430 SECTION III Hematology and Oncology hematology and oncology—Pathology Heme synthesis, The porphyrias are hereditary or acquired conditions of defective heme synthesis that lead to the porphyrias, and lead accumulation of heme precursors. Lead inhibits specific enzymes needed in heme synthesis, poisoning leading to a similar condition. CONDITION AFFECTED ENZYME ACCUMULATED SUBSTRATE PRESENTING SYMPTOMS Lead poisoning Ferrochelatase and Protoporphyrin, ALA Microcytic anemia (basophilic stippling in A ALA dehydratase (blood) peripheral smear A , ringed sideroblasts in bone marrow), GI and kidney disease. Acute intermittent Porphobilinogen Porphobilinogen, ALA porphyria deaminase (autosomal Children—exposure to lead paint mental dominant mutation) Uroporphyrin (tea- deterioration. Porphyria cutanea colored urine) tarda Uroporphyrinogen Adults—environmental exposure (eg, batteries, B decarboxylase ammunition) headache, memory loss, demyelination (peripheral neuropathy). Symptoms (5 P’s): Painful abdomen Port wine–colored Pee Polyneuropathy Psychological disturbances Precipitated by factors that ALA synthase (eg, drugs [CYP450 inducers], alcohol, starvation) Treatment: hemin and glucose. Blistering cutaneous photosensitivity and hyperpigmentation B . Most common porphyria. Exacerbated with alcohol consumption. Causes: familial, hepatitis C. Treatment: phlebotomy, sun avoidance, antimalarials (eg, hydroxychloroquine). MITOCHONDRIA Glucose, hemin Lead poisoning CYTOPLASM Sideroblastic anemia (X-linked) Succinyl CoA + glycine Aminolevulinic Porphobilinogen B₆ acid ALA dehydratase Porphobilinogen ALA synthase deaminase (rate-limiting step) Acute intermittent Mitochondrial Hydroxymethylbilane porphyria membrane Heme Uroporphyrinogen III Uroporphyrinogen Ferrochelatase decarboxylase Porphyria cutanea tarda Lead Fe2+ poisoning Protoporphyrin Coproporphyrinogen III
Hematology and Oncology hematology and oncology—Pathology SECTION III 431 Iron poisoning Acute Chronic Seen in patients with 1° (hereditary) or 2° (eg, FINDINGS High mortality rate associated with accidental MECHANISM ingestion by children (adult iron tablets may chronic blood transfusions for thalassemia or SYMPTOMS/SIGNS look like candy). sickle cell disease) hemochromatosis. TREATMENT Cell death due to formation of free radicals and Arthropathy, cirrhosis, cardiomyopathy, diabetes peroxidation of membrane lipids. mellitus and skin pigmentation (“bronze diabetes”), hypogonadism. Abdominal pain, vomiting, GI bleeding. Radiopaque pill seen on x-ray. May progress to Phlebotomy (patients without anemia) or anion gap metabolic acidosis and multiorgan chelation. failure. Leads to scarring with GI obstruction. Chelation (eg, deferoxamine, deferasirox), gastric lavage. Coagulation disorders PT—tests function of common and extrinsic pathway (factors I, II, V, VII, and X). Defect PT (Play Tennis outside [extrinsic pathway]). DISORDER INR (international normalized ratio) = patient PT/control PT. 1 = normal, > 1 = prolonged. Most Hemophilia A, B, or C common test used to follow patients on warfarin, which prolongs INR. A PTT—tests function of common and intrinsic pathway (all factors except VII and XIII). Defect Vitamin K deficiency PTT (Play Table Tennis inside). TT—measures the rate of conversion of fibrinogen fibrin. Prolonged by anticoagulants, hypofibrinogenemia, DIC, liver disease. Coagulation disorders can be due to clotting factor deficiencies or acquired factor inhibitors (most commonly against factor VIII). Diagnosed with a mixing study, in which normal plasma is added to patient’s plasma. Clotting factor deficiencies should correct (the PT or PTT returns to within the appropriate normal range), whereas factor inhibitors will not correct. PT PTT MECHANISM AND COMMENTS — Intrinsic pathway coagulation defect ( PTT). A: deficiency of factor VIII; X-linked recessive. Pronounce “hemophilia Ate (eight).” B: deficiency of factor IX; X-linked recessive. C: deficiency of factor XI; autosomal recessive. Hemorrhage in hemophilia—hemarthroses (bleeding into joints, eg, knee A ), easy bruising, bleeding after trauma or surgery (eg, dental procedures). Treatment: desmopressin, factor VIII concentrate, emicizumab (A); factor IX concentrate (B); factor XI concentrate (C). General coagulation defect. Bleeding time normal. activity of factors II, VII, IX, X, protein C, protein S. uploaded by medbooksvn
432 SECTION III Hematology and Oncology hematology and oncology—Pathology Platelet disorders All platelet disorders have bleeding time (BT), mucous membrane bleeding, and microhemorrhages (eg, petechiae, epistaxis). Platelet count (PC) is usually low, but may be DISORDER normal in qualitative disorders. Bernard-Soulier PC BT NOTES syndrome Glanzmann –/ Autosomal recessive defect in adhesion. GpIb platelet-to-vWF adhesion. thrombasthenia Labs: platelet aggregation, Big platelets. Immune – Autosomal recessive defect in aggregation. GpIIb/IIIa ( integrin αIIbβ3) thrombocytopenia platelet-to-platelet aggregation and defective platelet plug formation. Uremic platelet Labs: blood smear shows no platelet clumping. dysfunction Destruction of platelets in spleen. Anti-GpIIb/IIIa antibodies splenic macrophages phagocytose platelets. May be idiopathic or 2° to autoimmune disorders (eg, SLE), viral illness (eg, HIV, HCV), malignancy (eg, CLL), or drug reactions. Labs: megakaryocytes on bone marrow biopsy, platelet count. Treatment: glucocorticoids, IVIG, rituximab, TPO receptor agonists (eg, eltrombopag, romiplostim), or splenectomy for refractory ITP. – In patients with renal failure, uremic toxins accumulate and interfere with platelet adhesion. Thrombotic Disorders overlap significantly in symptomatology. May resemble DIC, but do not exhibit lab microangiopathies findings of a consumptive coagulopathy (eg, PT, PTT, fibrinogen), as etiology does not involve widespread clotting factor activation. EPIDEMIOLOGY PATHOPHYSIOLOGY Thrombotic thrombocytopenic purpura Hemolytic-uremic syndrome PRESENTATION Typically females Typically children DIFFERENTIATING SYMPTOMS LABS Inhibition or deficiency of ADAMTS13 (a Predominately caused by Shiga toxin–producing TREATMENT vWF metalloprotease) degradation of Escherichia coli (STEC) infection (serotype vWF multimers large vWF multimers O157:H7), which causes profound endothelial platelet adhesion and aggregation dysfunction. (microthrombi formation) Triad of thrombocytopenia ( platelets), microangiopathic hemolytic anemia ( Hb, schistocytes, LDH), acute kidney injury ( Cr) Triad + fever + neurologic symptoms Triad + bloody diarrhea Normal PT and PTT helps distinguish TTP and HUS (coagulation pathway is not activated) from DIC (coagulation pathway is activated) Plasma exchange, glucocorticoids, rituximab Supportive care
Hematology and Oncology hematology and oncology—Pathology SECTION III 433 Mixed platelet and coagulation disorders DISORDER PC BT PT PTT NOTES von Willebrand — — —/ Intrinsic pathway coagulation defect: vWF disease PTT (vWF carries/protects factor VIII). Disseminated Defect in platelet plug formation: vWF intravascular defect in platelet-to-vWF adhesion. coagulation Most are autosomal dominant. Mild but most common inherited bleeding disorder. Commonly presents with menorrhagia or epistaxis. Treatment: desmopressin, which releases vWF stored in endothelium. Widespread clotting factor activation thromboembolic state with excessive clotting factor consumption thromboses, hemorrhages (eg, blood oozing from puncture sites). May be acute (life-threatening) or chronic (if clotting factor production can compensate for consumption). Causes: heat Stroke, Snake bites, Sepsis (gram ⊝), Trauma, Obstetric complications, acute Pancreatitis, malignancy, nephrotic syndrome, transfusion (SSSTOP making new thrombi). Labs: schistocytes, fibrin degradation products (d-dimers), fibrinogen, factors V and VIII. Hereditary Autosomal dominant disorders resulting in hypercoagulable state ( tendency to develop thrombophilias thrombosis). DISEASE DESCRIPTION Antithrombin Has no direct effect on the PT, PTT, or thrombin time but diminishes the increase in PTT deficiency following standard heparin dosing. Factor V Leiden Can also be acquired: renal failure/nephrotic syndrome antithrombin loss in urine inhibition of factors IIa and Xa. Protein C or S deficiency Production of mutant factor V (guanine adenine DNA point mutation Arg506Gln mutation Prothrombin G20210A near the cleavage site) that is resistant to degradation by activated protein C. Complications mutation include DVT, cerebral vein thrombosis, recurrent pregnancy loss. ability to inactivate factors Va and VIIIa. risk of warfarin-induced skin necrosis. Together, protein C Cancels, and protein S Stops, coagulation. Point mutation in 3′ untranslated region production of prothrombin plasma levels and venous clots. uploaded by medbooksvn
434 SECTION III Hematology and Oncology hematology and oncology—Pathology Blood transfusion therapy COMPONENT DOSAGE EFFECT CLINICAL USE Packed RBCs Hb and O2 binding (carrying) capacity, Acute blood loss, severe anemia hemoglobin ~1 g/dL per unit, hematocrit ~3% per unit Platelets platelet count ~30,000/microL per unit Stop significant bleeding (thrombocytopenia, ( ∼5000/mm3/unit) qualitative platelet defects) Fresh frozen plasma/ coagulation factor levels; FFP contains all Cirrhosis, immediate anticoagulation reversal prothrombin coagulation factors and plasma proteins; PCC complex concentrate generally contains factors II, VII, IX, and X, as well as protein C and S Cryoprecipitate Contains fibrinogen, factor VIII, factor XIII, Coagulation factor deficiencies involving vWF, and fibronectin fibrinogen and factor VIII Albumin intravascular volume and oncotic pressure Post-paracentesis, therapeutic plasmapheresis Blood transfusion risks include infection transmission (low), transfusion reactions, transfusion-associated circulatory overload (TACO; volume overload pulmonary edema, hypertension), transfusion-related acute lung injury (TRALI; hypoxia and inflammation noncardiogenic pulmonary edema, hypotension), iron overload (may lead to 2° hemochromatosis), hypocalcemia (citrate is a Ca2+ chelator), and hyperkalemia (RBCs may lyse in old blood units). Leukemia vs lymphoma Leukemia Lymphoid or myeloid neoplasm with widespread involvement of bone marrow. Tumor cells are usually found in peripheral blood. Lymphoma Discrete tumor mass arising from lymph nodes. Variable clinical presentation (eg, arising in atypical sites, leukemic presentation). Hodgkin vs Hodgkin Non-Hodgkin non‑Hodgkin lymphoma Both may have constitutional (“B”) signs/symptoms: low-grade fever, night sweats, weight loss. Localized, single group of nodes with Multiple lymph nodes involved; extranodal contiguous spread (stage is strongest predictor involvement common; noncontiguous spread. of prognosis). Better prognosis. Worse prognosis. Characterized by Reed-Sternberg cells. Majority involve B cells; rarely of T-cell lineage. Bimodal distribution: young adults, > 55 years. Can occur in children and adults. Associated with EBV. May be associated with autoimmune diseases and viral infections (eg, HIV, EBV, HTLV). Hodgkin lymphoma Contains Reed-Sternberg cells: distinctive tumor giant cells; bilobed nucleus with the 2 halves as A mirror images (“owl eyes” A ). RS cells are CD15+ and CD30+ B-cell origin. 2 owl eyes × 15 = 30. SUBTYPE NOTES Nodular sclerosis Most common Mixed cellularity Eosinophilia; seen in immunocompromised patients Lymphocyte rich Best prognosis (the rich have better bank accounts) Lymphocyte depleted Worst prognosis (the poor have worse bank accounts); seen in immunocompromised patients
Hematology and Oncology hematology and oncology—Pathology SECTION III 435 Non-Hodgkin lymphoma TYPE OCCURS IN GENETICS COMMENTS Neoplasms of mature B cells Burkitt lymphoma Adolescents or young t(8;14)—translocation “Starry sky” appearance (StarBurst), sheets of adults of c-myc (8) and lymphocytes with interspersed “tingible body” heavy-chain Ig (14) macrophages (arrows in A ). Associated with “Burkid” lymphoma EBV. (more common in Mutations in BCL-2, kids) BCL-6 Jaw lesion B in endemic form in Africa; pelvis or abdomen in sporadic form. Diffuse large B-cell Usually older adults, t(14;18)—translocation lymphoma but 20% in children of heavy-chain Ig (14) Most common type of non-Hodgkin lymphoma and BCL-2 (18) in adults. Follicular lymphoma Adults t(11;14)—translocation Indolent course with painless “waxing and Mantle cell lymphoma Adult males >> adult of cyclin D1 (11) and waning” lymphadenopathy. Bcl-2 normally females heavy-chain Ig (14), inhibits apoptosis. CD5+ Marginal zone Adults Very aggressive, patients typically present with lymphoma t(11;18) late-stage disease. Primary central Adults EBV related; Associated with chronic inflammation (eg, nervous system associated with HIV/ Sjögren syndrome, chronic gastritis [MALT lymphoma AIDS lymphoma; may regress with H pylori eradication]). Considered an AIDS-defining illness. Variable presentation: confusion, memory loss, seizures. CNS mass (often single, ring-enhancing lesion on MRI) in immunocompromised patients C , needs to be distinguished from toxoplasmosis via CSF analysis or other lab tests. Neoplasms of mature T cells Caused by HTLV Adults present with cutaneous lesions; common Adult T-cell lymphoma Adults (associated with IV in Japan (T-cell in Tokyo), West Africa, and the drug use) Caribbean. Mycosis fungoides/ Adults Sézary syndrome B Lytic bone lesions, hypercalcemia. A Mycosis fungoides: skin patches and plaques D (cutaneous T-cell lymphoma), characterized by atypical CD4+ cells with “cerebriform” nuclei and intraepidermal neoplastic cell aggregates (Pautrier microabscess). May progress to Sézary syndrome (T-cell leukemia). CD uploaded by medbooksvn
436 SECTION III Hematology and Oncology hematology and oncology—Pathology Plasma cell dyscrasias Group of disorders characterized by proliferation of a single plasma cell clone, typically overproducing a monoclonal immunoglobulin (also called paraprotein). Seen in older adults. M spike Screening with serum protein electrophoresis (M spike represents overproduction of Monoclonal Albumin α α β γ Ig), serum immunofixation, and serum free light chain assay. Urine protein electrophoresis and immunofixation required to confirm urinary involvement (urine dipstick only detects albumin). Multiple myeloma Diagnostic confirmation with bone marrow biopsy. Waldenström Peripheral blood smear may show rouleaux formation A (RBCs stacked like poker chips). macroglobulinemia Overproduction of IgG (most common) > IgA > Ig light chains. Clinical features (CRAB): Monoclonal hyperCalcemia ( cytokine secretion [eg, IL-1, TNF-a, RANK-L] by malignant plasma cells gammopathy of osteoclast activity), Renal insufficiency, Anemia, Bone lytic lesions (“punched out” on x-ray undetermined B back pain). Complications: infection risk, 1° amyloidosis (AL). significance Urinalysis may show Ig light chains (Bence Jones proteinuria) with ⊖ urine dipstick. Bone marrow biopsy shows >10% monoclonal plasma cells with clock-face chromatin C and intracytoplasmic inclusions containing Ig. Overproduction of IgM (macroglobulinemia because IgM is the largest Ig). Clinical features include anemia, constitutional (“B”) signs/symptoms, lymphadenopathy, hepatosplenomegaly, hyperviscosity (eg, headache, bleeding, blurry vision, ataxia), peripheral neuropathy. Funduscopy shows dilated, segmented, and tortuous retinal veins (sausage link appearance). Bone marrow biopsy shows >10% monoclonal B lymphocytes with plasma cell features (lymphoplasmacytic lymphoma) and intranuclear pseudoinclusions containing IgM. Overproduction of any Ig type (M spike <3 g/dL). Asymptomatic (no CRAB findings). 1%–2% risk per year of progressing to multiple myeloma. Bone marrow biopsy shows <10% monoclonal plasma cells. A BC Myelodysplastic Stem cell disorders involving ineffective Pseudo-Pelger-Huët anomaly—neutrophils syndromes hematopoiesis defects in cell maturation of with bilobed (“duet”) nuclei A . Associated nonlymphoid lineages. Bone marrow blasts with myelodysplastic syndromes or drugs A < 20% (vs > 20% in AML). Caused by de (eg, immunosuppressants). novo mutations or environmental exposure (eg, radiation, benzene, chemotherapy). Risk of transformation to AML. More common in older adults.
Hematology and Oncology hematology and oncology—Pathology SECTION III 437 Leukemias Unregulated growth and differentiation of WBCs in bone marrow marrow failure anemia ( RBCs), infections ( mature WBCs), and hemorrhage ( platelets). Usually presents with circulating WBCs (malignant leukocytes in blood), although some cases present with normal/ WBCs. Leukemic cell infiltration of liver, spleen, lymph nodes, and skin (leukemia cutis) possible. TYPE NOTES Lymphoid neoplasms Acute lymphoblastic Most frequently occurs in children; less common in adults (worse prognosis). T-cell ALL can leukemia/lymphoma present as mediastinal mass (presenting as SVC-like syndrome). Associated with Down syndrome. Peripheral blood and bone marrow have lymphoblasts A . TdT+ (marker of pre-T and pre-B cells), CD10+ (marker of pre-B cells). Most responsive to therapy. May spread to CNS and testes. t(12;21) better prognosis; t(9;22) (Philadelphia chromosome) worse prognosis. Chronic lymphocytic Age > 60 years. Most common adult leukemia. CD20+, CD23+, CD5+ B-cell neoplasm. Often leukemia/small asymptomatic, progresses slowly; smudge cells B in peripheral blood smear; autoimmune lymphocytic hemolytic anemia. CLL = Crushed Little Lymphocytes (smudge cells). lymphoma Richter transformation—CLL/SLL transformation into an aggressive lymphoma, most commonly diffuse large B-cell lymphoma (DLBCL). Hairy cell leukemia Adult males. Mature B-cell tumor. Cells have filamentous, hairlike projections (fuzzy appearing on LM C ). Peripheral lymphadenopathy is uncommon. Causes marrow fibrosis dry tap on aspiration. Patients usually present with massive splenomegaly and pancytopenia. Stains TRAP (Tartrate-Resistant Acid Phosphatase) ⊕ (TRAPped in a hairy situation). TRAP stain largely replaced with flow cytometry. Associated with BRAF mutations. Treatment: purine analogs (cladribine, pentostatin). Myeloid neoplasms Acute myelogenous Median onset 65 years. Auer rods D ; myeloperoxidase ⊕ cytoplasmic inclusions seen mostly in leukemia APL (formerly M3 AML); circulating myeloblasts on peripheral smear. May present with leukostasis (capillary occlusion by malignant, nondistensible cells organ damage). Risk factors: prior exposure to alkylating chemotherapy, radiation, benzene, myeloproliferative disorders, Down syndrome (typically acute megakaryoblastic leukemia [formerly M7 AML]). APL: t(15;17), responds to all-trans retinoic acid (vitamin A) and arsenic trioxide, which induce differentiation of promyelocytes; DIC is a common presentation. Chronic myelogenous Peak incidence: 45–85 years; median age: 64 years. Defined by the Philadelphia chromosome leukemia (t[9;22], BCR-ABL) and myeloid stem cell proliferation. Presents with dysregulated production of mature and maturing granulocytes (eg, neutrophils, metamyelocytes, myelocytes, basophils E ) and splenomegaly. May accelerate and transform to AML or ALL (“blast crisis”). Responds to BCR-ABL tyrosine kinase inhibitors (eg, imatinib). A B CD E uploaded by medbooksvn
438 SECTION III Hematology and Oncology hematology and oncology—Pathology Myeloproliferative Malignant hematopoietic neoplasms with varying impacts on WBCs and myeloid cell lines. neoplasms Polycythemia vera Primary polycythemia. Disorder of RBCs, usually due to acquired JAK2 mutation. May present as intense itching after shower (aquagenic pruritus). Rare but classic symptom is erythromelalgia Essential (severe, burning pain and red-blue coloration) due to episodic blood clots in vessels of the thrombocythemia extremities A . Associated with hyperviscosity and thrombosis (eg, PE, DVT, Budd-Chiari Myelofibrosis syndrome). Polycythemia vera EPO (vs 2° polycythemia, which presents with endogenous or artificially EPO). Essential Treatment: phlebotomy, hydroxyurea, ruxolitinib (JAK1/2 inhibitor). thrombocythemia Myelofibrosis Characterized by massive proliferation of megakaryocytes and platelets. Symptoms include CML bleeding and thrombosis. Blood smear shows markedly increased number of platelets, which may be large or otherwise abnormally formed B . Erythromelalgia may occur. Atypical megakaryocyte hyperplasia TGF-β secretion fibroblast activity obliteration of bone marrow with fibrosis. Associated with massive splenomegaly and “teardrop” RBCs C . “Bone marrow cries because it’s fibrosed and is a dry tap.” RBCs WBCs PLATELETS PHILADELPHIA CHROMOSOME JAK2 MUTATIONS ⊝ ⊕ − − ⊝ ⊕ (30–50%) Variable Variable ⊝ ⊕ (30–50%) ⊕ ⊝ ABC Leukemoid reaction vs chronic myelogenous leukemia Leukemoid reaction Chronic myelogenous leukemia Myeloproliferative neoplasm ⊕ for BCR-ABL DEFINITION Reactive neutrophilia > 50,000 cells/mm3 Pseudo-Pelger-Huët anomaly NEUTROPHIL MORPHOLOGY Toxic granulation, Döhle bodies, cytoplasmic (LAP enzyme in malignant neutrophils) vacuoles LAP SCORE EOSINOPHILS AND BASOPHILS Normal
Hematology and Oncology hematology and oncology—Pathology SECTION III 439 Polycythemia PLASMA VOLUME RBC MASS O2 SATURATION EPO LEVELS ASSOCIATIONS Relative Appropriate absolute – – – Dehydration, burns. Inappropriate absolute – – – Lung disease, congenital heart disease, high Polycythemia vera altitude, obstructive sleep apnea. = 1º disturbance – Exogenous EPO (athlete misuse, also called “blood doping”), androgen supplementation. Inappropriate EPO secretion: malignancy (eg, RCC, HCC). EPO in PCV due to negative feedback suppressing renal EPO production. Chromosomal translocations TRANSLOCATION ASSOCIATED DISORDER NOTES t(8;14) Burkitt (Burk-8) lymphoma (c-myc activation) The Ig heavy chain genes on chromosome 14 are constitutively expressed. When other t(11;14) Mantle cell lymphoma (cyclin D1 activation) genes (eg, c-myc and BCL-2) are translocated next to this heavy chain gene region, they are t(11;18) Marginal zone lymphoma overexpressed. t(14;18) Follicular lymphoma (BCL-2 activation) t(15;17) APL (formerly M3 type of AML) t(9;22) (Philadelphia CML (BCR-ABL hybrid), ALL (less common); chromosome) Philadelphia CreaML cheese Langerhans cell Collective group of proliferative disorders of Langerhans cells (antigen-presenting cells normally histiocytosis found in the skin). Presents in a child as lytic bone lesions and skin rash or as recurrent otitis media with a mass involving the mastoid bone. Cells are functionally immature and do not A effectively stimulate primary T cells via antigen presentation. Cells express S-100 and CD1a. Birbeck granules (“tennis rackets” or rod shaped on EM) are characteristic A . uploaded by medbooksvn
440 SECTION III Hematology and Oncology hematology and oncology—pharmacology Tumor lysis syndrome Muscle Oncologic emergency triggered by massive K+ weakness tumor cell lysis, seen most often with lymphomas/leukemias. Usually caused Ca2+ Arrhythmias, by treatment initiation, but can occur ECG changes spontaneously with fast-growing cancers. Tumor cell PO₄³_ Calcium Release of K+ hyperkalemia, release of PO43– lysis Uric acid phosphate Seizures, hyperphosphatemia, hypocalcemia due to crystals tetany Ca2+ sequestration by PO43–. nucleic acid breakdown hyperuricemia acute kidney Uric acid Acute kidney injury. Prevention and treatment include crystals injury aggressive hydration, allopurinol, rasburicase. ` HEMATOLOGY AND ONCOLOGY—PHARMACOLOGY Heparin Activates antithrombin, which action primarily of factors IIa (thrombin) and Xa. Short half-life. MECHANISM Immediate anticoagulation for pulmonary embolism (PE), acute coronary syndrome, MI, deep CLINICAL USE venous thrombosis (DVT). Used during pregnancy (does not cross placenta). Monitor PTT. ADVERSE EFFECTS Bleeding (reverse with protamine sulfate), heparin-induced thrombocytopenia (HIT), osteoporosis NOTES (with long-term use), drug-drug interactions, type 4 renal tubular acidosis. HIT type 1—mild (platelets > 100,000/mm3), transient, nonimmunologic drop in platelet count that typically occurs within the first 2 days of heparin administration. Not clinically significant. HIT type 2—development of IgG antibodies against heparin-bound platelet factor 4 (PF4) that typically occurs 5–10 days after heparin administration. Antibody-heparin-PF4 complex binds and activates platelets removal by splenic macrophages and thrombosis platelet count. Highest risk with unfractionated heparin. Treatment: discontinue heparin, start alternative anticoagulant (eg, argatroban). Fondaparinux safe to use (does not interact with PF4). Low-molecular-weight heparins (eg, enoxaparin, dalteparin) act mainly on factor Xa. Fondaparinux acts only on factor Xa. Both are not easily reversible. Unfractionated heparin used in patients with renal insufficiency (low-molecular-weight heparins should be used with caution because they undergo renal clearance).
Hematology and Oncology hematology and oncology—pharmacology SECTION III 441 Warfarin Inhibits vitamin K epoxide reductase by competing with vitamin K inhibition of vitamin K– dependent γ-carboxylation of clotting factors II, VII, IX, and X and proteins C and S. Metabolism MECHANISM affected by polymorphisms in the gene for vitamin K epoxide reductase complex (VKORC1). In laboratory assay, has effect on extrinsic pathway and PT. Long half-life. CLINICAL USE “The ex-PresidenT went to war(farin).” ADVERSE EFFECTS A Chronic anticoagulation (eg, venous thromboembolism prophylaxis and prevention of stroke in atrial fibrillation). Not used in pregnant patients (because warfarin, unlike heparin, crosses placenta). Monitor PT/INR. Bleeding, teratogenic effects, skin/tissue necrosis A , drug-drug interactions (metabolized by cytochrome P-450 [CYP2C9]). Initial risk of hypercoagulation: protein C has shorter half-life than factors II and X. Existing protein C depletes before existing factors II and X deplete, and before warfarin can reduce factors II and X production hypercoagulation. Skin/tissue necrosis within first few days of large doses believed to be due to small vessel microthrombosis. Heparin “bridging”: heparin frequently used when starting warfarin. Heparin’s activation of antithrombin enables anticoagulation during initial, transient hypercoagulable state caused by warfarin. Initial heparin therapy reduces risk of recurrent venous thromboembolism and skin/ tissue necrosis. For reversal of warfarin, give vitamin K. For rapid reversal, give FFP or PCC. Heparin vs warfarin Heparin Warfarin Parenteral (IV, SC) Oral ROUTE OF ADMINISTRATION Blood Liver SITE OF ACTION Rapid (seconds) Slow, limited by half-lives of normal clotting ONSET OF ACTION Hours factors DURATION OF ACTION PTT (intrinsic pathway) Days MONITORING No PT/INR (extrinsic pathway) CROSSES PLACENTA Yes (teratogenic) Direct coagulation Do not usually require lab monitoring. factor inhibitors MECHANISM CLINICAL USE ADVERSE EFFECTS DRUG Directly inhibit thrombin Venous thromboembolism, Bleeding (idarucizumab can be Bivalirudin, (factor IIa) atrial fibrillation. Can be used used to inhibit dabigatran) argatroban, in HIT, when heparin is BAD dabigatran Directly inhibit (ban) factor Xa for the patient Bleeding (reverse with andexanet alfa) Apixaban, edoxaban, Oral agents. DVT/PE rivaroxaban treatment and prophylaxis; stroke prophylaxis in patients with atrial fibrillation uploaded by medbooksvn
442 SECTION III Hematology and Oncology hematology and oncology—pharmacology Anticoagulation reversal ANTICOAGULANT REVERSAL AGENT NOTES Heparin Protamine sulfate ⊕ charged peptide that binds ⊝ charged heparin Warfarin Vitamin K (slow) +/– FFP or PCC (rapid) Idarucizumab Monoclonal antibody Fab fragments Dabigatran Andexanet alfa Recombinant modified factor Xa (inactive) Direct factor Xa inhibitors Antiplatelets All work by platelet aggregation. DRUG MECHANISM CLINICAL USE ADVERSE EFFECTS Aspirin Irreversibly blocks COX Acute coronary syndrome; Gastric ulcers, tinnitus, allergic TXA2 release coronary stenting. incidence reactions, renal injury, Reye Clopidogrel, or recurrence of thrombotic syndrome (in children) prasugrel, ticagrelor stroke Bleeding Eptifibatide, tirofiban Block ADP (P2Y12) receptor Same as aspirin; dual ADP-induced expression antiplatelet therapy Bleeding, thrombocytopenia Cilostazol, of GpIIb/IIIa dipyridamole Nausea, headache, facial Block GpIIb/IIIa (fibrinogen Unstable angina, percutaneous flushing, hypotension, receptor) on activated platelets coronary intervention abdominal pain Block phosphodiesterase Intermittent claudication, cAMP hydrolysis stroke prevention, cardiac cAMP in platelets stress testing, prevention of coronary stent restenosis Thrombolytics Alteplase (tPA), reteplase (rPA), tenecteplase (TNK-tPA). MECHANISM Directly or indirectly aid conversion of plasminogen to plasmin, which cleaves thrombin and fibrin clots. PT, PTT, no change in platelet count. CLINICAL USE ADVERSE EFFECTS Early MI, early ischemic stroke, direct thrombolysis of high-risk PE. Bleeding. Contraindicated in patients with active bleeding, history of intracranial bleeding, recent surgery, known bleeding diatheses, or severe hypertension. Nonspecific reversal with antifibrinolytics (eg, aminocaproic acid, tranexamic acid), platelet transfusions, and factor corrections (eg, cryoprecipitate, FFP, PCC).
Hematology and Oncology hematology and oncology—pharmacology SECTION III 443 Cancer therapy—cell cycle Microtubule inhibitors Taxanes Bleomycin Vinca alkaloids – – – Cell cycle–independent drugs – Mitosis M Platinum compounds Cytokinesis Alkylating agents: G2 Double check Anthracyclines repair Busulfan Dactinomycin Topoisomerase inhibitors INTE Nitrogen mustards Etoposide RPHASE Nitrosoureas Teniposide – DNA Duplicate Procarbazine Irinotecan – synthesis cellular content Topotecan S G1 Antimetabolites ReGstOing Cladribine* *Cell cycle Cytarabine Rb, p53 modulate nonspecific 5-fluorouracil G1 restriction point Hydroxyurea Methotrexate Pentostatin Thiopurines Cancer therapy—targets DNA RNA Protein Cellular division Nucleotide synthesis MTX, 5-FU: Alkylating agents, platinum compounds: Vinca alkaloids: ↓ thymidine synthesis cross-link DNA inhibit microtubule formation Thiopurines: Bleomycin: Taxanes: ↓ de novo purine synthesis DNA strand breakage inhibit microtubule disassembly Hydroxyurea: Anthracyclines, dactinomycin: inhibits ribonucleotide DNA intercalators reductase Etoposide/teniposide: inhibits topoisomerase II Irinotecan/topotecan: inhibits topoisomerase I Antibody-drug conjugates Lysosomal Formed by linking monoclonal antibodies degradation with cytotoxic chemotherapeutic drugs. Antibody selectivity against tumor antigens Antibody Receptor-mediated allows targeted drug delivery to tumor cells Conjugate endocytosis while sparing healthy cells efficacy and toxicity. Drug Example: ado-trastuzumab emtansine (T-DM1) for HER2 ⊕ breast cancer. Cytotoxicity Drug release Tumor antigen uploaded by medbooksvn
444 SECTION III Hematology and Oncology hematology and oncology—pharmacology Antitumor antibiotics All are cell cycle nonspecific, except bleomycin which is G2/M phase specific. DRUG MECHANISM CLINICAL USE ADVERSE EFFECTS Bleomycin Induces free radical formation Testicular cancer, Hodgkin Pulmonary fibrosis, skin hyperpigmentation Dactinomycin breaks in DNA strands lymphoma (actinomycin D) Anthracyclines Intercalates into DNA, Wilms tumor, Ewing sarcoma, Myelosuppression Doxorubicin, preventing RNA synthesis rhabdomyosarcoma daunorubicin Generate free radicals Solid tumors, leukemias, Dilated cardiomyopathy Intercalate in DNA breaks in lymphomas (often irreversible; prevent with dexrazoxane), DNA replication myelosuppression Inhibit topoisomerase II Antimetabolites All are S-phase specific except cladribine, which is cell cycle nonspecific. DRUG MECHANISM CLINICAL USE ADVERSE EFFECTS Thiopurines Purine (thiol) analogs Rheumatoid arthritis, IBD, Myelosuppression; GI, liver Azathioprine, de novo purine synthesis SLE, ALL; steroid-refractory toxicity 6-mercaptopurine disease AZA is converted to 6-MP, 6-MP is inactivated by Cladribine, which is then activated by Prevention of organ rejection xanthine oxidase ( toxicity pentostatin HGPRT Weaning from glucocorticoids with allopurinol or febuxostat) Cytarabine (arabinofuranosyl Purine analogs unable to be Hairy cell leukemia Myelosuppression cytidine) processed by ADA, interfering 5-Fluorouracil with DNA synthesis Hydroxyurea Pyrimidine analog DNA Leukemias (AML), lymphomas Myelosuppression chain termination Methotrexate Inhibits DNA polymerase Pyrimidine analog bioactivated Colon cancer, pancreatic Myelosuppression, palmar- to 5-FdUMP thymidylate cancer, actinic keratosis, basal plantar erythrodysesthesia synthase inhibition cell carcinoma (topical) (hand-foot syndrome) dTMP DNA synthesis Effects enhanced with the addition of leucovorin Capecitabine is a prodrug Inhibits ribonucleotide Myeloproliferative disorders Severe myelosuppression, reductase DNA synthesis (eg, CML, polycythemia megaloblastic anemia vera), sickle cell disease ( HbF) Folic acid analog that Cancers: leukemias Myelosuppression (reversible competitively inhibits (ALL), lymphomas, with leucovorin “rescue”), dihydrofolate reductase choriocarcinoma, sarcomas hepatotoxicity, mucositis (eg, dTMP DNA mouth ulcers), pulmonary synthesis Nonneoplastic: ectopic fibrosis, folate deficiency pregnancy, medical (teratogenic), nephrotoxicity abortion (with misoprostol), rheumatoid arthritis, psoriasis, IBD, vasculitis
Hematology and Oncology hematology and oncology—pharmacology SECTION III 445 Alkylating agents All are cell cycle nonspecific. CLINICAL USE ADVERSE EFFECTS DRUG MECHANISM Used to ablate patient’s bone Severe myelosuppression (in marrow before bone marrow almost all cases), pulmonary Busulfan Cross-links DNA transplantation fibrosis, hyperpigmentation Nitrogen mustards Cross-link DNA Solid tumors, leukemia, Myelosuppression, SIADH, Cyclophosphamide, Require bioactivation by liver lymphomas, rheumatic Fanconi syndrome ifosfamide disease (eg, SLE, (ifosfamide), hemorrhagic granulomatosis with cystitis and bladder cancer Nitrosoureas Cross-link DNA polyangiitis) (prevent with mesna) Carmustine, lomustine Require bioactivation by liver Cross blood-brain barrier Brain tumors (including CNS toxicity (convulsions, Procarbazine glioblastoma multiforme) dizziness, ataxia) CNS entry Put nitro in your Mustang and Myelosuppression, pulmonary Mechanism unknown travel the globe toxicity, leukemia, disulfiram- Weak MAO inhibitor like reaction Hodgkin lymphoma, brain tumors Platinum compounds Cisplatin, carboplatin, oxaliplatin. Cross-link DNA. Cell cycle nonspecific. MECHANISM Solid tumors (eg, testicular, bladder, ovarian, GI, lung), lymphomas. CLINICAL USE Nephrotoxicity (eg, Fanconi syndrome; prevent with amifostine), peripheral neuropathy, ototoxicity. ADVERSE EFFECTS Microtubule inhibitors All are M-phase specific. CLINICAL USE ADVERSE EFFECTS DRUG MECHANISM Various tumors (eg, ovarian Myelosuppression, neuropathy, and breast carcinomas) hypersensitivity Taxanes Hyperstabilize polymerized Docetaxel, paclitaxel microtubules prevent Solid tumors, leukemias, Taxes stabilize society mitotic spindle breakdown Hodgkin and non-Hodgkin Vinca alkaloids lymphomas Vincristine (crisps the nerves): Vincristine, vinblastine Bind β-tubulin and inhibit neurotoxicity (axonal its polymerization into neuropathy), constipation microtubules prevent (including ileus) mitotic spindle formation Vinblastine (blasts the marrow): myelosuppression Topoisomerase All cause DNA degradation resulting in cell cycle arrest in S and G2 phases. inhibitors MECHANISM CLINICAL USE ADVERSE EFFECTS DRUG Inhibit topoisomerase I Colon, ovarian, small cell lung Severe myelosuppression, Irinotecan, topotecan “-tecone” cancer diarrhea Etoposide, teniposide Inhibit topoisomerase II Testicular, small cell lung Myelosuppression, alopecia “-bothside” cancer, leukemia, lymphoma uploaded by medbooksvn
446 SECTION III Hematology and Oncology hematology and oncology—pharmacology Tamoxifen Selective estrogen receptor modulator with complex mode of action: antagonist in breast tissue, partial agonist in endometrium and bone. Blocks the binding of estrogen to ER in ER ⊕ cells. MECHANISM Prevention and treatment of breast cancer, prevention of gynecomastia in patients undergoing CLINICAL USE prostate cancer therapy. ADVERSE EFFECTS Hot flashes, risk of thromboembolic events (eg, DVT, PE) and endometrial cancer. Anticancer monoclonal Work against extracellular targets to neutralize them or to promote immune system recognition antibodies (eg, ADCC by NK cells). Eliminated by macrophages (not cleared by kidneys or liver). AGENT TARGET CLINICAL USE ADVERSE EFFECTS Alemtuzumab CD52 Chronic lymphocytic leukemia risk of infections and (CLL), multiple sclerosis. autoimmunity (eg, ITP) Bevacizumab VEGF (inhibits blood vessel Colorectal cancer (CRC), Hemorrhage, blood clots, Cetuximab, formation) renal cell carcinoma (RCC), impaired wound healing panitumumab non–small cell lung cancer Rituximab (NSCLC), angioproliferative retinopathy Trastuzumab EGFR Metastatic CRC (wild-type Rash, elevated LFTs, diarrhea Pembrolizumab, nivolumab, RAS), head and neck cancer cemiplimab Atezolizumab, CD20 Non-Hodgkin lymphoma, Infusion reaction due to durvalumab, CLL, rheumatoid arthritis, cytokine release following avelumab ITP, TTP, AIHA, multiple interaction of rituximab with Ipilimumab sclerosis its target on B cells HER2 (“trust HER”) Breast cancer, gastric cancer Dilated cardiomyopathy (often reversible) PD-1 PD-L1 Various tumors (eg, NSCLC, risk of autoimmunity (eg, RCC, melanoma, urothelial dermatitis, enterocolitis, carcinoma) hepatitis, pneumonitis, endocrinopathies) CTLA-4
Hematology and Oncology hematology and oncology—pharmacology SECTION III 447 Anticancer small molecule inhibitors AGENT TARGET CLINICAL USE ADVERSE EFFECTS Alectinib, crizotinib ALK Non–small cell lung cancer Edema, rash, diarrhea Non–small cell lung cancer Rash, diarrhea Erlotinib, gefitinib, EGFR afatinib Imatinib, dasatinib, BCR-ABL (also other tyrosine CML, ALL, GISTs Myelosuppression, LFTs, nilotinib kinases [eg, c-KIT]) edema, myalgias Polycythemia vera Ruxolitinib JAK1/2 Multiple myeloma, mantle cell Bruises, LFTs Peripheral neuropathy, herpes Bortezomib, ixazomib, Proteasome (induce lymphoma carfilzomib arrest at G2-M phase via zoster reactivation ( T-cell accumulation of abnormal Melanoma activation cell-mediated proteins apoptosis) Often co-administered immunity) Rash, fatigue, nausea, diarrhea Vemurafenib, BRAF with MEK inhibitors (eg, encorafenib, trametinib) Myelosuppression, pneumonitis dabrafenib Breast cancer Palbociclib Cyclin-dependent kinase 4/6 Breast, ovarian, pancreatic, and Myelosuppression, edema, Olaparib (induces arrest at G1-S phase apoptosis) prostate cancers diarrhea Poly(ADP-ribose) polymerase ( DNA repair) Chemotoxicity amelioration DRUG MECHANISM CLINICAL USE Amifostine Free radical scavenger Nephrotoxicity from platinum compounds Cardiotoxicity from anthracyclines Dexrazoxane Iron chelator Myelosuppression from methotrexate (leucovorin Leucovorin (folinic Tetrahydrofolate precursor “rescue”); also enhances the effects of 5-FU acid) Hemorrhagic cystitis from cyclophosphamide/ Mesna Sulfhydryl compound that binds acrolein (toxic ifosfamide metabolite of cyclophosphamide/ifosfamide) Tumor lysis syndrome Rasburicase Recombinant uricase that catalyzes metabolism Acute nausea and vomiting (usually within of uric acid to allantoin 1-2 hr after chemotherapy) Ondansetron, 5-HT3 receptor antagonists Delayed nausea and vomiting (>24 hr after granisetron chemotherapy) Prochlorperazine, D2 receptor antagonists Neutropenia metoclopramide Anemia Aprepitant, NK1 receptor antagonists fosaprepitant Filgrastim, Recombinant G(M)-CSF sargramostim Epoetin alfa Recombinant erythropoietin uploaded by medbooksvn
448 SECTION III Hematology and Oncology hematology and oncology—pharmacology Key chemotoxicities Cisplatin, Carboplatin ototoxicity↓ Vincristine peripheral neuropathy↓↓ Bleomycin, Busulfan pulmonary fibrosis↓ Doxorubicin, Daunorubicin cardiotoxicity↓ Trastuzumab cardiotoxicity Cisplatin, Carboplatin nephrotoxicity↓ ↓ CYclophosphamide hemorrhagic cystitis Nonspecific common toxicities of nearly all cytotoxic chemotherapies include myelosuppression (neutropenia, anemia, thrombocytopenia), GI toxicity (nausea, vomiting, mucositis), alopecia.
HIGH-YIELD SYSTEMS Musculoskeletal, Skin, and Connective Tissue “Rigid, the skeleton of habit alone upholds the human frame.” ` Anatomy and 450 —Virginia Woolf, Mrs. Dalloway Physiology 462 481 “Beauty may be skin deep, but ugly goes clear to the bone.” ` Pathology 494 —Redd Foxx ` Dermatology ` Pharmacology “The finest clothing made is a person’s own skin, but, of course, society demands something more than this.” —Mark Twain “To thrive in life you need three bones. A wishbone. A backbone. And a funny bone.” —Reba McEntire This chapter provides information you will need to understand common anatomic dysfunctions, orthopedic conditions, rheumatic diseases, and dermatologic conditions. Be able to interpret 3D anatomy in the context of radiologic imaging. For the rheumatic diseases, create instructional cases that include the most likely presentation and symptoms: risk factors, gender, important markers (eg, autoantibodies), and other epidemiologic factors. Doing so will allow you to answer higher order questions that are likely to be asked on the exam. 449 uploaded by medbooksvn
450 SECTION III Musculoskeletal, Skin, and Connec tive Tissue anatomy and physiology ` MUSCULOSKELETAL, SKIN, AND CONNECTIVE TISSUE—ANATOMY AND PHYSIOLOGY Upper extremity nerves NERVE CAUSES OF INJURY PRESENTATION Axillary (C5-C6) Fractured surgical neck of humerus Flattened deltoid Anterior dislocation of humerus Loss of arm abduction at shoulder (> 15°) Loss of sensation over deltoid and lateral arm Musculocutaneous Upper trunk compression biceps (C5-C6) reflex (C5-C7) Loss of forearm flexion and supination Loss of sensation over radial and dorsal forearm Radial (C5-T1) Compression of axilla, eg, due to crutches or Injuries above the elbow cause loss of sensation sleeping with arm over chair (“Saturday night over posterior arm/forearm and dorsal hand, palsy”) wrist drop (loss of elbow, wrist, and finger extension) with grip strength (wrist extension Midshaft fracture of humerus necessary for maximal action of flexors) Repetitive pronation/supination of forearm, eg, Injuries below the elbow can cause paresthesias due to screwdriver use (“finger drop”) of the dorsal forearm (superficial radial nerve) or wrist drop (posterior interosseus nerve) Tricep function and posterior arm sensation spared in midshaft fracture Median (C5-T1) Supracondylar fracture of humerus proximal “Ape hand” and “Hand of benediction” lesion of the nerve Loss of wrist flexion and function of the lateral Carpal tunnel syndrome and wrist laceration two Lumbricals, Opponens pollicis, Abductor distal lesion of the nerve pollicis brevis, Flexor pollicis brevis (LOAF) Loss of sensation over thenar eminence and dorsal and palmar aspects of lateral 3 1/2 fingers with proximal lesion Ulnar (C8-T1) Fracture of medial epicondyle of humerus “Ulnar claw” on digit extension (proximal lesion) Radial deviation of wrist upon flexion (proximal Fractured hook of hamate (distal lesion) from fall on outstretched hand lesion) Compression of nerve against hamate as the flexion of ulnar fingers, abduction and wrist rests on handlebar during cycling adduction of fingers (interossei), thumb adduction, actions of ulnar 2 lumbrical muscles Loss of sensation over ulnar 1 1/2 fingers including hypothenar eminence Recurrent branch of Superficial laceration of palm “Ape hand” median nerve (C5-T1) Loss of thenar muscle group: opposition, abduction, and flexion of thumb No loss of sensation Humerus fractures, proximally to distally, follow the ARM (Axillary Radial Median) nerves
Musculoskeletal, Skin, and Connec tive Tissue anatomy and physiology SECTION III 451 Upper extremity nerves (continued) Axillary nerve C5 Median nerve C6 Musculocutaneous nerve C7 C8 Radial nerve in T1 spiral groove Median nerve Axillary nerve Radial nerve Radial nerve Intercostobrachial Ulnar nerve nerve Radial nerve Medial brachial Palm of hand cutaneous nerve Ulnar nerve Musculocutaneous Medial antebrachial nerve cutaneous nerve Median nerve Radial nerve Radial nerve Ulnar nerve Recurrent branch Radial nerve of median nerve Dorsum of hand Rotator cuff muscle Shoulder muscles that form the rotator cuff: SItS (small t is for teres minor). A Supraspinatus (suprascapular nerve)— abducts arm initially (before the action Supraspinatus Humerus of the deltoid); most common rotator Glenoid cuff injury (trauma or degeneration and Acromion impingement tendinopathy or tear [arrow in A ]), assessed by “empty/full can” test Coracoid Infraspinatus (suprascapular nerve)— externally rotates arm; pitching injury Infraspinatus Greater tubercle teres minor (axillary nerve)—adducts and externally rotates arm Teres minor Subscapularis Subscapularis (upper and lower subscapular Lesser tubercle nerves)—internally rotates and adducts arm Humerus Innervated primarily by C5-C6. Arm abduction MUSCLE NERVE DEGREE Supraspinatus Suprascapular Deltoid Axillary 0°–15° Trapezius Accessory 15°–90° Serratus Anterior Long Thoracic (SALT) > 90° > 90° uploaded by medbooksvn
452 SECTION III Musculoskeletal, Skin, and Connec tive Tissue anatomy and physiology Brachial plexus lesions Divisions of brachial plexus: Remember Erb palsy (“waiter’s tip”) C5 Upper Lateral To C6 Drink Klumpke palsy (claw hand) C7 Middle Axillary Musculocutaneous Cold C8 Lower Posterior Median (flexors) Beer Wrist drop T1 Ulnar (Extensors) Trunks of brachial plexus Winged scapula and the subclavian artery Radial pass between anterior and Deltoid paralysis Medial middle scalene muscles. Subclavian vein passes “Saturday night palsy” (wrist drop) Trunks Divisions Cords Branches anteromedial to the Di culty flexing elbow, variable Long thoracic scalene triangle. sensory loss Decreased thumb function, “hand of benediction” Intrinsic muscles of hand, claw hand Roots CONDITION INJURY CAUSES MUSCLE DEFICIT FUNCTIONAL DEFICIT Erb-Duchenne palsy PR(E”SwENaTitAeTrI’sONtip”) Erb palsy (“waiter’s Traction or tear Infants—lateral Deltoid, Abduction (arm tip”) of upper trunk: traction on neck supraspinatus hangs by side) C5-C6 roots during delivery Infraspinatus, Lateral rotation (arm Adults—trauma supraspinatus medially rotated) leading to neck traction (eg, Biceps brachii Flexion, supination falling on head Herb gets DIBs (arm extended and and shoulder pronated) in motorcycle on tips Klumpke palsy Traction or tear accident) Claw hand: of lower trunk: Intrinsic hand lumbricals normally C8-T1 roots Infants—upward muscles: flex MCP joints and force on arm lumbricals, extend DIP and PIP during delivery interossei, joints thenar, Thoracic outlet Compression Adults—trauma hypothenar Atrophy of intrinsic A syndrome of lower trunk (eg, grabbing a hand muscles; and subclavian tree branch to Same as Klumpke ischemia, pain, C5 Winged scapula vessels, most break a fall) palsy and edema C6 commonly due to vascular C7 within the Cervical/ compression scalene triangle anomalous first T1 ribs (arrows in Lesion of long A ), Pancoast thoracic nerve, tumor roots C5-C7 (“wings of Axillary node Serratus anterior Inability to anchor B heaven”) dissection after scapula to thoracic mastectomy, cage cannot stab wounds abduct arm above horizontal position B
Musculoskeletal, Skin, and Connec tive Tissue anatomy and physiology SECTION III 453 Wrist region Scaphoid, lunate, triquetrum, pisiform, hamate, A B capitate, trapezoid, trapezium A . (So long to pinky, here comes the thumb) 1st MC Scaphoid (palpable in anatomic snuff box B ) is the most commonly fractured carpal bone, Trapezoid Capitate Hamate typically due to a fall on an outstretched hand. Complications of proximal scaphoid fractures Trapezium Triquetrum include avascular necrosis and nonunion due to retrograde blood supply from a branch of Scaphoid Pisiform the radial artery. Occult fracture not always seen on initial x-ray. Lunate Dislocation of lunate may impinge median Radius Ulna nerve and cause carpal tunnel syndrome. Fracture of the hook of the hamate can cause ulnar nerve compression—Guyon canal syndrome. Flexor retinaculum (transverse carpal ligament) Ulnar artery Palmar surface Flexor digitorum Ulnar nerve superficialis tendons Guyon canal Median nerve Hypothenar Flexor carpi eminence radialis tendon Thenar eminence Plane of Carpal bones section Flexor pollicis Flexor digitorum longus tendon profundus tendons Carpal tunnel (with contents) uploaded by medbooksvn
454 SECTION III Musculoskeletal, Skin, and Connec tive Tissue anatomy and physiology Hand muscles Thenar (median)—Opponens pollicis, Abductor Both groups perform the same functions: pollicis brevis, Flexor pollicis brevis—superficial Oppose, Abduct, and Flex (OAF). Thenar Hypothenar head (deep head by ulnar nerve). eminence eminence DAB = Dorsals ABduct. Hypothenar (ulnar)—Opponens digiti minimi, PAD = Palmars ADduct. Abductor digiti minimi, Flexor digiti minimi brevis. Dorsal interossei (ulnar)—abduct the fingers. Palmar interossei (ulnar)—adduct the fingers. Lumbricals (1st/2nd, median; 3rd/4th, ulnar)— flex at the MCP joint, extend PIP and DIP joints. Distortions of the hand At rest, a balance exists between the extrinsic flexors and extensors of the hand, as well as the A intrinsic muscles of the hand—particularly the lumbrical muscles (flexion of MCP, extension of DIP and PIP joints). “Clawing” A —seen best with distal lesions of median or ulnar nerves. Remaining extrinsic flexors of the digits exaggerate the loss of the lumbricals fingers extend at MCP, flex at DIP and PIP joints. Deficits less pronounced in proximal lesions; deficits present during voluntary flexion of the digits. SIGN “Ulnar claw” “Hand of benediction” “Median claw” “Trouble making PRESENTATION a fist” CONTEXT Extending fingers/at Making a fist Extending fingers/at Closing the hand rest rest LOCATION OF LESION Distal ulnar nerve Proximal median Distal median nerve Proximal ulnar nerve nerve Note: Atrophy of the thenar eminence can be seen in median nerve lesions, while atrophy of the hypothenar eminence can be seen in ulnar nerve lesions.
Musculoskeletal, Skin, and Connec tive Tissue anatomy and physiology SECTION III 455 Actions of hip muscles MUSCLES ACTION Gluteus medius, gluteus minimus Adductor magnus, adductor longus, adductor brevis Abductors Gluteus maximus, semitendinosus, semimembranosus, long head of biceps femoris Adductors Iliopsoas (iliacus and psoas), rectus femoris, tensor fascia lata, pectineus, sartorius Extensors Gluteus medius, gluteus minimus, tensor fascia latae Flexors Iliopsoas, gluteus maximus, piriformis, obturator internus, obturator externus Internal rotation External rotation Knee exam Lateral femoral condyle to anterior tibia: ACL. Femur Medial femoral condyle to posterior tibia: PCL. TEST LAMP. Lateral Medial condyle condyle Anterior drawer sign PROCEDURE ACL PCL Posterior drawer sign Positive in ACL tear. Tibia glides anteriorly LCL MCL Valgus stress test (relative to femur) when knee is at 90° angle. Lateral Alternatively, Lachman test done (places knee meniscus Medial Varus stress test at 30° angle). meniscus Fibula McMurray test Bending knee at 90° angle, posterior gliding of Tibia tibia due to PCL injury. Abnormal passive abduction. Knee either extended or at ~ 30° angle, lateral (valgus) force medial space widening of tibia MCL injury. Abnormal passive adduction. Knee either extended or at ~ 30° angle, medial (varus) force lateral space widening of tibia LCL injury. During flexion and extension of knee with rotation of tibia/foot (LIME): Pain, “popping” on internal rotation and varus force Lateral meniscal tear (Internal rotation stresses lateral meniscus) Pain, “popping” on external rotation and valgus force Medial meniscal tear (External rotation stresses medial meniscus) uploaded by medbooksvn
456 SECTION III Musculoskeletal, Skin, and Connec tive Tissue anatomy and physiology Lower extremity nerves NERVE INNERVATION CAUSE OF INJURY PRESENTATION/COMMENTS Iliohypogastric Sensory—suprapubic region Abdominal surgery Burning or tingling pain in (T12-L1) Motor—transversus abdominis Laparoscopic surgery surgical incision site radiating to inguinal and suprapubic and internal oblique Tight clothing, obesity, region pregnancy, pelvic procedures Genitofemoral nerve Sensory—scrotum/labia upper medial thigh and (L1-L2) majora, medial thigh Pelvic surgery anterior thigh sensation beneath the inguinal Motor—cremaster ligament (lateral part of the femoral triangle); absent Lateral femoral Sensory—anterior and lateral cremasteric reflex cutaneous (L2-L3) thigh thigh sensation (anterior and Obturator (L2-L4) Sensory—medial thigh lateral) Motor—obturator externus, Meralgia paresthetica— adductor longus, adductor compression of lateral femoral brevis, gracilis, pectineus, cutaneous nerve tingling, adductor magnus numbness, burning pain in anterolateral thigh thigh sensation (medial) and adduction Femoral (L2-L4) Sensory—anterior thigh, Pelvic fracture, compression leg extension ( patellar medial leg from retroperitoneal reflex) hematoma or psoas abscess Motor—quadriceps, iliacus, pectineus, sartorius Sciatic (L4-S3) Motor—semitendinosus, Herniated disc, posterior Splits into common peroneal semimembranosus, biceps hip dislocation, piriformis and tibial nerves femoris, adductor magnus syndrome
Musculoskeletal, Skin, and Connec tive Tissue anatomy and physiology SECTION III 457 Lower extremity nerves (continued) NERVE INNERVATION CAUSE OF INJURY PRESENTATION/COMMENTS Common (fibular) Superficial peroneal nerve: Trauma or compression of PED = Peroneal Everts and peroneal (L4-S2) Sensory—dorsum of foot lateral aspect of leg, fibular Dorsiflexes; if injured, foot (except webspace between neck fracture dropPED hallux and 2nd digit) Motor—peroneus longus Knee trauma, Baker cyst Loss of sensation on dorsum and brevis (proximal lesion); tarsal of foot tunnel syndrome (distal Deep peroneal nerve: lesion) Foot drop—inverted and Sensory—webspace plantarflexed at rest, loss of between hallux and 2nd eversion and dorsiflexion; digit “steppage gait” Motor—tibialis anterior TIP = Tibial Inverts and Tibial (L4-S3) Sensory—sole of foot Plantarflexes; if injured, can’t Motor—biceps femoris (long stand on TIPtoes head), triceps surae, plantaris, Inability to curl toes and loss of popliteus, flexor muscles of sensation on sole; in proximal foot lesions, foot everted at rest with weakened inversion and plantar flexion Superior gluteal Motor—gluteus medius, gluteus Iatrogenic injury during Trendelenburg sign/gait— (L4‑S1) minimus, tensor fascia latae intramuscular injection pelvis tilts because weight- to superomedial gluteal bearing leg cannot maintain region (prevent by choosing alignment of pelvis through superolateral quadrant, hip abduction preferably anterolateral region) Lesion is contralateral to the side of the hip that drops, ipsilateral to extremity on which the patient stands Normal Trendelenburg sign Inferior gluteal (L5-S2) Motor—gluteus maximus Posterior hip dislocation Difficulty climbing stairs, rising from seated position; loss of Pudendal (S2-S4) Sensory—perineum Stretch injury during hip extension Motor—external urethral and childbirth, prolonged cycling, horseback riding sensation in perineum and anal sphincters genital area; can cause fecal and/or urinary incontinence Can be blocked with local anesthetic during childbirth using ischial spine as a landmark for injection uploaded by medbooksvn
458 SECTION III Musculoskeletal, Skin, and Connec tive Tissue anatomy and physiology Ankle sprains Anterior talofibular ligament—most common Anterior inferior tibiofibular ligament ankle sprain overall, classified as a low ankle Fibula Tibia Anterior talofibular sprain. Due to overinversion/supination of foot. Posterior inferior ligament tibiofibular ligament Talus Always tears first. Navicular Cuneiform bones Anterior inferior tibiofibular ligament—most Posterior talofibular common high ankle sprain. ligament Calcaneus Cuboid Calcaneofibular ligament Tarsals Metatarsals Phalanges Signs of lumbosacral Paresthesia and weakness related to specific lumbosacral spinal nerves. Intervertebral disc (nucleus radiculopathy pulposus) herniates posterolaterally through annulus fibrosus (outer ring) into spinal canal due to thin posterior longitudinal ligament and thicker anterior longitudinal ligament along midline of vertebral bodies. Nerve affected is usually below the level of herniation. ⊕ straight leg raise, ⊕ contralateral straight leg raise, ⊕ reverse straight leg raise (femoral stretch). Disc level L3-L4 L4-L5 L5-S1 L4 pedicle (cut) herniation L4 L5 S1 Nerve root L4 body L4 nerve root Dermatome L4-L5 disc protrusion L5 body L5 nerve root L5-S1 disc protrusion Clinical Weakness of knee extension Weakness of dorsiflexion Weakness of plantar flexion S1 nerve root findings Di culty in heel walking Di culty in toe walking ↓ patellar reflex ↓Achilles reflex S2 nerve root Neurovascular pairing Nerves and arteries are frequently named together by the bones/regions with which they are associated. The following are exceptions to this naming convention. LOCATION NERVE ARTERY Axilla/lateral thorax Long thoracic Lateral thoracic Surgical neck of humerus Axillary Posterior circumflex Midshaft of humerus Radial Deep brachial Distal humerus/cubital fossa Median Brachial Popliteal fossa Tibial Popliteal Posterior to medial malleolus Tibial Posterior tibial
Musculoskeletal, Skin, and Connec tive Tissue anatomy and physiology SECTION III 459 Motoneuron action T-tubules are extensions of plasma membrane in contact with the sarcoplasmic reticulum, allowing potential to muscle for coordinated contraction of striated muscles. contraction Myelin sheath A ction potential opens presynaptic voltage- gated Ca2+ channels, inducing acetylcholine Q Action potential (ACh) release. Ca2+ P ostsynaptic ACh binding leads to muscle Axon cell depolarization at the motor end plate. ACh vesicle Depolarization travels over the entire muscle cell and deep into the muscle via the Action potential T-tubules. R ACh S M embrane depolarization induces conformational changes in the voltage- AChR DHPR sensitive dihydropyridine receptor (DHPR) Motor end plate and its mechanically coupled ryanodine receptor (RR) Ca2+ release from the T sarcoplasmic reticulum (buffered by calsequestrin) into the cytoplasm. Sarcoplasmic Ca2+ Ca2+ Tropomyosin is blocking myosin-binding reticulum RR sites on the actin filament. Released Ca2+ binds to troponin C (TnC), shifting SERCA T-tubule tropomyosin to expose the myosin-binding sites. U Ca2+ TnC M yosin head binds strongly to actin Actin Tropomyosin (crossbridge). Pi released, initiating power stroke. Ca2+ Y ADP Pi During the power stroke, force is produced as myosin pulls on the thin filament A . ATP X Myosin Myosin-binding site Muscle shortening occurs, with shortening Cocked V of H and I bands and between Z lines (HI, Detached I’m wearing shortZ). The A band remains W ADP Pi the same length (A band is Always the same ATP length). ADP is released at the end of the ADP ADP Crossbridge power stroke. B inding of new ATP molecule causes A Power stroke Pi detachment of myosin head from actin filament. Ca2+ is resequestered. ATP hydrolysis into ADP and Pi results in myosin head returning to high-energy position (cocked). The myosin head can bind to a new site on actin to form a crossbridge if Ca2+ remains available. Reuptake of calcium by sarco(endo)plasmic reticulum Ca2+ ATPase (SERCA) muscle relaxation. Actin (thin filament) M line Z line Myosin (thick filament) H band I band A band I band Sarcomere (Z line to Z line) uploaded by medbooksvn
460 SECTION III Musculoskeletal, Skin, and Connec tive Tissue anatomy and physiology Types of skeletal Two types, normally distributed randomly within muscle. Muscle fiber type grouping commonly muscle fi ers occurs due to reinnervation of denervated muscle fibers in peripheral nerve damage. CONTRACTION VELOCITY Type I Type II FIBER COLOR PREDOMINANT METABOLISM Slow Fast MITOCHONDRIA, MYOGLOBIN Red White TYPE OF TRAINING NOTES Oxidative phosphorylation sustained Anaerobic glycolysis contraction Endurance training Weight/resistance training, sprinting Think “1 slow red ox” Think “2 fast white antelopes” Skeletal muscle adaptations Atrophy Hypertrophy MYOFIBRILS (removal via ubiquitin-proteasome system) (addition of sarcomeres in parallel) MYONUCLEI (selective apoptosis) (fusion of satellite cells, which repair damaged myofibrils; absent in cardiac muscles) Vascular smooth muscle contraction and relaxation Agonist Acetylcholine, bradykinin, etc Endothelial cells Ca2+ Receptor Ca2+ L-arginine NO synthase NO L-type voltage Ca2+ Smooth muscle cell NO di usion gated Ca2+ channel Action ↑ Ca2+ NO cGMP potent–ia–l – emoblararinzaetion GTP ↑ Ca2+–calmodulin complex Myosin + actin dep M Myosin–light-chain Myosin-P Myosin–light-chain kinase + actin phosphatase (MLCK) (MLCP) CONTRACTION RELAXATION ↑ Ca2+ CONTRACTION Nitric oXide RELAXATION
Musculoskeletal, Skin, and Connec tive Tissue anatomy and physiology SECTION III 461 Muscle proprioceptors Specialized sensory receptors that relay information about muscle dynamics. PATHWAY Muscle stretch receptors Golgi tendon organ LOCATION/INNERVATION length and speed of stretch via tension via DRG activation ACTIVATION BY dorsal root ganglion (DRG) activation of inhibitory interneuron inhibition of of inhibitory interneuron and α motor neuron agonist muscle (reduced tension within muscle simultaneous inhibition of antagonist and tendon) muscle (prevents overstretching) and activation of agonist muscle (contraction). Body of muscle/type Ia and II sensory axons Tendons/type Ib sensory axons muscle stretch. Responsible for deep tendon muscle tension reflexes Dorsal root Dorsal root a fiber a fiber InterneuronVentral root Vaemnto(rtatool arrognaooefintubirseotr)n a fiber (to antagonist) (to antagonist) a motor neuron (to agonist) a fiber a fiInbteerrneuron (to agonist) (to agonist) Ia and II fiber Ia and II fiber Ib fiber (from Ib fiber (from (from muscle (from muscle Golgi tendon) Golgi tendon) spindle) spindle) Bone formation Endochondral ossification Bones of axial skeleton, appendicular skeleton, and base of skull. Cartilaginous model of bone is first made by chondrocytes. Osteoclasts and osteoblasts later replace with woven bone and then Membranous remodel to lamellar bone. In adults, woven bone occurs after fractures and in Paget disease. ossification Defective in achondroplasia. Bones of calvarium, facial bones, and clavicle. Woven bone formed directly without cartilage. Later remodeled to lamellar bone. uploaded by medbooksvn
462 SECTION III Musculoskeletal, Skin, and Connec tive Tissue Pathology Cell biology of bone Builds bone by secreting collagen and catalyzing mineralization in alkaline environment via ALP. Osteoblast Differentiates from mesenchymal stem cells in periosteum. Osteoblastic activity measured by Osteoclast bone ALP, osteocalcin, propeptides of type I procollagen. Parathyroid hormone Dissolves (“crushes”) bone by secreting H+ and collagenases. Differentiates from a fusion of Estrogen monocyte/macrophage lineage precursors. RANK receptors on osteoclasts are stimulated by RANKL (RANK ligand, expressed on osteoblasts). OPG (osteoprotegerin, a RANKL decoy receptor) binds RANKL to prevent RANK-RANKL interaction osteoclast activity. At low, intermittent levels, exerts anabolic effects (building bone) on osteoblasts and osteoclasts (indirect). Chronically PTH levels (1° hyperparathyroidism) cause catabolic effects (osteitis fibrosa cystica). Inhibits apoptosis in bone-forming osteoblasts and induces apoptosis in bone-resorbing osteoclasts. Causes closure of epiphyseal plate during puberty. Estrogen deficiency (surgical or postmenopausal) cycles of remodeling and bone resorption risk of osteoporosis. Osteoclast precursor OPG RANK Di erentiation RANKL Osteoblast Activated osteoclast Bone formation Bone resorption ` MUSCULOSKELETAL, SKIN, AND CONNECTIVE TISSUE—PATHOLOGY Overuse injuries of the elbow Medial (golfer’s) Repetitive wrist flexion or idiopathic pain near medial epicondyle. elbow tendinopathy Lateral (tennis) elbow Repetitive wrist extension (backhand shots) or idiopathic pain near lateral epicondyle. tendinopathy
Musculoskeletal, Skin, and Connec tive Tissue Pathology SECTION III 463 Clavicle fractures Common in children and as birth trauma. A Usually caused by a fall on outstretched hand or by direct trauma to shoulder. Weakest point at the junction of middle and lateral thirds; fractures at the middle third segment are most common A . Presents as shoulder drop, shortened clavicle (lateral fragment is depressed due to arm weight and medially rotated by arm adductors [eg, pectoralis major]). Wrist and hand injuries Compression of ulnar nerve at wrist. Classically May also be seen with fracture/dislocation of Guyon canal seen in cyclists due to pressure from the hook of hamate. syndrome handlebars. Suggested by ⊕ Tinel sign (percussion of wrist Carpal tunnel Entrapment of median nerve in carpal tunnel causes tingling) and Phalen maneuver (90° syndrome (between transverse carpal ligament and carpal flexion of wrist causes tingling). bones) nerve compression paresthesia, Metacarpal neck pain, and numbness in distribution of median Associated with pregnancy (due to edema), fracture nerve. Thenar eminence atrophies but rheumatoid arthritis, hypothyroidism, diabetes, A sensation spared, because palmar cutaneous acromegaly, dialysis-related amyloidosis; may branch enters hand external to carpal tunnel. be associated with repetitive use. Also called boxer’s fracture. Common fracture caused by direct blow with a closed fist (eg, from punching a wall). Most commonly seen in the 5th metacarpal A . Psoas abscess Collection of pus in iliopsoas compartment. May spread from blood (hematogenous) or from A adjacent structures (eg, vertebral osteomyelitis, tuberculous spondylitis [also called Pott disease], pyelonephritis). Associated with Crohn disease, diabetes, and immunocompromised states. Staphylococcus aureus most commonly isolated, but may also occur 2° to tuberculosis. Findings: flank pain, fever, inguinal mass, ⊕ psoas sign (hip extension exacerbates lower abdominal pain). Labs: leukocytosis. Imaging (CT/MRI) will show focal hypodense lesion within the muscle plane (red arrow in A ). Treatment: abscess drainage, antibiotics. uploaded by medbooksvn
464 SECTION III Musculoskeletal, Skin, and Connec tive Tissue Pathology Common knee conditions “Unhappy triad” Common injury in contact sports due to lateral force impacting the knee when foot is planted on the ground. Consists of damage to the ACL Valgus force ACL A , MCL, and medial meniscus (attached to PCL LCL MCL). However, lateral meniscus involvement is more common than medial meniscus involvement in conjunction with ACL and MCL injury. Presents with acute pain and signs of joint instability. MM MCL LM Anterior view of left knee Prepatellar bursitis Inflammation of the prepatellar bursa in front of the kneecap (red arrow in B ). Can be caused by repeated trauma or pressure from excessive Inflamed Patella Poplitea kneeling (also called “housemaid’s knee”). prepatellar bursa Femur Synovia Patella Tibia Femur Tibia Popliteal cyst Also called Baker cyst. Popliteal fluid collection (red arrow in C ) in gastrocneImnflaimuse-d Patella Popliteal cyst semimembranosus bursa commonplryepatellar bursa Femur Synovial space communicating with synovial space Patella Tibia and related to chronic joint disease (eg, Femur osteoarthritis, rheumatoid arthritis). Tibia A BC Fem Fem Fem Fem Pat (lat cond) (med cond) ACL Tib Post meniscus Pop a Tib Ant meniscus
Musculoskeletal, Skin, and Connec tive Tissue Pathology SECTION III 465 Common musculoskeletal conditions Costochondritis Inflammation of costochondral or costosternal junctions. Presents with sharp, positional chest pain and focal tenderness to palpation. More common in younger female patients. May mimic cardiac (eg, MI) or pulmonary (eg, pulmonary embolism) diseases. De Quervain Noninflammatory thickening of abductor Extensor retinaculum Extensor tenosynovitis pollicis longus and extensor pollicis brevis pollicis tendons pain or tenderness at radial styloid. brevis ⊕ Finkelstein test (pain at radial styloid with active or passive stretch of thumb tendons). Inflamed Abductor risk in new mothers (lifting baby), golfers, tendon sheaths pollicis longus racquet sport players, “thumb” texters. Dupuytren Caused by fibroblastic proliferation and thickening of superficial palmar fascia. Typically involves contracture the fascia at the base of the ring and little fingers. Unknown etiology; most frequently seen in males > 50 years old of Northern European descent. Ganglion cyst Fluid-filled swelling overlying joint or tendon sheath, most commonly at dorsal side of wrist. Usually resolves spontaneously. Iliotibial band Overuse injury of lateral knee that occurs primarily in runners. Pain develops 2° to friction of syndrome iliotibial band against lateral femoral epicondyle. Limb compartment pressure within fascial compartment of a limb venous outflow obstruction and arteriolar syndrome collapse anoxia, necrosis, rhabdomyolysis acute tubular necrosis. Causes include significant long bone fractures (eg, tibia), reperfusion injury, animal venoms. Presents with severe pain and tense, swollen compartments with passive stretch of muscles in the affected compartment. Increased serum creatine kinase and motor deficits are late signs of irreversible muscle and nerve damage. 5 P’s: pain, pallor, paresthesia, pulselessness, paralysis. Medial tibial stress Also called shin splints. Common cause of shin pain and diffuse tenderness in runners and military syndrome recruits. Caused by bone resorption that outpaces bone formation in tibial cortex. Plantar fasciitis Inflammation of plantar aponeurosis characterized by heel pain (worse with first steps in the morning or after period of inactivity) and tenderness. Associated with obesity, prolonged standing or jumping (eg, dancers, runners), and flat feet. Heel spurs often coexist. Temporomandibular Group of disorders that involve the temporomandibular joint (TMJ) and muscles of mastication. disorders Multifactorial etiology; associated with TMJ trauma, poor head and neck posture, abnormal trigeminal nerve pain processing, psychological factors. Present with dull, constant unilateral facial pain that worsens with jaw movement, otalgia, headache, TMJ dysfunction (eg, limited range of motion). uploaded by medbooksvn
466 SECTION III Musculoskeletal, Skin, and Connec tive Tissue Pathology Childhood musculoskeletal conditions Radial head Also called nursemaid’s elbow. Common elbow injury in children < 5 years. Caused by a sudden subluxation pull on the arm immature annular ligament slips over head of radius. Injured arm held in slightly flexed and pronated position. Humerus Ulna Radius Osgood-Schlatter Also called traction apophysitis. Overuse injury caused by repetitive strain and chronic avulsion of disease the secondary ossification center of proximal tibial tubercle. Occurs in adolescents after growth spurt. Common in running and jumping athletes. Presents with progressive anterior knee pain. Patellar Overuse injury that commonly presents in young, female athletes as anterior knee pain. tendon Exacerbated by prolonged sitting or weight-bearing on a flexed knee. Tibial tuberosity Patellofemoral syndrome Patella Femur Developmental Abnormal acetabulum development in newborns. Risk factor is breech presentation. Results in hip dysplasia of the hip instability/dislocation. Commonly tested with Ortolani and Barlow maneuvers (manipulation of newborn hip reveals a “clunk”). Confirmed via ultrasound (x-ray not used until ~4–6 months Legg-Calvé-Perthes because cartilage is not ossified). disease Idiopathic avascular necrosis of femoral head. Commonly presents between 5–7 years with Slipped capital insidious onset of hip pain that may cause child to limp. More common in males (4:1 ratio). Initial femoral epiphysis x-ray often normal. A Classically presents in an obese young adolescent with hip/knee pain and altered gait. Increased axial force on femoral head epiphysis displaces relative to femoral neck (like a scoop of ice cream slipping off a cone). Diagnosed via x-ray A .
Musculoskeletal, Skin, and Connec tive Tissue Pathology SECTION III 467 Common pediatric fractures Greenstick fracture Incomplete fracture extending partway through A B bwoidntehfaoiflsboonneteAnsfioolnloswidienN;gocrmboeamlnpdriensgsisotnressisd; e intact (compare to torus fracture). Bone is bent Normal like a green twig. Greenstick fracture Torus (buckle) fracture Axial force applied to immGaretuenrseticbkofrnaceture cortex buckles on compression (concave) side and fractures B . Tension (convex) side remains solid (intact). Torus fracture Normal Normal Complete fracture Greenstick fracture Torus fracture Achondroplasia Failure of longitudinal bone growth (endochondral ossification) short limbs. Membranous Goresesnifsitcicaktfriaocnturies not affected large head relative toTloirmusbfrsa.ctCureonstitutive activCaotimopnletoeffrfaicbturroeblast Osteoporosis growth factor receptor (FGFR3) actually inhibits chondrocyte proliferation. > 85% of mutations A occur sporadically; autosomal dominant with full penetrance (homozygosity is lethal). Associated with paternal age. Most common cause of short-limbed dwarfism. Torus fracture Complete fracture Trabecular (spongy) and cortical bone lose mass Can lead to vertebral compression despite normal bone mineralization and lab fractures A —acute back pain, loss of height, MCvooamslupt leectsoe m(frsaemcrtuuoremnlyCdau2+e atnod PbOon43e−)r.esorption kyphosis. Also can present with fractures of femoral neck, distal radius (Colles fracture). ( osteoclast number and Caecnttriavl ietxypa)nsrieonlated Restricted Normal Normal to estrogen levels, old agoef i,ntaernvedrtecbriagl arette intervertebral intervertebral intervertebral smoking. Can be 2° to drudisgcs (eg, steroids, foramen disc foramen alcohol, anticonvulsants, anticoagulants, thyroid replacement therapy) or other conditions (eg, hyperparathyroidism, hyperthyroidism, multiple myeloma, malabsorption syndromes, anoMrildecxoima)p.ression fracture Normal vertebrae Diagnosed by bone mineral density measurement Central expansion Restricted Normal by DEXA (dual-energy x-ray absorptiometry) of intervertebral intervertebral intervertebral at the lumbar spine, total hip, and femoral disc foramen disc neck, with a T-score of ≤ −2.5 or by a fragility fracture (eg, fall from standing height, minimal trauma) at hip or vertebra. One-time screening recommended in females ≥ 65 years old. Prophylaxis: regular weight-bearing exercise Mild compression fracture Normal vertebra and adequate Ca2+ and vitamin D intake throughout adulthood. Treatment: bisphosphonates, teriparatide, SERMs, denosumab (monoclonal antibody against RANKL). uploaded by medbooksvn
468 SECTION III Musculoskeletal, Skin, and Connec tive Tissue Pathology Osteopetrosis Failure of normal bone resorption due to defective osteoclasts thickened, dense bones that are A prone to fracture. Mutations (eg, carbonic anhydrase II) impair ability of osteoclast to generate acidic environment necessary for bone resorption. Overgrowth of cortical bone fills marrow space pancytopenia, extramedullary hematopoiesis. Can result in cranial nerve impingement and palsies due to narrowed foramina. X-rays show diffuse symmetric sclerosis (bone-in-bone, “stone bone” A ). Bone marrow transplant is potentially curative as osteoclasts are derived from monocytes. Osteomalacia/rickets Defective mineralization of osteoid B A (osteomalacia) or cartilaginous growth plates (rickets, only in children). Most commonly due to vitamin D deficiency. X-rays show osteopenia and pseudofractures in osteomalacia, epiphyseal widening and metaphyseal cupping/fraying in rickets. Children with rickets have pathologic bow legs (genu varum A ), beadlike costochondral junctions (rachitic rosary B ), craniotabes (soft skull). vitamin D serum Ca2+ PTH secretion serum PO43−. Hyperactivity of osteoblasts ALP. Osteitis deformans Also called Paget disease of bone. Common, Hat size can be increased due to skull thickening A localized disorder of bone remodeling A ; hearing loss is common due to skull caused by osteoclastic activity followed by deformity. osteoblastic activity that forms poor-quality bone. Serum Ca2+, phosphorus, and PTH Stages of Paget disease: levels are normal. ALP. Mosaic pattern of Early destructive (lytic): osteoclasts woven and lamellar bone (osteocytes within Intermediate (mixed): osteoclasts + osteoblasts lacunae in chaotic juxtapositions); long bone Late (sclerotic/blastic): osteoblasts chalk-stick fractures. blood flow from arteriovenous shunts may cause high-output May enter quiescent phase. heart failure. risk of osteosarcoma. Treatment: bisphosphonates. Avascular necrosis of Infarction of bone and marrow, usually very Branch of Watershed bone painful. Most common site is femoral obturator artery area (infarcted) head (watershed area) A (due to insufficiency A of medial circumflex femoral artery). Causes Medial femoral include glucoCorticoids, chronic Alcohol circumflex overuse, Sickle cell disease, Trauma, SLE, “the Bends” (caisson/decompression disease), LEgg- artery (posterior) Calvé-Perthes disease (idiopathic), Gaucher Lateral femoral disease, Slipped capital femoral epiphysis— circumflex CASTS Bend LEGS. artery (anterior)
Musculoskeletal, Skin, and Connec tive Tissue Pathology SECTION III 469 Lab values in bone disorders DISORDER SERUM Ca2+ PO43− ALP PTH COMMENTS Osteoporosis — — —— bone mass — —— Osteopetrosis —/ — Dense, brittle bones. Ca2+ in severe, malignant — disease Paget disease of bone — Abnormal “mosaic” bone architecture Osteitis fibrosa cystica Primary “Brown tumors” due to fibrous replacement of hyperparathyroidism — bone, subperiosteal thinning Secondary Idiopathic or parathyroid hyperplasia, adenoma, carcinoma hyperparathyroidism Often as compensation for CKD ( PO43− Osteomalacia/rickets excretion and production of activated vitamin D) Hypervitaminosis D Soft bones; vitamin D deficiency also causes 2° hyperparathyroidism Caused by oversupplementation or granulomatous disease (eg, sarcoidosis) = 1° change. uploaded by medbooksvn
470 SECTION III Musculoskeletal, Skin, and Connec tive Tissue Pathology Primary bone tumors Metastatic disease is more common than 1° bone tumors. Benign bone tumors that start with o are more common in boys. TUMOR TYPE EPIDEMIOLOGY LOCATION CHARACTERISTICS Benign tumors Osteochondroma Most common benign Metaphysis of long bones Lateral bony projection of growth bone tumor plate (continuous with marrow space) Osteoma Surface of facial bones covered by cartilaginous cap A Osteoid osteoma Males < 25 years old Cortex of long bones Middle age Rarely transforms to chondrosarcoma Osteoblastoma Adults < 25 years old Vertebrae Males > females Associated with Gardner syndrome Chondroma Medulla of small bones of Giant cell tumor Males > females hand and feet Presents as bone pain (worse at night) that is relieved by NSAIDs 20–40 years old Epiphysis of long bones (often in knee region) Bony mass (< 2 cm) with radiolucent osteoid core B Similar histology to osteoid osteoma Larger size (> 2 cm), pain unresponsive to NSAIDs Benign tumor of cartilage Locally aggressive benign tumor Neoplastic mononuclear cells that express RANKL and reactive multinucleated giant (osteoclastlike) cells. “Osteoclastoma” “Soap bubble” appearance on x-ray C
Musculoskeletal, Skin, and Connec tive Tissue Pathology SECTION III 471 Primary bone tumors (continued) TUMOR TYPE EPIDEMIOLOGY LOCATION CHARACTERISTICS Malignant tumors Metaphysis of long bones Pleomorphic osteoid-producing cells (often in knee region). (malignant osteoblasts). Osteosarcoma Accounts for 20% of 1° (osteogenic sarcoma) bone cancers. Medulla of pelvis, proximal Presents as painful enlarging mass or femur and humerus. pathologic fractures. Peak incidence of 1° tumor in males < 20 years. Codman triangle D (from elevation of periosteum) or sunburst pattern on Less common in older x-ray E (think of an osteocod [bone adults; usually 2° to fish] swimming in the sun). predisposing factors, such as Paget disease Aggressive. 1° usually responsive to of bone, bone infarcts, treatment (surgery, chemotherapy), radiation, familial poor prognosis for 2°. retinoblastoma, Li-Fraumeni syndrome. Tumor of malignant chondrocytes. Lytic (> 50%) cases with intralesional Chondrosarcoma Most common in adults > 50 years old. calcifications, endosteal erosion, cortex breach. Ewing sarcoma Most common in White Diaphysis of long bones patients, generally males (especially femur), pelvic Anaplastic small blue cells of < 15 years old. flat bones. neuroectodermal (mesenchymal) origin (resemble lymphocytes) F . AB Differentiate from conditions with similar morphology (eg, lymphoma, chronic osteomyelitis) by testing for t(11;22) (fusion protein EWS-FLI1). “Onion skin” periosteal reaction. Aggressive with early metastases, but responsive to chemotherapy. 11 + 22 = 33 (Patrick Ewing’s jersey number). C Diaphysis Round cell lesions Fibrous dysplasia D E F Ewing sarcoma Simple bone cyst Myeloma Epiphysis Metaphysis Osteochondroma Osteoid osteoma Physis Giant cell tumor Osteosarcoma uploaded by medbooksvn
472 SECTION III Musculoskeletal, Skin, and Connec tive Tissue Pathology Osteoarthritis vs rheumatoid arthritis Osteoarthritis A Rheumatoid arthritis B PATHOGENESIS Mechanical—wear and tear destroys articular Autoimmune—inflammation C induces cartilage (degenerative joint disorder) formation of pannus (proliferative granulation inflammation with inadequate repair tissue), which erodes articular cartilage and (mediated by chondrocytes). bone. PREDISPOSING FACTORS Age, female, obesity, joint trauma. Female, HLA-DR4 (4-walled “rheum”), HLA- DRB1, tobacco smoking. ⊕ rheumatoid factor (IgM antibody that targets IgG Fc region; in 80%), anti-cyclic citrullinated peptide antibody (more specific). PRESENTATION Pain in weight-bearing joints after use (eg, Pain, swelling, and morning stiffness lasting at the end of the day), improving with rest. > 1 hour, improving with use. Symmetric Asymmetric joint involvement. Knee cartilage joint involvement. Systemic symptoms loss begins medially (“bowlegged”). No (fever, fatigue, weight loss). Extraarticular systemic symptoms. manifestations common.* JOINT FINDINGS Osteophytes (bone spurs), joint space narrowing Erosions, juxta-articular osteopenia, soft tissue (asymmetric), subchondral sclerosis and cysts, swelling, subchondral cysts, joint space loose bodies. Synovial fluid noninflammatory narrowing (symmetric). Deformities: cervical (WBC < 2000/mm3). Development of subluxation, ulnar finger deviation, swan neck Heberden nodes D (at DIP) and Bouchard F , boutonniere G . Involves MCP, PIP, wrist; nodes E (at PIP), and 1st CMC; not MCP. not DIP or 1st CMC. TREATMENT Activity modification, acetaminophen, NSAIDs, NSAIDs, glucocorticoids, disease-modifying intra-articular glucocorticoids. agents (eg, methotrexate, sulfasalazine), biologic agents (eg, TNF-α inhibitors). *Extraarticular manifestations include cervical subluxation, rheumatoid nodules (fibrinoid necrosis with palisading histiocytes) in subcutaneous tissue and lung (+ pneumoconiosis = Caplan syndrome), interstitial lung disease, pleuritis, pericarditis, anemia of chronic disease, neutropenia + splenomegaly (Felty syndrome: SANTA—Splenomegaly, Anemia, Neutropenia, Thrombocytopenia, Arthritis [Rheumatoid]), AA amyloidosis, Sjögren syndrome, scleritis, carpal tunnel syndrome. Osteoarthritis Normal Rheumatoid arthritis B Joint capsule A Thickened and synovial Pannus Synovial proliferation capsule lining Hypervascularity Synovial cavity Dense inflammatory Thinned and infiltrate fibrillated Cartilage cartilage synovial fluid Bone Osteophyte Eroding cartilage Loose bodies Bone erosion Subchondral sclerosis Subchondral bone cyst CDEFG
Musculoskeletal, Skin, and Connec tive Tissue Pathology SECTION III 473 Gout Acute inflammatory monoarthritis caused by precipitation of monosodium urate crystals in joints. Risk factors: male sex, hypertension, obesity, diabetes, dyslipidemia, alcohol use. Strongest risk FINDINGS factor is hyperuricemia, which can be caused by: A Underexcretion of uric acid (90% of patients)—largely idiopathic, potentiated by renal failure; can be exacerbated by alcohol and certain medications (eg, thiazide diuretics). SYMPTOMS Overproduction of uric acid (10% of patients)—Lesch-Nyhan syndrome, PRPP excess, cell B turnover (eg, tumor lysis syndrome), von Gierke disease. Crystals are needle shaped and ⊝ birefringent under polarized light (yellow under parallel light, blue under perpendicular light A ). Serum uric acid levels may be normal during an acute attack. Asymmetric joint distribution. Joint is swollen, red, and painful. Classic manifestation is painful MTP joint of big toe (podagra). Tophus formation B (often on external ear, olecranon bursa, or Achilles tendon). Acute attack tends to occur after a large meal with foods rich in purines (eg, red meat, seafood), trauma, surgery, dehydration, diuresis, or alcohol consumption (alcohol [beer > spirits] metabolites compete for same excretion sites in kidney as uric acid uric acid secretion and subsequent buildup in blood). TREATMENT Acute: NSAIDs (eg, indomethacin), glucocorticoids, colchicine. Chronic (preventive): xanthine oxidase inhibitors (eg, allopurinol, febuxostat). Calcium Formerly called pseudogout. Deposition of Chondrocalcinosis (cartilage calcification) on pyrophosphate deposition disease calcium pyrophosphate crystals within the x-ray. A joint space. Occurs in patients > 50 years old; Crystals are rhomboid and weakly ⊕ birefringent both sexes affected equally. Usually idiopathic, under polarized light (blue when parallel to sometimes associated with hemochromatosis, light) A . hyperparathyroidism, joint trauma. Acute treatment: NSAIDs, colchicine, Pain and swelling with acute inflammation glucocorticoids. (pseudogout) and/or chronic degeneration Prophylaxis: colchicine. (pseudo-osteoarthritis). Most commonly The blue P’s of CPPD—blue (when parallel), affected joint is the knee. positive birefringence, calcium pyrophosphate, pseudogout. uploaded by medbooksvn
474 SECTION III Musculoskeletal, Skin, and Connec tive Tissue Pathology Systemic juvenile Systemic arthritis seen in < 16 years of age. Usually presents with daily spiking fevers, salmon-pink idiopathic arthritis macular rash, arthritis (commonly 2+ joints). Associated with anterior uveitis. Frequently presents with leukocytosis, thrombocytosis, anemia, ESR, CRP. Sjögren syndrome Autoimmune disorder characterized by A common 1° disorder or a 2° syndrome A destruction of exocrine glands (especially associated with other autoimmune disorders lacrimal and salivary) by lymphocytic (eg, rheumatoid arthritis, SLE, systemic infiltrates. Predominantly affects females sclerosis). 40–60 years old. Complications: dental caries; mucosa-associated Findings: lymphoid tissue (MALT) lymphoma (may Inflammatory joint pain present as parotid enlargement); risk of giving Keratoconjunctivitis sicca (decreased tear birth to baby with neonatal lupus. production and subsequent corneal damage) gritty or sandy feeling in eyes Focal lymphocytic sialadenitis on labial salivary Xerostomia ( saliva production) mucosal gland biopsy can confirm diagnosis. atrophy, fissuring of the tongue A Presence of antinuclear antibodies, rheumatoid factor (can be positive in the absence of rheumatoid arthritis), antiribonucleoprotein antibodies: SS-A (anti- Ro) and/or SS-B (anti-La) Bilateral parotid enlargement Anti-SSA and anti-SSB may also be seen in SLE. Septic arthritis S aureus, Streptococcus, and Neisseria gonorrhoeae are common causes. Usually monoarticular. A Affected joint is often swollen A , red, and painful. Synovial fluid purulent (WBC > 50,000/mm3). Complications: osteomyelitis, chronic pain, irreversible joint damage, sepsis. Treatment: antibiotics, aspiration, and drainage (+/– debridement) to prevent irreversible joint damage. Disseminated gonococcal infection—STI that presents as either purulent arthritis (eg, knee) or triad of polyarthralgia, tenosynovitis (eg, hand), dermatitis (eg, pustules).
Musculoskeletal, Skin, and Connec tive Tissue Pathology SECTION III 475 Seronegative Arthritis without rheumatoid factor (no anti-IgG antibody). Strong association with HLA-B27 spondyloarthritis (MHC class I serotype). Subtypes (PAIR) share variable occurrence of inflammatory back pain (associated with morning stiffness, improves with exercise), peripheral arthritis, enthesitis Psoriatic arthritis (inflamed insertion sites of tendons, eg, Achilles), dactylitis (“sausage fingers”), uveitis. Ankylosing Associated with skin psoriasis and nail lesions. Seen in fewer than 1/3 of patients with psoriasis. spondylitis Asymmetric and patchy involvement A . Dactylitis and “pencil-in-cup” deformity of Inflammatory bowel DIP on x-ray B . disease Reactive arthritis Symmetric involvement of spine and sacroiliac Bamboo spine (vertebral fusion) C . joints ankylosis (joint fusion), uveitis, aortic Costovertebral and costosternal ankylosis may regurgitation. cause restrictive lung disease. More common in males, with age of onset usually 20–40 years. Crohn disease and ulcerative colitis are often associated with spondyloarthritis. Classic triad: “Can’t see, can’t pee, can’t bend my knee.” Conjunctivitis Associated with infections by Shigella, Urethritis Arthritis Campylobacter, E coli, Salmonella, Chlamydia, Yersinia. “She Caught Every Student Cheating Yesterday and overreacted.” ABC uploaded by medbooksvn
476 SECTION III Musculoskeletal, Skin, and Connec tive Tissue Pathology Systemic lupus Systemic, remitting, and relapsing autoimmune disease. Organ damage primarily due to a type III erythematosus hypersensitivity reaction and, to a lesser degree, a type II hypersensitivity reaction. Associated with deficiency of early complement proteins (eg, C1q, C4, C2) clearance of immune complexes. A Classic presentation: facial rash (spares nasolabial folds), joint pain, and fever in a female of reproductive age. prevalence in Black, Caribbean, Asian, and Hispanic populations in the US. B Libman-Sacks Endocarditis (LSE in SLE). RASH OR PAIN: Lupus nephritis (glomerular deposition of Rash (malar A or discoid B ) Arthritis (nonerosive) DNA-anti-DNA immune complexes) can be Serositis (eg, pleuritis, pericarditis) nephritic or nephrotic (causing hematuria or Hematologic disorders (eg, cytopenias) proteinuria). Most common and severe type is Oral/nasopharyngeal ulcers (usually painless) diffuse proliferative. Renal disease Common causes of death in SLE: renal disease Photosensitivity (most common), infections, cardiovascular Antinuclear antibodies disease (accelerated CAD). Lupus patients die Immunologic disorder (anti-dsDNA, anti-Sm, with redness in their cheeks. antiphospholipid) In an anti-SSA ⊕ pregnant patient, risk Neurologic disorders (eg, seizures, psychosis) of newborn developing neonatal lupus congenital heart block, periorbital/diffuse rash, transaminitis, and cytopenias at birth. Mixed connective Features of SLE, systemic sclerosis, and/or tissue disease polymyositis. Associated with anti-U1 RNP antibodies (speckled ANA). Antiphospholipid 1° or 2° autoimmune disorder (most commonly Anticardiolipin antibodies can cause false- syndrome in SLE). positive VDRL/RPR. Diagnosed based on clinical criteria Lupus anticoagulant can cause prolonged PTT including history of thrombosis (arterial or that is not corrected by the addition of normal venous) or recurrent abortion along with platelet-free plasma. laboratory findings of lupus anticoagulant, anticardiolipin, anti-β2 glycoprotein I antibodies. Treatment: systemic anticoagulation.
Musculoskeletal, Skin, and Connec tive Tissue Pathology SECTION III 477 Polymyalgia rheumatica SYMPTOMS Pain and stiffness in proximal muscles (eg, shoulders, hips), often with fever, malaise, weight loss. Does not cause muscular weakness. More common in females > 50 years old; associated with giant cell (temporal) arteritis. FINDINGS ESR, CRP, normal CK. TREATMENT Rapid response to low-dose glucocorticoids. Fibromyalgia Most common in females 20–50 years old. Chronic, widespread musculoskeletal pain associated with “tender points,” stiffness, paresthesias, poor sleep, fatigue, cognitive disturbance (“fibro fog”). Normal inflammatory markers like ESR. Treatment: regular exercise, antidepressants (TCAs, SNRIs), neuropathic pain agents (eg, gabapentinoids). Polymyositis/ Nonspecific: ⊕ ANA, CK. Specific: ⊕ anti-Jo-1 (histidyl-tRNA synthetase), ⊕ anti-SRP (signal dermatomyositis recognition particle), ⊕ anti-Mi-2 (helicase). Polymyositis Progressive symmetric proximal muscle weakness, characterized by endomysial inflammation with Dermatomyositis CD8+ T cells. Most often involves shoulders. Clinically similar to polymyositis, but also involves Gottron papules A , photodistributed facial erythema (eg, heliotrope [violaceous] edema of the eyelids B ), “shawl and face” rash C , mechanic’s hands (thickening, cracking, irregular “dirty”-appearing marks due to hyperkeratosis of digital skin D . risk of occult malignancy. Perimysial inflammation and atrophy with CD4+ T cells. AB CD Myositis ossifi ans Heterotopic ossification involving skeletal muscle (eg, quadriceps). Associated with blunt muscle trauma. Presents as painful soft tissue mass. Imaging: eggshell calcification. Histology: metaplastic bone surrounding area of fibroblastic proliferation. Benign, but may be mistaken for sarcoma. uploaded by medbooksvn
478 SECTION III Musculoskeletal, Skin, and Connec tive Tissue Pathology Vasculitides EPIDEMIOLOGY/PRESENTATION NOTES Large-vessel vasculitis May also cause aortitis or vertebral artery infarct. Giant cell (temporal) Females > 50 years old. arteritis Unilateral headache, possible temporal artery Focal granulomatous inflammation A . ESR. IL-6 levels correlate with disease tenderness, jaw claudication. May lead to irreversible blindness due to activity. Treat with high-dose glucocorticoids prior to anterior ischemic optic neuropathy. Associated with polymyalgia rheumatica. temporal artery biopsy to prevent blindness. Most commonly affects carotid artery branches. Granulomatous thickening and narrowing of Takayasu arteritis Usually Asian females < 40 years old. aortic arch and proximal great vessels B . “Pulseless disease” (weak upper extremity ESR. Treatment: glucocorticoids. pulses), fever, night sweats, arthritis, myalgias, skin nodules, ocular disturbances. Raynaud phenomenon is often present. Segmental thrombosing vasculitis with vein and Medium-vessel vasculitis nerve involvement. Buerger disease Heavy tobacco smoking history, males < 40 Treatment: smoking cessation. (thromboangiitis years old. obliterans) Formerly called mucocutaneous lymph node Intermittent claudication. May lead to syndrome. gangrene C , autoamputation of digits, superficial nodular phlebitis. CRASH and burn on a Kawasaki. May develop coronary artery aneurysms E ; Kawasaki disease Usually Asian children < 4 years old. Bilateral nonexudative bulbar Conjunctivitis, thrombosis or rupture can cause death. Treatment: IV immunoglobulin and aspirin. Rash (polymorphous desquamating), Different stages of transmural inflammation Adenopathy (cervical), Strawberry tongue (oral mucositis) D , Hand-foot changes (edema, with fibrinoid necrosis. erythema), fever. Innumerable renal microaneurysms F and Polyarteritis nodosa Usually middle-aged males. spasms on arteriogram (string of pearls Hepatitis B seropositivity in 30% of patients. appearance). Fever, weight loss, malaise, headache. Treatment: glucocorticoids, cyclophosphamide. GI: abdominal pain, melena. PAN usually affects the SKIN: Skin, Kidneys, Hypertension, neurologic dysfunction, Intestines (GI), Nerves. cutaneous eruptions, renal damage. Immune complex vasculitis. Typically involves renal and visceral vessels, Associated with HLA-B51. spares pulmonary arteries. Immune complex–mediated leukocytoclastic vasculitis; late involvement indicates systemic Small-vessel vasculitis vasculitis. Behçet syndrome incidence in people of Turkish and eastern Mediterranean descent. Recurrent aphthous ulcers, genital ulcerations, uveitis, erythema nodosum. Can be precipitated by HSV or parvovirus. Flares last 1–4 weeks. Cutaneous small- Occurs 7–10 days after certain medications vessel vasculitis (penicillins, cephalosporins, sulfonamides, phenytoin, allopurinol) or infections (eg, HCV, HIV). Palpable purpura, no visceral involvement.
Musculoskeletal, Skin, and Connec tive Tissue Pathology SECTION III 479 Vasculitides (continued) EPIDEMIOLOGY/PRESENTATION NOTES Small-vessel vasculitis (continued) Eosinophilic Asthma, sinusitis, skin nodules or purpura, Formerly called Churg-Strauss syndrome. granulomatosis with peripheral neuropathy (eg, wrist/foot drop). Granulomatous, necrotizing vasculitis with polyangiitis Can also involve heart, GI, kidneys (pauci- eosinophilia G . immune glomerulonephritis). MPO-ANCA/p-ANCA, IgE level. Granulomatosis with Upper respiratory tract: perforation of nasal Triad: polyangiitis septum, chronic sinusitis, otitis media, Focal necrotizing vasculitis mastoiditis. Necrotizing granulomas in lung and upper airway Lower respiratory tract: hemoptysis, cough, Necrotizing glomerulonephritis dyspnea. PR3-ANCA/c-ANCA H (anti-proteinase 3). Renal: pauci-immune rapidly progressive CXR: large nodular densities. glomerulonephritis (hematuria, red cell casts). Treatment: glucocorticoids in combination with rituximab or cyclophosphamide. Immunoglobulin A Most common childhood systemic vasculitis. Formerly called Henoch-Schönlein purpura. vasculitis Often follows URI. Vasculitis 2° to IgA immune complex Classic triad: deposition. Hinge pain (arthralgias) Associated with IgA nephropathy (Berger Stomach pain (abdominal pain associated disease). with intussusception) Treatment: supportive care, possibly Palpable purpura on buttocks/legs I glucocorticoids. Microscopic Necrotizing vasculitis commonly involving No granulomas. polyangiitis lung, kidneys, and skin with pauci-immune MPO-ANCA/p-ANCA (anti-myeloperoxidase). glomerulonephritis J and palpable purpura. Treatment: cyclophosphamide, glucocorticoids. Presentation similar to granulomatosis with polyangiitis but without nasopharyngeal involvement. Mixed Often due to viral infections, especially HCV. Cryoglobulins are immunoglobulins that cryoglobulinemia Triad of palpable purpura, weakness, arthralgias. precipitate in the Cold. May also have peripheral neuropathy and renal Vasculitis due to mixed IgG and IgM immune disease (eg, glomerulonephritis). complex deposition. A BC DE F GH I J uploaded by medbooksvn
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