Inflammation- case studies

Dr suvarna nalapat

CASE 1:

A 19-year-old woman presented to the emergency room with severe left lower quadrant abdominal pain. She had fever, BP 100/70 mm Hg. Physical examination revealed extreme tenderness in the left lower quadrant. Her WBC count showed a leukocytosis (19,200) with a "left shift" (75% segs and 10% bands). She was taken to surgery and a laparotomy revealed that the left fallopian tube and ovary were adherent and dilated and filled with yellow purulent material that was spilling into the peritoneal cavity from a site of rupture. Culture of this material grew Neisseria gonorrheae.

HP microscopic

High power
The high power microscopic appearance of the fallopian tube is shown here. What is the predominant cell type filling the lumen?

Tuboovarian mass
gross appearance of the tube and ovary, and sectioning reveals what fills them

What is the diagnosis? questions

Grossly the tube and ovary are adherent. What is demonstrated on sectioning? 2. A microscopic cross section shows tube with a thickened wall and dilated lumen. What is the predominant inflammatory cell type seen in the wall and filling lumen? 3. What has happened to the vascular structures (blood vessels, lymphatics) in the tube? 4. What is the process that is leading to appearance of pink, homogenous material separating tissue structures , on serosa?
1.

1. The lumen is dilated and filled with

purlent exudate. 2. These cells are neutrophils (PMN's, polys). They are forming a purulent exudate. The localized collection of pus is an abscess 3. They are dilated. The blood vessels are congested (filled with blood). Lymphatics are not normally seen unless there is inflammation or obstruction

Over an 18 hour period, a 24-year-old man noticed increasing abdominal pain which was first centered in the periumbilical region, but later localized in the right lower abdominal quadrant. Physical examination demonstrated involuntary guarding and rebound tenderness in the right lower quadrant. A CBC revealed a WBC count of 18,550/microliter with a left shift. He was taken to surgery and an appendectomy was performed. The appendix examined in surgical pathology was swollen and covered with a purulent exudate.

peripheral blood smear

What type of leukocyte is increased in number?

Gross and microscopic

questions
Sections of the appendix show what predominant inflammatory cell type in the wall? 2. Through what series of steps are these inflammatory cells undergoing to reach the wall? 3. In some places the wall shows disruption of the tissue. What is this process? 4. How does the CBC relate to the findings in the appendix?
1.

1. There are numerous PMN's present, typical of acute inflammation. Also seen are marked vascular dilation with congestion and tissue edema (leading to the swollen appearance of the appendix). A fibrinopurulent exudate is present on the surface, producing the gross appearance noted in surgical pathology

2 .Chemotactic factors (such as C5a and leukotriene) are drawing in the neutrophils. The neutrophils are undergoing margination in blood vessels (mainly venules) and emigrating into the tissues.

3. This is suppurative necrosis (a form of liquefactive necrosis) resulting from the action of the PMN's on the tissue. 4.Leukocytosis and a left shift are typical of many acute inflammatory processes.

Following left anterior descending coronary artery thrombosis with an acute myocardial infarction involving most of the free wall of the left ventricle, a 73-year-old man experienced partial paralysis of his right side. He also developed acute renal failure and hematuria. He died a short time later. gross appearance of the cardiac lesion; of the renal lesion, and microscopic findings are seen as follows

cardiac

renal

Microscopic findings kidney

Higher power

questions
Describe the lesion in the heart at autopsy. 2. Diagnose and describe the lesion in the kidney removed at autopsy. What would be the typical gross appearance? 3. How did the renal lesion result from the myocardial infarction? 4. What was the probable cause of his paralysis
1.

answers
1. An area of coagulative necrosis is

present in the anterior left ventricular free wall and septum. 2.The section of kidney shows a triangular-shaped zone, with its base at the capsular surface and its apex pointed at the medulla, that has loss of cellular detail: the nuclei are gone (karyolysis) and the cytoplasm shows enhanced red staining (eosinophilia

4. The inflammation has led to exudation. The pink material is fibrin. Thus, there is a fibrinous exudate Diagnosis:Acute salpingitis with tuboovarian abscess. N. gonorrheae can lead to chronic inflammation of the tube with scarring, upon which an acute process can be superimposed.

microscopic
1. Note that the ghosts of tubules and

glomeruli are preserved. One small branch of a renal artery actually show the cause, a thrombus in an artery near the apex of the area of necrosis. This necrosis is the result of ischemia, leading to an infarction (coagulative necrosis). It is very recent, so that little inflammatory infiltrate is present.

answer
3A mural thrombus developed on the endocardium overlying the area of myocardial infarction. A portion of this thrombus broke off and was sent out into the systemic circulation, eventually going out the renal artery and lodging in a small branch to occlude the blood supply to a cortical segment and cause an infarct 4A thrombus probably travelled to a cerebral artery, leading to brain infarction (a "stroke").

An 83-year-old woman experienced cough, fever, and shaking chills for two days prior to admission. Physical examination revealed rales in the right lung base. She was coughing up a small amount of yellowish sputum. Chest x-ray initially showed a right lower lobe infiltrate, but several days later showed infiltrates throughout the right lung. Sputum culture grew Streptococcus pneumoniae. (gross appearance of the lung, and the microscopic findings).

gross
1. How would you

describe the gross appearance of the lung?

microscopic
What do you see in the alveolar spaces in the lung?

microscopic

questions
3.How would this differ from a causative agent such as influenza virus? 4.What chemical mediators are responsible for fever? 5.What is the diagnosis?

answers
1. Patchy areas of yellowish tan

consolidation are present, consistent with bacterial pneumonia. 2. The alveolar spaces are filled with an exudate containing numerous neutrophils along with some macrophages and pink strands of fibrin generated by the coagulation system initiated by the inflammatory process. Alveolar capillaries are congested and filled with RBC's

answers
3. Inflammation caused by viruses is typically interstitial and mostly composed of mononuclear cells. However, the damage done by viral inflammation in the lung can predispose to bacterial infection 1. Interleukin-1 (IL-1) and tumor necrosis factor (TNF) are the mediators most associated with development of fever.

diagnosis
1. This is an acute pneumonia.

Streptococcus pneumoniae is a bacterial organism that typically produces a lobar pattern of pulmonary involvement. A more virulent organism (usually seen in hospitalized patients) is Staphylococcus aureus which can cause abscess formation.

case5

A 35-year-old man had a history of intravenous drug use. Over several days' time, he developed a high fever, then dyspnea. On physical examination, his temperature was 39.4 C (103 F), and a heart murmur was heard. Needle tracks and a red, tender, fluctuant area were noted near the left antecubital fossa. A blood culture grew Staphylococcus aureus. Despite antibiotic therapy, he died three days later. The aortic valve is shown. Sectioning of the myocardium revealed multiple small soft yellow foci .The epicardium showed a shaggy appearance .

Myocardial lesion

Pericardial surface

questions
What is the appearance of the aortic valve Note the dark purple focus in this section of myocardium. Describe what you see in these foci How do these foci in the myocardium relate to the lesions on the aortic valve? 3. Bacteria are being phagocytozed because what agents are acting as opsonins? 4. What is the diagnosis? What is the pathogenesis of this process? 5. What is the process involving the
1. 2.

answers
1. At autopsy, the aortic valve showed

extensive necrosis with vegetations composed of yellowish-red, friable material. 2. These foci are small abscesses filled with neutrophils. The myocardium and adjacent epicardial fat show suppurative necrosis.

answers
3. The vegetations on the aortic valve break off and embolize. Some may go out the coronary arteries to myocardium. These are "septic" emboli because they contain bacteria. 1. Immunoglobulin (IgG) and complement C3b.

answers
5. This is acute bacterial endocarditis with septic emboli and myocardial and epicardial abscesses. Most IV drug users do not use sterile needles, so are at risk for infection (his antecubital lesion was an abscess at the site of injection).

case6

A 53-year-old man was the driver of a car involved in a head-on collision with another vehicle at 45 mph. He was not wearing a seat belt and his vehicle did not have an airbag. He sustained blunt trauma to the upper abdomen. On admission to hospital, he complained of severe abdominal and mid-back pain. He appeared gravely ill. A peritoneal lavage revealed bloody abdominal fluid. Serum lipase was 7500 U/L. At surgery, multiple liver lacerations were noted, and there were flecks of white, chalky material in adipose tissue adjacent to a slightly swollen pancreas.

pancreas

microscopic

questions
1. Diagnose and describe what you see

grossly (and microscopically .How does this lesion occur? 2. Name another site at which trauma can produce this lesion

answers
1. This is fat necrosis. Scattered tan

areas are seen throughout the pancreas. There is not much of a neutrophilic exudate, but the adipose tissue shows areas of necrosis that are smudgy, amorphous, and pink to violaceous (compared with normal adipose tissue)

answers
2. The blunt force traumatic injury (probably from the steering wheel) damaged the pancreas so that pancreatic enzymes (lipases) were released and began to digest surrounding tissues. Thus, fatty acids released from triglycerides combined with calcium to produce the white, chalky, soap-like material typical of fat necrosis 1. Trauma to the breast may produce fat necrosis.

case7

A 42-year-old woman underwent hysterectomy because of pelvic pain and irregular menstrual cycles associated with heavy menstrual bleeding. She also complained of an intermittent, whitish mucoid vaginal discharge between periods for several months.

Gross cervix

microscopic

microscopic

What is the diagnosis

What is the gross appearance of the cervix Microscopically, the uterine cervix at the squamocolumnar junction has ectocervix lined by glycogen rich, non-keratinizing stratified squamous epithelium. The endocervical canal is lined by a layer of columnar mucinous epithelial cells. At the squamocolumnar junction, the mucinous epithelium exhibits focal squamous metaplasia. What do you see adjacent to this area in the fibromuscular stroma 3. Why is there metaplasia
1. 2.

1. The epithelium is red (hyperemic) with

dilated blood vessels. 2. There is a moderate chronic inflammatory cell infiltrate. This infiltrate consists of lymphocytes, plasma cells, macrophages, and a few neutrophils 3The columnar epithelium has undergone squamous metaplasia in response to the chronic irritation. This process is reversible

chronic cervicitis. This inflammation led to the discharge noted by the patient. Etiologic agents could include: yeast (Candida), trichomonas, Gardnerella, chlamydia, or N. gonorrheae

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