hyperplasia of type II pneumocytes

Edema

Interstitial edema and predominantly mononuclear exudate

INTERSTITIAL PNEUMONITIS

PATHOGENESIS: The aspiration that leads to pulmonary abscesses often occurs in the setting of depressed consciousness. Not surprisingly, alcoholism is the single most common predisposing condition. The deposition of enough bacteria to produce a lung abscess requires two conditions. A large number of

Congested and dilated capillary

INTERSTITIAL FIBROSIS (rare) RESOLUTION

FIGURE 12-10. Pathogenesis of interstitial pneumonia. Although interstitial pneumonia is most commonly caused by viruses, other organisms may also cause significant interstitial inflammation. Type I cells are the most sensitive to damage, and loss of their integrity leads to intra-alveolar edema. The proteinaceous exudate and cell debris form hyaline membranes, and type II cells multiply to line the alveoli. Interstitial inflammation is characterized mainly by mononuclear cells. The disease generally resolves completely but occasionally progresses to interstitial fibrosis.

bacterial infections, in which intra-alveolar exudates predominate and the interstitium is only incidentally involved. Cytomegalovirus produces a characteristic pneumonia that features an intense interstitial lymphocytic infiltrate. The alveoli are lined by type II cells that have regenerated to cover the epithelial defect left by necrosis of type I cells. The infected alveolar cells are very large (cytomegaly) and display a single, dark, basophilic nuclear inclusion with a peripheral halo and multiple indistinct cytoplasmic, basophilic inclusions. Measles infection, which involves both the airways and the parenchyma, is characterized by very large (100 ␮m across) multinucleated giant cells that have nuclear inclusions and large

FIGURE 12-11. Cytomegalovirus pneumonitis. The infected alveolar cells are enlarged and display the typical dark-blue nuclear inclusions. (Inset) A higher-power view shows infected alveolar cells that display a single basophilic nuclear inclusion with a perinuclear halo and multiple, indistinct, basophilic, cytoplasmic inclusions.

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anaerobic bacteria must be present in the oral flora, as in persons with poor oral hygiene or periodontal disease. In addition, the cough reflex or tracheobronchial clearance must be impaired, as is the case in alcoholics, those suffering from drug overdose, epileptics, and neurologically impaired persons. Other causes of lung abscess include necrotizing pneumonias, bronchial obstruction, infected pulmonary emboli, penetrating trauma, and extension of infection from tissues adjacent to the lung.

PATHOLOGY: Lung abscesses mostly range from 2 to 6 cm in diameter, and 10% to 20% have multiple cavities. They exhibit abundant polymorphonuclear leukocytes and, depending on the age of the lesion, variable numbers of macrophages. Debris from necrotic tissue may be evident. The abscess is surrounded by hemorrhage, fibrin, and inflammatory cells. As the abscess ages, a fibrous wall forms around the margin. The cavity thus formed contains air, necrotic debris, and inflammatory exudate (Fig. 12-12), creating a fluid level that is easily seen radiographically. CLINICAL FEATURES: Almost all patients with lung abscess present with cough, fever, and the production of large amounts of foul-smelling sputum. Many patients complain of pleuritic chest pain, and 20% develop hemoptysis. Complications of lung abscess include rupture into the pleural space, with resulting empyema and severe hemoptysis. The abscess may drain into a bronchus, with subsequent dissemination of the infection to other parts of the lung. Despite vigorous antimicrobial therapy, principally directed against anaerobic bacteria, the mortality rate of lung abscess remains 5% to 10%.

Diffuse Alveolar Damage (Acute Respiratory Distress Syndrome [ARDS]) Diffuse alveolar damage (DAD) refers to a pattern of reaction to injury of alveolar epithelial and endothelial cells from a variety of acute insults. The clinical counterpart of DAD is ARDS. In this disorder, a patient with apparently normal lungs sustains pulmonary damage and then develops rapidly progressive respiratory failure. The overall mortality rate of DAD is more than 50%, and in patients older than 60 years, it is as high as 90%.

FIGURE 12-12. Pulmonary abscess. A large, cystic abscess contains a purulent exudate and is contained by a fibrous wall. Pneumonia is present in the surrounding pulmonary parenchyma.

PATHOGENESIS: DAD is the common pathological endpoint of a large variety of pulmonary insults. These include respiratory tract infections, sepsis, shock, aspiration of gastric contents, inhalation of toxic gases, near-drowning, radiation pneumonitis, and a large assortment of drugs and other chemicals. These diverse conditions share the ability to injure the epithelial and endothelial cells of the alveoli, thereby producing DAD. Hence, the precise cause of DAD cannot be determined from the morphologic appearance of the lung alone, unless caused by a specific identifiable infectious agent. Some patients have an idiopathic form of DAD referred to clinically as acute interstitial pneumonia. The mechanism of pulmonary injury resulting in DAD is not entirely clear. It is thought that activation of complement (e.g., by endotoxin in the case of gram-negative septicemia) results in the sequestration of neutrophils and their subsequent activation. In turn, the neutrophils release oxygen radicals and hydrolytic enzymes, which damage the capillary endothelium of the lung. However, ARDS has also been reported to occur in severely neutropenic patients. In DAD produced by inhalation of toxic gases or near-drowning, the damage occurs primarily at the alveolar epithelial surface. The alveolar epithelial junctions are usually very tight; damage to the epithelium disrupts these junctions, permitting exudation of fluid and proteins from the interstitium into the alveolar spaces. PATHOLOGY: As DAD evolves, the initial exudative phase is followed by an organizing phase. The exudative phase of DAD develops during the first week after the pulmonary insult and features edema, leakage of plasma proteins, accumulation of inflammatory cells, and hyaline membranes (Fig. 12-13). The earliest alveolar injury is characterized by degenerative changes in endothelial cells and type I pneumocytes. This is followed by sloughing of type I cells, leaving alveolar basement membranes denuded. Interstitial and alveolar edema is prominent by the first day but soon recedes. “Hyaline membranes” begin to appear by the second day and are the most conspicuous morphologic feature of the exudative phase after 4 to 5 days. These eosinophilic, glassy “membranes” consist of precipitated plasma proteins as well as cytoplasmic and nuclear debris from sloughed epithelial cells. Interstitial inflammation, consisting of lymphocytes, plasma cells, and macrophages, is apparent early and reaches its maximum in about a week. Toward

FIGURE 12-13. Diffuse alveolar damage, acute (exudative) phase. The alveolar septa are thickened by edema and a sparse inflammatory infiltrate. The alveoli are lined by eosinophilic hyaline membranes.

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FIGURE 12-14. Diffuse alveolar damage, acute and organizing phase. In addition to hyaline membranes, the alveolar walls are thickened by fibroblasts and loose connective tissue.

the end of the first week and persisting during the subsequent organizing stage, regularly spaced, cuboidal type II pneumocytes become arrayed along the denuded alveolar septa. The alveolar capillaries and pulmonary arterioles may exhibit fibrin thrombi. In fatal cases of DAD, the lungs are heavy, edematous, and virtually airless. The organizing phase of DAD, beginning about a week after the initial injury, is marked by the proliferation of fibroblasts within alveolar walls (Fig. 12-14). Interstitial inflammation and proliferated type II pneumocytes persist, but hyaline membranes are no longer formed. Alveolar macrophages digest the remnants of hyaline membranes and other cellular debris. Loose fibrosis thickens the alveolar septa. This fibrosis resolves in mild cases. In patients who do not recover, DAD can progress to end-stage fibrosis; remodeling of the lung architecture produces multiple cyst-like spaces throughout the lung (honeycomb lung). These spaces are separated from each other by fibrous tissue and lined by type II pneumocytes, bronchiolar epithelium, or squamous cells. CLINICAL FEATURES: Patients destined to develop ARDS have a symptom-free interval for a few hours after the initial insult, after which tachypnea and dyspnea mark the onset of the syndrome. As ARDS progresses, dyspnea worsens, and the patient becomes cyanotic. Diffuse, bilateral, interstitial, and alveolar infiltrates are noted radiologically. Arterial hypoxemia at this stage cannot be reversed simply by increasing oxygen tension in the inspired air, and mechanical ventilation becomes necessary. Fatal cases eventuate in alveolar hypoventilation, progressive hypoxemia, and increasing PCO2. Patients who survive ARDS may recover normal pulmonary function but, in severe cases, are left with scarred lungs, respiratory dysfunction, and in some instances, pulmonary hypertension.

Diffuse Alveolar Damage May Have Specific Causes Specific noninfectious etiologies of DAD include the following: • Oxygen: It is usually safe to breathe 40% to 50% oxygen for long periods, but normal persons breathing 75% oxygen for as little as 24 hours have shown evidence of early signs of pulmonary toxicity. Such toxicity is thought to be caused by increased production of activated oxygen species in the lung (see Chapter 1). • Shock: ARDS often follows shock from any cause, including gram-negative sepsis, trauma, or blood loss, in which case the pulmonary condition is colloquially referred to as “shock lung.” The pathogenesis of DAD associated with shock is poorly understood and is likely multifactorial.

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• Aspiration: Aspiration of gastric contents introduces acid with a pH less than 3.0 into the alveoli. The severe chemical injury to the alveolar-lining cells leads to DAD. In near drowning, aspiration of water produces pulmonary injury and DAD. • Drug-Induced Diffuse Alveolar Damage: Many drugs cause DAD, especially cytotoxic chemotherapeutic agents such as bleomycin. Bizarre, atypical, hyperchromatic nuclei in type II cells are particularly common in cases of alveolar damage from chemotherapy. Damage progresses despite discontinuation of the offending agent, although it may be modified by administering corticosteroids. Progressive interstitial fibrosis occurs, usually with retention of lung structure. Drugs other than chemotherapeutic agents (e.g. nitrofurantoin, amiodarone, and penicillamine) may also cause DAD. • Radiation Pneumonitis: Radiation pneumonitis occurs in two forms: acute DAD and chronic pulmonary fibrosis. Alveolar injury is believed to be caused by oxygen radicals generated by the radiolysis of water (see Chapter 1). Acute radiation pneumonitis occurs in as many as 10% of patients irradiated for cancer of the lung or breast or for mediastinal lymphoma. DAD caused by radiation is mostly dose related, appears 1 to 6 months after radiation therapy, and is usually followed by recovery. Chronic radiation pneumonitis is characterized by interstitial fibrosis and may follow acute DAD or may develop insidiously. The disease remains asymptomatic unless a substantial volume of the lung is affected. • Paraquat: The ingestion of the widely used herbicide paraquat is associated with DAD. Pulmonary disease becomes apparent 4 to 7 days after ingestion, as ARDS develops. Patients rarely recover once pulmonary complications have evolved. The intraalveolar exudate organizes in such a way that the alveolar framework persists, and the airspaces are filled with loose granulation tissue.

Respiratory Distress Syndrome of the Newborn is a Counterpart of ARDS The counterpart of ARDS in the neonatal period is termed newborn respiratory distress syndrome (NRDS). NRDS, also called hyaline membrane disease, is a result of immaturity in the surfactant system at birth, usually as a consequence of severe prematurity. NRDS and bronchopulmonary dysplasia are discussed in detail in Chapter 6.

Diffuse Pulmonary Hemorrhage Syndromes Diffuse alveolar hemorrhage can occur in diverse clinical settings (Table 12-1). Histologically, the diseases are characterized by acute hemorrhage (intra-alveolar red blood cells) or chronic hemorrhage (hemosiderosis). In virtually all of these disorders, a neutrophilic infiltrate of the alveolar wall (neutrophilic capillaritis) is present. This lesion tends to be most prominent in hemorrhagic syndromes associated with Wegener granulomatosis or systemic lupus erythematosus. A linear pattern of fluorescence is seen in antibasement membrane antibody disease, termed Goodpasture syndrome. A granular pattern is present in immune complex–associated diseases, such as systemic lupus erythematosus. Pauci-immune disorders consist of antineutrophil cytoplasm antibody-associated diseases (e.g., Wegener granulomatosis or idiopathic pulmonary hemorrhage syndromes), in which no etiology or immunologic mechanism can be determined (see Table 12-1). For additional details, see Chapters 10 and 16.

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TABLE 12–1

Conditions of Pulmonary Hemorrhage Disease

Immunological Mechanism

Immunofluorescence Pattern

Goodpasture syndrome

Antibasement membrane antibody

Linear

Systemic lupus erythematosus

Immune complexes

Granular

Antineutrophil cytoplasmic antibody

Negative or pauci-immune

Mixed cryoglobulinemia Henoch-Schönlein purpura IgA disease Wegener granulomatosis Idiopathic glomerulonephritis Idiopathic pulmonary hemorrhage

No immunological marker

Obstructive Pulmonary Diseases Several different diseases, including chronic bronchitis, emphysema, asthma, and in some classifications, bronchiectasis and cystic fibrosis, are grouped together as obstructive pulmonary diseases because they have in common an obstruction to air flow in the lungs. Chronic obstructive pulmonary disease applies to chronic bronchitis and emphysema, in which forced expiratory volume, measured by spirometry, is decreased. In the lung, narrowed airways produce increased resistance, whereas loss of elastic recoil results in diminished pressure. Airway narrowing occurs in chronic bronchitis or asthma, and emphysema causes loss of recoil.

Chronic Bronchitis is a Chronic Productive Cough for More Than half of the Time Over 2 Years

nantly chronic bronchitis have had a productive cough for many years that is initially more severe in the winter months. As the malady becomes more chronic, coughing becomes constant, exertional dyspnea and cyanosis supervene, and cor pulmonale may ensue. The combination of cyanosis and edema secondary to cor pulmonale has led to the label “blue bloater” for such patients. Acute respiratory failure in patients with advanced chronic bronchitis consists of progressive hypoxemia and hypercapnia.

Emphysema Causes Overinflation of the Lungs in Smokers Emphysema is a chronic lung disease characterized by enlargement of air spaces distal to the terminal bronchioles, with destruction of their walls but

Chronic bronchitis is primarily a disease of cigarette smokers (see Chapter 8), and 90% of cases occur in persons who smoke. The frequency and severity of acute respiratory tract infections are increased in patients with chronic bronchitis. Conversely, infections have been incriminated in the etiology and progression of the disorder. Although chronic bronchitis is more common among urban dwellers in areas of substantial air pollution and in workers exposed to toxic industrial inhalants, the effects of cigarette smoking far outweigh other contributing factors. PATHOLOGY: The main morphologic finding in chronic bronchitis is an increase in size of the bronchial mucus-secreting apparatus (Fig. 12-15). Two types of cells line the mucous glands: pale mucous cells, which are more common, and serous cells, which are more basophilic and contain granules. Chronic bronchitis is characterized by hyperplasia and hypertrophy of the mucous cells and an increased ratio of mucous to serous cells. Thus, both the individual acini and the glands enlarge (Fig. 12-16). Other morphologic changes in chronic bronchitis are variable and include: • Thickening of the bronchial wall by mucous gland enlargement and edema, which leads to encroachment on the bronchial lumen • An increase in the number of goblet cells (hyperplasia) in the bronchial epithelium • Increased smooth muscle, which may indicate bronchial hyperreactivity • Squamous metaplasia of the bronchial epithelium, reflecting epithelial damage from tobacco smoke, which is probably independent of the other changes seen in chronic bronchitis CLINICAL FEATURES: Chronic bronchitis is often accompanied by emphysema (see below); it is often difficult to separate the relative contribution of each disease to the clinical presentation. In general, patients with predomi-

FIGURE 12-15. Chronic bronchitis. The bronchial submucosa is greatly expanded by hyperplastic submucosal glands that compose well over 50% of the thickness of the bronchial wall. The Reid index equals the maximum thickness of the bronchial mucous glands internal to the cartilage (b to c) divided by the bronchial wall thickness (a to d).

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Goblet cell hyperplasia

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Squamous metaplasia

Basal cell metaplasia Basement membrane thickening Scattered lymphocytes Mucus

Macrophage

Mucous gland hyperplasia Cartilage

FIGURE 12-16. Chronic bronchitis. Morphological changes in chronic bronchitis.

without fibrosis. Although emphysema is classified in anatomical terms, the severity of emphysema is more important than the type. PATHOGENESIS: The major cause of emphysema is cigarette smoking, and moderate-to-severe emphysema is rare in nonsmokers (see Chapter 8). A balance exists between elastin synthesis and catabolism in the lung. Emphysema results when elastolytic activity increases or when antielastolytic activity is reduced. Increased numbers of neutrophils, which contain serine elastase and other proteases, are found in the bronchoalveolar lavage fluid of smokers. Smoking also interferes with ␣1-antitrypsin (␣1-AT) activity by oxidizing methionine residues in ␣1-antitrypsin. Hence, unopposed and increased elastolytic activity leads to destruction of elastic tissue in the walls of distal air spaces, thereby impairing elastic recoil. 〈1-AT DEFICIENCY: A hereditary deficiency in ␣1-AT, which is coded for by the Pi (protease inhibitor) locus, accounts for only about 1% of all patients with COPD, but most patients with emphysema under age 40 have this deficiency. ␣1-AT, circulating glycoprotein produced in the liver, is a major inhibitor of a variety of proteases, including elastase, trypsin, chymotrypsin, thrombin, and bacterial proteases. In fact, this protein accounts for 90% of antiproteinase activity in the blood. In the lung, it inhibits neutrophil elastase, an enzyme that digests elastin and other structural components of the alveolar septa. The most serious abnormality is associated with the PiZ allele, which occurs in approximately 5% of the population. It is more common in persons of Scandinavian origin and is rare in the Jewish population, blacks, and Japanese. PiZZ homozygotes have only 15% to 20% of the normal plasma concentration of ␣1-AT because the abnormal protein is poorly secreted by the liver. These persons are at risk for both cir-

rhosis of the liver (see Chapter 14) and emphysema. In fact, PiZZ homozygotes who do not smoke show a mean age at onset of emphysema between ages 45 and 50 years; those who smoke develop it at about age 35. However, two thirds of nonsmoking PiZZ homozygotes show no evidence of emphysema.

PATHOLOGY: Emphysema is morphologically classified according to the location of the lesions within the pulmonary acinus (Fig. 12-17). Only the proximal part of the acinus (respiratory bronchiole) is selectively involved in centrilobular emphysema, whereas the entire acinus is destroyed in panacinar emphysema. CENTRILOBULAR EMPHYSEMA: This form of emphysema is most frequent and is usually associated with cigarette smoking and with clinical symptoms. Centrilobular emphysema is characterized by the destruction of the cluster of terminal bronchioles near the end of the bronchiolar tree in the central part of the pulmonary lobule (Fig. 12-18A). Dilated respiratory bronchioles form enlarged air spaces, which are separated from each other and from the lobular septa by normal alveolar ducts and alveoli. As centrilobular emphysema progresses, bronchioles proximal to the emphysematous spaces are inflamed and narrowed (see Fig. 12-18B). Centrilobular emphysema is most severe in the upper lobes and the superior segments of the lower lobes. PANACINAR EMPHYSEMA: In panacinar emphysema, the acinus is uniformly involved, with destruction of the alveolar septa from the center to the periphery of the acinus. The loss of alveolar septa is illustrated in the histologic comparison of lung affected by ␣1-AT deficiency with a normal lung at the same magnification (Fig. 12-19). In the final stage, panacinar emphysema leaves behind a lacy network of supporting tissue (“cotton-candy lung”).

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Alveolar duct

Respiratory bronchioles Terminal bronchiole

Septum

Alveoli NORMAL ACINUS Respiratory bronchioles

Alveolar duct

Respiratory bronchioles

Septum

Terminal bronchiole

Alveolar ducts and alveoli

Septum

Terminal bronchiole

Chronic inflammation and fibrosis

Alveoli

CENTRILOBULAR EMPHYSEMA

PANACINAR EMPHYSEMA

FIGURE 12-17. Types of emphysema. The acinus is the unit gas-exchanging structure of the lung distal to the terminal bronchiole. It consists of (in order) respiratory bronchioles, alveolar ducts, alveolar sacs, and alveoli. In centrilobular (proximal acinar) emphysema, the respiratory bronchioles are predominantly involved. In paraseptal (distal acinar) emphysema, the alveolar ducts are particularly affected. In panacinar (panlobular) emphysema, the acinus is uniformly damaged.

B FIGURE 12-18. Centrilobular emphysema. A. A whole mount of the left lung of a smoker with mild emphysema shows enlarged air spaces scattered throughout both lobes, which represent destruction of the terminal bronchioles in the central part of the pulmonary lobule. These abnormal spaces are surrounded by intact pulmonary parenchyma. B. In a more advanced case of centrilobular emphysema, the destruction of the lung has progressed to produce large, irregular air spaces.

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B FIGURE 12-19. Panacinar emphysema. A. This lung, from a patient with ␣1-antitrypsin deficiency, shows large, irregular air spaces and a markedly reduced number of alveolar walls. B. The extensive loss of alveolar walls in A is emphasized by comparison with this section of normal lung at the same magnification.

Diffuse panacinar emphysema is typically associated with ␣1-AT deficiency, but it is also often found in cigarette smokers in association with centrilobular emphysema. In such cases, the panacinar pattern tends to occur in the lower zones of the lung, whereas centrilobular emphysema is seen in the upper regions. LOCALIZED EMPHYSEMA: This condition, previously known as “paraseptal emphysema,” is characterized by destruction of alveoli and resulting emphysema in only one, or at most, a few locations. The remainder of the lungs is normal. The lesion is usually found at the apex of an upper lobe, although it may occur anywhere in the pulmonary parenchyma, such as in a subpleural location. Although it is of no clinical significance itself, rupture of an area of localized emphysema produces spontaneous pneumothorax (see below). Progression of localized emphysema can result in a large area of destruction, termed a bulla, which ranges in size from as small as 2 cm to a large lesion that occupies much of a hemothorax. CLINICAL FEATURES: Most patients with symptomatic emphysema are seen at age 60 years or older with a prolonged history of exertional dyspnea but with a minimal, nonproductive cough. Tachypnea and a prolonged expiratory phase are typical. The most prominent radiologic abnormality is overinflation of the lung, as evidenced by enlarged lungs, depressed diaphragms, and an increased posteroanterior diameter (barrel chest). Because these patients have a higher respiratory rate and an increased minute volume, they can maintain arterial hemoglobin saturation at near-normal levels and so are called “pink puffers.” The clinical course of emphysema is marked by inexorable decline in respiratory function and progressive dyspnea, for which no treatment is adequate.

Asthma is Characterized by Episodic Airflow Obstruction Patients who suffer from asthma typically have paroxysms of wheezing, dyspnea, and cough. Acute episodes of asthma may alternate with asymptomatic periods or may be superimposed on a background of chronic airway obstruction. Severe acute asthma unresponsive to therapy is termed status asthmaticus. Most asthmatic patients, even when apparently well, have some persistent airflow obstruction and morphologic lesions. In the United States, bronchial asthma affects up to 10% of children and 5% of adults. For unknown reasons, the prevalence of asthma in the United States has doubled since 1980. Although the initial attack of the disease can occur at any age, half of the cases appear in patients younger than 10 years, and the incidence is twice as high in boys as in girls. By age 30, both genders are affected equally.

PATHOGENESIS: Asthma was classically divided into extrinsic (allergic) and intrinsic (idiosyncratic) categories, depending on inciting factors. The consensus hypothesis attributes bronchial hyperresponsiveness in asthma to an inflammatory reaction produced by diverse stimuli. After exposure to an inciting factor (e.g., allergens, drugs, cold, exercise), inflammatory mediators released by activated macrophages, mast cells, eosinophils, and basophils induce bronchoconstriction, increased vascular permeability, and mucus secretion, and serve to recruit additional effector cells. Inflammation of the bronchial walls also may injure the epithelium, stimulating nerve endings and initiating neural reflexes that further aggravate and propagate the bronchospasm. The best-studied situation associated with the induction of asthma is that of inhaled allergens. In a sensitized person, an inhaled allergen interacts with TH2 cells and IgE antibody bound to the surface of mast cells, which are interspersed among the epithelial cells of the bronchial mucosa (Fig. 12-20). As a result, TH2 cells and mast cells release mediators of type I (immediate) hypersensitivity, including histamine, bradykinin, leukotrienes, prostaglandins, thromboxane A2, and platelet-activating factor (PAF), as well as cytokines such as interleukin (IL)-4 and IL-5. The inflammatory mediators cause (1) smooth muscle contraction, (2) mucous secretion, and (3) increased vascular permeability and edema. Each of these effects is a potent, albeit reversible, cause of airway obstruction. IL-5 produces terminal differentiation of eosinophils in the bone marrow. Chemotactic factors, including leukotriene B4 as well as neutrophil and eosinophil chemotactic factors, attract neutrophils, eosinophils, and platelets to the bronchial wall. In turn, eosinophils release leukotriene B4 and PAF, thereby aggravating bronchoconstriction and edema. The discharge of eosinophil granules, which contain eosinophil cationic protein and major basic protein, into the bronchial lumen further impairs mucociliary function and damages epithelial cells. Epithelial cell injury is suspected to stimulate nerve endings in the mucosa, initiating an autonomic discharge that contributes to airway narrowing and mucous secretion. Moreover, leukotriene B4 and PAF recruit more eosinophils and other effector cells, and so continue the vicious circle that prolongs and amplifies the asthmatic attack. Recent evidence suggests that activated T lymphocytes also help propagate the inflammatory response through various cytokine networks.

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Al le rg en

A IMMEDIATE RESPONSE Columnar cell

4 Mucus hypersecretion

Goblet cell

2 Allergen binds to IgE on mast cells

IgE

4 Edema Capillary

3 Mast cells degranulate

• INFLAMMATORY MEDIATORS • CHEMOTACTIC FACTORS Eosinophils 4 Bronchoconstriction

Smooth muscle PMN

B DELAYED RESPONSE 1 ?Ciliary function

1 Epithelial damage

4 Mucus hypersecretion

2 Afferent nerve discharge

3 Efferent (vagal) nerve discharge

Eosinophils 4 Bronchoconstriction PMNs

FIGURE 12-20. Pathogenesis of asthma. A. Immunologically mediated asthma. Allergens interact with immunoglobulin E (IgE) on mast cells, either on the surface of the epithelium or, when there is abnormal permeability of the epithelium, in the submucosa. Mediators are released and may react locally or by reflexes mediated through the vagus. B. The discharge of eosinophilic granules further impairs mucociliary function and damages epithelial cells. Epithelial cell injury stimulates nerve endings in the mucosa, thereby initiating an autonomic discharge that contributes to airway narrowing and mucus secretion. PMNs, polymorphonuclear neutrophils.

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ALLERGIC ASTHMA: This is the most common form of asthma and is usually seen in children. One third to one half of all patients with asthma have known or suspected reactions to allergens such as pollens, animal hair, or fur, and house dust contaminated with mites. INFECTIOUS ASTHMA: A common precipitating factor in childhood asthma is a viral respiratory tract infection. In children under 2 years of age, RSV is the usual agent; in older children, rhinovirus, influenza, and parainfluenza are common inciting organisms. EXERCISE-INDUCED ASTHMA: Exercise can precipitate bronchospasm in more than half of all asthmatics. In some patients, exercise is the only inciting factor. Exercise-induced asthma is related to the magnitude of heat or water loss from the airway epithelium. The more rapid the ventilation (severity of exercise) and the colder and drier the air breathed, the more likely is an attack of asthma. The condition may be the consequence of mediator release or vascular congestion in the bronchi secondary to rewarming of the airways after the exertion. OCCUPATIONAL ASTHMA: More than 80 different occupational exposures have been linked to the development of asthma. In some instances, these substances provoke allergic asthma via IgE-related hypersensitivity. Examples are animal handlers, bakers, and workers exposed to wood and vegetable dusts, metal salts, pharmaceutical agents, and industrial chemicals. In other cases, occupational asthma seems to result from direct release of mediators of smooth muscle contraction after contact with an offending agent. Such a mechanism is postulated in byssinosis (“brown lung”), an occupational lung disease in cotton workers. DRUG-INDUCED ASTHMA: Drug-induced bronchospasm occurs mostly in patients with known asthma. The best-known of-

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fender is aspirin, but other nonsteroidal anti-inflammatory agents have also been implicated. It is estimated that up to 10% of adult asthmatics are sensitive to aspirin. AIR POLLUTION: Massive air pollution, usually in episodes associated with temperature inversions, is associated with bronchospasm in patients with asthma and other pre-existing lung diseases. Sulfur dioxide, oxides of nitrogen, and ozone are the commonly implicated environmental pollutants. EMOTIONAL FACTORS: Psychological stress can aggravate or precipitate an attack of bronchospasm in as many as half of all asthmatics. It is believed that vagal efferent stimulation is the underlying mechanism. PATHOLOGY: Most information on the pathology of asthma has been derived from autopsies on patients who have died in status asthmaticus, and thus only the most severe lesions are described. On gross examination, the lungs are remarkably distended with air, and airways are filled with thick, tenacious, adherent mucus plugs. Microscopically, these plugs (Fig. 12-21A) contain strips of epithelium and many eosinophils. Charcot-Leyden crystals, derived from phospholipids of the eosinophil cell membrane, are also seen. In some cases, the mucoid exudate forms a cast of the airways (Curschmann spirals), which may be expelled with coughing. One of the most characteristic features of status asthmaticus is hyperplasia of bronchial smooth muscle. Bronchial submucosal mucous glands are also hyperplastic (see Fig. 12-21A). The submucosa is edematous and contains a mixed inflammatory infiltrate, with variable numbers of eosinophils. The epithelium does not display the normal pseudostratified appearance and may be denuded, with only basal cells remaining (see Fig. 12-21B). The basal cells are hyper-

B FIGURE 12-21. Asthma. A. A section of lung from a patient who died in status asthmaticus reveals a bronchus containing a luminal mucus plug, submucosal gland hyperplasia, and smooth muscle hyperplasia (arrows). B. Higher magnification shows hyaline thickening of the subepithelial basement membrane and marked inflammation of the bronchiolar wall with numerous eosinophils. The mucosa exhibits an inflamed and metaplastic epithelium (arrowheads). The epithelium is focally denuded (short arrows).

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plastic, and squamous metaplasia is seen. Goblet cell hyperplasia is also apparent. Characteristically, the epithelial basement membrane appears thickened. CLINICAL FEATURES: A typical asthma attack begins with a feeling of tightness in the chest and nonproductive cough. Both inspiratory and expiratory wheezes appear, the respiratory rate increases, and the patient becomes dyspneic. Characteristically, the expiratory phase is particularly prolonged. The end of the attack is often heralded by severe coughing and expectoration of thick, mucus-containing Curschmann spirals, eosinophils, and Charcot–Leyden crystals. Status asthmaticus refers to severe bronchoconstriction that does not respond to the drugs that usually abort the acute attack. This situation is potentially serious and requires hospitalization. Patients in status asthmaticus have hypoxemia and often hypercapnia, and in particularly severe episodes, they may die. The cornerstone of asthma treatment includes administration of ␤-adrenergic agonists, inhaled corticosteroids, cromolyn sodium, methylxanthines, and anticholinergic agents. Systemic corticosteroids are reserved for status asthmaticus or resistant chronic asthma. The inhalation of bronchodilators often provides dramatic relief.

Pneumoconioses The pneumoconioses are pulmonary diseases caused by dust inhalation. Most inhaled dusts are innocuous and simply accumulate in the lung. However, some lead to crippling pulmonary diseases. The specific types of pneumoconioses are named according to the substance inhaled (e.g., silicosis, asbestosis, talcosis) or, if the offending agent is uncertain, the occupation is simply cited (e.g., “arc welder’s lung”). PATHOGENESIS: The most important factor in the production of symptomatic pneumoconioses is the capacity of inhaled dusts to stimulate fibrosis (Fig. 12-22). Thus, small amounts of silica may produce extensive fibrosis, whereas coal and iron are only weakly fibrogenic. In general, lung lesions produced by inorganic dusts reflect the dose and size of the particles that reach the lung. The most dangerous particles are those that reach the peripheral zones (i.e., the smallest bronchioles and the acini). Particles greater than 10 ␮m in diameter deposit on bronchi and bronchioles and are removed by the mucociliary escalator. Smaller particles reach the acinus, and the smallest ones behave as a gas and are exhaled.

Silicosis is Caused by Inhalation of Silicon Dioxide (Silica) Silicosis was described historically as a disease of sandblasters. Mining also involves exposure to silica, as do numerous other occupations. The use of air-handling equipment and face masks has substantially reduced the incidence of silicosis. PATHOGENESIS: After their inhalation, silica particles are ingested by alveolar macrophages. Silicon hydroxide groups on the surface of the particles form hydrogen bonds with phospholipids and proteins, an interaction that is presumed to damage cellular membranes and thereby kill the macrophages. The dead cells release free silica particles and fibrogenic factors. The released silica is then reingested by macrophages, and the process is amplified.

PATHOLOGY: SIMPLE NODULAR SILICOSIS: This is the most common form of silicosis and is almost inevitable in any worker with long-term exposure to silica. Ten to 40 years after the initial exposure to silica, the lungs contain silicotic nodules, which are less than 1 cm in diameter (usually 2 to 4 mm). On histologic examination, they have a characteristic whorled appearance, with concentrically arranged collagen that forms the largest part of the nodule (Fig. 12-23). At the periphery, there are aggregates of mononuclear cells, mostly lymphocytes and fibroblasts. Polarized light reveals doubly refractile needle-shaped silicates within the nodule. Hilar nodes may become enlarged and calcified, often at the periphery of the node (“eggshell calcification”). Simple silicosis is not ordinarily associated with significant respiratory dysfunction. PROGRESSIVE MASSIVE FIBROSIS: Progressive massive fibrosis is defined radiologically as nodular masses of more than 2 cm diameter in a background of simple silicosis. These larger lesions represent the coalescence of smaller nodules. Most of these lesions are 5 to 10 cm across and are usually in the upper zones of the lungs bilaterally (Fig. 12-24). Morphologically, they often exhibit central cavitation. Disability is caused by destruction of lung tissue that has been incorporated into the nodules. CLINICAL FEATURES: Simple silicosis is usually a radiologic diagnosis without significant symptoms. Dyspnea on exertion and later at rest suggests progressive massive fibrosis or other complications of silicosis. It is well recognized that tuberculosis is much more common in patients with silicosis than in the general population. Silicosis does not predispose to lung cancer.

Coal Workers’ Pneumoconiosis (CWP) Reflects Inhalation of Carbon Particles PATHOGENESIS: Coal dust is composed of amorphous carbon and other constituents including variable amounts of silica. Amorphous carbon by itself is not fibrogenic because of its inability to kill alveolar macrophages and produces only an innocuous anthracosis. By contrast, silica is highly fibrogenic, and inhaled anthracotic particles may thus lead to anthracosilicosis.

PATHOLOGY: CWP is typically divided into simple CWP and complicated CWP (also known as progressive massive fibrosis). The characteristic lung lesions of simple CWP include nonpalpable coal-dust macules and palpable coal-dust nodules. Both are typically multiple and scattered throughout the lung as 1- to 4-mm black foci. Microscopically, a coal-dust macule exhibits numerous carbonladen macrophages that surround distal respiratory bronchioles, extend to fill adjacent alveolar spaces, and infiltrate peribronchiolar interstitial spaces. There is an accompanying mild dilation of respiratory bronchioles (focal dust emphysema), which probably results from atrophy of smooth muscle. Nodules are round or irregular, may or may not be associated with bronchioles, and consist of dust-laden macrophages associated with a fibrotic stroma. They occur when coal is admixed with fibrogenic dusts, such as silica and are more properly classified as anthracosilicosis. Although simple CWP was once thought to cause severe disability, it is now clear that at worst, it causes minor pulmonary function impairment. When coal miners have severe airflow obstruction, it is usually due to smoking. Complicated CWP occurs on a background of simple CWP and is defined as a lesion 2.0 cm or greater in size. Patients with complicated CWP may have significant respiratory impairment.

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SILICA

COAL Macrophage

261

Macrophage

Type I

Macrophage

Type I Type II

Type II

Type I

Interstitial macrophage

Interstitial space

Interstitial macrophage

Interstitial space Interstitial macrophage

Fibrogenic factor(s)

Fibroblasts Collagen

Fibroblast

Lymphocytes

Dilated respiratory bronchioles FOCAL DUST EMPHYSEMA

Macrophage Terminal bronchiole

Fibroblast SILICOTIC NODULE

Asbestos body

Collagen

Distal air space

Interstitial fibrosis ASBESTOSIS

FIGURE 12-22. Pathogenesis of pneumoconioses. The three most important pneumoconioses are illustrated. In simple coal workers’ pneumoconiosis, massive amounts of dust are inhaled and engulfed by macrophages. The macrophages pass into the interstitium of the lung and aggregate around the respiratory bronchioles. Subsequently, the bronchioles dilate. In silicosis, the silica particles are toxic to macrophages, which die and release a fibrogenic factor. In turn, the released silica is again phagocytosed by other macrophages. The result is a dense fibrotic nodule, the silicotic nodule. Asbestosis is characterized by little dust and much interstitial fibrosis. Asbestos bodies are the classic features.

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FIGURE 12-23. Silicosis. A silicotic nodule is composed of concentric whorls of dense, sparsely cellular collagen. At the edge of the nodule are dust deposits that contain carbon pigment and silica particles.

Asbestos-Related Diseases May be Reactive or Neoplastic Asbestos (Greek, unquenchable) includes a group of fibrous silicate minerals that occur as long, thin fibers. It has been used for a variety of purposes for more than 4,000 years, most recently, for insulation, construction materials, and brake linings. There are six natural types of asbestos, which can be divided into two mineralogical groups. Chrysotile accounts for the bulk of commercially used asbestos. If coal is the classic example of much dust and little fibrosis, asbestos is the prototype of little dust and much fibrosis (see Fig. 12-22). Exposure to asbestos can cause a number of thoracic complications, including asbestosis, benign pleural effusion, pleural plaques, diffuse pleural fibrosis, rounded atelectasis, and mesothelioma. All commercially used forms of asbestos have been associated with asbestos-related lung diseases. ASBESTOSIS: Asbestosis is diffuse interstitial fibrosis resulting from inhalation of asbestos fibers. The development of asbestosis requires heavy exposure to asbestos of the type historically seen in asbestos insulators and factory workers. PATHOGENESIS: Asbestos fibers deposit in distal airways and alveoli, particularly at bifurcations of alveolar ducts. The smallest particles are engulfed by macrophages, but many larger fibers penetrate into the interstitial space. The first lesion is an alveolitis that is directly related to asbestos exposure. The release of inflammatory mediators by activated macrophages and the fibrogenic character of the free asbestos fibers in the interstitium promote interstitial pulmonary fibrosis. PATHOLOGY: Asbestosis is characterized by bilateral, diffuse interstitial fibrosis and asbestos bodies in the lung (Fig. 12-25). In the early stages, fibrosis occurs in and around alveolar ducts and respiratory bronchioles, as well as in the periphery of the acinus. When asbestos fibers deposit in bronchioles and respiratory bronchioles, they incite a fibrogenic response that leads to mild chronic airflow obstruction. Thus, asbestos may produce obstructive as well

FIGURE 12-24. Progressive massive fibrosis. A whole mount of a silicotic lung from a coal miner shows a large area of dense fibrosis containing entrapped carbon particles.

as restrictive defects. Asbestosis is usually more severe in the lower zones of the lung. Asbestos bodies are found in the walls of bronchioles or within alveolar spaces, often engulfed by alveolar macrophages. The particle has distinctive morphologic features, consisting of a clear, thin asbestos fiber (10 to 50 ␮m long) surrounded by a beaded iron–protein coat. By light microscopy, it is golden brown (see Fig. 12-25) and stains strongly with the Prussian blue stain for iron. The fibers are only partly engulfed by macrophages because they are too large for a single cell. The macrophages coat the asbestos fiber with protein, proteoglycans, and ferritin. Exposure to asbestos also leads to additional complications. BENIGN PLEURAL EFFUSION: Benign pleural effusion associated with asbestos inhalation has been observed in about 3% of workers exposed to asbestos. PLEURAL PLAQUES: Pleural plaques typically occur on parietal and diaphragmatic pleura, often 20 years after exposure to asbestos. Plaques may be found in up to 15% of the general population, and half of all patients with plaques at autopsy may not have a history of asbestos exposure. On gross examination, pleural plaques are pearly white and have a smooth or nodular surface. They are usually bilateral, may measure greater than 10 cm in diameter, and may become calcified. Histologically, they consist of acellular, dense, hyalinized fibrous tissue, with numerous slit-like spaces in a parallel fashion (“basket-weave pattern”). Pleural plaques are not predictors of asbestosis, nor do they evolve into mesotheliomas. MESOTHELIOMA: The relationship between asbestos exposure and malignant mesothelioma is firmly established. Sometimes, exposure is indirect and slight, for example, wives of asbestos workers who wash their husbands’ clothes. More often, mesothelioma is seen in workers heavily exposed to asbestos. This disease is discussed below with diseases of the pleura.

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vocation. Thus, farmer’s lung occurs in farmers exposed to Micropolyspora faeni from moldy hay, bagassosis results from exposure to Thermoactinomyces sacchari in moldy sugar cane, maple bark–stripper’s disease is seen in persons exposed to the fungus Cryptostroma corticale from moldy maple bark, and bird fancier’s lung affects bird keepers with long-term exposure to proteins from bird feathers, blood, and excrement. Hypersensitivity pneumonitis may also be caused by fungi growing in stagnant water in air conditioners, swimming pools, hot tubs, and central heating units. In many cases, especially in the chronic form of hypersensitivity pneumonitis, the inciting antigen is never identified.

FIGURE 12-25. Asbestos bodies. These ferruginous bodies are golden brown and beaded, with a central, colorless, nonbirefringent core fiber. Asbestos bodies are encrusted with protein and iron.

CARCINOMA OF THE LUNG: In asbestos workers who smoke, the incidence of carcinoma of the lung is increased to up to 60 times that of the nonsmoking population or up to three times that of smokers. The link between asbestos is thought to require asbestosis (diffuse interstitial fibrosis).

Berylliosis Displays Noncaseating Granulomas Berylliosis refers to the pulmonary disease that follows inhalation of beryllium. Today, this metal is used principally in structural materials in aerospace industries, in the manufacture of industrial ceramics, and in nuclear reactors. Exposure to beryllium may also occur in those who mine and extract beryllium ores. PATHOLOGY: Berylliosis occurs as an acute chemical pneumonitis or a chronic pneumoconiosis. In the acute form, symptoms begin within hours or days after inhalation of metal particles and manifest pathologically as diffuse alveolar damage. Of all persons with acute beryllium pneumonitis, 10% progress to chronic disease, although chronic berylliosis is often encountered in workers without any history of an acute illness. Chronic berylliosis differs from other pneumoconioses in that the amount and duration of exposure may be small. The lesion is thus suspected to be a hypersensitivity reaction. Pathologically, the pulmonary lesions are indistinguishable from those of sarcoidosis (see below). Multiple noncaseating granulomas are distributed along the pleura, septa, and bronchovascular bundles. Disease progression can lead to end-stage fibrosis and honeycomb lung. Patients with chronic berylliosis have an insidious onset of dyspnea 15 or more years after the initial exposure. The disease appears to be associated with an increased risk of lung cancer.

Interstitial Lung Disease A large number of pulmonary disorders are grouped as interstitial, infiltrative, or restrictive diseases because they are characterized by inflammatory infiltrates in the interstitial space and have similar clinical and radiologic presentations. The conditions vary from minimally symptomatic to severely incapacitating and sometimes lethal interstitial fibrosis.

Hypersensitivity Pneumonitis (Extrinsic Allergic Alveolitis) is a Response to Inhaled Antigens Inhalation of many antigens leads to hypersensitivity pneumonitis (i.e., acute or chronic interstitial inflammation in the lung). Most of the responsible antigens are encountered in occupational settings, and the diseases are often labeled according to a specific

PATHOGENESIS: Hypersensitivity pneumonitis represents a combination of immune complex-mediated (type III) and cell-mediated (type IV) hypersensitivity reactions, although the precise contribution of each is still debated. Importantly, most persons with serum precipitins to inhaled antigens do not develop hypersensitivity pneumonitis on exposure, a fact that suggests a genetic component in host susceptibility. PATHOLOGY: Acute hypersensitivity pneumonitis is characterized by a neutrophilic infiltrate in alveoli and respiratory bronchioles. Most cases have serum IgG precipitating antibodies against the offending agent. The main microscopic features of chronic hypersensitivity pneumonitis include bronchiolocentric cellular interstitial pneumonia, poorly formed noncaseating granulomas, and organizing pneumonia (Fig. 12-26A,B). The bronchiolocentric interstitial infiltrate varies from subtle to severe and consists of lymphocytes, plasma cells, and macrophages; eosinophils are distinctly uncommon. Poorly formed noncaseating granulomas are present in two thirds of cases (see Fig. 12-26B). Organizing pneumonia is found in two thirds of cases and may form the lesion of bronchiolitis obliterans (see Fig. 12-26A). In the end stage, interstitial inflammation recedes, leaving pulmonary fibrosis, which may resemble usual interstitial pneumonia. CLINICAL FEATURES: Hypersensitivity pneumonitis may be first seen as acute, subacute, or chronic pulmonary disease, depending on the frequency and intensity of exposure to the offending antigen. The prototype of hypersensitivity pneumonitis is “farmer’s lung.” Typically, a farm worker enters a barn where hay has been stored for winter feeding. After a lag period of 4 to 6 hours, the worker rapidly develops dyspnea, cough, and mild fever. Symptoms remit within 24 to 48 hours but return on re-exposure; with time, they become chronic. Patients with the chronic form of hypersensitivity pneumonitis have a more nonspecific presentation, with an indolent onset of dyspnea and cor pulmonale. Removal of the environmental antigen is the only adequate long-term treatment for hypersensitivity pneumonitis. Steroid therapy may be effective in acute forms and for some chronically affected patients.

Sarcoidosis is a Granulomatous Disease of Unknown Etiology In sarcoidosis, the lung is the organ most frequently involved, but lymph nodes, skin, spleen, liver, and the eye are also common targets. EPIDEMIOLOGY: Sarcoidosis is a worldwide disease, affecting all races and both genders. The differences in prevalence among racial and ethnic groups are remarkable. In North America, sarcoidosis is much more common in blacks than in whites; the ratio is reported to be as high as 10:1. By contrast, the disease is uncommon in tropical Africa. The incidence of pediatric cases is particularly high among blacks in the southeastern United States.

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B FIGURE 12-26. Hypersensitivity pneumonitis. A. A lung biopsy specimen shows a mild peribronchiolar chronic inflammatory interstitial infiltrate, with a focus of intraluminal organizing fibrosis. B. Focal poorly formed granulomas were scattered in the lung biopsy specimen.

PATHOGENESIS: Although the exact pathogenesis of sarcoidosis remains obscure, there is a consensus that it represents an exaggerated helper/inducer T-lymphocyte response to exogenous or autologous antigens. These cells accumulate in the affected organs, where they secrete lymphokines and recruit macrophages, which participate in the formation of noncaseating granulomas. The organs that contain sarcoid granulomas have CD4⫹ to CD8⫹ T-cell ratios of 10:1, compared with 2:1 in uninvolved tissues. The basis for this abnormal accumulation of helper/inducer T lymphocytes is unclear. Nonspecific polyclonal activation of B cells by T-helper cells leads to hyperglobulinemia, a characteristic feature of active sarcoidosis. PATHOLOGY: Pulmonary sarcoidosis most commonly affects the lung and hilar lymph nodes, although either involvement may occur separately. Histologically, multiple sarcoid granulomas are scattered in the interstitium of the lung (Fig. 12-27). The distribution is distinctive—along the pleura and interlobular septa and around bronchovascular bundles (see Fig. 12-27A). Fibrosis may be observed at the periphery of the granuloma and may show an onion-skin pattern of lamellar fibrosis around the giant cells. Vasculitis can be demonstrated in two

thirds of open lung biopsy specimens from patients with sarcoidosis. Asteroid bodies (star-shaped crystals) and Schaumann bodies (small lamellar calcifications) may be seen in the granulomas (see Fig. 12-27B), although they are not specific for sarcoidosis and may be present in most granulomatous process. CLINICAL FEATURES: Sarcoidosis most often occurs in young adults of both genders. Acute sarcoidosis has an abrupt onset, usually followed by spontaneous remission within 2 years and an excellent response to steroids. Chronic sarcoidosis has an insidious onset, and patients are more likely to have persistent or progressive disease. The malady may also affect the skin. Black patients tend to have more severe uveitis, skin disease, and lacrimal gland involvement. Cough and dyspnea are the major respiratory complaints. No laboratory test is specific for the diagnosis of sarcoidosis. Serum levels of angiotensin-converting enzyme are elevated in two thirds of patients with active sarcoidosis, and 24-hour urine calcium is frequently increased. The laboratory data, together with the clinical and radiologic findings, allow the diagnosis of sarcoidosis to be established with a high probability. The prognosis in pulmonary sarcoidosis is favorable, and most patients do not develop clinically significant sequelae. Resolution occurs in 60% of patients with pulmonary sarcoidosis, but the disease directly accounts for the patient’s death in 10% of cases. Corticosteroid therapy is effective for active sarcoidosis.

B FIGURE 12-27. Sarcoidosis. A. Multiple noncaseating granulomas are present along the bronchovascular interstitium. B. Noncaseating granulomas consist of tight clusters of epithelioid macrophages and multinucleated giant cells. Several asteroid bodies are present.

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Usual Interstitial Pneumonia (UIP) Refers Clinically to Idiopathic Pulmonary Fibrosis UIP is one of the most common types of interstitial pneumonia, with an annual incidence of 6 to 14.6 cases per 100,000 persons. It has a slight male predominance and a mean age at onset of 50 to 60 years. The clinical terms idiopathic pulmonary fibrosis or cryptogenic fibrosing alveolitis are often applied. PATHOGENESIS: The etiology of UIP is unknown, but viral, genetic, and immunologic factors are thought to play a role. A viral etiology is favored by a history of flu-like illness in some patients. A genetic role is suggested by cases of familial UIP and the association of UIP-like diseases in patients with inherited disorders such as neurofibromatosis and Hermansky-Pudlak syndrome. An immunologic component has been proposed because collagen vascular diseases such as rheumatoid arthritis, systemic lupus erythematosus, and progressive systemic sclerosis may also occur in about 20% of cases. UIP also appears in the context of other autoimmune disorders, and patients frequently exhibit circulating autoantibodies (e.g., antinuclear antibodies and rheumatoid factor). Immune complexes have been demonstrated in the circulation, the inflamed alveolar walls, and bronchoalveolar-lavage specimens, although the antigen has not been identified. It has been postulated that alveolar macrophages become activated upon phagocytosis of immune complexes, after which they release cytokines that recruit neutrophils. These in turn damage alveolar walls, setting in motion a series of events that culminates in interstitial fibrosis.

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PATHOLOGY: UIP demonstrates a histologic pattern that occurs in a variety of clinical settings, including collagen vascular disease, chronic hypersensitivity pneumonitis, drug toxicity, and asbestosis. Grossly, fibrosis is often patchy, with areas of dense scarring and honeycomb cystic change (Fig. 1228A). The histologic hallmark of UIP is patchy chronic inflammation and interstitial fibrosis, with zones of normal lung adjacent to fibrotic regions (see Fig. 12-28B). Areas of loose fibroblastic tissue (fibroblast foci) are found adjacent to dense collagen (see Fig. 12-28C). Dense scarring fibrosis causes remodeling of the lung architecture, resulting in collapse of alveolar walls and formation of cystic spaces (see Fig. 12-28A). Lymphoid aggregates, sometimes containing germinal centers, are occasionally noted, particularly in UIP associated with rheumatoid arthritis. Extensive vascular changes, especially intimal fibrosis and thickening of the media, may be associated with pulmonary hypertension. CLINICAL FEATURES: UIP begins insidiously, with the gradual onset of dyspnea on exertion and dry cough, usually over a period of 1 to 3 years. The classic auscultatory finding is late inspiratory crackles and fine (“Velcro”) rales at the lung bases. Tachypnea at rest, cyanosis, and cor pulmonale eventually ensue. The prognosis is bleak, with a mean survival of 4 to 6 years. Patients are treated with corticosteroids and sometimes cyclophosphamide, but lung transplantation generally offers the only hope of a cure. A rapidly progressive variant of UIP is termed acute interstitial pneumonia and is often fatal.

FIGURE 12-28. Usual interstitial pneumonitis. A. A gross specimen of the lung shows patchy dense scarring with extensive areas of honeycomb cystic change, predominantly affecting the lower lobes. This patient also had polymyositis. B. A microscopic view shows patchy subpleural fibrosis with microscopic honeycomb fibrosis. The areas of dense fibrosis display remodeling, with loss of the normal lung architecture. C. Movat stain highlights the fibroblastic focus in green, which contrasts with the adjacent area of yellow staining of dense collagen and black staining of collapsed elastic fibers.

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Organizing Pneumonia Features Polypoid Plugs of Tissue that Fill the Bronchiolar Lumen and Surrounding Alveolar Spaces Organizing pneumonia pattern was previously referred to as “bronchiolitis obliterans–organizing pneumonia”. It is not specific for any particular etiologic agent, and the cause cannot be determined from the morphologic appearance. The disorder is observed in many settings, including respiratory tract infections (particularly viral bronchiolitis), inhalation of toxic materials, administration of a number of drugs, and several inflammatory processes (e.g., collagen vascular diseases). Importantly, a substantial number of cases remain idiopathic and are referred to as cryptogenic organizing pneumonia (or idiopathic bronchiolitis obliterans–organizing pneumonia). PATHOLOGY: Histologically, the organizing pneumonia pattern features patchy areas of loose organizing fibrosis and chronic inflammatory cells in the distal airways adjacent to normal lung. Plugs of organizing fibroblastic tissue occlude bronchioles (bronchiolitis obliterans), alveolar ducts, and surrounding alveoli (organizing pneumonia; Fig. 12-29). The pattern is predominantly one of patchy alveolar organizing pneumonia, and bronchiolitis obliterans may not be seen in all cases. The architecture of the lung is preserved, with none of the remodeling or honeycomb changes seen in UIP. An obstructive or endogenous lipid pneumonia demonstrating foamy lipid-laden macrophages may develop if there is significant bronchiolitis obliterans due to the occlusion of the distal airways. The alveolar septa are only slightly thickened with chronic inflammatory cells, and hyperplasia of type II pneumocytes is mild. CLINICAL FEATURES: Organizing pneumonia pattern generally presents in the 5th decade. Onset is acute, with fever, cough, and dyspnea. Many patients have a history of a flu-like illness 4 to 6 weeks before the onset of symptoms. As noted above, some individuals may have predisposing conditions. Corticosteroid therapy is effective, and some patients recover within weeks to months even without therapy.

Vasculitis and Granulomatosis Many pulmonary conditions result in vasculitis, most of which are secondary to other inflammatory processes, such as necrotizing granulomatous infections. Only a few primary idiopathic vasculitis syndromes affect the lung, the most important of which are

Wegener granulomatosis, Churg-Strauss granulomatosis, and necrotizing sarcoid granulomatosis. The vasculitides are discussed in detail in Chapter 10.

Pulmonary Hypertension In fetal life, the pulmonary arterial walls are thick, and pulmonary arterial pressure is correspondingly high. Blood is oxygenated through the placenta, not the lungs. Thus, the high fetal pulmonary arterial pressure serves to shunt the output of the right ventricle through the ductus arteriosus into the systemic circulation, effectively bypassing the lungs. After birth, the lungs are responsible for oxygenating venous blood, and the ductus arteriosus closes. The lungs must thus adapt to accept the entire cardiac output, a situation that demands the high-volume and low-pressure system of the mature lung. Accordingly, by 3 days after birth, pulmonary arteries dilate, their walls become thin, and pulmonary arterial pressure declines. Increases in either pulmonary blood flow or vascular resistance may lead to higher pulmonary arterial pressure. Whatever the cause, characteristic morphologic abnormalities result from increased pulmonary artery pressure (Fig. 12-30). Grades 1, 2, and 3 are generally reversible; grades 4 and above are usually not. • Grade 1: Medial hypertrophy of muscular pulmonary arteries and appearance of smooth muscle in pulmonary arterioles • Grade 2: Intimal proliferation with increasing medial hypertrophy • Grade 3: Intimal fibrosis of muscular pulmonary arteries and arterioles, which may be occlusive (Fig. 12-31A). • Grade 4: Formation of plexiform lesions together with dilation and thinning of pulmonary arteries. These nodular lesions are composed of irregular interlacing blood channels and impose a further obstruction in the pulmonary circulation (see Fig. 12-31B). • Grade 5: Plexiform lesions in combination with dilation or angiomatoid lesions. Rupture of dilated thin-walled vessels, with parenchymal hemorrhage and hemosiderosis, is also present. • Grade 6: Fibrinoid necrosis of arteries and arterioles Even mild atherosclerosis of the pulmonary artery is uncommon when pulmonary arterial pressure is normal. However, with all grades of pulmonary hypertension, atherosclerosis is seen in the largest pulmonary arteries. Increased pressure in the lesser circulation leads to hypertrophy of the right ventricle (cor pulmonale).

B FIGURE 12-29. Organizing pneumonia pattern. A. Polypoid plugs of loose fibrous tissue are present in a bronchiole and the adjacent alveolar ducts and alveoli. B. The alveolar spaces contain similar plugs of loose organizing connective tissue.

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SMALL PULMONARY ARTERIES

Endothelium

Thin muscularis

Internal elastic lamina External elastic lamina

Intimal fibrosis

Muscularis FETAL

Hypertrophic muscularis

POSTNATAL

PULMONARY HYPERTENSION (EARLY)

PULMONARY HYPERTENSION (LATE)

FIGURE 12-30. Histopathology of pulmonary hypertension. In late gestation, the pulmonary arteries have thick walls. After birth, the vessels dilate, and the walls become thin. Mild pulmonary hypertension is characterized by thickening of the media. As pulmonary hypertension becomes more severe, there is extensive intimal fibrosis and muscle thickening.

Pulmonary Hypertension May be Considered Precapillary or Postcapillary in Origin The primary source of increased flow or resistance, whether proximal or distal to the pulmonary capillary bed, may be used to understand the pathophysiology of pulmonary hypertension. Precapillary hypertension includes left-to-right cardiac shunts as

well as primary pulmonary hypertension, thromboembolic pulmonary hypertension, and hypertension secondary to fibrotic lung disease and hypoxia. Postcapillary hypertension includes pulmonary veno-occlusive disease, as well as hypertension secondary to left-sided cardiac disorders, such as mitral stenosis and aortic coarctation. (See Chapter 11 for discussion of the role of cardiac disease in pulmonary hypertension.)

B FIGURE 12-31. Pulmonary arterial hypertension. A. A small pulmonary artery is virtually occluded by concentric intimal fibrosis and thickening of the media. B. A plexiform lesion (arrow) is characterized by a glomeruloid proliferation of thinwalled vessels adjacent to a parent artery, which shows marked hypertensive changes of intimal fibrosis and medial thickening.

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Primary Pulmonary Hypertension Primary pulmonary hypertension is a rare idiopathic condition caused by increased tone within the pulmonary arteries. It occurs at all ages but is most common in young women in their 20s and 30s. The disorder presents as an insidious onset of dyspnea. Physical signs and radiologic abnormalities are initially slight, but become more apparent with time. Severe pulmonary hypertension (i.e., plexiform lesions) eventually ensues, and patients die of cor pulmonale. Medical treatment is ineffective, and heart–lung transplantation is indicated.

Recurrent Pulmonary Emboli Multiple thromboemboli in the smaller pulmonary vessels often result from asymptomatic, episodic showers of small emboli from the periphery. They gradually restrict the pulmonary circulation and lead to pulmonary hypertension. Some patients have evidence of peripheral venous thrombosis, usually in the leg veins, or a history of circumstances predisposing to venous thrombosis. If the condition is diagnosed during life, placement of a filter in the inferior vena cava usually prevents further embolization.

Hypoxemia Can Result in Constriction of Small Pulmonary Arteries and Pulmonary Hypertension Predisposing conditions that are likely to produce hypoxemia-associated pulmonary hypertension include chronic airflow obstruction (chronic bronchitis), infiltrative lung disease, and living at a high altitude. Severe kyphoscoliosis or extreme obesity (Pickwickian syndrome) may mechanically interfere with ventilation and result in pulmonary hypertension.

Cardiac Disease May Result in Pulmonary Hypertension Left ventricular failure increases pulmonary venous pressure and, to some extent, pulmonary arterial pressure. By contrast, mitral stenosis produces severe venous pulmonary hypertension and significant pulmonary artery hypertension. In such cases, the lungs exhibit lesions of both pulmonary hypertension and chronic passive congestion (see Chapter 7).

Carcinoma of the Lung EPIDEMIOLOGY: Regarded as a rare tumor as late as 1945, carcinoma of the lung is today the most common cause of cancer death worldwide. In the United States, it is the most common cause of cancer death in both men and women. Approximately 85% of lung cancers occur in cigarette smokers (see Chapter 8). The peak age for lung cancer is between 60 and 70 years, and most patients are between 50 and 80 years old. The former male predominance is decreasing, because of increased smoking among women. PATHOGENESIS: Individual carcinomas of the lung have multiple genetic alterations that are likely be to the result of a stepwise progression from a normal cell toward a malignant tumor. Carcinogenic products in tobacco are clearly involved in this process. Some of the more common genetic alterations associated with lung carcinoma are as follows: • K-ras oncogene: Mutations in this oncogene are found in adenocarcinomas (25%), large cell tumors (20%), and less commonly in squamous cell carcinoma (5%). The mutations correlate with smoking and a poor prognosis. • Myc oncogene: Overexpression of this gene occurs in 10% to 40% of small cell carcinomas but is rare in other types.

• Bcl-2: This antiapoptotic protooncogene is expressed in 25% of squamous cell carcinomas and 10% of adenocarcinomas. • Rb and p53: Mutations in both of these important tumor suppressor genes are found in 80% of small cell carcinomas. Both genes are somewhat less frequently mutated in nonsmall cell tumors (50% and 25%, respectively). • Deletions in the short arm of chromosome 3 (3p): Such deletions are frequently found in all types of lung cancers. PATHOLOGY: The most important issue in the histological subclassification of lung cancer is separating small cell carcinoma from the other types (nonsmall cell carcinoma), because small cell carcinoma responds to chemotherapy, whereas other histological types do not. Any cancer with a component of small cell carcinoma is regarded as a subtype of that tumor (see below). CLINICAL FEATURES: The overall 5-year survival rate for all patients with lung cancer has remained at 15% for the past 2 decades. The 5-year survival rate at all stages is 42% for bronchioloalveolar carcinoma, 17% for adenocarcinoma, 15% for squamous cell carcinoma, 11% for large cell carcinoma, and 5% for small cell carcinoma. Tumor stage remains the single most important predictor of prognosis.

Some Clinical Features are Common to All Subtypes LOCAL EFFECTS: Most central endobronchial tumors produce symptoms related to bronchial obstruction, such as cough, dyspnea, hemoptysis, chest pain, obstructive pneumonia, and pleural effusion. Tumors arising peripherally are more likely to be discovered either on routine chest radiographs or after they have become advanced and invaded the chest wall, with resulting chest pain, superior vena cava syndrome, and nerve-entrapment syndromes. Growth of a lung cancer (usually squamous) in the apex of the lung (Pancoast tumor) may extend to involve the eighth cervical and first and second thoracic nerves, leading to shoulder pain that radiates down the arm in an ulnar distribution (Pancoast syndrome). A Pancoast tumor may also paralyze cervical sympathetic nerves and cause Horner syndrome, characterized on the affected side by (1) depression of the eyeball (enophthalmos), (2) ptosis of the upper eyelid, (3) constriction of the pupil (miosis), and (4) absence of sweating (anhidrosis). METASTASES: Carcinomas of the lung metastasize most frequently to regional lymph nodes, particularly the hilar and mediastinal nodes, but also to the brain, bone, and liver. The most frequent site of extranodal metastases is the adrenal gland, although adrenal insufficiency is distinctly uncommon.

Squamous Cell Carcinoma Squamous cell carcinoma accounts for 30% of all invasive lung cancers in the United States. After injury to the bronchial epithelium, such as occurs with cigarette smoking, regeneration from the pluripotent basal layer commonly occurs in the form of squamous metaplasia. The metaplastic mucosa follows the same sequence of dysplasia, carcinoma in situ, and invasive tumor as that observed in sites that are normally lined by squamous epithelium, such as the cervix or skin. PATHOLOGY: Most squamous cell carcinomas arise in the central portion of the lung from the major or segmental bronchi, although 10% originate in the periphery. They tend to be firm, grey-white, 3- to 5-cm ulcerated lesions, which extend through the bronchial wall into the adjacent parenchyma (Fig. 12-32A). The appearance of the cut surface is variable, depending on the degree of necrosis and hemorrhage. Central cavitation is frequent. On occasion, a central squamous carcinoma occurs as an endobronchial tumor.

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B FIGURE 12-32. Squamous cell carcinoma of the lung. A. The tumor grows within the lumen of a bronchus and invades the adjacent intrapulmonary lymph node. B. A photomicrograph shows well-differentiated squamous cell carcinoma with a keratin pearl composed of cells with brightly eosinophilic cytoplasm.

The microscopic appearance of squamous cell carcinoma is highly variable. Well-differentiated squamous cell carcinomas display keratin “pearls,” which are eosinophilic aggregates of keratin surrounded by concentric (“onion skin”) layers of squamous cells (see Fig. 12-32B). Individual cell keratinization also occurs, in which a cell’s cytoplasm assumes a glassy, intensely eosinophilic appearance. Intercellular bridges are identified in some well-differentiated squamous cancers as slender gaps between adjacent cells, which are traversed by fine strands of cytoplasm. By contrast,

some squamous tumors are so poorly differentiated that they show no foci of keratinization and are difficult to distinguish from large cell, small cell, or spindle cell carcinomas. Tumor cells may be readily found in the sputum, in which case the diagnosis is made by exfoliative cytology.

Adenocarcinoma Adenocarcinoma of the lung comprises one third of all invasive lung cancers in the United States. It tends to arise in the periphery

FIGURE 12-33. Adenocarcinoma of the lung. A. The malignant epithelial cells of an acinar adenocarcinoma form glands. B. A papillary adenocarcinoma consists of malignant epithelial cells growing along thin fibrovascular cores. C. A tumor grows in the pattern of solid adenocarcinoma with mucin formation. Several intracytoplasmic mucin droplets stain positively with the mucicarmine stain.

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which is distinguished by regular glands lined by cuboidal or columnar cells (see Fig. 12-33A). Papillary adenocarcinomas exhibit a single cell layer on a core of fibrovascular connective tissue (see Fig. 12-33B). Solid adenocarcinomas with mucus formation are poorly differentiated tumors, distinguishable from large cell carcinomas by demonstrating mucin with mucicarmine or periodic acid–Schiff (see Fig. 12-33C). Patients with stage I adenocarcinomas (localized to the lung) who undergo complete surgical removal have a 5-year survival rate of 50% to 80%.

Bronchioloalveolar Carcinoma

FIGURE 12-34. Bronchioloalveolar carcinoma. The cut surface of the lung is solid, glistening, and mucoid, an appearance that reflects a diffusely infiltrating tumor.

and is often associated with pleural fibrosis and subpleural scars, which can result in pleural puckering. In nonsmokers who develop lung cancer, the proportion of adenocarcinomas is greater. PATHOLOGY: At initial presentation, adenocarcinomas of the lung most often appear as irregular masses 2 to 5 cm in diameter, although they may be so large as to replace an entire lobe. On cut section, the tumor is grayish-white and often glistening, depending on the amount of mucus production. Central adenocarcinomas may have predominantly endobronchial growth and invade bronchial cartilage. There are four major subtypes of adenocarcinoma, as defined by the World Health Organization (Fig. 12-33; see Figs. 12-34 and 12-35): (1) acinar, (2) papillary, (3) solid with mucus formation, and (4) bronchioloalveolar. However, it is common to encounter a mixture of these histologic subtypes. Bronchioloalveolar carcinoma is distinctive and is discussed below. Pulmonary adenocarcinoma may reflect the architecture and cell population of any part of the respiratory mucosa, from the large bronchi to the smallest bronchioles. The neoplastic cells may resemble ciliated or nonciliated columnar epithelial cells, goblet cells, cells of bronchial glands, or Clara cells. The most common histologic type of adenocarcinoma features the acinar pattern,

Bronchioloalveolar carcinoma is a distinctive subtype of adenocarcinoma that grows along pre-existing alveolar walls and accounts for 1% to 5% of all invasive lung tumors. It has not been definitively linked to smoking. Copious mucin in the sputum (bronchorrhea) is a distinctive sign of bronchioloalveolar carcinoma but is seen in fewer than 10% of patients. On gross examination, bronchioloalveolar carcinoma may appear as a single peripheral nodule or coin lesion (⬎50% of cases), multiple nodules, or a diffuse infiltrate indistinguishable from lobar pneumonia (Fig. 12-34). Two thirds of tumors are nonmucinous, consisting of Clara cells and type II pneumocytes, in which cuboidal cells grow along the alveolar walls (Fig. 12-35); the remaining one-third are mucinous tumors featuring columnar goblet cells filled with mucus (see Fig. 12-35B). Patients with stage I bronchioloalveolar carcinomas have a good prognosis; but those who have multiple nodules or diffuse lung involvement are more likely to have a poor outcome.

Small Cell Carcinoma Small cell carcinoma (previously “oat cell” carcinoma) is a highly malignant epithelial tumor of the lung that exhibits neuroendocrine features. It accounts for 20% of all lung cancers and is strongly associated with cigarette smoking. The male-to-female ratio is 2:1. The tumor grows and metastasizes rapidly, and 70% of patients are first seen in an advanced stage. A variety of paraneoplastic syndromes are distinctive for small cell carcinoma, including diabetes insipidus, ectopic adrenocorticotropic hormone (ACTH, corticotropin) syndrome, and the Eaton-Lambert (myasthenic) syndrome, which is associated with muscle weakness in the lower extremities. PATHOLOGY: Small cell carcinoma usually appears as a perihilar mass, frequently with extensive lymph node metastases. On cut section, it is soft and white but often shows extensive hemorrhage and necrosis. The tumor typically spreads along bronchi in a submucosal and cir-

B FIGURE 12-35. Bronchioloalveolar carcinoma. A. Nonmucinous bronchioloalveolar carcinomas consist of atypical cuboidal to low columnar cells proliferating along the existing alveolar walls. B. Mucinous bronchioloalveolar carcinoma consists of tall columnar cells filled with apical cytoplasmic mucin that grow along the existing alveolar walls.

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mally found in the bronchial epithelium. These neoplasms account for 2% of all primary lung cancers, show no gender predilection, and are not related to cigarette smoking. Although neuropeptides are readily demonstrated in the tumor cells, most are endocrinologically silent. PATHOLOGY: Carcinoid tumors are characterized histologically by an organoid growth pattern and uniform cytologic features, including eosinophilic, finely granular cytoplasm and nuclei with finely granular chromatin (Fig. 12-38). CLINICAL FEATURES: Carcinoid tumors grow so slowly that half of patients are asymptomatic at presentation. Such tumors are often discovered as a mass in a chest radiograph. Patients with typical carcinoids have an excellent prognosis, with a 90% 5-year survival rate after surgery. FIGURE 12-36. Small cell carcinoma of the lung. This tumor consists of small oval to spindle-shaped cells with scant cytoplasm, finely granular nuclear chromatin, and conspicuous mitoses.

cumferential fashion. Histologically, small cell carcinoma consists of sheets of small, round, oval or spindle-shaped cells with scant cytoplasm. Their nuclei are distinctive, featuring finely granular nuclear chromatin and absent or inconspicuous nucleoli (Fig. 12-36). A high mitotic rate is characteristic, with an average of 60 to 70 mitoses per 10 high-power fields. Necrosis is frequent and extensive. Unlike other lung cancers, small cell carcinomas show marked sensitivity to chemotherapy. From an oncologist’s standpoint, all other lung cancers are grouped together as “nonsmall cell carcinoma.”

Large Cell Carcinoma Large cell carcinoma is a diagnosis of exclusion in a poorly differentiated tumor that does not show features of squamous or glandular differentiation and has been shown not to be a small cell carcinoma (Fig. 12-37). This tumor type accounts for 10% of all invasive lung tumors. The cells are large and exhibit ample cytoplasm. The nuclei frequently show prominent nucleoli and vesicular chromatin. Some large cell carcinomas exhibit pleomorphic giant cells or spindle cells.

Carcinoid Tumors Carcinoid tumors of the lung comprise two subtypes of neuroendocrine neoplasms and are thought to arise from the resident neuroendocrine cells nor-

FIGURE 12-37. Large cell carcinoma of the lung. This poorly differentiated tumor is growing in sheets. The tumor cells are large and contain ample cytoplasm and prominent nucleoli.

FIGURE 12-38. Carcinoid tumor of the lung. A. A central carcinoid tumor (arrow) is circumscribed and protrudes into the lumen of the main bronchus. The compression of the bronchus by the tumor caused the postobstructive pneumonia seen in the distal lung parenchyma (right). B. A microscopic view shows ribbons of tumor cells embedded in a vascular stroma.

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and a large collection of air in the pleural space. The condition is usually due to rupture of a subpleural emphysematous bleb. In most cases, spontaneous pneumothorax subsides by itself, but some patients require withdrawal of the air. Tension pneumothorax refers to unilateral pneumothorax extensive enough to shift the mediastinum to the opposite side, with compression of the opposite lung. The condition may be lifethreatening and must be relieved by immediate drainage.

Pleural Effusion Pleural effusion is the accumulation of excess fluid in the pleural cavity. Normally, only a small amount of fluid in the pleural cavity lubricates the space between the lungs and chest wall. Fluid secreted into the pleural space from the parietal pleura is absorbed by the visceral pleura. The severity of a pleural effusion varies from a few milliliters of fluid to a massive accumulation that shifts the mediastinum and the trachea to the opposite side. HYDROTHORAX: This term refers to an effusion that resembles water and would be regarded as edema elsewhere. It may be due to increased hydrostatic pressure within the capillaries, as occurs in patients with heart failure or in any condition that produces systemic or pulmonary edema.

FIGURE 12-39. Metastatic carcinoma of the lung. A section through the lung shows numerous nodules of metastatic carcinoma corresponding to “cannon ball” metastases seen radiologically.

Pulmonary Metastases are More Common than Primary Lung Tumors In one third of all fatal cancers, pulmonary metastases are evident at autopsy. Metastatic tumors in the lung are typically multiple and circumscribed. When large nodules are seen in the lungs radiologically, they are called “cannon ball” metastases (Fig. 12-39). The histologic appearance of most metastases resembles that of the primary tumor. Uncommonly, metastatic tumors may mimic bronchioloalveolar carcinoma, in which cases the usual primary site is the pancreas or stomach. In lymphangitic carcinoma, a metastatic tumor spreads widely through pulmonary lymphatic channels to form a sheath of tumor around the bronchovascular tree and veins. Clinically, patients suffer from cough and shortness of breath and display a diffuse reticulonodular pattern on the chest radiograph. The common primary sites are the breast, stomach, pancreas, and colon.

THE PLEURA Pneumothorax Pneumothorax is defined as the presence of air in the pleural cavity. It may occur with traumatic perforation of the pleura or may be “spontaneous.” Traumatic causes include penetrating wounds of the chest wall (e.g., a stab wound or a rib fracture). Traumatic pneumothorax is most commonly iatrogenic and is seen after aspiration of fluid from the pleura (thoracentesis), pleural or lung biopsies, transbronchial biopsies, and positive pressure-assisted ventilation. Spontaneous pneumothorax is typically encountered in young adults. For example, while exercising vigorously, a tall young man develops acute chest pain and shortness of breath. A chest radiograph shows collapse of the lung on the side of the pain

PYOTHORAX: A turbid effusion containing many polymorphonuclear leukocytes (pyothorax) results from infections of the pleura. This may occasionally be caused by an external penetrating wound that introduces pyogenic organisms into the pleural space. More commonly, it is a complication of bacterial pneumonia that extends to the pleural surface, the classic example of which is pneumococcal pneumonia. EMPYEMA: This disorder is a variant of pyothorax in which thick pus accumulates within the pleural cavity, often with loculation and fibrosis. HEMOTHORAX: This term refers to blood in the pleural cavity as a result of trauma or rupture of a vessel (e.g., dissecting aneurysm of the aorta). CHYLOTHORAX: Chylothorax is the accumulation of milky, lipid-rich fluid (chyle) in the pleural cavity as a result of lymphatic obstruction. It has an ominous portent, because lymphatic obstruction suggests disease of the lymph nodes in the posterior mediastinum.

Tumors of the Pleura: Malignant Mesothelioma Malignant mesothelioma is a neoplasm of mesothelial cells that is most common in the pleura but also occurs in the peritoneum, pericardium, and the tunica vaginalis of the testis. EPIDEMIOLOGY: Approximately 2,000 persons develop these tumors yearly in the United States. In the United States, Great Britain and South Africa, the large majority of patients report exposure to asbestos. The latency period between asbestos exposure and the appearance of malignant mesothelioma is about 20 years, with a range of 12 to 60 years. PATHOLOGY: Grossly, pleural mesotheliomas often encase and compress the lung, extending into fissures and interlobar septa, a distribution often referred to as a “pleural rind” (Fig. 12-40A). Invasion of the pulmonary parenchyma is generally limited to the periphery adjacent to the tumor, and lymph nodes tend to be spared. Microscopically, classic mesotheliomas show a biphasic appearance, with epithelial and sarcomatous patterns (see Fig. 12-40B). Glands and tubules that resemble adenocarcinoma are admixed with sheets of spindle cells that are similar to a fibrosarcoma.

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FIGURE 12-40. Pleural malignant mesothelioma. A. The lung is encased by a dense pleural tumor that extends along the interlobar fissures but does not involve the underlying lung parenchyma. B. This mesothelioma is composed of a biphasic pattern of epithelial and sarcomatous elements.

Useful criteria for diagnosing mesothelioma include the absence of mucin, presence of hyaluronic acid (positive Alcian blue staining), and demonstration of long, slender microvilli by electron microscopy. CLINICAL FEATURES: The average age of patients with mesothelioma is 60 years. Patients are first seen with a pleural effusion or a pleural mass, chest pain, and nonspecific symptoms, such as weight loss and

malaise. Pleural mesotheliomas tend to spread locally within the chest cavity, invading and compressing major structures. Metastases can occur to the lung parenchyma and mediastinal lymph nodes, as well as to extrathoracic sites such as the liver, bones, peritoneum, and adrenals. Treatment is largely ineffective, and prognosis is poor. Few patients survive longer than 18 months after diagnosis.

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The Gastrointestinal Tract Frank A. Mitros Emanuel Rubin

THE ESOPHAGUS Congenital Disorders Tracheoesophageal Fistula Rings and Webs Esophageal Diverticula Motor Disorders Achalasia Scleroderma Hiatal Hernia Esophagitis Reflux Esophagitis Barrett Esophagus Infective Esophagitis Esophageal Varices Neoplasms Esophageal Carcinoma Adenocarcinoma of the Esophagus

THE STOMACH Congenital Disorders Gastritis Acute Hemorrhagic Gastritis Chronic Gastritis Peptic Ulcer Disease Gastric and Duodenal Ulcer Disease Diseases Associated With Peptic Ulcers Pathology and Clinical Details Benign Neoplasms Stromal Tumors Epithelial Polyps Malignant Tumors Carcinoma of the Stomach Pathology and Clinical Details

THE SMALL INTESTINE Congenital Disorders Atresia and Stenosis Meckel Diverticulum Meconium Ileus 274

Infections of the Small Intestine Bacterial Diarrhea Rotavirus and Norwalk Virus Vascular Diseases of the Small Intestine Superior Mesenteric Artery Occlusion Chronic Intestinal Ischemia Malabsorption Luminal-Phase Malabsorption Intestinal-Phase Malabsorption Lactase Deficiency Celiac Disease Whipple Disease Mechanical Obstruction Neoplasms Benign Tumors Malignant Tumors

THE LARGE INTESTINE Congenital Disorders Congenital Megacolon (Hirschsprung Disease) Anorectal Malformations Infections of the Large Intestine Pseudomembranous Colitis Neonatal Necrotizing Enterocolitis Diverticular Disease Diverticulosis Diverticulitis Inflammatory Bowel Disease Crohn Disease Ulcerative Colitis Vascular Diseases Ischemic Injury Angiodysplasia (Vascular Ectasia) Hemorrhoids Polyps of the Colon and Rectum Adenomatous Polyps Hyperplastic Polyps

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Familial Adenomatous Polyposis (FAP) Nonneoplastic Polyps Malignant Tumors Adenocarcinoma of the Colon and Rectum Cancers of the Anal Canal

THE APPENDIX

The Esophagus

tion immediately after birth. In another variant, termed an H-type fistula, a communication exists between an intact esophagus and an intact trachea. In some cases (see Fig. 13-1C), the lesion becomes symptomatic only in adulthood, when repeated pulmonary infections call attention to it.

Congenital Disorders Tracheoesophageal Fistula

Tracheoesophageal fistula is the most common esophageal anomaly (Fig. 13-1). It is frequently combined with some form of esophageal atresia. In some cases, it is associated with a complex of anomalies identified by the acronym Vater syndrome (vertebral defects, anal atresia, tracheoesophageal fistula, and renal dysplasia). Esophageal atresia and fistulas are often associated with congenital heart disease. PATHOLOGY: In 90% of tracheoesophageal fistulas, the upper portion of the esophagus ends in a blind pouch, and the superior end of the lower segment communicates with the trachea. In this type of atresia, the upper blind sac soon fills with mucus, which the infant then aspirates. Surgical correction is feasible, albeit difficult. Among the remaining 10% of fistulas, the most common is a communication between the proximal esophagus and the trachea; the lower esophageal pouch communicates with the stomach. Infants with this condition develop aspira-

Appendicits Mucocele Neoplasms of the Appendix

Rings and Webs Cause Dysphagia ESOPHAGEAL WEBS: Occasionally, a thin mucosal membrane projects into the esophageal lumen. Webs are usually single but may be multiple and can occur anywhere in the esophagus. They are often successfully treated by dilation with large rubber bougies; occasionally, they can be excised with biopsy forceps during endoscopy. PLUMMER-VINSON (PATERSON-KELLY) SYNDROME: This disorder is characterized by (1) a cervical esophageal web, (2) mucosal lesions of the mouth and pharynx, and (3) iron-deficiency anemia. Dysphagia, often associated with aspiration of swallowed food, is the most common clinical manifestation. Ninety percent of cases occur in women. Carcinoma of the oropharynx and upper esophagus is a recognized complication. SCHATZKI RING: This lower esophageal narrowing is usually seen at the gastroesophageal junction. The upper surface of the mucosal ring has stratified squamous epithelium; the lower, columnar epithelium. Although it has been noted in up to 14% of barium meal examinations, Schatzki ring is usually asymptomatic. Patients with narrow Schatzki rings, however, may complain of intermittent dysphagia.

Esophageal Diverticula Often Reflect Motor Dysfunction A true esophageal diverticulum is an outpouching of the wall that contains all layers of the esophagus. If a sac has no muscular layer, it is a false diverticulum. Esophageal diverticula occur in the hypopharyngeal area above the upper esophageal sphincter, in the middle esophagus, and immediately proximal to the lower esophageal sphincter.

Esophagus Trachea

C Congenital tracheoesophageal fistulas. A. The most common type is a communication between the trachea and the lower portion of the esophagus. The upper segment of the esophagus ends in a blind sac. B. In a few cases, the proximal esophagus communicates with the trachea. C. The least common anomaly, the H type, is a fistula between a continuous esophagus and the trachea. FIGURE 13-1.

ZENKER DIVERTICULUM: Zenker diverticulum is an uncommon lesion that appears high in the esophagus and affects men more than women. Disordered function of cricopharyngeal musculature is generally thought to be involved in the pathogenesis of this false diverticulum. Most affected persons who come to medical attention are older than 60 years, suggesting that this diverticulum is acquired. The typical symptom is regurgitation of food eaten some time previously (occasionally days), in the absence of dysphagia. Recurrent aspiration pneumonia may be a serious complication. When symptoms are severe, surgical intervention is the rule. TRACTION DIVERTICULA: Traction diverticula are outpouchings that occur principally in the midportion of the esophagus. They were so named because of their now-uncommon finding of attachment to adjacent tuberculous mediastinal lymph nodes. It is now believed that these pouches most often reflect a disturbance in the motor function of the esophagus. A diverticulum in the midesophagus ordinarily has a wide stoma, and the pouch is usually higher than its orifice. Thus, it does not retain food or secretions and remains asymptomatic, with only rare complications.

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EPIPHRENIC DIVERTICULA: These diverticula are located immediately above the diaphragm. Motor disturbances of the esophagus (e.g., achalasia, diffuse esophageal spasm) are found in two thirds of patients with this true diverticulum. Reflux esophagitis may play a role in the pathogenesis of this condition. Unlike other diverticula, epiphrenic diverticula are encountered in young persons. Nocturnal regurgitation of large amounts of fluid stored in the diverticulum during the day is typical. When symptoms are severe, surgical intervention is directed toward correcting the motor abnormality (e.g., myotomy).

Motor Disorders The automatic coordination of muscular movement during swallowing is a motor function that results in free passage of food through the esophagus. The hallmark of motor disorders is difficulty in swallowing, termed dysphagia. Dysphagia is often an awareness that a bolus of food is not moving downward and in itself is not painful. Pain on swallowing is odynophagia. Motor disorders can be caused by either esophageal or systemic defects in striated muscle function, neurological diseases affecting afferent nerves, or peripheral neuropathies occurring in association with diabetes or alcoholism.

Achalasia Features Impaired Function of the Lower Esophageal Sphincter Achalasia, at one time termed cardiospasm, is characterized by failure of the lower esophageal sphincter to relax in response to swallowing and the absence of peristalsis in the body of the esophagus. As a result of these defects in both the outflow tract and the pumping mechanisms of the esophagus, food is retained within the esophagus, and the organ hypertrophies and dilates conspicuously (Fig. 13-2). Achalasia is associated with the loss or absence of

ganglion cells in the esophageal myenteric plexus. In Latin America, achalasia is a common complication of Chagas disease, in which the ganglion cells are destroyed by the protozoa Trypanosoma cruzi. Dysphagia, occasionally odynophagia, and regurgitation of material retained in the esophagus are common symptoms of achalasia. Squamous carcinoma of the esophagus is also a complication.

Scleroderma Causes Fibrosis of the Esophageal Wall Scleroderma (progressive systemic sclerosis) leads to fibrosis in many organs and produces a severe abnormality of esophageal muscle function (see Chapter 4). The disease mainly affects the lower esophageal sphincter, which may become so impaired that the lower esophagus and upper stomach are no longer distinct functional entities and are visualized as a common cavity. In addition, there may be a lack of peristalsis in the entire esophagus. Microscopically, fibrosis of esophageal smooth muscle (especially the inner layer of the muscularis propria) and nonspecific inflammatory changes are seen. Intimal fibrosis of small arteries and arterioles is common and may play a role in the pathogenesis of the fibrosis. Clinically, patients have dysphagia and heartburn caused by peptic esophagitis, due to reflux of acid from the stomach (see below).

Hiatal Hernia Hiatal hernia is a herniation of the stomach through an enlarged esophageal hiatus in the diaphragm. Two basic types of hiatal hernia are observed (Fig. 13-3). SLIDING HERNIA: An enlargement of the diaphragmatic hiatus and laxity of the circumferential connective tissue allows a cap of gastric mucosa to move upward to a position above the diaphragm. This condition is common. Sliding hiatal hernia is asymptomatic in most patients; only 5% of patients diagnosed radiologically complain of symptoms referable to gastroesophageal reflux. PARAESOPHAGEAL HERNIA: This uncommon form of hiatal hernia is characterized by herniation of a portion of gastric fundus alongside the esophagus through a defect in the diaphragmatic connective tissue membrane that defines the esophageal hiatus. The hernia progressively enlarges, and the hiatus grows increasingly wide. In extreme cases, most of the stomach herniates into the thorax. CLINICAL FEATURES: Symptoms of hiatal hernia, particularly heartburn and regurgitation, are attributed to gastroesophageal reflux of gastric contents, primarily related to incompetence of the lower esophageal sphincter. Classically, symptoms are exacerbated when the affected person is recumbent, which facilitates acid reflux. Dysphagia, painful swallowing, and occasionally bleeding may also be troublesome. Large herniations carry a risk of gastric volvulus or intrathoracic gastric dilation. Sliding hiatal hernias generally do not require surgical repair; symptoms are often treated medically. By contrast, an enlarging paraesophageal hernia should be surgically treated, even in the absence of symptoms.

Esophagitis Reflux Esophagitis is Caused by Regurgitation of Gastric Contents Esophagus and upper stomach of a patient with advanced achalasia. The esophagus is markedly dilated above the esophagogastric junction, where the lower esophageal sphincter is located. The esophageal mucosa is redundant and has hyperplastic squamous epithelium. FIGURE 13-2.

Reflux esophagitis, by far the most common type of esophagitis, is often found in conjunction with a sliding hiatal hernia, although it may occur through an incompetent lower esophageal sphincter without any demonstrable anatomical lesion.

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Esophagus Stomach

Sliding hiatal hernia Diaphragm

Paraesophageal hiatal hernia Stomach

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PATHOLOGY: The first grossly evident change caused by gastroesophageal reflux is hyperemia. Areas affected by reflux are susceptible to superficial mucosal erosions and ulcers, which often appear as vertical linear streaks. Microscopically, mild injury to the squamous epithelium is manifested by cell swelling (hydropic change). The basal region of the epithelium is thickened, and the papillae of the lamina propria are elongated and extend toward the surface because of reactive proliferation. Capillary vessels within the papillae are often dilated. An increase in lymphocytes is seen in the squamous epithelium, and eosinophils and neutrophils may be present. Esophageal stricture may eventuate in those patients in whom the ulcer persists and damages the esophageal wall deep to the lamina propria. In this circumstance, reactive fibrosis can narrow the esophageal lumen.

Barrett Esophagus is Replacement of Esophageal Squamous Epithelium by Columnar Epithelium Barrett esophagus is a result of chronic gastroesophageal reflux. This disorder occurs in the lower third of the esophagus but may extend higher. There is a slight male predominance and a more than twofold increased risk for Barrett esophagus among smokers. Patients with Barrett esophagus are placed in a regular surveillance program to detect early microscopic evidence of dysplastic mucosa.

Achalasia

Schatzki ring

PATHOLOGY: Metaplastic Barrett epithelium may partially involve the circumference of short segments or may line the entire lower esophagus (Fig. 13-4A). Microscopically, the sine qua non of Barrett esophagus is the presence of a distinctive type of epithelium, referred to as “specialized epithelium.” It consists of an admixture of intestinelike epithelium characterized by well-formed goblet cells interspersed with gastric foveolar cells (see Fig. 13-4B). Complete intestinal metaplasia, with Paneth cells and absorptive cells, occurs occasionally. Inflammatory changes are often superimposed on the epithelial alterations. Barrett esophagus may transform into adenocarcinoma, the risk correlating with the length of the involved esophagus and the degree of dysplasia (see below).

Infective Esophagitis is Associated with Immunosuppression CANDIDA ESOPHAGITIS: This fungal infection has become commonplace because of an increasing number of immunocompromised persons. Esophageal candidiasis also occurs in patients with diabetes, those receiving antibiotic therapy, and uncommonly in persons with no known predisposing factors. Dysphagia and severe pain on swallowing are usual.

FIGURE 13-3.

Disorders of the esophageal outlet.

PATHOGENESIS: The principal barrier to the reflux of gastric contents into the esophagus is the lower esophageal sphincter. Transient reflux is a normal event, particularly after a meal. When these episodes become more frequent and are prolonged, esophagitis results. Agents that decrease the pressure of the lower esophageal sphincter (e.g., alcohol, chocolate, fatty foods, cigarette smoking) are also associated with reflux. Certain central nervous system depressants (e.g., morphine, diazepam), pregnancy, estrogen therapy, and the presence of a nasogastric tube may lead to reflux esophagitis. Although acid is damaging to the esophageal mucosa, the combination of acid and pepsin may be particularly injurious. Moreover, gastric fluid often contains refluxed bile from the duodenum, which is harmful to the esophageal mucosa. Alcohol, hot beverages, and spicy foods may also damage the mucosa directly.

PATHOLOGY: In mild cases of candidiasis, a few small, elevated white plaques surrounded by a hyperemic zone are present on the mucosa of the middle or lower third of the esophagus. In severe cases, confluent pseudomembranes lie on a hyperemic and edematous mucosa. Microscopically, Candida sometimes involves only the superficial layers of the squamous epithelium. The candidal pseudomembrane contains fungal mycelia, necrotic debris, and fibrin. Involvement of deeper layers of the esophageal wall can lead to disseminated candidiasis or fibrosis, sometimes severe enough to create a stricture. HERPETIC ESOPHAGITIS: Esophageal infection with herpesvirus type I is most frequently associated with lymphomas and leukemias and is often manifested by odynophagia. However, on occasion, it may occur in otherwise healthy individuals. PATHOLOGY: The well-developed lesions of herpetic esophagitis grossly resemble those of candidiasis. Microscopically, lesions are superficial, and epithelial cells exhibit typical nuclear herpetic inclusions and occasional multinucleation. Necrosis of infected cells leads to ulcera-

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B Barrett esophagus. A. The presence of the tan tongues of epithelium interdigitating with the more proximal squamous epithelium is typical of Barrett esophagus. B. The specialized epithelium has a villiform architecture and is lined by cells that are foveolar gastric type cells and intestinal goblet type cells. FIGURE 13-4.

tion, and candidal and bacterial superinfection results in the formation of pseudomembranes.

Esophageal Varices Esophageal varices are dilated veins immediately beneath the mucosa (Fig. 13-5) that are prone to rupture and hemorrhage (also see Chapter 14). They arise in the lower third of the esophagus, virtually always in patients with cirrhosis and portal hypertension. The lower esophageal

veins are linked to the portal system through gastroesophageal anastomoses. If portal system pressure exceeds a critical level, these anastomoses become prominent in the upper stomach and lower esophagus. When varices are greater than 5 mm in diameter, they are prone to rupture, leading to life-threatening hemorrhage. Reflux injury or infective esophagitis can contribute to variceal bleeding.

Neoplasms Esophageal Carcinoma Varies Geographically and Histologically EPIDEMIOLOGY: Worldwide, most esophageal cancers are squamous cell carcinomas, but adenocarcinoma is now more common in the United States (see below). Geographic variations in the incidence of esophageal carcinoma are striking. There is an esophageal cancer belt extending across Asia from the Caspian Sea region of northern Iran and through Central Asia and Mongolia to northern China. In parts of China, the mortality rate from esophageal cancer in men may be 70 times that in the United States. Esophageal cancer is uncommon in the United States and accounts for only about 2% of cancer deaths. American blacks, however, have a much higher incidence than whites.

FIGURE 13-5. Esophageal varices. A. Numerous prominent blue venous channels are seen beneath the mucosa of the everted esophagus, particularly above the gastroesophageal junction. B. Section of the esophagus reveals numerous dilated submucosal veins.

PATHOGENESIS: Geographic variations in esophageal cancer, even in relatively homogeneous populations, suggest that environmental factors contribute strongly to its development. However, no single factor has been incriminated. • Cigarette smoking increases risk of esophageal cancer 5to 10-fold. The number of cigarettes smoked correlates with the frequency of esophageal dysplasia.

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• Excessive consumption of alcohol is a major risk factor in the United States, even when cigarette smoking is taken into account. • Nitrosamines and aniline dyes produce esophageal cancer in animals, but direct evidence for their contribution to human esophageal cancer is lacking. • Diets low in fresh fruits, vegetables, animal protein, and trace metals are described in areas with endemic esophageal cancer. However, the close proximity of endemic and nonendemic areas renders a causative role for these dietary factors unlikely. • Plummer-Vinson syndrome, celiac sprue, and achalasia for unknown reasons are associated with an increased incidence of esophageal cancer. • Chronic esophagitis has been related to esophageal cancer in areas in which this tumor is endemic. • Chemical injury with esophageal stricture is a risk factor. Of persons who have an esophageal stricture after ingestion of lye, 5% develop cancer 20 to 40 years later. • Webs, rings, and diverticula are sometimes associated with esophageal cancer. PATHOLOGY: About half of cases of esophageal cancer involve the lower third of the esophagus; the middle and upper thirds account for the remainder. Grossly, the tumors are of three types: (1) ulcerating (Fig. 13-6A), (2) polypoid, which project into the lumen (Fig. 13-6B), and (3) infiltrating, in which the principal plane of growth is in the wall. The bulky polypoid tumors tend to obstruct early, whereas those that are ulcerated tend to be smaller and are more likely to bleed.

Infiltrating tumors gradually narrow the lumen by circumferential compression. Local extension of tumor into mediastinal structures is commonly a major problem. Microscopically, neoplastic squamous cells range from well differentiated, with epithelial “pearls,” to poorly differentiated tumors that lack evidence of squamous differentiation. Occasional tumors have a predominant spindle cell population of tumors cells (metaplastic carcinoma). The rich lymphatic drainage of the esophagus provides a route for most metastases. Metastases to liver and lung are common, but almost any organ may be involved. CLINICAL FEATURES: The most common presenting complaint is dysphagia, but by this time, most tumors are unresectable. Patients with esophageal cancer are almost invariably cachectic, due to anorexia, difficulty in swallowing, and the remote effects of a malignant tumor. Surgery and radiation therapy are useful for palliation, but the prognosis remains dismal. Many patients are inoperable, and of those who undergo surgery, only 20% survive for 5 years.

Adenocarcinoma of the Esophagus As its incidence has recently increased, adenocarcinoma of the esophagus is now more common (60%) in the United States than is squamous carcinoma. Virtually all adenocarcinomas arise in the background of Barrett esophagus, although a rare case may originate in submucosal mucous glands. Endoscopic surveillance for adenocarcinoma is now commonly done in patients with Barrett esophagus, particularly in those with dysplasia. The symptoms and clinical course of esophageal adenocarcinoma are similar to those of squamous cell carcinoma.

B Esophageal carcinoma. A. Squamous cell carcinoma. There is a large ulcerated mass present in the squamous mucosa with normal squamous mucosa intervening between the carcinoma and the stomach. B. Adenocarcinoma. There is a large exophytic ulcerated mass lesion just proximal to the gastroesophageal junction. The well-differentiated adenocarcinoma was separated from the most proximal squamous epithelium by a tan area representing Barrett esophagus. FIGURE 13-6.

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THE STOMACH Congenital Disorders: Congenital Pyloric Stenosis Congenital pyloric stenosis is concentric enlargement of the pyloric sphincter and narrowing of the pyloric canal that obstructs the gastric outlet. This disorder is the most common indication for abdominal surgery in the initial 6 months of life. It is four times more common in boys than in girls and affects first-born children more than subsequent ones. Pyloric stenosis occurs in 1 in 250 white infants but is rare in blacks and Asians. PATHOGENESIS: Congenital pyloric stenosis may have a genetic basis; there is a familial tendency, and the condition is more common in identical than in fraternal twins. It also occurs with Turner syndrome, trisomy 18, and esophageal atresia. Embryopathies associated with rubella infection and maternal intake of thalidomide have also been associated with congenital pyloric stenosis. PATHOLOGY: Gross examination of the stomach shows concentric pyloric enlargement and narrowing of the pyloric canal. The only consistent microscopic abnormality is extreme hypertrophy of the circular muscle coat. After pyloromyotomy, the lesion disappears, although occasionally a small mass remains. CLINICAL FEATURES: Projectile vomiting is the main symptom and is usually seen within the first month of life. Consequent loss of hydrochloric acid leads to hypochloremic alkalosis in one third of infants. A palpable pyloric lesion and visible peristalsis are common. Surgical incision of hypertrophied pyloric muscle is curative.

Gastritis Acute Hemorrhagic Gastritis is Associated with Drugs and Stress Acute hemorrhagic erosive gastritis is characterized by mucosal necrosis. Erosion of the mucosa may extend into the deeper tissues to form an ulcer. The necrosis is accompanied by an acute inflammatory response and hemorrhage, which may be severe enough to result in exsanguination. PATHOGENESIS: Acute hemorrhagic gastritis is most commonly associated with the intake of aspirin, other NSAIDs, excess alcohol, or ischemic injury. These agents injure the gastric mucosa directly and exert their effects topically. Oral administration of corticosteroids may also be complicated by acute hemorrhagic gastritis. Any serious illness that is accompanied by profound physiologic alterations that require substantial medical or surgical intervention renders the gastric mucosa more vulnerable to acute hemorrhagic gastritis because of mucosal ischemia. The factor common to all forms of acute hemorrhagic gastritis is thought to be the breakdown of the mucosal barrier, which permits acid-induced injury. Stress ulcers and erosions occur in severely burned persons (Curling ulcer) and commonly result in bleeding. Ulceration may be deep enough to cause perforation of the

stomach. Patients occasionally exhibit both gastric and duodenal ulcers. Central nervous system trauma, accidental or surgical (Cushing ulcer), may also cause stress ulcers. These ulcers, which may also occur in the esophagus or duodenum, are characteristically deep and carry a substantial risk of perforation. Severe trauma, especially if accompanied by shock, prolonged sepsis, and incapacitation from many debilitating chronic diseases, also predisposes to development of acute hemorrhagic gastritis. Hypersecretion of gastric acid has been incriminated in the pathogenesis of acute hemorrhagic gastritis, but its role is not clear. Nevertheless, gastric acid plays a permissive role, because inhibition of gastric acid secretion (e.g., with histaminereceptor antagonists) protects against the development of stress ulcers. Microcirculatory changes in the stomach induced by shock or sepsis suggest that ischemic injury may contribute to the development of acute hemorrhagic gastritis. Failure of defense mechanisms of the gastric mucosa are also likely to play a role. For example, prostaglandin deficiency caused by nonsteroidal anti-inflammatory drugs (NSAIDs) that inhibit prostaglandin synthesis, has been postulated to decrease mucosal resistance to gastric contents. Both steroids and NSAIDs may lead directly to decreased mucus production. Decreasing the intraluminal pH of the gastric mucosa is protective in hemorrhagic shock, supporting the role of acid in the pathogenesis of certain erosions. PATHOLOGY: Acute hemorrhagic gastritis is characterized grossly by widespread petechial hemorrhages in any portion of the stomach or regions of confluent mucosal or submucosal bleeding. Lesions vary from 1 to 25 mm across and appear occasionally as sharply punched-out ulcers. Microscopically, patchy mucosal necrosis, which can extend to the submucosa, is visualized adjacent to normal mucosa. Fibrinous exudate, edema, and hemorrhage in the lamina propria are present in early lesions. In extreme cases, penetrating ulcers may reach the serosa. CLINICAL FEATURES: Symptoms of acute hemorrhagic gastritis range from vague abdominal discomfort to massive, life-threatening hemorrhage and clinical manifestations of gastric perforation. Patients with gastritis induced by aspirin and other NSAIDs may be seen with hypochromic, microcytic anemia caused by undetected chronic bleeding. Treatment with antacids and histamine-receptor antagonists has proved useful.

Chronic Gastritis is Autoimmune or Environmental Chronic gastritis refers to chronic inflammatory diseases of the stomach, which range from mild superficial involvement of gastric mucosa to severe atrophy. This heterogeneous group of disorders exhibits distinct anatomical distributions within the stomach, varying etiologies, and characteristic complications. The predominant symptom is dyspepsia. The diseases are also commonly discovered in asymptomatic persons undergoing routine endoscopic screening.

Autoimmune Atrophic Gastritis and Pernicious Anemia Autoimmune atrophic gastritis is a chronic, diffuse inflammatory disease of the stomach that is restricted to the body and fundus. This disorder typically exhibits: • Diffuse atrophic gastritis in the body and fundus of the stomach, with lack of, or minimal involvement of, the antrum • Antibodies to parietal cells and intrinsic factor

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• Significant reduction in or absence of gastric secretion, including acid • Increased serum gastrin, owing to G-cell hyperplasia of the antral mucosa • Enterochromaffin-like cell hyperplasia in the atrophic oxyntic mucosa, secondary to gastrin stimulation Pernicious anemia is a megaloblastic anemia caused by malabsorption of vitamin B12, owing to a deficiency of intrinsic factor. In most cases, pernicious anemia is a complication of autoimmune gastritis. The latter disorder is also associated with extragastric autoimmune diseases such as chronic thyroiditis, Graves’ disease, Addison disease, vitiligo, diabetes mellitus type I, and myasthenia gravis (see also Chapter 20). PATHOGENESIS: Autoimmune gastritis is so named because of the presence of autoantibodies and the association with other diseases that have a similar pathogenesis. Circulating antibodies to parietal cells, some of which are cytotoxic in the presence of complement, occur in 90% of patients with pernicious anemia. Importantly, about 20% of individuals over 60 years have parietal cell antibodies, although few have pernicious anemia. The majority of patients also have intrinsic factor autoantibodies that interfere with vitamin B12 absorption. In addition, anti-thyroid antibodies are common.

Multifocal Atrophic Gastritis (Environmental Metaplastic Atrophic Gastritis) Multifocal atrophic gastritis is a disease of uncertain etiology that typically involves the antrum and adjacent areas of the body. This form of chronic gastritis has these features: • It is considerably more common than the autoimmune variety of atrophic gastritis and is four times as frequent among whites as in other races. • It is not linked to autoimmune phenomena. • Like autoimmune gastritis, it is often associated with reduced acid secretion (hypochlorhydria). • Complete absence of gastric secretion (achlorhydria) and pernicious anemia are uncommon. EPIDEMIOLOGY AND PATHOGENESIS: The age and geographic distribution of environmental metaplastic atrophic gastritis parallel those of gastric carcinoma; this type of gastritis seems to be a precursor of this cancer. The disease exhibits a striking localization to certain populations and is particularly common in Asia, Scandinavia, and parts of Europe and Latin America. It also increases in incidence with age in all populations in which it is prevalent. Offspring of emigrants from areas of high risk for stomach cancer to those of low risk lose their predisposition to this tumor, suggesting the importance of environmental factors such as diet and Helicobacter pylori (see below). PATHOLOGY: The pathologic features of autoimmune and multifocal atrophic gastritis are similar, except for the localization of the autoimmune type to the fundus and body and the multifocal variety mainly to the antrum. ATROPHIC GASTRITIS: This condition is characterized by prominent chronic inflammation in the lamina propria. Occasionally, lymphoid cells are arranged as follicles, an appearance that has led to an erroneous diagnosis of lymphoma, especially in patients with H. pylori infection (see below). Involvement of gastric glands leads to degenerative changes in their epithelial

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cells and ultimately to a conspicuous reduction in the number of glands (thus the name atrophic gastritis). Eventually, inflammation may abate, leaving only a thin atrophic mucosa, in which case the term gastric atrophy is applied. INTESTINAL METAPLASIA: This lesion is a common and important histopathologic feature of both autoimmune and multifocal types of atrophic gastritis. In response to injury of the gastric mucosa, the normal epithelium is replaced by one composed of cells of the intestinal type. Numerous mucin-containing goblet cells and enterocytes line crypt-like glands. Paneth cells, which are not normal inhabitants of the gastric mucosa, are present. Intestinal-type villi may occasionally form. The metaplastic cells also contain enzymes characteristic of the intestine but not of the stomach (e.g., alkaline phosphatase, aminopeptidase).

Atrophic Gastritis and Stomach Cancer Persons with autoimmune or multifocal atrophic gastritis have an elevated risk of carcinoma of the stomach. Patients with pernicious anemia, who invariably have atrophic gastritis, have a threefold greater risk for gastric adenocarcinoma and a 13-fold higher risk of carcinoid (neuroendocrine) tumors. Cancer arises in the antrum several times more frequently than in the body of the stomach, suggesting that antral gastritis is related to gastric carcinogenesis. Intestinal metaplasia of the stomach has been identified as a preneoplastic lesion for several reasons: (1) gastric cancer arises in areas of metaplastic epithelium, (2) half of all stomach cancers are of the intestinal cell type, and (3) many gastric cancers show aminopeptidase activity similar to that seen in areas of intestinal metaplasia.

Helicobacter pylori Gastritis H. pylori gastritis is a chronic inflammatory disease of the antrum and body of the stomach caused by H. pylori and occasionally by Helicobacter heilmannii. It is the most common type of chronic gastritis in the United States. H. pylori infection is also strongly associated with peptic ulcer disease of the stomach and duodenum (see below). PATHOGENESIS: Helicobacter species are small, curved, gram-negative rods (Proteobacteria) with polar flagella and a corkscrew-like motion. The prevalence of infection with this organism increases with age: by age 60 years, half the population has serologic evidence of infection. Twin studies have shown genetic influences in susceptibility to infection with H. pylori. Intrafamilial clustering of H. pylori infection suggests that these bacteria may spread from person to person. Two thirds of those who have been infected with H. pylori show histologic evidence of chronic gastritis. H. pylori is considered to be the pathogen responsible for chronic antral gastritis rather than a commensal organism that colonizes injured gastric mucosa because (1) gastritis develops in healthy persons after ingesting the organism, (2) H. pylori attaches to the epithelium in areas of chronic gastritis and is absent from uninvolved areas of the gastric mucosa, (3) eradicating the infection with bismuth or antibiotics cures the gastritis, (4) antibodies against H. pylori are routinely found in persons with chronic gastritis, and (5) the increasing prevalence of H. pylori infection with age parallels that of chronic gastritis. Chronic infection with H. pylori also predisposes to the development of mucosa-associated lymphoid tissue (MALT) lymphoma of the stomach and is associated with adenocarcinoma of the stomach (see below). PATHOLOGY: The curved rods of H. pylori are found in the surface mucus of epithelial cells and in gastric foveolae (Fig. 13-7). Active gastritis features polymorphonuclear leukocytes in glands and their lumina as

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B Helicobacter pylori-associated gastritis. A. The antrum shows an intense lymphocytic and plasma cell infiltrate, which tends to be heaviest in the superficial portions of the lamina propria. B. The microorganisms appear on silver staining as small, curved rods on the surface of the gastric mucosa. FIGURE 13-7.

well as increased numbers of plasma cells and lymphocytes in the lamina propria (see Fig. 13-7A). Lymphoid hyperplasia with germinal centers is frequent and is the setting for the development of MALT lymphoma.

Peptic Ulcer Disease Peptic ulcer disease refers to focal destruction of gastric mucosa and the small intestine, principally the proximal duodenum, caused by the action of gastric secretions. About 10% of the population of Western industrialized countries may develop such ulcers at some time during their lives. However, both the incidence and prevalence of duodenal ulcers have declined substantially during the past 30 years.

Gastric and Duodenal Ulcer Disease Have Unique Features For practical purposes, peptic ulcer disease affects the distal stomach and proximal duodenum. Many clinical and epidemiologic features distinguish gastric from duodenal ulcers; the common factor that unites them is the gastric secretion of hydrochloric acid. EPIDEMIOLOGY: The peak age for peptic ulcer disease has progressively increased in the past 50 years, and for duodenal ulcer disease, it is now between 30 and 60 years of age, although the disorder may occur in persons of any age and even in infants. Gastric ulcers afflict the middleaged and elderly more than the young. For duodenal ulcers, there is a male predominance. By contrast, the incidence of gastric ulcers is similar in men and women. PATHOGENESIS: Numerous etiologic factors have been implicated in the pathogenesis of peptic ulcers, but no single agent seems to be responsible.

Environmental Factors DIET: Little evidence supports the contention that any food or beverage, including coffee and alcohol, contributes to the development or persistence of peptic ulcers. However, cirrhosis from any cause is associated with an increased incidence of peptic ulcers. DRUGS: Aspirin, other NSAIDs, and analgesics are important contributing factors for peptic ulcers. CIGARETTE SMOKING: Smoking is a definite risk factor, particularly for gastric ulcers.

Genetic Factors First-degree relatives of people with duodenal or gastric ulcers have a threefold increased risk of developing an ulcer, but only at the same site. Identical twins show a 50% concordance, indicating that environmental factors are also involved. BLOOD GROUP ANTIGENS: The risk of duodenal (but not gastric) ulcer is 30% higher in persons with type O blood than in those with other types. People who do not secrete blood-group antigens in saliva or gastric juice (nonsecretors) carry a 50% increased risk for duodenal ulcers. PEPSINOGEN I: A person with a high circulating level of pepsinogen I has five times the normal risk of developing a duodenal ulcer. Serum levels of this proenzyme correlate with the capacity for gastric acid secretion and are considered a measure of parietal cell mass. Elevated levels of pepsinogen I occur in half of children of ulcer patients with hyperpepsinogenemia and has been attributed to autosomal dominant inheritance.

Physiologic Factors in Duodenal Ulcers Hydrochloric acid secretion is necessary for the formation and persistence of peptic ulcers in the stomach and duodenum. The maximal capacity for

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gastric acid production is reflected in total parietal cell mass. Patients with duodenal ulcers may have up to double normal parietal cell mass and maximal acid secretion. However, there is a large overlap with normal values, and only one third of these patients secrete excess acid. Acid secretion in people with duodenal ulcers may also be more sensitive than normal to gastric secretagogues such as gastrin, possibly as the result of increased vagal tone or increased affinity of parietal cells for gastrin. Accelerated gastric emptying has been noted in patients with duodenal ulcers. This condition might lead to excessive acidification of the duodenum. However, as with other factors, there is an overlap with normal rates. Normally, duodenal bulb acidification inhibits further gastric emptying. In most patients with duodenal ulcers, this inhibitory mechanism is absent; duodenal acidification leads to continued, rather than delayed, gastric emptying. The pH of the duodenal bulb reflects the balance between delivery of gastric juice and its neutralization by biliary, pancreatic, and duodenal secretions. In ulcer patients, duodenal pH after a meal decreases to a lower level and remains depressed for a longer time than in normal persons. Such duodenal hyperacidity reflects the gastric factors discussed above. Impaired mucosal defenses have been invoked as contributing to peptic ulceration. These mucosal factors, including prostaglandin function, may or may not be similar to those protecting the gastric mucosa.

Increased postprandial gastrin

Cytokines Gastritis

283

Reduced somatostatin

Increased basal gastric acid secretion Histamine metabolites

Helicobacter pylori infection

Hyperacidity of duodenal bulb

Duodenitis and gastric metaplasia

DUODENAL ULCER

Physiologic Factors in Gastric Ulcers Gastric ulcers almost invariably arise in the setting of epithelial injury by H. pylori or chemical gastritis. The mechanisms by which chronic gastritis predisposes to gastric ulceration are obscure. Most patients with gastric ulcers secrete less acid than do those with duodenal ulcers and even less than normal persons. The concurrence of gastric ulcers and gastric hyposecretion implies: (1) the gastric mucosa may in some way be particularly sensitive to low concentrations of acid; (2) something other than acid may damage the mucosa, such as NSAIDs; or (3) the gastric mucosa may be exposed to potentially injurious agents for unusually long periods.

The Role of Helicobacter pylori H. pylori is isolated from the gastric antrum of virtually all patients with duodenal ulcers. The converse is not true; that is, only a small minority of persons infected with this bacterium have duodenal ulcer disease. Thus, H. pylori infection may be a necessary, but not sufficient, condition for the development of peptic ulcers in the duodenum. Just how H. pylori infection predisposes to duodenal ulcers is not completely known, but several mechanisms have been proposed. Cytokines produced by inflammatory cells that respond to H. pylori infection stimulate gastrin release and suppress somatostatin secretion. The release of histamine metabolites from the organism itself may stimulate basal gastric acid secretion. There is some evidence that H. pylori infection might indirectly cause an increased acid load in the duodenum, thereby contributing to duodenal ulceration. Acidification of the duodenal bulb leads to islands of metaplastic gastric mucosa in the duodenum in many patients with a peptic ulcer. It has been postulated that infection of the metaplastic epithelium by H. pylori renders the mucosa more susceptible to peptic injury (Fig. 13-8). Infection with H. pylori is probably also important in the pathogenesis of gastric ulcers, because this organism is responsible for most cases of the chronic gastritis that underlies this disease. About 75% of patients with gastric ulcers harbor H. pylori. The remaining 25% of cases may represent an association with other types of chronic gastritis. The various gastric and duodenal factors that have been implicated as possible mechanisms in the pathogenesis of duodenal ulcers are summarized in Figure 13-9.

Possible mechanisms in the pathogenesis of duodenal ulcer disease associated with Helicobacter pylori infection. FIGURE 13-8.

Several Diseases are Associated with Peptic Ulcers CIRRHOSIS: The incidence of duodenal ulcers in patients with cirrhosis is 10 times greater than that in normal individuals. CHRONIC RENAL FAILURE: End-stage renal disease with hemodialysis increases the risk of peptic ulceration. Patients subjected to renal transplantation also show a substantially increased incidence of peptic ulceration and its complications, such as bleeding and perforation. HEREDITARY ENDOCRINE SYNDROMES: There is an increased incidence of peptic ulcers in persons with multiple endocrine neoplasia, type I (see Chapter 21). Zollinger-Ellison syndrome, a cause of severe peptic ulceration, is characterized by gastric hypersecretion caused by a gastrin-producing islet cell adenoma of the pancreas. ␣1-ANTITRYPSIN DEFICIENCY: Almost one third of patients with this disease have peptic ulcers, the incidence of which is even higher if patients also have lung disease. Moreover, peptic ulcer is increased in people heterozygous for mutant ␣1-antitrypsin. CHRONIC PULMONARY DISEASE: Long-standing pulmonary dysfunction significantly increases the risk of ulcers, and it is estimated that fully one fourth of those with such disorders have peptic ulcer disease. Conversely, chronic lung disease is increased two- to threefold in persons who have peptic ulcers.

Gastric and Duodenal Ulcers are Similar Microscopically PATHOLOGY: Most peptic ulcers arise in the lesser gastric curvature, in the antral and prepyloric regions, and in the first part of the duodenum. Gastric ulcers (Fig. 13-10) are usually single and smaller than 2 cm in diameter. Ulcers on the lesser curvature are commonly associated with chronic gastritis, whereas those on the

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greater curvature are often related to NSAIDs. The edges of the ulcers tend to be sharply punched out, with overhanging margins. Deeply penetrating ulcers produce a serosal exudate that may cause adherence of the stomach to surrounding structures. Scarring of ulcers in the prepyloric region may be severe enough to produce pyloric stenosis. Grossly, chronic peptic ulcers may closely resemble ulcerated gastric carcinomas. Duodenal ulcers (Fig. 13-11) are ordinarily on the anterior or posterior wall of the first part of the duodenum, close to the pylorus. The lesions are usually solitary, but it is not uncommon to find paired ulcers on both walls, so-called kissing ulcers. Microscopically, gastric and duodenal ulcers are similar (Fig. 13-12). From the lumen outward, the following are noted: (1) a superficial zone of fibrinopurulent exudate; (2) necrotic tissue; (3) granulation tissue; and (4) fibrotic tissue at the base of the ulcer, which exhibits variable degrees of chronic inflammation. Ulceration may penetrate the muscle layers, causing them to be interrupted by scar tissue after healing. Blood vessels on the margins of the ulcer are often thrombosed. The mucosa at the margins tends to be hyperplastic; as the ulcer heals, the mucosa grows over the ulcerated area as a single layer of epithelium. Duodenal ulcers are usually accompanied by peptic duodenitis, with Brunner gland hyperplasia and gastric mucin cell metaplasia.

CLINICAL FEATURES: The symptoms of gastric and duodenal ulcers are sufficiently similar that the two conditions are generally not distinguishable by history or physical examination. The classic case of duodenal ulcer is characterized by epigastric pain 1 to 3 hours after a meal or pain that awakens the patient at night. Both alkali and food relieve the symptoms. Dyspeptic symptoms commonly associated with gallbladder disease, including fatty food intolerance, distention, and belching, occur in half of patients with peptic ulcers. The major complications of peptic ulcer disease are hemorrhage, perforation with peritonitis, and obstruction. HEMORRHAGE: The most common complication of peptic ulcers is bleeding, which occurs in up to 20% of patients. Bleeding is often occult and, in the absence of other symptoms, may manifest as iron-deficiency anemia or occult blood in stools. Massive lifethreatening bleeding is a well-known complication of active peptic ulcers. PERFORATION: Perforation is a serious complication of peptic ulcers, which occurs in 5% of patients. In one third of the cases, there are no antecedent symptoms of a peptic ulcer. Perforations occur more often with duodenal than with gastric ulcers, mostly on the anterior wall of the duodenum. Perforation carries a high mor-

Increased vagal activity (? psychological factors)

Parietal cell hyperplasia GASTRIC FACTORS DUODENAL FACTORS

H. pylori

Increased HCl

Gastric glands

Sensitivity of mucosa to acid injury Increased sensitivity of parietal cells to stimulators of HCl secretion (e.g., gastrin, histamine)

Decreased mucosal – HCO3 secretion Rapid gastric emptying

PEPTIC ULCER Hyperacidification of duodenal bulb Decreased retrograde motility impairs neutralization by pancreatic alkaline secretions

FIGURE 13-9.

Pancreatic secretions

Gastric and duodenal factors in the pathogenesis of duodenal peptic ulcers. H. pylori, Helicobacter pylori; HCl, hydrochloric acid; HCO3-, bicarbonate.

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FIGURE 13-10. Gastric ulcer. There is a characteristic sharp demarcation from the surrounding mucosa, with radiating gastric folds. The base of the ulcer is gray because of fibrin deposition.

tality rate. The risk of death for perforated gastric ulcers is 10% to 40%, which is two to three times more than for duodenal ulcers (⬃10%). Perforations are occasionally complicated by hemorrhage. Although shock, abdominal distention, and pain are common symptoms, perforations are occasionally diagnosed for the first time at autopsy, particularly in institutionalized, elderly patients. MALIGNANT TRANSFORMATION OF BENIGN GASTRIC ULCERS: Malignant transformation of a duodenal ulcer is very uncommon. However, although cancers originating in benign peptic ulcers probably account for less than 1% of all malignant tumors in the stomach, such tumors have been well documented. TREATMENT: In the past, peptic ulcers were treated by subtotal gastrectomy. However, the disease is now cured by using antibiotics to eliminate H. pylori and by blocking gastric acid secretion with histamine receptor blockers and proton pump inhibitors.

Benign Neoplasms Stromal Tumors in the Stomach Tend to be Nonaggressive Nearly all gastrointestinal stromal tumors (GISTs) are derived from the pacemaker cells of Cajal embedded in the muscular tis-

B FIGURE 13-12. Gastric ulcer. A. There is full-thickness replacement of the gastric muscularis with connective tissue. B. Photomicrograph of a peptic ulcer with superficial exudate over necrosis, granulation tissue, and fibrosis.

sue of the GI tract. GISTs include the vast majority of mesenchymal-derived stromal tumors of the entire GI tract. The pacemaker cells and the tumor cells express the c-kit oncogene (CD117), which encodes a tyrosine kinase that promotes cell proliferation. Many of gastric GISTs, independently of size, tend to behave in a nonaggressive fashion, as opposed to small and large bowel tumors, which more commonly behave in a malignant manner. Gastric GISTs are usually submucosal and covered by intact mucosa or, when they project externally, by peritoneum. The cut surface is whorled. Microscopically, the tumors are variably cellular and are composed of spindle-shaped cells with cytoplasmic vacuoles embedded in a collagenous stroma. The cells are disposed in whorls and interlacing bundles. With few exceptions, GISTs are considered tumors of low malignant potential. Treatment of GISTs consists mainly of surgical resection and administering an inhibitor of the specific tyrosine kinase.

Epithelial Polyps May Represent Either Hyperplasia or a Neoplastic Process

FIGURE 13-11. Duodenal ulcer. There are two sharply demarcated duodenal ulcers surrounded by inflamed duodenal mucosa. The gastroduodenal junction is in the midportion of the photograph.

HYPERPLASTIC POLYPS: These lesions are by far the most common of the gastric polyps. They may be single or multiple and are seen as pedunculated or sessile lesions of variable sizes. Hyperplastic polyps are common in the hydrochloric acid—secreting mucosa of the body and fundus of patients with autoimmune metaplastic atrophic gastritis, but they also occur in the antrum of patients with H. pylori gastritis. Microscopically, the polyps consist of elongated, branched crypts lined by foveolar epithelium, beneath which pyloric or gastric glands are present. They appear to

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represent a response to injury, and their epithelium is not dysplastic. Hyperplastic polyps of the stomach have no malignant potential. TUBULAR ADENOMAS (ADENOMATOUS POLYPS): These are true neoplasms that occur most commonly in the antrum. They range from smaller than 1 cm in diameter to a considerable size; the average dimension is about 4 cm. Most adenomatous polyps are sessile and are usually solitary. Microscopically, adenomas show tubular or a combination of tubular and villous structures. The glands are usually lined by dysplastic epithelium, which is sometimes intestinalized. Adenomatous polyps manifest a malignant potential, variably reported at 5% to 75%. This risk increases with the size of the polyp and is greatest for lesions larger than 2 cm. Dysplasia can also occur in flat gastric mucosa. The presence of multiple tubular adenomas in the stomach of patients with familial adenomatous polyposis greatly increases the risk of developing adenocarcinoma. FUNDIC GLAND POLYPS: Fundic gland polyps are characterized by dilated acid-producing glands lined by parietal and chief cells and by mucous cell metaplasia. They are mostly seen in patients treated with proton pump inhibitors. These polyps are not considered preneoplastic, and patients have no increased risk of gastric carcinoma.

Malignant Tumors Carcinoma of the Stomach is Associated with Many Environmental Factors EPIDEMIOLOGY: About 50 years ago, gastric carcinoma was the most common cause of cancer deaths, but in a surprising reversal, in men in the United States, it now accounts for only about 3% of such deaths. The incidence of stomach cancer remains exceedingly high in such countries as Japan and Chile, where rates are seven to eight times that in the United States. Emigrants from high-risk to low-risk areas show a decline in the incidence of cancer of the stomach (see Chapter 5), which strongly implicates environmental factors in the carcinogenic process. PATHOGENESIS: Although correlations have been demonstrated with a number of factors, the causes of gastric cancer remain elusive. DIETARY FACTORS: Gastric cancer is more common among persons who eat large amounts of starch, smoked fish and meat, and pickled vegetables. Benzpyrene, a potent carcinogen, has been detected in smoked foods. NITROSAMINES: Nitrosamines are potent carcinogens in animals, and secondary amines are converted to nitrosamines in the presence of nitrates or nitrites. High concentrations of nitrate have been found in the soil and water in certain areas that feature a high incidence of gastric cancer, and processed meats and vegetables contain considerable amounts of nitrates and nitrites. The decrease in gastric cancer in the United States parallels the increased use of refrigeration, which inhibits conversion of nitrates to nitrites and also obviates the need for such food preservatives. Consumption of whole milk and fresh vegetables rich in vitamin C is inversely related to the occurrence of stomach cancer. Vitamin C inhibits the nitrosation of secondary amines in vivo. GENETIC FACTORS: Heredity is not thought to play an important role in most cases of gastric carcinoma, but the disease occurs with higher frequency in persons who suffer hereditary nonpolyposis colorectal cancer (HNPCC) syndrome (see below). Blood type A is found in 38% of the general population, whereas half of patients with gastric cancer display this blood type.

AGE AND GENDER: Gastric cancer is uncommon in persons younger than 30 years of age and shows a sharp peak in incidence in individuals over 50. In countries with a high incidence of this tumor, the male-to-female ratio is about 2:1, but the United States demonstrates only a slight male predominance. HELICOBACTER PYLORI: Serologic studies have shown a high prevalence of gastric infection with H. pylori many years before the appearance of stomach cancer. Because gastric adenocarcinoma develops in only a small proportion of persons infected with H. pylori, and because some stomach cancers are found in uninfected persons, H. pylori alone is neither sufficient nor necessary for gastric carcinogenesis. Atrophic gastritis, pernicious anemia, subtotal gastrectomy, and gastric adenomatous polyps are discussed above as factors associated with a high risk of stomach cancer. PATHOLOGY: Gastric adenocarcinoma accounts for more than 95% of malignant gastric tumors. It occurs in two major but overlapping types: diffuse and intestinal. Most intestinal type gastric cancers originate from areas of intestinal metaplasia. By contrast, less-differentiated and anaplastic tumors of the diffuse type are more likely to derive from the necks of gastric glands without intestinal metaplasia. Cancers are most common in the distal stomach, the lesser curvature of the antrum, and the prepyloric region. Adenocarcinoma may occur anywhere, but is rare in the fundus. ADVANCED GASTRIC CANCER: By the time most gastric cancers in the Western world are detected, they have penetrated beyond the submucosa into the muscularis propria and may extend through the serosa. The macroscopic appearance of these advanced cancers is of great importance in distinguishing carcinomas from benign lesions and assessing the degree of spread. Advanced gastric cancers are divided into three major macroscopic types (Figure 13-13). • Polypoid (fungating) adenocarcinoma accounts for one third of advanced cancers. The tumor is a solid mass, often several centimeters in diameter, that projects into the stomach lumen. The surface may be partly ulcerated, and deeper tissues may or may not be infiltrated. • Ulcerating adenocarcinomas comprise another third of all gastric cancers. They have shallow ulcers of variable size. Surrounding tissues are firm, raised, and nodular. Characteristically, the lateral margins of the ulcer are irregular and the base is ragged. This appearance stands in contrast to that of the usual benign peptic ulcer, which exhibits punchedout margins and a smooth base. • Diffuse or infiltrating adenocarcinoma accounts for one tenth of all stomach cancers. No true tumor mass is seen; instead, the wall of the stomach is thickened and firm. If the entire stomach is involved, it is called linitis plastica. In the diffuse type of gastric carcinoma, invading tumor cells induce extensive fibrosis in the submucosa and muscularis. Thus, the wall is stiff and may be more than 2 cm thick. Microscopically, the histologic pattern of advanced gastric cancer varies from a well-differentiated adenocarcinoma with gland formation (intestinal type) to a poorly differentiated carcinoma without glands. Tumor cells may contain cytoplasmic mucin that displaces the nucleus to the periphery of the cell, resulting in the so-called signet ring cell (Fig. 13-14). EARLY GASTRIC CANCER: Early gastric cancer is defined as a tumor limited to the mucosa or submucosa. Early gastric cancer is strictly a pathologic diagnosis based on depth of invasion; the term does not refer to the duration of the disease, its size, presence of symptoms, absence of metastases, or curability. Early gastric cancer may sometimes demonstrate a more benign course and greater curability because it has an inherently lower biological potential for invasion.

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EARLY GASTRIC CANCER Mucosa Muscularis mucosae Submucosa Muscularis Lymph node Serosa POLYPOID CARCINOMA A

Lymph node metastases ULCERATING CARCINOMA B FIGURE 13-14. Infiltrating gastric carcinoma. A. Numerous signet ring cells (arrows) infiltrate the lamina propria between intact crypts. B. Mucin stains highlight the presence of mucin within the neoplastic cells.

Gastric cancer metastasizes mainly via lymphatics to regional lymph nodes of the lesser and greater curvature, porta hepatis, and subpyloric region. Distant lymphatic metastases also occur; the most common is an enlarged supraclavicular node, called a Virchow node. Hemato-genous spread may seed any organ, including the liver, lung, or brain. Direct extension to nearby organs is often seen. The tumor can also spread to the ovaries, where it commonly elicits a desmoplastic response, which is termed a Krukenberg tumor.

INFILTRATING CARCINOMA (LINITIS PLASTICA)

“Signet ring” carcinoma Thickened fibrotic submucosa Thickened muscularis Lymph node metastases

FIGURE 13-13. The major types of gastric cancer.

CLINICAL FEATURES: In the United States and Europe, most patients with gastric cancer have metastases when they are first seen for examination. The most frequent initial symptom is weight loss, usually with anorexia and nausea. Most patients complain of epigastric or back pain, a symptom that mimics benign gastric ulcer and is often relieved by antacids or H2-receptor antagonists. However, as the disease advances, symptomatic amelioration with medical therapy disappears. Gastric outlet obstruction may occur with large tumors of the antrum or prepyloric region. Massive bleeding is uncommon, but chronic bleeding often leads to anemia and finding occult blood in the stools. Tumors involving the esophagogastric junction cause dysphagia and may mimic achalasia and esophageal adenocarcinoma.

Gastric Lymphoma is the Most Common Extranodal Lymphoma Primary lymphoma of the stomach accounts for about 5% of all gastric malignancies and 20% of all extranodal lymphomas.

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Clinically and radiologically, it mimics gastric adenocarcinoma. The age at diagnosis is usually 40 to 65 years, and there is no gender predominance. The tumors grossly resemble carcinomas, because they may be polypoid, ulcerating, or diffuse. Most gastric lymphomas are low-grade B-cell neoplasms of the MALToma type and arise in the setting of chronic H. pylori gastritis with lymphoid hyperplasia. Some of the tumors actually regress after eradication of the H. pylori infection.

THE SMALL INTESTINE Congenital Disorders Atresia and Stenosis Cause Neonatal Intestinal Obstruction ATRESIA: Atresia is defined as a complete occlusion of the intestinal lumen, which may manifest as (1) a thin intraluminal diaphragm, (2) blind proximal and distal sacs joined by a cord, or (3) disconnected blind ends. STENOSIS: This is an incomplete stricture, which narrows but does not occlude, the lumen. Stenosis may also be caused by an incomplete diaphragm. It is usually symptomatic in infancy, but cases presenting in middle-aged adults have been recorded. Intestinal atresia or stenosis is diagnosed on the basis of persistent vomiting of bile-containing fluid within the first day of life. Meconium is not passed. The obstructed fetal intestine is dilated and filled with fluid, which can be detected radiologically. Surgical correction is usually successful, but there are often other complicating anomalies.

Meckel Diverticulum Causes Bleeding, Obstruction, and Perforation Meckel diverticulum, caused by persistence of the vitelline duct, is an outpouching of the gut on the antimesenteric border of the ileum, 60 to 100 cm from the ileocecal valve in adults. It is the most common and the most clinically significant congenital anomaly of the small intestine. Two thirds of patients are younger than 2 years of age. PATHOLOGY: In adults, Meckel diverticulum is about 5 cm long, slightly narrower than the ileum. A fibrous cord may hang freely from the apex of the diverticulum or may be attached to the umbilicus. The anomaly is a true diverticulum, possessing all the coats of normal intestine; the mucosa is similar to that of the adjoining ileum. Most Meckel diverticula are asymptomatic and discovered only as incidental findings at laparotomy for other causes or at autopsy. Of the minority that becomes symptomatic, about half contain ectopic gastric, duodenal, pancreatic, biliary, or colonic tissue. CLINICAL FEATURES: The potential complications of Meckel diverticulum include hemorrhage, perforation, obstruction and diverticulitis, the last presenting with symptoms indistinguishable from appendicitis.

Meconium Ileus is an Early Complication of Cystic Fibrosis Neonatal intestinal obstruction in cystic fibrosis is caused by the accumulation of tenacious meconium in the small intestine. The abnormal consistency of the meconium reflects a deficiency in pancreatic enzymes and the high viscosity of intestinal mucus. In half of affected infants, meconium ileus is complicated by (1) volvulus, (2) perforation with meconium peritonitis, or (3) intestinal atresia.

Infections of the Small Intestine Bacterial Diarrhea is a Major Cause of Death Worldwide Infectious diarrhea is particularly lethal in infants living in underdeveloped countries. The small bowel normally has few bacteria (usually ⬍104/mL), which are mostly aerobic (such as lactobacilli) and ordinarily do not colonize the small intestine. Infectious diarrhea is caused by bacterial colonization, for example, with toxigenic strains of Escherichia coli and Vibrio cholerae. The most significant factor in infectious diarrhea is increased intestinal secretion, stimulated by bacterial toxins and enteric hormones. Decreased absorption and increased peristaltic activity contribute less to the diarrhea. The agents of infectious diarrhea are conveniently classified into toxigenic organisms such as V. cholerae and toxigenic strains of E. coli, which produce diarrhea by elaborating toxins and invasive bacteria, of which Shigella, Salmonella, and certain strains of E. coli, Yersinia, and Campylobacter are the most widely recognized. Individual agents responsible for infectious diarrhea are discussed in Chapter 9.

Rotavirus and Norwalk Virus are the Most Common Causes of Viral Gastroenteritis in the United States ROTAVIRUS: Rotavirus infection is a common cause of infantile diarrhea. It accounts for about half of acute diarrhea in hospitalized children younger than 2 years of age. Rotavirus has been demonstrated in duodenal biopsy specimens and is associated with injury to the surface epithelium and impaired intestinal absorption for periods of up to 2 months. NORWALK VIRUSES: These agents account for one third of the epidemics of viral gastroenteritis in the United States. The virus targets the upper small intestine, where it causes patchy mucosal lesions and malabsorption. Vomiting and diarrhea are usual, and the symptoms resolve within 2 days. Other viruses implicated as etiological agents of infective diarrhea include echovirus, coxsackievirus, cytomegalovirus, adenovirus, and coronavirus.

Vascular Diseases of the Small Intestine Decreased intestinal blood flow from any cause can lead to ischemic bowel disease. The most common type of ischemic bowel disease is acute intestinal ischemia, which is associated with injury ranging from mucosal necrosis to transmural bowel infarction. Chronic intestinal ischemic syndromes are less common and generally require the severe compromise of two or more major arteries, usually by atherosclerosis.

Superior Mesenteric Artery Occlusion is the Most Common Cause of Acute Intestinal Ischemia PATHOGENESIS: ARTERIAL OCCLUSION: Sudden occlusion of a large artery by thrombosis or embolization leads to small bowel infarction before collateral circulation comes into play. Depending on the size of the artery, infarction may be segmental or may lead to gangrene of virtually the entire small bowel (Fig. 13-15). Occlusive intestinal infarction is most often caused by embolic or thrombotic occlusion of the superior mesenteric artery or its larger branches. Less com-

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through the damaged wall and cause peritonitis or septicemia. If the patient survives the episode of hypoperfusion, the bowel may be completely repaired, or it may heal with granulation tissue and fibrosis, with eventual stricture formation. CLINICAL FEATURES: Mesenteric artery occlusion is heralded the by abrupt onset of abdominal pain. Bloody diarrhea, hematemesis, and shock are common. In untreated cases, perforation is frequent. As infarction progresses, systemic manifestations become more severe (multiple organ dysfunction syndrome). In extensive infarction, as a result of occlusion in the proximal portion of the superior mesenteric artery, almost the entire small bowel must be resected, which is a situation incompatible with ultimate survival.

Chronic Intestinal Ischemia Leads to Recurrent Abdominal Pain Atherosclerotic narrowing of major splanchnic arteries produces chronic intestinal ischemia and is associated with intermittent abdominal pain, termed intestinal (abdominal) angina. Characteristically, the pain begins within a half hour of eating and lasts for a few hours. PATHOLOGY: Chronic small-bowel ischemia may promote fibrosis and stricture formation, and the latter may produce intestinal obstruction or, occasionally, malabsorption due to stasis and bacterial overgrowth. FIGURE 13-15. Infarct of the small bowel. This infant died after an episode of intense abdominal pain and shock. Autopsy demonstrated volvulus of the small bowel that had occluded the superior mesenteric artery. The entire small bowel is dilated, gangrenous, and hemorrhagic.

monly, ischemic necrosis of the bowel results from vasculitis, which often involves small arteries. In addition to intrinsic vascular lesions, volvulus, intussusception, and incarceration of the intestine in a hernial sac may all lead to arterial as well as venous occlusion. NONOCCLUSIVE INTESTINAL ISCHEMIA: Nonocclusive intestinal infarction may be extensive and is seen in hypoxic patients with reduced cardiac output secondary to shock from a variety of causes, including hemorrhage, sepsis, and acute myocardial infarction. Shock leads to redistribution of blood flow to the brain and other vital organs. The drastically lowered perfusion pressure in the arterioles causes their collapse, thereby aggravating the ischemia. THROMBOSIS OF MESENTERIC VEINS: Causes of mesenteric vein thrombosis include hypercoagulable states, stasis, and inflammation (pylephlebitis). Almost all thromboses affect the superior mesenteric vein; only 5% involve the inferior mesenteric vein. PATHOLOGY: Infarcted bowel is edematous and diffusely purple. The demarcation between infarcted bowel and normal tissue is usually sharp, although venous occlusion may feature a more diffuse appearance. Extensive hemorrhage is seen in the mucosa and submucosa and is especially prominent in venous occlusion (e.g., mesenteric vein thrombosis). The mucosal surface shows irregular white sloughs, the wall becomes thin and distended, and bubbles of gas (pneumatosis) may be present in the bowel wall and mesenteric veins. The serosal surface is cloudy and covered by an inflammatory exudate. Dysfunction of smooth muscle interferes with peristalsis and leads to adynamic ileus, in which the bowel proximal to the lesion is dilated and filled with fluid. Intestinal organisms may pass

Malabsorption Malabsorption is a general term that describes a number of clinical conditions in which important nutrients are inadequately absorbed by the GI tract. Although some nutrient absorption occurs in the stomach and colon, only absorption from the small intestine, mainly in the proximal portion, is clinically important. Normal intestinal absorption is characterized by a luminal phase and an intestinal phase (Fig. 13-16). The luminal phase, consisting of those processes that occur within the lumen of the small intestine, alters the physicochemical state of the various nutrients so that they can be taken up by the small-bowel absorptive cells. In the luminal phase of intestinal absorption, pancreatic enzymes and bile acids must be secreted into the duodenal lumen in adequate amounts and in a normal physicochemical condition (e.g., a regulated flow of gastric contents into the duodenum at an appropriately high pH). The intestinal phase includes those processes that occur in the cells and transport channels of the intestinal wall.

Luminal-Phase Malabsorption Often Reflects Insufficient Bile Acids or Pancreatic Enzymes • Interruption of the normal continuity of the distal stomach and duodenum occurs after gastroduodenal surgery (gastrectomy, antrectomy, pyloroplasty). • Pancreatic dysfunction can occur as a result of chronic pancreatitis, pancreatic carcinoma, or cystic fibrosis. • Deficient or ineffective bile salts may result from three possible causes: 1. Impaired excretion of bile resulting from liver disease. 2. Bacterial overgrowth from a disturbance in gut motility. This is seen in such conditions as blind-loop syndrome, multiple diverticula of the small bowel, and muscular or neurogenic defects of the intestinal wall (e.g., amyloidosis, scleroderma, diabetic enteropathy). When GI motility is defective, bile salts are deconjugated by the excess bacterial flora, after which they cannot form micelles, which are essential for normal absorption of monoglycerides and free fatty acids.

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Common bile duct

CHOLESTASIS (intra- or extrahepatic)

BI LE

SECRETORY INSUFFICIENCY Pancreatic duct SE

LUMINAL PHASE

LIPA

PANCREATIC INSUFFICIENCY (e.g., chronic pancreatitis, cystic fibrosis) DIABETES (peripheral neuropathy)

Bacteria

AMYLOIDOSIS

IMPAIRED MOTILITY WITH BACTERIAL OVERGROWTH AND BILE SALT INACTIVATION

BLIND LOOP SYNDROME

SCLERODERMA

INTESTINAL PHASE

SHORT BOWEL SYNDROME (e.g., surgical)

WHIPPLE DISEASE SPRUE

IMPAIRED MUCOSAL FUNCTION

LYMPHOMA

FIGURE 13-16. Causes of malabsorption.

3. Deficient bile salts due to the absence or bypass of the distal ileum caused by surgical excision, surgical anastomoses, fistulas, or ileal disease (e.g., Crohn disease, lymphoma).

Intestinal-Phase Malabsorption Frequently Reflects Specific Enzyme Defects or Impaired Transport Although abnormalities in any one of the four components of the intestinal phase may cause malabsorption, some diseases affect more than one of these components. Figure 13-16 summarizes the major causes of malabsorption. PATHOGENESIS: MICROVILLI: The intestinal disaccharidases and oligopeptidases are integrally bound to the microvillous membranes. Disaccharidases are essential for sugar absorption, because only monosaccharides can be absorbed by intestinal epithelial cells. Abnormal function of the microvilli may be primary (as in primary disaccharidase deficiencies) or secondary, when there is damage to the villi, as in celiac disease (sprue). The various enzyme deficiencies (e.g., of lactase) are characterized by intolerance for the corresponding disaccharides.

ABSORPTIVE AREA: The considerable length of the small bowel and the amplification of its surface wall by the intestinal folds provide a large absorptive surface. Severe diminution in this area may result in malabsorption. The surface area may be diminished by (1) small-bowel resection (short-bowel syndrome), (2) gastrocolic fistula (bypassing the small intestine), or (3) mucosal damage secondary to a number of small intestinal diseases (celiac disease, tropical sprue, and Whipple disease). METABOLIC FUNCTION OF THE ABSORPTIVE CELLS: For their subsequent transport to the circulation, nutrients within the absorptive cells depend on their metabolism within these cells. Monoglycerides and free fatty acids are reassembled into triglycerides and coated with proteins (apoproteins) to form chylomicrons and lipoprotein particles. Specific metabolic dysfunction is seen in abetalipoproteinemia, a disorder in which the absorptive cells cannot synthesize the apoprotein required for the assembly of lipoproteins and chylomicrons. Nonspecific damage to small intestinal epithelial cells occurs in celiac disease, tropical sprue, Whipple disease, and hyperacidity due to gastrinoma. TRANSPORT: Nutrients are transported from the intestinal epithelium through the intestinal wall by way of blood capil-

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laries and lymphatic vessels. Impaired transport of nutrients through these conduits is probably an important factor in the malabsorption associated with Whipple disease, intestinal lymphoma, and congenital lymphangiectasia. CLINICAL FEATURES: Malabsorption may be either specific or generalized. • Specific or isolated malabsorption refers to an identifiable molecular defect that causes malabsorption of a single nutrient. Examples of this group are the disaccharidase deficiencies (notably lactase deficiency) and deficiency of gastric intrinsic factor, which causes malabsorption of vitamin B12 and consequently pernicious anemia. • Generalized malabsorption describes a condition in which absorption of several or all major nutrient classes is impaired. It leads to generalized malnutrition.

Lactase Deficiency Causes Intolerance to Milk Products The intestinal brush border contains disaccharidases that are important for the absorption of carbohydrates. As a prominent constituent of milk and many other dairy products, lactose is one of the most common disaccharides in the diet. Typically, the symptoms of lactase deficiency begin in adolescence, and patients complain of abdominal distention, flatulence, and diarrhea after the ingestion of dairy products. Eliminating milk and its products from the diet relieves these symptoms. Diseases that injure the intestinal mucosa (e.g., celiac disease) may also lead to acquired lactase deficiency.

Celiac Disease Reflects an Immune Response to Gluten in Cereals Celiac disease (celiac sprue, gluten-sensitive enteropathy) is characterized by (1) generalized malabsorption, (2) small intestinal mucosal lesions, and (3) a prompt clinical and histopathologic response to the withdrawal of gluten-containing foods from the diet. EPIDEMIOLOGY: Celiac disease is worldwide and affects all ethnic groups. There is a slight female predominance, 1.3:1. Most cases are diagnosed during childhood. PATHOGENESIS: Genetic predisposition and gluten exposure are crucial factors in the development of celiac disease. ROLE OF CEREAL PROTEINS: The ingestion of glutencontaining cereals such as wheat, barley, or rye flour by persons with quiescent celiac sprue is followed by the clinical and histopathologic features of active disease. Gliadin, the alcohol soluble fraction of gluten, has the same effect. GENETIC FACTORS: Concordance for celiac disease in first-degree relatives ranges between 8% and 18% and reaches 70% in monozygotic twins. About 90% of patients with celiac disease carry HLA-B8, and a comparable frequency has been reported for HLA DR8 and DQ2. IMMUNOLOGIC FACTORS: The intestinal lesion in celiac disease is characterized by damage to the epithelial cells and a marked increase in the number of T lymphocytes within the epithelium and of plasma cells in the lamina propria. Gliadin challenge of persons with treated celiac sprue stimulates local immunoglobulin synthesis. Serum antigliadin antibodies are present in almost all patients, but their role in pathogenesis is unknown.

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A region of amino acid sequence homology has been found between ␣-gliadin and a protein of an adenovirus (serotype 12) that infects the human GI tract. Most (90%) untreated patients with celiac disease have serologic evidence of prior infection with this virus. Exposure of a genetically susceptible person to gluten-containing cereals might then stimulate an immune reaction to the protein at the intestinal epithelial cell surface. ASSOCIATION WITH DERMATITIS HERPETIFORMIS: Celiac disease is occasionally associated with dermatitis herpetiformis, a vesicular skin disease that typically affects extensor surfaces and exposed parts of the body. Almost all patients with dermatitis herpetiformis have a small-bowel mucosal lesion similar to that of celiac disease, although only 10% have overt malabsorption. Treatment with a strict gluten-free diet leads to improvement in both GI symptoms and skin lesions. Malabsorption in celiac disease probably results from multiple factors, including reduced intestinal mucosa surface area (due to blunting of villi and microvilli) and impaired intracellular metabolism within damaged epithelial cells. PATHOLOGY: The hallmark of fully developed celiac disease is a flat mucosa, with (1) blunting or total disappearance of villi, (2) damaged mucosal surface epithelial cells with numerous intraepithelial lymphocytes (T cells), and (3) increased plasma cells in the lamina propria but not in deeper layers (Fig. 13-17). The most severe histologic abnormalities in untreated celiac disease usually occur in the duodenum and proximal jejunum. There is a progressive decrease in disease manifestations distally, and in some cases, the ileal mucosa appears virtually normal. The clinical severity of the disease is related to the length of the affected intestine. CLINICAL FEATURES: Fully developed celiac disease is characterized by generalized malabsorption. The signs and symptoms of generalized malabsorption are often initially manifested in older children and adults. Growth retardation is more frequently encountered in young children.. Late complications in some cases include ulcerative jejunitis, small-bowel T-cell lymphoma, and other malignancies of the GI tract. Treatment with a strict gluten-free diet is usually followed by a complete and prolonged clinical and histopathologic remission.

Whipple Disease is a Rare Infection of the Small Bowel Malabsorption is the most prominent feature of Whipple disease. White men in their 30s and 40s are most affected. The disease is systemic, and other clinical findings include fever, increased skin pigmentation, anemia, lymphadenopathy, arthritis, pericarditis, pleurisy, endocarditis, and central nervous system involvement. PATHOGENESIS: Whipple disease typically shows infiltration of the small-bowel mucosa by macrophages packed with small, rod-shaped bacilli. The causative organism is one of the actinomycetes, Tropheryma whippelii. The results of several studies suggest that host susceptibility factors, possibly defective T-lymphocyte function, may be important in predisposing to the disease. Macrophages from patients with Whipple disease exhibit a decreased ability to degrade intracellular microorganisms. Dramatic clinical remissions occur with antibiotic therapy. PATHOLOGY: The bowel wall is thickened and edematous, and mesenteric lymph nodes are usually enlarged. Villi are flat and thickened, and the lamina propria is extensively infiltrated with large foamy macrophages (Fig. 13-18A) with cytoplasm that is filled with large glycoprotein granules that stain strongly with periodic acid–Schiff. These granules correspond to lysosomes engorged with bacilli in various stages of degeneration (see Fig. 13-18B). The

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C FIGURE 13-17. Celiac disease. A. Normal proximal small intestine shows tall slender villi with crypts present at the base. B. Normal surface epithelium shows an occasional intraepithelial lymphocyte as well as an intact brush border. C. A mucosal biopsy from a patient with advanced celiac disease shows complete loss of the villi with infiltration of the lamina propria by lymphocytes and plasma cells. The crypts are increased in height. D. At higher power, the surface epithelium is severely damaged with large numbers of intraepithelial lymphocytes and loss of the brush border.

other normal cellular components of the lamina propria (i.e., plasma cells and lymphocytes) are depleted. The lymphatic vessels in the mucosa and submucosa are dilated, and large lipid droplets are frequently present within lymphatics and in extracellular spaces, a finding that suggests lymphatic obstruction. In contrast to the striking distortion of the villous architecture, epithelial cells show only patchy abnormalities, including attenuation of microvilli and accumulation of lipid droplets within the cytoplasm. Mesenteric lymph nodes draining affected segments of small bowel reveal similar microscopic changes. A characteristic infiltration by macrophages containing bacilli may also be found in most other organs. Whipple disease is treated successfully with appropriate antibiotics.

Mechanical Obstruction Mechanical obstruction to the passage of intestinal contents can be caused by (1) a luminal mass, (2) an intrinsic lesion of the bowel wall, or (3) extrinsic compression.

INTUSSUSCEPTION: In this form of intraluminal small-bowel obstruction, a segment of bowel (intussusceptum) protrudes distally into a surrounding outer portion (intussuscipiens). Intussusception usually occurs in infants or young children, in whom it often occurs without a known cause. In adults, the leading point of an intussusception is usually a lesion in the bowel wall, such as Meckel diverticulum, or a tumor. Once the leading point is entrapped in the intussuscipiens, peristalsis drives the intussusceptum forward. In addition to acute intestinal obstruction, intussusception compresses the blood supply to the intussusceptum, which may become infarcted. If the obstruction is not relieved spontaneously, surgical treatment is required. VOLVULUS: This is a cause of an acute abdomen and is an example of intestinal obstruction in which a segment of gut twists on its mesentery, kinking the bowel and usually interrupting its blood supply. Volvulus often indicates an underlying congenital abnormality. ADHESIONS: Fibrous scars caused by previous surgery or peritonitis cause obstruction by kinking or angulating the bowel or directly compressing the lumen.

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melanin pigmentation, which is particularly evident on the face, buccal mucosa, hands, feet, and perianal, and genital areas. Except for the buccal pigmentation, the freckle-like macular lesions usually fade at puberty. The polyps occur mostly in the proximal small intestine but are sometimes seen in the stomach and the colon. Patients have symptoms of obstruction or intussusception; in as many as one fourth of cases, however, the diagnosis is often suggested by pigmentation in an otherwise asymptomatic person. Peutz-Jeghers syndrome is associated with inactivating mutations of a gene (LKB1) on chromosome 19p that encodes a protein kinase. Carriers of the defective gene are also at increased risk for cancers of the breast, pancreas, testis, and ovary. PATHOLOGY: Peutz-Jeghers polyps are hamartomas, with branching networks of smooth muscle fibers continuous with the muscularis mucosae that supports the glandular epithelium of the polyp. Peutz-Jeghers polyps are generally considered benign, but 3% of patients develop adenocarcinoma, although not necessarily in the hamartomatous polyps.

Malignant Tumors of the Small Bowel are Uncommon Adenocarcinoma

EPIDEMIOLOGY: Although small intestinal adenocarcinomas are a minute proportion of all GI tumors, they account for half of all malignant small-bowel tumors. Most are located in the duodenum and jejunum. The majority occur in middle-aged persons, and there is a moderate male predominance. Crohn disease of the small bowel is a risk factor for adenocarcinoma in that location. Familial adenomatous polyposis, Hereditary nonpolyposis colon cancer syndrome (Lynch syndrome), and celiac disease are additional risk factors.

Neoplasms

PATHOLOGY AND CLINICAL FEATURES: Adenocarcinoma of the small intestine may be polypoid, ulcerative, or simply annular and stenosing. In addition to causing intestinal obstruction directly, a polypoid tumor may be the lead point of an intussusception. Adenocarcinomas originate from crypt epithelium, rather than the villi and, therefore, resemble colorectal cancers. The symptoms of small-bowel adenocarcinoma commonly relate to progressive intestinal obstruction. Occult bleeding is common and often leads to iron-deficiency anemia. If adenocarcinoma of the duodenum involves the papilla of Vater, it is termed ampullary carcinoma. This tumor causes obstructive jaundice or pancreatitis. By the time the patient becomes symptomatic, most adenocarcinomas have metastasized to local lymph nodes, and the overall 5-year survival rate is less than 20%.

Less than 5% of all GI tumors arise in the small intestine.

Primary Intestinal Lymphoma

FIGURE 13-18. Whipple disease. A. A photomicrograph of a section of jejunal mucosa shows distortion of the villi. The lamina propria is packed with large, pale-staining macrophages. Dilated mucosal lymphatics are prominent. B. A periodic acid-Schiff (PAS) reaction shows numerous macrophages filled with cytoplasmic granular material. C. An electron micrograph shows small bacilli in a macrophage.

HERNIAS: Loops of small bowel may be incarcerated in an inguinal or femoral hernia, in which case, the lumen may become obstructed and the vascular supply compromised.

Benign Tumors Include Adenomas and PeutzJeghers Polyps Adenomas Small-bowel adenomas resemble those of the colon. Depending on the predominant component, adenomatous polyps of the small intestine may be tubular, villous, or tubulovillous (see later under Polyps of the Colon and Rectum). Villous adenoma is rare in the small intestine, usually occurring in the duodenum, especially the periampullary region. Adenomas, especially the villous type, may undergo malignant transformation. Benign adenomas are frequently asymptomatic, but bleeding and intussusception are occasional complications.

Peutz-Jeghers Syndrome Peutz-Jeghers syndrome is an autosomal dominant hereditary disorder characterized by intestinal hamartomatous polyps and mucocutaneous

Primary lymphoma originates in nodules of lymphoid tissue normally present in the mucosa and superficial submucosa (MALT). Lymphoma is the second most common malignant tumor of the small intestine in industrialized countries, where it accounts for about 15% of small-bowel cancers. Another type of primary lymphoma comprises more than two thirds of all cancers of the small intestine in less-developed countries. The latter variety of intestinal lymphoma was originally described in Mediterranean populations, but it is now clear that it is distributed throughout the poorer parts of the world. These two types of lymphoma have distinct epidemiologic, clinical, and pathologic features and are respectively termed, Western type and Mediterranean lymphoma. The cause of primary lymphoma of the small bowel is unknown, but an association with celiac disease is well documented, occurring in as many as one tenth of patients with primary lymphoma. The persistent activation of lymphocytes in the bowel is thought to predispose to subsequent development of T-cell lymphoma. However, although a gluten-free diet usually improves the inflammatory com-

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ponent of the enteropathy, T-cell lymphoma can still occur. The risk of intestinal lymphoma is also increased in conditions that favor the development of nodal lymphoma, particularly immunodeficiency following treatment with immunosuppressive drugs. MEDITERRANEAN LYMPHOMA: Mediterranean lymphoma typically occurs in poor countries in young men of low socioeconomic status; it is therefore thought to have an environmental cause. This neoplasm is associated with ␣-heavy chain disease, a proliferative disorder of intestinal B lymphocytes, which secrete the heavy chain of IgA without light chains. Mediterranean lymphoma and ␣-chain disease are considered to be the same disorder, termed immunoproliferative small intestinal disease. Mediterranean intestinal lymphoma predominantly involves the duodenum and proximal jejunum. A long segment of small intestine, or even the entire small bowel, is characteristically affected. Typically, a diffuse infiltrate of plasmacytoid lymphocytes or plasma cells is seen in the mucosa and submucosa. Lymphomatous infiltration of the mucosa leads to mucosal atrophy and severe malabsorption. WESTERN-TYPE INTESTINAL LYMPHOMA: This disorder usually affects adults older than 40 years of age and children younger than 10. It is most common in the ileum, where it is seen as (1) a fungating mass that projects into the lumen, (2) an elevated ulcerated lesion, (3) a diffuse segmental thickening of the bowel wall, or (4) plaque-like mucosal nodules. Intestinal obstruction, intussusception, and perforation are important complications. Occult bleeding is common, and massive acute hemorrhage may also occur. Microscopically, all varieties of malignant lymphoma are encountered. When extraintestinal spread is present, the 5-year survival rate is less than 10%. Chronic abdominal pain, diarrhea, and clubbing of fingers are the most frequent clinical signs of intestinal lymphoma. Diarrhea and weight loss reflect the underlying malabsorption. Patients with Mediterranean lymphoma tend to survive longer than those with the Western type of lymphoma.

Carcinoid Tumor (Neuroendocrine Tumors) The term carcinoid tumor has been largely replaced by the term neuroendocrine tumors (NETs). These tumors are all considered malignant but usually with low metastatic potential. NETs account for about 20% of all small intestinal malignancies. Important considerations include the site of origin size, depth of invasion, hormonal responsiveness, and presence or absence of function. The appendix is the most common GI site of origin, followed by the rectum. Tumors at these sites are usually small and rarely aggressive. The next most common site is the ileum, where they are often multi-

ple, and more aggressive. They are also seen in association with the multiple endocrine neoplasia syndromes, usually type I. PATHOLOGY: Macroscopically, small carcinoid tumors present as submucosal nodules covered by intact mucosa. Large carcinoids may grow in a polypoid, intramural, or annular pattern (Fig. 13-19A) and often undergo secondary ulceration. As they enlarge, carcinoid tumors invade the muscular coat and penetrate the serosa, often causing a conspicuous desmoplastic reaction. This fibrosis is responsible for peritoneal adhesions and kinking of the bowel, which may lead to intestinal obstruction. Microscopically, these neoplasms appear as nests, cords, and rosettes of uniform, small, round cells, (see Fig. 13-19B). Occasional gland-like structures are also seen. Nuclei are remarkably regular, and mitoses are rare. Abundant eosinophilic cytoplasm contains cytoplasmic granules. NETs metastasize first to regional lymph nodes. Subsequently, hematogenous spread produces metastases at distant sites, particularly the liver. CLINICAL FEATURES: Carcinoid syndrome is an uncommon clinical condition caused by the release of a variety of active tumor products. Most NETs are to some extent functional, but this syndrome mainly occurs in patients with extensive hepatic metastases. Classic symptoms include diarrhea (often the most distressing symptom), episodic flushing, bronchospasm, cyanosis, telangiectasia, and skin lesions. Half of patients also have right-sided cardiac valvular disease.

THE LARGE INTESTINE Congenital Disorders Congenital Megacolon (Hirschsprung Disease) Reflects a Segmental Absence of Ganglion Cells Hirschsprung disease is a disorder in which dilation of the colon results from the congenital absence of ganglion cells, in most cases, in the wall of the rectum (Fig. 13-20). In one fourth of cases, ganglion cells are deficient in more proximal portions of the colon. The incidence of the disorder is estimated to be 1 in 5,000 live births, and 80% of patients are male. PATHOGENESIS: The pathogenesis of Hirschsprung disease can be traced to an interruption of the developmental sequence that leads to innervation of the colon. Given that the aganglionic rec-

B FIGURE 13-19. Neuroendocrine tumor of small intestine. A. A resected segment of distal ileum shows multiple neuroendocrine tumors (arrows). B. A photomicrograph of the lesion in A demonstrates cords of uniform small, round cells.

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A FIGURE 13-20. Hirschsprung disease. A. A photomicrograph of ganglion cells in the wall of the rectum. B. A rectal biopsy specimen from a patient with Hirschsprung disease shows a nonmyelinated nerve in the mesenteric plexus and an absence of ganglion cells.

tum (and occasionally the adjacent colon) is permanently contracted because of the absence of relaxation stimuli, the fecal contents do not readily enter this stenotic area, and the proximal bowel becomes dilated. Most cases of Hirschsprung disease are sporadic, but 10% of cases are familial. Half of the familial cases and 15% of sporadic cases reflect inactivating mutations of the RET receptor tyrosine kinase gene on chromosome 10q (see multiple endocrine neoplasia 2 syndrome, Chapter 21). Some cases involve mutations in the endothelin-B receptor or in genes that encode ligands of the RET receptor and endothelin-B receptor. The incidence of congenital megacolon is elevated 10fold in infants with Down syndrome. PATHOLOGY: The large intestine in Hirschsprung disease has a constricted and spastic segment that represents the aganglionic zone. Proximal to this region, the bowel is very dilated. The definitive diagnosis of Hirschsprung disease is made on the basis of absence of ganglion cells in a rectal biopsy specimen (see Fig. 13-20B). CLINICAL FEATURES: Hirschsprung disease is the most common cause of congenital intestinal obstruction. The clinical signs are delayed passage of meconium by a newborn and vomiting in the first few days of life. In children who have short rectal segments lacking ganglion cells and who have only partial obstruction, constipation, abdominal distention, and recurrent fecal impactions are characteristic. The most serious complication of congenital megacolon is an enterocolitis, in which necrosis and ulceration affect the dilated proximal segment of the colon and may extend into the small intestine. The treatment for Hirschsprung disease is surgical removal of the aganglionic segment.

Anorectal Malformations are Common Developmental Defects These malformations vary from minor narrowing to serious and complex defects and result from arrested development of the caudal region of the gut in the first 6 months of fetal life. Malformations include anorectal agenesis or stenosis and imperforate anus. Fistulas between the malformation and the bladder, urethra, vagina, or skin may occur in all types of anorectal anomalies.

Infections of the Large Intestine The principal infections of the colon, including tuberculosis and amebiasis, are discussed in Chapter 9 or above in the context of

small intestine infectious diarrhea. Most of the remaining infectious diseases are transmitted sexually and involve the anorectal region, often in male homosexuals, including gonorrhea, syphilis, lymphogranuloma venereum, anorectal herpes, and venereal warts (condylomata acuminata). Immunosuppressed people have a high incidence of colonic infections (e.g., amebiasis and shigellosis). Bone marrow transplant recipients often contract cytomegalovirus and herpes infection of the GI tract.

Pseudomembranous Colitis Usually Follows Antibiotic Treatment Pseudomembranous colitis is a generic term for an inflammatory disease of the colon that is characterized by exudative plaques on the mucosa. PATHOGENESIS: Clostridium difficile, which is also implicated in neonatal necrotizing enterocolitis, is the offending organism in pseudomembranous colitis associated with antibiotic therapy. The organism is not invasive but produces toxins that damage the colonic mucosa. The mechanism by which C. difficile becomes pathogenic is not entirely clear, although alteration of fecal flora by antibiotics contributes. Only 2% to 3% of healthy adults harbor the organism, whereas 10% to 20% of those who were recently treated with antibiotics are infected. The microbe can be isolated from the stools of 95% of patients with antibiotic-associated pseudomembranous colitis. PATHOLOGY: Macroscopically, the colon, particularly the rectosigmoid region, shows raised yellowish plaques up to 2 cm in diameter, which adhere to the underlying mucosa (Fig. 13-21). The intervening mucosa appears congested and edematous but is not ulcerated. In severe cases, plaques coalesce into extensive pseudomembranes. Necrosis of the superficial epithelium is believed to be the initial pathologic event. Subsequently, the crypts become disrupted and expanded by mucin and neutrophils. The pseudomembrane consists of the debris of necrotic epithelial cells, mucus, fibrin, and neutrophils. CLINICAL FEATURES: Antibiotic-associated infections with C. difficile are virtually always accompanied by diarrhea, but in most cases, the disorder does not progress to colitis. In patients with pseudomembranous colitis, fever, leukocytosis, and abdominal cramps are superimposed on the diarrhea. Before the use of antibiotics, many patients with this form of colitis died within hours or days from ileus and irreversible shock. Today, pseudomembranous colitis, although

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B FIGURE 13-21. Pseudomembranous colitis. A. The colon shows variable involvement ranging from erythema to yellowgreen areas of pseudomembrane. B. Microscopically, the pseudomembrane consists of fibrin, mucin, and inflammatory cells (largely neutrophils).

still serious, is usually controlled with appropriate antibiotics and supportive fluid and electrolyte therapy.

Neonatal Necrotizing Enterocolitis Complicates Prematurity Necrotizing enterocolitis is one of the most common acquired surgical emergencies in newborns. It is particularly common in premature infants after oral feeding and is likely related to an ischemic event involving the intestinal mucosa, which is followed by bacterial colonization, usually with C. difficile. The lesions vary from those of typical pseudomembranous enterocolitis to gangrene and perforation of the bowel.

Diverticular Disease Diverticular disease refers to two entities: a condition termed diverticulosis and an inflammatory complication called diverticulitis.

Diverticulosis Reflects Environmental and Structural Factors Diverticulosis is an acquired herniation (diverticulum) of the mucosa and submucosa through the muscular layers of the colon. EPIDEMIOLOGY: Diverticulosis shows a striking geographic variation and is common in Western societies and infrequent in Asia, Africa, and developing countries. Diverticulosis increases in frequency with age. In Western countries, about 10% of persons are affected.

PATHOGENESIS: The striking variation in the prevalence of diverticulosis implies that environmental factors are primarily responsible for the disease. Western populations consume a diet in which refined carbohydrates and meat have replaced crude cereal grains. It is widely assumed that the lack of indigestible fibers in some way predisposes to the formation of diverticula in susceptible persons. In this respect, the larger fecal mass in those who ingest a high-fiber diet diminishes spontaneous motility and intraluminal pressure in the colon; the latter is hypothesized as important in the process of herniation. In addition to pressure, defects in the wall of the colon are required for the formation of a diverticulum. The circular muscle of the colon is interrupted by connective tissue clefts at the sites of penetration by the nutrient vessels. With increasing age, this connective tissue loses its resilience and, therefore, its resistance to the effects of increased intraluminal pressure. PATHOLOGY: The abnormal structures in diverticulosis are, in a strict sense, pseudodiverticula, in which only the mucosa and submucosa are herniated through the muscle layers. True diverticula involve all layers of the intestinal wall. The sigmoid colon is affected in 95% of cases, but diverticulosis can affect any segment of the colon, including the cecum. Diverticula vary in number from a few to hundreds. Most appear in parallel rows between the mesenteric and lateral taeniae. They measure up to 1 cm in depth and are connected to the intestinal lumen by necks of varying length and caliber. The muscular wall of the affected colon is consistently thickened. Microscopically, a diverticulum characteristically is seen as a flask-like structure that extends from the lumen through the muscle layers (Fig. 13-22). Its wall is continuous with the surface mucosa and thus has an epithelium and a submucosa. The base of the diverticulum is formed by serosal connective tissue. CLINICAL FEATURES: Diverticulosis is generally asymptomatic, and 80% of affected persons remain symptom free. Many patients complain of episodic colicky abdominal pain. Both constipation and diarrhea, sometimes alternating, may occur, and flatulence is common. Sudden, painless, and severe bleeding from colonic diverticula is a cause of serious lower GI hemorrhage in the elderly, occurring in as many as 5% of persons with diverticulosis. Chronic blood loss may lead to anemia.

Diverticulitis Refers to Inflammation at the Base of a Diverticulum Diverticulitis presumably results from irritation caused by retained fecal material. In 10% to 20% of patients with diverticulosis, diverticulitis supervenes at some point. PATHOLOGY: Diverticulitis produces inflammation of the wall of the diverticulum, an event that may lead to perforation and release of fecal bacteria into the peridiverticular tissues. The resulting abscess is usually contained by the appendices epiploicae and the pericolonic tissue. Infrequently, free perforation leads to generalized peritonitis. Fibrosis in response to repeated episodes of diverticulitis may constrict the bowel lumen, causing obstruction. Fistulas may form between the colon and adjacent organs, including the bladder, vagina, small intestine, and skin of the abdomen. Additional complications include pylephlebitis and liver abscesses. CLINICAL FEATURES: The most common symptoms of diverticulitis, usually following microscopic or gross perforation of the diverticulum, are persistent lower abdominal pain and fever. Changes in bowel habits, ranging from diarrhea to constipation, are frequent, and dysuria indicates bladder irritation. Most patients have tenderness

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The disease usually appears in adolescents or young adults and is most common among persons of European origin, with a considerably higher frequency in the Jewish population. There is a slight female predominance (1.6:1). PATHOGENESIS: Concordance rates in twin pairs and siblings strongly implicate a genetic predisposition to Crohn disease. A family history of inflammatory bowel disease is more common for Crohn disease than for ulcerative colitis. A putative susceptibility locus for Crohn disease has been assigned to the centromeric region of chromosome 16 where it is associated with the NOD2/CARD15 locus, which codes for an intracellular receptor for bacterial products involved in innate immunity. The possibility that Crohn disease reflects immunologically mediated damage to the intestine is suggested by (1) the chronic and recurrent nature of the inflammation and (2) its association with systemic manifestations that are suggestive of autoimmune disease. Most recent immunologic studies focus on the possible role of cell-mediated cytotoxicity. The fecal stream appears to be of prime importance in the pathogenesis of Crohn disease, as evidenced by (1) the beneficial effects of surgical bypass, (2) the pattern of preanastomotic recurrence in patients with side-to-end anastomotic sites, and (3) the frequency of early inflammatory lesions (aphthoid erosions) in the epithelium in association with mucosal lymphoid tissue.

B FIGURE 13-22. Diverticulosis of the colon. A. The colon was inflated with formalin. The mouths of numerous diverticula are seen between the taenia (arrows). There is a blood clot seen protruding from the mouth of one of the diverticula (arrowhead). This was the source of massive GI bleeding. B. Sections show mucosa including mucularis mucosae, which has herniated through a defect in the bowel wall producing a diverticulum.

in the left lower quadrant, where a mass may be palpated. Leukocytosis is the rule. Antibiotic treatment and supportive measures usually alleviate acute diverticulitis, but about 20% of patients eventually require surgical intervention.

Inflammatory Bowel Disease Inflammatory bowel disease is a term that describes two diseases: Crohn disease and ulcerative colitis. Although these two disorders have different clinical courses as well as natural histories and are usually clearly distinguishable, they have certain common features.

Crohn Disease Features Chronic, Segmental, Transmural Inflammation of the Intestine Crohn disease occurs principally in the distal small intestine but may involve any part of the digestive tract and even extraintestinal tissues. The colon, particularly the right colon, may be affected. EPIDEMIOLOGY: Crohn disease occurs worldwide, with an annual incidence of 0.5 to 5 per 100,000. Reports from various countries indicate that the incidence has increased dramatically over the past 30 years.

PATHOLOGY: Two major characteristics of Crohn disease differentiate it from other GI inflammatory diseases. First, the inflammation usually involves all layers of the bowel wall and is, therefore, referred to as transmural inflammatory disease. Second, the involvement of the intestine is discontinuous; that is, segments of inflamed tissue are separated by apparently normal intestine. It is convenient to classify Crohn disease into four broad macroscopic patterns. The disease involves (1) mainly the ileum and cecum in about 50% of cases, (2) only the small intestine in 15%, (3) only the colon in 20%, and (4) mainly the anorectal region in 15%. In women with anorectal Crohn disease, the inflammation may spread to involve the external genitalia. The macroscopic and microscopic features of Crohn disease are variable. Grossly, the bowel and adjacent mesentery are thickened as well as edematous, and mesenteric fat often wraps around the bowel (“creeping fat”). Mesenteric lymph nodes are frequently enlarged, firm, and matted together. The intestinal lumen is narrowed by a combination of edema and fibrosis. Nodular swelling, fibrosis, and mucosal ulceration lead to a “cobblestone” appearance (Fig. 13-23A). In early cases, ulcers have either an aphthous or a serpiginous appearance; later, they become deeper and appear as linear clefts or fissures (see Fig. 13-23B). The cut surface of the bowel wall shows the transmural nature of the disease, with thickening, edema, and fibrosis of all layers. Involved loops of bowel are often adherent, and fistulas between such segments are frequent. These fistulas may also penetrate from the bowel into other organs, including the bladder, uterus, vagina, and skin. Lesions in the distal rectum and anus may create perianal fistulas, a well-known presenting feature. Microscopically, Crohn disease appears as a chronic inflammatory process. During early phases of the disease, the inflammation may be confined to the mucosa and submucosa. Small, superficial mucosal ulcerations (aphthous ulcers) are seen. Later, long, deep, fissure-like ulcers are seen, and vascular hyalinization and fibrosis become apparent. The microscopic hallmark of Crohn disease is transmural, nodular, lymphoid aggregates (Fig. 13-24). Discrete, noncaseating granulomas, mostly in the submucosa, may be present. Although the pres-

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B FIGURE 13-23. Crohn disease. A. The terminal ileum shows striking thickening of the wall of the distal portion with distortion of the ileocecal valve. A longitudinal ulcer is present (arrows). B. Another longitudinal ulcer is seen in this segment of ileum. The large rounded areas of edematous damaged mucosa give a “cobblestone” appearance to the involved mucosa. A portion of the mucosa to the lower right is uninvolved. B

ence of granulomas is strong evidence in favor of Crohn disease, less than half of the cases show these lesions. The pathologic features of Crohn disease are summarized in Figure 13-25. CLINICAL FEATURES: The clinical manifestations and natural history of Crohn disease are highly variable and relate to the anatomical sites involved by the disease. The most frequent symptoms are abdominal pain and diarrhea, which are seen in more than 75% of patients, and recurrent fever, evident in 50%. When the small intestine is diffusely involved, malabsorption and malnutrition may be major features. Crohn disease of the colon leads to diarrhea and sometimes colonic bleeding. In a few patients, the major site of involvement is the anorectal region, and recurrent anorectal fistulas may be the presenting sign. Intestinal obstruction and fistulas are the most common intestinal complications of Crohn disease. Occasionally, free perforation of the bowel occurs. Small bowel cancer is at least threefold more common in patients with Crohn disease, and the disease also predisposes to colorectal cancer. No cure for Crohn disease is available. Several medications suppress the inflammatory reaction, including corticosteroids, sulfasalazine, metronidazole, 6-mercaptopurine, cyclosporine, and anti-TNF antibodies. Surgical resection of obstructed areas or of

FIGURE 13-24. Crohn disease. A. The colon involved with Crohn disease shows an area of mucosal ulceration, an expanded submucosa with lymphoid aggregates, and numerous lymphoid aggregates in the subserosal tissues immediately adjacent to the muscularis externa. B. This mucosal biopsy in Crohn disease shows a small epithelioid granuloma (arrows) between two intact crypts.

severely involved portions of intestine and drainage of abscesses caused by fistulas are often required.

Ulcerative Colitis is a Chronic Superficial Inflammation of the Colon and Rectum Ulcerative colitis is characterized by chronic diarrhea and rectal bleeding, with a pattern of exacerbations and remissions and with the possibility of serious local and systemic complications. EPIDEMIOLOGY: In Europe and North America, the incidence of ulcerative colitis is 4 to 7 per 100,000 population, and its prevalence is 40 to 80 per 100,000. It usually begins in early adult life, with a peak incidence in the third decade. However, it also occurs in childhood and old age. In the United States, whites are affected more commonly than blacks.

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FIGURE 13-25. Crohn disease. A schematic representation of the major features of Crohn disease in the small intestine.

PATHOGENESIS: The cause of ulcerative colitis is unknown. In some families as many as six patients with this disease have been described, and concordance has been reported in monozygotic twins. However, available family studies do not suggest any distinct mode of genetic transmission. The possibility that an abnormal immune response may be involved has been studied extensively. There is abundant lymphoid tissue throughout the colon, and ulcerative colitis may occur with autoimmune-like conditions, such as uveitis, erythema nodosum, and vasculitis. Increased circulating antibodies against antigens in colonic epithelial cells and against cross-reacting antigens in enterobacteria may occur. Antineutrophil cytoplasmic antibodies are found in 80% of patients with ulcerative colitis. However, these abnormalities are neither unique for ulcerative colitis, nor are they a prerequisite for the development of the disease.

PATHOLOGY: Three major pathologic features characterize ulcerative colitis and help to differentiate it from other inflammatory conditions: • Ulcerative colitis is a diffuse disease. It usually extends from the most distal part of the rectum for a variable distance proximally (Fig. 13-26). Sparing of the rectum or involvement of the right side of the colon alone is rare and suggests the possibility of another disorder, such as Crohn disease. • Inflammation in ulcerative colitis is generally limited to the colon and rectum. It rarely involves the small intestine, stomach, or esophagus. • Ulcerative colitis is essentially a mucosal disease. Deeper layers are uncommonly involved, mainly in fulminant cases and usually in association with toxic megacolon. The following morphologic sequence may develop rapidly or over a course of years.

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PROGRESSIVE COLITIS: As the disease continues, mucosal folds are lost. Lateral extension and coalescence of crypt abscesses can undermine the mucosa, leaving areas of ulceration adjacent to hanging fragments of mucosa. Such mucosal excrescences are termed inflammatory polyps. Granulation tissue develops in denuded areas. Importantly, the strictures characteristic of Crohn disease are absent. Microscopically, colorectal crypts may appear tortuous, branched, and shortened in the late stages, and the mucosa may be diffusely atrophic. ADVANCED COLITIS: In long-standing cases, the large bowel is often shortened, especially in the left side. Mucosal folds are indistinct and are replaced by a granular or smooth mucosal pattern. Microscopically, advanced ulcerative colitis is characterized by mucosal atrophy and a chronic inflammatory infiltrate in the mucosa and superficial submucosa. Paneth metaplasia is common. FIGURE 13-26. Ulcerative colitis. Prominent erythema and ulceration of the colon begin in the ascending colon and are most severe in the rectosigmoid area.

EARLY COLITIS: Early in the evolution of the disease, the mucosal surface is raw, red, and granular. It is frequently covered with a yellowish exudate and bleeds easily. Later small, superficial erosions or ulcers may appear. These occasionally coalesce to form irregular, shallow, ulcerated areas that appear to surround islands of intact mucosa. The microscopic features of early ulcerative colitis include (1) mucosal congestion, edema, and microscopic hemorrhages; (2) a diffuse chronic inflammatory infiltrate in the lamina propria; and (3) damage and distortion of the colorectal crypts, which are often surrounded and infiltrated by neutrophils. Suppurative necrosis of the crypt epithelium gives rise to the characteristic crypt abscess, which appears as a dilated crypt filled with neutrophils (Fig. 13-27).

CLINICAL FEATURES: The clinical course and manifestations are very variable. Most patients (70%) have intermittent attacks, with partial or complete remission between attacks. A small number (⬍10%) have a very long remission (several years) after their first attack. The remaining 20% have continuous symptoms without remission. MILD COLITIS: Half of patients with ulcerative colitis have mild disease. Their major symptom is rectal bleeding, sometimes accompanied by tenesmus (rectal pressure and discomfort). The disease in these patients is usually limited to the rectum but may extend to the distal sigmoid colon. Extraintestinal complications are uncommon, and in most patients in this category, disease remains mild throughout their lives. MODERATE COLITIS: About 40% of patients have moderate ulcerative colitis. They usually have recurrent episodes of loose bloody stools, crampy abdominal pain, and frequently low-grade fever, lasting days or weeks. Moderate anemia is a common result of chronic fecal blood loss.

FIGURE 13-27. Ulcerative colitis. A. A full-thickness section of colon resected for ulcerative colitis shows inflammation affecting the mucosa with sparing of the submucosa and muscularis propria. B. Sections of a mucosal biopsy from a patient with active ulcerative colitis show expansion of the lamina propria and several crypt abscesses (arrows). C. Chronic ulcerative colitis shows significant crypt distortion and atrophy.

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SEVERE COLITIS: About 10% of patients have severe or fulminant ulcerative colitis, often during a flare of activity. They may have more than 6 and sometimes more than 20 bloody bowel movements daily, often with fever and other systemic manifestations. Blood and fluid loss rapidly leads to anemia, dehydration, and electrolyte depletion. Massive hemorrhage may be life-threatening. A particularly dangerous complication is toxic megacolon, which is characterized by extreme dilation of the colon and an associated high risk for perforation. Fulminant ulcerative colitis is a medical emergency requiring immediate, intensive medical therapy, and, in some cases, prompt colectomy. About 15% of patients with fulminant ulcerative colitis die of the disease. The distinction between ulcerative colitis and Crohn colitis is based on different anatomical localization and histopathology (Table 13-1). The medical treatment of ulcerative colitis depends on the sites involved and the severity of the inflammation. The 5-aminosalicylate–based compounds are the mainstays of treatment for patients with mild-to-moderate ulcerative colitis. Corticosteroids and immunosuppressive and immunoregulatory agents (azathioprine or mercaptopurine) are used in patients who have severe and refractory disease.

Extraintestinal Manifestations Arthritis is seen in 25% of patients with ulcerative colitis. Eye inflammation (mostly uveitis) and skin lesions develop in about 10%. The most common cutaneous lesions are erythema nodosum and pyoderma gangrenosum; the latter is a serious, noninfective disorder characterized by deep, purulent, necrotic ulcers in the skin. Liver disease occurs in about 4% of patients, most commonly primary sclerosing cholangitis. Thromboembolic phenomena, usually deep vein thromboses of the lower extremities, occur in 6% of ulcerative colitis patients.

Ulcerative Colitis and Colorectal Cancer People with long-standing ulcerative colitis have a higher risk of colorectal cancer than the general population. Colorectal epithelial dysplasia is a neoplastic epithelial proliferation and precursor to colorectal carcinoma in patients with long-term ulcerative colitis. Highgrade epithelial dysplasia reflects a significant risk for the development of colorectal cancer, and when identified in a biopsy, it is a strong indication for colectomy.

TABLE 13–1

Comparison of the Pathologic Features in the Colon of Crohn Disease and Ulcerative Colitis Lesion Macroscopic Thickened bowel wall Luminal narrowing “Skip” lesions Right colon predominance Fissures and fistulas Circumscribed ulcers Confluent linear ulcers Pseudopolyps Microscopic Transmural inflammation Submucosal fibrosis Fissures Granulomas Crypt abscesses

Crohn Disease

Ulcerative Colitis

Typical Typical Common Typical Common Common Common Absent

Uncommon Uncommon Absent Absent Absent Absent Absent Common

Typical Typical Typical Common Uncommon

Uncommon Absent Rare Absent Typical

301

Vascular Diseases The Colon is Subject to the Same Types of Ischemic Injury as the Small Intestine Unlike the small bowel, extensive infarction of the colon is uncommon, and chronic segmental disease is the rule. Most cases of ischemic colitis are caused by atherosclerosis of major intestinal arteries, and the disease usually occurs in individuals older than 50 years of age. The most vulnerable areas are those between adjacent arterial distributions such as the splenic flexure, the so-called watershed areas. PATHOLOGY: Most patients do not require immediate surgical intervention, as acute signs often stabilize. On endoscopy, multiple ulcers, hemorrhagic nodular lesions, or pseudomembranes are seen. Biopsy reveals ischemic necrosis of the bowel: mucosal ulceration, crypt abscesses, edema, and hemorrhage. Such patients may recover completely or may develop a colonic stricture. CLINICAL FEATURES: Ischemic disease of the rectosigmoid area typically manifests as abdominal pain, rectal bleeding, and a change in bowel habits. On clinical grounds alone, ischemic colitis often cannot be distinguished from some forms of infective colitis, ulcerative colitis, and Crohn colitis.

Angiodysplasia (Vascular Ectasia) May Cause Intestinal Bleeding Angiodysplasia (vascular ectasia) refers to localized arteriovenous malformations, mainly in the cecum and ascending colon, which produce lower intestinal bleeding. The mean age at presentation is 60 years. Younger persons preferentially exhibit lesions at other sites, including the rectum, stomach, and small bowel. The diagnosis is difficult and often requires selective mesenteric arteriography or colonoscopy. Surgical removal of the affected segment is curative. PATHOLOGY: The resected specimen displays small, often multiple vascular lesions, usually smaller than 0.5 cm in diameter. Microscopically, the submucosal veins and capillaries are tortuous, thin walled, and dilated. The attenuated walls of these vessels are presumably responsible for their propensity to bleed.

Hemorrhoids are Associated with Rectal Bleeding Hemorrhoids are dilated venous channels of the hemorrhoidal plexuses. They result from downward displacement of the anal cushions. Internal hemorrhoids arise from the superior hemorrhoidal plexus above the pectinate line, whereas external hemorrhoids originate from the inferior hemorrhoidal plexus below that line. Hemorrhoids are common in Western countries, to some degree afflicting at least half of the population over 50 years old. They are common in pregnancy, presumably because of the increased abdominal pressure. PATHOLOGY: Microscopic examination of hemorrhoidectomy specimens discloses dilated vascular spaces with excess smooth muscle in their walls. Hemorrhage and thrombosis of varying severity are common. CLINICAL FEATURES: The salient clinical feature of hemorrhoids is bleeding. Chronic blood loss may lead to iron-deficiency anemia. Rectal prolapse often develops. Prolapsed hemorrhoids may become irreducible and lead to painful strangulated hemorrhoids. Thrombosis of external hemorrhoids is exquisitely painful and requires evacuation of the intravascular clot.

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Polyps of the Colon and Rectum A GI polyp is defined as a mass that protrudes into the lumen of the gut. Polyps are subdivided according to their attachment to the bowel wall (e.g., sessile or pedunculated, with a discrete stalk), their histopathologic appearance (e.g., hyperplastic or adenomatous), and their neoplastic potential (i.e., benign or malignant). By themselves, polyps are only infrequently symptomatic and their clinical importance lies in their potential for malignant transformation.

Adenomatous Polyps are Premalignant Lesions Adenomatous polyps (tubular adenomas) are neoplasms that arise from the mucosal epithelium. They are composed of neoplastic epithelial cells that have migrated to the surface and have accumulated beyond the needs for replacement of the cells that are sloughed into the lumen. EPIDEMIOLOGY: The prevalence of adenomatous polyps of the colon is highest in industrialized countries. As in diverticular disease, the diet is the only consistent environmental difference between high-risk and low-risk populations that has been identified. In the United States, it appears that at least one adenomatous polyp is present in half of the adult population, a figure that increases to more than twothirds among individuals older than 65 years of age. There is a modest male predominance (1.4:1), and blacks have a higher proportion of right-sided adenomas and cancers. PATHOLOGY: Almost half of all adenomatous polyps of the colon in the United States are located in the rectosigmoid region and can, therefore, be detected by digital examination or by sigmoidoscopy. The remaining half are evenly dis-

tributed throughout the rest of the colon. The macroscopic appearance of an adenoma varies from a barely visible nodule or small, pedunculated adenoma to a large, sessile (flat) adenoma. Adenomas are classified by architecture into tubular, villous, and tubulovillous types. TUBULAR ADENOMAS: These constitute two thirds of benign large bowel adenomas. Tubular adenomas are typically smooth-surfaced lesions, usually less than 2 cm in diameter, which often have a stalk (Fig. 13-28). Some tubular adenomas, particularly the smaller ones, are sessile. Microscopically, tubular adenoma has closely packed epithelial tubules, which may be uniform or irregular and excessively branched (see Fig. 13-28C). The tubules are embedded in a fibrovascular stroma similar to that in the normal lamina propria. Although most tubular adenomas show little epithelial dysplasia, one-fifth (particularly larger tumors) may have dysplastic features, which vary from mild nuclear pleomorphism to invasive carcinoma (Fig. 13-29). In high-grade dysplasia, glands become crowded and highly irregular in size and shape. Papillary or cribriform (sieve-like or perforated) growth patterns are common. As long as the dysplastic focus is confined to the mucosa, the lesion is cured by resection of the polyp. The risk of invasive carcinoma correlates with the size of the tubular adenoma. Only 1% of tubular adenomas smaller than 1 cm display invasive cancer at the time of resection; among those between 1 and 2 cm, 10% harbor malignancy; and among those larger than 2 cm, 35% are cancerous. VILLOUS ADENOMAS: These polyps constitute one tenth of colonic adenomas and are found predominantly in the rectosigmoid region. They are typically large, broad-based, elevated lesions with a shaggy, cauliflower-like surface (Fig. 13-30A), although they can be small and pedunculated. Most are larger than

FIGURE 13-28. Tubular adenoma of the colon. A. The adenoma shows a characteristic stalk and bosselated surface. B. The bisected adenoma shows the stalk covered by the adenomatous epithelium. The ashen white color is cautery at the polypectomy resection margin from the polypectomy. C. Microscopically, the adenoma shows a repetitive pattern that is largely tubular. The stalk, which is in continuity with the submucosa of the colon, is not involved and is lined by normal colonic epithelium.

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B FIGURE 13-29. Adenocarcinoma arising in a pedunculated adenomatous polyp. A. Both low-grade dysplasia and highgrade dysplasia are present. The latter is characterized by a cribriform pattern and increased nuclear pleomorphism (arrows). B. Trichrome stain showing tumor invading the stalk (blue). Because there was a margin of resection of greater than 1 mm, polypectomy was sufficient therapy.

2 cm in diameter. Microscopically, villous adenomas are composed of thin, tall, finger-like processes that superficially resemble the villi of the small intestine. They are lined externally by neoplastic epithelial cells and are supported by a core of fibrovascular connective tissue corresponding to the normal lamina propria (see Fig. 13-30B). The histopathology of dysplasia in villous adenomas is comparable to that in tubular adenomas. However, villous adenomas contain foci of carcinoma more often than do tubular adenomas. In polyps smaller than 1 cm across, the risk is 10 times higher than that for comparably sized tubular adenomas. Of greater importance is the fact that 50% of villous adenomas larger than 2 cm harbor invasive carcinoma. Given that most villous adenomas measure more than 2 cm in greatest dimension, more than one third of all resected villous adenomas contain invasive cancer. TUBULOVILLOUS ADENOMAS: Many adenomatous polyps have both tubular and villous features. Polyps with more than 25% and less than 75% villous architecture are termed tubulovillous. These adenomas tend to be intermediate in distribution and size between the tubular and villous forms, and one-fourth to onethird are larger than 2 cm across. Tubulovillous polyps are also intermediate between tubular and villous adenomas in the risk of invasive carcinoma. PATHOGENESIS: The pathogenesis of adenomas of the colon and rectum involves neoplastic alteration of crypt epithelial homeostasis, which includes (1) diminished apoptosis, (2) persistent cell replication, and (3) failure to mature and differentiate as the epithelial cells migrate toward the surface of the crypts (Fig. 13-31). Normally, DNA synthesis ceases when cells reach the upper third of the crypts, after which they mature, migrate to the surface, and become senescent. They then undergo apoptosis or are sloughed into the lumen. Adenomas represent focal disruption of this orderly sequence. Mitotic figures are initially visualized not only along the entire length of the crypt but also on the mucosal surface. As the lesion evolves, cell proliferation exceeds the rate of apoptosis and sloughing, and cells begin to accumulate in the upper crypts and on the surface. Eventually, the accumulated cells on the mucosal surface form tubules or villous structures, in concert with stromal elements. Prophylactic polypectomies have significantly reduced the risk of subsequent cancer development.

Hyperplastic Polyps are Frequent in the Rectum Hyperplastic polyps are small, sessile mucosal excrescences that display exaggerated crypt architecture. They are the most common polypoid lesions of the colon and are particularly frequent in the rectum. Hyperplastic polyps are present in 40% of rectal specimens in persons younger than 40 years of age and in 75% of older persons. They are more common than usual in colons with adenomatous polyps and in populations with higher rates of colorectal cancer. PATHOGENESIS: Hyperplastic polyps are believed to arise due to a defect in proliferation and maturation of normal mucosal epithelium. In a hyperplastic polyp, proliferation occurs at the base of the crypt, and upward migration of the cells is slowed. Thus, epithelial cells differentiate and acquire absorptive characteristics lower in the crypts. Moreover, cells persist at the surface longer do than normal cells. PATHOLOGY: Hyperplastic polyps are small, sessile, raised mucosal nodules, up to 0.5 cm in diameter but occasionally larger. They are almost always multiple. Histologically, the crypts of hyperplastic polyps are elongated and may show cystic dilation. The epithelium contains goblet cells and absorptive cells, with no dysplasia. The surface cells are elongated and exhibit a tufted appearance, which accounts for the serrated contour of the glands near the surface.

Familial Adenomatous Polyposis (FAP) is an Autosomal Dominant Trait that Invariably Leads to Cancer Also termed adenomatous polyposis coli (APC), FAP accounts for less than 1% of colorectal cancers. It is caused by a mutation of the APC gene on the long arm of chromosome 5 (5q21-22) (see below). Most cases are familial, but 30% to 50% reflect new mutations. FAP is characterized by hundreds to thousands of adenomas carpeting the colorectal mucosa, sometimes throughout its length, but particularly in the rectosigmoid area. The adenomas are mostly of the tubular variety, although tubulovillous and villous adenomas are also present. Microscopic adenomas, sometimes involving a single

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A FIGURE 13-30. Villous adenoma of the colon. A. The colon contains a large, broad-based, elevated lesion that has a cauliflower-like surface. A firm area near the center of the lesion proved on histologic examination to be an adenocarcinoma. B. Microscopic examination shows finger-like processes with fibrovascular cores lined by hyperchromatic nuclei.

crypt, are numerous. A few polyps are usually present by age 10, but the mean age for occurrence of symptoms is 36 years, by which time cancer is often already present. Carcinoma of the colon and rectum is inevitable, and the mean age of onset is 40 years. Total colectomy before the onset of cancer is curative, but some patients also have tubular adenomas in the small intestine and stomach that have the same malignant potential as those in the colon. Genetic testing for FAP is available, but mutations are found in only 75% of familial cases. Gardner syndrome is a phenotypic variant of FAP defined by extracolonic lesions, including osteomas and congenital hypertrophy of the retinal pigmented epithelium.

Non-Neoplastic Polyps are Acquired Lesions Non-neoplastic polyps are entirely different entities and are grouped together solely because of their gross appearance as raised lesions of the colonic mucosa.

Juvenile Polyps (Retention Polyps) Juvenile polyps are hamartomatous proliferations of the colonic mucosa. They are most common in children younger than 10 years of age, although one-third occur in adults.

Benign colonic neoplasms Tubular adenoma Normal

Initial proliferative abnormality

Villous adenoma

Progressive proliferative abnormality

Colonic crypt

Invasive adenocarcinoma

40%

Invasive adenocarcinoma

FIGURE 13-31. The histogenesis of adenomatous polyps of the colon. The initial proliferative abnormality of the colonic mucosa, the extension of the mitotic zone in the crypts, leads to the accumulation of mucosal cells. The formation of adenomas may reflect epithelial–mesenchymal interactions.

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PATHOLOGY: Juvenile polyps are single or (rarely) multiple. They mostly occur in the rectum, but may be seen anywhere in the small or large bowel. Grossly, most are pedunculated lesions up to 2 cm in diameter. They have smooth, rounded surfaces, unlike the fissured surfaces of adenomatous polyps. Microscopically, dilated and cystic epithelial tubules filled with mucus (hence the name “retention polyp”) are embedded in a fibrovascular lamina propria (Fig. 13-32). Surface epithelial erosion is common, and reactive epithelial proliferation is evident, but the epithelium usually lacks dysplasia. Patients with five or more juvenile polyps, or juvenile polyps present outside the colon along with a family history of juvenile polyps, have a high likelihood of the syndrome of familial juvenile polyposis. These patients have an increased risk for GI carcinoma, not necessarily arising from the polyps or even the segment of the GI tract in which they are located.

Inflammatory Polyps Inflammatory polyps are not neoplasms but are elevated nodules of inflamed, regenerating epithelium. They are commonly found in association with ulcerative colitis and Crohn disease, but they are also encountered in cases of amebic colitis and bacterial dysentery. Microscopically, inflammatory polyps are composed of a variable component of distorted and inflamed mucosal glands, often intermixed with granulation tissue. As healing proceeds, epithelial regeneration characterized by large, basophilic epithelial cells restores mucosal architecture. Although these lesions are not precancerous, they occur in chronic inflammatory diseases that are associated with a high incidence of cancer (e.g., ulcerative colitis) and must thus be distinguished from adenomatous polyps.

Malignant Tumors Adenocarcinoma of the Colon and Rectum is an Example of Multistep Carcinogenesis In Western societies, colorectal cancer is the most common cause of cancer deaths that are not directly attributable to tobacco use. Approximately 5% of Americans develop this cancer during their lifetime. Although the widely used term colorectal implies a common biology, the differences between cancers of the colon and rectum seem to be more fundamental than simple location. For instance, whereas colon cancer is much more common in the United States than in Japan, the incidence of rectal cancer in the two populations is nearly the same. Moreover, colon cancer shows a slight female preponderance, whereas rectal cancer is somewhat more common in men.

Molecular Genetics of Colorectal Cancer In 85% of cases of colorectal carcinoma, it has been estimated that at least 8 to 10 mutational events must accumulate before an invasive cancer with metastatic potential develops. This process is initiated in histologically normal mucosa, proceeds through an adenomatous precursor stage, and ends as invasive adenocarcinoma. The most important mutational events are illustrated in Figure 13-33 and involve: • APC gene: As noted above, germline mutations in APC (adenomatous polyposis coli), a putative tumor-suppressor gene, lead to familial adenomatous polyposis. In most sporadic colorectal cancers, the same gene is mutated. Some tumors with normal APC have mutations in the ␤-catenin gene (its product binds to the APC protein). APC mutations are seen in normal colonic mucosa preceding development of sporadic adenomas. These data suggest an important role for APC in the early development of most colorectal neoplasms.

B FIGURE 13-32. Juvenile polyp. A. The resected specimen shows a rounded surface that is dark because of hemorrhage and ulceration. The cut surface is cystic. B. Microscopically, the polyp displays cystically dilated glands.

• Ras oncogene: Activating mutations of the ras protooncogene occur early in tubular adenomas of the colon. • DCC gene: A putative tumor-suppressor gene, DCC (“deleted in colon cancer”) is located on chromosome 18 and is often missing in colorectal cancers. • p53 tumor-suppressor gene: In the most common type of adenocarcinoma of the colon, mutation of p53 participates in the transition from adenoma to carcinoma and is a late event in the carcinogenic pathway. • Mismatch repair associated genes: In 15% of colorectal cancers, DNA repair is impaired, leading to deficient correction of spontaneous replication errors, particularly in simple repetitive sequences (microsatellites).

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NORMAL EPITHELIUM

Loss of APC HYPERPROLIFERATIVE EPITHELIUM

Loss of DNA methylation EARLY ADENOMA

Ras mutation

INTERMEDIATE ADENOMA

Loss of DCC LATE ADENOMA

Loss of p53 ADENOCARCINOMA

FIGURE 13-33. Model of some of the genetic alterations involved in colonic carcinogenesis following the tumor suppressor pathway. APC, adenomatous polyposis coli; DCC, “deleted in colon cancer.”

Risk Factors Increasing age is probably the single most important risk factor for colorectal cancer in the general population. Risk is low before age 40 and increases steadily to age 50, after which it doubles with each decade. Chronic inflammatory bowl disease, prior colorectal cancer, diet, and genetic factors are all risk factors (as discussed above). Persons with two or more first- or second-degree relatives with colorectal cancer constitute 20% of all patients with this tumor. About 5% to 10% of all colorectal cancers are inherited as autosomal dominant traits. PATHOLOGY: Grossly colorectal cancers resemble adenocarcinomas elsewhere in the gut. They tend to be polypoid and ulcerating or infiltrative and may be annular and constrictive (Fig. 13-34A). Polypoid cancers are more common in the right colon, particularly in the cecum, where the large caliber of the colon allows unimpeded intraluminal growth. Annular constricting tumors are more common in the distal colon. Ulceration of tumors, regardless of growth pattern, is common. The vast majority of colorectal cancers are adenocarcinomas (see Fig. 13-34B), which are microscopically similar to their counterparts in other parts of the digestive tract. Approximately 10% to 15% secrete large quantities of mucin; these are called mucinous adenocarcinomas. Colorectal cancer spreads by direct extension or vascular/lymphatic invasion. The connective tissues of the serosa offer little resistance to tumor spread, and cancer cells are often found in the fat and serosa at some distance from the primary tumor. The peritoneum is occasionally involved, in which case, there may be multiple deposits throughout the abdomen. Colorectal cancer invades

B FIGURE 13-34. Adenocarcinoma of the colon. A. A resected colon shows an ulcerated mass with enlarged, firm, rolled borders. B. Microscopically, this colon adenocarcinoma consists of moderately differentiated glands with a prominent cribriform pattern and frequent central necrosis.

lymphatic channels and initially involves the lymph nodes immediately underlying the tumor. Venous invasion leads to blood-borne metastases, which involve the liver in most patients with metastatic disease. The prognosis of colorectal cancer is more closely related to the degree of tumor extension through the large bowel wall than to its size or histopathological characteristics. Current staging of colorectal carcinomas uses the TNM classification (tumor, lymph nodes, metastasis). In this system, a T1 tumor invades the submucosa; a T2 tumor infiltrates into, but not through, the muscularis propria; a T3 tumor invades into the subserosal tissue; and T4 tumors penetrate the serosa or involve adjacent organs. N refers to the presence or absence of nodal metastases, and M indicates the presence or absence of extranodal metastases. CLINICAL FEATURES: Initially, colorectal cancer is clinically silent. As the tumor grows, the most common sign is occult blood in the feces when the tumor is in the proximal portions of the colon. Both occult blood and bright red blood in the feces may occur if a lesion is in the distal colorectum. Cancers on the left side of the colon, where the caliber of the lumen is small and the fecal contents are more solid, often constrict the lumen, producing obstructive symptoms. These are manifested as changes in bowel habits and abdominal pain. Occasionally, colorectal cancer perforates early and induces peritonitis. By contrast, on the right side of the colon, particularly

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in the cecum, the lumen is large and fecal contents are liquid. As a result, tumors can grow to a large size without causing symptoms of obstruction. In this situation, chronic asymptomatic bleeding may cause iron-deficiency anemia, which is often the first indication of colorectal cancer. Periodic fiberoptic colonoscopy and testing for occult blood in the feces improves the prognosis of colorectal cancer, because these methods can often detect the disease at an early stage. The only curative treatment for colorectal cancer is surgery. Small polyps are easily removed endoscopically; large lesions require segmental resection. Tumors close to the anal verge often necessitate abdominal–perineal resection and colostomy, although newer surgical techniques may allow sphincter preservation. In rectal cancers, the use of adjuvant chemotherapy and radiotherapy before surgery improves the prognosis.

Hereditary Nonpolyposis Colon Cancer (HNPCC)

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resection is sometimes carried out. More than half of the patients survive for at least 5 years.

THE APPENDIX Appendicits Acute appendicitis is an inflammatory disease of the wall of the vermiform appendix that leads to transmural inflammation and perforation with peritonitis. This condition is by far the most common disease of the appendix and is the most frequent cause of an abdominal emergency. Although the incidence peaks in the second and third decades, acute appendicitis may occur in individuals of any age.

HNPCC, or Warthin-Lynch syndrome, is an autosomal dominant inherited disease that accounts for 3% to 5% of all colorectal cancers. It is characterized by (1) the onset of colorectal cancer at a young age, (2) few adenomas (hence “nonpolyposis”), (3) a high frequency of carcinomas proximal to the splenic flexure (70%), (4) multiple synchronous or metachronous colorectal cancers, and (5) extracolonic cancers, including endometrial and ovarian cancers, adenocarcinomas of the stomach, small intestine, and hepatobiliary tract, and transitional cell carcinomas of the renal pelvis and ureter.

PATHOGENESIS: Acute appendicitis relates to obstruction of its orifice, with secondary distention of the lumen and bacterial invasion of the wall. Mechanical obstruction by fecaliths or solid fecal material in the cecum is found only in one third of cases, and the factor that precipitates the disease in the other two thirds of the patients is unknown. As secretions distend an obstructed appendix, intraluminal pressure increases and eventually exceeds the venous pressure. This causes venous stasis, ischemia, and invasion by intestinal bacteria.

PATHOGENESIS AND PATHOLOGY: HNPCC is caused by a germline mutation followed by a second somatic mutation in DNA mismatch repair genes, most commonly hMSH2 (human MutS homolog 2) on chromosome 2p and hMLH1 (human MutL homolog 1) on chromosome 3p. These mutations lead to widespread genomic instability, particularly in simple repetitive sequences (microsatellites), which are particularly prone to replication errors. Histologically, HNPCC-related colorectal cancers are characterized by a high frequency of mucinous, signet ring cell and solid (medullary) carcinomas.

PATHOLOGY: The appendix is congested, tense, and covered by a fibrinous exudate. Its lumen often contains purulent material. A fecalith may be evident (Fig. 1335). Microscopically, early cases show mucosal microabscesses and a purulent exudate in the lumen. As infection progresses, the entire wall becomes infiltrated with neutrophils, which eventually reach the serosa. Perforation of the wall releases the luminal contents into the peritoneal cavity. The complications of appendicitis are principally related to perforation, which occurs in one third of children and young adults. Almost all children under 2 years have a perforated appendix at the time of operation, as do three fourths of patients over 60.

Cancers of the Anal Canal are Epidermoid Carcinomas Carcinomas of the anal canal, which constitute 2% of cancers of the large bowel, may arise at or above the dentate line. These tumors occur in both genders but are more common in women and in blacks.

CLINICAL FEATURES: Acute appendicitis is typically manifested as epigastric or periumbilical cramping pain, but the pain may be diffuse or initially restricted to the right lower quadrant. Shortly thereafter, nausea and vomiting occur, and the patient develops a low-grade fever and moderate leukocytosis. The pain shifts to the right lower quadrant, where point tenderness is the rule. Treatment is surgical

PATHOLOGY: Anal cancers have various histologic patterns, such as squamous, basaloid (cloacogenic), or mucoepidermoid. However, the different tumor types exhibit similar clinical behavior and so are all classed as epidermoid carcinomas. Carcinoma of the anus penetrates directly into surrounding tissues, including internal and external sphincters, perianal soft tissues, prostate, and vagina. CLINICAL FEATURES: Infection with human papilloma virus and chronic inflammatory disease of the anus (e.g., venereal disease), fissures, and trauma predispose to anal cancer. Factors associated with genital carcinoma, poor hygiene, indiscriminate sexual practices, and genital warts also contribute to the development of anal cancer. The usual symptoms of anal cancers include bleeding, pain, and an anal or rectal mass. Often, a tumor is not clinically recognized as a malignant lesion and may be discovered only in a hemorrhoidectomy specimen. Combined chemotherapy and radiation therapy is the customary treatment, although abdominal–perineal

FIGURE 13-35. Acute appendicitis. The lumen of this acutely inflamed appendix is dilated and contains a large fecalith.

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in the vast majority of cases. As perforation carries a much higher risk of death than does laparoscopic surgery, early surgical intervention is warranted, even if the diagnosis of acute appendicitis is not entirely secure.

villous adenomatous mucosa. Cystadenocarcinoma exhibits infiltrating neoplastic glands into the wall of the appendix. When a mucocele results from mucus secretion by a cystadenoma or cystadenocarcinoma of the appendix, perforation may lead to seeding of the peritoneum by mucus-secreting tumor cells, a condition known as pseudomyxoma peritonei.

Mucocele Mucocele refers to a dilated mucus-filled appendix. The pathogenesis may be neoplastic or non-neoplastic. In the non-neoplastic variety, chronic obstruction leads to retention of mucus in the appendiceal lumen. Most mucoceles are associated with neoplastic epithelium. In the presence of a mucinous cystadenoma or a mucinous cystadenocarcinoma, the dilated appendix is lined by a

Neoplasms of the Appendix: Carcinoid Tumors Carcinoid tumors of the appendix are common, and are unlikely to metastasize except in the rare case when they are larger than 1.5 cm in size.

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The Liver and Biliary System Raphael Rubin Emanuel Rubin

THE LIVER Bilirubin Metabolism and the Mechanics of Jaundice Normal Bilirubin Overproduction of Bilirubin Decreased Hepatic Uptake of Bilirubin Hereditary Syndromes Demonstrating Decreased Bilirubin Conjugation Hereditary Syndromes Demonstrating Decreased Transport of Conjugated Bilirubin Neonatal (Physiologic) Jaundice Impaired Canalicular Bile Cirrhosis Hepatic Failure Inadequate Clearance of Bilirubin Hepatic Encephalopathy Defects of Coagulation Hypoalbuminemia Hepatorenal Syndrome Endocrine Complications of Cirrhosis Portal Hypertension Intrahepatic Portal Hypertension Prehepatic Portal Hypertension Posthepatic Portal Hypertension: Budd-Chiari Syndrome Complications of Portal Hypertension Viral Hepatitis Hepatitis A Hepatitis B Hepatitis D Hepatitis C Hepatitis E Pathology of Viral Hepatitis Acute Hepatitis Chronic Hepatitis Autoimmune Hepatitis

Alcoholic Liver Disease Fatty Liver and Associated Lesions Alcoholic Hepatitis Alcoholic Cirrhosis Primary Biliary Cirrhosis Primary Sclerosing Cholangitis Iron-Overload Syndromes Hereditary Hemochromatosis (HH) Secondary Iron Overload Syndromes Heritable Disorders Associated with Cirrhosis Wilson Disease Cystic Fibrosis ␣1-Antitrypsin (␣1-AT) Deficiency Inborn Errors of Carbohydrate Metabolism Toxic Liver Injury Zonal Hepatocellular Necrosis Fatty Liver Acute Intrahepatic Cholestasis Lesions Resembling Viral Hepatitis Chronic Hepatitis Vascular Lesions Neoplastic Lesions Vascular Disorders Congestive Heart Failure Shock Infarction Bacterial Infections Parasitic Infestations Cholestatic Syndromes of Infancy Neonatal Hepatitis Biliary Atresia Benign Tumors and Tumor-Like Lesions Hepatic Adenomas Focal Nodular Hyperplasia Hepatic Hemangiomas Malignant Tumors of the Liver Hepatocellular Carcinoma (HCC)

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Cholangiocarcinoma (Bile Duct Carcinoma) Metastatic Cancer

THE GALLBLADDER AND EXTRAHEPATIC BILE DUCTS Cholelithiasis Cholesterol Stones Risk Factors for Cholesterol Stones

The liver lobule is a polyhedral structure (Fig. 14-1), classically depicted as a hexagon. Portal triads (or portal tracts) are found peripherally at the angles of the polygon and are so named because they contain intrahepatic branches of the (1) bile ducts, (2) hepatic artery, and (3) portal vein. However, from a functional point of view, the lobule should be thought of as an acinus with its center in the portal tract (see Fig. 14-1). Such a concept takes into account the functional gradients that exist within the lobule.

Portal tract Terminal hepatic venule

Pigment Stones Clinical Features of Gallstones Acute Cholecystitis Chronic Cholecystitis Tumors Adenocarcinoma Carcinoma of the Bile Duct and the Ampulla of Vater

THE LIVER The functions served by the liver can be broadly categorized as metabolic, synthetic, storage, catabolic, and excretory. METABOLIC FUNCTIONS: The liver is the central organ of glucose homeostasis, maintaining blood glucose levels by glycogenolysis and gluconeogenesis. SYNTHETIC FUNCTIONS: Most serum proteins, including albumin and blood coagulation factors, are synthesized in the liver. In addition, complement, other acute phase reactants, and binding proteins for iron, copper, and vitamin A are liver products. STORAGE FUNCTIONS: The liver is an important storage site for glycogen, triglycerides, iron, copper, and lipid-soluble vitamins. CATABOLIC FUNCTIONS: Endogenous substances, including hormones and serum proteins, are catabolized by the liver to maintain a balance between their production and their elimination. The liver is also the principal site for the detoxification of foreign compounds (xenobiotics). EXCRETORY FUNCTIONS: The principal excretory product of the liver is bile, an aqueous mixture of conjugated bilirubin, bile acids, phospholipids, cholesterol, and electrolytes. Bile not only provides a repository for the products of heme catabolism but is also vital for fat absorption in the small intestine.

1 2

Bilirubin Metabolism and the Mechanics of Jaundice Portal tract

Bilirubin is the End Product of Heme Catabolism

Terminal hepatic venule

Morphologic and functional concepts of the liver lobule. In the classic, morphologic liver lobule, the periphery of the hexagonal lobule is anchored in the portal tracts, and the terminal hepatic venule is in the center. The functional liver lobule is an acinus derived from the gradients of oxygen and nutrients in the sinusoidal blood. In this scheme, the portal tract, with the richest content of oxygen and nutrients, is in the center (zone 1). The region most distant from the portal tract (zone 3) is poor in oxygen and nutrients and surrounds the terminal hepatic venule. FIGURE 14-1.

Bilirubin has no known physiologic function, although a role as an antioxidant has been suggested. Up to 85% of bilirubin is derived from senescent erythrocytes, which are removed from the circulation by mononuclear phagocytes of the spleen, bone marrow, and liver. The remaining bilirubin arises from the degradation of heme produced from other sources, the most important of which is the premature breakdown of hemoglobin in developing erythroid cells in the bone marrow. Circulating bilirubin is bound to albumin for transport to the liver. The transfer of bilirubin from the blood to the bile involves four steps: 1. Uptake: The albumin–bilirubin complex is dissociated, and bilirubin is transported across the sinusoidal hepatocyte plasma membrane. This transport likely involves specific recognition of bilirubin by a plasma membrane receptor. 2. Binding: Within the hepatocyte, bilirubin is bound to a group of cytosolic proteins known collectively as glutathione-Stransferases (also termed ligandins). 3. Conjugation: For its excretion, bilirubin is complexed with glucuronic acid by the uridine diphosphate glucuronyl trans-

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ferase (UGT) system The reaction forms bilirubin diglucuronide and a small amount (⬍10%) of the monoglucuronide. 4. Excretion: Conjugated bilirubin diffuses through the cytosol to the bile canaliculus, where it is excreted into the bile by an energy-dependent carrier-mediated process. Hyperbilirubinemia refers to an increased concentration of bilirubin in the blood (⬎1.0 mg/dL) and may be associated with: • Jaundice or icterus describes yellow skin and sclerae (Fig. 14-2), with color that becomes apparent when the circulating bilirubin concentration exceeds 2.0 to 2.5 mg/dL. • Cholestasis is the presence of plugs of inspissated bile in dilated bile canaliculi and visible bile pigment in hepatocytes. • Cholestatic jaundice is characterized by histologic cholestasis and hyperbilirubinemia. As shown in Figure 14-3, many conditions are associated with hyperbilirubinemia. Overproduction of bilirubin, interference with hepatic uptake or intracellular metabolism of bilirubin, and impairment of bile excretion are all causes of jaundice.

Overproduction of Bilirubin Can Lead to Unconjugated Hyperbilirubinemia An increased production of bilirubin results from increased destruction of erythrocytes (i.e., hemolytic anemia) or ineffective erythropoiesis (dyserythropoiesis). In unusual circumstances, the breakdown of erythrocytes in a large hematoma (e.g., after trauma) may also provide excess bilirubin. The hyperbilirubinemia of uncomplicated hemolytic disease principally involves unconjugated bilirubin, whereas in parenchymal liver disease, both conjugated and unconjugated bilirubin participate. Although the unconjugated hyperbilirubinemia of hemolytic disease is of little clinical significance in the adult, hemolytic disease of the newborn may be catastrophic and result in concentrations of unconjugated bilirubin high enough to cause kernicterus characterized by damage to the infantile central nervous system (see Chapter 6). Kernicterus has generally been associated with bilirubin concentrations greater than 20 mg/dL, but subtle psychomotor retardation may follow considerably lower bilirubin concentrations.

Decreased Hepatic Uptake of Bilirubin is a Common Cause of Jaundice Hyperbilirubinemia can result from impaired hepatic uptake of unconjugated bilirubin. Such a situation occurs in generalized liver cell injury, exemplified by viral hepatitis. Certain drugs (e.g.,

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rifampin and probenecid) interfere with the net uptake of bilirubin by the liver cell and may produce a mild unconjugated hyperbilirubinemia.

Decreased Bilirubin Conjugation Occurs in a Number of Hereditary Syndromes Three syndromes demonstrating hyperbilirubinemia are associated with either a total lack or decreased levels of hepatic UGT activity. The clinical differentiation is based on total serum bilirubin levels, which range from 1 to 6 mg/dL in Gilbert syndrome (which is essentially asymptomatic) to 20 to 45 mg/dL in Crigler-Najjar syndrome type I (which is lethal in infancy without intervention).

Crigler-Najjar Syndrome Crigler-Najjar syndrome type I is a rare, recessively inherited malady characterized by chronic, severe, unconjugated hyperbilirubinemia, owing to the complete absence of hepatic UGT activity (see above). A variety of mutations in the UGT gene lead to the synthesis of a completely inactive enzyme. The bile in this condition is colorless and contains no conjugated bilirubin and no more than trace amounts of unconjugated bilirubin. The morphologic appearance of the liver is normal. Infants with Crigler-Najjar syndrome type I invariably develop bilirubin encephalopathy and usually die in the first year of life if not treated by liver transplantation. Crigler-Najjar syndrome type II is similar to but less severe than type I and manifests only a partial decrease in the activity of UGT.

Gilbert Syndrome Gilbert syndrome is an inherited, mild, chronic unconjugated hyperbilirubinemia (⬍6 mg/dL) that is caused by impaired clearance of bilirubin in the absence of any detectable functional or structural liver disease. The disease is most often inherited as an autosomal recessive and is related to reduced expression of the UGT gene (often but not exclusively related to mutations in the promoter region). Gilbert syndrome is exceptionally common, occurring in 3% to 7% of the population. It is seen more often in men than in women and is usually recognized after puberty. Gilbert syndrome is harmless and, for the most part, without symptoms other than cosmetic.

Decreased Transport of Conjugated Bilirubin Often Involves Mutations in the Multidrug Resistance Protein (MRP) Family MRPs are molecules that mediate organic ion transport across membranes, including conjugated bilirubin, bile acids, and phospholipids. Mutations in these proteins, as well as an array of other canalicular transporters, impair hepatocellular secretion of bilirubin glucuronides and other organic anions into the canalicular lumen. The diseases vary in severity from innocuous to lethal, owing to the heterogeneity of the mutations.

Dubin-Johnson Syndrome Dubin-Johnson syndrome is a benign autosomal recessive disease characterized by chronic conjugated hyperbilirubinemia and conspicuous deposition of melanin-like pigment in the liver. The disease is linked to mutations that result in the complete absence of MRP2 protein (also referred to as the canalicular multispecific organic anion transporter, cMOAT) in hepatocytes. The syndrome is rare, but certain groups, such as the Iranian Jewish population, have a considerably higher incidence.

FIGURE 14-2.

Jaundice. A patient in hepatic failure displays a yellow sclera.

PATHOLOGY: The microscopic appearance of the liver is entirely normal in Dubin-Johnson syndrome, except for the accumulation of coarse, iron-free, dark-brown granules in hepatocytes and Kupffer cells, primarily in the centrilobular zone. By electron microscopy, the pigment is seen in enlarged lysosomes. The accumulation of this intracellular pigment is reflected in a grossly pigmented, or “black,” liver.

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TISSUE MACROPHAGE

Senescent RBCs

New RBCs 120 days

Hgb 85%

Heme Bilirubin

HEMOLYTIC ANEMIA • Erythroblastosis • Immune hemolysis • Congenital RBC disease (e.g., sickle cell, thassemia, spherocytosis) DYSERYTHROPOIESIS

15%

Immature RBCs

Circulating bilirubin Bone marrow Myoglobin Extraerythroid cytochromes

Bilirubin

IMPAIRED UPTAKE • Hepatocellular injury (e.g., viral hepatitis) • Drugs • Newborn

Ligandin

Bilirubin-protein complex

HEPATOCYTE

Glucuronyl transferase

Bilirubin glucuronide

Intracellular transport

REDUCED GLUCURONYL TRANSFERASE ACTIVITY • Newborn • Gilbert syndrome • Crigler-Najjar syndrome IMPAIRED TRANSPORT INTO CANALICULUS • Hepatocellular injury (e.g., viral or alcoholic hepatitis) • Toxins • Dubin-Johnson syndrome • Rotor syndrome CANALICULAR CHOLESTASIS • Hepatocellular injury (e.g., viral or alcoholic hepatitis) • Drugs and toxins • Pregnancy • Extrahepatic biliary obstruction

Mechanisms of hyperbilirubinemia at the level of the hepatocyte. Bilirubin is derived principally from the senescence of circulating red blood cells (RBCs), with a smaller contribution from the degradation of erythropoietic elements in the bone marrow, myoglobin, and extra erythroid cytochromes. Hyperbilirubinemia and jaundice result from overproduction of bilirubin (hemolytic anemia), dyserythropoiesis, impaired bilirubin uptake, or defects in its hepatic metabolism. The locations of specific blocks in the metabolic pathway of bilirubin in the hepatocyte are illustrated. Hgb, hemoglobin. FIGURE 14-3.

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CLINICAL FEATURES: Except for mild intermittent jaundice, most patients with Dubin-Johnson syndrome do not complain of any symptoms, although vague nonspecific complaints are common. Half of those affected have dark urine. The serum bilirubin value varies from 2 to 5 mg/dL, although it may be much higher transiently.

Neonatal (Physiologic) Jaundice Occurs in Most Newborns Infants who exhibit hyperbilirubinemia in the absence of any specific disorder are said to suffer from physiologic jaundice. PATHOGENESIS: The liver of the newborn assumes the responsibility for bilirubin clearance before its conjugating and excretory capacities are fully developed. Moreover, the demands on the liver in the newborn are actually increased because of augmented destruction of circulating erythrocytes during this period. As a consequence, 70% of normal newborns exhibit transient unconjugated hyperbilirubinemia. This physiologic jaundice is more pronounced in premature infants, both because the hepatic clearance of bilirubin is less developed and because the turnover of erythrocytes is more pronounced than in the term infant. The hepatic bilirubin-conjugating capacity reaches adult levels about 2 weeks after birth; the ligandin level takes somewhat longer to reach adult values. As a result of this hepatic maturation, serum bilirubin levels rapidly decline to adult values. Absorption of light by unconjugated bilirubin generates water-soluble bilirubin isomers. Thus, phototherapy of the skin is now routinely used in cases of neonatal jaundice.

Impaired Canalicular Bile Flow Accompanied by Visible Biliary Pigment (Cholestasis) Reflects Either Extrahepatic or Intrahepatic Biliary Obstruction Functionally, cholestasis represents decreased bile flow through the canaliculus and reduced secretion of water, bilirubin, and bile acids by the hepatocyte. Cholestasis may be produced by intrinsic liver disease, in which case the term intrahepatic cholestasis is used (see Fig. 14-4) or by obstruction of the large bile ducts, a condition known as extrahepatic cholestasis. The inability to excrete bile acids into the canaliculus results in elevated serum and hepatocellular bile acid concentrations. Much of the hepatic injury and progression to cirrhosis associated with

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cholestasis is due to the accumulation of bile acids within hepatocytes. Bile acids induce injury by their detergent action and by direct activation of apoptotic pathways. Elevated serum bile acid concentrations are the likely cause of severe itching (pruritus). The extrahepatic biliary system may be obstructed by a number of lesions. These include gallstones passing through the cystic duct to lodge in the common bile duct, cancer of the bile duct or surrounding tissues (pancreas or ampulla of Vater), external compression by enlarged neoplastic lymph nodes in the porta hepatis (as in Hodgkin disease), benign strictures (postoperative scarring or primary sclerosing cholangitis), and congenital biliary atresia. PATHOGENESIS: The biochemical basis of cholestasis is not entirely clear. In the case of extrahepatic biliary obstruction, the effects clearly begin with increased pressure in the bile ducts. However, in the early stages, the biochemical and morphologic events at the canalicular level are similar to those that occur with intrahepatic cholestasis, including a centrilobular predilection for the appearance of canalicular bile plugs (Fig. 14-4). The invariable presence of bile constituents in the blood of persons with cholestasis implies regurgitation of conjugated bilirubin from the hepatocyte into the bloodstream. PATHOLOGY: The morphologic hallmark of cholestasis is the presence of brownish bile pigment within dilated canaliculi and in hepatocytes (see Fig. 14-4). The canaliculus is enlarged. In the hepatocyte, bile stasis is reflected in the presence of large, bile-laden lysosomes. When cholestasis persists, secondary morphologic abnormalities develop. Scattered necrotic hepatocytes probably reflect a toxic effect of excess intracellular bile. Within the sinusoids, the macrophages and Kupffer cells contain bile pigment and cellular debris. Whereas early cholestasis is restricted almost exclusively to the central zone, chronic cholestasis is also marked by the appearance of bile plugs in the periphery of the lobule. In extrahepatic biliary obstruction, the liver is swollen and bile stained. Initially, centrilobular cholestasis is accompanied by edema of the portal tracts. As obstruction proceeds, mononuclear inflammatory cells infiltrate the portal tracts. Tortuous and distended bile ductules, characterized by a high cuboidal epithelium, proliferate. Damaged hepatocytes containing large amounts of bile manifest (1) hydropic swelling, (2) diffuse impregnation with bile pigment, and (3) a reticulated appearance. This triad is termed feathery degeneration. Dilated bile ducts may rupture, promoting the formation of bile lakes (Fig. 14-5), which appear as focal, golden-yellow deposits that are surrounded by degenerating hepatocytes. Within bile ducts and proliferated ductules, biliary concretions may be conspicuous. With time, the portal tracts become enlarged and fibrotic. Typically, the periductal fibrosis is concentric, giving rise to the term “onion-skin fibrosis.” In untreated extrahepatic biliary obstruction, septa eventually extend between the portal tracts of contiguous lobules to form micronodular cirrhosis (discussed below). CLINICAL FEATURES: Cholestasis usually presents with jaundice, regardless of its underlying cause. Pruritus (itching) is common and can be severe and intractable. Cholesterol accumulates in the skin in the form of xanthomas. Malabsorption may develop in cases of protracted cholestasis (see Chapter 13).

Cirrhosis

FIGURE 14-4.

Bile stasis. A photomicrograph of the liver shows prominent bile plugs in dilated bile canaliculi.

Cirrhosis, the end stage of chronic liver disease, is defined as the destruction of the normal liver architecture by fibrous septa that encompass regenerative nodules of hepatocytes. This morphologic pattern invariably results from persistent liver cell necrosis. Advanced cases of cirrhosis all tend to have a similar appearance, and often the cause can no longer be ascertained by morphologic examination alone. During earlier stages,

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Hepatic Failure Hepatic failure is the clinical syndrome that occurs when the mass of liver cells or their function is inadequate to sustain the vital activities of the liver. Liver failure may develop acutely, most commonly as a result of viral hepatitis or toxic liver injury. By contrast, chronic liver diseases, such as chronic viral hepatitis or cirrhosis, may lead to an insidious onset of hepatic failure. The consequences of acute and chronic hepatic failure are depicted in Figure 14-8, which deals with the complications of cirrhosis, the most common cause of hepatic failure. Although advances in supportive care have improved survival in acute hepatic failure, the mortality rate for this condition remains above 50%.

Inadequate Clearance of Bilirubin by the Liver Causes Jaundice

Bile infarct (bile lake). A photomicrograph of the liver in a patient with extrahepatic biliary obstruction shows an area of necrosis and the accumulation of extravasated bile. FIGURE 14-5.

on the other hand, the characteristic features of the inciting pathogenic insult may be evident. For example, fat and Mallory bodies are typical of alcoholic liver injury, whereas chronic inflammation and periportal necrosis define chronic hepatitis. A spectrum of nodular patterns has been defined in cirrhosis. At one end is micronodular cirrhosis usually found early in the course of a disease. At the other end of the spectrum, ordinarily late in the progression of the disease, is macronodular cirrhosis. Between these two extremes are many cases that show features of both types. MICRONODULAR CIRRHOSIS: Micronodular cirrhosis exhibits nodules scarcely larger than a lobule, measuring less than 3 mm in diameter. The micronodules show no landmarks of lobular architecture in the form of portal tracts or central venules. The connective tissue septa separating the nodules are usually thin, but irregular focal collapse of parenchyma may lead to the presence of wider septa. In active stages of the cirrhotic process, numerous mononuclear inflammatory cells and proliferated bile ductules inhabit the septa. The prototype of micronodular cirrhosis is alcoholic cirrhosis, but this pattern may also be observed in cirrhosis from many other causes. MACRONODULAR CIRRHOSIS: Macronodular cirrhosis is classically associated with chronic hepatitis. It also occasionally results from submassive confluent hepatic necrosis (see below), in which case the liver may be grossly misshapen. The liver demonstrates grossly visible, coarse, irregular nodules, which are mirrored histologically by large nodules of varying size and shape that are encircled by bands of connective tissue (Fig. 14-6). The connective tissue septa in macronodular cirrhosis are characteristically broad and contain elements of pre-existing portal tracts, mononuclear inflammatory cells, and proliferated bile ductules. Micronodular cirrhosis can be converted into a macronodular pattern by continued regeneration and expansion of existing nodules. This is particularly true of alcoholics who are persuaded to abstain from drinking. PATHOGENESIS: The diseases associated with cirrhosis are listed in Table 14-1. They have little in common except that they are all accompanied by persistent liver cell necrosis. Most cases of cirrhosis are attributable to alcoholism or chronic viral hepatitis. Despite advances in diagnostic modalities, approximately 15% of cases are of unknown origin and are classified as cryptogenic cirrhosis.

Hepatic failure is always associated with jaundice as a result of inadequate clearance of bilirubin by the diseased liver. Hyperbilirubinemia associated with hepatic failure is for the most part conjugated, although the level of unconjugated bilirubin also tends to increase. On occasion, increased erythrocyte turnover may add to unconjugated hyperbilirubinemia, thereby aggravating the jaundice.

Hepatic Encephalopathy Refers to Neurologic Signs and Symptoms of Liver Failure Hepatic encephalopathy progresses from sleep disturbance and irritability (stage I) to coma (stage IV) in patients who suffer chronic unrelenting liver failure or the diversion of the portal circulation. Progression may occur over a period of many months or may evolve rapidly in days or weeks in cases of fulminant hepatic failure. PATHOGENESIS: The pathogenesis of hepatic encephalopathy remains elusive. It is probable that the condition is caused in part by injurious compounds absorbed from the intestine that have escaped hepatic detoxification either because of hepatocyte dysfunction or the existence of structural or functional vascular shunts. The latter mechanism is particularly evident after the surgical construction of a portal–systemic anastomosis for the relief of portal hypertension (see below), in which the resultant neurological abnormality is termed portasystemic encephalopathy. Substances proposed to account for hepatic encephalopathy include: AMMONIA: Levels of ammonia are usually increased in the blood and brain of patients with hepatic encephalopathy. The brain detoxifies ammonia by using it to synthesize glutamate and glutamine. Excess levels of these molecules may alter neurotransmission and brain osmolality. However, the correlation between the increased concentration of blood ammonia and the severity of hepatic encephalopathy is inexact. GABA: Neural inhibition, mediated by the ␥-aminobutyric acid (GABA)–benzodiazepine receptor complex, is accentuated in hepatic encephalopathy by increased levels of benzodiazepine-like molecules. OTHER SUBSTANCES: These include mercaptans that result from the breakdown of sulfur-containing amino acids in the colon. The characteristic breath odor of patients with hepatic failure, termed fetor hepaticus, reflects the presence of mercaptans in saliva. Increased blood levels of aromatic amino acids, may lead to decreased synthesis of normal neurotransmitters (such as norepinephrine) and augmented production of false neurotransmitters (e.g., octopamine), which may also play a role in encephalopathy.

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B FIGURE 14-6.

Macronodular cirrhosis. A. The liver is misshapen, and the cut surface reveals irregular nodules and connective tissue septa of varying width. B. A photomicrograph shows nodules of varying size and irregular fibrous

septa.

PATHOLOGY: In patients who have died with chronic liver disease and hepatic coma, the most striking changes are found in the astrocytes. These brain cells are increased in number and size and show swelling, nuclear enlargement, and nuclear inclusions characteristic of Alzheimer type II astrocytes. The deep layers of the cerebral cortex and subcortical white matter, the basal ganglia, and the cerebellum exhibit laminar necrosis and a spongiform appearance. In patients with acute hepatic failure, cerebral edema is the major cause of death, occurring in more than half of the cases, of-

TABLE 14–1

Major Causes of Cirrhosis Alcoholic liver disease Nonalcoholic fatty liver disease Chronic hepatitis Chronic viral hepatitis Autoimmune hepatitis Drugs Biliary disease Extrahepatic biliary obstruction Primary biliary cirrhosis Sclerosing cholangitis Metabolic disease Hemochromatosis Wilson disease ␣1-Antitrypsin deficiency Tyrosinemia Glycogen storage disease Hereditary fructose intolerance Hereditary storage diseases Galactosemia Cryptogenic

ten in conjunction with uncal and cerebellar herniation. This edema is not simply a terminal event but is rather a specific lesion associated with hepatic coma, although the precise mechanism is obscure.

Defects of Coagulation Often Cause Bleeding Reduced hepatic synthesis of coagulation factors and thrombocytopenia are the principal causes for the impaired hemostasis in liver failure. Decreased production of most clotting factors (fibrinogen; prothrombin; factors V, VII, IX, and X) reflects the generalized impairment of protein synthesis by the liver. Thrombocytopenia (⬍80,000/␮L) occurs commonly in hepatic failure and is accompanied by qualitative abnormalities in platelet function. Thrombocytopenia may result from (1) hypersplenism, (2) bone marrow depression, or (3) the consumption of circulating platelets by intravascular coagulation. Disseminated intravascular coagulation occurs frequently in liver failure. Intravascular coagulation may be stimulated by necrosis of liver cells, activation of factor XII (Hageman factor) by endotoxin, or inadequate hepatic clearance of activated clotting factors from the circulation.

Hypoalbuminemia Complicates Hepatic Failure A decreased level of circulating albumin is secondary to impaired hepatic synthesis of albumin and is an important factor in the pathogenesis of edema, which often complicates chronic liver disease.

Hepatorenal Syndrome Refers to Renal Failure Secondary to Hepatic Failure Hepatorenal syndrome is characterized by the features of renal hypoperfusion, namely, oliguria, azotemia, and increased plasma creatinine levels. The syndrome usually occurs in the setting of cirrhosis and indicates a poor prognosis. Curiously, the kidneys clearly maintain the ability to function normally. Kidneys from patients who have died of the hepatorenal syndrome function well when trans-

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planted into recipients with chronic renal failure. Conversely, in patients with the hepatorenal syndrome, liver transplantation can restore renal function. Vasoactive substances produced by the failing liver or inadequately cleared by it seem to contribute to the renal hemodynamic changes. In any event, the hepatorenal syndrome is caused by inadequate perfusion of the kidneys when local vasodilation can no longer counteract the effects of vasoconstriction.

Endocrine Complications are Associated with Cirrhosis It is important to distinguish between the direct effects of alcohol abuse, a common cause of liver disease, and changes that are better attributed to hepatic dysfunction. Chronic liver failure in men leads to feminization, characterized by gynecomastia, a female body habitus, and a female distribution of pubic hair (female escutcheon). In addition, vascular manifestations of hyperestrogenism are common and include spider angiomas in the territory drained by the superior vena cava (upper trunk and face) and palmar erythema (Fig. 14-7). Feminization is attributed to reduced hepatic catabolism of estrogens and weak androgens. The weak androgens (androstenedione and dehydroepiandrosterone) are converted to estrogenic compounds in peripheral tissues, thereby adding to the burden of circulating estrogens.

Portal Hypertension Portal hypertension is defined as a sustained increase in portal venous pressure and results from obstruction to blood flow somewhere in the portal circuit. The major complications of increased portal pressure and the opening of collateral channels are bleeding from gastroesophageal varices, ascites, and splenomegaly. For the sake of convenience, obstruction to the flow of portal blood can be pictured as (1) prehepatic, occurring before the blood enters the liver; (2) intrahepatic, occurring during transit through the portal tracts and lobules; and (3) posthepatic, occurring after the exit of the blood from the lobules (Fig. 14-8).

Intrahepatic Portal Hypertension is Usually Caused by Cirrhosis Regenerative nodules in the cirrhotic liver impinge on the hepatic veins, thereby obstructing blood flow distal to the lobules. The small portal veins and venules are trapped, narrowed, and often obliterated by scarring of the portal tracts. Moreover, blood flow through the hepatic artery is increased, and small arteriovenous communications become functional. In this way, portal hypertension due to obstruction of blood flow distal to the sinusoid is augmented by increased arterial blood flow. In addition, increased splanchnic arterial blood flow, the cause of which is unclear, is an important factor in the maintenance of portal hypertension. Intrahepatic vasoconstriction in cirrhosis may further exacerbate portal hypertension. Central vein sclerosis and sinusoidal fibrosis also contribute to the development of portal hypertension in alcoholic liver disease. In fact, portal hypertension can result from alcoholic central sclerosis alone, even in cases that do not progress to cirrhosis. Worldwide, hepatic schistosomiasis is a major cause of intrahepatic portal hypertension (see Chapter 9 for details). Idiopathic portal hypertension refers to occasional cases of intrahepatic portal hypertension with spleno-megaly that occur in the absence of any demonstrable intrahepatic or extrahepatic disease. In some countries (e.g., England, Japan), idiopathic portal hypertension accounts for 15% to 35% of all cases that require surgery to decompress the portal circulation.

Prehepatic Portal Hypertension is Often Caused by Portal Vein Thrombosis Portal vein thrombosis occurs most commonly in the setting of cirrhosis. Other causes of portal vein thrombosis include tumors, infections, hypercoagulability states, pancreatitis, and surgical trauma. Some cases are of unknown etiology. Primary hepatocellular carcinoma characteristically invades branches of the portal vein and occasionally occludes the main portal vein. Portal hypertension may also occur in patients with splenomegaly from a variety of causes, including polycythemia vera, myeloid metaplasia, and chronic myelogenous leukemia. In cirrhosis, the accompanying splenomegaly that augments blood flow in the splenic vein may further aggravate portal hypertension.

Posthepatic Portal Hypertension Refers to Obstruction to Blood Flow Beyond the Liver Lobules: Budd-Chiari Syndrome Budd-Chiari syndrome is a congestive disease of the liver caused by occlusion of the hepatic veins and their tributaries. PATHOGENESIS: The principal cause of the Budd-Chiari syndrome is thrombosis of the hepatic veins, in association with such diverse conditions as polycythemia vera (10% to 40% of cases) and other myeloproliferative disorders, hypercoagulable states associated with malignant tumors, the use of oral contraceptives, pregnancy, bacterial infections, paroxysmal nocturnal hemoglobinuria, metastatic and primary tumors in the liver, and surgical trauma. In 20% of cases, no specific cause is evident. Thrombosis is most common in the large hepatic veins close to their exit from the liver and in the intrahepatic portion of the inferior vena cava. Hepatic veno-occlusive disease is a variant of the Budd-Chiari syndrome and is caused by occlusion of the central venules and small branches of the hepatic veins. Most commonly, this disorder is traced to the ingestion of toxic pyrrolizidine alkaloids present in plants of the Crotalaria and Senecio genera, which are sometimes used in the formulation of herbal teas (comfrey is the most common in Europe and North America). It is also seen in patients treated with certain antineoplastic chemotherapeutic agents and after hepatic irradiation. Veno-occlusive disease is also reported in association with bone marrow transplantation, possibly as a manifestation of graft-versus-host disease. PATHOLOGY: In the acute stage of hepatic vein thrombosis, the liver is swollen and tense, and the cut surface exhibits a mottled appearance and oozes blood. In the chronic stage, the cut surface is paler, and the liver is firm, because of an increase in connective tissue. Microscopically, the hepatic veins display thrombi in varying stages of evolution, from recent clots to well-organized thrombi that have been canalized. In the acute stage of both the Budd-Chiari syndrome and venoocclusive disease, the sinusoids of the central zone are dilated and packed with erythrocytes. The liver cell plates are compressed, and there is necrosis of centrilobular hepatocytes. In long-standing venous congestion, fibrosis of the central zone radiating into the more peripheral portions of the lobules is conspicuous. The sinusoids are dilated, and the central-to-midzonal hepatocytes show pressure atrophy. Eventually, connective tissue septa link adjacent central zones to form nodules with a single portal tract in the center, a process known as reverse lobulation. The fibrosis is usually not severe enough to justify a label of cirrhosis. CLINICAL FEATURES: Complete thrombosis of the hepatic veins presents as an acute illness characterized by abdominal pain, enlargement of the liver, ascites, and mild jaundice. Acute hepatic failure and death often occur rapidly. The more

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Hepatic encephalopathy Jaundice Coagulopathy ENDOCRINE Pulmonary vascular shunts (↓02 saturation)

Gynecomastia

Renal failure (hepatorenal syndrome)

Vascular spiders

Hypoalbuminemia Portal hypertension

Female escutcheon Testicular atrophy

FIGURE 14-7.

Complications of cirrhosis and hepatic failure.

Vena cava

POSTHEPATIC • Vena cava obstruction or back pressure • Thrombosis of hepatic veins (Budd-Chiari syndrome) • Alcoholic central sclerosis (without cirrhosis) • Venoocclusive disease

Hepatic vein

INTRAHEPATIC • Cirrhosis • Schistosomiasis • Sarcoidosis • Primary biliary cirrhosis (before cirrhotic stage) • Congenital hepatic fibrosis • Toxin (e.g., arsenic)

Portal tract

Central vein

PREHEPATIC • Portal vein thrombosis • Increased splenic flow (e.g., myeloid metaplasia) FIGURE 14-8.

Causes of portal hypertension.

Venous flow from spleen

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usual course, in which the obstruction of the hepatic venous circulation is incomplete, is marked by similar symptoms but may pursue a protracted course over periods ranging from a month to a few years. More than 90% of patients with Budd-Chiari syndrome develop ascites, usually severe, and splenomegaly is seen in more than 30%. Most patients eventually die in hepatic failure or from the complications of portal hypertension. Liver transplantation has been successful in curing the disease.

Portal Hypertension Leads to Systemic Complications Esophageal Varices Esophageal varices arise from the opening of portal–systemic collaterals as an adaptation to decompress the portal venous system. One of the most common causes of death in patients with cirrhosis and other disorders associated with portal hypertension is exsanguinating upper gastrointestinal tract hemorrhage from bleeding esophageal varices. PATHOGENESIS: The collaterals of most clinical significance are located in the submucosa of the lower esophagus and upper stomach and are the result of communications between the portal vein and the gastric coronary vein. Because of the increased blood flow and higher pressure that follow the opening of these collaterals, the submucosal veins in the vicinity of the esophagogastric junction become dilated and protrude into the lumen (see Chapter 13). There is no simple correlation between portal venous pressure and the risk of variceal bleeding, although the risk does rise with increasing size of the varices. The back-pressure in the portal vein is also transmitted to its tributaries, including the inferior hemorrhoidal veins, which become dilated and tortuous (anorectal varices). Collateral veins radiating about the umbilicus produce a pattern known as caput medusae. CLINICAL FEATURES: The prognosis in patients with bleeding esophageal varices is poor, and the acute mortality rate may be as high as 40%. In patients with cirrhosis who survive an initial episode of variceal bleeding, long-term survival is unlikely because of a high risk of rebleeding or worsening liver failure. Permanent decompression of the portal circulation can be achieved by surgically constructed portasystemic shunts. In some cases, liver transplantation is an alternative to shunt surgery.

Splenomegaly The spleen in portal hypertension enlarges progressively and often gives rise to the syndrome of hypersplenism—that is, a decrease in the life span of all of the formed elements of the blood and, therefore, a reduction in their circulating numbers (pancytopenia). Hypersplenism is attributed to an increased rate of removal of erythrocytes, leukocytes, and platelets secondary to the prolonged transit time through the hyperplastic spleen. On gross examination, the spleen is firm and enlarged, up to 1,000 g, and its cut surface is uniformly deep red, with an inapparent white pulp. Microscopically, the splenic sinusoids are dilated, and their walls are thickened by fibrous tissue and lined by hyperplastic endothelial cells and macrophages.

Ascites Ascites refers to the accumulation of fluid in the peritoneal cavity. It often accompanies portal hypertension, and the amount of fluid may be so great (frequently many liters) that it not only distends the abdomen but also interferes with breathing. The onset of ascites in cirrhosis is associated with a poor prognosis.

PATHOGENESIS: Although clearly important in the pathogenesis of cirrhosis, the mechanisms of renal sodium and water retention remain controversial. Hypovolemia resulting from transudation of water and sodium into the peritoneal space, intrinsic defects in volume regulation not secondary to decreased intravascular volume, and peripheral arterial vasodilation have all been suggested to play a role (Fig. 14-9). Other factors contribute to the formation of ascites in cirrhosis. Portal hypertension increases the hydrostatic pressure in the mesenteric capillaries. At the same time, the low serum albumin characteristic of cirrhosis is associated with decreased plasma oncotic pressure. The resulting imbalance in Starling forces leads to transudation of fluid into the peritoneal cavity. Finally, the rate of formation of hepatic lymph exceeds the capacity of the lymphatics to remove it, and the liver “weeps” lymph into the abdomen.

Spontaneous Bacterial Peritonitis Spontaneous bacterial peritonitis is an important complication in patients with both cirrhosis and ascites. The infection is extremely dangerous and carries a very high mortality rate, even when treated with antibiotics. Presumably, the ascitic fluid is seeded with bacteria from the blood or lymph or by the passage of bacteria through the bowel wall.

Viral Hepatitis Viral hepatitis is an infection of hepatocytes that produces necrosis and inflammation of the liver. Many viruses and other infectious agents can produce hepatitis and jaundice, but in the industrialized world, more than 95% of viral hepatitis cases involve a limited number of hepatotropic viruses, named from A to G.

Hepatitis A Virus is the Most Common Cause of Acute Hepatitis Hepatitis A virus (HAV) is a small RNA-containing enterovirus of the picornavirus group (which includes poliovirus). The hepatocyte is the principal site of viral replication, although gastrointestinal epithelial cells may also be infected. Shedding of progeny virus into the bile accounts for its appearance in the feces. HAV is not directly cytopathic, and hepatic injury has been attributed to an immunologic reaction to virally infected hepatocytes. EPIDEMIOLOGY: The only reservoir for HAV is the acutely infected person, and transmission depends primarily on serial passage from person to person by the fecal–oral route. In the United States, about 10% of the population younger than 20 years of age have serologic evidence of previous HAV infection. This circumstance indicates that most infections with HAV are anicteric and remain undetected. Hepatitis A is common in day care centers and among international travelers and male homosexuals, the latter reflecting oral–anal contact. However, in about half of all cases of hepatitis A, no source can be identified. An effective vaccine for hepatitis A confers long-term protection against the disease. CLINICAL FEATURES: After an incubation period of 3 to 6 weeks, persons infected with HAV develop nonspecific symptoms, including fever, malaise, and anorexia. Concomitantly, liver injury is evidenced by a rise in serum aminotransferase activity (Fig. 14-10). As the activities of aminotransferases begin to decline, usually 5 to 10 days later, jaundice may appear. It remains evident for an average of 10 days but may persist for more than a month. In most cases, the elevated levels of aminotransferases return to normal by the time

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ALBUMIN

319

CIRRHOTIC LIVER Decreased albumin production

Increased portal pressure Lymph exudation

Increased hydrostatic pressure Decreased oncotic pressure

Mesenteric capillary

Formation of abdominal fluid Decreasing intravascular volume Increasing intravascular volume

Increased aldosterone (adrenal) Increased Na+ reabsorption (kidney)

ASCITES Pathogenesis of ascites. In addition to the other factors depicted, the traditional concept holds that renal retention of sodium is a response to a decreased “effective” blood volume. An alternative view (overflow hypothesis) considers the increased renal reabsorption of sodium to be a primary effect of cirrhosis that precedes the formation of ascites. Peripheral vasodilation should also considered. Na⫹, sodium. FIGURE 14-9.

jaundice has disappeared. Hepatitis A never pursues a chronic course. There is no carrier state, and infection provides lifelong immunity. Fatal fulminant hepatitis occurs only rarely.

Hepatitis B Virus is a Major Cause of Acute and Chronic Liver Disease Hepatitis B virus (HBV) is a hepatotropic DNA hepadnavirus. The DNA of HBV is predominantly double-stranded and consists of one long circular strand containing the entire genome and a shorter complementary strand that varies from 50% to 85% of the length of the longer strand. The HBV genome contains four genes: • Core (C) gene: The core of the virus contains the core antigen (HBcAg) and the e antigen (HBeAg), both products of the C gene. • Surface gene: The core of HBV is enclosed in a coat that expresses an antigen termed hepatitis B surface antigen (HBsAg). The surface coat is synthesized by infected hepato-

cytes independently from the viral core and is secreted into the blood in vast amounts. HBsAg particles are immunogenic but not infectious. The intact and infectious virus is also synthesized in the hepatocyte (Dane particle). • Polymerase gene: The P gene encodes the DNA polymerase. • X gene: The small X protein activates viral transcription and probably plays a role in the pathogenesis of hepatocellular carcinoma associated with chronic HBV infection. EPIDEMIOLOGY: It is estimated that there are about 200 million chronic carriers of HBV in the world, constituting an enormous reservoir of infection. Carrier rates vary from as low as 0.3% (United States and Western Europe) to 20% in Southeast Asia, sub-Saharan Africa, and Oceania, where the high rate is sustained by vertical transmission of the virus from a carrier mother to her newborn. In the United States, it is estimated that there are 1.3 million chronic HBV carriers, and 50,000 persons are newly infected with HBV annually. Of these new cases, only one-fourth are clinically

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CLINICAL FEATURES: There are three well-recognized clinical courses associated with HBV infection (Fig. 14-11):

SEROLOGIC EVENTS

IgM Anti-HAV IgG Anti-HAV Relative value SERUM TRANSAMINASE clinical activity Exposure

PRESENCE OF HEPATITIS A VIRUS

Liver

Relative value

Feces

Exposure Blood 2

FIGURE 14-10.

6 Weeks

Typical serologic events associated with hepatitis A (HAV).

recognized because of jaundice. Fulminant hepatitis B results in 250 to 300 deaths per year. Routine screening of blood for HBsAg has essentially eliminated the hazard of posttransfusion hepatitis. Whereas no more than 10% of adults infected with HBV become carriers, neonatal hepatitis B is, as a rule, followed by persistent infection in the absence of immunoprophylaxis at birth. In the United States, chronic HBV carriers are particularly common among male homosexuals and drug addicts. Humans are the only significant reservoir of HBV. Unlike hepatitis A, hepatitis B is neither transmitted by the fecal–oral route nor does it contaminate food and water supplies. Although HBsAg is found in most secretions, infectious virus has been demonstrated only in blood, saliva, and semen. Hepatitis B is transmitted by shared blood (often by drug abusers) and frequently by hetero- or homosexual contact. Synthetic vaccines for hepatitis B, composed of recombinant HBsAg or its immunogenic epitopes, are highly effective, confer lifelong immunity, and have greatly reduced the prevalence of the disease. It is now routine in the United States to administer the vaccine to infants. Prompt neonatal immunization of infants born to infected mothers is highly effective in preventing vertical transmission. PATHOGENESIS: HBV is not directly cytopathic, as reflected in the fact that asymptomatic chronic carriers of the virus maintain a large burden of infectious virus in the liver for years without functional or biochemical evidence of liver cell injury. Cytotoxic (CD8⫹) T lymphocytes directed against multiple HBV epitopes are the major mediators of the destruction of hepatocytes and consequent clinical liver disease. Although the intact viral genome is not integrated into the host DNA, genomic fragments are progressively integrated, after which they produce a variety of viral antigens. Thus, despite declining infectivity of the blood, chronic hepatitis tends to persist.

• Acute hepatitis • Fulminant hepatitis • Chronic hepatitis ACUTE HEPATITIS B: Most patients have acute, self-limited hepatitis similar to that produced by HAV, in which complete recovery and lifelong immunity are the rule. The symptoms of hepatitis B are, for the most part, also similar to those of hepatitis A, although acute hepatitis B tends to be somewhat more severe. Typically, symptoms do not appear until 2 to 3 months after exposure, but incubation periods of less than 6 weeks and as long as 6 months are occasionally encountered. Many cases, including virtually all infections in infants and children, are anicteric and, therefore, not clinically apparent. HBsAg, the first marker to appear in the serum of patients with acute hepatitis B, is detected 1 week to 2 months after exposure (see Fig. 14-11). It disappears from the blood during the convalescent phase in patients who recover rapidly from the acute hepatitis. Simultaneously with, or shortly after, the disappearance of HBsAg, antibody to HBsAg (anti-HBs) is found in the blood. Its appearance heralds complete recovery, and its presence provides lifelong immunity. HBcAg (core antigen) does not circulate in the blood, but antibody to HBcAg (anti-HBc) appears shortly after HBsAg. Anti-HBcAg does not clear the virus or protect against reinfection, although it is a marker of previous HBV infection. HBeAg, the second circulating antigen to appear in hepatitis B, is seen before the onset of clinical disease and after the appearance of HBsAg. It generally disappears within about 2 weeks while HBsAg is still present. The presence of HBeAg in the serum correlates with a period of intense viral replication and, hence, maximal infectivity of the patient. Anti-HBe appears shortly after the disappearance of the antigen and is detectable for up to 2 or more years after resolution of the hepatitis. FULMINANT HEPATITIS B: Rarely, acute hepatitis B pursues a fulminant course, characterized by massive liver cell necrosis, hepatic failure, and a high mortality rate. CHRONIC HEPATITIS B: Chronic hepatitis refers to the presence of necrosis and inflammation in the liver for more than 6 months. In 5% to 10% of patients with hepatitis B, HBs antigenemia does not resolve, in which case the infection persists, and the disease progresses to chronic hepatitis B. For unknown reasons, 90% of patients with chronic hepatitis B are male. Patients with chronic hepatitis B do not have detectable antiHBs in the blood, although some manifest circulating HBsAg–antiHBs complexes. These immune complexes cause a variety of extrahepatic ailments, including a serum sickness-like syndrome (fever, rash, urticaria, acute arthritis), polyarteritis, glomerulonephritis, and cryoglobulinemia. In fact, one third to one half of patients with polyarteritis nodosa are carriers of HBV. Some chronic carriers who were initially negative for anti-HBs eventually develop measurable antibody (often after many years), clear the virus, and are restored to full health. Others (no more than 3% of all patients with hepatitis B) never develop anti-HBs and suffer from relentless and progressive chronic hepatitis that leads to cirrhosis. Hepatitis associated with persistent HBsAg antigenemia is often accompanied by the continued presence of HBeAg. As is discussed in detail under the heading of Hepatocellular Carcinoma, chronic hepatitis B is associated with a significant risk of liver cancer. The possible outcomes of infection with HBV are summarized in Figure 14-12.

Hepatitis D Virus (HDV) is a Defective RNA Virus Infection with HDV must occur either simultaneously with HBV infection (coinfection) or after HBV infection (superinfection). HDV and HBsAg are cleared together, and the clinical

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321

Normal hepatocyte nucleus

RECOVERY Symptoms, ALT, Bilirubin Anti-HBc

Exposure

An ti-H

Relative value

HB 1

Months

Years

CHRONIC HBsAg CARRIER WITH ACTIVE HEPATITIS Symptoms, ALT, Bilirubin Anti-HBc Exposure

HB sA g

Relative value

Replicative viral DNA

HB 1

Months

Years

HBsAg

HBV

Integrated nonreplicative DNA ASYMPTOMATIC HBsAg CARRIER

Anti-HBc

Exposure

Relative value

Symptoms, ALT, Bilirubin

eAg

4 Months

3 Years

HBsAg

FIGURE 14-11. Typical serologic events in three distinct outcomes of hepatitis B. (Top panel) In most cases, the appearance of antibody to HBsAg (anti-HBs) ensures complete recovery. Viral DNA disappears from the nucleus of the hepatocyte. (Middle panel) In about 10% of cases of hepatitis B, HBs antigenemia is sustained for longer than 6 months, due to the absence of anti-HBs. Patients in whom viral replication remains active, as evidenced by sustained high levels of HBeAg in the blood, develop active hepatitis. In such cases, the viral genome persists in the nucleus but is not integrated into host DNA. (Lower panel) Patients in whom active viral replication ceases or is attenuated, as reflected in the disappearance of HBeAg from the blood, become asymptomatic carriers. In these individuals, fragments of the hepatitis B virus (HBV) genome are integrated into the host DNA, but episomal DNA is absent.

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course is generally no different from that of the usual acute hepatitis B. However, in some patients, coinfection with HDV leads to severe, fulminant, and often fatal hepatitis, particularly in intravenous drug abusers. Superinfection of an HBV carrier with HDV typically increases the severity of an existing chronic hepatitis. In fact, 70% to 80% of HBsAg carriers superinfected with HDV develop chronic hepatitis.

Hepatitis C Virus is a Common Cause of Chronic Hepatitis and Cirrhosis Hepatitis C virus (HCV) is classified as a flavivirus and contains a single strand of RNA. Six different but related HCV genotypes are recognized; types 1, 2, and 3 are the most common (72% in the United States and Western Europe). Genotypes 2 and 3 are more responsive to antiviral therapy than is type 1. In an individual patient, many mutant HCV strains arise, which likely accounts for several features of infection, including (1) the inability of antiHCV IgG antibodies to clear the infection, (2) persistent and relapsing infection (chronic hepatitis), and (3) lack of progress in developing a vaccine. EPIDEMIOLOGY: The prevalence of HCV is variable, ranging from 1.6% in the United States to 22% in Egypt. It is estimated that 200 million people are infected worldwide. HCV is the most common indication for liver transplantation, accounting for up to half of all patients on the waiting list. HCV infection is transmitted by contact with infected blood and is particularly associated with intravenous drug abuse and high-risk sexual behavior (particularly among male homosexuals). The risk from blood transfusions has been almost completely eliminated, owing to screening of the blood supply for anti-HCV antibodies. Vertical transmission of HCV from an infected mother to her newborn baby is infrequent (about 5%), although it is more common in the case of women infected with HIV. About 40% of cases occur in the absence of known risk factors.

PATHOGENESIS: HCV is not directly cytopathic, as evidenced by the fact that many chronic carriers of the virus often have no evidence of liver cell injury. Despite active humoral and cellular immune responses directed against all viral proteins, most patients display persistent viremia. Liver cell injury has been attributed to cytotoxic T-cell responses to virally infected hepatocytes. The mechanisms by which HCV persists have not been clarified. CLINICAL FEATURES: The incubation period of hepatitis C is similar to that of hepatitis B. Elevated serum aminotransferase activities (Fig. 14-13) are usually found within 1 to 3 months of exposure to the virus (range, 2 to 26 weeks). The presence of HCV RNA in the serum can be detected by the polymerase chain reaction within 2 weeks of infection. Anti-HCV antibodies usually appear 7 to 8 weeks after HCV infection and persist during the chronic infection phase. The clinical course of acute hepatitis C is surprisingly mild and is only very rarely complicated by fulminant hepatitis. In fact, only 10% of patients become jaundiced in the acute phase. The major consequences of infection with HCV relate to chronic disease (Fig. 14-14). The probability of persistent HCV infection and chronic hepatitis is at least 80% and may be higher. Moreover, chronic hepatitis ensues in 50% to 70% of infected persons. Clinical morbidity in most patients remains mild for at least 10 years and in many cases, for 20 or more years. Importantly, approximately 20% of patients with chronic hepatitis C eventually develop cirrhosis. In patients with well-established cirrhosis, up to 5% a year develop primary hepatocellular carcinoma. Extrahepatic manifestations of hepatitis C are well recognized. Chronic HCV infection has been associated with essential mixed cryoglobulinemia, membranoproliferative glomerulonephritis, porphyria cutanea tarda, and sicca syndrome. A higher incidence of lymphoma has also been described in patients with chronic hepatitis C. Treatment with ␣-interferon and antiviral agents has been beneficial in many patients with chronic hepatitis C.

HBV INFECTION

65% Transient subclinical infection

35% Symptomatic acute hepatitis

>90% Recovery

10% Chronic hepatitis

1% Death or Confluent hepatic necrosis

70-90% Asymptomatic HbsAg carrier

100%

10-30% Chronic hepatitis and Cirrhosis

2%-6% annually RECOVERY

FIGURE 14-12.

Possible outcomes of infection with the hepatitis B virus (HBV).

50 % ≤ 50%

≤ 50 % > 50%

Nuclear atypia Round nuclei Variation in shape and size Variation in staining Hyperchromasia Coarsely clumped chromatin Prominent nucleoli Frequent mitoses Abnormal mitoses

Grading of endometrial adenocarcinoma. The grade depends primarily on the architectural pattern, but significant nuclear atypia changes a grade 1 tumor to grade 2, and a grade 2 tumor to grade 3. Nuclear atypia is characterized by round nuclei; variation in shape, size, and staining; hyperchromasia; coarsely clumped chromating; prominent nucleoli; and frequent and abnormal mitoses. Significant nuclear atypia if present increases the tumor grade. FIGURE 18-15.

411

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Pedunculated submucosal

generative hyalinization that are sharply demarcated from adjacent normal myometrium. Leiomyomas that display low mitotic activity (ⱕ4 mitoses per 10 high-power fields) lack nuclear atypia and geographical necrosis and have little or no malignant potential. “Mitotically active leiomyomas” show brisk mitotic activity but are small, sharply demarcated from the adjacent normal myometrium, and lack both geographical necrosis and significant cellular atypia. They are generally considered to be benign. Microscopically leiomyomas exhibit interlacing fascicles of uniform spindle cells, in which nuclei are elongated and have blunt ends (see Fig. 18-17B). The cytoplasm is abundant, eosinophilic, and fibrillar. The myocytes of leiomyomas and adjacent myometrium are cytologically identical.

Subserosal

Intramural Submucosal

CLINICAL FEATURES: Submucosal leiomyomas may cause bleeding, owing to ulceration of the thinned, overlying endometrium. Some submucosal leiomyomas become pedunculated and protrude through the cervical os, eliciting cramping pains. Many intramural leiomyomas are symptomatic because of sheer bulk, and large ones may interfere with bowel or bladder function or cause dystocia in labor. Leiomyomas usually grow slowly but occasionally enlarge rapidly during pregnancy. Large symptomatic leiomyomas are removed by myomectomy or hysterectomy.

Leiomyosarcoma is Rare in Comparison to Leiomyoma Leiomyomas of the uterus. The leiomyomas are intramural; submucosal (a pedunculated one appearing in the form of an endometrial polyp) and subserosal (one compressing the bladder and the other compressing the rectum). FIGURE 18-16.

Leiomyosarcoma is a malignancy of smooth muscle origin with an incidence of only 1/1,000 that of its benign counterpart. It accounts for 2% of uterine malignancies. Its pathogenesis is uncertain, but at least some appear to arise from within leiomyomas. Women with leiomyosarcomas are on average more than a decade older (age above 50 years) than those with leiomyomas, and the malignant tumors are larger (10 to 15 cm vs. 3 to 5 cm).

rare before age 20, and most regress after menopause. Although often multiple, each leiomyoma is monoclonal (see Chapter 5). Estrogen promotes their growth, although it does not initiate them.

PATHOLOGY: Leiomyosarcoma should be suspected if an apparent leiomyoma is soft, shows areas of necrosis on gross examination, has irregular borders (invasion into neighboring myometrium), or does not bulge above the surface when cut. Mitotic activity, cellular atypia, and geographical necrosis are the best diagnostic criteria. Size is an important feature. Tumors under 5 cm in diameter almost never recur, but most leiomyosarcomas are large and are advanced when detected and are usually fatal despite combinations of surgery, radiation therapy, and chemotherapy.

PATHOLOGY: Grossly, leiomyomas are firm, pale gray, whorled, and without encapsulation (Figs. 18-16 and 18-17). They range from 1 mm to more than 30 cm in diameter. The cut surface bulges, and the borders are smooth and distinct from neighboring myometrium. Most leiomyomas are intramural, but some are submucosal, subserosal, or pedunculated. Many, especially larger ones, show areas of de-

Leiomyoma of the uterus. A. A bisected uterus displays a prominent, sharply circumscribed fleshy tumor. B. Microscopically, smooth muscle cells intertwine in bundles, some of which are cut longitudinally (elongated nuclei) and others transversely. FIGURE 18-17.

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FALLOPIAN TUBE Salpingitis Salpingitis is inflammation of the fallopian tubes, typically due to infections ascending from the lower genital tract. The most common causative organisms are Neisseria gonorrhoeae, Escherichia coli, Chlamydia, and Mycoplasma. Infection is typically polymicrobial. Acute episodes of salpingitis (particularly those associated with chlamydial infection) may be asymptomatic. A fallopian tube damaged by prior infection is particularly susceptible to reinfection. In most cases, chronic salpingitis develops only after repeated episodes of acute salpingitis. PATHOLOGY AND CLINICAL FEATURES: In acute salpingitis, microscopic examination reveals marked infiltration by polymorphonuclear leukocytes, pronounced edema, and congestion of the mucosal folds (plicae). The inflammatory infiltrate in chronic salpingitis consists of lymphocytes and plasma cells. Edema and congestion tend to be minimal. In late stages, the fallopian tube may seal and become distended with pus (pyo salpinx) or a transudate (hydrosalpinx). The fallopian tube allows ascending microorganisms from the lower genital tract to reach the peritoneal cavity, leading to peritonitis and PID. The adjacent ovary may also be involved, sometimes giving rise to a tuboovarian abscess. Complications also ensue from damage to the fallopian tube itself. Destruction of the epithelium or deposition of fibrin on the mucosa results in formation of fibrin bridges, which cause the plicae to adhere to one another The damage caused by chronic salpingitis may impair tubal motility and the passage of sperm, in which case infertility results. Chronic salpingitis is a common cause of ectopic pregnancy, because adherent mucosal plicae create pockets in which ova become entrapped.

Ectopic Pregnancy Ectopic pregnancy refers to implantation of a fertilized ovum outside the endometrium. More than 95% of ectopic pregnancies occur in the fallopian tube, mostly in the distal and middle thirds. PATHOLOGY: Ectopic pregnancy results when passage of the conceptus along the fallopian tube is impeded, for example, by mucosal adhesions or abnormal tubal motility secondary to inflammatory disease or endometriosis. The trophoblast readily penetrates the mucosa and muscular tubal wall. Blood from the implantation site in the tube enters the peritoneal cavity, causing abdominal pain. The thin tubal wall usually ruptures by the 12th week of gestation. Tubal rupture is life-threatening to the mother because it can result in rapid exsanguination. Ectopic pregnancy must be treated promptly with surgical or chemotherapeutic intervention.

OVARY Cystic Lesions of the Ovaries Cysts are the most common cause of enlarged ovaries. Those that arise from the invaginated surface epithelium (serous cysts) are quite common. Almost all of the rest derive from ovarian follicles.

Follicle Cysts Tend to be Asymptomatic Follicle cysts are thin-walled, fluid-filled structures that are lined internally by granulosa cells and externally by theca interna cells. They occur at any

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age up to menopause, are unilocular and may be single or multiple, unilateral, or bilateral. These cysts arise from ovarian follicles and are probably related to abnormalities in pituitary gonadotropin release. PATHOLOGY: Follicle cysts rarely exceed 5 cm in the greatest dimension. In an unstimulated state, the granulosa cells of the cyst have uniform, round nuclei and little cytoplasm. Theca cells are small and spindleshaped. Occasionally, the layers may be luteinized, in which case the lumen contains fluid high in estrogen or progesterone. If the cyst persists, hormonal output can cause precocious puberty in a child and menstrual irregularities in an adult. The only significant complication is mild intraperitoneal bleeding.

Corpus Luteum Cyst Can Bleed A cyst results from delayed resolution of a corpus luteum’s central cavity. Continued progesterone synthesis by the luteal cyst leads to menstrual irregularities. Rupture of a cyst can cause mild hemorrhage into the abdominal cavity. A corpus luteum cyst is typically unilocular, 3 to 5 cm in size, and possesses a yellow wall. The contents of the cyst vary from serosanguinous fluid to clotted blood. Microscopic examination shows numerous large, luteinized granulosa cells. The condition is self-limited.

Theca Lutein Cysts Relate to High Gonadotropin Levels Theca lutein cysts, also known as hyperreactio luteinalis, are commonly multiple and bilateral. They are associated with high levels of circulating gonadotropins (e.g., in pregnancy, hydatidiform mole, choriocarcinoma, and exogenous gonadotropin therapy) or physical impediments to ovulation (dense adhesions, cortical fibrosis). The excessive gonadotropin levels lead to exaggerated stimulation of the theca interna and extensive cyst formation. PATHOLOGY: Multiple thin-walled cysts filled with clear fluid replace both ovaries. Microscopically, cysts show a markedly luteinized layer of theca interna. Ovarian parenchyma shows edema and foci of luteinized stromal cells. Intra-abdominal hemorrhage secondary to torsion or rupture of the cyst may require surgical intervention.

Polycystic Ovary Syndrome Polycystic ovary syndrome, also known as Stein-Leventhal syndrome, describes (1) clinical manifestations related to the secretion of excess androgenic hormones, (2) persistent anovulation, and (3) ovaries containing many small subcapsular cysts. It was described initially as a syndrome of secondary amenorrhea, hirsutism, and obesity. However, clinical presentations are now known to be far more variable and include amenorrheic women who appear otherwise normal and, even rarely, have ovaries lacking polycystic features. Polycystic ovary syndrome is a common cause of infertility, and 7% of women experience the condition. PATHOGENESIS: The central abnormality in polycystic ovary syndrome is a state of functional ovarian hyperandrogenism with elevated levels of LH, although increased amounts of this hormone are probably a result, rather than a cause, of ovarian dysfunction (Fig. 18-18). Excess ovarian androgens act locally to cause (1) premature follicular atresia, (2) multiple follicular cysts, and (3) a persistent anovulatory state. Impaired follicular maturation causes decreased secretion of progesterone. Peripherally, hyperandrogenism leads to hirsutism, acne, and male-pattern (androgen-dependent) alopecia.

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Luteinizing hormone

Insulin resistance

Hyperinsulinemia

Dysregulation of androgen secretion

Intra-ovarian androgen (Theca cell/luteinized stromal cell)

Hyperandrogenemia

Hirsutism Acne Androgen-dependent alopecia

Long term effects; endometrial hyperpasia/carcinoma

Epithelial Tumors Account for More than 90% of Ovarian Cancers

Follicular atresia

Tumors of common epithelial origin can be broadly classified as (1) benign, (2) of borderline malignancy (also called atypical proliferating or low malignant potential), and (3) malignant. Estrone (peripherally converted) Progesterone Amenorrhea Infertility Polycystic ovaries

CHRONIC ANOVULATION FIGURE 18-18.

older than 60 years, but may occur in younger women with a family history of the disease. Unfortunately, this cancer is difficult to detect early in its evolution, when it is still curable. More than three fourths of patients already have extragonadal tumor spread to the pelvis or abdomen at the time of diagnosis. The broad range of histologic features in these tumors reflects the diverse anatomical structure of the ovary itself. The classification of ovarian tumors identifies them by the tissue of origin (Fig. 18-19). Most frequently encountered tumors arise from surface epithelium and are termed common epithelial tumors. Other important groups include germ cell tumors, sex cord/stromal tumors, steroid cell tumors, and tumors metastatic to the ovary.

Pathogenesis of the polycystic ovary syndrome.

PATHOLOGY: On gross examination, both ovaries are enlarged. The surface is smooth, reflecting the absence of ovulation. On cut section, the cortex is thickened and discloses numerous theca-lutein type cysts, typically 2 to 8 mm in diameter. These are arranged peripherally around a dense core of stroma or scattered throughout an increased amount of stroma. Microscopically, the following features are present: (1) numerous follicles in early stages of development; (2) follicular atresia; (3) increased stroma, occasionally with luteinized cells (hyperthecosis); and (4) morphologic signs of an absence of ovulation (thick, smooth capsule, and absence of corpora lutea and corpora albicantiae). Many subcapsular cysts show thick zones of theca interna, in which some cells may be luteinized. CLINICAL FEATURES: Nearly three quarters of women in the United States with anovulatory infertility have polycystic ovary syndrome. Patients are typically in their 20s and report early obesity, menstrual problems, and hirsutism. Half of women with polycystic ovary syndrome are amenorrheic and most others have irregular menstrual periods. Only 75% of affected women are actually infertile, indicating that some do occasionally ovulate. Unopposed acyclic estrogen activity increases the incidence of endometrial hyperplasia and adenocarcinoma. Treatment of polycystic ovary syndrome is mostly hormonal and is directed toward interrupting the constant excess of androgens.

Ovarian Tumors Ovarian cancer is the second most frequent gynecological malignancy after endometrial cancer. In the United States, it carries a higher mortality rate than all other female genital cancers combined. Approximately 20,000 new cases of ovarian cancer are diagnosed each year in the United States, and more than 15,000 women die from the disease. These tumors predominate in women

EPIDEMIOLOGY: Epidemiologic studies suggest that common epithelial neoplasms are related to repeated disruption and repair of the epithelial surface, which is part of cyclic ovulation. Thus, tumors most commonly afflict women who are nulliparous and, conversely, occur least often in women in whom ovulation has been suppressed (e.g., by pregnancy or oral contraceptives). A family history of ovarian carcinoma is occasionally elicited. Women with a first-degree relative with ovarian cancer have a 3.5fold increased risk of developing the same disease. Women with a history of ovarian carcinoma are also at greater risk for breast cancer and vice versa. A gene implicated in many hereditary breast cancers, BRCA-1 (17q12-q23), has been incriminated in familial ovarian cancers as well. Women who bear BRCA-1 tend to develop ovarian cancer much earlier than those who have sporadic ovarian cancer, but their prognosis is considerably better. PATHOGENESIS: Most common epithelial tumors, especially serous carcinomas, arise from the ovarian surface epithelium or serosa. As the ovary develops, the surface epithelium may extend into the ovarian stroma to form glands and cysts. PATHOLOGY: In order of decreasing frequency, the common epithelial tumors are: • Serous tumors, which resemble the epithelium of the fallopian tube • Mucinous tumors, which mimic the mucosa of the endocervix • Endometrioid tumors, which are similar to the glands of the endometrium • Clear cell tumors, which display glycogen-rich cells that resemble endometrial glands in pregnancy • Transitional cell tumors, which resemble the mucosa of the bladder • Mixed tumors

Benign Epithelial Tumors SEROUS OR MUCINOUS ADENOMAS: Benign common epithelial tumors are almost always serous or mucinous adenomas and generally arise in women between 20 and 60 years old. The neoplasms are frequently large, often 15 to 30 cm in diameter. Some, particularly the mucinous variety, reach massive proportions, exceeding 50 cm in diameter, in which case they may mimic the appearance of a term pregnancy. Benign epithelial tumors are typically cystic, hence the term cystadenoma. Serous cystadenomas are more commonly bilateral (15%) than mucinous cystadenomas and tend to be unilocular (Fig. 18-20). By contrast, muci-

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SEROSAL EPITHELIUM Benign— Serous cystadenoma Mucinous cystadenoma Brenner tumor

GERM CELL

Borderline— Serous and mucinous cystadenomas Malignant— Serous adenocarcinoma Mucinous adenocarcinoma Endometrioid carcinoma Transitional cell carcinoma

Benign— Dermoid cyst (teratoma) Malignant— Dysgerminoma Yolk sac tumor Choriocarcinoma Embryonal carcinoma

Hilus cell tumor (benign)

GONADAL STROMA Benign— Thecoma Fibroma Malignant— Granulosa cell tumor Sertoli–Leydig cell tumor

FIGURE 18-19.

Classification of ovarian neoplasms based on cell of origin.

nous tumors characteristically show hundreds of small cysts (locules) (Fig. 18-21). As opposed to their malignant counterparts, benign ovarian epithelial tumors tend to have thin walls and lack solid areas. Microscopically, one layer of tall columnar epithelium lines the cysts. Papillae, when present, consist of a fibrovascular core covered by a single layer of tall columnar epithelium identical to that of the cyst lining.

TRANSITIONAL CELL TUMOR (BRENNER TUMOR): The typical Brenner tumor is benign and occurs at all ages, with half of the cases presenting in women over the age of 50 years. Size varies from a microscopic focus to masses as large as 8 cm or more in diameter. Histologically, Brenner tumors show solid nests of transitional-like (urothelium-like) cells encased in a dense, fibrous stroma. The most superficial epithelial cells may exhibit mucinous differentiation.

Serous cystadenoma of the ovary. The fluid has been removed from this huge unilocular serous cystadenoma. The wall is thin and translucent. On microscopic examination, the cyst is lined by a single layer of ciliated tubal-type epithelium. FIGURE 18-20.

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A FIGURE 18-21.

Mucinous cystadenoma of the ovary. A. The tumor is characterized by numerous cysts filled with thick, viscous fluid. B. A single layer of mucinous epithelial cells lines the cyst.

Borderline Tumors (Tumors of Low Malignant Potential) or Atypical Proliferative Tumors “Borderline tumors” comprise a well-defined group of ovarian tumors that share an excellent prognosis, despite histologic features suggesting cancer. They generally occur in women between the ages of 20 and 40 years but may also be encountered in older women. In terms of biological behavior, the tumor is “of low malignant potential” but shows atypical and proliferative morphology. A surgical cure is almost always possible if the tumor is confined to the ovaries. Even when it has spread to the pelvis or abdomen, 80% of patients are alive after 5 years, although there is a significant rate of late recurrence. Serous tumors of borderline malignancy are more commonly bilateral (35%) than those that are mucinous (5%) or other types. The tumors vary in size, although mucinous ones are sometimes gigantic (100⫹ kg). In serous tumors of borderline malignancy, papillary projections, ranging from fine and exuberant to grape-like clusters arising from the cyst wall, are common. Microscopically, these structures resemble papillary fronds in benign cystadenomas, but they are distinguished from them by (1) epithelial stratification, (2) nuclear atypism, and (3) mitotic activity. The same criteria apply to borderline mucinous tumors, although papillary projections are less conspicuous. By definition, the presence of more than focal microinvasion (which is defined as discrete nests of epithelial cells that invade less than 3 mm into the ovarian stoma) identifies a tumor as frankly malignant, rather than borderline. However, borderline tumors with lymph node metastases or implants in the peritoneum, whether noninvasive or invasive, are still considered “borderline,” reflecting that this category is well defined and carries a prognosis far better than the usual adenocarcinoma.

Malignant Epithelial Tumors Malignant epithelial tumors of the ovary are most common between 40 and 60 years of age and are rare under the age of 35. By the time an ovarian cancer has reached 10 to 15 cm, it has often spread beyond the ovary and seeded the peritoneum. SEROUS ADENOCARCINOMA: This tumor (commonly called “cystadenocarcinoma”) is the most common malignancy of the ovary, accounting for one third of all ovarian cancers. Advanced stage tumors tend to be bilateral, as are two thirds of serous cancers with extragonadal spread. On gross examination, serous tumors tend to be uniform throughout and are usually uniloculated or pauciloculated, with soft, delicate papillae lining the entire sur-

face. Solid areas, often with necrosis and hemorrhage, are common (Fig. 18-22). Microscopically, serous adenocarcinomas vary from well differentiated to poorly differentiated. In the latter case, the papillary pattern may be inconspicuous, with most areas composed of solid sheets of malignant cells. Stromal and capsular invasion by the tumor cells is evident. Laminated calcified concretions, referred to as psammoma bodies, are present in one third of cases (see Fig. 18-22C). MUCINOUS ADENOCARCINOMA: Mucinous cystadenocarcinoma constitutes about 10% of ovarian cancers. When confined to the ovary, one-sixth of cases are bilateral. Mucinous cancers are typically multilocular, with hundreds to thousands of small cysts. Primary ovarian mucinous tumors often contain both solid areas with clearly malignant features and cystic areas with papillary projections, which typically appear as benign or borderline tumors. Microscopically, the same mucinous tumor may display a full range of appearances from well to poorly differentiated. Well-differentiated mucinous tumors contain neoplastic glands lined by tall columnar, mucin-producing cells, usually with some solid or cribriform areas (Fig. 18-23). Poorly differentiated mucinous adenocarcinomas exhibit irregular nests and cords of tumor cells and numerous mitoses. Stromal invasion is the rule, and infiltration of the serosa is common. ENDOMETRIOID ADENOCARCINOMA: Endometrioid adenocarcinoma histologically resembles its endometrial counterpart, may include areas of squamous differentiation, and is second only to serous adenocarcinoma in frequency, accounting for 20% of all ovarian cancers. The tumor occurs most commonly after menopause. In contrast to serous and mucinous neoplasms, most endometrioid tumors are malignant. Up to one half of these cancers are bilateral. On gross examination, endometrioid carcinomas vary in size from 2 cm to more than 30 cm. Most are largely solid and exhibit necrotic areas, although they may be cystic. Microscopically, they are graded according to the same scheme used for endometrial adenocarcinomas. Between 15% and 50% of patients with endometrioid carcinoma of the ovary also harbor an endometrial cancer. As with all malignant epithelial tumors of the ovary, the prognosis depends on the stage at which it presents. CLEAR CELL ADENOCARCINOMA: This ovarian cancer, which is closely related to endometrioid adenocarcinoma, often

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Serous cystadenocarcinoma. A. The ovary is enlarged by a solid tumor that exhibits extensive necrosis (N). B. Microscopic examination shows a papillary cancer invading the ovarian stroma. Several psammoma bodies are present (arrows). C. A higher-power view shows the laminated structure of a psammoma body. FIGURE 18-22.

occurs in association with endometriosis. It constitutes 5% to 10% of all ovarian cancers, usually occurring after menopause. The size ranges from 2 to 30 cm in diameter, and 40% are bilateral. Most of these tumors are partially cystic and exhibit necrosis and hemorrhage in the solid areas. Microscopically, clear cell ovarian adenocarcinoma displays sheets or tubules of malignant cells with clear cytoplasm. In its tubular form, malignant cells often display bulbous nuclei that protrude into the lumen of the tubule (“hobnail cells”). The clinical course parallels that of endometrioid carcinoma.

cific symptoms, metastatic cancers are associated with ascites, weakness, weight loss, and cachexia. Survival for patients with malignant ovarian tumors is generally poor. Overall, the 5-year survival rate is only 35%, because more than half of the tumors have spread to the abdominal cavity or elsewhere by the time they are discovered. The cornerstone to managing ovarian cancer is surgery, which removes the primary tumor, establishes the diagnosis, and assesses the extent of spread. Adjuvant chemotherapy is used to treat distant occult sites of tumor spread.

CLINICAL FEATURES: Most ovarian tumors do not secrete hormones. However, an antibody to the cancer antigen, CA-125, in the serum detects half of the epithelial tumors that are confined to the ovary and 90% that have already spread. Ovarian masses rarely cause symptoms until they are large. When they distend the abdomen, they cause pain, pelvic pressure, or compression of regional organs. By the time ovarian cancers are diagnosed, many have metastasized (implanted) to the surfaces of the pelvis, abdominal organs, bladder, diaphragm, paracolic gutters, or omentum. Lymphatic dissemination carries malignant cells preferentially to para-aortic lymph nodes. In addition to spe-

Germ Cell Tumors Tend to be Benign in Adults and Malignant in Children Tumors derived from germ cells constitute one fourth of all ovarian tumors. In adult females, germ cell tumors are virtually all benign (mature cystic teratoma, dermoid cyst), whereas in children and young adults, they are largely cancerous. In children, germ cell tumors are the most common type of ovarian cancer (60%); they are rare after menopause. The neoplastic germ cell may follow one of several lines of differentiation, giving rise to tumors analogous to those found in the male testes (Fig. 18-24; see also Chapter 17).

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Dysgerminoma is treated surgically, and the 5-year survival rate for patients with stage I tumor approaches 100%. Because the tumor is highly radiosensitive and also responsive to chemotherapy, 5-year survival rates even for higher-stage tumors still exceed 80%.

Teratoma Teratoma is a tumor of germ cell origin that differentiates toward somatic structures. Most teratomas contain tissues from at least two and usually all three embryonic layers. MATURE TERATOMA (MATURE CYSTIC TERATOMA, DERMOID CYST): This benign neoplasm accounts for one fourth of all ovarian tumors, with a peak incidence in the third decade. Mature teratomas develop by parthenogenesis. Haploid (postmeiotic) germ cells endoreduplicate to give rise to diploid, genetically female, tumor cells (46,XX).

Mucinous cystadenocarcinoma. The malignant glands are arranged in a cribriform pattern and are composed of mucin-producing columnar cells. FIGURE 18-23.

PATHOLOGY: Mature teratomas are cystic and more than 90% contain skin, sebaceous glands, and hair follicles (Fig. 18-25). Half exhibit smooth muscle, sweat glands, cartilage, bone, teeth, and respiratory tract epithelium. Tissues such as gut, thyroid, and brain are seen less frequently. Struma ovarii refers to a cystic lesion composed pre-

Dysgerminoma Dysgerminoma is the ovarian counterpart of testicular seminoma and is composed of primordial germ cells. It accounts for less than 2% of all ovarian cancers but constitutes 10% of these malignancies in women younger than 20 years of age. Most patients are between 10 and 30 years old. The tumors are bilateral in 15% of cases. PATHOLOGY: Grossly, dysgerminomas are often large and firm and have a bosselated external surface. The cut surface is soft and fleshy. Microscopic examination reveals large nests of monotonously uniform tumor cells, which have a clear glycogen-filled cytoplasm and irregularly flattened central nuclei. Fibrous septa containing lymphocytes traverse the tumor.

NO DIFFERENTIATION

Germ Cell

Dysgerminoma (ovarian seminoma)

DIFFERENTIATION

Embryonal carcinoma

Extraembryonic tissue

Embryonic tissue B

Endodermal sinus (yolk sac) tumor

FIGURE 18-24.

Choriocarcinoma

Teratoma (ectoderm, mesoderm, endoderm)

Classification of germ cell tumors of the ovary.

Mature cystic teratoma of the ovary. A. A mature cystic teratoma has been opened to reveal a solid knob (arrow) from which hair projects. B. A photomicrograph of the solid knob shows epidermal and respiratory components. Tissue resembling the skin exhibits an epidermis (E) with underlying sebaceous glands (S). The respiratory tissue consists of mucous glands (M), cartilage (C), and respiratory epithelium (R). FIGURE 18-25.

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dominantly of thyroid tissue (5% to 20% of mature cystic teratomas). Rare cases of hyperthyroidism have been associated with struma ovarii. Very few (1%) of dermoid cysts become malignant. These cancers usually occur in older women and correspond to the tumors that arise in other differentiated tissues of the body. Three fourths of all cancers that arise in dermoid cysts are squamous cell carcinomas. The remainder includes carcinoid tumors, basal cell carcinoma, thyroid cancer, adenocarcinoma, and others. The prognosis of patients with malignant transformation of mature cystic teratoma is related largely to stage of the cancer.

nations are useful both for diagnosis and follow-up. The tumor is highly aggressive but responds to chemotherapy.

IMMATURE TERATOMA: Immature teratomas of the ovary are composed of elements derived from the three germ layers. However, unlike mature cystic teratoma, the immature variety contains embryonal tissues. Immature teratoma accounts for 20% of malignant tumors at all sites in women under the age of 20 years and becomes progressively less common in older women.

Ovarian Fibroma

PATHOLOGY: Immature teratoma is predominantly solid and lobulated, with numerous small cysts. Solid areas may contain grossly recognizable immature bone and cartilage. Microscopically, multiple tumor components are usually found, including those differentiating toward nerve (neuroepithelial rosettes and immature glia) glands and other structures found in mature cystic teratomas. Survival correlates with tumor grade. Well-differentiated immature teratomas generally have a favorable outcome, but high-grade tumors (predominantly embryonal tissue) have a poor prognosis.

Yolk Sac Tumor Yolk sac tumor is a highly malignant tumor of women under the age of 30 years that histologically resembles the mesenchyme of the primitive yolk sac. It is the second most common malignant germ cell tumor and is almost always unilateral. PATHOLOGY: Typically, the neoplasm is large and displays extensive necrosis and hemorrhage. Microscopic examination reveals multiple patterns. The most common appearance is a reticular, honeycombed structure of communicating spaces lined by primitive cells. Schiller-Duval bodies are found sparingly in a few tumors but are characteristic. They consist of papillae that protrude into a space lined by tumor cells, resembling the glomerular Bowman’s space. The papillae are covered by a mantle of embryonal cells and contain a fibrovascular core and a central blood vessel. Yolk sack tumors secrete ␣-fetoprotein, which can be demonstrated histochemically within eosinophilic droplets. Detection of ␣-fetoprotein in the blood is useful for diagnosis and for monitoring the effectiveness of therapy. The neoplasm was previously nearly always fatal but with chemotherapy, the 5-year survival rate for stage I yolk sac tumors exceeds 80%.

Choriocarcinoma Choriocarcinoma of the ovary is a rare tumor that mimics the epithelial covering of placental villi, namely, cytotrophoblast and syncytiotrophoblast. Derivation from ovarian germ cells is assumed if the tumor arises before puberty or in combination with another germ cell tumor. In women of reproductive age, however, ovarian choriocarcinoma may also be a metastasis from an intrauterine gestational tumor. Choriocarcinoma of germ cell origin manifests in young girls as precocious sexual development, menstrual irregularities, or rapid breast enlargement. PATHOLOGY: Choriocarcinoma is unilateral, solid, and widely hemorrhagic. Microscopically, it shows a mixture of malignant cytotrophoblast and syncytiotrophoblast (see placenta, choriocarcinoma, below). The syncytial cells secrete hCG, which accounts for the frequent finding of a positive pregnancy test result. Serial serum hCG determi-

Sex Cord/Stromal Tumors are Clinically Functional Tumors of the sex cord and stroma originate from either primitive sex cords or from mesenchymal stroma of the developing gonad. They account for 10% of ovarian tumors. The tumors range from benign to lowgrade malignant and may differentiate toward female (granulosa and theca cells) or male (Sertoli and Leydig cells) structures.

Fibromas account for 75% of all stromal tumors and 7% of all ovarian tumors. They occur at all ages, with a peak in the perimenopausal period and are virtually always benign. PATHOLOGY: Fibromas are solid, firm, and white. Microscopically, the cells resemble the stroma of the normal ovarian cortex, appearing as well-differentiated spindle cells embedded in variable amounts of collagen. Half of the larger tumors are associated with ascites and, rarely, with ascites and pleural effusions (Meigs syndrome).

Thecoma Thecomas are functional ovarian tumors that arise in postmenopausal women and are almost always benign. They are closely related to fibromas but additionally contain varying amounts of steroidogenic cells, which in many cases produce estrogens or androgen. PATHOLOGY: Thecomas are solid tumors, usually 5 to 10 cm in diameter. The cut section is yellow, due to the presence of many lipid-laden theca cells. Microscopically, the cells are large and oblong to round, with a vacuolated cytoplasm that contains lipid. Bands of hyalinized collagen separate nests of theca cells. Because of estrogen output by the tumor, thecomas in premenopausal women commonly cause irregularity in menstrual cycles and breast enlargement. Endometrial hyperplasia and cancer are well-recognized complications.

Granulosa Cell Tumor Granulosa cell tumor is the prototypical functional neoplasm of the ovary associated with estrogen secretion. This tumor should be considered malignant because of its potential for local spread and the rare occurrence of distant metastases. PATHOGENESIS: Most granulosa cell tumors occur after menopause (adult form) and are unusual before puberty. The juvenile form, which occurs in children and young women, has distinct clinical and pathologic features (hyperestrinism and precocious puberty). PATHOLOGY: Adult-type granulosa cell tumors, like most ovarian tumors, are large and focally cystic to solid. The cut surface shows yellow areas, representing lipid-laden luteinized granulosa cells and white zones of stroma and focal hemorrhages (Fig. 18-26). Microscopically, granulosa cell tumors display an array of growth patterns: (1) diffuse (sarcomatoid); (2) insular (islands of cells); or (3) trabecular (anastomotic bands of granulosa cells). Haphazard orientation of nuclei about a central degenerative space results in a characteristic follicular pattern (Call-Exner bodies) (see Fig. 18-26B). Tumor cells are typically spindle-shaped and commonly have a cleaved, elongated nucleus (coffee bean appearance). CLINICAL FEATURES: Three fourths of granulosa cell tumors secrete estrogens. Thus, benign endometrial hyperplasia is a common presenting sign. It predisposes to EIN or endometrial adenocarcinoma if the functioning

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B Granulosa cell tumor of the ovary. A. Cross-section of the enlarged ovary shows a variegated solid tumor with focal hemorrhages. The yellow areas represent collections of lipid-laden luteinized granulosa cells. B. The orientation of tumor cells about central spaces results in the characteristic follicular pattern (Call-Exner bodies). FIGURE 18-26.

granulosa cell tumor remains undetected. When detected clinically, 90% of granulosa cell tumors are confined to the ovary (stage I). The 10-year survival rate for these patients is greater than 90%. Tumors that have extended into the pelvis and lower abdomen have a poorer prognosis. Late recurrence after surgical removal is not uncommon after 5 to 10 years and is usually fatal.

Sertoli-Leydig Cell Tumors Ovarian Sertoli-Leydig cell tumor (arrhenoblastoma or androblastoma) is a rare mesenchymal neoplasm of low malignant potential that resembles the embryonic testes. It is the prototypical androgen-secreting ovarian tumor. Sertoli-Leydig cell tumors occur at all ages but are most common in young women of childbearing age. PATHOLOGY: Sertoli-Leydig cell tumors are unilateral, most measuring between 5 and 15 cm in diameter. They tend to be lobulated, solid, and brown to yellow. Microscopically, they vary from well differentiated to poorly differentiated and some exhibit heterologous elements (e.g., mucinous glands and, rarely, even cartilage). The most characteristic features are large Leydig cells, which have abundant eosinophilic cytoplasm and a central round-to-oval nucleus with a prominent nucleolus. The tumor cells are embedded in a sarcomatoid stroma, which often differentiates into immature solid tubules of embryonic Sertoli cells (Fig. 18-27).

enough to manifest clinically, the colon is the most frequent site of origin. The tumor cells usually stimulate the ovarian stroma to differentiate into hormonally active cells (luteinized stromal cells), thereby inducing androgenic and sometimes estrogenic symptoms. Krukenberg tumors are ovarian metastases in which the tumor appears as nests of mucin-filled “signet-ring” cells within a cellular stroma derived from the ovary. The stomach is the primary site in 75% of cases, and most of the other Krukenberg tumors are from the colon.

PLACENTA AND GESTATIONAL DISEASE Infections Chorioamnionitis Results from Ascending Infection Chorioamnionitis is inflammation of the amnion, chorion, and extraplacental membranes. Infectious organisms ascend from the maternal birth canal, commonly after premature rupture of the membranes.

CLINICAL FEATURES: Nearly half of all patients with Sertoli-Leydig cell tumors exhibit androgenic effects. Initially, these are expressed as defeminization (breast atrophy, amenorrhea, and loss of hip fat), followed by signs of virilization including hirsutism, male escutcheon, enlarged clitoris, and deepened voice. These signs lessen or disappear following tumor removal. Well-differentiated tumors are virtually always cured by surgical resection, but poorly differentiated tumors may metastasize.

Tumors Metastatic to the Ovary May Mimic a Primary Tumor About 3% of ovarian cancers arise elsewhere. The most common primary sites are the breast, large intestine, endometrium, and stomach, in descending order. These tumors vary in size from microscopic lesions to large masses. Of those metastatic tumors large

Sertoli-Leydig cell tumor. Immature solid tubules of embryonic Sertoli cells are adjacent to clusters of Leydig cells that exhibit abundant eosinophilic cytoplasm. FIGURE 18-27.

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The inflammatory process affects primarily the membranes (chorioamnionitis) rather than the chorionic villi. PATHOLOGY: The amniotic fluid is usually cloudy. Membrane walls are slightly opaque, malodorous, and edematous. Microscopically, they show a neutrophilic infiltrate, often with fibrin deposition. With more extensive spread, the umbilical cord may become infected (funisitis). Generally, chorionic villi remain free of inflammatory infiltrate. Microorganisms isolated from placentas with chorioamnionitis, in descending frequency, are (1) genital mycoplasmas (Ureaplasma urealyticum, Mycoplasma hominis), (2) anaerobic organisms of the Bacteroides group, and (3) aerobes (group B streptococci, E. coli, and Gardnerella vaginalis).

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Genetic Predesposition • Immune response genes • Histocompatibility antigens • Race

Inadequate Trophoblastic Invasion of Maternal Spiral Anteries

CLINICAL FEATURES: Acute chorioamnionitis is found in 10% of placentas and is associated with preterm labor, fetal and neonatal infections, and intrauterine hypoxia. The risks of chorioamnionitis to the fetus include (1) pneumonia after inhalation of infected amniotic fluid, (2) skin or eye infections from direct contact with organisms in the fluid, and (3) neonatal gastritis, enteritis, or peritonitis from ingesting infected fluid. Major risks to the mother are intrapartum fever, postpartum endometritis, and pelvic sepsis with venous thrombosis.

Maternal Vascular Disease • Hypertension • Diabetes • ↑ Sympathetic vasoconstrictor activity

Parity

Placental Ischemia Placental endothelial toxin ?

Preeclampsia and Eclampsia Generalized Endothelial Cell Injury The hypertensive disorders of pregnancy, namely preeclampsia and eclampsia, define a syndrome of hypertension, proteinuria, and edema, and, most severely, convulsions. Preeclampsia occurs in 6% of pregnant women in their last trimester, especially with the first child. The disorder becomes eclampsia if convulsive seizures appear. PATHOGENESIS: The pathogenesis of preeclampsia and eclampsia is still not resolved. Immunologic and genetic factors have been invoked as well as altered vascular reactivity, endothelial injury, and coagulation abnormalities (Fig. 18-28). Regardless of the precise cause, certain features are characteristic: • Preeclampsia occurs with hydatidiform mole (see below), which suggests that the trophoblast is the most likely responsible tissue and that preeclampsia is a trophoblastic disease. • Maternal blood flow to the placenta is markedly reduced because the normal changes in the maternal spiral arteries of the placental bed do not take place. • Renal involvement in preeclampsia contributes to hypertension and proteinuria. • DIC is a prominent feature of preeclampsia. Treatment with antiplatelet agents, particularly low-dose aspirin, ameliorates or prevents DIC. • The risk of preeclampsia in the first pregnancy is manyfold higher than in subsequent pregnancies. Findings suggest that previous exposure to paternal antigens may protect against the disease. • Eclampsia is a cerebrovascular disorder characterized by seizures, worsening hypertension, and cerebral edema. It is often the first sign of preeclampsia but does not necessarily evolve from it. The pathologic changes in the placenta reflect reduced maternal blood flow to the uteroplacental unit. The key factor in preeclampsia resides in the spiral arteries of the uteroplacental bed, which never fully dilate. These arteries are smaller than normal and retain their musculoelastic wall, which is ordinarily attenuated by infiltrative trophoblasts. Normally, extravillous trophoblast invades these arteries and destroys their vascular tone, thereby allowing the vessels to dilate. In preeclampsia, up to half of spiral arteries escape invasion by endovascular trophoblastic tissue, and thus di-

endothelin NO• PGI2 Vasospasm

Vascular permeability

DIC

Hypertension Proteinuria Edema

Pre-eclampsia

Convulsions

ECLAMPSIA FIGURE 18-28.

Pathogenesis of preeclampsia and eclampsia. NO, nitric oxide; PGI2, prostacyclin.

lation does not occur. In women with preeclampsia, the spiral arteries commonly exhibit acute atherosis, (fibrinoid necrosis with accumulation of lipid-laden macrophages), thrombosis and resultant focal placental infarctions, which contribute to inadequate blood flow and placental ischemia. PATHOLOGY: The placenta and maternal organs of women with preeclampsia show conspicuous changes. Extensive placental infarction is seen in nearly one third of women with severe preeclampsia. Retroplacental

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hemorrhage occurs in 15% of patients. Microscopically, chorionic villi show signs of underperfusion. The cytotrophoblastic cells lining them are hyperplastic, and the basement membrane is thickened. The kidneys always show glomerular changes. Glomeruli are enlarged, and endothelial cells are swollen. Fibrin is present between the endothelial cells and the glomerular capillary basement membrane. Mesangial cell hyperplasia is common. The changes in the maternal kidneys are reversible with therapy or after delivery. Fatal cases of eclampsia often show cerebral hemorrhages, ranging from petechiae to large hematomas. CLINICAL FEATURES: Preeclampsia usually begins insidiously after the 20th week of pregnancy with (1) excessive weight gain occasioned by fluid retention, (2) increased maternal blood pressure, and (3) proteinuria. As preeclampsia progresses from mild to severe, diastolic pressure persistently exceeds 110 mm Hg, proteinuria is greater than 3 g/day, and renal function declines. DIC often supervenes. Preeclampsia is treated with antihypertensive and antiplatelet

drugs, but definitive therapy requires removing the placenta, hopefully by normal delivery.

Gestational Trophoblastic Disease The term gestational trophoblastic disease is a spectrum of disorders with abnormal trophoblast proliferation and maturation, as well as neoplasms derived from trophoblast.

Complete Hydatidiform Mole Does Not Contain an Embryo Complete hydatidiform mole is a placenta with grossly swollen chorionic villi resembling bunches of grapes and showing varying degrees of trophoblastic proliferation. Villi are enlarged, often exceeding 5 mm in diameter (Fig. 18-29).

C FIGURE 18-29. Complete hydatidiform mole. A. Complete mole in which the entire uterine cavity is filled with swollen villi. B. The villi are each 1 to 3 mm in diameter and appear grape-like. C. Individual molar villi, many of which have cavitated central cisterns, exhibit considerable trophoblastic hyperplasia and atypia. The blood vessels of the villi have atrophied and disappeared.

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PATHOGENESIS: Complete mole results from fertilization of an empty ovum that lacks functional maternal DNA. Most commonly, a haploid (23,X) set of paternal chromosomes introduced by monospermy duplicates to 46,XX, but dispermic 46,XX and 46,XY moles also occur. Because the embryo dies at a very early stage, before placental circulation has developed, few chorionic villi develop blood vessels, and fetal parts are absent. RISK FACTORS: The risk of hydatidiform mole relates to maternal age and has two peaks. Girls younger than 15 years of age have a 20-fold higher risk than women between 20 and 35 years. The risk increases progressively for women over 40 years of age. Women older than 50 years of age have 200 times the risk of those between 20 and 40. The incidence is manyfold higher in Asian women than among white women. Women who had a prior hydatidiform mole have a 20-fold greater risk of a subsequent molar pregnancy than does the general population. PATHOLOGY: Molar tissue is voluminous and consists of macroscopically visible villi that are obviously swollen. Microscopically, many individual villi have cisternae, which are central, acellular, fluid-filled spaces devoid of mesenchymal cells. The trophoblast is hyperplastic and composed of syncytiotrophoblast, cytotrophoblast, and intermediate trophoblast. Considerable cellular atypia is present. CLINICAL FEATURES: Patients with complete moles commonly present between the 11th and 25th weeks of pregnancy and complain of excessive uterine enlargement and often abnormal uterine bleeding. Passage of tissue fragments, which appear as small grape-like masses, is common. The serum hCG concentration is markedly elevated and increases with time Complications of complete mole include uterine hemorrhage, DIC, uterine perforation, trophoblastic embolism, and infection. The most important complication is the development of choriocarcinoma, which occurs in 2% of patients after the mole has been evacuated. Treatment consists of suction curettage of the uterus and subsequent monitoring of serum hCG levels. As many as 20% of patients require adjuvant chemotherapy for persistent disease, as

judged by stable or rising hCG levels. With such management, the survival rate approaches 100%.

Partial Hydatidiform Mole Features Triploid Cells Partial hydatidiform mole is a distinct form of mole that almost never evolves into choriocarcinoma (see Table 18-3). These moles have 69 chromosomes (triploidy), of which one haploid set is maternal and two are paternal in origin. This abnormal chromosomal complement results from fertilization of a normal ovum (23,X) by two normal spermatozoa, each carrying 23 chromosomes, or a single spermatozoon that has not undergone meiotic reduction and bears 46 chromosomes. The fetus associated with a partial mole usually dies after 10 weeks’ gestation, and the mole is aborted shortly thereafter. In contrast to a complete mole, fetal parts may be present. PATHOLOGY: Partial moles have two populations of chorionic villi. Some are normal, whereas others are enlarged by hydropic swelling and show central cavitation. Trophoblastic proliferation is focal and less pronounced than in a complete mole. Blood vessels are typically found within chorionic villi and contain fetal (nucleated) erythrocytes.

Invasive Hydatidiform Mole Penetrates the Underlying Myometrium PATHOLOGY: Villi of a hydatidiform mole may extend only superficially into the myometrium or may invade the uterus and even the broad ligament. The mole tends to enter dilated venous channels in the myometrium, and one third of them spread to distant sites, mostly the lungs. Unlike choriocarcinoma (see below), distant deposits of an invasive mole do not penetrate beyond the confines of the blood vessels in which they are lodged, and death from such spread is unusual. The clinical distinction between invasive mole and choriocarcinoma is often difficult. Histologically, invasive moles show less hydropic change than complete moles. Trophoblastic proliferation is usually prominent. Uterine perforation is a major complication, but occurs in only a minority of cases. Theca lutein cysts, which may occur with any form of trophoblastic disease as a result of hCG stimulation, are prominent with invasive moles.

TABLE 18–3

Comparative Features of Complete and Partial Hydatidiform Mole Features

Complete Mole

Partial Mole

Karyotype

46,XX

47,XXY or 47,XXX

Parental origin of haploid genome sets

Both paternal

1 maternal, 2 paternal

Preoperative diagnosis Marked vaginal bleeding Uterus Serum hCG

Mole 3+ Large High

Missed abortion 1+ Small Less elevated

Hydropic villi Trophoblastic proliferation Atypia hCG in tissue

All Diffuse Diffuse 3+

Some Focal Minimal 1+

Embryo present Blood vessels Nucleated erythrocytes

No No No

Some Common Sometimes

Persists after initial therapy

20%

Choriocarcinoma

2% after mole

No choriocarcinoma

hCG, human chorionic gonadotropin.

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Choriocarcinoma is a Tumor Allograft in the Host Mother Gestational choriocarcinoma is a malignant tumor derived from trophoblast. EPIDEMIOLOGY: Choriocarcinoma occurs in 1 in 30,000 pregnancies in the United States; in eastern Asia, the frequency is far greater. The incidence seems related to abnormalities of pregnancy. Thus, the tumor occurs in 1 of 160,000 normal gestations, 1 of 15,000 spontaneous abortions, 1 of 5,000 ectopic pregnancies, and 1 of 40 complete molar pregnancies. Although the risk that a complete hydatidiform mole will transform into choriocarcinoma is only 2%, it is still several orders of magnitude higher than if the pregnancy were normal. PATHOLOGY: The uterine lesions of choriocarcinoma range from microscopic foci to huge necrotic and hemorrhagic tumors. Viable tumor is usually confined to the rim of the neoplasm because, unlike most other cancers, choriocarcinoma lacks an intrinsic tumor vasculature. Histo-

logically, the tumor contains a dimorphic population of cytotrophoblast and syncytiotrophoblast, with varying degrees of intermediate trophoblast. By definition, tumors containing any villous structures, even if metastatic, are considered to be a hydatidiform mole and not choriocarcinoma. Choriocarcinoma invades primarily through venous sinuses in the myometrium. It metastasizes widely by the hematogenous route, especially to lungs (more than 90%), brain, gastrointestinal tract, liver, and vagina. CLINICAL FEATURES: Abnormal uterine bleeding is the most frequent initial indication that heralds choriocarcinoma. Occasionally, the first sign relates to metastases to the lungs or brain. In some cases, it may only become evident 10 or more years after the last pregnancy. With currently available chemotherapy, recognition of risk factors (high hCG levels and prolonged interval since antecedent pregnancy), and early treatment, most patients are cured. Survival rates exceed 70% for tumors that have metastasized and virtually 100% remission is expected if a tumor is localized. Serial serum hCG levels monitor the effectiveness of treatment.

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The Breast Ann D. Thor Adeboye O. Osunkoya

Fibrocystic Change Proliferative Fibrocystic Change Sclerosing Adenosis Benign Tumors Fibroadenoma Intraductal Papillomas Cancer of the Breast Hereditary Factors Nonhereditary Factors

Carcinoma In Situ Invasive Carcinoma Metastases Prognosis Phyllodes Tumor The Male Breast Gynecomastia Cancer

Diseases of the breast have been recognized throughout history, certainly because of their necessity for infant survival. An Egyptian surgical papyrus dating from 1600 BC, possibly the oldest medical text extant, describes a breast tumor which may have been cancer. The Greek physician Soranus detailed breast care during lactation to prevent nipple abscesses. Celsus recognized the breast as being particularly susceptible to “carcinoma.” References to a female medica a mammis suggests that specialists in breast disease were recognized in Roman medicine. Although it is now a matter of choice in deciding if the breast is to be used in its natural function, nursing, breast cancer remains one of the leading causes of death in women. It is, therefore, important to understand the biology of malignant tumors and of factors associated with an increased risk of cancer.

Fibrocystic Change Fibrocystic change is a constellation of morphologic features characterized by (1) cystic dilation of terminal ducts, (2) a relative increase in fibrous stroma, and (3) variable proliferation of terminal duct epithelial elements. It is most often diagnosed in women from their late 20s to the time of menopause. Fibrocystic change occurs to some degree in 75% of adult women in the United States. Symptomatic fibrocystic change, in which large, clinically detectable cysts are formed, may be seen in 10% of women between 35 and 55 years of age. The frequency of fibrocystic change decreases after menopause. Lesions demonstrating florid proliferation are designated proliferative fibrocystic change. Such lesions are more common in populations that have an increased risk of breast cancer, but progression to cancer has not been documented. Fibrocystic change without epithelial proliferation (nonproliferative fibrocystic change) does not involve an increased risk of breast cancer. PATHOLOGY: Nonproliferative fibrocystic change is characterized by an increase in dense, fibrous stroma and some cystic dilation of the terminal ducts (Fig. 19-1B,C). Most often, cystic changes are minor and do not cause discrete masses. The large cysts, up to 5 cm in diameter, often contain dark, thin fluid that imparts a blue color to the unopened cysts (blue-

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domed cysts of Bloodgood; see Fig. 19-1B). On microscopic examination, the epithelium lining the cysts varies from columnar to flattened or may even be entirely absent. Apocrine metaplasia is frequently seen in nonproliferative fibrocystic change (see Fig. 19-1D). The metaplastic cells are larger and more eosinophilic than the usual duct lining cells and resemble apocrine sweat gland epithelium. The most common of several forms of proliferative fibrocystic change is an increase in the number of cells or layers lining the dilated terminal ducts, termed ductal epithelial hyperplasia (see Fig. 19-1E). Epithelial proliferation can at times become exuberant and widespread, forming intraductal epithelial papillary structures with central fibrovascular cores (papillomatosis). Proliferative (hyperplastic) lesions may also demonstrate cytologic atypia. These atypical lesions are subclassified by the degree of microscopic atypia and the extent of breast involvement (see below).

Proliferative Fibrocystic Change Increases the Risk of Cancer • Proliferative, nonatypical fibrocystic change is associated with a minimal increased risk for the development of invasive cancer (1.5- to 2-fold). • Atypical hyperplasia with fibrocystic change is associated with a 4- to 5-fold increased risk for developing invasive cancer

compared to the general population. This risk increases further if there is a strong family history of the disease. Atypical hyperplasia may be multifocal and bilateral. The risk of subsequent carcinoma is equal in both breasts. Women at high risk may reduce their chances of developing breast cancer by chemical or surgical castration or the administration of anti-estrogenic agents (e.g., tamoxifen). Exogenous hormones (e.g., estrogens) may increase the risk of breast cancer, particularly in postmenopausal women or women at high risk for breast cancer, although the extent to which this might occur is controversial.

Sclerosing Adenosis is a Less Common Variant of Proliferative Fibrocystic Change This lesion is characterized by proliferation of small ducts and myoepithelial cells with surrounding stromal fibrosis. Sclerosing adenosis is almost always associated with other forms of proliferative fibrocystic change. On mammogram, these lesions often demonstrate microcalcifications in patterns that resemble those seen in malignancies and may be difficult to distinguish clinically from cancer. Microscopically, lobular units may be deformed and enlarged, forming a mass of epithelial and stromal elements, which can be difficult to distinguish from invasive carcinoma.

Interlobular stroma Interlobular stroma Interlobular duct Terminal duct or acinus Fat

B Terminal duct lobular unit

C Nonproliferative fibrocystic change

D Fibrocystic change. A. Normal terminal lobular unit. B. Surgical specimen: Cysts of various sizes are dispersed in dense, fibrous connective tissue. Some of the cysts are large and contain old blood-tinged proteinaceous debris. C. Nonproliferative fibrocystic change combines cystic dilation of the terminal ducts with varying degrees of apocrine metaplasia of the epithelium and increased fibrous stroma. D. Apocrine metaplasia: Epithelial cells have apocrine features with eosinophilic cytoplasm. E. Proliferative fibrocystic change: Terminal duct dilation and intraductal epithelial hyperplasia are present. FIGURE 19-1.

E Proliferative fibrocystic change

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Benign Tumors Fibroadenoma is the Most Common Benign Neoplasm of the Breast These benign neoplasms are composed of epithelial and stromal elements that originate from the terminal ductal lobular unit. Fibroadenomas are usually solitary masses, although some women develop more than one during their lifetime. They are most often diagnosed in women between the ages of 20 and 35 years. Fibroadenomas commonly enlarge more rapidly during pregnancy (i.e., they are hormone-responsive) and cease to grow after menopause. Some fibroadenomas are associated with an increase in breast cancer risk, including (1) complex fibroadenomas (those associated with large cysts, sclerosing adenosis, calcifications or papillary apocrine change), (2) fibroadenoma with adjacent proliferative disease, or (3) fibroadenoma in patients with a first-degree family history of breast cancer. PATHOLOGY: Fibroadenomas vary in size, from a microscopic, incidental lesion to a large tumor, most often 2 to 4 cm in diameter. They are rubbery tumors that are sharply demarcated from the surrounding breast. These lesions can be identified on mammography or by palpation. Fibroadenomas are typically mobile and may be tender, particularly during the mid-to-late menstrual cycle. The cut surface appears glistening, gray-white, and sharply demarcated from the adjacent breast (Fig. 19-2A). On microscopic examination, fibroadenomas are composed of a mixture of fibrous connective tissue and ducts (see Fig. 19-2B). The ducts may be either simple and round or elongate and branching and are dispersed within a characteristic fibrous stroma, which varies from loose and myxomatous to hyalinized collagen. This connective tissue, which forms most of the tumor, often compresses the proliferated ducts, reducing them to curvilinear slits. The epithelium’s appearance ranges from the double layer of epithelium of normal lobules to varying degrees of hyperplasia.

Intraductal Papillomas Occur in the Lactiferous Ducts of Middle-Aged and Older Women Intraductal papillomas typically arise from the surface of the large, subareolar ducts of middle-aged and older women and are often associated with a serous or bloody nipple discharge. A solitary intraductal papilloma is neither a premalignant lesion nor is it a marker of risk for breast cancer.

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PATHOLOGY: Intraductal papilloma is a single tumor, usually a few millimeters in diameter, which is attached to the wall of the duct by a fibrovascular stalk. The papillomatous portion consists of a double layer of epithelial cells, an outer layer of cuboidal or columnar cells, and an inner layer of more-rounded myoepithelial cells.

Cancer of the Breast Breast cancer is the most common malignancy of women in the United States, and the mortality rate from this disease among women is second only to that of lung cancer. EPIDEMIOLOGY: The incidence of breast cancer has slowly increased over the past 20 years but now appears to have leveled off. Death rates have decreased during the last 25 years because of earlier detection and better therapy. Currently, one in eight American women may be expected to develop breast cancer, one quarter of whom will die of the disease. In Western industrialized countries with high rates of breast cancer, the incidence of this tumor continues to increase throughout life. The disease is uncommon before the age of 35 years. Breast cancer is four to five times more frequent in Western industrialized countries than in developing countries. It has been suggested that diet, in particular dietary fat, may in part explain differences in the geographical distribution of breast cancer, but this concept remains controversial. Breast cancer rarely develops in men, although when it does occur, it may be equally deadly (see below). PATHOGENESIS: The pathogenesis of breast cancer is poorly understood, but epidemiologic, molecular, and genetic studies outline complex risk factors. Breast cancers also exhibit diversity in histopathology, molecular features, and overall patient outcomes. Hence, the disease can be viewed as a multifaceted and complex epithelial malignancy.

Approximately 5% of Breast Cancers are Thought to Reflect Hereditary Factors The strongest association with an increased risk for breast cancer is a family history, specifically breast cancer in first-degree relatives (mother, sister, daughter). The risk is greater when the relative is afflicted at a young age or with bilateral breast cancer.

B Fibroadenoma. A. Surgical specimen. This well-circumscribed tumor was easily enucleated from the surrounding tissue. The cut surface is characteristically glistening tannish-white and has a septate appearance. B. Microscopic section. Elongated epithelial duct structures are situated within a loose, myxoid stroma. FIGURE 19-2.

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The BRCA1 gene (breast cancer 1), a tumor suppressor gene located on chromosome 17 (17q21), has been implicated in the pathogenesis of hereditary breast and ovarian cancers, and possibly prostate and colon cancer. Mutations in this tumor-suppressor gene are thought to be carried by 1 in 200 to 400 people in the United States. Germline point mutations and deletions in BRCA1 confer a 60% to 85% lifetime risk for breast cancer, with more than half of the tumors developing before 50 years of age. It is currently suspected that mutated BRCA1 is responsible for 20% of all cases of inherited breast cancer and is responsible for about 3% of all breast cancers. Somatic mutations in BRCA1 are infrequently detected in sporadic breast cancers. The BRCA2 gene, located on chromosome 13q12, has been incriminated in approximately 20% of hereditary breast cancers. Women with one copy of a mutated BRCA2 gene have a 30% to 40% lifetime chance of developing breast cancer. Like patients with BRCA1, these women have an increased risk of ovarian cancer. BRCA2 mutations also put male carriers at increased risk of breast cancer. Mutations of BRCA2 are particularly common among Ashkenazi Jewish women. The p53 gene is mutated in the Li-Fraumeni syndrome (see Chapter 5). Breast cancer will develop in almost all young women with the disease. Germline (inherited) mutations in p53 account for 1% of breast cancers among women under the age of 40 years. Somatic p53 mutations are common in sporadic breast cancers.

Most Breast Cancers are Not Associated with Heritable Factors HORMONAL STATUS: A link between breast cancer and the hormonal status of women is strongly suggested by the association of (1) early menarche, (2) late menopause, and (3) older age at first-term pregnancy, with an increased the risk of disease. Nulliparous women, or those who become pregnant for the first time after age 35, have a two- to threefold higher risk of breast cancer than women whose first pregnancy occurred before age 25. RADIATION: The female breast is susceptible to radiation-induced neoplasia. The risk of breast cancer was increased in atomic bomb survivors and in women irradiated for postpartum mastitis and Hodgkin disease; the highest risk occurred when exposure took place in childhood and adolescence. Modern mammographic techniques use extremely low doses of radiation that are unlikely to pose a hazard. PREVIOUS CANCER OF THE BREAST: Women who have previously had breast cancer have at least a 10-fold increased risk of developing a second primary breast cancer in the same or in the contralateral breast. FIBROCYSTIC CHANGE: Women with proliferative fibrocystic change (and particularly those demonstrating atypical hyperplasia) are at increased risk for cancer (see above). PATHOLOGY: Breast cancers are almost entirely adenocarcinomas derived from progenitor cells of the glandular epithelium. They are classified based on a combination of histologic pattern and cytologic characteristics.

Carcinoma In Situ of the Breast is Often a Preinvasive Lesion The term carcinoma in situ refers to the presence of apparently malignant epithelial cells that have not penetrated the basement membrane. Histologically, the various subtypes of carcinoma in situ have invasive counterparts. However, only 20% to 30% of women with biopsy-proven ductal carcinoma in situ (DCIS), but who received no further therapy, subsequently developed invasive cancer. A strong family history for breast cancer elevates the risk for breast cancer in women with in situ disease.

The diagnosis of DCIS has risen significantly in the last three decades, with the advent of more sensitive mammographic techniques. Intraductal carcinomas arise within terminal ductal lobular units as dysplastic cells replace normal or hyperplastic cells and spread by luminal extension. Low- and moderate-grade lesions show little cell proliferation or necrosis. High-grade lesions have pronounced cytologic atypia, rapidly proliferating cells, and necrosis. DCIS-COMEDOCARCINOMA (HIGH-GRADE) SUBTYPE: This subtype is composed of very large, pleomorphic epithelial cells with abundant cytoplasm, irregular nuclei, and often prominent, heterogeneous nucleoli. Cancer cells grow rapidly within ducts and frequently demonstrate intraductal necrosis (Fig. 19-3). Grossly, the lesion often shows distended duct-like structures containing white, necrotic material resembling comedos, which often undergoes dystrophic calcification; this results in multiple, microscopic calcified bodies, which can be visualized on a mammogram. These microcalcifications may assume a linear, branching appearance because of their intraductal location (see Fig. 19-3A). Although the malignant cells do not invade through the basement membrane, this form of carcinoma in situ may incite chronic inflammation, neovascularization, and a desmoplastic response (fibroblast proliferation and subsequent fibrosis) in a peritubular distribution (see Fig. 19-3B,C). DCIS-NONCOMEDOCARCINOMA (LOW-TO-MODERATE-GRADE SUBTYPES): This tumor has multiple architectural patterns, which are often intermixed and exhibit a spectrum of cytologic atypia. The patterns are classified as micropapillary, cribriform (Fig. 19-4), and solid. The tumor cells and nuclei are smaller and more regular than those of the comedo type. Noncomedo DCIS is less likely than the comedo type to incite a desmoplastic response in the surrounding tissue. Necrosis is minimal or absent. RISK OF INVASIVE DISEASE: DCIS, treated only by biopsy, carries a 30% risk of developing invasive carcinoma in the same breast over the ensuing 20 years. The risk of cancer in the contralateral breast is also increased but not to the same degree as with lobular carcinoma in situ (see below). The chance of local recurrence as either in situ or invasive cancer is substantially greater for the comedo than the noncomedo subtypes. LOBULAR CARCINOMA IN SITU (LCIS): The second most common subtype of in situ breast carcinoma also arises in the terminal ductal lobular unit. In this tumor, cells tend to be smaller and more monotonous than in DCIS, with round, regular nuclei and minute nucleoli (Fig. 19-5). The malignant cells appear as solid clusters that pack and distend the terminal ducts but not to the extent of DCIS. LCIS may also have duct microcalcifications that are detectable radiographically. The lesion does not usually incite dense fibrosis and chronic inflammation so characteristic of DCIS and so is less likely to cause a detectable mass. Lobular carcinoma is associated with truncating mutations of the E-cadherin gene. As with DCIS, 20% to 30% of women with LCIS receiving no further treatment after biopsy will develop invasive cancer within 20 years. About half of these invasive cancers will arise in the contralateral breast and may be either lobular or ductal cancers. As a result, LCIS, more than DCIS, is a harbinger of an increased risk of subsequent invasive cancer in both breasts. PAPILLARY CARCINOMA IN SITU: Papillary carcinoma in situ is much less common than either DCIS or LCIS. This neoplasm originates in the larger branches of the ductal system. The tumor is usually well differentiated and exhibits a papillary configuration. The neoplastic cells are typically small and regular, making it difficult in some cases to distinguish from a benign intraductal papilloma. Papillary carcinoma in situ does not carry an increased risk of developing invasive cancer if it is completely resected.

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C A

Ductal carcinoma in situ. A. Specimen radiograph of core biopsy shows linear and punctate atypical calcifications that are highly suspicious for cancer. B. Low-power photomicrograph showing high-grade in situ ductal carcinoma. C. High-power image of a duct expanded by in situ ductal carcinoma. D. High-power photomicrograph of tissue calcification. FIGURE 19-3.

Invasive carcinoma of the breast exhibits a morphologic spectrum, and different subtypes are associated with varying prognoses (Table 19-1).

On gross examination, IDC is typically firm and shows irregular margins. The cut surface is pale gray, gritty, and flecked with yellow, chalky streaks (see Fig. 19-6B). Microscopically, IDC is characterized by irregular nests and cords (tubules) of cytologically aberrant epithelial cells outside of the ductal-lobular units and located haphazardly within the stroma (see Fig. 19-6C).

Invasive Ductal Carcinoma (IDC)

Paget Disease of the Nipple

Invasive (or infiltrating) ductal carcinoma is the most common histologic type of breast cancer. Invasion is defined by the presence of tumor cells outside of the duct-lobular units and extending into breast stroma. Invasion of the stroma incites a desmoplastic reaction, which may lead to a firm, palpable mass. The tumor may modify the contour of the breast or be visible as a dense mass lesion by mammography or ultrasonography (Fig. 19-6A). Invasive breast cancers are variably associated with calcifications.

Paget disease is an uncommon variant of ductal carcinoma, either in situ or invasive, that extends to involve the epidermis of the nipple and areola. This condition usually comes to medical attention because of an eczematous change in the skin of the nipple and areola. Microscopically, large cells with clear cytoplasm (Paget cells) are

Invasive Breast Carcinoma Exhibits an Array of Subtypes

Lobular carcinoma in situ. The lumina of the terminal duct lobular units are distended by tumor cells, which exhibit round nuclei and small nucleoli. The cancer cells in the lobular form of carcinoma in situ are smaller and have less cytoplasm than those in the ductal type. FIGURE 19-5.

FIGURE 19-4.

Ductal carcinoma in situ–noncomedo type. A cribriform arrangement of tumor cells is evident.

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Medullary Carcinoma

TABLE 19–1

Frequency of Histologic Subtypes of Invasive Breast Cancer Subtype

Frequency (%)

Invasive ductal carcinoma Pure Mixed with other types (including lobular)

55 25

Invasive lobular carcinoma (pure)

Medullary carcinoma (pure)

Panhyperplasia (predominantly granulocytic)

Panhyperplasia (predominantly erythroid)

Panhyperplasia with fibrosis

Large megakaryocytes in clusters

Bone Marrow Histopathology

M:E ratio

10:1 to 50:1

ⱕ2:1

2:1 to 5:1

Fibrosis

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