Dr Devesh Mishra

Director
PRIME INSTITUTE OF MEDICAL EDUCATION
(Website: www.primepg.org )
Contact numbers: +91 - 8586996883, 8586996894.

“Master blaster” guess for AIIMS nov

2018

Molecular classification of breast cancers:

TRALI (Transfusion-Related Acute Lung Injury)
☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆

● It is the most common cause of death after blood transfusion.

● It presents as an acute respiratory distress syndrome (ARDS) either during or

within #6_hours of transfusion.

■ #Mechanism_of_TRALI:

Donor anti HLA-I and HLA-II antibodies will activate neutrophil within recipient's
body, which will cause sequestration of activated neutrophils within the pulmonary
capillaries, leading to acute lung injury by releasing inflammatory mediators like
cytokines....
Adipokines:
-----------------------
*Adipose tissue acts as a functional endocrine organ. It secrets variety of proteins
into the systemic circulation, which are termed adipokines (or adipose cytokines).

*Adipokines can divided into:

A) "Pro-hyperglycemic adipokines" are Resistin and Retinol Binding Protein-4

(RBP4).

B ) Anti-hyperglycemic adipokines are Leptin and Adiponectin

* Adiponectin levels are decreased in obesity, leading to insulin resistance.

Carcinoid:
• Most common site for carcinoid is GIT>>> Lungs.
• Most common site for carcinoid in GIT is Appendix (38%)>>> Small
intestine (29%).

References:
a) Devitas Oncology 10/e page 553
b) Sabiston 20/e page 1272

• Although over 60% of carcinoid tumors originate in the gastrointestinal

system, about 25% of all carcinoids have a pulmonary origin, representing the
second most common involved site. (Devitas Oncology 10/e page 553).

{Sabiston 20/e page 1272}

• Seventy percent to 80% of NETs are asymptomatic and found incidentally at
the time of surgery. In the gastrointestinal tract, more than 90% of NETs are found
in five typical sites:

a) Appendix (38%),
b) Small intestine (29%),
c) Colon (13%),
d) Stomach (12%), and
e) Rectum (8%).
• The changes in these distributions are associated with the increased
incidence of NETs along with the changes of the World Health Organization
classification of these tumors in 2010.
• The malignant potential (ability to metastasize) is related to location, size,
depth of invasion, and growth pattern.
a) Only approximately 3% of appendiceal NETs metastasize, but
b) About 35% of ileal NETs are associated with metastasis.

• Most (approximately 75%) gastrointestinal NETs are smaller than 1 cm in

diameter, and about 2% of these are associated with metastasis.
• In contrast, NETs 1 to 2 cm in diameter and larger than 2 cm are associated
with metastasis in 50% and 80% to 90% of cases, respectively.
Increased hemoglobin F is seen in all of the given condition: -
*****************************************************
1) Aplastic anemia
2) Juvenile CML
3) Hereditary spherocytosis,
4) Myeloproliferative disorders
5) Homozygous sickle cell disease

Type 1.5 Diabetes Mellitus

--------------------------------------

• Type 1.5 diabetes is also known as type 3 diabetes.

• Type 1.5 diabetes is a non-official term that is sometimes used to refer to a
form of type 1 diabetes known as Latent Autoimmune Diabetes in Adults (LADA).
• Type 1.5 Diabetes refers to a form of type 1 diabetes that can share some
features that are more commonly associated with type 2 diabetes.
• Type 1.5 diabetes also has a slow onset, similar to type 2 diabetes.
• However, type 1.5 diabetes is an autoimmune disease like type 1 diabetes
and will almost certainly require insulin therapy at some point in the future.
• They are often Misdiagnosed as having type 2 diabetes.
• Around 15-20% of people diagnosed with type 2 diabetes may actually have
Type 1.5 diabetes.
• People with type 1.5 diabetes often do not have standard type 2 diabetes
symptoms, including metabolic syndrome indicators.
• People with type 1.5 diabetes often have a lower risk of heart problems once
blood sugar is controlled.

● Most common cause of viral myocarditis is Parvovirus B19> Herpes >

Coxsackie.
#Ref: -
1) Braunwald cardiology 10 e.
2) Moss & Adams' Heart Disease in Infants (Page 1247)

**********************************************************
*****

Apolipoprotein€4 allele is associated with "increased

risk"of-----ALZHEIMER's DISEASE.
 SOFT TISSUE TUMOUR:
1) Most common soft tissue tumor of childhood and adolescence---
rhabdomyosarcoma ( embryonal type)
2) Most common soft tissue tumor of adults-----lipoma
3) mc malignant soft tissue tumor of adults ----liposarcoma.
• Most common site of SARCOMAS --- EXTREMITIES (lower> upper)
>>>>>retroperitoneum

Diagnosis of AML:
( Ref—wintrobe 13/e page ---1548..)

■ For most cases of AML, blast cell count >20% or more in either Peripheral
Blood or bone marrow is necessary for diagnosis of AML..

■ For cases with one of three cytogenetic abnormalities, a diagnosis of AML can
be made with a LOWER BLAST COUNT also :---
1) t (15;17)
2) t (8;21)
3) inversion 16 or t (16;16).

Flow cytometry

• Flow cytometry measures multiple characteristics of individual particles flowing

in single file in a stream of fluid.
• It provides rapid analysis of multiple characteristics of single cells.
• It can measure following characteristics:
a) Cell size
b) Cytoplasmic complexity
c) DNA or RNA content
d) Wide range of membrane-bound and intracellular proteins.
• Flow cytometry measures optical and fluorescence characteristics of single cells.
• Principle of flow cytometry:
It measure fluorescence intensity produced by fluorescent-labelled antibodies
detecting proteins or ligands that bind to specific cell-associated molecules, such as
DNA binding by propidium iodide.
• The direction of light scattered by the cell correlates to:
a) Forward Scatter (FS) for Cell size.
b) Side Scatter (SS) for density of the cell (Granularity, vacuoles and
membrane size).
• Live cells will have more forward scatter(FS) than dead and apoptotic cells.
• Granulocytes or monocytes have more granularity or vacuoles and they will have
more side scattering (SS).

• Clinical uses of flow cytometry:

a) Immunology
1) Histocompatibility cross-matching
2) Transplantation rejection
3) Immunodeficiency studies
4) HLA-B27 detection
5) Lymphocytosis

b) Oncology
1) DNA content and S phase of tumors
2) Measurement of proliferation markers e.g. Ki-67.
c) Leukemia and lymphoma phenotyping
d) Reticulocyte enumeration

FUNGAL STAIN

1) PAS stain----only for live fungus ( not for degenerated).

2) Gomorri methenamine silver stain ---used for both live and degenerated fungi
and this is best stain for fungi detection...

Pi-RNA (Piwi interacting RNA)

*M/c type of non-coding -RNA
*Found both in nucleus & cytoplasm
*26-31 nucleotide, size varies from 1-100 kb.
*Role in RNA silencing via formation of RNA induced silencing complex(RISC).
pi-RNA interacts with 'piwi' proteins.
*These pi-RNA complexes have been linked to both epigenetics & post
transcriptional gene silencing of 'retrotransposons' & other genetic elements in
Germ cell lines,particularly those in spermatogenesis.
*Major advances in the pi-RNA field have been achieved by use of "Next
generation sequencing techniques".
GIST (Gastrointestinal Stromal Tumors)

Prognosis correlates with following features.

a) Tumor size (Recurrence or Metastases are rare when tumors are less than 5 cm
but common when more than 10 cm.)
b) Mitotic index
c) Location (gastric GISTs are less aggressive than GIST of small intestine).
d) Increased numbers of chromosomal alterations like (loss or deletion of
chromosome 9, 14 and 22) correlate with poor prognosis.

(Harrison 19/e page no. 1233)-

Globally, Mycobacterium tuberculosis is the most common opportunistic infection

in HIV-infected individuals.(Chap. 202)
CHLOROMAS (=GRANULOCYTIC SARCOMAS) are most commonly
a/w translocation---t(8:21) and AML-M2.
Reference____
1) WINTROBE13/e page no1648
2) Nelson Textbook of Pediatrics 19E Page 1737

Most common cause of PAPILLARY NECROSIS (=Necrotising

Papillitis)----DIABETES MELLITUS
References:
1) Robbins pathology (Pathologic basis of disease) (8/e page no.1143; 9/e page
no-1119)
Inflammasome-complex:-
a) contains INTERLEUKIN-1.
b) mutation is a/w FAMILIAL MEDITERRANEAN FEVER.
Conventional cytogenetics detect both numerical and structural
chromosomal aberrations (overall resolution is 5 Mega bases (Mb);
breakpoint resolution is 5 to 15 Mb).
Stem cells self-renewal is controlled by following genes:-
1) OCT3/4
2) Sox-2
3) C-Myc
4) Kfl-4

Plasma cell leukemia (WHO criterion) in peripheral blood: -

1) plasma cells more than 20% of cells
2) absolute plasma cell count of more than 2 × 109/L.
Fatty acid-binding protein
▪ a/k/a Brain lipid-binding protein (=BLBP)/Brain-type fatty
acid-binding protein(=B-FABP)/Fatty acid-binding protein 7.
▪ Seen on mature astrocytes.
▪ Essential for morphogenic activity during CNS development.
▪ It is required for the establishment of the radial glial fiber system in
developing brain, a system that is necessary for the migration of
immature neurons to establish cortical layers.

Laminopathies
(also known as nuclear envelopathies) have a large variety of clinical
symptoms including skeletal and/or cardiac muscular dystrophy,
lipodystrophy and diabetes, dysplasia, dermopathy, neuropathy,
leukodystrophy, and progeria (premature aging).
 Most common malignancy after renal transplantation is-----skin (
squamous cell cancer)>>> Non-Hodgkins Lymphoma) >>>>Kaposi
sarcoma.
Biochemical markers that have been correlated with the degree of dementia
in Alzheimer's disease include :
a) Loss of choline acetyltransferase.
b) Synaptophysin Immunoreactivity.
c) Amyloid burden.
Genetic Pregeroid Syndromes
 Size of donor and recipient organ doesn’t matter in kidney transplantation.
(Reference---Bailey and Love's short practice of surgery; 26e/page 1413..by
Norman williams...)
Transfusion transmitted hepatitis is most commonly due to "Hepatitis B" infection .
(Harrison 19/e..138e-3).
 #Autoimmunity_Mechanism......

" #AIRE gene".......

■ Negative selection of autoreactive T cells in the thymus requires expression of
the autoimmune regulator (AlRE) gene that enables the expression of
tissue-specific proteins in thymic medullary epithelial cells.

● Peptides from these proteins are expressed in the context of major

histocompatibility complex (MHC) molecules and mediate the central deletion of
autoreactive T cells.

■ The absence of AlRE gene expression leads to a failure of negative selection of

autoreactive cells， autoantibody production， and severe inflammatory
destruction of multiple organs.
■ Individuals deficient in AIRE gene expression develop "Autoimmune
Polyendocrinopathy-Candidiasis Ectodermal Dystrophy (APECED).

Cryoprecipitate (Wintrobe 13e: pg 553):

*It is prepared by thawing one unit of FFP at 1°C to 6°C.

*Each unit of this cryoprecipitate contains approximately 80 to

120 units of Factor VIII and at least 150 mg of fibrinogen. It also contains factor
XIII, fibronectin, and the high-molecular-weight multimers of vWF.

*At present time, cryoprecipitate is most often used for correction of

#hypofibrinogenemia (<100 mg/dl) in bleeding patients.

CARD15 gene ( CAspase Recruitment Domain-containing protein 15

gene )

● Also known as:

A) "Nucleotide-binding oligomerization domain-containing protein 2 (NOD2)"

B) Inflammatory bowel disease protein 1 (IBD1).

■ It is a protein that in humans is encoded by the NOD2 gene located on

chromosome 16q.

● It plays an important role in the immune system. It recognizes bacterial

molecules (peptidoglycans) and stimulates an immune reaction.
● It is associated with :

A) Inflammatory Bowel disease.

B) Blau syndrome.

( ¤ It is an autosomal dominant genetic inflammatory disorder which affects the

skin, eyes, and joints.
¤ Symptoms usually begin before the age of 4.
¤ Disease manifests as early onset cutaneous sarcoidosis, granulomatous arthritis,
and uveitis.)

C) Pulmonary sarcoidosis.

D) Graft versus Host Disease (GVHD)

Genome editing, or genome editing with engineered nucleases (GEEN)

●●●●●●●●●●●●●●●●●●●●●●●●●●

■ It is a type of genetic engineering in which DNA is inserted, deleted or replaced

in the genome of a living organism using engineered nucleases, or "molecular
scissors."

■ These nucleases create site-specific double-strand breaks (DSBs) at desired

locations in the genome.
■ The induced double-strand breaks are repaired through nonhomologous
end-joining (NHEJ) or homologous recombination (HR), resulting in targeted
mutations ('edits').

■ Four families of engineered nucleases being used:

A) meganucleases,

B) zinc finger nucleases (ZFNs)

C) transcription activator-like effector-based nucleases (TALEN), and

D) #Clustered_regularly_interspaced_short_palindromic_repeats (CRISPR)-Cas
system
Pancoast tumor is most commonly associated with ----Squamous cell carcinoma
of lung.
Reference__
Thurlbeck's Pathology of the Lung---- By Andrew M. Churg, Jeffrey L. Myers
(page no 449)

HEMATURIA

● it is defined as presence of 3 or more red blood cells (RBCs) per high-power

field in 3 of 3 consecutive centrifuged specimens obtained at least 1 week apart.
●It is of two categories:
a) Glomerular hematuria:
• Brown-colored urine,
• RBC casts and DYSMORPHIC (small, deformed, misshapen, sometimes
fragmented) RBCs and proteinuria
• seen in --- glomerulonephritis
b) Nonglomerular hematuria:
• Reddish or pink urine, passage of blood clots
• ISOMORPHIC /eumorphic (normal-sized, biconcavely shaped) erythrocytesseen
in -----renal stone ( most common cause) ; renal infection; renal tumour
"Homeobox protein CDX-2"

●It is a protein encoded by the CDX2 gene.

● This gene is a member of the caudal-related homeobox transcription factor

family that is expressed in the nuclei of intestinal epithelial cells.

■ It is considered as biomarker of
1) Intestinal inflammation.
2) colorectal carcinoma.
#Massive_blood_transfusion ......

● Hypokalemia >>>>>Hyperkalemia.........

● Hypokalemia is actually a more common occurrence with large volume

transfusion because the large volumes of citrate are metabolized to bicarbonate
causing a metabolic alkalosis.

Neubauer counting chamber's calculations for RBC; Platelets and WBC:-

● The counting grid is composed of 9 big squares, measuring 1 x 1 mm.

● From these squares, the central square contains 25 medium sized squares each
measuring 0.2 x 0.2 mm.
● These are further divided into 16 small squares each measuring 0.05 x 0.05 mm.
● The large central square is also called the erythrocyte grid.
● The squares highlighted in red correspond to 80 small squares, that are used to
establish the erythrocyte and platelet counts.
● The large squares marked in blue are used to establish the leukocyte count.

_______________________________
A) Erythrocyte (RBC ) Counting:
---------------------------------------------------
● In a manual erythrocyte count, 10 µl of EDTA blood (collected with an
Eppendorf pipette) is diluted in 1990 µl of isotonic erythrocyte dilution solution.
● This results in a dilution of 1:200.
● This suspension must be well-mixed and be immediately placed into the
counting chamber.
● After approximately 3 minutes, the erythrocytes will have settled, and one may
begin counting the erythrocytes in 80 small squares.
● The calculation of the erythrocyte count is achieved by following the formula
below using these factors:
1) Number of RBC counted in the small squares.
2) Dilution of the cell solution.
3) Number of counted small squares.
4) Volume above one small square.
5) Conversion factor is necessary in order to arrive at the volume of one liter. Since
we are dealing with one µl, this is equal to 106 (1 µl = 1 x 106 L or 1 L = 1 x 106
µl).
■ #Calculations:
RBC count / µl = {Number of RBC counted × Dilution (200)} ÷ {Number of
squares counted (80) ×volume of 1 small square (0.00025 µl)}
i.e.
RBC count / µl = (Number of RBC counted × 200) ÷ (80) ×0.00025 µl)
i.e.
RBC count / µl = (Number of RBC counted × 200) ÷ (0.02 µl)
● Example with 500 counted RBCs.
RBC count / µl = (Number of RBC counted × 200) ÷ (0.02 µl)
i.e. RBC count / µl = (500 × 200) ÷ (.02 µl) = 5000000 / µl
________________________________________
B) Platelet Counting:
--------------------------------------
● In a platelet count, 50 µl EDTA blood (collected with an Eppendorf pipette) is
mixed in 950 µl dilution solution (collected with an Eppendorf pipette).
● This results in a dilution of 1:20.
● The mixture must stand approximately 5 minutes so that the erythrocytes are
completely lysed.
● Then the suspension is mixed and put into the counting chamber.
● The chamber is left in a moist environment for 20-30 minutes so the platelets can
settle without the chamber drying.
● Like the erythrocyte count, 80 small squares are counted.
● Calculation of the platelet count is achieved by using the formula below using
these factors:
1) Number of platelets counted in the small squares.
2) Dilution of the cell solution.
3) Number of counted squares.
4) Volume above a square.
5) Conversion factor which is necessary in order to come to the volume of one
liter. Since we are moving in the µl area, this is equal to 106 (1 µl = 1 x 106 L or 1
L = 1 x 106 µl).
■ #Calculation:
Platelet counts / µl = Number of platelets counted × Dilution (20) ÷Number of
squares counted (80) ×volume of 1 small square (0.00025 µl)
i.e.
Platelet count / µl = (Number of Platelets counted × 20 ) ÷ (80 × 0.00025 µl)
i.e.
Platelet count / µl = (Number of Platelets counted × 20) ÷ (0.02 µl)
● Example with 200 counted platelets.
Platelet count / µl = (Number of platelets counted × 20) ÷ (.02 µl)
i.e. Platelets count / µl = (200 × 200) ÷ (.02 µl) = 200000 / µl
_________________________________________
C) Leukocyte (WBC ) Counting :
_----------------------------------------------------
● In the manual WBC count, 50 µl of EDTA-blood (collected with an Eppendorf
pipette) is mixed together with 950 µl dilution solution (e.g. Türk's solution,
collected with an Eppendorf pipette).
● This constitutes a dilution of 1:20. The erythrocytes will be lysed, and the
leukocyte nucleus will be stained.
● The counting chamber is immediately filled after mixing. After 2 minutes, one
may begin counting the leukocytes in the 4 large squares.
● Calculation of the leukocyte count is achieved by following the formula below
using these factors:
1) Number of leukocytes counted in the big squares.
2) Dilution of the cell solution
3) Number of counted big squares.
4) Volume above a big square.
5) Conversion factor which is necessary in order to come to the volume of one
liter. Since we are moving in the µl area, this is equal to 106 (1 µl = 1 x 106 L or 1
L = 1 x 106 µl)
■ #Calculations:
WBC count / µl = Number of WBC counted × Dilution (20) ÷Number of squares
counted (4) ×volume of 1 big square (0.1 µl)
i.e.
WBC count / µl = (Number of WBC counted × 20) ÷ (4 × 0.1 µl)
i.e.
WBC count / µl = (Number of WBC counted × 20) ÷ (0.4 µl)
■ Example with 200 counted WBCs.
WBC count / µl = (Number of WBC counted × 20) ÷ (0.4 µl)
= (200 × 20) ÷ (0.4 µl) =10000 / µl
"Molecular classification of breast cancer based on "Gene expression profiling".

#Harrison ( 19/e page 526)...

+________________________________________________
BLOOD- BANKING
■ SAGM additive solution provides
optimum red Cell viability.
1) Sodium Chloride provides isotonicity
2) Adenine maintains ATP for red cell viability
3) Glucose supports red cell metabolism (Nutrition)
4) Mannitol helps reduce red cell lysis
■ SHELF LIFE (WHOLE BLOOD / RED CELLS ) IN :
1) ACD( acidified citrate dextrose) = 21 days
(> 70% transfused cells viable after 24 hours)
2) CPD( Citrate phosphate dextrose) = 21 days
3) Citrate Phosphate Dextrose Adenine (CPDA) = 35 days
4) SAGM ( Saline Adenine Glucose Mannitol)= 42 days
■ Whole blood:
● Storage temp.= 2-6 0c
● 1 unit raises Hb by ---1gm/dl and haematocrit by 3%.
■ After collection from donor ,blood should be processed for component
separation within 6 hrs
■ Storage and duration:
1) Whole blood / packed red cells--- 2-6 0c for 42 days
2) Platelets----22-24 0c for 5 days with continuous agitation
3) Fresh frozen plasma---below -18 degree c for 1 year
4) Cryoprecipitate------ below -18 degree c for 1 year
●●●●●●●●●●●●●●●●●●●
Transfusion protocols:
●●●●●●●●●●●●●●●●●●●●
■ Transfusion should commence within 30 minutes of removing blood bag from
refrigerator of blood bag.
(after that it will increase risk of bacterial contamination)
1) Whole blood /packed rbc --transfusion must be completed within 4 hrs.
2) Platelet and FFP----within 20 minutes.

■ Transfusion set should have standard filter of 170 micron meter pore size

■ Usual needle size =18-19 gauge

■ Not necessary to warm blood before transfusion

■ Patient should be monitored during 1st 15 minutes, following this every hour, at
the end and after 4 hrs after end of transfusion.
***************************************
MASSIVE BLOOD TRANSFUSION
**************************************
defined as :-
1) adults
------------------
a) replacement of >1 blood volume in 24 hours ,or
b) >50% of blood volume in 4 hours (adult blood volume is approximately 70
mL/kg).
2) children,
---------------------
● transfusion of >40 mL/kg (blood volume in children over 1 month old is
approximately 80 mL/kg).
● electrolyte abnormalities are :-
1) hypocalcemia
2) hypomagnesemia
3) hypokalemia
4) hyperkalemia
5) metabolic alkalosis ( due to excess citrate is converted to bicarbonate in liver)
■ Bleeding following massive transfusion can occur due to hypothermia, dilutional
coagulopathy, platelet dysfunction, fibrinolysis, or hypofibrinogenemia.

■ Transfusion of 15 to 20 units of blood products causes dilutional

thrombocytopenia

■ Massive bloodTransfusions
Initially TRANSIENT HYPERGLYCEMIA due to glucose in preservatives;
this leads to insulin release and may cause HYPOGLYCEMIA
● Overall most commonly--- HYPOGLYCEMIA > HYPERGLYCEMIA
*************************************
TRALI (Transfusion-Related Acute Lung Injury)
● is the most common cause of major morbidity and death after transfusion. It
presents as an acute respiratory distress syndrome (ARDS) either during or within
6 h of transfusion.
Revised and latest Multiple myeloma diagnostic criteria [ Revised
International Myeloma Working Group (IMWG) ]
● The revised IMWG criteria allow, in addition to the classic CRAB features, three
“myeloma defining events” (MDEs).
● The presence of at least one of these markers is considered sufficient for a
diagnosis of multiple myeloma, regardless of the presence or absence of symptoms
or CRAB features.
● Each of these markers has been associated with an approximately 80% or higher
risk of developing myeloma-related organ damage within two years.
¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤
The new definition of active multiple myeloma is:
¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤
■ Clonal bone marrow plasma cells ≥10% or biopsy-proven bony or
extramedullary plasmacytoma and any one or more of the following CRAB
features and myeloma-defining events:
1) Evidence of end organ damage that can be attributed to the underlying plasma
cell proliferative disorder, specifically:
A) Hypercalcemia: serum calcium >0.25 mmol/L (>1mg/dL) higher than the upper
limit of normal or >2.75 mmol/L (>11mg/dL)
B) Renal insufficiency: creatinine clearance <40 mL per minute or serum
creatinine >177µmol/L (>2mg/dL).
C ) Anemia: hemoglobin valure of >20g/L below the lowest limit of normal, or a
hemoglobin value <100g/L
D)Bone lesions: one or more osteolytic lesion on skeletal radiography, CT, or
PET/CT.
■ If bone marrow has <10% clonal plasma cells, more than one bone lesion is
required to distinguish from solitary plasmacytoma with minimal marrow
involvement.
■ Any one or more of the following biomarkers of malignancy (MDEs ;Myeloma
Defining Events):
1) 60% or greater clonal plasma cells on bone marrow examination.
2) Serum involved / uninvolved free light chain ratio of 100 or greater, provided
the absolute level of the involved light chain is at least 100mg/L (a patient’s
“involved” free light chain—either kappa or lambda—is the one that is above the
normal reference range; the “uninvolved” free light chain is the one that is
typically in, or below, the normal range).
3) More than one focal lesion on MRI that is at least 5mm or greater in size.
LIVER FUNCTION TESTS (LFTS):-

■ Normal LFT’s do not exclude the possibility of chronic liver disease.

■ typical set of LFTS will include:

1) ALANINE – AMINOTRANSFERASE(=ALT =SGPT) –

*************************************

● Normal (5-45 U/L)

● high level suggests----- viral or drug induced hepatitis, or extensive hepatitis
with necrosis of another source.
●Normal levels in infants are 2-times that of adults
● Found mainly in liver
● It is fairly specific for liver damage.
●Levels will be raised before jaundice appears.
● Levels of ALT fluctuate slightly throughout the day, and are particularly raised
after exercise.
● It is generally raised in liver problems, and less so in problems with the bile duct.
It may also be raised in heart problems.
● More specific for liver damage than AST.
●Levels of ALT and AST both raised above 2x normal then this is significant.
●If transferases are very high (greater than 1000 U/L) then the diagnosis is almost
certainly hepatitis
● Alcoholic liver disease will never cause an AST of >1000 u/L

2) ASPARTATE TRANSAMINASE (=AST =serum glutamic oxaloacetic

transaminase (SGOT)
***********************************
● Normal ( 5-45 U/L )
●Raised in--- viral hepatitis, severe skeletal muscle trauma, extensive surgery, drug
induced hepatic trauma,
●Levels from 10-20x normal may suggest MI, and alcoholic cirrhosis.
●5-10x normal may suggest chronic cirrhosis
● Mildly raised levels are often found it fatty liver (steatosis), liver metastasis and
PE.
●These enzymes are found in the liver, RBC’s, cardiac and skeletal muscle, kidney
and brain tissue. As a result, damage to any of these areas can result in an
increased level on test result.
● Remember, high levels are likely to be liver OR heart problems OR muscle
damage .

3) ALKALINE PHOSPHATASE (=ALP) -

***************************************
●Normal (25-110 U/L )
● found in cells lining bile duct and in bone.
●physiologically elevated level in high bone turnover(=adolescence ) and in third
trimester of pregnancy.
● largely elevated in bile duct blockage, and slightly raised in liver disease (e.g.
hepatitis or liver cancer)

4) GAMMA-GLUTAMYL TRANSPEPTIDASE (= GGT)

*************************************
●Normal (<65 U/L )
● more sensitive marker for cholestatic damage than ALP, Gamma glutamyl
transpeptidase (GGT)
●Raised levels ---- in obstruction of the bile ducts.
●GGT is often used to confirm that AST readings are due to liver damage.
● used to monitor cirrhosis caused by alcoholism.

5) BILIRUBIN
*********************
●Normal (0.1–1.0 mg/dL)
● Most commonly used to asses for obstructive jaundice.
● raised in liver damage and in cases of severe RBC damage.
●Test for urobillogen can be useful in determining whether it is due to RBC’s or a
problem with the liver / bile system.

6) ALBUMIN –
*****************
●Normal (3.5 to 5.3 g/dL)
●major protein constituent of plasma, and accounts for over 50% of all plasma
proteins.
●It is manufactured in the liver from ingested amno-acids. It helps to regulate
osmotic pressure as well as transport nutrients and waste products.
●half-life:-
1) albumin ---2 weeks
2) pre-albumin -----2 days

● It may often be reduced as a result of;

1) Diarrhoea
2) Liver disease
3) Poor diet
4) Iron deficiency
5) Infection

7) INR (=INTERNATIONAL NORMALIZED RATIO)

******************************************
● INR are measures of the extrinsic pathway of coagulation.
●also called "ProTime INR" and "INR PT".
● used to determine the clotting tendency of blood, in the measure of warfarin
dosage, liver damage, and vitamin K status.

8) 5' NUCLEOTIDASE:
***********************
●specific for cholestasis or damage to the intra or extrahepatic biliary system
●used as a substitute for GGT for ascertaining whether an elevated ALP is of
biliary or extra-biliary origin.

●●●●●●●●●●●●●●●●●●
INTERPRETATIONS:-
●●●●●●●●●●●●●●●●●●

1) ALP raised, ALT slightly raised – likely to be a problem in bile duct.

2) ALT raised, ALP slightly raised – likely to be a problem in liver.

3) Very high ALT, slightly raised AST – suggests viral / drug induced / sever
necrosis of liver

4) ASP raised, ALT slightly raised – suggests alcoholic or drug induced cirrhosis.

●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●
RATIO OF AST AND ALT CAN BE USEFUL IN DIFFERENTIAL:-
●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●

■ ALT is more specific for liver damage than AST

1) AST: ALT =1
******************
Associated with ischaemia (CCF and ischaemic necrosis and hepatitis)

2) AST: ALT >2.

******************
a. Associated with Alcoholic hepatitis
b. Alcohol induced deficiency of pyridoxal phosphate

3) AST: ALT <1

*******************
a. High rise in ALT specific for Hepatocellular damage
b. Paracetamol toxicity with hepatocellular necrosis
c. Viral hepatitis, ischaemic necrosis, toxic hepatitis.

TUBERCULOSIS

● a/k/a KOCH’s disease

● acid fastness – due to MYCOLIC ACID

● Virulence factor --- “CORD factor”

a) PRIMARY TUBERCULOSIS
●●●●●●●●●●●●●●●●●●●●●●●

●Most commonly seen in children

● a/w unsensitised and unexposed individuals

●source of organism--- exogenous
● most commonly starts as “LATENT DISEASE”
● unilateral hilar lymph enlargement

■ GHON’S FOCUS:-
**********************
● Subpleural fibrocaseous lesion (CONSOLIDATION) of lung parenchyma.
● microscopically contains epitheloid granulomatous inflammation

■GHON’S COMPLEX:-
**********************
●Consists of Subpleural ghon’s focus and involved lymph nodes.

●Ghon's complex found below clavicle.

■RANKE’S COMPLEX :-
***********************
● Ghon’s focus alongwith FIBROSIS and CALCIFICATION known as RANKE’S
COMPLEX.

●Calcification
●Pleural effusion
●Erythema nodosum
● Phlyctenular conjunctivitis
b) POST-PRIMARY
(=SECONDARY)PULMONARY TUBERCULOSIS
●●●●●●●●●●●●●●●●●●●●●●●●●

● Seen in previously sensitized host due to reactivation of latent primary lesions

● frequently a/w decreased immune status

■PUHL’S LESION:-
********************
● Lesion in lung apex.
● No lymph node involvement

■ SIMON FOCUS
*******************
● it is a tuberculous (TB) nodule formed in lung apex.
● Due to spread of primary TB infection from elsewhere in the body to lung apex
via bloodstream.
● Simon focus nodules are often calcified.

■ ASSMAN FOCUS:-
**********************
●infraclavicular lesion of chronic pulmonary T.B.
● Lymph node involvement is RARE.
secondary TB more likely to cavitate than primary TB.
●Endobronchial spread along nearby airways is relatively common finding,
resulting in relatively well-defined 2-4 mm nodules or branching lesions
TREE-IN-BUD APPEARANCE on CT scan.

#tuberculoma formation and miliary TB are also recognised patterns of secondary

TB.

c) MILIARY PULMONARY TUBERCULOSIS

●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●
●Miliary tuberculosis is uncommon but carries a poor prognosis.
● It represents haematogeneous dissemination of an uncontrolled tuberculous
infection.
● seen both in primary and post-primary tuberculosis.
● lungs are usually the easiest location to image.
● Miliary deposits appear as 1-3 mm diameter nodules.

■ RICH FOCUS :-
*******************
● It is a tuberculous granuloma occurring on brain cortex that ruptures into
subarachnoid space, causing tuberculous meningitis.

■WEIGERT’S FOCUS :-
*************************
● Subintimal foci in pulmonary vein. ( d/t metastatic caseous TB.)

■ SIMMOND’S FOCUS:-
**********************
● Localized tb foci in liver.

■■■■■■■■■■■■■■■■■■■■
CONGENITAL TUBERCULOSIS:-
■■■■■■■■■■■■■■■■■■■■

● Infection with tubercle bacilli either during intrauterine life or before complete
passage through birth canal is termed as congenital tuberculosis.

● Three possible modes of infection of fetus:-

1) Hematogenous infection via umbilical vein
2) fetal aspiration of infected amniotic fluid
3) fetal ingestion of infected amniotic fluid

● Most common "site" and most common "site of primary complex " both is ---
LIVER ( primary complex in liver is suggestive of congenital TB)

● Prognosis is poor.

● Revised criteria for diagnosis of congenital tuberculosis ( by Cantwell ) :-

******************************************
● Proven tuberculosis lesions in the infant plus one of the following:-

i. Lesions occurring in the first week of life.

ii. A primary hepatic complex

iii. Maternal genital tract or placental tuberculosis, and

iv. Exclusion of postnatal transmission by thorough investigation of contacts.

Riboflavin (vitamin B2 ) deficiency causes circum corneal congestion.

Glucocoticoid induces apoptosis.

Ref:- Cecil textbook of medicine 25/ed ..pg no.78

#MACROPHAGES:-

A) CLASSICALLY ACTIVATED MACROPHAGES (=M1)

#Involved in inflammation e.g microbicidal actions ; phagocytosis; killing

microorganisms

#Examples are ---IL-1;2;6;8;TNF;IFN etc.

B) ALTERNATIVELY ACTIVATED MACROPHEGES (=M2)

#Has - ANTI-INFLAMMATORY cytokines :

1) IL-4;
2) IL-10;
3) IL-13
4) TGF( transforming growth factor)-BETA

#Function--- wound repair and fibrosis.

HODGKIN'S LYMPHOMA

■ Most common lymph node affected - cervical lymph node.

● WHO classification ( 2 types on the basis of Reed Sternberg cells)

A) CLASSICAL—(following 4 subtypes)
******************************************
■ Best / most specific marker for RS cells ---- PAX-5 (>90%...latest info) > CD 30
(80 to 100% of classical HL).
Other markers CD 15 ( 75-85% ).

( Reference-------
Goldman's Cecil Medicine ; page 1229..---
Lee Goldman (MD.), Andrew I. Schafer
Elsevier Health Sciences, 2012 )

1) NODULAR SCLEROSIS.
****************************
• Most common HL (world)
• Mediastinal involvement most common in this HL.
• Male and female are equally affected ( other HL, males are more commonly
affected)
• Lacunar reed Sternberg cells are seen (cytoplasmic lacuna formed due to tissue
fixation artefact )
• “Collagen Bands” are forming nodules in Lymph nodes.

2) MIXED CELLULARITY
**************************
• Most common HL in India
• Maximum RS cells are seen.

3) LYMPHOCYTE DEPLETED.
*******************************
• Least common type of HL
• RS cells (various names) ---pleomorphic / Mummified / necrobiotic
• Worst prognosis

4) LYMPHOCYTE RICH
**************************
• Minimum RS cells are seen.

B) LYMPHOCYTE PREDOMINANT:-
***********************************

• Popcorn RS cells (or lympho - histiocytic (L&H ) RS cells )

• Immunophenotyping- CD 20 (=BCL6+ve), CD 45, CD 79a, EMA (Epithelial
Membrane Antigen)
• Best prognosis amongst all HL.
●●●●●●●●●●●●●●●●●●●●●●●●
#HIGH yield info about HL:-
●●●●●●●●●●●●●●●●●●●●●●●●

■ EBV and HIV infections ,both are most commonly a/w(amongst Hodgkins
lymphoma subtype)----MIXED CELLULARITY (HODGKINS LYMPHOMA)

■ HIV associated Hodgkins Lymphomas are ----

#mixed cellularity (most common)
#nodular sclerosis and
#lymphocyte depleted

■EBV not associated with HL—

1) Nodular sclerosis
2) lymphocyte predominant
STAINS

1) HEMATOXYLIN stain:
------------------------------------------
#Blue and basic

#Stains NEGATIVELY CHARGED substances e.g. DNA and RNA

#Nucleus stained.

2) EOSIN :
------------------
#Pink and acidic.

#Stains POSITIVELY CHARGED structures e.g. mitochondria

#Cytoplasm is stained.

3) Oil red O stain:

-----------------------------
#fat/lipid (on frozen section)

■ other stains for lipid /fat are:

a) Sudan black B
b) Sudan IV
c) Annexin V
d) Osmium teroxide

4) PAS Stain :
------------------------
a) Glycogen
b) Fungus and amoeba
c) Basement membrane
d) Lymphoblast (BLOCK LIKE POSITIVITY)
e) Erythroblast (DIFFUSELY POSITIVE)

5) CALCIUM STAINS :
------------------------------------
a) Von kossa
b) Alizarin red
c) Calcein

6) PERL’S PRUSSIAN BLUE :

--------------------------------------------
#Iron/hemosiderin

7) FUNGUS STAINS:
---------------------------------
a) Gomori’s methenamine silver stains ---(best fungal stain; stains both live and
dead fungus)

b) PAS stain----only live fungus staining

8) AMYLOID STAINS:
------------------------------------
a) Lugol’s iodine—gross specimen
b) Hematoxylin and eosin
c) Methyl violet
d) Crystal violet
e) Thioflavin T
f) Toluidine blue
g) PAS
h) Alcian blue
i) CONGO RED STAIN--- pink/red under ordinary light
And APPLE –GREEN BIREFRINGERENCE on POLARISED
MICROSCOPY(DIAGNOSTIC)

9) ALCIAN BLUE STAIN;

----------------------------------------
#Mucin and mucosubstances

10) ACID FAST STAIN

-------------------------------------
#Mycobacterium

11) FONTANA MASSON:

-----------------------------------------
#Melanin and Argentaffin cells.

12) MASSON’s TRICHROME STAINS:

----------------------------------------------------'-------
#Collagen and connective tissue

13) VERHOFF-VON-GIESON (VVG):

------------------------------------------------------
#Elastic fibres ( other stain---ORCEIN stain)

14) TOLUIDINE BLUE:

------------------------------------
#Mast cells

15) LUXOL FAST BLUE:

-------------------------------------
#Myelin

16) BIELSCHOWSKY STAIN:

--------------------------------------------
(uses silver stain)
#Neurofibrillary tangles and neuritic plaques.

(GLOBOCAN 2012 fact sheet/latest)

■■■■■■■
WORLD
■■■■■■■
Most common cancer
A) MALE

1) Incidence---Lung cancer
2)Mortality---Lung cancer
B)FEMALE

1)Incidence----Breast ca
2)Mortality----Breast cancer

C) OVERALL
● Most common incidence and mortality both---Lung cancer

■■■■■■■■■
INDIA
■■■■■■■■■

Most common cancer

A)MALE
1) incidence ---oral cancer
2) Mortality----Lung cancer

B)FEMALE
● Incidence and mortality both --Breast cancer
C) OVERALL
● mortality and incidence both--Breast cancer
THROMBOELASTOGRAPHY (TEG)

● method of testing the efficiency of blood coagulation.

● assess platelet function, clot strength, and fibrinolysis .

● detects both hypo- and hyperfunctional stages of the clotting process

● detects known or established hypercoagulable states induced by surgery

(hypercoagulable state---- Factor V Leiden mutation, protein C, protein S, and
antithrombin III deficiencies.)

● predict bleeding in cardiac surgery

● can also be used to guide transfusion therapy during postoperative bleeding.

REYE SYNDROME

■ fatal syndrome that has detrimental effects to organs, especially the brain and
liver

■ lower level of blood sugar (hypoglycemia).

■ classic features are a rash, vomiting, and liver damage.

■ Unknown etiology but associated with aspirin consumption by children with

viral illness, it also occurs in the absence of aspirin use
■ LABORATORY TESTS:-
-----------------------------------------

● elevated liver enzymes, elevated ammonia levels, and low serum glucose levels.

■ HISTOLOGIC CHANGES:-
----------------------------'-----------------
● All cells have pleomorphic, swollen mitochondria that are reduced in number (
diagnostic finding)

● Liver --- fatty liver with minimal inflammation (Microvesicular Steatosis ) and
glycogen depletion.

● Hepatic mitochondrial dysfunction results in hyperammonemia, which is thought

to induce astrocyte edema, resulting in cerebral edema and increased intracranial
pressure (ICP).
In normal liver---
a) Collagen Type 1 and 3 is present at--- portal tract and around Central vein .

b) Collagen Type 4 present in Space of Disse

■ In Cirrhotic liver---- Collagen Type 1 and 3 both are present at space of disse.
CHROMOTHRYPSIS:
Means chromosome shattering; a/k/a dramatic chromosome catastrophe)
1)seen in OSTEOSARCOMAS(other bone cancers too) and GLIOMAS.
2) dozens to hundreds of chromosomal breaks occurs in single or several
chromosomes,then they are repaired haphazardly
3)this will activate Oncogenes and inactivate Tumor suppressor gene.
4)its mechanism of carcinogenesis.

#Pseudolymphoma

• benign infiltration of lymphoid cells or histiocytes that microscopically resembles

a malignant lymphoma.
• occurs in younger population
• associated with collagen diseases, SLE, Sjögren syndrome, phenytoin therapy
• may present with concomitant lymphoma
Recurrence risk in DOWN SYNDROME.
HLA and MALARIA:
1) HLA-B53 --- protect against severe falciparum malaria

2) HLA-DRB1*04 was associated with severe malaria.

#MLPA (Multiplex Ligation –dependent Probe Amplification )

------------------------------------

•It blends DNA hybridisation, DNA ligation and PCR amplification

•to detect deletions and duplications of any size (it includes size that are too
large to be detected by PCR and too small to be amplified by FISH)
•example is CYSTIC FIBROSIS ( it can detect deletion of each of the 27 exons
of CFTR gene)
CARCINOID -TUMORLETS :-
TUMORLET :-
#defined as hyperplasia of neuroendocrine cells that are 5 mm or less in size
and lack of mitotic activity and necrosis.

#Size is currently the only criteria discriminating tumorlet from typical

carcinoid.

#Pulmonary carcinoid tumorlet is always associated with underlying lung

disease such as bronchiectasis and fibrosis .
#Receptor on neuronal membrane that induces development of
Glioma---CD133.

Most important prognostic factor in ALL is " response to treatment".

Ref:- winteobe 13/e pg 1616

CYSTIC FIBROSIS

■ Autosomal recessive.

■Chromosome 7q.

■ Most common mutation is F508 CFTR gene.

■ Type II is most common.

■Type I is having worse prognosis.

■Type V is having best prognosis

RUSHTON BODIES (RB) (=HYALINE BODIES ):-
■ Seen in odontogenic cysts

■ These are eosinophilic, straight or curved, irregular or rounded structures

within the epithelial lining of odontogenic cysts which is surrounded by Dense
lymphoplasmacytic infiltrate.
Most common pattern of inheritance in "Alport syndrome" is "X-Linked
dominant" pattern (85%).

Ref :-
-----------
1) Oxford textbook of Medicine vol.1 page no 415.

3) Oski textbook of pediatrics ,pg no. 1876.

Most important cause of edema in Nephrotic syndrome is "Sodium and
water retention".

References:
--------------------
1) Brenner and Rector' the kidney pg no.851.

2)Heptinstall's Pathology of kidney. Page no . 131.

Most common cytogenetic abnormality in MDS (MyeloDysplastic
Syndrome)--:

a) in children--- monosomy 7
b) adults---5q- (deletion)
c) overall ---5q- (deletion)

References:

1) Blood: Principles and practice of hematology; Volume1... page no.345

2) Cecil textbook of medicine ...page no 1200.

3) Epidemiology of chronic disease by Randall page no 315.

4)The Myelodysplastic syndrome ...pg no 57

#M cells are Antigen Presenting Cells.

(Ref:- Textbook of histology and practical guide by Dr.Gunasegaran).

■ HIV infection is most commonly associated with Mixed cellularity
Hodgkins Lymphoma.

Reference:-

Wintrobe 13/e .pg 2001

Paired-box gene 8 (PAX8)

■ PAX8 Gene encodes a transcription factor associated with important roles

in embryogenesis and disease.

■ PAX8 has been demonstrated to be crucial in determining cell fate during

the development of the thyroid, kidney, brain, eyes and Müllerian system .

■ PAX-8 regulates expression of the Wilms’ tumor suppressor gene (WT1).

■ PAX8 is expressed at high levels in specific types of tumor e.g. thyroid
cancers , renal carcinomas and pancreatic neuroendocrine tumors.

■ PAX8 is useful for the detection and differential diagnosis of ovarian

carcinoma.

■ The consistency of PAX8 staining in epithelial ovarian carcinomas

(EOCs) and the fallopian tube has provided morphological evidence that
EOC may originate from the fallopian tube.

"Acquired ImmunoDeficiency Syndrome (AIDS)-defining cancers" or

"AIDS-defining malignancies":

■ There are 3 malignancies

A) Kaposi sarcoma
B) Non-Hodgkin lymphoma, and
C) Cervical cancer.

■ A diagnosis of any one of these cancers marks the point at which HIV
infection has progressed to AIDS.
Plasmodium species :

☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆

■ Row 1: Plasmodium vivax (top). Left, ring forms (note double

rings/RBC—not limited to P. falciparum);
Image 2, early rings (notice the ameboid shape and lack of stippling/from
EDTA blood);
Image 3, developing troph (note the enlarged RBC and ameboid shape);
Image 4, mature schizont (∼12–24 merozoites), last image, mature
gametocyte (probably macrogametocyte).

■ Row 2: Plasmodium ovale. Left, early ring (note stippling, fimbriated

RBC edges and non-ameboid trophozoite); image 2, developing ring (note
stippling and fimbriated RBC edges; image 3, older developing troph; image
4, mature schizont (∼8–12 merozoites); last image, mature gametocyte
(probably macrogametocyte).

■ Row 3: Plasmodium malariae. Left, ring form; images 2 and 3, band

forms; image 4, mature schizont (∼6–12 merozoites); last image, mature
gametocyte (probably macrogametocyte).

■ Row 4: Plasmodium falciparum.

Left, ring forms (note Maurer’s clefts/dots); images 2 and 3, multiple
rings/RBC (note accol´e forms in image 2 & ‘‘headphone’’ rings in image
3); images 4 and 5, mature crescent-shaped gametocytes.
■ Row 5: Plasmodium knowlesi. Left, ring form; images 2 and 3, band
forms (resemble those seen in P. malariae); image 4, developing schizont;
last image, mature gametocyte (probably macrogametocyte).

"Blood Transfusion" transmitted malaria is by "Trophozoites".

Ref: Panikar Pg 77.

SEROLOGY OF HEPATITIS B:-

1) HBsAg—
¤¤¤¤¤¤¤¤¤¤¤¤¤

● Considered to be infected ( can be acute/chronic or carriers)

● Persistence of HBsAg is used to differentiate acute from chronic infection.

●Presence of the antigen longer than 6 months after initial exposure
indicates chronic infection.

2) anti-HBs—
¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤
● Implies either active or passive immunization that usually persists for life.

● Protected.

3) Anti-HBc—
¤¤¤¤¤¤¤¤¤¤¤¤¤

■ (NOTE:- HbcAg is not detectable in serum)

● first detectable antibody

● IgM anti-HBc indicates acute infection.( most reliable and earliest marker
of acute hepatitis infection).

● Only serologic marker detectable during the “window period “ .

● IgG anti-HBc indicates previous or ongoing infection.

4) HbeAg:-
¤¤¤¤¤¤¤¤¤¤¤
● High infectivity and active disease.

● Higher rates of viral transmission.

● Marker of viral replication and infectivity. ( HbeAg----produced only

during replication of the virus)

5) anti-HBe:
¤¤¤¤¤¤¤¤¤¤¤¤¤¤

● It indicates "low infectivity."

● Loss of HBeAg and appearance of anti-HBe in serum is called

“seroconversion”

● Indicates clinical improvement (=remission of the disease).

6) HBV DNA (quantitative viral load)

¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤

● It indicates viral burden and viral replication.

● Assess recovery from infection and candidacy for antiviral therapy.

● To differentiate between inactive carrier state and chronic active hepatitis

in chronic HBV infection.
NOTE:-
●●●●●●●●●●●
A) Imp info :-
¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤
1) Qualitative marker of HBV-replication-----HbeAg.

2) Quantitative marker of HBV-replication:-

Definitive is HBV-DNA >HBV-DNA polymerase

■ Earliest marker of infection ------HBsAg.

■Earliest marker of "Acute Infection"----IgM anti-HBc.

●●●●●●●●●●●●●●●●●●●●●●●●●

■ "INACTIVE CARRIERS ":-

¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤

● Refers to HBeAg-negative with normal serum ALT levels and low (<
2000 IU/mL) or undetectable HBV DNA.

■ Precore or Basic core mutant HBV:-

¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤

● Also referred to as HBeAg-negative, or anti-HBe-positive HBV.

● HBeAg-negative and anti-HBe-positive patients with high serum
HBV-DNA levels (>10000 copies /ml) and persistent or intermittent
elevations in alanine aminotransferase (ALT) activity.

● It represents severe and progressive form of liver disease.

● It is associated with frequent development of cirrhosis and HCC.

■ " Hepatitis B "Super carrier" :-

¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤

● High titres of HBsAg and HBV-DNA in blood along with HBeAg.

● It indicates early stage of carrier and "highly infectious".

■ " Hepatitis B "Simple carrier" :-

¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤

● Low titre of HBsAg , anti HBe positive, and HBV-DNA negative.

● It indicates late stage of carrier and they will transmit infection when large
quantities of blood are transferred.

BREAST CANCER PROGNOSIS:

1)NON -METASTATIC:---

Axillary lymph node status is most important prognostic factor in the

absence of distant metastses.(Robbins 8/e-page 1089)

2)METASTATIC (ER/PR and HER2/Neu receptors.):-

■ ER/PR +ve----- good prognosis.

■ HER2/Neu receptors overexpression----carries poor prognosis.

Differential diagnosis based on (cytokeratin ) CK7 and CK 20.

Reference:-
Diagnostic Immunohistochemistry by David J Dabbs - Page 616.

Most common primary for metastatic spleen tumour is "Melanoma".

(Ref:- Harrison 19/e pg 412)

Hairy cell leukemia
Patients are prone to:

■ Unusual infections like Mycobacterium avium intracellulare(MAI)

■ Vasculitic syndrome e.g. Polyarteritis Nodosa (PAN).

Excess production of AB 42 is a key initiator of cellular damage in

Alzheimer's disease (AD).
(Harrison 19/e page 2600)

#Forward and #Reverse grouping of ABO Blood Group :-

■ To determine the ABO type:

A) Red cells must be tested with anti-A and Anti-B and,

B) Serum/plasma tested with A and B red cells.

¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤

■ Forward grouping :-

¤ Identifies the antigens on the red cells.

● Tests the recipient or donor red cells with anti-A and anti-B sera.
#interpreations are:

1) Cells agglutinated only with anti-A serum are group A

2) Cells agglutinated only with anti-B serum are group B

3) Cells that do not agglutinate with anti-A or anti-B are group O.

¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤

■ Reverse grouping:-

¤ Identifies the presence of antibodies in the serum/plasma

¤ It confirms the reaction obtained by the forward grouping test.

¤ tests the serum/plasma from the recipient or donor with group A red cells
and group B red cells

#Interpretations :-

1) Agglutination with group B cells indicates the presence of anti-B in the

plasma – Group A individual
 2) Agglutination with group A cells indicates the presence of anti-A in the
plasma – Group B individual.

4) Agglutination with group A cells and group B cells both indicates the
presence of anti-A in and anti-B both in the plasma – Group O individual.

Papillary renal cell carcinoma arise from "proximal tubule epithelium".

Reference : Campbell Urology

Salivary Gland tumours

■Most common tumour of minor salivary glands ----Adenocystic carcinoma.

( 75% of tumours in minor salivary glands are malignant.).

● Most common tumour of major salivary glands

" and "

most common benign salivary gland tumour ------ Plemorphic adenoma

●" Pediatrics age group"

☆☆☆☆☆☆☆☆☆☆☆☆☆
Most common tumour of major salivary glands or most common benign salivary
gland tumour ----- Hemangioma

● #Adults
☆☆☆☆☆☆☆☆

■ Most common malignancy -Mucoepidermoid carcinoma > Adenoid cycstic

carcinoma

● #Pediatrics:-
☆☆☆☆☆☆☆☆☆☆☆☆
Most common malignancy ----------Mucoepidermoid carcinoma> Acinic cell
carcinoma

☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆

● Most common radiation induced neoplasm of Salivary gland is

--------Mucoepidermoid carcinoma.

● Salivary gland tumor more commonly seen in males ------ Warthins tumour.

"Acute Phase Protein":

● Most important cytokine for acute phase protein------- IL-6.

[Ref----1) (Wintrobe 13/e..page no 272)

2) N Engl J Med 1999; 340:448-454.]

● Major inducers of acute phase proteins are IL1, IL6, and TNF.

● Two mediators IL1 and IL6 have been used to classify acute phase proteins into
two subgroups.

A ) TYPE 1 ACUTE PHASE PROTEINS :

---------------------------------------------------------------------
■ They are those that require the synergistic action of IL6 and IL1 for maximum
synthesis.

■ Examples of Type 1 proteins are C-reactive protein, serum amyloid A and

Alpha-1-acid glycoprotein 1.

B) TYPE 2 ACUTE PHASE PROTEINS :-

--------------------------------------------------------------------

■ They are those that require IL6 only for maximal induction.

■ Examples of Type 2 proteins are fibrinogen chains, haptoglobin, and

alpha-2-Macroglobulin.

Interleukins

● IL2 ----- induces proliferation of TH1 cells .

● IL3 ----- induces proliferation of myeloid stem cells.

● IL4 ------
¤ Produced by TH2 cells (blocks proliferation of TH1 cells along with IL10).
¤ Associated with IgE class switch ( similar to IL13)

● IL6 -----

¤ Required for activation of B cells to plasma cells

¤ Key role in synthesis of acute phase proteins during inflammation.

● IL7---- induces proliferation of lymphoid stem cells.

● IL8 ------ chemotactic for neutrophil.

● IL10 ------ blocks proliferation of TH1 cells (produced by TH2 cells).

● IL11------- increases the platelet count.

● IL12 ------ induces proliferation of TH1 cells along with IL2.

● IL13 ----- class switch to IgE.

Type 2 AutoImmune hepatitis

■ It has Anti LKM (Liver ,kidney and microsome) antibodies .

■ These are antibodies against cyt p450.

■ LKM antibodies and their association.

A) LKM1 ------- Chronic Hepatitis C.

B) LKM 2 ------ Drug Induced Hepatitis.

C) LKM 3 ----- chronic hepatitis D.

"Hypersensitivity pneumonitis (HP) " or extrinsic allergic alveolitis

■ Hypersensitivity pneumonitis (HP) or extrinsic allergic alveolitis is an

inflammatory lung condition that involves both :

a) Type III (Immune complex mediated) hypersensitivity reaction.

b) Type IV (Cell mediated) hypersensitivity reaction. (Predominant type)

● (NOTE: Overall type 4> type 3 HSR)....

■■■■■■■■■■■■■■■■■■■■■■■■■■

■ Allergic Bronchopulmonary Mycoses (ABPM) will have all these types of HSR:

a) Type I hypersensitivity reaction.

b) Type III (Immune complex mediated) hypersensitivity reaction.
c) Type IV (Cell mediated) hypersensitivity reaction.
About 65% of human monogenic disorders are autosomal dominant， 25% are
autosomal reιessive， and 5% are X-linked.

(Ref:- Harrison 19/e page 437)/

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#Gene_Knock_in

#Gene_Knock_out

#Gene_knock_down

●●●●●●●●●●●●●●●●●●●●

A) Gene Knockin:-
¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤
■ This technique alters the genetic locus of interest by a one-for-one substitution of
DNA sequence information or by the addition of sequence information that is not
found on said genetic locus.

■ This technology is different from knockout technology in that knockout

technology aims to either delete part of the DNA sequence or insert irrelevant
DNA sequence information to disrupt the expression of a specific genetic locus.

■ A “gene knockin” can be seen as a “gain “of function mutation and a “gene
knockout “a “loss” of function mutation.

B) Gene knockout :-
¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤

■ It is a process of cutting DNA-fragments from the gene using enzymes deleting

the genetic information for a functioning protein. Such method is called “Gene
knockout”.

C) Gene knockdown :-
¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤

■ In this technique protein production is blocked by using particular substances

e.g. microRNAs or siRNA.

■ The reduction can occur either through genetic modification or by treatment with
a reagent such as a short DNA or RNA oligonucleotide that has a sequence
complementary to either gene or an mRNA transcript (e.g. by small interfering
RNA (siRNA).
■ It is used for learning about a gene that has been sequenced, but has an unknown
or incompletely known function.

■ "Largest chromosome" in human being is Chromosome 1.

( It contains about 249 million DNA building blocks (base pairs) and representing
approximately 8 percent of the total DNA in cells.)

■ "Smallest chromosome" in human being is Chromosome 21.

(It contains 48 million nucleotides (the building material of DNA) representing

about 1.5 percent of the total DNA in cells.)

#Systemic Sclerosis and #antibodies.....

"Fibrillarin (anti U3 RNP) is associated with "diffuse scleroderma".

( #Ref:- Harrison 19/e pg 2157).

Biomarkers of acute kidney injury(clinically important)

1) Cystatin c

2) Neutrophil gelatinase–associated lipocalin (NGAL)

3)kidney injury molecule-1 (Kim-1),

4) Alpha1 microglobulin

5)Retinol binding protein

6) kidney injury molecule-1

7) Interleukin18.

8) osteopontin,

9) clusterin,

10) Glutathione S-transferase α,

11)tissue inhibitor of metalloproteinase-1 (TIMP-1),

#Harrison_19e_update
Factors controlling the regulation of gene and protein expression that change with
aging.

A) Epigenetic state of the chromosomes (e.g.， DNA methylation and histone

acetylation) and microRNAs (miRNA) DNA methylation correlates with age.
B) Histone acetylation is regulated by many enzymes including SIRT 1， a
protein that has marked effects on aging and the response to dietary restriction.

C) miRNAs are a very large group of noncoding lengths of RNA (18-25

nucleotides) that inhibit translation of multiple different mRNAs through binding
their 3' untranslated regions (UTRs).

The expression of miRNAs usually decreases with aging and is altered in some
age-related diseases.

■ Specific miRNAs linked with aging pathways include miR-21 (associated with
target of rapamycin pathway) and miR-1 (associated with insulin/insulin-like
growth factor 1 pathway).

#Harrison_19e(pg.2612)

● Mutations in the glucocerebrosidase (GBA) gene associated with Gaucher's

disease numerically represent the most important risk factor for the development of
PD.

● Mechanism:
It is not known precisely.
GBA mutations are associated with altered autophagy and lysosomal function and
could impair clearance of αlpha-synuclein.
Diabetes Ketoacidosis vs Hyperglycemic Hyperosmolar State (HHS).

#Harrison19e
☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆☆

NECROPTOSIS:

■ It is hybrid of Necrosis+Apoptosis but considered as NECROSIS)

■ Also known as programmed cell death without caspase activation

● It is both pathological (ischaemic brain injury, neurodegenerative diseases and

viral infections ) and physiological ( formation of mammalian bone growth plate )

● Under conditions that are insufficient to trigger apoptosis, TNFα activates

TNFR1 and in turn induces the recruitment of RIP1and RIP3 kinase and other
proteins to form complex (which includes RIP1, RIP3, caspase 8 ).

■ formation of this complex leads to necroptosis (caspase 8 is not activated here in

this pathway)

● Necroptosis differs from Apoptosis by following features (that’s why they are
considered as NECROSIS ---- “Caspase independent programmed cell death” )

1) Shows cell swelling

2) Cell membrane damage
3) Presence of inflammation
Infectious diseases and AUTOPHAGY :
#Many pathogens are degraded by autophagy e.g. mycobacteria, Shigella spp., and
HSV-1.
#This is one way by which microbial proteins are digested and delivered to antigen
presentation pathways.
#Macrophage-specific deletion of "Atg5" increases susceptibility to tuberculosis.
Blood collection tube (Vacutainers)

Chédiak-Higashi syndrome
___________________________

● Autosomal recessive.
● Disordered coalescence of lysosomal granules Responsible gene found at
1q42-45. The encoded protein (LYST) has structural features homologous to a
vacuolar sorting protein.

● Impaired functions are :

a) Decreased neutrophilic chemotaxis, degranulation, and bactericidal activity;

b) platelet storage pool defect; impaired NK function; failure to disperse
melanosomes

● Clinical features :
a) Neutropenia, recurrent pyogenic infections.
b) Propensity for the development of marked hepatosplenomegaly in the
accelerated phase.
c) Partial albinism:
d) Defects in myelopoiesis result in neutropenia.
e) Advanced disease is characterized by lymphocytic tissue infiltrates and
pancytopenia.

■ Death usually occurs by 7 years of age because of infection.

PURE RED CELL APLASIA (PRCA) or ERYTHROBLASTOPENIA:-
• type of anemia affecting precursors to red blood cells but not to white blood cells
• bone marrow ceases to produce red blood cells.
• Causes include:
1) Autoimmune disease.
2) Thymoma
3) Viral infections---- HIV, herpes, parvovirus B19 (Fifth disease), or hepatitis
4) T large granular lymphocyte leukemia
5) Idiopathic.
6) ABO incompatibility
7) Drugs, e.g., mycophenolic acid or erythropoietin;NSAIDs
8) Congenital -----"hereditary pure red cell aplasia" (a/k/a Diamond-Blackfan
anemia)
Bone morphogenetic Protein:--- involved in embryogenesis(MORPHOGENIC) ;
apoptosis; and cell proliferation and differentiation (MITOGENIC)….( robbins 9e)
Reticulocuyte
counts:
Devitas Oncology update

Devitas Oncology update

Molecular cytogenetics UPDATE